Your daily Selection of IRIN Africa PlusNews reports, 2/1/2007

February 1, 2007

U N I T E D N A T I O N S

Office for the Coordination of Humanitarian Affairs

Integrated Regional Information Network (IRIN) -

[These reports do not necessarily reflect the views of the United Nations]

CONTENT:

1 - INDONESIA: On a razor's edge - HIV vulnerability in Aceh

2 - LAOS: Keeping the lid on HIV

3 - LAOS: Regional Buddhist HIV outreach programme making an impact

4 - MYANMAR: Interview with MSF-Holland country director

5 - MYANMAR: Uphill struggle to contain HIV/AIDS

1 - INDONESIA: On a razor's edge - HIV vulnerability in Aceh

BANDA ACEH, 1 February (PLUSNEWS) - Ratnawati Zulkifli, 32, will always remember

the morning of the tsunami, a day still etched in her mind nearly two years

after this century's greatest natural disaster to date.

" I lost everything that day, and everyone I love, " she said, sitting on the

steps of the crowded barracks-like structure she shares with her sister and two

children in one of the ramshackle wooden shelters where many of the displaced

still live on the outskirts of Banda Aceh, capital of Indonesia's devastated

Nanggroe Aceh Darussalam (NAD) Province, more commonly known as Aceh.

More than 130,000 people died and over 500,000 were left homeless when the

tsunami struck on 26 December 2004. Living conditions in the barracks, meant to

be temporary, are poor. Most residents are women, many of whom lost their

husbands and have no choice but to care for their children alone, often without

a source of income or support.

Billions of dollars in international assistance have enabled thousands of

survivors to be relocated to permanent housing, and signs of reconstruction are

everywhere, but the plight of many displaced women is still dire. Isolated and

alone, they face social instability, poverty and powerlessness - conditions that

could heighten their vulnerability to another possible tsunami that could sweep

the nation - HIV/AIDS.

HIV IN INDONESIA TODAY

Indonesia's National AIDS Commission estimates that between 90,000 and 120,000

people are living with HIV, with 13 million to 20 million at risk of contracting

the virus, including mobile populations and commercial sex workers.

Although there is low prevalence in the general population, there is a

concentrated epidemic among certain population groups, with injecting drug users

and the sex industry fuelling the epidemic.

More than 80 percent of all cases involve men, and there has been an upsurge in

needle-related HIV infections in the last six years. According to Ministry of

Health figures for 2005, current infection rates among injecting drug users

constitute 48 percent of all reported cases, and more than 60 percent to 90

percent in many provinces.

Intravenous drug use, previously rare in Indonesia, has become widespread, with

drug-related HIV now being reported in nearly all of the country's 33 provinces,

but programmes are actually reaching fewer than 10,000 of the country's

estimated 160,000 injecting drug users.

" The amount of unsafe injecting going on without adequate information to educate

them, is huge, " Jane , country representative for the Joint United Nations

Programme on HIV/AIDS (UNAIDS), told IRIN in the Indonesian capital, Jakarta.

" About one in two drug users in Indonesia appear to be living with HIV, " she

said, describing needle sharing as the main vehicle for transmitting the virus.

The epidemic in Indonesia, a nation of over 225 million, appears to be

concentrated mainly in Riau, on the island of Sumatra, Papua, Jakarta and East

Jawa on the island of Java, and the island of Bali. In Papua alone, the

prevalence rate is already well above 5 percent, commented.

According to the NAD Province AIDS Commission, as of March 2006, all provinces

had reported cases of HIV/AIDS, including Aceh, a particularly conservative part

of the country.

CONFLICT AND DISASTER

Indonesia, an archipelago of some 17,000 islands, was worst affected by the

tsunami, with Aceh at the western end of the country's northernmost island,

Sumatra, taking the hardest hit.

Already reeling from decades of strife between Indonesian military forces and

the Acehnese rebel movement, GAM, the tsunami unleashed a wave of new problems,

intensifying vulnerability among marginalised populations in what was previously

an isolated region.

The United Nations Development Fund for Women (UNIFEM) noted that women

accounted for about 55 percent to 70 percent of tsunami casualty figures, and

had suffered physical, social, economic and psychological harm and deprivation.

Years of conflict had multiplied the roles of many women, obliging them to head

households, sustain subsistence economies, raise children, care for the sick,

wounded and elderly; they were described as the lifelines of Acehnese

communities.

