Where there are no drugs: TB-HIV dilemma for migrants
In late October 2010, a large group of people living in and around Mae Sot, Tak province were closing in on a terrible 'milestone' of sorts: all of them – over 60 migrant children, women and men – were living with HIV and taking antiretroviral (ARV) drugs, which they needed to stay alive. Some were also co-infected with tuberculosis (TB), the most frequent opportunistic infection (OI) experienced by people living with HIV/AIDS (PLHIV).
Each group member's daily regimen of drugs – a one-year 'buffer' provided by an international non-governmental organization (INGO) pulling its operations out of the country – was about to run out, with no new supplier in sight.
"We have been unable to secure a sustainable source of ARVs for our patients," explains a staff of the Mae Tao Clinic, a clinic providing health care services to migrants and displaced people near the Thai-Burma border. "If they stop taking their medication, we face a crisis."
Adherence to a prescribed ARV drug regimen is essential; people living with HIV and/or TB who stop taking medication for whatever reason, and even only for a few days, can develop a resistance. Drug-resistance is dangerous, because it is irreversible and the new strains of the disease can be passed on to others.
Multi-drug- and extensively drug-resistant tuberculosis (or, respectively, MDR and XDR TB) is an even greater potential threat than HIV drug resistance in terms of impact, because unlike HIV – a blood-borne disease –, TB is transmitted from person to person through the air. A rampant increase in drug resistance can thus indeed fuel a public health crisis.
The Mae Tao Clinic representative said that "from a public health perspective TB is more difficult to handle, mainly because of time-related compliance issues. People with TB have to take medication daily for six months. If they interrupt this treatment, which happens frequently with migrants who are on the move and may stop taking drugs when they feel better, then drug resistance can occur."
Another often under-estimated problem accompanying drug resistance is the subsequent need for different drugs to replace the first regimen. These second- or third-line drugs are much more expensive and difficult to procure – here in Thailand, for example, the main first-line ARV combination therapy (for example GPO-VIR S30) is locally produced and distributed, bringing down the cost; but second- or third-line drugs must be imported, tend to be much more expensive than first-line medicine and may require special handling, like refrigeration, which complicates delivery in unstable settings.
Thais living with HIV have the right to, and usually receive, free ARVs through the National Access to Antiretroviral Program for People living with HIV/AIDS, or NAPHA. People without a Thai ID can buy ARVs for a minimum of 1,350 baht per month, although NAPHA set up a provisional extension programme to cover vulnerable populations who do not have access via regular channels like Thai social welfare card holders.
Access is inevitably restricted for individuals or families already subject to the most dire of circumstances: many migrants and displaced people along the Thai-Burma border live a day-to-day existence that may include a lack of food security and reliable shelter. This can, and does frequently lead to greater vulnerability to infection and illness. An HIV positive migrant in poor health is thus more likely to contract opportunistic infections (OI) like TB, or Hepatitis C, another highly problematic OI.
A representative of a community-based organization in northern Thailand shared that "along the Thai-Burma border abutting Shan State, in Chiang Mai province, we support 125 members of the Shan community living with HIV, of whom 50 currently receive free ARVs. Unfortunately, beginning in December 2010, any new patients will have to pay for treatment – so this will affect any of the 75 not yet on ARVs who might need them in the future." There are about one or two new cases every month, and some of them also have TB.
She added that they "…have a limited budget aimed at helping with general hospital costs for community members, but we've been using it to cover ARV-related costs for our PLHIV."
Given the existing obstacles to accessing adequate and appropriate treatment, it is not surprising that migrants may start with the TB six-month short course, but then, despite doctor's instructions, stop taking the drugs once they feel better. Many migrants are by nature already mobile, which further complicates consistent compliance and follow up by medical staff.
It is this population – in addition to other key populations like sex workers, injecting drug users and prisoners – that should be the main beneficiary of effective prevention efforts and increased access to a regular supply of drugs.
In a country that currently receives generous funding from the Global Fun to fight HIV/AIDS, TB and Malaria (GFATM), how is it possible we cannot manage to take care of our most vulnerable fellow humans?
SERVICES AND GAPS
A representative of the Thai Northern Network of People Living with HIV stated that "local hospitals do provide ARVs to migrants and displaced people as part of NAPHA's extension programme, but they are bound by a quota system which always favours Thai citizens over unregistered migrants."
He admitted that "sometimes Thais who fear being stigmatized and discriminated against by colleagues will request treatment under the extension programme instead of the regular system, because this way they can remain anonymous."
Mae Tao Clinic already offers a number of relevant services for PLHIV, including voluntary counseling and testing (VCT), home-based care and peer educators. Relatively simple preventive approaches can also be applied in the context of TB-related services, such as face-masks and better ventilation in places where people go to get tested.
"A more systematic, consistent integration of HIV and TB programmes is key," claimed another Mae Tao Clinic staff; he went on to say that "since it was at this point beyond the clinic's capacity to offer TB treatment, it was essential to have one group or entity able to take full responsibility for managing a comprehensive TB programme and willing to deal with problems such as non-compliance or adherence due to mobility."
There is an international NGO currently providing TB services in Mae Sot, serving part of the area previously covered by the INGO that pulled out last year. Yet the new organisation has limited reach and cannot accept patients outside of its focal communities, including those likely to move across the border. These unfortunate ones have to look elsewhere, and more often than not, they end up at Mae Tao Clinic.
Regarding the 'stranded' HIV-positive people, clinic staff approached the closest hospitals for help, and only Propha agreed to treat 20 people under its NAPHA extension scheme. Mae Sot, Mae Sariang and Mae Ramat hospitals were not accepting any new patients.
"We are now waiting to hear whether the Regional NAPHA Extension Unit in Pitsanuloke can help coordinate the provision of ARVs directly to Mae Tao," said the first Mae Tao Clinic staff. "This is easier and more cost-effective than transporting a large group of patients back and forth each month."
It seems that drug resistance is here to stay – at least for now – and so the best response would include not only addressing the most immediate needs to mitigate impact, but also introducing some longer-term measures.
In addition to the interventions mentioned above, anti-stigma and -discrimination campaigns targeting Thai society would help PLHIV at all levels access existing ARV providers without fear of being socially outcast.
The representative of the Northern Network of People Living with HIV wondered whether "everything could be related to national security issues and that maybe there is no real will to find a sustainable solution to these urgent cross-border issues."
Also, "there seems to be little real interest among TB service providers to collaborate more with the HIV/AIDS sector," an independent consultant supporting HIV/AIDS-related work at national and local levels in Thailand noted. "Because TB has for so long been considered 'solved' as a public health issue here, they do not have a sense of urgency…"
Well, it can't get any more urgent for those people living with HIV/AIDS and TB here, and now - and who may soon become drug resistant due to apathy and ineffective programme design and interventions. Acknowledging and fully understanding the reality of this is the first step, acting decisively and comprehensively, the second. Here, and now. (CONSTANZE RUPRECHT - CNS)