HIV in the Aftermath

Breaking the HIV/AIDS and disaster connection

By Sheri Fink, MD, PhD*

In the province of Aceh, Indonesia, in the weeks following last December’s tsunami disaster, children began showing up at medical clinics hot with fever and covered with the characteristic red rash that spells measles. The cramped tent camps where the children had taken shelter were a catalyst for the spread of the disease, which takes an alarmingly deadly toll in displaced populations. Our team of health workers ventured out daily with national health authorities to prick arms with vaccination needles and pop vitamin A capsules—which can lessen measles complications—into tiny mouths.

As we traveled from camp to camp, the reproductive health nurse on our team found time, even in the midst of the outbreak, to identify midwives, learn about the situation of women, and distribute kits filled with obstetrical supplies and materials.

She had been hired for this job. While once emergency relief was synonymous with providing food, shelter, clean water, and basic medical services, now supporting good reproductive health has unquestionably joined these as a top priority. Part of the reason is HIV/AIDS. Relief experts now recognize that devastation—such as that caused by the tsunami—can heighten AIDS risk factors, making HIV prevention efforts a vital part of an emergency response.

“Many of the conditions that facilitate the spread of HIV are worsened in a post-disaster context,” says Yannick Guegan, who works with the humanitarian affairs department of UNAIDS, the Joint United Nations Programme on HIV/AIDS.

Guegan points to the mass displacement of people, social instability, worsening poverty due to income loss, and the influx of new populations, including reconstruction and relief workers, soldiers and transporters, as factors associated in the past with the transmission of HIV/AIDS. “The experience from other emergency situations, like in South Africa some years ago or in East Timor, has demonstrated an increased vulnerability in emergency situations, and that can change the incidence of sexually-transmitted disease, including HIV/AIDS.”

But survivors have many competing needs in the aftermath of disasters, so only simple methods of promoting HIV prevention are feasible. In the mid-1990s, aid agencies developed the Minimum Initial Service Package (MISP), a set of actions to counter HIV risk and sexual violence and attend to other reproductive health requirements in the midst of acute emergencies.

MISP addresses HIV prevention in two key ways: making condoms freely available and ensuring that medical equipment and blood for transfusion are free from infectious agents. “Anything more comprehensive than that wouldn’t really be appropriate in the first few weeks,” says Sandy Krause, who directs the reproductive health project of the Women’s Commission for Refugee Women and Children.

Krause and a colleague set out for Asia soon after the tsunami hit, visiting emergency responders in Aceh to talk about MISP and assess its implementation. The results were disappointing. Workers providing assistance on the ground often hadn’t heard of MISP and were not implementing its precepts.

Over the past several years MISP has received a stamp of approval from many of the “key players” in disaster and emergency response—from the United Nations refugee agency UNHCR to the disaster relief standards organization SPHERE. These top-level backers are urging relief workers to integrate simple approaches to HIV/AIDS prevention into emergency disaster assistance activities. They are also calling for a transition to more comprehensive HIV/AIDS prevention and education activities in the post-emergency response, taking the opportunity to help communities develop programs that will be sustainable over the long term. “The approach of the UN in the post-tsunami period is trying to develop a ‘recovery plus’ plan, making things better than they were before,” says Guegan. “We see it as an opportunity to accelerate the response to HIV.”

Understanding the risk after the tsunami

The tsunami struck low HIV-prevalence countries such as Sri Lanka and Indonesia, where UNAIDS estimates less than 1:1000 adults aged 15-49 is infected with HIV. The disaster also hit countries such as India and Thailand where adult prevalence runs higher (0.4 - 1.3% in India and about 1.8% in Thailand), and Somalia where HIV prevalence is not known. Most worryingly, India’s tsunami-stricken state of Tamil Nadu has the highest HIV infection rates in the country; 2003 data suggested that 83.8% of injection drug users and 8.8% of female commercial sex workers were HIV infected.

The fear is that these rates could escalate if post-tsunami hardships and stress push survivors into drug use and other high-risk activities. Untold numbers of families have lost boats, businesses and other sources of income. Guegan fears that resulting widespread destitution could pressure women into commercial sex work.

