The following article is reproduced from the SLMA NEWS + Magazine DECEMBER 2020 with kind permission from the Editorial Board of the Sri Lanka Medical Association.
Combating HIV/AIDS in the New Normal
Dr I L Jayaweera (MBBS , PG Diploma in Venereology, MD in Venereology) Acting Consultant Venereologist , Base Hospital Puttalam Each year on the 1st of December,people around the world unite to show support for people living with HIV (PLHIV) and remember those who have died from AIDS-related illnesses. Founded in 1988, World AIDS Day was the first-ever international day for global health. Every year, United Nations agencies, governments and civil society join together to campaign around specific themes related to HIV.
Global HIV statistics[1]
- 38.0 million [31.6–44.5 million] people globally were living with HIV in 2019.
- 1.7 million [1.2–2.2 million] people became newly infected with HIV in 2019.
- 690 000 [500 000–970 000] people died from AIDS-related illnesses in 2019.
According to UNAIDS, this year, the world’s attention has been focused on the impact of COVID-19 pandemic on health and how pandemics affect lives and livelihoods. COVID-19 is showing once again how health is interlinked with other critical issues, such as reducing inequality, human rights, gender equality, social protection and economic growth. With this in mind, the global theme of this yearsWorld AIDS Day is “Global solidarity, shared responsibility’’. Globally the COVID-19 crisis has exacerbated the challenges faced by people living with HIV, women and girls being key populations. These include issued in access to life-saving health care, and the crisis has widened the social and economic inequalities that increase the vulnerability of marginalized groups due to HIV. This inturnhas affected the prevention and reach out services.(1)
“Covid – 19 is showing once again how health is interlined with other critical issues, such as reducing inequality, human rights, gender equality, social protection and economic growth”
The Sri Lankan Context
Sri Lanka is a country with a low HIV prevalence (community prevalence 0.02%). Even though the estimated number of people living with HIV is around 3600, there has been a gradual increase in the number of newly reported HIVinfectedpersonsin Sri Lanka mainly due to increased uptake of testing(2). NSACP is working tirelessly with its stakeholders towards prevention and early diagnosis and treatement. In 2019 alone, 439 new HIV infections were reported, of which 359 were males.Unprotected homosexual activities accounted for the majority of HIV transmissions in 2019.
“even though the estimated number of people living with HIV is around 3600, there has been a gradual increase in the number of newly reported HIV infected persons in Sri Lanka (2)”
The graph below shows the trends of reported HIV infections in Sri Lanka by age and sex, 2011-2019.
Graph 1 – the trends of reported HIV infections by age and sex, 2011-2019. (Source – Annual Report 2019, National STD/ AIDS Control Programme)
“Three is a gradual increase in the number of infected people in the 15 – 24 age group”
According to the chart below, youth are at risk of HIV-and there is a gradual increase in the number of infected people in the 15-24 age group. Graph 2 shows the number of young people (15-24 y) newly diagnosed with HIV from 2014-2019.
Graph 2 – The number of young people (15-24 y) newly diagnosed with HIV from 2014-2019. (Source – Annual Report 2019, National STD/ AIDS Control Programme)
According to this, there is a significant rise in the reported HIV infections among the youth. Considering this important epidemic pattern, Sri Lanka adopted the theme “Youth responsibility to stop HIV”, as the AIDS Day theme for the year 2020.
The majority of the infected youth are males who are school dropouts. It is alarming to see that there is a significant proportion of people with higher education among those infected.
Adolescents and Sex in Sri Lanka
Though there are strong cultural and religious traditions against sex before marriage in the country, the age of sexual debut for both males and females has been found to be early: 15.3 years for males while for females it is a little earlier at 14.4 years.(3)According to the National Youth Survey 2012-2013, among the sexually active unmarried youth, 7.2% had two sexual partners, while 3.2% declared having three or more sexual partners during the past one year. Furthermore, 0.5% of sexually active unmarried youth had engaged in sexual intercourse with a casual partner met accidentally, and 0.7% had sex with a commercial sex partner (3). “Though there are strong cultural and religious traditions against sex before marriage in the country the age of sexual debut for both males and females has been found to be early: 15.3 years for males while for females it is a little earlier at 14.4 years” The findings of the National Survey for Emerging Issues among Adolescents in Sri Lanka (2004) report that a significant number of adolescents are sexually active. Among school-attending adolescents, about 6 % had engaged in sexual intercourse with the opposite sex, and 10 % had engaged in sexual intercourse with persons of the same sex. Among out-of-school adolescents, sex with the opposite sex was more common (22%), while a few (9%) had had sexual contacts with persons of the same sex. Most of those who engaged in heterosexual acts had had sex while in a relationship with their partners, but few (12%) had had sex with commercial sex workers. During such sexual activities with the opposite sex, a low number of adolescents (39%) had reported the use of condoms (4).
