Midterm Review of the National Strategic Plan on HIV/AIDS (2011-2013)
HIV in Humanitarian Settings
Humanitarian contexts of different origins are frequently encountered in Myanmar. Myanmar is prone to natural disasters and vulnerable to the effects of climate change and conflict, impacting socio-economic progress and particularly the health infrastructure of the country. The coastal regions are frequently exposed to cyclones, tropical storms and tsunamis, while the hilly regions suffer from recurrent landslides and soil erosion. Rainfall-induced flooding is a periodic phenomenon across the country and earthquakes are likely. Myanmar has also been experiencing ongoing conflicts in Kachin State, the South-East of Myanmar, and Rakhine State, which have resulted in a significant displacement of the population. Damaged health services and infrastructure are a common consequence of humanitarian emergencies and can lead to an absent or weak health system. This includes systems for the prevention, treatment, care and support for HIV/AIDS. HIV Context: The HIV epidemic in Myanmar is concentrated, with HIV transmission primarily occurring among high-risk population groups. These key populations include female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and the clients and sexual partners of these sub-populations. For key populations, surveillance data from 2012 showed HIV prevalence in the sentinel groups at 7.1% in female sex workers, 8.9% in men who have sex with men, 18% in male injecting drug users, and 4.1% in clients of female sex workers. Further data on HIV prevalence among the sexual partners of these key populations is not well known. However, all sentinel groups have shown a considerable decrease in prevalence over the last few years1. Vulnerabilities to HIV in Humanitarian settings: Several factors heightening the risk of exposure to HIV have been highlighted during the recent humanitarian emergencies occurring in the Asia Pacific region. Humanitarian emergencies often result in disintegration of community, family life and stable relationships; an Oxfam study2 done in India post tsunami revealed that more than 20% of all respondents were engaging in sex with non-regular partners. 1
NAP; Progress Report 2012: National Strategic Plan for HIV/AIDS in Myanmar. National AIDS Programme, Reporting period: January 2012 – December 2012; Yangon, Myanmar; September 2013. 2 Oxfam field studies; Understanding the Effect of the Tsunami and Its Aftermath on Vulnerability to HIV in Coastal India, March 2007
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In such context, it has been observed that migration of people seeking new job opportunities increases resulting in a mixing of populations originated from high and low HIV prevalence areas. Engaging in high-risk behavior (i.e. sex trade for goods or services) was commonly reported notably in India, Pakistan and Nepal, as new coping mechanism to the disruption of livelihood. Several factors such as overcrowded shelters (floods, Nepal, 2008) poor water and sanitation planning (earthquake, Pakistan, 2005) and increased alcohol use (during the conflict in Sri Lanka) have been shown to further increase the exposure of women and girls to Sexual and GenderBased Violence (SGBV). Humanitarian Situations and Key Populations: There is little information available on how most at risk populations are affected by humanitarian situations. It has been reported that in certain contexts Key Populations are forced into hiding by stigma in general and also by fear of arrest due to increased security presence. Testimonies deplore shortages of supplies for substance users and inaccessibility to HIV prevention commodities for those at risk of unsafe sexual behaviour (such as condoms and post-exposure prophylaxis). Indeed Key populations are disproportionately affected by the disruption of services, notably critical HIV prevention programmes like outreach of sex workers and harm reduction services for drug users including access to clean needles, syringes, condoms, and opiate substitution therapy. Humanitarian Situations and PLHIV: Disruption of health care services may also greatly affects People Living with HIV if they lose access to treatment (ART and TB medications), care and support services e.g. food & livelihoods. A study conducted by the Asia Pacific Network of PLHIV (APN+)3 assessing the impact of the December 2004 Asian Tsunami on people living with HIV and AIDS (PLHIV) in several countries of the region “found that positive people were affected by the Asian Tsunami of December 2004. They faced increased challenges due to the Tsunami such as illness, unemployment, poverty, psychological trauma and discrimination. While many tens of thousands of non-positive people also faced these challenges, positive people were placed at increased risk due to the double impact of HIV and the Tsunami on their physical and mental health, and the isolation and discrimination they often felt from their own families and communities. The Study reported that it appears as though much of the post-Tsunami efforts related to HIV/AIDS have been focused on prevention, with only minor small-scale activities focused on existing positive people. 3
APN+; The Asian Tsunami: An analysis of its effect on people living with HIV and AIDS; March 2007; www.apnplus.org
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The non-governmental support group Myanmar Positive Group (MPG) has reported similar testimonies since it first intervened in relief operations following the Nargis cyclone. Challenges faced addressing HIV in humanitarian settings: Although progress have been made during the last decade, a lack of understanding of HIV issues is still wide spread among humanitarian actors traditionally involved in emergencies and disaster relief operations; HIV response is still absent from most national relief planning. Moreover, because of the concentrated nature of the epidemic in Asia including in Myanmar, it has proven to be very challenging to promote attention for HIV prevention, treatment, care and support during a humanitarian response, as a result of the competition with many other relief priorities. Stigma remains the main barrier for reaching out to people with greatest (HIV) needs in humanitarian settings; however this barrier can be partly overcome if community based organizations, self-help groups and agencies supporting them are fully involved in both preparedness, planning and operational response. In Myanmar, despite all encountered challenges, some self-support groups and associations have continued to be involved in providing support to PLHIV in humanitarian crises; as was exhibited during the inter-communal violence that erupted in Rakhine State in June, 2012 they, “have proven to be instrumental in ensuring continuum of care for PLHIV in acute phase of the emergency”. 4 Existing Guidelines: The 2010 revised Inter Agency Standing Committee Guidelines for HIV/AIDS Interventions in Emergency Settings5 provides coordination guidance for humanitarian actors. They are based on the understanding that all humanitarian actors involved in an emergency have a degree of responsibility to prevent and mitigate HIV and stress the fact that HIV in humanitarian context must be dealt with through a multi-sectorial approach. A field guide has been developed regionally6 to provide simplified guidance, more adapted to the Asian context (concentrated epidemic). The matrix provided in the annex is extracted from the guide; it summarizes the initial multi-sectorial response.
