336th Meeting – Tuesday, July 26th 2011

Access to HIV-Related Health Services for Minorities and International Migrants

A talk and presentation by Peter Kunstadter

 

Present: Suriya Smutkupt, Linda Markowski, Ryan Gehrmann, Meredith Weber, Potapohn Mano, Chalisa Kallaryaramitra, Thet Naing Tun, Ratawit Ouaprachanon, Sak Htoo, Guy Cardinal, Brian  Doberstyn, Daniel and Mukda Bellamy, Anchalee Singhametra, Rebecca Weldon, David Williams, Paul Hancock, John Cadet, Gonzague Jourdain, Oliver Puginier, Yupaluck Lange, Lamar and Chongchit  Robert, Gary Suwannarat, Bonnie Brereton, Fred Unger, Louis Gabaude. An audience of 28 plus a few who missed the list.     

The PHPT Access to Care Team:

Rasamee Thawsirichuchai, Wirachon Yangyernkun, Lahkela Chaw’ta, Ampha Kadnok and Peter Kunstadter With considerable assistance from Suchada Ayuman, RN, Suwimon A’pa, Pranee Klongkachonkiri and Adeline Lautissier

Program for HIV Prevention and Treatment, Chiang Mai (PHPT)

Research supported by: Global Fund to Fight AIDS, Tuberculosis and Malaria, Oxfam (UK), Thai-US Education Foundation (Fulbright)

Disclaimer: Opinions expressed are those of the authors (or at least those of PK).  They do not necessarily represent views of the funders or the Ministry of Public Health.

Summary

Our research at PHPT on HIV/AIDS is undertaken with the ultimate objectives of:

·        Preventing transmission of HIV (especially mother-to-child transmission),

·        Diagnosing infection promptly (especially among children born to infected mothers), and

·        Insuring that all infected individuals receive the services they need, including counseling, testing and treatment (especially for “marginal” populations)

We work in close collaboration with Ministry of Public Health (MoPH) health and policy personnel, and with Community Advisory Boards, to insure that our research is relevant to their needs, and to speed the incorporation of research results into practice.

Chiang Dao District, Chiang Mai Province.  We are working primarily with Chinese, Lahu and Tai Yai (Shan) populations. We selected this area and these groups for research after they had been identified by MoPH health personnel as groups in which there was relatively high known prevalence of HIV, but relatively low use of available services 

In our research we are looking at:

·        Factors or variables that we hypothesize will facilitate or constrain effective delivery and use of the services (“independent variables”);

·        Use of existing health services (especially antenatal care which is the primary entry point for HIV services) (“dependent variables”);

·        Potential solutions to problems of access to care that we identify from interviews and observations

Together with Ministry of Public Health personnel and community members we consider potential interventions to increase effective use of the services.

We start from the assumption that there are important differences in access to and effective use of health care:

·        Between ethnic groups, associated with their cultures, and

·        Between Thai citizens and non-citizens (most of whom are international migrants) because of MoPH eligibility requirements for free health services, and

·        Between individuals based on their individual characteristics which are sometimes closely linked to ethnicity and citizenship.

Because some members of the same ethnic groups we work with are Thai citizens while others are migrants, we can make controlled comparisons to tease out the effects of these two major variables of ethnicity and migration status or citizenship.

Some results of our research:  Some Major Differences between and within Communities:
There are large statistically and substantively significant differences in the distribution of socio-economic characteristics within and between ethnic groups, for example with regard to Thai language ability, education, and knowledge about HIV.

Associated with these variables there are major differences between and within groups in use of health services, such as antenatal care – and then with HIV counseling and testing services

Despite differences within and between the populations examined so far, there is substantial agreement on some major constraints to access to health services:

·        Lack of transportation to sources of service,

·        Lack of Thai language ability among patients (or lack of ability in their language among health personnel),

·        Lack of knowledge or information about illness and about the health care system

A few basics about HIV/AIDS and some good news

1. AIDS is the complex of diseases caused by the destruction of the immune system associated with infection with the Human Immuno-suppression Virus (HIV). 

