TRANSITIONS AND CHALLENGES IN HIV/AIDS PREVENTION

UNCLAS SECTION 01 OF 04 COLOMBO 000803

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: TRANSITIONS AND CHALLENGES IN HIV/AIDS PREVENTION
ACTIVITIES IN SRI LANKA


1. (SBU) SUMMARY: Though Sri Lanka is still considered a low
prevalence country for HIV/AIDS, most local HIV/AIDS experts
agree that interventions must shift from general awareness
campaigns to behavior change approaches targeted at
vulnerable and at-risk populations. Government bureaucracy,
lack of systematic data on risk behaviors, low knowledge
levels, infection rates of at-risk groups and limited
financial and human resources, however, inhibit this shift.
Stigma and related discrimination further complicate
interventions towards at-risk groups by making them
"hidden." End Summary

CURRENT SITUATION
--------------

2. (U) Statistics: According to available statistics from
the National STD/AIDS Program, the cumulative number of HIV
cases since 1986 (when the first case was identified) is

743. Ninety-eight new cases were reported within the first
nine months of 2005. Estimates of Sri Lanka's infection
rates range from 0.04% to 0.08% making it a low prevalence
country. Most HIV/AIDS experts in conservative, primarily
Buddhist Sri Lanka agree the figures are dramatically
underrepresented due to social stigma and discrimination
surrounding getting tested, as well as ignorance of the need
to be tested if engaged in unprotected sex.


3. (SBU) Janet Leno, UNAIDS country coordinator, believes
that the government erroneously attributes the low
prevalence to its general awareness campaigns and mass
communication. She instead cites Sri Lanka's relative
isolation (as an island),its comparatively low promiscuity,
an ancient tradition of non-penetrative sex (much of the
documentation on HIV/AIDS in Sri Lanka discuss the
prevalence of Kamasutric practices that would not lead to
transmission),and low intra-venous drug use as the major
factors. Nonetheless, high risk factors exist, including a
significant level of commercial sex work, especially
surrounding military camps, low condom use, high sexually
transmitted infection (STI) rates, high number of migrant
and displaced populations returning from high HIV/AIDS
prevalence regions, increasing drug use, increasingly
sexually active youth, low knowledge and awareness of
HIV/AIDS among vulnerable and underserved populations, and a
limited surveillance system for monitoring. The few studies
done by both local and international NGOs suggest a low
level of knowledge and continued risky behavior. Such
findings contradict assertions about the effectiveness of
current HIV/AIDS awareness campaigns.

STIGMA AND DISCRIMINATION PERMEATE SRI LANKAN SOCIETY
-------------- --------------

4. (SBU) Accompanying limited knowledge about HIV/AIDS is
widespread stigma and discrimination within the health
sector, the workplace, current legislation, and the media.

--Health Sector: A recent Center for Policy Alternatives
(CPA) report documents high levels of stigmatization within
the healthcare sector, but respondents noted a marked
improvement at the National STD clinic and at the Infectious
Disease Hospital (IDH),the national referral hospital.
Caregivers' lack of experience and a severe lack of
resources of dealing with the disease are often blamed for
feeding discriminating sentiments.

--Workplace: High levels of discrimination in the workplace
have resulted in 98% of those infected with HIV losing their
jobs, an issue currently being addressed by ILO's HIV/AIDS
in the Workplace Program, which was launched on July 8th,

2005.

--Legislation: No laws exist to protect the rights of people
living with HIV/AIDS (PLWHAs). Homosexual behavior is

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illegal in Sri Lanka under Section 365A of the Penal Code.
Recent efforts to decriminalize it led to a public backlash
and even more stringent anti-homosexual provisions.

--Media: The media has been critiqued in the past for
"numbers-oriented" reporting, breaches in confidentiality,
casting moral judgments on mode of transmission, and
sensationalizing AIDS as a "killer disease." Leno suggested
that the media can play an important role as an outlet for
PLWHAs to begin speaking out publicly so that the disease
becomes "normalized." Therefore, incorporation of the media
into future work would help reduce stigma and
discrimination.

SLOW GSL BUREAUCRACY JUMPSTARTED BY WORLD BANK FUNDS
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5. (SBU) National STD/AIDS Committee: Despite commendation
for its early recognition of the HIV/AIDS threat, the GSL
has made slow progress on its national AIDS policy and its
strategy plan. (Note: Its National AIDS Committee has not
met in over six months due to a vacancy in the chair. End
Note.) In addition, local HIV/AIDS activist Sherman de Rose
has criticized the committee for prioritizing a clinical
rather than a community focus and stresses the need to
diversify committee representation beyond medical doctors to
include other stakeholders.

