After the tsunami: HIV prevention and disaster relief

In the weeks following last December's tsunami disaster, children began showing up at medical clinics in Aceh, Indonesia, hot with fever and covered with the characteristic red rash that spells measles. The cramped tent camps where the children lived helped spread this disease, which takes a surprisingly deadly toll in populations displaced from their homes. 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 clean baby delivery supplies and materials.

She had been hired for this job. Emergency relief was once about providing food, shelter, clean water, and basic medical services. But now, supporting good reproductive health has unquestionably joined these as a top priority, partly because of HIV/AIDS. Relief experts now recognize that devastation—such as that caused by the tsunami—can heighten AIDS risk factors, making HIV prevention efforts an important 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 mass displacements of people from their homes and communities, 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."

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 and sexual violence and attend to other reproductive health needs in the midst of pressing emergencies. Over the past several years MISP has received a stamp of approval from many of the key agencies in disaster and emergency response—from the United Nations refugee agency UNHCR, to the disaster standards organization SPHERE. These top-level backers are urging relief workers to integrate simple approaches to HIV/AIDS prevention into emergency disaster assistance activities.

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 response to the tsunami also provides communities with the opportunity to develop more comprehensive HIV/AIDS prevention and education activities as part of the post-emergency response 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, meaning make 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 that less than one out of every thousand 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 the case of Thailand), and Somalia where HIV prevalence is not known. India's tsunami-stricken state of Tamil Nadu has the highest HIV/AIDS rates in the entire country; 2003 data showed that 83.8% of injection drug users and 8.8% of female commercial sex workers in this state were infected with HIV. The fear is that these rates could rise if post-tsunami hardships and stresses push survivors into drug use or other high-risk activities like commercial sex work. Untold numbers of families have lost boats, businesses, and other sources of income, and Guegan fears that the resulting poverty could also pressure women into sex work.

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. In some countries HIV rates among military personnel are 2-5 times those of respective civilian populations. The presence of soldiers could contribute to the spread of HIV/AIDS, and history has highlighted that risk. During the six years of the Ugandan Civil War, researchers found a link between the geographic pattern of AIDS and the placement of the Ugandan National Liberation Army.

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 February and early March 2005, Krause and her team from the Women's Commission conducted interviews and focus groups in Indonesia's hard-hit Aceh province. Acehnese women reported being uncomfortable living in camps with strangers. Krause's 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."

Krause found that similar stigma extended 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] didn't want to be seen as knowing."

Krause thinks that the tsunami survivors' lack of HIV/AIDS awareness and their unwillingness to even talk about HIV underscores an urgent need for AIDS prevention activities. Her team found that two months after the tsunami, condoms were not accessible. Boys said that they had to pretend to be married in order to obtain condoms. "It's unethical not to make condoms available," Krause says.

But Krause found it difficult to convince aid workers to take simple steps like making condoms available, without establishing an extensive reproductive health program. "That's what we can't get people to comprehend. They try to set up more comprehensive services," she says. "People don't think you can do something without doing something grand."

Ideas into reality

As part of a major United Nations funding appeal for tsunami relief, the United Nations Population Fund (UNFPA) in January 2005 requested US$6 million to reduce HIV transmission, implement MISP, and prevent sexual violence. This amount was a small portion of the assistance available, only 0.6% of nearly $1 billion requested.

Henia Dakkak has been working for UNFPA in Aceh. She says that her group has brought ample supplies of male and female condoms, safe baby delivery equipment, and other reproductive health materials into tsunami-affected nations. UNFPA provides these supplies in the form of pre-packaged kits tailored to the needs of small clinics and larger hospitals.

Dakkak says that cities like Banda Aceh have a particular need for the supplies because the tsunami devastated the area's pre-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 provide medical assistance. "They were thinking we have trauma, we have emergency, so let us bring the emergency things that were needed," says Dakkak. "So when it came to the basics, like having condoms, they were not available."

Taking the long view

Assistance for tsunami survivors will be required for years to come and Guegan thinks 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 in the [immediate] crisis itself," he says, referring to 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, UNFPA is now using all forms of media to spread information on preventing HIV infection. "People need to protect themselves, people need to understand the risks," says Dakkak. 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," she says. "They are open to making sure 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 antiretroviral treatment program to districts in the tsunami zone that were not previously covered. UNAIDS officials have also been visiting donors and relief agencies to promote the idea that HIV/AIDS programs should be included with regular assistance activities. This will help to avoid stigmatizing those who access the services. Aid workers are also trying to improve the aid response by considering women's safety when designing camps, as well as considering the special needs of people living with HIV/AIDS when designing food distribution programs.

If the efforts go well the tsunami response may improve HIV/AIDS programs in future disasters, conflicts, and other emergencies. Research on HIV prevention has already demonstrated that while disasters like the tsunami may have heightened HIV risk factors, they do not have to increase HIV transmission.

Leaving Aceh two months after the tsunami struck, after a tremendous outpouring of generosity from donors around the world, it was disappointing to witness families still living in tent camps with few sources of clean drinking water. Some residents were forced against their will into cramped wooden barracks. 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.