The Angel’s Care Centre at Moreh, 110 km from Imphal, Manipur, and on the border with Myanmar, one of the worst HIV-infected countries of the world, has to provide medical help not just to the over 400 People Living with HIV and AIDS (PLHA) in Moreh but to the infected of Myanmar who cross the border desperate for medical help.

The fact that Moreh is close to the Golden Triangle (Myanmar, Laos and Thailand) of the drug route, and within sniffing distance from India’s National Highway 39, has compounded the problem. Forty per cent of the Manipuri families inject drugs and there are 33,403 HIV positive in Manipur.

In fact, Manipur is one of the six HIV high prevalence states of the country with 1.13 per cent of the people infected. But in Manipur, as in the adjoining Nagaland, it is a deadly combination of alcohol and drugs in the form of tablets that the young turn to for their ‘high.’ When this fails to satisfy them, they have no qualms about injecting heroin no 4 and other drug opiates. Since a dose of heroin costs just Rs 20 in Moreh as against Rs 100 and more in Imphal, young people in this small border town resort to it when angry, depressed and even when happy and in need of celebration.

Though India is the medical destination for a range of ailments -- heart surgery to kidney transplants and corneal replacement, the treatment of HIV-infected from across the border is almost a clandestine operation. In a state like Manipur where adequate facilities are not available for treatment of the local HIV-infected population, many feel it is difficult to justify treatment of foreigners, however poor they are, coming from a country that has not been able to provide medical succour to its people.

Sachin, project coordinator of the Angel Care Centre, and Sumati, secretary of the NGO Meetei Leimarol Sinnai Sang (MLSS), Imphal, however, feel frustrated about their inability to help the very young and very sick people from across the border. Some are 20 years or even younger and others 40. They come with acute skin infection, TB and other ailments. At any given time, there are 60 to 70 patients from Myanmar and Sachin says they are HIV positive.

Many of them are farmers and daily wage labourers who buy the ART (antiretroviral therapy) medicines from pharmacies in Myanmar. They do not have reports on their CD-4 count or level of immunity because they have no access to these facilities in their own country.

Without a CD-4 count report, they cannot be given ART in Moreh. So they are treated for subsidiary ailments and sent home. Since MLSS runs a DOTS Centre in Imphal and there is high prevalence of HIV among the TB-infected, the people from Myanmar are able to access the TB medicines from Manipur. They cross the border regularly for the treatment but since they speak only Burmese, there are problems of communication.

While hospitals in Morey and even those in Imphal are in a dilemma about treating PLHA from across the border, Dr Priyo Kumar of JN Hospital, Manipur, says since the country lies on India’s border, treating patients from Myanmar is quite ethical. Besides it also helps protect Manipur’s population from the infected from across the border.

With the present support from the Global Fund for AIDS, Tuberculosis and Malaria coming to an end this March, Sachin and Sumati are worried about the future of the Angel Care Centre which has become the lifeline for over 200 PLHA. It has a 10-bedded community care centre and is providing antiretroviral therapy to 55 persons from Moreh-21 men, 32 women and two children. The ART Link Centre was set up only in November 2009. If instead of upgrading the Angel Care Centre, it has to close down, there will be a vacuum in the care and support of PLHA. They will have to travel 110 km to Imphal for treatment, says Sumati.

In Manipur, the combination of HIV with Hepatitis B and Hepatitis C is playing havoc in the lives of those infected. This phenomenon has not been seen in other parts of the country. However at the JN Hospital, one of the top hospitals for treatment of HIV, the increased risk to the life of an HIV-infected from Hepatitis B is given special attention. Hopefully other hospitals and caregivers will realise the gravity of HIV with Hepatitis and give it due importance.

There has been a small decline in injecting drug users in Manipur and now the HIV-infected are joining the network of positive people. They have gained confidence and some have even become peer educators.

Take the case of Hanglem Bimola, 40, a widow on ART, now working with MLSS as a peer educator. A graduate from Bishnupur district of Manipur, Bimola married in 1996 an injecting drug user in Imphal not knowing his HIV status and had a baby girl the following year. When she was pregnant again, her husband died. The child born in 1999 too died after three months.

Then the discrimination by her in-laws began. They would not eat food cooked by her and she had to stay in a separate room. She then went to her parents’ house and in 2001 fell ill and was diagnosed as HIV positive.

She tried to support herself and her child by selling vegetables but no one would buy her vegetables because of her HIV status. So she moved to Imphal. Bimola recalls that after she bathed in a public pond at Utlou village, people of the village held a public meeting and disinfected the pond because they feared the water was contaminated.

Then she got in touch with the NGO MLSS and soon graduated to becoming a peer educator. Now she works with the Bishnupur Network of Positive People in an Access to Care and Treatment project.

In the case of Romeo S Misao, 37, he took to drugs to gain popularity among his peers. He was only 17 then and soon got addicted to it. When his parents found out and stopped giving him money, he started stealing and selling off things at home — he even sold his blood — to be able to buy heroin. In 1994 when he fell sick he was diagnosed HIV positive.

When Misao disclosed his status, his friends began distancing themselves from him. He took to alcohol to get over the depression. After coming out of a rehab clinic, he learnt through some articles in magazines that there was life beyond HIV. He then went for psychological help. Tested for Hepatitis C/HIV, he was found positive and put on medication. Misao has joined the Network of Positive People at Senapati and his life has changed for the better.

Dr Priyo Kumar feels creating awareness and getting people to access services is the biggest challenge of the state, especially in areas that are hard to reach. The first case of HIV was seen in Manipur in 1989-90. Thereafter for a few years, many people suffered on account of common Opportunistic Infections, which could not be detected and some even led to death. Complications like cryptomeningitis, penicilliosis and toxoplasma were common.

Doctors could not diagnose cryptococcal meningitis and injection amphotericin-B was not available in Manipur. The cost of medicines was prohibitive and some HIV-infected had to spend Rs 5,000 per 100 tablets of zidovudine (retrovir).

With the introduction of HAART (highly active antiretroviral therapy) in 1996, HIV became like any other chronic manageable disease like diabetes, hypertension or arthritis but treatment was still beyond the reach of the common man. Many people ended up with incomplete regimens complicating their health profile further. Side effects were also reported.

But challenges continue to persist in Manipur. Of the six ART centres, only two are providing good service. There is a dearth of sound health professionals. In 2000, identification of HIV was still a problem especially among wives and partners of sex workers who remained unaware of their status. Also spread of the infection from mother to child continued to be a serious issue and inadequate medical infrastructure led to situations where opportunistic infections were often undiagnosed and follow-up was inadequate.