What drives the HIV infection in Burma?

And I think you have to see the failure to respond to the HIV/Aids epidemic as part of something much larger, which is the failure to respond to the will and aspirations and well being, health and education of the Burmese people as a whole

It is clear that the spread of HIV in Burma is a direct consequence of the high levels of injected drug use in some parts of the country and because of unprotected sexual intercourse. 2 As Burma is one of the world's largest producers and exporters of opium and heroin, it is inevitably that drugs intended for export leak into the local market. The junta does not yet take a public health approach to drug injection, so sterile needles are not available and sharing has become the norm.

It is no surprise that the public health sector is marginal in a country that spends a very small part of its GPD on these issues. According to UN estimates, the regime cut health care spending from 0.38% of the country's GDP in 1995-1996 to 0.17% in 1999-2000. By comparison, the US government spends almost 14% of its GDP on healthcare, while Canada spends just over 9%. Burma's health care system was ranked second from bottom in a 2000 World Health Organization survey of UN member states, beating out only war-torn Sierra Leone for world's worst healthcare system. 3

There is no doubt that unprotected paid sex between men and women is a major driver of the epidemic. Sex work is common in places where men are far from their homes and have more money and power than women. Examples are truck routes, border crossing points, and mining areas in particular.

Homosexual sex is not uncommon, at least at spiritual festivals. However, little research has been done on sex between men so it is not known to what extent it contributes to the epidemic.

Burma is a country of various ethnic minorities with different languages and customs. The ongoing civil war, coupled with human rights abuses like forced relocation and work, torture, extrajudicial killings and extortion of money and properties have caused massive internal displacement and an exodus of ethnic groups into neighboring countries. Because of this, the virus can easily travel and mutate 4 between populations in different corners of the country as well as across borders.

Geographical mapping of officially reported HIV/Aids cases shows that eastern states or divisions have been hardest hit. The central and delta regions have "moderate" rates and the “lowest” were found on the western border. 5

Border areas

Burma shares a long border with Thailand and China in the east. Expecting high income and better living conditions lots of (mostly young) people cross these borders. More than a million migrant workers are currently working in Thailand while significant numbers are also working along the Chinese and Indian borders in the west. Most of these migrant workers do not have official papers, making them even more vulnerable because of their restricted access to prevention and healthcare services. It also increases their vulnerability to exploitation.

Many are unable to speak the language of the host country and end up in sex, seafaring or construction work, where they are highly vulnerable to HIV infection and have little or no access to information.

Internal migration is almost as dangerous. With few opportunities in the ongoing civil war, lots of people, especially in minority areas, are on the move. This seasonal migration driven by poverty leads to large numbers becoming infected. They are gathering around gem, jade and gold mines, logging camps and in the fishing communities along the coasts. Health professionals commonly recognize these places as transmission hot spots.

What makes this situation even worse is the limited access to condoms, bad access to health care, social stigmatization of people already infected, media censorship and the repressive government in general. This provides good ground for the epidemic's future growth.

The area the worst hit by the epidemic is the Shan state. Dr. Chris Breyer estimates that more than 10% of adults there are now HIV positive. "That is the worst ever incidence in the region", he says. "It is on the level of northern Thailand a decade ago. The difference then was the Thai government recognized it and did something about it, whereas the military junta allowing this one out of control” says Breyer. 6

In northern Kachin state there has also been a dramatic increase in the number of people living with HIV/Aids. The rebel Kachin Independence Organisation (KIO), which has signed a truce with the military regime in Rangoon, says privately that the area is being devastated by the disease. The former KIO leader Bran Seng, who died several years ago, once said in an interview that he had entered into ceasefire negotiations with Burma's military rulers for fear that HIV/Aids was destroying the Kachin people. "I realized that with HIV/Aids there was a real danger we might win the battle (against the Burmese army), but lose the war (against the disease)," he said. 7

The government response

It is hard to say what exactly the government's position is towards the crisis. The regime first admitted there was problem in early 1999. HIV/Aids specialists, health workers and diplomats in Rangoon say Burma's military government has shown an increased degree of acceptance over the last two years. This can be seen by the allowance of intervention from western aid organizations including UNAIDS. A UN joint program has been implemented for the years 2003-2005 involving the Burmese regime, international relief groups, local government affiliated aid groups and the opposition National League for Democracy (NLD). Special care has been taken to ensure that the NLD has a strong say in where they feel the money should be allocated, according to those close to the program. Burma has introduced two programs of promoting 100% condom use and preventing mother-to-child transmission, having expanded the programs to over 50 townships. According to the National Aids Program (NAP), Burma has also carried out a sexual survey of people aged between 15 and 49 with the assistance of UNAIDS and UN Children's Fund, and the results are to be used to tailor HIV/Aids awareness and prevention programs to make them more effective.

