HIV (Human Immunodeficiency Virus) is an illness that comes with a lot of stigma attached. The reasons for this are many, from it being nearly untreatable when it was first discovered (it is treatable now), to the social and moral taboos that have been constructed around it, and are still actively used to discriminate against Persons Living with HIV (PLHIV) today.
As of 2020, Sri Lanka is a low-prevalent country for HIV (less than 0.1% of the general population), but there has been a gradual increase in the number of new diagnoses of HIV-infected persons reported in recent times.
The main mode of HIV transmissions in Sri Lanka occurs through unprotected sex and most frequently by unprotected same-sex relationships between males. Other communities at high risk of HIV infection, in addition to MSM (men who have sex with men) are female sex workers, the prison population, transgender persons, persons who use drugs, and tourism service providers. These at-risk populations are often called Key Populations (KPs)
The background behind Sri Lanka’s HIV/AIDs response
Sri Lanka’s HIV/AIDS response has benefited from significant support and contributions from the Government through the Ministry of Health and Indigenous Medicine’s National STD/AIDS Control Programme (NSACP), local Civil Society Organisations (CSOs), and through funding and technical support from development partners, mainly The Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM).
In 2022, the GFATM will be completing its HIV eradication drive in Sri Lanka and handing it over entirely to the Government of Sri Lanka with a list of recommendations to be implemented to smoothly spearhead HIV awareness and prevention.
NSACP Programme Director Dr. Rasanjali Hettiarachchi explained that the GFATM main role in the national HIV/AIDS response is giving funds for intervention activities with key populations and handling community-based organisations, community-based clinics, and community-based awareness, including condom distribution and linking to people to national clinics including providing funding for community-based organisations.
“Other normal activities are done by the GoSL,” Dr Hettiarachchi said. “This includes conducting clinics at the central level (42 clinics around the island) providing treatment, drugs, and laboratory facilities.”
With the GFATM ceasing activities in Sri Lanka from 2021, the Government will be stepping in to help community-based organisations with funding. Dr Hettiarachchi explained that from next year onwards, the Government is to pay for community-based organisations in five districts.
A forum organised by the Rotaract Club of Kelaniya, titled “Warada Kothanada?”, highlighted the potential gaps that may occur with this transition that will see the Government of Sri Lanka solely responsible for local HIV prevention and awareness, without the support and funding of the GFATM.
Human rights activist and journalist Kaushal Ranasinghe, who moderated the forum, explained that part of why funding systems like GFATM are being removed is because of Sri Lanka’s new status as a middle-income country, which automatically makes us ineligible for some forms of aid, something that is a growing concern, given that in recent years, Sri Lanka has seen a rise of HIV infections.
Youth Advocacy Network Sri Lanka (YANSL) Co-Founder Dakshitha Wickremarathne explained that the increase of infections can be attributed to several things, both positive and negative. One factor might be more open testing and that the outreach of services has improved, which has led to better access and more testing. The pandemic can also be a contributing factor to this increase in infections, with there being a big hit in contraception supply chains and access to pharmacies because of the lockdown, which could have led to condoms being less available, and in turn, more KPs engaging in unprotected sex.
How we currently respond to HIV/AIDS in the field
Wickremarathne explained that NSACP is a focal point in responding to HIV and AIDs with their wide network of STI prevention clinics in most district-level hospitals in the country, where anyone can go and get tested, not just for HIV and AIDs, but also for other STIs. These clinics practice awareness as well with brochures, leaflets, generic campaigns, as well as targeted campaigns for at-risk populations (sex workers, prison populations, beach boys, the gay community, the transgender community, intravenous drug users, and other similar at-risk communities).
The NSACP, the Family Planning Association (FPA), and other grantees of the GFATM also hold informal campaigns within these at-risk communities themselves, promoting awareness of HIV, how to be safe, how to get tested, and what to do if they do have HIV or AIDS. These informal campaigns include sharing posters from person to person, or sharing information digitally on social media.