After the disaster many women, like Ratnawati, found themselves living in camps

for displaced persons or barracks where they were alone, powerlessness and

subject to increased domestic violence and other forms of abuse - all conditions

that could enhance the risk of HIV/AIDS.

" Women and children are particularly vulnerable after a disaster such as this.

Many had lost their husbands and were forced to be the breadwinners, " said

Herawati Daud, assistant project officer for HIV/AIDS with the United Nations

Children's Fund (UNICEF) in Banda Aceh.

NEW CHALLENGES

Aceh had no facilities for HIV testing and treatment before the tsunami, forcing

those seeking such services to travel south for 12 hours to Medan, the

provincial capital of North Sumatra Province.

Sex and contraception are largely taboo subjects in Aceh's staunchly

conservative Islamic society. According to Baby Rivona, programme director of

the recently established Media Aceh Partnerships (MAP), a nongovernmental

organisation (NGO), and one of the few people in Aceh Province working with

HIV-positive people, even the government was hesitant in referring to women as

being vulnerable, given religious restrictions on such discussions, while

promoting condom usage might be misconstrued as condoning premarital sex.

Indeed, many Acehnese believe the tsunami was a punishment for insufficient

piety, resulting in an even stronger emphasis on religion and its traditional

views on family values.

Despite efforts by the NAD Province AIDS Commission prior to the tsunami to

address HIV/AIDS, the sensitive nature of the subject meant there was little or

no data on HIV prevalence.

" Our concern in a tragedy like this is to see a province like NAD from being a

province with almost no HIV prevalence, or perhaps hidden incidence, to a being

a place where, due to increased drug usage, vulnerability among women and sexual

exploitation, more and more people becoming infected, " warned.

KEY RISK FACTORS

Describing Acehnese as a high-risk population as a result of the disaster,

particularly women and children, the HIV prevention coordinator for UNAIDS in

Banda Aceh, Peissel, commented, " IDP [internally displaced person]

camps breed high-risk behaviour. " People in such environments were introduced to

those they would not normally associate or live with, and there was always the

potential risk of sexual exploitation, rape, or sex for food.

Gordon, programme director for a local NGO, Yakita, which has done

extensive work with young people and injecting drug users, agreed, pointing out

that in the confined quarters of barracks for the displaced, sex became either a

vehicle or a commodity. " There is more potential for young people to have sex

under the circumstances of living in these camps, as people looking to express

.... [themselves], or getting what they want in return. "

THE IMPACT OF THE RESPONSE EFFORT

Besides interaction between groups that normally would not mix socially, the

potential increase in sexual activity, and a large military presence as a result

of the conflict, thousands of people, foreign as well as local, poured into the

area to provide emergency and reconstruction assistance, bringing the unique

impact of the heightened humanitarian response.

Of particular importance, said Peissel, was the arrival of tens of thousands of

migrant workers from other parts of the country, such as Medan and Jakarta -

mostly mobile men with money - some of whom might be infected with HIV and other

sexually transmitted infections (STIs).

After extended periods of separation from their families, engaging in sexual

activity with the local population was inevitable. It was not uncommon for

construction camps to be set up alongside barrack housing for the displaced,

often sharing facilities such as showers and toilets.

Uniformed personnel, who had been on conflict-related duty for upwards of two

years at a stretch in the area, were also deployed in emergency and

reconstruction efforts. " We all know that there is always a higher rate of STIs

and HIV among the armed forces, " Peissel said, because they were also men with

money and therefore contributed to the expansion of sex work.

COMMERICAL SEX WORKERS

Access to groups at high risk of HIV was particularly difficult because the sex

industry, already rising to meet the demand, has largely been driven underground

by the conservative attitude towards sex in Aceh.

There are no organised brothels in the traditional sense, but it is not uncommon

for some hairdressers and other establishments to act as fronts for such

activity, making access and intervention all but impossible.

THE RISK OF INJECTING DRUG USE

Although the primary risk of HIV infection now is reportedly via unprotected

sex, given the steady rise in needle-related infection rates throughout the

country, coupled with the acute lack of health services in Aceh - health

infrastructure was destroyed by the disaster - experts are more than concerned.