2. Illness and death associated with untreated HIV infection is generally the result of “opportunistic infections or OIs” such as tuberculosis or pneumonia, and other conditions caused by the loss of the immune system.

3. Illness and death of HIV-infected individuals can now be prevented or long-delayed, and infected individuals can often live near-normal lives by taking antiretroviral medicines (ya tan virus), so that HIV-infection can now be considered to be a chronic illness, much like hypertension or diabetes, which must be managed and treated throughout life. 

4. Antiretroviral treatment is good enough so that, in successfully treated patients, the virus can no longer be detected circulating in the blood.  At this level of infection the immune system can recover, OIs can be prevented.  This means that for HIV/AIDS, as with many infectious diseases, treatment is also an important method to prevent the spread of the disease agent.

5. Methods of diagnosis of blood samples for infected patients are very accurate and can be fast (within a few hours, therefore, with a single visit to clinic or hospital),

But there is a “window period” after infection, when the virus is replicating, is not present in sizeable enough numbers in the blood to be detected by conventional means (meaning that recently infected people need to be retested after the presumed “window period”)

And rapid testing is not in wide use, patients are required to return for 2nd visit.  In the absence of rapid testing this is expensive for patients       

6. Infected infants, whose immune system is not fully developed, are at high risk of severe illness and death. 

In the past infants born to infected mothers could not be tested until they were at least 6 months old (“window period” after birth).  Meanwhile, they had to be treated to prevent OIs, fed on formula, and had to be monitored carefully for developments of fatal illnesses before they could be tested and diagnosed.  This was expensive for the parents and the health care system and dangerous for infants. 

Very young infants can now be tested by a DNA-PCR method (developed at PHPT) which requires only a few drops of blood on blotting paper.  In other words, this method of diagnosis does not require immediate access to a laboratory or transportation of fresh blood sample with a cold chain.  In turn, this means that very young infants can now be tested without requiring a hospital visit (very important in areas distant from the hospital where tests are performed, and much less expensive for the parents).

But not everyone or every facility uses these methods

7. Transmission of HIV can be prevented by using barriers (condoms, rubber gloves, etc.) when at risk of contact with blood or other body fluids

8. Transmission of HIV between mother and child during pregnancy and at time of delivery can be prevented by treating the infected mother with anti-retroviral drugs

The rate of transmission from mother to child has been reduced by this treatment from around 30% among un-treated mothers to 1-2% among treated mothers by methods developed and tested and by PHPT, and now adopted national policy by the MoPH and as the world standard by the WHO.

Transmission after birth can be prevented by feeding infant with milk formula rather than allowing breast feeding.

But not everyone uses these methods.

Health policies for HIV in Thailand

Thai national health policy now provides free or very low cost “universal health care” for all Thai citizens. Government Health Insurance covers >95% of Thai citizens.  Services for Thai citizens include pre- and post-HIV test counseling, diagnosis and treatment of HIV infections and their associated “opportunistic infections” (OIs) with antiretroviral (ARV) and antibiotic drugs

But policy does not always equal practice,

And not everyone who is eligible uses the services

And the services are not available to everyone

In part because of the cost of drugs is still high relative to treatments for other conditions, the antiretroviral treatments for Thai citizens are supported by a grant from the Global Fund to Fight HIV, Tuberculosis and Malaria under the NAPHA program,

But non-citizens are not eligible for the NAPHA Program

A “NAPHA Extension” program established a treatment program for non-citizens,

But the “NAPHA Extension” quota is much too small for all the non-citizens who need the ARV services

This is a major constraint for services for migrants

Entry into HIV/AIDS services

Antenatal care (ANC) is a primary “entry point” for HIV services

ANC services are supposed to include pre- and post-HIV test counseling and all pregnant women and their spouse or partner in Thailand including migrant women and spouse, are supposed to receive ANC information, including pre- and post-HIV test counseling

