One of the few international organisations working in Myanmar on HIV/AIDS prevention and treatment is the health nongovernmental organisation (NGO) Medecins Sans Frontieres (MSF) Holland. Country director Frank Smithuis spoke about the challenges of working with vulnerable groups, many of whom are criminalised by the government.

QUESTION: What is the main thrust of MSF's HIV/AIDS programme in Myanmar?

ANSWER: I think we have a fairly comprehensive package. We started here originally with preventative activities: health education, and condom promotion and distribution; then we moved to the large-scale treatment of sexually transmitted diseases and offered needle exchange programmes. In the beginning we offered clinical care for those with HIV/AIDS and opportunistic infections like TB [tuberculosis]. Since 2003 we have been offering antiretroviral drugs.

Q: What successes in reducing HIV/AIDS prevalence can you point to with these programmes?

A: It is difficult to measure such things. We work a lot with high-risk populations like sex workers and intravenous drug users. These groups are very mobile, therefore it's not easy to measure what we really have achieved.

But I know in some areas, like mining areas in the north, in Pakant, which could be seen as one of the epicentres of the disease in this country, through our five clinics in the area we have decreased the prevalence of gonorrhoea among sex workers from about 20 percent to less than 1 percent. Sexually transmitted infections facilitate HIV/AIDS infections, so we are confident that this sort of programme lowers HIV/AIDS rates.

Q: You've mentioned high-risk populations like sex workers and drug users but, in a country as poor as Myanmar, what other groups are particularly at risk from the disease?

A: One group I should not forget is men who have sex with men, another is migrants. If you look at the mining areas, there are mainly migrants working there. In general, the migrant population, for a variety of reasons, is not in a stable family environment and is exposed to high-risk behaviour.

Q: The government has been criticised for having a head-in-the-sand approach to HIV/AIDS prevention and treatment. Is that changing and, if so, is that having an impact on MSF's work in Myanmar?

A: MSF started here in 1993. At this time the HIV/AIDS epidemic was not well known ... it was also very difficult to talk about HIV, and HIV prevention and care. That has changed quite dramatically: now the government acknowledges that HIV is one of the three main disease burdens in the country. That is an important step. The government has also agreed to a number of activities on prevention and treatment, but I do not think that that's enough.

One problem is that high-risk people and their activities are still illegal and, therefore, it's still difficult to reach these people, to decrease the risk behaviour. On the one hand, the department of health wants to reach these people; on the other, the police will feel it their duty to arrest these people if they are engaged in criminal activities.

That is why I think it is very important that NGOs are involved, as we [MSF] do not have an obligation to enforce the law - we are just there to help them [high-risk groups] reduce the risk, or to deal with their disease.

Q: How, then, would a needle exchange programme work here if intravenous drug users are criminalised?

A: Yes, because needle exchanges are still officially illegal, that is a problem; on the other hand, at the moment, some organisations are involved with needle exchanges and it seems the authorities close their eyes and let them happen.

Q: Does the international response to HIV/AIDS in Myanmar need to improve?

A: Myanmar is one of the countries that receive the least overseas development aid - this is obviously for political reasons. There are serious health problems in this country; MSF focuses on HIV/AIDS, malaria, TB and sexually transmitted diseases. The population suffers hugely from these and many other diseases and the international community helps much less than in other countries, and there is absolutely no reason for it.

Donors are worried that aid money might end up in the wrong hands. That is a legitimate worry, but I do not think it is a reason to exclude Myanmar more than any other country. I think it is very important that more money comes to the people of Myanmar, and that the international organisations here monitor that money to ensure it is used for the purposes for which it was designed.

Q: What about building civic society? Then more money could be channelled through NGOs, for example.

A: Yes, there are a number of organisations working on that, but there again, there is the worry of how these independent organisations can work in an independent way. So, I think it should be tried; it should be monitored and, if it works, it should be continued.

Q: Some observers say the HIV/AIDS prevalence rate here has stabilised, is that a view that MSF subscribes to?

A: It is very difficult to know, because we do not do surveillance of HIV rates. The impression we get from our clinics is that the number of patients is still increasing. Having said that, we are dealing with people with clinical AIDS - that is a trend that follows years after the prevalence of HIV, so it does not necessarily show that the prevalence rate is increasing still. But I would be quite reluctant to be complacent and think that we have this thing beaten.

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