In 1990, drug-related crimes in Indonesia accounted for between 5 percent and 10

percent of all incarcerations - but this has risen steadily ever since. " The

increase of incarcerations directly due to drugs in one form or another has gone

up 400 percent in a decade, " Gordon commented, and in some prisons in Jakarta

today it was closer to 60 percent.

There are no accurate assessments to determine the extent of drug usage, but a

visit to Aceh's Rutan Kelas IIB prison in the town of Jantho, 42km outside Banda

Aceh, is revealing. Of the 201 inmates in the facility, 150 - or 75 percent -

were jailed for drug-related offences.

" If you are talking about high risk, you're not going to find a better indicator

than that, " said Gordon, a reformed addict whose NGO now oversees seven recovery

centres and one drop-in centre.

Equally troubling is that marijuana, cheap and plentiful in the area, is now

being used in exchange for 'Shaba Shaba', or amphetamines, which can also be

injected. " Amphetamines were largely unheard of in this part of Indonesia two

years ago. The fact that people are using them now points to a much deeper

problem, and a huge risk factor, " Gordon warned.

Three young local men serving sentences for either possession or dealing at the

Rutan Kelas prison IIB were interviewed by IRIN/PlusNews. " We felt lonely after

the tsunami, " said one 24-year-old serving an eight-month sentence for

possession of marijuana. " We lost our families; we lost everything. "

All three said they knew someone who was injecting drugs - something that would

have been almost impossible two years ago. Another young man who shared his cell

with up to 15 inmates nodded in agreement. " More and more people are using drugs

- it's a way of escaping the stress. "

A WAY FORWARD

Despite some progress, there is much work to be done, but the taboo on

discussing sex or condom usage is making the task all but impossible.

" It's a matter of reaching a critical mass, " said Ip Daroesman, programme

manager with the Aceh Partnership in Health, a local NGO, which runs a facility

for the Burnett Institute, the Australian International Health Institute and

World Vision Australia. " There is a lot of misconception about how the virus is

transmitted; there is still a lot of fear. "

" Some people have such low levels of awareness that they believed whatever HIV

was actually in the area was brought in by the international community, " Rivona

added.

Ensuring that interventions are sustainable after members of the international

community have gone home is critical.

" Aceh ... is sitting on a razor's edge, because ... the number of HIV-positive

people that have been identified is relatively low, " Daroesman said. " Aceh is in

a position where its tradition can actually save it but ... you're not going to

get very far in stopping that if you can't talk about things openly and begin

educating people. "

ds/he/oa

The following article is part of a web special on HIV/AIDS in Asia. Please see:

http://www.irinnews.org/webspecials/Asia-HIVAIDS/default.asp

[ENDS]

2 - LAOS: Keeping the lid on HIV

VIENTIANE, 1 February (PLUSNEWS) - Being sexually active couldn't be more

natural for Wath Jommanevong, 27, who hopes to marry one day when he has enough

money. " I like sex. Sex is good, " he said with a grin, standing beside his

three-wheeled taxi or 'samlor' on the streets of the Laotian capital, Vientiane.

" Sometimes the sex is free. Sometimes you pay. "

Such candour was not always possible. Since the collapse of the former Soviet

Union in 1991, when commercial sex, and to a certain degree pre-marital or

non-marital sex, was suppressed by the threat of arrest or fines, Laos has

experienced a barrage of change.

The country is opening up economically and socially, altering the lifestyles of

its six million inhabitants and, increasingly, their attitudes to and

perceptions of sex.

How the government addresses those challenges will have a direct effect on the

spread of HIV.

<b>LOW PREVALENCE</b>

Laos is surrounded by countries with higher infection rates, but the nation

enjoys low prevalence, estimated by the government's Centre for HIV/AIDS/STIs

(CHAS) at less than 0.1 percent of the adult population.

Between the first reported case of HIV in 1990 and the end of 2005, 1,827 cases

of HIV infection were officially recorded, with 1,190 people still living with

the virus.

Almost 95 percent of infections occurred through heterosexual sexual

transmission, 3.9 percent from mother to child, 0.7 percent in men who have sex

with men (MSM), 0.3 percent from blood products and 0.2 percent by unsterilised

needles.

While the number of cases among the general population remains low - although

unofficial estimates assume a much higher figure - the same studies indicate

that there is little room for complacency. In 2004, prevalence rates among

commercial sex workers in the country rose to 2.02 percent, compared to 0.9

percent in 2001.