Women who deliver in hospital and have not been tested previously are supposed to be tested and treated at time of delivery

All children born to pregnant women are supposed to be tested and treated prophylactically until definitively found not to be infected

All infected children are supposed to be treated

But not all women, spouses, and children get these services

Population Movements and Control of Disease

The association of infectious disease with population movement between areas of poor vs. good public health is a worldwide phenomenon exacerbated by major disparities in economic opportunities.  Trans-border population movements, especially between countries with disparate economies complicate the problems of disease infectious control and the ‘management’ of illness including both “continuity of care for patients and data management that is essential for epidemiological control.”

MoPH recognizes that migrants, minorities and the majority population are not epidemiologically isolated from one another.  Contagious diseases, whether vector-borne, such as malaria, or transmitted directly between humans, such as HIV/AIDS, have spread and will continue to spread between these populations.

MoPH policies and practices with regard to malaria specifically recognize this: Malaria diagnosis and treatment are free for everyone from government health facilities under a “don’t ask the patients & don’t tell the police or military authorities” (but we know who you are) system.

This system has been quite successful: Almost all malaria in Thailand in the past 50 years has occurred among people who move across the borders between Thailand (where malaria is well controlled) and Burma and Cambodia (where malaria is poorly controlled), and malaria has been confined to those border areas                                                     

HIV infection is much more difficult to control than malaria for many biomedical and social- behavioral reasons:

Long asymptomatic period of HIV so infections cannot be detected or recognized by symptoms for many years after infection;

HIV is often highly stigmatized so people who are infected or think they might be infected do not want to disclose their infection

HIV infection requires life-time treatment at high direct and indirect cost to providers and patients and thus treatment is not economically feasible for low income people and countries

“Not my responsibility”                                           

Reminder: Why are we doing this research?

We are looking for constraints to effective access to and use of health services related to HIV/AIDS in order to seek ways of reducing constraints and increasing effective delivery of services.  We think there are important differences between groups in the constraints, and possibly in the potential solutions to the problems we identify and describe.  What important differences are there in access to and use of services associated with ethnicity and citizenship?  Here are some numbers from our interviews and explanations of what we think they mean.

1. Distributions of socioeconomic and demographic characteristics by ethnicity and citizenship: Number of

    Children Born to Lahu and Chinese Women in Past Five Years: Thai Citizens vs. Non-Citizens

Ethnicity of Respondents

Thai Citizens

Not Thai Citizens

Number of women

Number of Children

Children

per Woman

Number of women

Number of Children

Children

per

Woman

Lahu

193

225

1.17

71

81

1.14

Chinese

12

16

1.33

175

274

1.57

Tai Yai (Shan)

-

-

-

20

21

1.05

Fertility in Thailand has declined over the past 40 years so that number of births is now slightly less than the number of births needed to replace the current population.

Lahu and Chinese Thai citizens have lower recent fertility than non-Thai citizens;

Fertility of Lahu and Chinese citizens is coming down to approach the level of the general Thai population.

Chinese citizens and especially Chinese non-citizen women had 38% more children per mother in the past five years; Chinese citizen women had 14% more children per woman than Lahu citizen women.

Our small sample of Tai Yai non-citizens had low fertility. 

Implications with regard to HIV services: More pregnancies implies more chance for ANC, and thus more chance for HIV counseling and testing (and more chance for infected mothers to transmit HIV to children if not diagnosed and treated); as fertility declines ANC will be less effective as an entry point for HIV services and family planning will be come more important as an entry point.


