Between 2011 and 2014, Myanmar more than doubled the number of people living with HIV who are on long-term antiretroviral-therapy (ART), the gold standard for HIV treatment. This is fantastic news. Furthermore, while Médecins Sans Frontières (MSF) continues to be one of the biggest providers of HIV care in Myanmar, currently treating 35,000 patients across the country, by the end of 2014, almost half of all ART drugs in Myanmar were being provided in the public sector.
But despite these achievements, the harsh reality remains that today only half the estimated 210,000 people living with HIV in Myanmar receive ART. So as we mark Word AIDS day this year, and acknowledge the huge progress that has been made in Myanmar, we need to ask ourselves: why is this? And, even more importantly, what needs to happen next?
We have entered a new phase in the HIV epidemic in Myanmar. Success in starting more people on proper treatment has also brought a new challenge: how do we maintain the long term support of those already on treatment, while simultaneously ensuring that the remaining people living with HIV know their status and have access to services? Part of the answer lies in simplifying the way we support those already on lifelong treatment.
Once they are on drugs and responding well to therapy, the condition of people living with HIV becomes stable. While the virus remains in their body, they become healthy and are able to return to their lives as long as treatment is maintained. But crucially, that support no longer requires close follow up from a medical doctor at every visit. Their illness is diagnosed and the treatment determined. Now, their treatment regimen mainly needs to be managed and followed up. This means people other than medical doctors can do it.
This has various benefits for the patients and the treatment providers. First, it frees up medical doctors to start new patients on treatment and to focus on HIV patients with complications, for which their expertise is far more needed. Second, it makes it possible to move treatment support closer to people’s homes, so they don’t have to travel for care, making it easier for them to lead a normal life.
MSF has successfully trialled this approach in Dawei District. There, MSF supports four National AIDS Programme (NAP) decentralised ART sites. By October this year, MSF had transferred the long-term treatment support of more than 500 stable people living with HIV to these sites. They are closer to home for many people who used to come to the MSF clinic before and run almost entirely by nurses, although those nurses can refer patients to a medical doctor if extra expertise is required. Once people saw that the service at these sites was equally high in quality, many asked if they too could have their treatment support transferred to a decentralised clinic. When treatment support is available closer to home, and does not require waiting all day to see a doctor, returning to a normal life is far easier. And interestingly, when we tell people they no longer require in-depth medical consultations and so can be seen by a nurse, it seems to make them feel good and more confident about their health.
Giving nurses the knowledge and tools to do this is possible. In Yangon, MSF provides ART treatment to approximately 17,000 people living with HIV. Since 2010, MSF nurses in Yangon have been trained alongside medical doctors in how to manage stable patients. Although they can still refer patients to a doctor if necessary, nurses now manage the majority of patients, as about 80% of the cohort is currently stable.
Myanmar’s success in starting more people living with HIV on treatment has brought new challenges. But evidence shows that involving nurses more in treatment support makes better use of Myanmar’s existing pool of medical skills – especially at township and peripheral level. And that is crucial for HIV treatment to succeed on a larger scale, and for Myanmar’s success in this area to continue.