" This has increased because the knowledge of HIV among certain high-risk groups

remains low, " Dr Phouthone Southalack, deputy director of CHAS, told

IRIN/PlusNews. " Moreover, we have a much more mobile population than before,

making the risk of spreading the virus higher. "

According to CHAS, the main propellant of HIV in Laos is the so called mobile

populations, comprising sex workers, their clients, and migrant labourers, many

of whom travel outside the country or make regular trips between rural and urban

areas.

" Our government is fully aware of this and is committed to containing the

problem at this level, " Southalack said. But that may be easier said than done:

low levels of awareness, limited access to prevention and protection, including

condoms, increase the likelihood of infection rates rising in the impoverished,

landlocked nation.

KEY CHALLENGES

Laos, a largely Buddhist country, was isolated until fairly recently, but there

are now more than 180,000 Lao nationals living as registered migrants in

neighbouring Thailand, where prevalence rates among the general population stand

at 1.4 percent.

Many mobile men are potential clients of sex workers, but fail to consider

themselves as being at risk of HIV/AIDS and sexually transmitted infections

(STIs). According to UNAIDS, other factors, such as the low socioeconomic status

of women, high levels of poverty and a widening generation gap, are contributing

to the spread of HIV.

There is also a growing use of recreational drugs, particularly amphetamines. An

alarming number of sex workers are also thought to be injecting drugs, which

could substantially deepen the HIV problem. Alcohol plays a significant role in

the spread of the virus, particularly in relation to commercial sex and condom

use, while behaviour patterns among young people are changing.

" More young people in Laos are having pre-marital sex at a younger age, " said

Sythong Nouansengsy, executive director of Population Services International,

which has been advocating for safer sex and condom use since 1998. " This puts

the country's prevalence rates in danger. "

" Urban society is loosening up, " Tony of Family Health International

(FHI) agreed.

Such changing perceptions can be seen at popular meeting places and restaurants

along the banks of the Mekong River, where young patrons may pair off for more

romantic interludes afterwards - a sign of more liberal attitudes towards sex in

this otherwise conservative society.

MSM

Xay Boulommavong, peer education supervisor at the Peuan Mai or New Friend

Centre, the only facility of its kind dedicated to supporting members of the MSM

community, warned that young people, including gay men, were not only having

more sex, but more partners as well.

" There is a lot more freedom in terms of sexual behaviour in Laos than before, "

Boulommavong said. " Nowadays, everyone has a mobile phone and motorbike, meaning

everyone seems to have a network of people they can tap into, any time, any

place, for sex. "

MSM is a particularly high-risk group in need of further awareness, with condom

usage perhaps even lower than among the general population. " Some MSM have

limited understanding of HIV, and feel that if they are having sex with a man

they aren't at risk of becoming infected. That's problematic, and that's why we

are here, " said the activist.

Paramount to any successful intervention effort, however, is how to do deal with

the growing number of sex workers - an estimated 8,000 women - much to the

chagrin of the authorities. Although they work hard to keep the sex industry

under wraps, a short stroll down Setthathirat Road, in the heart of Vientiane,

reveals that this is proving all but impossible.

" I work here every night, " Ning, 22, giggled in broken English. Most of her

clients are Thai businessmen who come across the Mekong River for the weekend.

She occasionally has run-ins with the law, but she and her friends are generally

back on the street next day.

One reason cited for the increase in sex work is the upsurge in large-scale

infrastructure projects being undertaken by the government, which is eager to

open the country up for further development.

Hundreds of men, separated from their wives and families, now work for extended

periods on a variety of bridge and road projects in areas like Champasak, in the

far south, and Vientiane, in the northwest near the border with Thailand,

resulting in innumerable informal brothels sprouting up to cater to the demand.

Sex work in Laos generally takes a more subtle approach than in neighbouring

Thailand and Cambodia. It is often conducted behind the closed doors of massage

parlours or guesthouses catering for Laotian men with money, and makes access

for outreach programmes particularly difficult.

Clients in these establishments, many of whom are married, might share a drink

and food with one of the working women before retiring upstairs for sex, which

can set patrons back anywhere from US$25 to $30, a price largely out of reach to

the average man.