2.  Woman’s Ethnicity, ANC Information, HIV Counseling and HIV Testing for Lahu and Chinese Wives and Husbands by  

     Woman’s Citizenship

Woman’s Ethnicity

Thai Citizens

Not Thai citizens

Number of Children

Did not get ANC information

Neither parent was counseled

Neither parent was ever tested

Number of Children

Did not get ANC information

Neither parent was counseled

Neither parent was ever tested

Wife

Husband

 

 

Lahu

225

1.33%

21.8%

46.7%

0.9%

  81

19.8%

48.1%

58.0%

17.3%

Chinese

  16

0.00%

43.8%

50.0%

0.0%

274

  8.0%

66.1%

28.8%

17.2%

Proportions of men who did not get ANC information are considerably higher than proportions of women;

Proportions of men and women not counseled are high, but proportions never tested are very low among citizens of both ethnic groups;

Proportions not participating in ANC and not tested are higher among non-citizens than among citizens.

Aside from ANC, are HIV tests being carried out among non-Thai speakers without the required counseling? 

  If so, does the lack of counseling contribute to the lack of accurate information about HIV?


3a.  Constraints that Caused Non-Thai Citizen Respondents to Delay or not to Get a Service they Needed: Members of Lahu Communities vs. Members of Chinese Community

Constraint, listed in rank order of proportion of non-Thai citizen Lahu women who reported it had caused them to delay or not to use health service

Non-Thai Citizen Lahu

Non-Thai Citizen Chinese

% who delayed or did not go

rank

% who delayed or did not go

Rank

Time waiting for service is too long

        95.0

    1

        25.8

   8

Lack transportation

        77.1

    2

        40.9

   6

Lack money for transport

        75.7

    3

        51.1

   1

Lack someone to accompany

        69.0

    4

        46.2

   4

Lack Thai language

        63.4

    5

        50.0

   2

Don’t know how to talk with doctor

        61.4

    6

        28.5

   7

Feared harassment from govt. official

        56.3

    7

        23.1

   9

Lack money for service or medicine

        53.6

    8

        50.0

   2

Not eligible for free service

        46.5

    9

        44.6

   5

Tried medicine from market or drugstore first

        45.1

  10

          9.7

 11

Feared prejudice/discrimination from health care providers

        43.7

  11

          3.2

 18

Feared scolding from doctor

        42.9

  12

          8.1

 13

Don’t know where to go for service

        36.6

  13

        11.8

 10

Can’t leave house or children

        32.2

  14

          8.6

 12

Seriously ill but thought not serious

        31.0

  15

          3.2

 18

Feared stigma in own society

        26.8

  16

          5.9

 14

Tried traditional method first

        25.4

  17

          4.3

 16

Didn’t know enough about illness

        22.9

  18

          2.7

 21

Didn’t think illness could be successfully treated

        18.3

  19

          3.2

 18

Lack permission from household member

        15.5

  20

          3.8

 17

Can’t leave job to get care

        14.1

  21

          4.4

 15

Transportation, money and language are important constraints in both Lahu and Chinese Non-Citizen groups.

Significantly higher proportions of Lahu Non-Citizen women reported problems than Non-Citizen Chinese women for all constraints, including time/distance, costs, language and social factors. 


4.  Woman’s Ethnicity and Acceptability of Interventions to Decrease Constraints Associated with Language and Transportation,  by Citizenship

Woman’s Ethnicity

Thai Citizens

Not Thai citizens

Would use mobile team health services

Would use translator services

Would use mobile team health services

Would use translator services

 

N

%

N

%

Lahu

188

98.4

191

99.0

Chinese

  11

91.7

  11

91.7

Cost and inconvenience of travel to sources of service and language problems are important constraints for both teams.  Mobile teams and translation services might reduce these constraints.

Mobile team and translation services are highly acceptable to both Lahu and Chinese citizens and non-citizens. 

The high level of intended use among those who say they speak Thai suggests that respondents expect translation services to provide them with something, such as social support from an ethnic sister, in addition to just interpretation.


Now that we have some quantitative data to illustrate the problems, what’s to do about the “buts”?

