Since the first case was detected in 1986, the total number reported by the end of the third quarter of 2008 was 1029 persons. As opposed to the reported numbers, the estimated numbers amount to 3800 to 4000 people living with HIV in Sri Lanka.
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| Partcipants at the 13th Annual Scientific Sessions of the Sri Lanka College of Venereologists |
Among the reported cases, nearly 84% of persons have acquired HIV through heterosexual contact and 11% through homo/bi sexual contacts, totalling 95%, who have acquired HIV through sexual exposure. The majority (80%) of them were in the 15-49 year age group.
Though the majority of HIV infections have been reported from the Western Province, patients have been reported from all districts and from all walks of life
National response
Sri Lanka has been classified as a low prevalence (that is <1% in general population and <5% among high risk groups) or a country in the latent stage of the epidemic, according to the newer classification of the HIV epidemic in Asia. Therefore, what should be the best possible national response to the HIV epidemic?
While we are in a low prevalence or latent stage of the epidemic, the generalized or mature epidemics have created devastation in other parts of the world. What is important to understand is the Window of Opportunity that we have been provided with. How best can we use this window of opportunity?
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| Dr. G.
Weerasinghe |
It is evident that the response should be urgent.
The promotional activities aimed at schoolchildren, general awareness programmes are necessary but we need to use the window of opportunity to address issues that will stop or slow down the epidemic NOW.
The response should be effective and evidence based.
The available data do not suggest the possibility of expansion of HIV epidemic through Injecting Drug Use in Sri Lanka where 95% patients have acquired HIV through UNPROTECTED sex.
Sexual behaviours among Lankans
We often like to or pretend to think that sexuality is something related to Western cultures and the people in the East are distant from sexuality. This is one major denial not only by Sri Lankan society at large, but even to some extent by the medical profession as well.
[Dr. Weerasinghe also cited numerous statistics and surveys including the Behavioural Surveillance Survey 2006-07, with regard to the average number of partners of groups such as those who attended the sexually transmitted diseases (STD) treatment clinics, three-wheel drivers, male drug users, male factory workers, beach boys, Men having Sex with Men (MSM) and female sex workers.]
The real size of the beach boy population is not known, though it is estimated to be 30,000. By definition they are sex workers. Traditional thinking is that they sell sex to foreign male tourists, but a survey done in Gampaha, Colombo, Kalutara and Galle has indicated that in reality beach boys are active bisexuals doing business with both sexes.
Clients of sex workers
Who are these clients? Where are they coming from? What are their numbers or estimates? Do they have casual sex also?
It seems that men who buy sex from women far outnumber the insignificant numbers of injecting drug users in Sri Lanka, MSM and beach boys even after considering them together.
Taken together it is estimated that 300,000 to 1 million sexually-active adult population practise high risk sexual behaviours. Casual sex is not considered here.
It is reasonable to assume that nearly one million of sexually active adults may be included in those groups.
Sexually Transmitted Infections
Sexually Transmitted Infections (STIs) are another dimension of high risk behaviours and they reflect the level of high risk behaviours that exist in society.
The association between STIs and HIV is well documented and understood. STIs facilitate both acquisition as well as transmission of HIV infection. If we consider the distribution of major STIs by age groups from 2003 to 2007 it is clear that the most affected age group is between 15 to 44 years.
The data, however, reflect only the tip of the ice-berg. The annual estimates of new episodes of STIs are between 60,000 to 200,000.
The figures of STIs are clear evidence of the extent of risky behaviours that people do have, namely unprotected sex.
In Sri Lanka, HIV transmission is driven primarily through unprotected sex be it commercial or casual, hetero or homo. When one considers the sex trade whether it is by female sex workers, male sex workers, MSM or beach boys, the key factors that facilitate the HIV transmission are: proportion of men who visit female sex workers; client/partner turnover; levels of condom use.
Condom use
The level of condom use is an important dimension. The Behavioural Surveillance Survey indicates that except for male factory workers and three wheel drivers with commercial partners, condom use among them with non-regular partners and male and female drug users with regular, non-regular and commercial partners is low.
While condom use among sex workers in casinos with clients was not up to the needed level, it was extremely low among brothel, massage parlour, street, karaoke and casino based sex workers with their non-paying partners. While the beach boys and MSM have high numbers of partners, condom use among them was extremely low with both female and male partners.
In summary, while the so-called Most At Risk Persons (MARPs) such as different categories of female sex workers, male sex workers including beach boys and MSM, have high partner turnover rates, condom use among them was low. According to estimates, the proportion of men who buy sex also seems to be considerable. Evidence indicated that migrant workers were also increasingly vulnerable in environments they were employed in other countries and especially those who were engaged in unskilled work in Middle Eastern countries.
What is needed urgently is the implementation of the single most effective intervention – the promotion of consistent use of condoms among female sex workers and their clients, MSM, beach boys and migrant workers.
One dimension is the importance of an enabling environment. While health care services and relevant stakeholders are trying to promote condoms, other arms of government are doing exactly the opposite. Certain legal provisions drive some of these high risk groups into hiding, making them inaccessible for health care delivery systems.
The effect of condom promotion on the HIV epidemic has been proven beyond any doubt in Asia and elsewhere in the world.
Promotion of condoms should be part of a comprehensive package, but centred around that single most effective intervention. Other interventions without this essential component will be of little use.
In summary: While there could be and should be the medium-term and long-term objectives and interventions to achieve those objectives, the need of the hour is an urgent and effective intervention/s to stop the upward trend of the HIV epidemic in Sri Lanka.
The single most effective intervention is the promotion of condom use to at least 60% among the above-mentioned groups. While there could be specific and targeted interventions to promote condoms among sex workers, MSM, beach boys and migrant workers, the clients of sex workers have to be reached through a condom social marketing programme.
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