" If the price of sex - which is currently quite high - gets down to a level

below $5 per act, then you'll have a situation where client volume will probably

increase and you'll have the ingredients for an HIV outbreak, " said.

" The lower the price, the higher the number of partners. "

Once you start having more than two partners a night, and you have a less than

50 percent condom usage, you have a serious problem, and it is " time to ring the

alarm bell " , he commented.

At one such popular venue in Vientiane, upwards of 30 girls could be working on

any night. But, unlike their Thai counterparts across the river, they appeared

to have more control over who they went with, providing a greater capacity to

negotiate safer sex: if they did not like the customer, they were free to get up

and leave.

" I always insist on the man wearing a condom and if he refuses, I don't go with

him, " said one demure 20-year-old, who dreams of one day opening up her own

beauty parlor with the money she earns. " Sometimes I find a customer. Sometimes

I don't. " She hesitated when asked how many customers she might have in a night.

Many of the women are finding a growing number of customers. The latest round of

surveillance, undertaken in the country in 2004, showed an accelerated

transmission of HIV among sex workers in Bokeo Province in the north, bordering

Thailand, and the central, highly populated province of Savanakhet.

Bokeo has reached an HIV prevalence of 3.9 percent, while rates in Savanakhet

had risen to 3.3 percent, compared to 1 percent in 2001. Data collected in six

provinces revealed an overall increase of HIV among sex workers from 0.9 percent

in 2001 to 2.02 percent in 2004.

Equally worrying was the number of STIs reported among sex workers - ranging

from 19.9 percent to 46 percent for chlamydia and/or gonorrhoea - suggesting

that consistent condom usage remained a key challenge.

A WAY FORWARD

Pushing for consistent condom usage will require sustained interventions,

according to CHAS director Southalack. " The government is committed at the

highest level to these efforts and - given similar campaigns now taking place in

neighbouring countries - properly assisted by the international community, we

can do it. "

ds/oa/he

The following article is part of a web special on HIV/AIDS in Asia. Please see:

http://www.irinnews.org/webspecials/Asia-HIVAIDS/default.asp

[ENDS]

3 - LAOS: Regional Buddhist HIV outreach programme making an impact

VIENTIANE, 30 January (PLUSNEWS) - A unique outreach programme based on the

teachings of Buddhism is playing a significant role in supporting those living

with HIV/AIDS in Laos and other countries of the Mekong region - the Yunnan

Province of southern China, Laos, Thailand, Cambodia and Vietnam.

" A person living with HIV faces a number of challenges: there is still a great

deal of stigma towards people living with AIDS and our programme aims to address

that, " the Venerable Vichit Singhalath, President of the Lao Buddhism

Association, told IRIN/PlusNews at his office in the Lao capital, Vientiane.

Buddhism exerts considerable influence in much of South East Asia; Laos, a

nation of 6 million, is no exception.

Despite the political upheavals of the last three decades and a spreading race

towards development and modernisation, monks, nuns and temples still play a

significant role in the community, providing spiritual guidance and rituals that

mark events in the lives of individuals from cradle to cremation.

" Buddhism is deeply identified with the history and culture of people in the

region, " said Prudence Borthwick, HIV/AIDS section head for the UN Children's

Fund (UNICEF). " Monks are influential figures in rural communities and can thus

be powerful advocates for people with HIV/AIDS. "

The Metta Dhamma Project aims to mobilise monks to lead communities in HIV

prevention and AIDS care. Launched in 2001 by the Lao Buddhist Fellowship

Organisation and the Lao Front for National Construction, with support from

UNICEF and the government, it is already having an impact.

According to Singhalath, there are Buddhist organisations in every village,

which report on the specific needs of the community, and know who is

HIV-positive. " The function of the monk is to provide spiritual guidance to

those living with HIV, providing them guidance to live a happier and healthier

life. "

The Metta Dhamma Project is active in six provinces, and the capital. It

supports people with HIV/AIDS by offering home visits, meditation classes,

traditional healing ceremonies and informal counselling. At the same time, monks

conduct HIV prevention education by incorporating HIV messages into their

preaching.

While faith-based organisations are not the usual partners in HIV/AIDS care and

support, their position in society makes them powerful advocates in promoting

community understanding. " Traditional rituals provide comfort, relieve stress

and generate a sense of security in believers, " Borthwick said.

