HIV and TB on the Border
“… UNAIDS estimates that [in Burma] HIV prevalence among pregnant women is currently about 2 per cent. Such a prevalence rate is well above the 1 per cent benchmark that indicates a generalised epidemic in which HIV infection has spread from high-risk groups to the general population. The HIV/AIDS situation in [Burma] therefore has important regional considerations. Pregnant women have a high prevalence rate of up to 13 per cent in the areas of highest HIV/AIDS impact. The high infection rate among pregnant women and the lack of anti-retroviral drugs imply a rapidly increasing rate of mother-to-child HIV transmission.” 
The treatment of HIV has become a significant issue for MTC since Médecins Sans Frontières (MSF) closed their Anti-Retroviral (ARV) Programme in Mae Sot area in 2010. We have taken on the 46 HIV positive patients that MSF were treating, and have been providing them with antiretroviral medication while we pursue measures to assure they will continue to receive treatment in the future. New patients that meet the criteria for ARVs are referred to the Mae Sot Hospital for treatment. Unfortunately, this does not guarantee that they will receive treatment, as the Thai programme is already full; patients are accepted only as vacancies occur. There remains a large unfulfilled need for proper management of HIV infection, including ARV medicines, in the migrant community served by MTC.
Currently, one of the major venues for HIV testing is the blood donation centre, with most donors being factory workers. Every year, the clinic conducts an HIV education and counselling workshop for this section of the migrant population. The factories work with MTC on both education and providing blood donors. Twice a year, MTC provides HIV counselling and testing for factory workers. Ultimately, the factory delegates become HIV education supporters, as well as coordinators for blood donation.
Clearly, the migrant and cross-border communities are not composed solely of factory workers. In recognition of the complex demographics of these communities, MTC has tried to enable a peer support network for the migrant community, as a means of taking advantage of opportunities to network, provide HIV prevention education, and raise awareness. This happens through both community collaboration as well as medical collaboration, for example with Mae Sot Hospital.
Some people come to Thailand to avoid the stigmatisation they would be subjected to were they to be treated in Burma. At MTC, patients feel they have a safe and accepting environment for treatment. MTC achieves this by providing a comprehensive approach, including home-based care, nutrition support, and psychosocial services.
The HIV programme in the clinic has become integrated across departments, rather than existing as a completely separate department. It is conducted across blood donors in the blood bank, via antenatal testing in the reproductive health departments, family planning and counselling. Family planning issues relevant to HIV patients are addressed in the Reproductive Health Outpatient Department.
Aside from addressing HIV across the clinic’s programmes, MTC aims to provide a comprehensive and proactive approach to HIV. This approach has stemmed from the clinic’s institutional knowledge that instead of focusing on a specific element of HIV ( such as testing), what is needed is a comprehensive approach that encompasses the empowerment of people living with HIV, education of the community, as well as working with women, health workers and community based organisations. It is an approach which cuts across all of the clinic’s departments as well as partner organisations.
History of HIV at MTC
Prior to 1999, the clinic staff had a reasonably good understanding of prevalence of people infected with HIV via blood donors, antenatal and other testing; what staff members lacked, however, was a good understanding of what information migrant workers had about the disease. Since condom use was and continues to be stigmatised (condoms were illegal in Burma until 1992), high school dropout rates are high, and the population is very mobile, the staff feared a high level of misconceptions. Even if the misconceptions were addressed, condom availability was limited due to constant economic pressure on the community.
Facing this confluence of public health dangers, in 2000 MTC, Thai Public Health authorities, and Burma Medical Association conducted the HIV/AIDs KAP (Knowledge and Practices) Survey. This was the first time this type of survey focusing on migrant workers had been conducted. The results showed that the community had poor knowledge of the disease – typical misconceptions included the ideas that antibiotics could prevent HIV, that transmission wasn’t possible with only one exposure, and community leaders and teachers were typically reluctant to have the sensitive discussions that HIV education entails, especially with adolescent students. Since that time, willingness to discuss the issues has improved.
HIV Services at MTC
Preventing Mother-to-Child Transmission (PMTCT)
From 2001 to 2003, MTC joined the Prenatal HIV Prevention Trial (PHPT), a collaborative pilot project that provided no-cost testing for all antenatal care patients. Blood samples were sent to the laboratory at Mae Sot Hospital and then combined with data from three other sites in Thailand. Anti-retroviral medications were given to those testing positive in order to prevent mother-to-child transmission. Both mother and infant received followed up visits, and milk formula was provided to replace breast milk. Whilst constituting a positive step forward in preventing mother-to-child transmission, this programme didn’t include treatment of opportunistic infections, home based-care, or nutritional support.
Voluntary Counselling and Testing
The Voluntary Counselling and Testing (VCT) Programme began in 2003. It is a free, confidential and anonymous HIV/AIDS counselling and testing service offered six days a week at the clinic. Partners of all positive clients are also encouraged to go to the VCT centre. VCT is a rapid test that produces results in thirty minutes, so the clinic can offer pre and post-test counselling. VCT clients have a higher prevalence of HIV infection than the general population since the majority of them present with symptoms of a sexually transmitted disease, indicating a higher risk for exposure to the virus.
When the VCT Programme started there, were only about 10 people tested per month, now there are approximately 100 people tested monthly. News has spread by word of mouth through the factories and housing areas that at MTC, one can get a free, anonymous HIV test and straight answers to questions. The role the programme plays in educating the community is very important, and it has been highly successful in getting information about HIV to the migrant community.
Home Based Care
Before the Home Based Care Programme (HBC), patients were often lost to follow-up since there was no organised means of contacting them. This was especially problematic for pregnant women who tested positive. The goal is that by providing home visits, the clinic can ensure continuity of care while increasing opportunities for counselling on risk reduction, personal care and health education. The home-based care staff are generally persons living with HIV who have decided they want to help others. They carry the most convincing messages since new clients can identify with them.
The three medics working with the HIV/AIDS programme, from the Blood Transfusion Programme, the PMTCT Programme and the VCT and Home-based Care Programmes, have worked for several years on their programmes and are justifiably proud of the progress that has been made. Because of education and peer support, patients are now more receptive to health education counselling and are less afraid to ask about their risk of HIV exposure. They are proud that the patients living with HIV have a better quality of life than before. The peer-group meetings run by the HIV programme have helped patients deal collectively with issues of stigmatisation and isolation and have increased exposure to education and support.
However, there are significant challenges for the program. Patient and staff security is a problem, particularly for home-based care workers. Peer counsellors do not have work permits in Thailand so when they are making home visits, they face the threat of arrest and detention by police; security issues are even greater for clients coming to the clinic, especially from cross-border areas. Moreover, many HIV/AIDS patients cannot work and therefore do not have an income. Social stigmatisation of HIV/AIDS patients is also a problem in the workplace and in the community.
An ongoing challenge is managing pregnant women and mothers with HIV. MTC provides milk powder, but HIV peer counsellors need to explain how to prepare and use the milk powder. This might seem like a simple task, but when the mother’s living environment may be transient, without electricity, clean water, and clean cooking vessels, it becomes a challenge.
 UNFPA, “United Nations Population Fund Proposed Projects and Programs: Recommendations by the Executive Director; Proposed Special Assistance to Myanmar”, 13 July 2001. UN Doc DP/FPA/MMR.