HIV/AIDS IN MALDIVES -- LOW PREVALENCE BUT

UNCLAS SECTION 01 OF 03 COLOMBO 000776 SIPDIS SIPDIS, SENSITIVE STATE FOR OIE DANIEL SINGER AND REBECCA S DALEY STATE FOR SA/INS E.O. 12958: N/A TAGS: TBIO KSTH ECON PREL SOCI WHO EAGR CASC MV SUBJECT: HIV/AIDS IN MALDIVES -- LOW PREVALENCE BUT WORRISOME TRENDS ¶1. (SBU) SUMMARY: Despite a low reported prevalence of HIV/AIDS in Maldives, the lack of surveillance among high risk populations and risky behavior among Maldivian drug- using youth suggest underreporting and the potential for a serious, but silent, outbreak. Even though Government of Maldives (GORM) and UN officials express interest in developing targeted, behavioral change strategies, a lack of top-level GORM support, religious and cultural sentiments,and few resources limit the number and type of interventions possible. End Summary. Surveillance: From Mandatory Testing to Informed Consent -------------- ¶2. (SBU) According to UNAIDS County Coordinator Jan Leno (resident in Sri Lanka),Maldives currently tests every pregnant woman, incoming migrant, or local resident returning after more than six months abroad. Dr. Sheena Moosa, Director of Health Services for the Ministry of Health, reported that four atolls have voluntary counseling and testing and that the surveillance procedure has now moved to informed consent. Worrisome Social Trends and HIV/AIDS Risk -------------- ¶3. (SBU) Both Moosa and Mohamed Ramez, the National HIV/AIDS Program Coordinator, perceived Maldives to be at high risk for HIV/AIDS, with the former citing recent social developments such as the rise of massage parlors (a potential source of commercial sex),private prostitution rings, and emerging intravenous (IV) drug use as causes for concern. Re-evaluating Strategy: From Sailors to Youth, From Awareness to BCC -------------- ¶4. (SBU) Shaheem, Ramez, and Dunya Maumoon, Assistant Representative for United Nations Population Fund (UNFPA) Maldives, acknowledged that the most recent HIV/AIDS cases attest that transmission now occurs more internally, between husband and wife and tourist and local, whereas before cases were confined to travelers and sailors returning from abroad. Ramez and Maumoon both championed the concept of behavioral change strategies but lack knowledge about implementation. (Note: Behavioral Change Communication strategies develop tailored health messages that are disseminated through a variety of channels, such as peer education, mass media, and counseling, in order to elicit risk-reduction behavioral change. End Note.) ¶5. (SBU) Ramez mentioned the need to sensitize high-level senior officials to the problem, as they must approve all HIV/AIDS activities but appear to believe that traditional awareness methods have been sufficient. Subsequent meetings with GORM officials at least partially confirmed Ramez's observations. Maumoon has suggested that the GORM begin marketing condoms but mentioned that several GORM departments and religious leaders remain reluctant, preferring public campaigns focused on morality and values. (Note: The government maintains tight restrictions over the media with the three major print media sources owned by government ministers or families. End Note.) Maumoon felt such attitudes reflect ignorance about the reality of youth and their behavior, particularly increased drug use. She lamented previous aversion to discussing drug abuse, which is now a serious problem. Disregard for Safety and Stigma within Healthcare System -------------- ¶6. (U) A recent healthcare management survey found that island clinics lacked good infection control, as workers failed to cap and dispose of needles properly or use gloves. COLOMBO 00000776 002 OF 003 Given the low incidence of HIV infection, doctors must be sent abroad for exposure to cases. To date, two doctors at the national referral hospital have attended training in Thailand. Ramez admitted there is still a stigma attached to HIV infection, and medical personnel still fear providing service even with precautions. Such attitudes are difficult to eliminate, he complained, given the low prevalence. Reasons for Low Prevalence: Awareness or Atoll Distance? -------------- ¶7. (SBU) According to Shaheem, most Maldivians are aware of HIV/AIDS, and previous GORM initiatives have helped stunt the spread of the disease. (Note: The 2004 Maldives Reproductive Health Survey, in which 97% reported awareness of HIV/AIDS, and other informants' observations support this conjecture about high levels of awareness, but reported promiscuity among drug users highlights a need for more in- depth research to ascertain whether awareness translates into behavior modification. Maumoon also reported that a UNFPA survey revealed that even though almost all people know about transmission precautions, less than half use condoms. End Note.) ¶8. (SBU) Ramez attributed the low prevalence of HIV to the geographical distribution of the atolls, as the physical separation of island communities slows the spread of disease. Mamooya also cited high levels of education and extensive testing and monitoring. Nonetheless, she feared numbers could be higher due to factors such as young men working away from home, high rates of serial monogamy and divorce and the drug use problem. In particular, Ramirez mentioned that little information existed on the infection rates of youth and voiced concern the some exchanged sex for drugs. Drug Use and HIV/AIDS: Alarming Bedfellows -------------- ¶9. (SBU) The recent 2003 UNDP Rapid Situation Assessment of Drug Abuse in Maldives identified several risky behaviors that put this sub-population at high-risk for HIV/AIDS. Despite a majority of drug users reporting awareness of common modes of HIV/AIDS transmissions, 73% did not perceive themselves at risk for infection, less than 30% reported condom use, and 92% reported a sexual experience in their teenage years. In addition, of the drug user respondents interviewed (202),75% reported sexual experiences with 26% of them engaging in commercial sex. Even though only 8% reported actual injection use, over half reported seeing others inject. Twenty-five percent reported knowing a friend or acquaintance with HIV/AIDS, a high number considering Maldives only has 11 official cases. Such statistics suggest that HIV/AIDS could quickly spread if an outbreak occurs in this population. Limited Funding, Limited Interventions -------------- ¶10. (SBU) Ramirez reported that finances were tight and that Maldives' low prevalence status prevented them from accessing several pots of money, such as the Global Fund through UNAIDS. The British Council funded a few media spots two years ago and UNICEF recently funded a project addressing mother-to child transmission. Currently the government sponsors one or two workshops for employees of resorts and the Department of Public Health has trained 3-4 people to do activities in the atolls, but they are not active since the have no incentive (i.e. salary). ¶11. (U) For youth, a health center in Male distributes condoms and offers counseling and access to doctors, but it COLOMBO 00000776 003 OF 003 is only utilized by a small percentage of the population, presumably in part due to its reputation as a "condom distribution center." UNFPA launched a life skills pilot project in five schools for two years, but contraceptive use can only be discussed above the age of 16. Strong religious and cultural sentiments that the discussion of such issues promotes promiscuity still prevail. ¶12. (SBU) Comment: A conservative, traditional society with a government that has a slow approach to change and reform, Maldives is at a crossroads in HIV/AIDS awareness and needs to find ways to bridge the cultural/religious divide that keeps more practical, proven techniques from being employed in its efforts to prevent this deadly problem. In particular, the absence of infection rate statistics on Maldivian drug users, recent reports of their risky sexual behavior, rising IV use, a lack of funds and governmental and religious aversion to discussing or addressing this issue suggest this group is at an increased risk for HIV/AIDS. End Comment. ENTWISTLE