Clinic on frontier of AIDS care

Center provides medicine for Chinese, needy across border in Myanmar, reports Shan Juan in Ruili, Yunnan province.

Every third month, A Yu (not her real name) an ethnic Chinese from Myanmar who has full-blown AIDS, drives for 45 minutes to visit a clinic in Ruili, Yunnan province, where she replenishes her supply of medicine and undergoes medical checkups.

The neatly dressed 33-year-old contracted the disease from her late husband, who died of AIDS in 2004, and she has been receiving free antiviral medication at the Better Clinic on Guomen Street, Ruili, Yunnan province, for seven months.

Ruili, a county-level city in Yunnan's Dehong prefecture, is a major crossing point between China and Myanmar and sits directly opposite the town of Muse on the other side of the border.

A Yu pays a toll of 2 yuan (32 cents) every time she enters China via the Ruili checkpoint. "The free treatment really helps because I can't afford to see the private doctor in Myanmar anymore. That costs 2,000 to 3,000 yuan a month. The staff members treat me well, so I'll continue to get my medication here," she said, speaking on the condition that her real name would not be used.

She's one of 47 AIDS patients from Myanmar being treated at the Better Clinic. The three-room clinic, on the second floor of the Guomen Community Health Center, employs five staff members; two doctors; a nurse; a daily operations manager; and a Chinese-Myanmarese interpreter. The walls are painted light blue and decorated with paintings depicting natural scenery, meaning the place looks nothing like a typical Chinese hospital.

Operations manager Ren Guoliang said the clinic is treating 93 HIV patients from Myanmar, and those like A Yu who have full-blown AIDS are receiving antiretroviral treatment. The local health authority pays a subsidy of 20 yuan per patient per month for the follow-up checks, which include tests for CD4 (an indicator of immunity levels) viral load (a measure of the severity of a viral infection), and HIV screening and counseling for patients' partners.

"People from Myanmar get the same service as the 68 Chinese patients at the clinic," Ren said.

Free treatment

Li Zhoulin, deputy director of Ruili's Center for Disease Control and Prevention, said that since October the Yunnan Provincial Health Authority has been providing free AIDS treatment and follow-up checks for patients from Myanmar who face financial difficulties.

The patients include the spouses of local Chinese, plus some injection drug users, or IDUs, and sex workers who cross the border frequently.

"In many cases, the treatment for patients works as a preventative measure for other people, too," Li said.

Initially, the services were only available to Myanmar nationals married to Chinese citizens, but since the start of the year the program has been extended to needy patients who visit China regularly, or work and live in the country.

However, there are concerns about the delivery of the checkup services and patient management.

"Some, particularly the IDUs and vagabonds, are hard to contact, and treatment compliance is very difficult to ensure," Li said, adding that poor compliance, which leads to heightened resistance to medicines, can be fatal.

Jia Manhong, deputy director of the Yunnan provincial CDC, said about 100 people from Myanmar are receiving free antiretroviral drugs in Ruili, and now other border towns and counties, such as Xishuangbanna, Longchuan, and Mangshi, are following suit.

Official figures show that Ruili has 7,700 people with HIV - the second-highest prevalence incidence rate in China after Liangshan in Sichuan province - and 53 percent of the sufferers come from Myanmar.

"Things appears to be getting worse," Li said, noting that of the 508 newly diagnosed sufferers in Ruili last year, 80 percent were Myanmar nationals who work in the city.

"We have to do something to reverse the trend. It doesn't matter that the people are not Chinese," he said.

Luo Guangju, a 34-year-old from Muse who married a Chinese man and moved across the border in 2005, said the services are essential and greatly appreciated.

Luo discovered she was HIV positive in 2007 when she gave birth to her daughter at a hospital in Ruili. The girl has a clean bill of health, so far.

"I've been on ARV drugs at the Better Clinic for six months. I gained some weight after the medication and feel OK now. I live in China as a wife and mother, so it's difficult for me to go back to Myanmar for treatment," Luo said, smiling diffidently.

Her husband, a welder, only tested positive for HIV in 2009, when their daughter turned 2 years of age, and has been on treatment since. "He didn't care, and we had unprotected sex," Luo said.

The couple makes about 4,000 yuan a month, according to Luo, who said, "China has better job opportunities, so I think we will stay here."

Advanced equipment

Huang Fangyan, the doctor at the Better Clinic, said HIV knows no borders, particularly given the low levels of awareness among local people.

Ruili boasts advanced medical equipment and has the capacity to treat large numbers of patients, factors that have resulted in many Myanmar nationals who live close to the border choosing to travel to the city for medical treatment, Huang said. More than 40,000 people from Myanmar enter and leave the city via the checkpoint every day, official statistics show.

According to Li, since 2009, the two countries have collaborated to curb contagious diseases such as HIV/AIDS, dengue fever, and plague (which still exists in small pockets around the world, but in a far less virulent form than the one that devastated Europe in medieval times), Li said. The increased level of cooperation has seen vulnerable groups including long-haul truck drivers, IDUs and prostitutes covered by anti-HIV/AIDS programs that include regular screening, prevention, lectures, and referrals for treatment. "Information is regularly shared between the two sides", according to Li, who added, "Preventive measures need to be undertaken, too."

