Mainstream HIV prevention into ‘Tsunami’ response (BMJ letter)

[Guest guest]

British Medical Journal (BMJ) rapid response article.

http://bmj.bmjjournals.com/cgi/eletters/330/7482/59#92036

Mainstream HIV prevention into `Tsunami' response

10 January 2005

Dr.Joe , Convenor, APPACHA ,

Dr.Mridula Bandyopadhyay, The University of Melbourne, 3010

The direct and indirect impact of the `Asian Tsunami' is staggering.

The latest estimates of deaths are over 146 000 (anticipated to rise

over 185 000), with over 525 000 injured, over 20 000 missing, close

to 1.6 million displaced, and over 1 million estimated homeless

(Moszynski, 2005).

The initial governmental and community response to this terrible

disaster was to organise an immediate relief operation consisting of

food, shelter and medical attention. The global response was

extraordinary. Even, aid recipient country such as India, declined

bilateral aid, so that aid could go to other needy countries and

deployed 32 warships, over 80 aircrafts, unmanned aerial vehicles and

17,500 members of the army to locate and aid the survivors and victims

and pledged US$25 million aid to the Tsunami affected neighbouring

countries.

As we are gradually moving into the next phase (the long term) of the

Tsunami disaster response, it is imperative to mainstream HIV/AIDS

prevention and care programs as part of a long term re-reconstruction

of the affected communities and individuals.

Though natural calamities do not transmit HIV, however, some of the

post disaster situations may provide a fertile environment which would

enhance vulnerability of individuals to HIV. Although, a systematic

analysis has yet to be undertaken on how natural disasters could

enhance vulnerability to HIV, based on our understandings about the

social context of HIV vulnerability, we could safely predict that the

post Tsunami situation could lead to insecure conditions, exacerbating

the spread of HIV/AIDS. The Tsunami disaster could contribute to

inadequate safe blood, shortage of clean injecting equipments for

injecting drug users, an insufficient supply of condoms and health

care; and the vulnerability of displaced people, especially women and

children to sexual abuse and violence. In addition, during the periods

of population displacement, HIV/AIDS prevention and care is often

disrupted.

The HIV epidemic presents key challenges to both humanitarian and

development assistance, and to the interface between them. The

challenges raised by the HIV pandemic in the Asia Pacific are only

beginning to be fully realised now, and HIV is clearly a massive

crisis in all the Tsunami affected areas and can be described as an

emergency.

HIV/AIDS has profound humanitarian consequences, both by directly

causing illness and death, and in terms of the wider impact it has on

societies. These consequences will develop over decades. The existing

models of humanitarian response to natural calamities may not be

appropriate in understanding and integrating an effective HIV

response. Equally, existing models of development assistance are

likely to prove inadequate in developing an HIV response.

There is ample evidence to advocate for mainstreaming an effective HIV

response to the Tsunami Disaster response. Elsey and Kutengule (2002)

defined mainstreaming HIV/AIDS into disaster relief as the process of

analysing how HIV/AIDS impacts on post disaster situations and

developing appropriate responses, including the impact of the disaster

on people who are already living with HIV/AIDS and survived the disaster.

Mainstreaming HIV programming into humanitarian responses is to

determine how each sector should respond based on its comparative

advantage. In this context the specific organisational response may

include: putting in place policies and practices that protect staff

from vulnerability to infection and support staff who are living with

HIV/AIDS, whilst also ensuring that training and recruitment takes

into consideration future staff depletion rates, and future planning

takes into consideration the disruption caused by increased morbidity

and mortality. Humanitarian organisations must ensure those infected

and affected by the pandemic are included and are able to benefit from

their activities. Agencies must also ensure that their activities do

not increase the vulnerability of the communities to HIV/STIs, or

undermine their options for coping with the affects of the pandemic.

The " Tsunami response " is now moving from the immediate humanitarian

response to developmental phase. The UNAIDS Working Definition of

Mainstreaming AIDS (2004) into development work is more illuminating

" Mainstreaming AIDS is a process that enables development actors to

address the causes and effects of AIDS in an effective and sustained

manner, both through their usual work and within their workplace " .

`Development actors' are all the people and institutions involved in

development, including all sectors and levels of government, the

business sector, civil society, and international agencies. Whilst

`usual work' is the work that development actors are supposed to do as

set forth by their mandate, mission or business interests.

Based on current experiences aimed at mainstreaming HIV/AIDS at

different levels, five simple principles have emerged that attempts to

provide a comprehensive framework to analyse where and when to

introduce and implement HIV/AIDS mainstreaming (UNADS/GTZ 2002).

Principle 1 underscores the importance of developing a clearly defined

and focused entry point or theme for mainstreaming HIV/AIDS in order

to maintain the critical focus necessary to make an impact.

Principle 2 maintains that, at the country level, mainstreaming does

not take place outside of the existing national context. Thus National

Policies or Strategic Frameworks for HIV/AIDS should be used as the

frame of reference. Mainstreaming efforts should be located within

existing institutional structures.

Principle 3 necessitates advocacy, sensitisation and capacity building

in order to place people in a better position to undertake

mainstreaming. Mainstreaming cannot be expected to develop of its own

accord.

Principle 4 asserts the need to maintain a distinction between two

domains in mainstreaming: the internal domain or workplace, where

staff risks and vulnerabilities are addressed; and the external

domain, where the institution undertakes HIV/AIDS interventions based

on its mandate and capacities in support of local or national

strategic efforts.

Principle 5 highlights the importance of developing strategic

partnerships based upon comparative advantage, cost effectiveness and

collaboration.