However, the regime still needs to make major efforts to bring the epidemic into public consciousness if the country's problem is to be contained. The regime's low health care budget and the hesitation to allocate funds to Rangoon by international aid agencies have further postponed any proper advancement in the country's battle against HIV/Aids.

Skeptics also agreed that the regime has recently shown a greater interest in the problem, but they think this is motivated by increasing funding coming in to fight HIV/Aids, and not by humanitarian concerns. "They have to be interested because there is more money coming in", stated one western HIV/Aids specialist based in Rangoon. Dr. Chris Breyer has the same view. He states "it is very obvious that the health and well being of the Burmese people is not in the interest of the military junta. Their real only interest is holding on power at all costs. And I think you have to see the failure to respond to the HIV/Aids epidemic as part of something much larger, which is the failure to respond to the will and aspirations and well being, health and education of the Burmese people as a whole ... They control HIV/Aids by controlling the information. You control it by controlling the virus." 8

But what is for certain is that the government approved the UN initiated Joint Program on AIDS. Programming has improved and also staff capabilities; for example younger staff trained overseas are hired and promoted.

One of the most obvious changes of the last three years has been greater government openness to talk about HIV/Aids issues. International NGO's and government agencies can now talk about it more freely, develop education materials with less scrutiny, use the mass media more quickly and most important of all, promote condom use. Fewer restrictions underlie distribution, even in places where sex is sold. Billboards promoting condom use are now also seen outside Rangoon, and advertisements, drawings and articles are being published more often in newspapers and magazines. There is still censorship of the media however, and some photographs, posters and audio materials are not approved. This inevitably leads to further delays in the distribution of this education material.

One of the biggest problems is that not all areas of the country where infections are occurring are covered. People at risk of infection continue to be marginalized and coverage of condom promotion and other activities is still limited. Most staff are vulnerable to pressure by local government officials and traveling to ceasefire and border areas is still difficult, involving lengthy permission procedures. The same is the case for NGO's working along the Thai border. If the Thai government would grant worker status to health volunteers and NGO workers they could do much more for their migrant community.

Despite all these efforts, the level of knowledge and awareness of HIV/Aids is still extremely low. Information on, for example, condom use is very low as well. 9

Uncertain future?

The political situation in Burma is extremely uncertain. Former Prime Minister Khin Nyunt is now under house arrest on suspicion of corruption. He had chaired a key government committee on health issues and had supported greater involvement of international NGO's in fighting HIV/Aids. It is now very unclear whether further steps forward will be possible. There was also some hope that a response to the crisis would contribute to a dialogue between the military government and the NLD. This unfortunately not happened. Crackdowns on the NLD have further weakened its structure and party leader Aung San Suu Kyi is still under house arrest.

The level of HIV/Aids cases depend most on patterns of risk behavior in the general population, about which mostly nothing is known. The most important point is that HIV prevalence is increasing in Burma and the higher it gets, the less risk behavior is needed to continue its increase. If a certain point is passed, controlling and preventing new infections becomes extremely difficult. It also becomes more and more expensive for prevention programs and the health care system in general because there are more sick people and orphans to take care about.

The impact of this global epidemic is felt beyond the health care sector. HIV/Aids has caused changes in the social, economic and security situations in many countries because the most productive age groups are seriously affected. If the people of Burma have the opportunity to unite and work together in response to the HIV/Aids epidemic, it will be a very positive example of the country's political stability and will help the democratization process.

The country will continue to face the negative effects for a long time. The widespread incidence of HIV/Aids is a security problem in itself, undermining both personal and national security. It can also undermine the already weak capacity of the state to govern and has a devastating impact on the economy. In 1998, Daw Aung San Suu Kyi reaffirmed this view when she said "Burma needs effective education programs and services now. Unless we act urgently, HIV infection could reach epidemic proportions in our country and become a major threat to our social stability and economic potential."

Endnotes:

1. Estimated numbers include: 330,000 (lowest range - 170,000, highest range - 620,000), UNAIDS report on the global AIDS epidemic 2004; 338911, Xinhua General News December 2, 2004; and many others


2. Studies suggest that the prvalence rate among sex workers is up to 60 pre cent


3. Edging towards disaster, The Irrawaddy, May 2003


4. Mandalay is a particularly intense transmission location. By determining the types of HIV that infect people there, a team of researchers from the National AIDS program and Japan has reported that the virus in Mandalay is mutating into a unique recombinant forms. This happens only when many people with one type of HIV have sex or share injecting equipment with people with another type


5. UNAIDS report on the global AIDS epidemic 2004


6. Inter Press News Agency, July 2004


7. See Endnote 6


8. AIDS takes the backseat in Burma. An interview with Dr Chris Beyer, The Irrawaddy, July 2004. Dr Beyrer a leading US AIDS exper


9. See Endnote 8