Since the first case of HIV in Laos was recorded in 1990, the figure has climbed

to 1,827 by the end of 2005, of whom 1,190 were still living with the virus.

Almost 95 percent of all infections occurred by means of heterosexual

transmission, 3.9 percent from mother to child, 0.7 percent in men who have sex

with men (MSM), 0.3 percent from blood products, and 0.2 percent by using

unsterilised needles.

Although the number of cases in the general population is low, health experts

warn there is little room for complacency - making efforts like the Metta Dhamma

Project all the more important.

The Buddhist response to HIV/AIDS throughout South East Asia is based on the

Thai grassroots model, a product of that country's struggle with a generalised

AIDS epidemic. Buddhist monks initiated prevention and care activities to assist

the sick, widows and orphans in their local communities, and have continued to

develop and provide care and prevention services since about 1992.

UNICEF Thailand began funding HIV/AIDS training for monks to expand the

grassroots response, the Sangha Metta, an NGO established in 1998. UNICEF's East

Asia Pacific Regional Office then sought to export the lessons from the Thai

experience to Xishuangbanna, Yunnan, China.

After a period of advocacy and consultation, the Chinese government and UNICEF

invited the NGO to conduct training in Yunnan from 1998 to 1999; UNICEF provided

advocacy, training and technical support to other countries in the region over

the next eight years. From 2000 to 2002, UNICEF worked with its country offices

to introduce the Buddhist Leadership Initiative (BLI) in Cambodia and Laos, and

the initiative was introduced in Vietnam, Myanmar and Mongolia between 2003 and

2004.

The BLI in all countries aims to work with the national government and religious

structures, and has accomplished the initial task of advocating successfully to

governments and senior Buddhist monks and nuns for ordained Buddhists to play a

part in the national AIDS response, and in introducing and piloting the

involvement of monks and nuns in the HIV/AIDS response at local pagoda/temple

level in five Mekong countries and Mongolia.

This has been accomplished by orientation training and advocacy events, as well

as the rollout of a regional strategy to assist monks in planning their

response, Borthwick explained, noting that monks in all countries were now

engaged in caring for people with HIV and building HIV resilience among young

people, although the number of monks and temples involved varied from country to

country.

According to UNICEF, the success of advocacy can be seen by the involvement and

cooperation of the Departments of Religion and National or Provincial AIDS

Committees - for example in China, where the Yunnan AIDS Bureau and the

Sipsongpanna Buddhist Association have worked closely together to develop a

nationally recognised model for community care and support programmes, or in

Cambodia where the authorities are working with temples at the local level to

increase access to antiretroviral (ARV) treatment for community members with

HIV/AIDS.

In Cambodia, monks are playing a growing role in ensuring access to treatment

for people with HIV/AIDS. One abbot reportedly took 17 people by boat from his

remote temple to receive ARV treatment at the nearest provincial ARV treatment

centre. In other countries, donation boxes are used to raise travel funds for

people with HIV to access treatment.

In Laos, monks are cooperating with self-help groups to provide meditation and

spiritual healing for people with HIV/AIDS, and developing an innovative

curriculum for teaching 'Buddhist Life Skills to Young People'. In Mongolia, the

newest country to join in the BLI, monks in the capital, Ulan Bator, have taken

the lead in advocacy for people with HIV and AIDS by organising a candlelight

memorial to commemorate those who had died of AIDS.

In reclusive Myanmar, the government still regards working with monks as

sensitive, but Rattana Metta, a network of eight lay Buddhist organisations, was

formed in September 2004 to initiate a coordinated response to HIV/AIDS. HIV

prevention education, based on Buddhist teaching and using a peer education

approach, was initiated in 2005 in a few townships in the capital, Yangon, and

care and support has been introduced at a regular gathering of people living

with HIV, where they can share their experiences and receive spiritual support.

The number of monks trained by the programme varies from place to place, from

around 100 in Mongolia to 12,000 in Cambodia, but efforts for further expansion

are underway. Cambodia hopes to extend its programme from nine provinces to 15

over the next five years, while Laos has expanded from three provinces to six.

In Vietnam, a pilot project in two provinces is gradually being extended.