“In big towns like Chennai there are a lot of refugees who have been coming there after the tsunami, living in harsh conditions which may put them at risk of unsafe sexual behavior,” he says.

Sex workers will not lack potential customers. Thousands of outsiders have poured into tsunami-devastated areas to lend a hand in the reconstruction efforts, among them soldiers from around the world. Although there is no direct evidence linking military personnel to increased HIV transmission in disaster relief settings, in some countries HIV prevalence among military personnel is 2-5 times that of respective civilian populations. The presence of soldiers could logically contribute to the spread of HIV/AIDS, and history has highlighted that risk during wartime; in 1991 researchers found a link between the geographic pattern of AIDS and the placement of the Ugandan National Liberation Army during six years of civil war.

Tsunami-related HIV risks extend beyond drug use and sex work. Displaced persons’ camps and barracks, home to hundreds of thousands of tsunami survivors, pose their own threats. In hard-hit Aceh in February and early March, Krause and her team conducted interviews and focus groups. Acehnese women reported being uncomfortable living in camps with strangers and “going off to latrines that women and men share,” she says. “If there is an incident, are all the NGOs prepared to provide care for rape survivors? Basically we found none were prepared.”

Her team heard rumors of rapes. When Krause’s colleagues sought out one rape survivor they were told that her family had left the area. “The community was saying she wanted it, she wanted the sex,” says Krause. “She was isolated socially and then the family moved away.”

Similar stigma extends to HIV/AIDS. “I don’t think I’ve been anywhere where people knew less about HIV. And the stigma was so high, even people who knew [about HIV/AIDS] didn’t want to be seen as knowing.”

The tsunami survivors’ lack of HIV/AIDS awareness and their unwillingness to even discuss the subject underscores an urgent need for HIV prevention activities. Two months after the tsunami, Krause’s team found that in some areas condoms were not easily available; rather than being distributed, they sat behind the counter at health clinics. Young men reported that they had to pretend to be married in order to obtain condoms. “It’s unethical not to make condoms available,” she says.

Krause found it difficult to convince aid workers they could take simple steps like making condoms available without having to establish an extensive reproductive health program. “That’s what we can’t get people to comprehend. They try to set up more comprehensive services; people don’t think you can do something without doing something grand.”

Reproductive health training programs, for example, can wait. The first line of defense, condoms, should be made readily available, even if they cannot be actively distributed in the immediate aftermath of a disaster. “In a new emergency, there’s not time for that,” says Krause.

Ideas into reality: A slow metamorphosis

A relatively small portion of the disaster assistance pie is devoted to HIV prevention. As part of a major United Nations funding appeal for tsunami relief, the United Nations Population Fund in January requested US$6 million to reduce HIV transmission, implement MISP, prevent sexual violence, and ensure safe births. This represented a mere 0.6% of nearly $1 billion requested by fourteen United Nations and non-governmental organizations. UNFPA’s request was the only mention of HIV prevention in the entire 95-page appeal.

Still, $6 million buys quite a few condoms. Henia Dakkak has been working for UNFPA in Aceh and her group has brought ample supplies of male and female condoms, obstetric equipment, and other reproductive health materials into tsunami-affected nations. UNFPA provides these as pre-packaged kits tailored to the needs of small clinics and larger hospitals. Most recently, post-exposure antiretroviral (ARV) prophylaxis for rape survivors were added to the kits.

Places like Banda Aceh have a particular need for the supplies because the tsunami devastated the city’s existing family planning network. “They lost their offices, they lost their warehouses, they lost all their supplies,” says Dakkak.

UNFPA has even distributed condoms to militaries, including those that came to Aceh to provide medical assistance. “They were thinking we have trauma, we have emergency, so let us bring the emergency things that were needed,” she says. “So when it came to the basics, like having condoms, they were not available.”

Some UNFPA kits provide materials for HIV and hepatitis screening of blood to help avoid a tragedy like the one that resulted from Sierra Leone’s decade-long civil war, which ended in 2002. “During the war, a lot of people got infected through blood transfusions. People wanted to give blood immediately and there was no way of screening it.”