Guan Yong, an AIDS patient and drug user, has been on medication for more than 12 months at the Better Clinic. The 36-year-old lives in Muse, about 500 meters from the clinic, and was diagnosed two years ago in Myanmar but had difficulty accessing treatment.

Every morning, Guan visits a methadone outlet on the ground floor of the Better Clinic to pick up the pink liquid that helps keep him away from heroin and syringes.

About 35 Myanmar nationals collect methadone from the outlet, paying the same price as Chinese, 3 yuan per day, because the treatment is subsidized by the Chinese government.

After his daily "treat", Guan heads to a studio next door. It's called the 19th Layer Club, and is run by the clinic. Ren Guoliang, who came up with the club's name, said he was inspired by Chinese legend in which Hell has 18 layers, and the deeper one goes, the more suffering there is: "The suffering of drug users is even greater than in the deepest hell, so I named the place after that."

The visitors are mainly vagabonds and drug users, according to Guan, who is fluent in Myanmarese and Chinese and works as a volunteer helping with outreach work and patient referral for Myanmar people in Ruili.

"For a variety of reasons, some of them, especially the drug users and HIV sufferers, can't go home, but they need help," he said, adding that some stay in China for better-paid work, while others are dodging the military draft.

Patients usually visit the club after getting their methadone. "They come for a chat and to rest," Guan said, adding that patients can watch TV, take a shower, or take their pick of footwear and clothing donated by local people. Although the donated items are secondhand, they're clean and serviceable.

Several blocks away at the border checkpoint, a 20-something long-haul truck driver from Myanmar appeared shocked that the result of his HIV test was positive - his face was as white as a sheet of paper.

"Can we talk later? My mom is outside and I don't want her to know," he told A Fang, the interpreter at the Better Clinic, who provides information and counseling for those who test positive at the checkpoint's clinic, run by the local Entry-Exit Inspection and Quarantine Authority.

All long-haul truck drivers entering China from Myanmar are required to undergo HIV screening under the partnership between the two countries. "Follow-up services, including treatment referral, are provided for those diagnosed with HIV," Fang said.

Deemed one of the most vulnerable groups for HIV/AIDS, the drivers "contract the virus mainly through paying for sex", she said. About 30 Myanmar-based drivers are diagnosed with HIV every month at the checkpoint. The figure, accounting for 3 percent of all truck drivers passing through the checkpoint from Myanmar, is high by international standards.

To encourage greater awareness, the drivers are provided with lectures on safe sex, HIV/AIDS preventive measures and treatment, according to Fang.

Education

Yu Caifeng heads a local NGO called Ruikangyuan, which has partnered with the CDC on a program of AIDS intervention aimed exclusively at Myanmar prostitutes in Ruili. In her view, education is key to combating the spread of the disease.

"Educating the clients works better than simply informing the prostitutes," Yu said at her office, where racks of playing cards, videos, games and Myanmar fashion magazines give the impression of a playroom. The amenities are a way of encouraging prostitutes to use the services available.

Feng Hua (not her real name), a 19-year-old from Myanmar, said she planned to watch a movie after her "training session". She followed Yu's movements diligently, repeatedly pulling out a condom, squeezing the air out of the tip, and capping it on a plastic model.

Feng receives an average of 10 clients a day, charging them 50 yuan each. "I try my best to make them wear a condom because I don't want to get infected," she said.

The HIV surveillance team estimates that Ruili has a transient population of about 200 prostitutes from Myanmar, 1.6 percent of whom have HIV, a relatively high rate of incidence, said Li Zhoulin, who added that most of the clients are Chinese.

Yu noted that most of the sex workers are in their 20s, come from poor families, and usually sell sex for three to six months in Ruili.

The prostitutes are regularly contacted by outreach workers who provide tips on preventing the spread of the disease, distribute free condoms, and conduct checkups for HIV and other sexually transmitted diseases. However, most of the women prefer to be treated in Myanmar and "we help with their referral," Yu said.

Feng was concerned because the AIDS clinic in Muse, run by the charity Medecins Sans Frontieres has stopped accepting patients, citing a shortage of drugs and limited treatment capacity.

The only exceptions are children and pregnant women, said Sanjay, who heads the clinic, which treats 1,700 patients, including 40 Chinese. "No ID is required for treatment, and patients are given code numbers to protect their identities."

Sanjay called for a further escalation of cooperation between the two countries - to ensure that a larger number of patients in the border areas receive timely treatment - and for better patient management. He noted that a new phenomenon has emerged, where some patients are receiving free drugs from both sides of the border, and suggested that a special body be established in Ruili to care for patients from Myanmar.

Li, of the Ruili CDC, endorsed the suggestion, and said he was confident the spread of the disease could be slowed via increased cross-border cooperation. However, he said China's efforts to treat patients from Myanmar are makeshift, because sooner or later most of them will be transferred to their home country for treatment.

"This is recognized by the health authorities on both sides, and accords with the wishes of most of the patients," he said. "However, these people need assistance right now, and that's our main consideration."

Contact the author at shanjuan@chinadaily.com.cn

A drug user has set up home in the fields around Ruili.