Borthwick said the lack of funds remained a problem in scaling up, especially in

Myanmar, Mongolia and China. " These activities will be expanded to more

townships in Yangon, and to Mandalay, one of Myanmar's most heavily

AIDS-affected areas and a spiritual centre for Buddhism, if the project receives

more funding. "

ds/he/oa

The following article is part of a web special on HIV/AIDS in Asia. Please see:

http://www.irinnews.org/webspecials/Asia-HIVAIDS/default.asp

[ENDS]

4 - MYANMAR: Interview with MSF-Holland country director

YANGON, 30 January (PLUSNEWS) - 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 uis 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.

sc/oa/he

The following article is part of a web special on HIV/AIDS in Asia. Please see:

http://www.irinnews.org/webspecials/Asia-HIVAIDS/default.asp

[ENDS]

5 - MYANMAR: Uphill struggle to contain HIV/AIDS

YANGON, 1 February (PLUSNEWS) - Isolated Myanmar is grappling with one of the

worst HIV/AIDS epidemics in Asia - a struggle made all the harder by the tiny

amounts of international aid received by the military government.

Although condom use has more than tripled since 1999, and access to

antiretroviral treatment has increased markedly, HIV/AIDS services need to be

significantly scaled up, according to , UNAIDS Country Director in

Myanmar.

" The government is now taking the epidemic seriously here, but much more needs

to be done nationally to have real impact on containing the virus, " he said.

UNAIDS estimated that 360,000 people were living with the virus in 2005, and

national adult HIV prevalence stood at 1.3 percent. The official HIV/AIDS

programme has a budget of US$200,000 - just 60 US cents per person in a

population of 30 million.

The populations most at risk of contracting HIV/AIDS are sex workers, their

clients, injecting drug users, migrant workers and men who have sex with men

(MSM). There have been problems in accessing these groups, but UNAIDS points out

that more support has been forthcoming from the authorities.

An internal police directive issued several years ago said carrying condoms

could not be used as evidence of prostitution, but some anecdotes suggest this

policy has not been fully internalised at all levels. " There's still an urgent

needed to explain the importance of safe and trusting outreach activities to

so-called 'decriminalised' populations, " said.

At one of the very few drop-in centres for sex workers and MSM, outreach staff

make sure they have plenty of leaflets and condoms as they prepare to visit

three local brothels.

" There has been a definite increase in condom use over the past five years - we

have seen it, and we are working to increase it further, " said one of the

workers, who asked to remain anonymous.

The United Nations Children's Fund (UNICEF) has been working to help combat

HIV/AIDS since the early 90s. In the last five years it has significantly

expanded one project aimed at reducing mother-to-child transmission of the

virus. " But such services are still only available in less than one-third of the

country, " said Yasuda Tadashi, an HIV/AIDS project officer in the capital,

Yangon. " There is an urgent need to scale up. "

A relatively new UNICEF project in Myanmar, long-established in neighbouring

countries, involves working with Buddhist leaders to promote HIV prevention and

reduce stigma.

" It is not uncommon for villagers ... to shun a family where a member is

believed to be HIV positive, " said Tadashi. " But when a monk demonstrates that

he is happy to visit the family, and to accept food and rice from them ... this

one act does an enormous amount to reduce stigma and discrimination in that

community. "

Observers say the political situation complicates the fight against the disease.

Epidemiologist Beyrer of the s Hopkins Bloomberg School of Public

Health in Baltimore, in the US, points out that in countries such as Myanmar

" political and human rights considerations limit both what we know about HIV and

what a UN agency can say " .

A group of foreign and local nongovernmental organisations (NGOs) is now

offering a range of care and prevention services. " Well over a million people

will be assisted by the programme. We're going to work in disease hot-spots,

like the northern states, where there is high migration and high vulnerability, "

said Kirkwood, head of Save the Children Myanmar, one of the NGOs

spearheading the initiative.

Stigma and discrimination are serious impediments to fighting the epidemic. The

self-help groups that confront prejudice, common in many other countries where

HIV/AIDS is prevalent, are rarely seen in Myanmar - mainly due to the

government's dislike of any organised activity outside their control.

But the number of such groups is growing and there are now more than 30 in the

country. " The government remains suspicious of the few informal [HIV/AIDS

support] groups that do exist, " said Choo Phuah, Myanmar country director of the

International HIV Alliance. " But we are working to bring them together to form a

body that can influence the response and reassure the state that we just want to

help those with the virus. "

sc/oa/he

[ENDS]

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Subscriber: AIDS treatments

February 1, 2007