Taking the long view

Assistance for tsunami survivors will be required for years to come and Guegan says that HIV prevention and control programs will become even more important with the passing of time. “There are more risks in the [long-term] post-tsunami period than the [immediate] crisis itself,” he says, such as sexual violence and trafficking in the camps, and the long-term presence of transporters and workers in disaster-affected areas.

With the emergency phase of the tsunami disaster over, Dakkak says UNFPA is now harnessing all forms of media to spread information on preventing HIV infection, including billboards. “People need to protect themselves, people need to understand the risks,” she says. UNFPA has even turned to religious leaders in Aceh to inform the population about prevention methods ranging from abstinence to condoms, pointing out that the use of condoms is not contradictory to Islam. “We are using the mosques and the imams to talk about this,” says Dakkak. “They are open to talking about this and making sure that the community is protected.”

The influx of funding and aid workers also provides a chance to counter the risks by strengthening national AIDS programs in the tsunami-affected areas. Already UNAIDS has called on the Indian government to expand its ARV treatment program to regions hit by the tsunami that weren’t previously covered. UNAIDS officials have been visiting donors and relief agencies to promote the idea that HIV/AIDS programs be “mainstreamed” into a range of regular assistance activities, to avoid stigmatizing those who access the services and to improve each step of the aid response—from considering women’s safety when designing camps to considering the special needs of people living with HIV/AIDS when designing food distribution programs. This idea was endorsed by the humanitarian coordinating body, the Interagency Standing Committee, which in 2004 laid out guidelines for a cross-cutting, multi-sector approach to HIV/AIDS in all phases of emergency response and recovery.

If the efforts go well, the tsunami response promises to improve HIV/AIDS programs in future disasters, conflicts and other emergencies. In the past, those involved in relief work have not given sufficient consideration to HIV/AIDS and, conversely, those involved in AIDS prevention and treatment have not adequately considered refugees; few programs have involved refugees in HIV surveillance, voluntary counseling and testing, prevention of mother-to-child transmission, and ARV treatment programs. As of 2004, the Global Fund to Fight AIDS, Tuberculosis and Malaria had funded work in 23 refugee-hosting, sub-Saharan African states, and analysis by Paul Spiegel and Alia Nankoe of UNHCR revealed that only one fifth of these programs included reference to refugees.

There is also a need for research to better understand the relationships between societal disruptions and the spread of HIV. Anecdotal evidence suggests that some conflict zones, such as war-ravaged eastern Democratic Republic of Congo, are associated with an increased HIV prevalence, whilst refugee populations in Kenya, Rwanda and Tanzania, and war-affected populations in southern Sudan, Sierra Leone and Angola appear to have lower HIV rates than surrounding populations. Decreased mobility, isolation, and, arguably, better standards of healthcare and education provided in refugee camps may lie behind these differences. The results of research into HIV and its relationship with war and displacement could help guide policymakers and healthcare providers seeking ways to keep infection rates low when wars end and refugees return home.

Research on HIV prevention has already demonstrated that while disasters like the tsunami may heighten HIV risk factors, they do not have to increase HIV transmission. The knowledge and the tools to prevent HIV infection now exist in all tsunami-affected countries.

Leaving Aceh two months after the tsunami struck, knowing of the tremendous outpouring of generosity from donors around the world, it was disappointing to witness families still withering in broiling tent camps with few latrines and sources of clean drinking water. Some residents were cajoled against their will into cramped wooden barracks with paper-thin walls and rickety, hazardous stairways. Clearly the job of rebuilding real homes and restoring livelihoods remains urgent, but national governments and aid agencies have the resources to accomplish all this and more. Those involved in the recovery effort must seize the opportunity to strengthen public health structures, and ensure that prevention and care programs for HIV are not forgotten.

*Sheri Fink, M.D., Ph.D., is a freelance writer whose work has appeared in such publications as the New York Times and Discover Magazine, and the author of "War Hospital: A True Story of Surgery and Survival.”