Tsunami response presents an opportunity to use the community links

established through disaster relief programs to ensure that men, women

and children are aware of their rights to aid which is not conditional

on accepting sexual exploitation. The long term disaster relief staff

should have access to HIV/AIDS awareness, and to train them to

opportunities to carry out HIV education as part of the overall

disaster response.

The United Nations Inter-Agency Standing Committee Task Force on

HIV/AIDS in Emergency Settings has produced a detailed guideline for

HIV/AIDS interventions in emergency settings. The purpose of this

guideline is to enable governments and cooperating agencies, including

UN Agencies and NGOs, to deliver the minimum required multi-sectoral

response to HIV/AIDS during the early phase of any emergency situation.

These guidelines, focusing on the early phase of an emergency, should

not prevent organizations from integrating such activities in their

preparedness planning. As a general rule, this response should be

integrated into existing plans and the use of local resources should

be encouraged. A close and positive relationship with local

authorities is fundamental to the success of the response and will

allow for strengthening of the local capacity in the future

Harvey (2004) analysed the relationship between livelihood and

HIV/AIDS in the context of humanitarian programming. Livelihood

insecurity due to Tsunami could increase HIV vulnerability as local

social security networks have been severely disturbed by the disaster.

Based on Harvey's and UNADS/GTZ observations the following points in

relation to humanitarian programming in the context of an HIV/AIDS

epidemic should be taken into consideration:

1. Early-warning systems and assessments need to incorporate analyses

of HIV/AIDS and its impact on livelihoods.

2. The emergence of new types and areas of vulnerability due to

HIV/AIDS should be considered in assessment. Groups such as widows,

the elderly and orphans may be particularly vulnerable, and urban and

peri- urban areas may need to be assessed.

3. Targeting and the delivery of aid must be sensitive to the

possibility of AIDS-related stigma and discrimination.

4. The HIV/AIDS epidemic reinforces the existing need for humanitarian

programmes to be gender-sensitive.

5. Emergency interventions must aim to ensure that they do not

increase people's susceptibility to infection with HIV/AIDS.

6. Food aid in the context of HIV/AIDS should review ration sizes and

types of food and assess delivery and distribution mechanisms in light

of HIV/AIDS related vulnerabilities, such as illness, reduced labour

and increased caring burdens.

7. Labour-intensive public works programmes should consider the needs

of labour-constrained households, the elderly and the chronically ill.

8. HIV/AIDS reinforces the need for health issues to be considered as

a part of any humanitarian response.

9. Support to agricultural production (including seed distribution)

and pisciculture support should recognise adaptations that people are

making in response to HIV/AIDS.

10. Micro economic impact on people living with HIV in the disaster

affected areas to be considered.

11. As part of the Tsunami disaster challenge, all the agencies must

be encouraged to explore the possibility of mainstreaming HIV

prevention into their work.

12. All long term responses must explore the possibility of

distribution of condoms, where appropriate, in line with the UNAIDS

minimum package for HIV prevention in emergencies.

13. Mainstreaming HIV response into disaster relief starts with the

concerns of the community; policy makers and institutions need to

understand these issues.

14. There is an urgent need to document the evaluation and monitoring

of mainstreaming work into Tsunami response.

15. Tsunami response must also have an enabling environment which

would provide space for sharing HIV and AIDS concerns and to propose

solutions.

16. HIV prevention and care needs to be integrated into the Tsunami

disaster needs assessment

17. Long term Tsunami response must take into account HIV prevention

and care needs of the community

18. Tsunami affected national governments must ask their national HIV

programs to assess the impact of the disaster on their HIV programs

and to respond adequately.

19. Donor agencies and humanitarian agencies must allocate line item

specific funding for integrating HIV programs into the current

humanitarian responses.

20. UNAIDS along with other key stake holders may take leadership to

establish a regional mechanism to monitor the progress of

mainstreaming HIV into humanitarian responses and for rapid diffusion

of lessons learned from each setting.

References:

Moszynski (2005) Disease threatens millions in wake of Tsunami

BMJ, 330:59 (8January), doi:10.1136/bmj.330.7482.59

IASC TF (Not dated) Guidelines for HIV/AIDS interventions in emergency

settings. The Inter-Agency Standing Committee Task Force on HIV/AIDS

in Emergency Settings

UNAIDS/GTZ (2002) Mainstreaming HIV/AIDS: A conceptual framework and

implementing principles. June 2002

Elsey, Helen & Kutengule, Priscilla (2003): HIV/AIDS Mainstreaming: A

Definition, Some Experiences and Strategies. Liverpool School of

Tropical Medicine, HEARD, DFID Ghana.

UNAIDS (2004) Support to Mainstreaming AIDS in Development

Oxfam (2001) Lessons Learnt in Mainstreaming HIV/AIDS: Oxfam, Malawi.

Harvey, P., (2004) HIV/AIDS and humanitarian action. Humanitarian

Policy Group, Overseas Development Institute. UK. April 2004

. L., (2004) HIV/AIDS and humanitarian action: Insights from US

and Kenya-based agencies. Humanitarian Policy Group, Overseas

Development Institute. UK April 2004

Harvey, P., (2003) HIV/AIDS: What are the Implications for

Humanitarian Action? A Literature Review. Overseas Development

Institute, July 2003 (draft), http://www.odi.org.uk/Food-Security-

Forum/docs/Harvey.pdf

Competing interests: Dr is the convenor of Asia Pacific

people's alliance to combat HIV and AIDS (APPACHA)