Major disparities with regard to people who are not Thai citizens

Assimilation helps to reduce disparities, but is slow and politically complicated, especially with frequent changes in Thai government national verification policies, the granting of ID cards and restrictions associated with the non-normal types of ID cards

Health disparities between citizens and non-citizens are not news – major funders are aware of the well-studied, well-published facts.  This is both a political and conceptual problem

Funders of health services and health service policy makers at the highest levels continue to work with 19th (or earlier) century models of ethnicity and national borders

“Self-determination of nations” with clear borders did not work in the Balkans, in part because the “nations” (ethnic groups) were not neatly sorted out into mutually exclusive geographic areas that could become ethnically pure nation-states

These days no ethnic group is isolated, homogeneous, self-contained, this is an era of trans-border population movements (probably well over 250,000,000 people are currently living in a country other than where they were born.)                   

A Myriad of “Civil Society Organizations”

There is a proliferation of CSOs addressing various issues related to migrants or minorities and health services, including HIV/AIDS.  Activities run from prevention to service provision, and humanitarian activities (i.e., in refugee camps, which may be run like semi-fiefdoms by the NGO in whose charge they have been put).  There are estimated to be 200 to 300 NGOs working on HIV/AIDS with little or no coordination between them or between them and the MoPH, and no over-all comprehensive plan for the work they are supposed to be doing.  Lack of coordination includes no consistent policy with regard to diagnosis and treatment of disease, including HIV.  Types of CSOs include: NGOs, FBOs, Foundations, Registered or not registered, International, bi-national national or local, denominational religious, non-denominational religious, non-religious.  And they are all competing for the same funding.          

Earlier this year it was rumored that the Global Fund to Fight AIDS, Tuberculosis and Malaria (= Global Fund, GF) would focus on problems of migrants, but the latest word from the GF is that Thailand will no be eligible to compete for the bulk of the funds, and will only be eligible for the vague “improvement of health services” category of funding, so we can expect no help from that quarter, either in terms of funding or guidance and coordination of international activities.                         

None of the major funders or actors is dealing effectively with health problems that transcend national borders. 

WHO doesn’t do it

Gates fund doesn’t do it (even when they are not focused exclusively on technology development)

PEPFAR doesn’t do it

MSF doesn’t do it consistently (despite their name)

USAID does a little, Rockefeller does a little

Given the global recession, it is unlikely that bilateral funders will pick up this task, but it is likely that the flow of migrants will increase. 

Conclusion??

We have suggested ways of fixing up a little bit after the problem arrives with translators and mobile teams

But why not health services where the people come from in their own languages?

We need institutional innovation on a grand scale to deal with trans-national, trans-border health problems that cannot be resolved within any single country.

Future speakers

 337th Meeting – Tuesday, August 23rd 2011

The Preah Vihear conflict and the current political debate in Thailand

A talk by Volker Grabowsky

 338th Meeting – Tuesday, September 13th 2011

Pu Sae - Ya Sae Spirit Worship: Highlighting the two sacred mountains of Chiang Mai

A talk by Reinhard Hohler

Tuesday, November 15th 2011

Fabienne Jagou, who specializes in Tibetan-Chinese history.

 

Next Meeting

337th Meeting – Tuesday, August 23rd 2011

 

The Preah Vihear conflict and the current political debate in Thailand

A talk by Volker Grabowsky

 

The paper discusses the historical background of the current conflict surrounding the disputed Preah Vihear temple which lies on the border between Thailand and Cambodia. The judgement of the International Court of Justice in 1962, which put the temple under Cambodian sovereignty, is re-examined as well as the policies of the Cambodian and Thai governments in the following decades. Special attention is given to the reactions in Thailand following the registering of the temple as a UNESCO word heritage site in July 2008. The arguments put forward by the contending political parties and currents – PAD, UDD, etc. – are also studied in some detail.

Prof. Dr. Volker Grabowsky

Universität Hamburg

Asien-Afrika-Institut

Sprache und Kultur Thailands (Thaiistik)

Edmund-Siemers-Allee 1, Ostflügel

20146 Hamburg, Germany