Burma's leaders slowly moving to combat HIV

Poor nation's junta ignored danger for years

Rafael D. Frankel, Chronicle Foreign Service
San Francisco Chronicle - Thursday, April 3, 2003

Lantaya, Burma -- Set among a series of wooden shacks that are connected by bamboo bridges, the four thatched huts on stilts make up one of Burma's few AIDS clinics.

The clinic in this bedroom community 45 minutes outside the capital, Rangoon, has 11 patients. They are treated for malnutrition and other illnesses but are given few medications to stave off the virus. All sleep on wood-framed beds with thin foam pads.

The female patients are former sex workers, or wives who contracted HIV from their husbands. The men are drug addicts infected by unclean needles or migrant workers who frequented prostitutes. Those who aren't bedridden paint signs that promote safer sex to be posted in the community.

Despite such basic care sponsored by the Netherlands chapter of the prominent Nobel Prize-winning group Doctors Without Borders, these 11 AIDS patients are the lucky ones.

In Burma, an impoverished nation of 48 million people, there are only two hospitals that have AIDS wards, and few Burmese can afford the average $300-a- month cost of anti-retroviral drugs. Many rely on traditional medicines and advice from pharmacies.

Many observers blame this dire situation on a military government that has allowed the nation's health system to decay -- the World Health Organization ranked Burma 190 out of 191 member countries in 2000, above only Sierra Leone - - and practically ignored the AIDS epidemic until last year. Life expectancy is just 55 years, compared with 63 years in the rest of Asia.

For years, the ruling junta, which calls itself the State Peace and Development Council and calls the country Myanmar, had made AIDS a taboo subject. Health observers say that decision enabled the disease to gain a major foothold in Burma.

"It is their fault," said a Western AIDS worker, who, like other health activists, doctors and diplomats, spoke only on condition of anonymity for fear of government reprisals. "They are afraid of being criticized" by Western governments. Because the government tightly controls information, no one knows how many Burmese are HIV-positive. UNAIDS, the United Nations' program, estimates that 400,000 people were infected at the end of 2001, or just under 1 percent of 15- to 49-year-olds. That is the grouping UNAIDS defines as the "adult" population and the most vulnerable to infection.

The junta, however, has long insisted that the numbers are much lower because they say Burma has a culture that stresses abstinence before marriage and fidelity afterward. As a result, state AIDS campaigns had urged monogamy and fidelity while excluding the mention of condoms or the need for drug addicts to use clean needles.

"The cultural and social values of Myanmar society are found to have a protective effect to a greater extent than in many population groups," said junta member Gen. Khin Nyunt on World AIDS Day in December.

But a 1999 study by Chris Beyrer, an epidemiologist at the John Hopkins University School of Hygiene and Public Health who worked with the World Health Organization in Burma, suggests that at least 687,000 Burmese are HIV- positive, or almost 3.5 percent of Burma's adult population, which would be the highest rate in Asia. His team analyzed government figures at clinics and hospitals and narrowed the study to pregnant women, soldiers, sex workers, gay men and blood donors while excluding the nation's estimated 1.4 million drug users.

Beyrer, who studied AIDS in seven countries in his book "War in the Blood: Sex, Politics and AIDS in Southeast Asia," also blames the junta for the grim reality.

"There has been a complete failure on so many levels," Beyrer said. "The health care system is in collapse, grossly underfunded and neglected by the junta. The junta has been a disaster."

STRAIGHTS, DRUG USERS AT RISK

Heterosexuals account for 57 percent of infection rates in Burma, followed by intravenous drug users with 22 percent. Those who donated or received tainted blood are 4 percent, homosexuals make up 1.2 percent, and the cause was unknown for 13.5 percent, according to UNAIDS.

But health workers say the number of Burmese infected with HIV could be much higher because many people are unaware of the disease and go untreated.

The Burmese "know really only layman knowledge about transmission," said a local physician.

Some health experts also blame the international community. Most foreign assistance ceased after the junta suppressed Burma's democracy movement by force in 1988 and ignored the results of the 1990 election -- won by the opposition party led by Aung San Suu Kyi, who won the Nobel Peace Prize the next year.

Over the years, humanitarian groups have faced the dilemma of assisting AIDS patients without lending legitimacy to a repressive government. In 2001, donor funding for AIDS programs was less than $3.5 million, compared with Thailand, where foreign donors have spent between $30 million and $90 million per year in the past decade.

"I would fault the international community as much as the military in not supporting humanitarian work," said another foreign AIDS worker.

But there is now renewed hope that both the junta and international aid groups have turned a corner in fighting the AIDS epidemic.

A FEW ENCOURAGING SIGNS

Tony Lisle, the UNAIDS director for Southeast Asia, sees an "absolute groundswell of change in Myanmar in the last 18 months" in reference to the military's willingness to finally face up to the AIDS crisis.

Lisle said Burma's rulers have acknowledged AIDS as a "serious issue," and he points to several encouraging signs: a government-sponsored needle exchange program; an AIDS awareness billboard campaign; the appointment of a prominent doctor as the new minister of health; and a soap opera on state-owned television about a rich business family whose widowed patriarch is infected with HIV, which includes discussions of condom use.

A shift in policy on condoms is good news for Population Services International, a U.S. nongovernmental organization that was behind the television soap opera. The group has been promoting safer sex and distributing condoms since 1995 from riverboats that visit remote villages along the Irrawaddy River.

The organization is now distributing condoms unfettered. "This was unthinkable just three years ago," Lisle said.

Moreover, the Global Fund to Fight AIDS, created at the urging of U.N. Secretary-General Kofi Annan, is expected to provide $30 million in the next three years to foreign AIDS programs in Burma.

"It's all moving in the right direction," said another Western health worker.

HIV SPREADING IN RURAL AREAS

Yet the junta and the nongovernmental organization face a daunting challenge.

Although AIDS has long been an urban problem, the disease is spreading quickly to rural areas as a result of migrant workers and truck drivers having sex with prostitutes while traveling in such countries as India, China and Thailand. When they return, they pass the virus on to their wives and girlfriends, according to UNAIDS.

Another concern is the rising AIDS rate among urban female sex workers. UNAIDS says about 27 percent of sex workers in Rangoon and Mandalay are HIV- positive.

At a late-night "fashion show" at the Yangon International Hotel in Rangoon, young women paraded down a dance floor followed by a spotlight and the gaze of dozens of potential male clients.

"They are all up for negotiation," said a Malaysian businessman who asked not to be named. "Do they make the men wear condoms? Some do. Some don't. It depends on the girl and how much you pay them."

Meanwhile, despite the junta's apparent policy shift, its tight rein on society continues to complicate foreign AIDS programs.

Nongovernmental organizations complain about fiats that allow only government hospitals to carry out HIV tests and require permits to assemble a village to listen to a discussion on the disease.

"The generals don't allow any autonomy. Everything has to go through them," Beyrer said. "The health ministry knows there is a serious problem, but when you actually attempt to implement programs, it has to go through a general."

©2003 The San Francisco Chronicle