Wickremarathne however noted that there are no major large-scale national-level prevention campaigns for the public like TV or newspaper campaigns. “There is some level of national effort closer to HIV day in December. At that time, all these stakeholders come together to do public awareness efforts, but apart from that there is nothing major in terms of national awareness.”
Dr. Hettiarachchi shared that on a national level, the NSACP does conduct awareness programmes in schools as well as for government workers, prisons, medical officers, Public Health Inspectors and nurses, as well as community-based lectures, skill development training, and counselling programmes.
The gaps that the transition can create
With the impending transition, which may be delayed up until 2029, or see the GFATM still contributing to Sri Lanka’s HIV/AIDS response in a limited capacity – but this is still under discussion – there is concern, especially among community-based organisations, about the gaps that can arise when it comes to how Sri Lanka continues to fight HIV and AIDs.
FPA Sri Lanka AFAO Programme Officer Sriyal Nilanka shared that a Transition Readiness Assessment report carried out by UNAIDS with the Government of Sri Lanka to understand how ready the country is to solely take on HIV and AIDs prevention, outlined several key risks that need to be considered and taken into account by the Government when responding to HIV and AIDS in Sri Lanka. A key factor is stigma and discrimination towards key at-risk populations: “MSM, female sex workers, trans persons, persons who use drugs, and tourism service providers, all of these in some level are criminalised, and based on that criminalisation there is a bias and level of stigma, around PLHIV.”
Nilanka added that this is compounded by the fact that the given information around HIV, and HIV prevention is not up to par with the treatment itself.
“The country still lives under the mentality from back in the 1990s that AIDS is deadly. People still view HIV and AIDS synonymously. When you do start speaking about your HIV status, it is attributed to AIDS and you being a deadly and infectious person. The GFATM is working on fighting this, but the Government needs to take on understanding this stigma and discrimination and understanding its layers.”
Nilanka stressed that the Government needs to work towards educating people on treatment services, and especially on treatments as prevention, and understanding that once in treatment and living with an undetectable viral load, that there is no risk of transmission.
It also needs to work toward educating people on treatment services, especially on treatment as prevention.
Moving forward
“Both personally and professionally, there need to be systems to improve the knowledge of the general public, service providers, as well as PLHIV themselves to understand the difference between HIV and AIDS, being in treatment, and prevention.” Nilanka also highlighted that there can also be prejudice within healthcare itself, which needs to be addressed, and without a proper mechanism to redress stigma and discimination, this is unable to be achieved.
Wickremarathne shared that a lot of how the Government is able to take on HIV and AIDS prevention depends on how much of the national budget can be contributed to this. “There are obviously competing issues, like cancer and other non-communicable diseases, and obviously, when the Ministry of Health allocates budgets for different programmes, it is very difficult to make sure enough resources are allocated to keep the problem under control. But we must be in a position to be able to handle it on our own. Not just financially, but also technically, because the field of HIV is constantly changing.
“A few years ago, we didn’t have PrEP (Pre Exposure Prophylaxis). This field is constantly changing with more research and date. Medicines are being produced and distributed, and we need technical expertise as well. It’s important to identify those risks and bottlenecks and form a national effort to see how we can balance these efforts out. That is the best way to go for a transition I feel. We need to have a better plan in terms of identifying risk factors and have a way of funding interventions.”
Wickremarathne explained that this is where community-based organisations can come in, because each organisation focuses on a specific community, but this depends on the level of resources each organisation has – the human resources, time, and funding. “The community-based organisations play a bigger role in making sure their respective community is safe and healthy, and if they get HIV or AIDS, that they get treatment compassionately.
“The NSACP plays a bigger role in terms of national level sensitisation, funding, advocacy and around how one being discriminated by the law can still have access to equal healthcare. It’s a shared level of work. Sometimes when we work together there are sometimes a few instances where we point fingers and say ‘you can do better or do more’, but the need of the hour is to have more of a campaign, particularly because of the pandemic.
“It’s hard to say how the pandemic has affected the spread of HIV and AIDS within the country, and based on the scientific evidence, get all partners together, and get out of the stigma of HIV and AIDS and discriminating key populations, because they are also equal human beings and have to live a happy life,” he concluded.
