Increased hepatitis C virus co-infection and injection drug use in HIV-infected fishermen in Myanmar

Due to the mobile nature of seafaring, fishing industry communities’ close sexual networks, and their relative access to cash and income (and often, thus, the frequency with which they engage in transactional sex), fishermen have long been recognized as vulnerable to HIV infection [1‐4]. In Southeast Asia, where fisheries employ an estimated 30 million people and supply a quarter of global fish production annually, a prior review found HIV seroprevalence rates among fishing communities to be between 4.6 and 14 times higher than in the general population, ranging from 15.5% in Thailand (n = 818), 16.2% in Cambodia (n = 465), and 12.4% in Malaysia (n = 398) [5‐8]. In Myanmar, despite an abundance of coastline and fishing related economic activity, fishermen remain mostly unmonitored by HIV surveillance systems, international organizations, and national AIDS programming [9]. What’s more, the very behaviors that leave fishermen susceptible to HIV infection may also expose them to other infections such as hepatitis C virus (HCV), particularly among injection drug users [10]. This study describes the clinical, demographic, and treatment characteristics of HIV-infected fishermen attending an MSF HIV clinic, and compares their risk characteristics with non-fishermen HIV-infected males at the same clinical site. It is the first to look at this patient population in Myanmar.

This analysis establishes the clinical, demographic, and risk characteristics of a cohort of adult HIV patients about which, to date, no information has been published in Myanmar or in Southeast Asia. Occupations that demand mobility or migration are, by definition, less stable. In this case, they may also hold more health risks: Fishermen often have little access to health facilities and sources of health information while at sea, and they may be socially marginalized and endure real physical risks as part of their work. Weekly, seasonal, or long term migration is an expected part of the occupation, and close knit peer networks replacing family and community while far from home can increase the frequency of unsafe activities fishermen engage in [8].

Our results confirm that Myanmar fishermen also lead lifestyles suffused with risk, yet remain largely untargeted as a subgroup by social services and health and risk education providers in the country. Over 80% of fishermen under MSF’s care reported engaging in commercial sex (especially common in migrants away from their homes and families), which was particularly troubling since past meta-analyses have found that up to 90% of fishermen use condoms infrequently with their primary partners [14]. High risk IDU, especially among international fishermen, is also troubling in the world’s second largest opium producer (Myanmar is home to the notorious “Golden Triangle,” a major drug producing region that spans Myanmar, Laos, and Thailand) [15]. For certain occupations in Myanmar, such as miners in the north of the country, drug use is understood to be a problematic driver of morbidity, and programs target these groups with harm reduction and HIV interventions accordingly [9]. Yet fishermen in the south of the country fall almost entirely outside of these efforts, and national HIV surveillance data largely overlooks them and the Tanintharyi region in strategic documents [9]. Because of the retrospective, clinical nature of the data available for this analysis, an in-depth investigation of these factors was unavailable for this cohort and are worthy of future research. However our results make clear that HIV and harm reduction actors in Myanmar would do better to coordinate their activities to target fishermen with these programs.

Furthermore, risk factors such as IDU may be leading to increased proportions of HCV seroprevalence among fishermen. Rates seen in this analysis were higher than those found in other parts of Myanmar [16]. This is a serious issue. HCV therapies are not yet widely available in Myanmar, especially to vulnerable or indigent populations, and official guidance has only recently recommended using Direct Acting Anti-retrovirals (DAAs) rather than older, less expensive interferon based therapies that can interact with ART. Recent evidence has also suggested that people co-infected with HIV and HCV have a higher incidence of other illnesses, such as an almost two-fold risk of developing cancer [17]. The HIV/HCV co-infection rates seen in these fishermen, as well as the inter-related patterns of fishing, injecting drugs, and transactional sex, warrant further in depth study to better target HIV and HCV prevention and screening efforts, as well as better treatment of both diseases.

In Southeast Asia, the HIV epidemic is not generalized, but resides within specific higher risk groups. This analysis shows that in Myanmar, outside of the traditional CSW, MSM, and IDU risk group categories, fishermen disproportionally inject drugs, are HCV co-infected, and engage in transactional sex. Since many of these men are migrating internationally, they are of note to HIV actors across the region. A better understanding how lengths of time at sea and destinations may affect their risk for disease transmission could better target this group. Introducing systematic HCV screening and harm reduction services for fishermen in Myanmar could be important to curbing both the HIV and HCV epidemics there.