Reuters - The challenges of treating TB in Myanmar - MSF

Reuters - The challenges of treating TB in Myanmar - MSF
23 Mar 2009 19:05:00 GMT
Written by: MSF in Asia

Kyi Kyi Win* holds her four-year-old daughter and sits quietly on the floor of her modest house in Dawei, southern Myanmar. Every month, she receives a visit from Min Min Oo, a health worker with the international medical organisation Medecins Sans Frontieres (MSF), who comes to check that she takes her TB treatment properly.

"It all started with pain in my stomach. Soon I couldn't eat or drink, I lost a lot of weight and became very weak," Kyi Kyi Win remembers. But despite her rapidly deteriorating health, it took nearly a month before the 29-year-old mother was diagnosed with TB and began treatment.

"First I visited a midwife who gave me two injections, which cost 3000 kyats each ($3). It's a big sum of money for me but I didn't get better. I then went to a private clinic but that didn't work either so I had to go to a second private clinic, where they gave me an X-ray which cost me another 1500 kyats. It's there I was told for the first time that I had TB."

By that time, Kyi Kyi Win had heard of the MSF clinic providing free TB treatment and care in Dawei, Tanintharyi division. She enrolled in the programme and was also diagnosed with HIV. Her four-year-old daughter is also co-infected with HIV and TB.

The story of Kyi Kyi Win is common in the poor area of Tanintharyi division. Rates of HIV and TB co-infection are high - people with HIV are particularly vulnerable to TB because of their weakened immune systems. Treatment and diagnosis of TB is often delayed because of a lack of awareness about the disease. Patients tend to seek treatment at a late stage, often exposing their relatives to the risk of infection.

MSF began treating TB in Dawei in 2004, initially for HIV/TB co-infected patients before opening its project to the general population in 2006.

TB is one of Myanmar's major health problems and the prevalence rate ranks among the highest worldwide. A new nationwide TB prevalence study planned for 2009 is likely to show even higher rates, since previous estimates were widely believed to be based on outdated indicators. Yet, despite the National TB Programme's efforts to tackle the disease, many challenges remain.

GOING PRIVATE

Although TB treatment is available for free through the National TB Programme, many patients tend to turn to private clinics, a lot of which are not subsidized by NGOs and therefore do not provide free treatment. People go to private clinics either because they believe they will receive better care or because they don't know they can access TB treatment for free. But the cost often represents a big financial burden for poor patients.

Transport is also an obstacle especially in rural areas where travel to clinics can be difficult and expensive. MSF aims to facilitate access to healthcare by paying for transport costs and providing food support to patients, which is often critical for a full recovery.

"If health structures are far away, people may turn to self-medication. You can find all sorts of TB drugs and can purchase them without prescriptions," explains MSF Medical Supervisor Dr Myo Set Aung. "This poses a critical risk of treatment failure."

The lack of information about TB also often leads to poor adherence to treatment. TB requires a treatment regimen of at least six months, which must be followed until completion. "There is often a lack of financial resources and a shortage of staff in public health facilities, and providing information to patients is often overlooked," says Dr Myo Set Aung. As a result, many patients begin their treatment and interrupt it when they get better, most of the time to seek jobs in other areas or across the border. This means there's a high chance of them developing resistance to treatment and multidrug-resistant TB (MDR TB), which requires a much longer and extremely expensive treatment.

MSF aims to address these issues by providing counseling to patients and follow-up visits at home until the completion of the drug regimen. "Our home visits help patients to keep a low profile so that they don't get stigmatized for having TB or HIV," explains Min Min Oo, who has been visiting Kyi Kyi Win monthly. "We also speak to their care taker, someone in the family who is following and helping them throughout the duration of their treatment, because it's also critical to ensure patients understand the importance of complying with the treatment properly."

In March 2008, MSF also launched an active case finding team for TB in two Dawei townships. The aim is to encourage people to seek treatment as soon as possible and provide health education and free diagnosis to the population, who can then receive treatment at the clinic. Information also helps patients to protect their families from infection.

Poor adherence to treatment and lack of awareness can have tragic consequences. "I remember a 23-year-old who interrupted his treatment to go back to work in a mine. In the end he got MDR TB and couldn't be saved," Dr Myo Set Aung says. "His entire family was infected as well. They all died, one after the other. With enough information and help to adhere to his treatment, many lives could have been saved."

MSF is about to open a new project in partnership with the National TB Programme to provide treatment for MDR TB to 100 patients in Mandalay and Yangon this year. MSF will also provide support for medical training to Ministry of Health staff on this new treatment and on counseling skills.

However, the problem of funding is a crucial point. The Global Drug Facility has granted anti-TB drugs to the National TB Programme for free since 2002, but this is likely to be stopped at the end of the year. What will happen then?

Want to know more? Check out MSF's http://www.msf.org/tbday2009/ where people with TB describe the huge problems they face in getting diagnosed and treated..
*MSF has not used her real name