Even though some components of age appropriate sexuality education is available in the school curriculum, life skills and behavioral changes related to these subjects are not adequately addressed in Sri LankaMany factors make young people vulnerable to acquiring HIV. Their knowledge on sexually transmitted infections (STIs) including HIV are inadequate (5) and they lack the necessary life skills to avoid risky behaviors in order to prevent being infected with STIs and HIV. In the current context of the COVID-19 pandemic, young people study or work from home and are isolated from their peers. This gives enough opportunities for them to use technology including mobile phones and form new relationships with unknown or casual partners through the internet or various mobile applications (e.g. Facebook, Tinder or Grinder).Drug abuse is identified as a significant problem in this age group. These factors may lead them to engage in high-risk sexual behaviors.In addition, young people still face substantive challenges to access HIV and sexual and reproductive health services due to stigma. “Their knowledge on sexually transmitted infections (STIs) including HIV are inadequate and they lack the necessary life skills to avoid risky behaviours in order to prevent being infected with STIs and HIV” Young people should be the principal beneficiaries of HIV prevention strategies such as comprehensive sexual health education and life skills development. Through increased access to age-appropriate sexual health education, STIs including HIV, unintended pregnancies, gender-based violence (GBV) and gender inequality can be minimized.
Ending AIDS and Way forward
After achieving Elimination of Mother To Child Transmission (EMTCT) of HIV and syphillis in 2019, The National STD/AIDS Control Programme, Ministry of Health along with other stakeholders plan to end AIDS as a public health problem in Sri Lanka by the year 2025 five years earlier than the global target.
In order to end AIDS the following 90-90-90 targets to be achieved by 2022.
- 90% of all People Living with HIV(PLHIV) know their status.
- 90% of all PLHIV diagnosed receive Anti Retroviral Therapy(ART).
- 90% of all people on ART have viral suppression.
“Also about 1/3 of newly reported HIV infected patients are in advanced AIDS stage and indicating that there had been missed opportunities with past health care encounters”
The current status of 90-90-90 targets in Sri Lanka is shown in figure 1.
Figure 1 – Current status of 90-90-90 targets in Sri Lanka against the target by 2022 target (Source- Annual report 2019, NSACP.)
It is of paramount importance to increase testing and reduce stigma and discrimination. Also about 1/3 of newly reported HIV infected patients are in advanced/AIDS stage and indicating that there had been missed opportunities with past health care encounters. Therefore, it is imperative to test and diagnose those suspect of HIV infection early. The annexed chart in page …. shows clinical indications for HIV testing.
Blood tests to detect HIV are being performed free of charge while maintaining confidentiality at STI clinics and main hospitals throughout the country. Rapid HIV anitigen and antibody combo tests which gives a good result within 20 minutes also available. Young people are also provided with risk reduction counselling and behavioral change counselling to maintain their positive behaviors when they come for testing services
Services available at National STD/AIDS Control Programme (NSACP)for PLHIV
- Providing counselling, testing, treatment, care & support including anti-retroviral therapy (ART) and management of opprtunisticInfections
- Currently, there is no cure but the virus can be controlled effectively.Early initiation of drug therapy (ART) will make the virus undetectable in the blood. With good adherence to ART, PLHIV can live a near-normal life.
- When the viral load is undetectable with treatment, the risk of transmission with unprotected sex is zero
- Provision ART for Occupational Post Exposure Prophylaxis (PEP) and Pre Exposure Prophylaxis(PrEP).
- Prevention of mother to child transmission of HIV.
- Public health campaign for high risk and vulnerable populations to address thepreventive strategies like primary prevention and promotion of safer sex practices.
How to refer and contact NSACP
There is an island-wide network of STD and Sexual health clinics, anyone can walk in for clinic services. Routine referral by a health care person is not required. For further information please visitwww.aidscontrol.gov.lk. For more details on testing visitwww.know4sure.lk , hotlines 0112667163 /0710533633 or contact the local STD clinic around your area.
References
- https://www.unaids.org/en/World_AIDS_Day
- National STD/ AIDS Control Programme, Annual Report 2019, 2020 Available from: https://aidscontrol.gov.lk/images/pdfs/publications/NSACP_Annual-Report_2019.pdf
- Family Health Bureau. National Youth Health Survey 2012/2013, Sri Lanka. 2015.
- Thalagala N, Rajapakse L. National Survey on emerging issues among adolescents in Sri Lanka. Colombo, UNICEF [Internet]. 2004; Available from: http://www.unicef.org/srilanka/Full_Report.pdf
- Kanda, Koji & Obayashi, Yoshihide & Jayasinghe, Ananda & Silva, Tudor & Lee, Romeo & TAMASHIRO, Hiko. (2010). Current HIV/AIDS Knowledge, Perceptions and Practices among the General Population in Kandy, Sri Lanka: Program Implications. Kokusai Hoken Iryo (Journal of International Health). 11-19. 10.11197/jaih.25.11.