4 T. Htoon, K. Htin Soe, M. Thant Aung: PLHIV – Valuable actors of the humanitarian response – an experience from Myanmar; ICAAP 11, 2013 5
http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/jc1767_iasc_doc_en.pdf
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UNAIDS-RST and partners: A quick reference guide to integrating HIV in to humanitarian situations in Asia and the Pacific; Unpublished document
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Key Recommendations: In the preparation and planning stage (including at a distance from the crisis): Promote and build the capacity of PLHA self-help groups, engaging them in preparedness planning. Include commodities and medicines for addressing HIV in humanitarian settings in contingency planning and resource mobilization to be used at the onset of the emergency response. Raise awareness of HIV in humanitarian settings among key stakeholders, including the government of Myanmar, international agencies.
During the relief stage: At a minimum ensure continuity of access to essential HIV related drugs, care and support for PLHA, including the provision of PMTCT services to known pregnant women with HIV. Target key affected populations for HIV prevention services and promote interventions that safely allow them to continue to reach commodities, especially condoms and clean injecting equipment. Establish a multi-sectorial approach for prevention and response, including for sexual and gender based violence (SGBV). Ensure blood safety throughout the emergency (blood screening, universal precautions). Resume Voluntary Counseling and Confidential Testing (VCCT) services only when the situation is stabilized and comprehensive HIV services are available. Support involvement of self-help groups of PLHA in coordination, needs assessment and implementation of the HIV response and promote their access to proper funding resources. Throughout the preparation and relief stages (non-specific for humanitarian settings) Ensure confidentiality and privacy in all programs. Protect the human rights of key affected populations and PLHA. Prevent discrimination in the distribution of resources and the delivery of essential services.
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Annex – Multi-Sectoral Response to HIV in Humanitarian Settings in the First Days and Weeks7
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UNAIDS-RST and partners: A quick reference guide to integrating HIV in to humanitarian situations in Asia and the Pacific; Unpublished document.
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HIV in the Context of Return During the last decade, large numbers of Myanmar people have migrated abroad either seeking job opportunities or fleeing from conflict areas and social oppression. Many have relocated to Thailand. Among them are people who are currently living with HIV, including some that are receiving ART in their host country. In view of the recent political changes in Myanmar and taking into consideration the current trend of economic development, it is likely that the movement of migration will reverse and people may decide to return to Myanmar. In order to avoid treatment discontinuation for those returnees, the National AIDS Programme should prepare for this eventuality and establish a plan for developing treatment facilities in quantity and capacity in strategic areas to easily absorb the returnees into treatment programmes. Recommendations:8
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Adopt standardized referral procedures and formats which both sides can apply for crossborder referral of PLHA.
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Conduct up-to-date mapping of HIV treatment centers in the potential areas of return including their capacity and ART enrollment estimations and gap analysis.
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Stockpile ARV and OI drugs as a contingency for the likelihood of an abrupt influx of PLHA into the country’s HIV programmes.
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Enhance coordination between the National AIDS Programmes of Myanmar and Thailand to ensure smooth information flow from central to township level.
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Engage with PLHA self-help groups and networks in the process of planning for crossborder referral of PLHA.
Those recommendation were elaborated by participants in the 2nd Workshop of National Stakeholders of the HIV Response in Humanitarian Settings that took place in Yangon, on 13th November, 2013
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