--National AIDS Policy: The Committee still has not released
a national AIDS policy. Even though the current draft
reaffirms the GSL's commitment to critical issues such as
voluntary and confidential testing, condom promotion, and a
commitment to human rights and non-discrimination policies,
Leno felt it still needed more operational details,
particularly surrounding the provision of drugs.

--National Strategy Plan: The 2002-2006 Strategy Plan
included a long list of relevant actions, but did not
indicate priorities or the costs of implementing the various
actions, which will hopefully be rectified in the upcoming
plan for 2007-2011.


6. (U) National HIV/AIDS Prevention Project (NHAPP): The WB
pledged USD 12.6 million over five years to jumpstart
HIV/AIDS prevention activities through NHAPP. Begun in 2003,
the first component set up targeted interventions among
highly vulnerable groups to sensitize those at greatest
risk. A second round of proposals will give up to 40 grants
for community-level HIV/AIDS prevention among at-risk
populations with four larger grants to umbrella
organizations to take on entire at-risk populations in
certain locations. Funding will be used for data collection
and behavioral surveys to devise behavioral change
interventions and for capacity-building assistance to NGOs.

A SURVEY OF CURRENT INTERVENTIONS WITH AT-RISK POPULATIONS
-------------- --------------

7. (SBU) Both UNAIDS and USAID suggest that the most cost-
effective way to maintain low HIV prevalence is to provide
prevention through behavior change interventions to large
proportion of groups with highest risk behaviors. Current
interventions towards such groups include:

--Internal Migrant Workers: In 2005, partnering with a local
NGO, IOM trained peer educators in a two-day workshop. The
project found that poverty and a lack of awareness made
women traveling from rural areas particularly vulnerable.

--IDPs: No official studies on HIV/AIDS and IDPs exist as
their transitory situation inhibits follow-up. HIV/AIDS
education remains minimal, largely restricted to posters in
camps and a few youth life skills workshops in the East.

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--Overseas Domestic Workers: The Ministry of Labor Relations
and Foreign Employment (MOLRFE) currently conducts HIV/AIDS
awareness programs for women leaving for the Middle East to
work as domestic housemaids (a major source of remittance
income in Sri Lanka). Existing data suggests that this group
is possibly exploited for sex work abroad.

--Male Migrant Workers: As part of their HIV/AIDS in the
Workplace Program, ILO plans to train peer educators in 25
recruiting agencies. Indira Hettariarachchi, the National
Program Coordinator, acknowledged that behaviora change
strategies and follow-up monitoring woul be difficult with
this group because it was a one-time intervention.

--Drug Users: According to Leno, the driving force behind
HIV growth in Asia is intravenous drug use. Unofficially,
intravenous drug use has been reported, and a recent
assessment found that users engaged in risky behaviors such
as sex with multiple partners, no condoms, and casual sex.
Persecution by the police and stigma inhibit interventions
and HIV testing within this group.

--Child Sex Workers: Apparently there are no HIV/AIDS
programs in Sri Lanka targeting child sex workers. Maureen
Seneviratne, director of PEACE, an NGO that raises awareness
of the commercial exploitation of children, estimated that
at least 5,000 male children work as sex workers in beach
and mountain resort areas. According to Leno, Sri Lanka's
National Child Protection Agency (NCPA) has a good system of
identifying foreign pedophiles but the majority of child
exploitation is local and often within families.

FUTURE PROSPECTS
--------------


8. (U) USAID Funding: USAID is collecting bids for an
organization to offer capacity-building to more grassroots
NGOs and Community Based Organizations to enhance their
effectiveness in HIV/AIDS prevention activities for at-risk
groups.


9. (U) UNAIDS Activities: With a focus on risk and
vulnerability in 2006, UNAIDS activities fall under three
main categories: prevention, targeting at-risk populations,
and stigma and discrimination. UNAIDS still needs additional
funds, however, to expand to new risk groups, increase the
scale of its current interventions, support its move from
lecture-style to behavioral change-type interventions,
integrate its efforts into other health initiatives, involve
more stakeholders, and build local capacity.


10. (U) International Congress on AIDS in Asia and the
Pacific (ICAAP): From August 19-23, Sri Lanka will host the
annual ICAAP meeting, which will bring together politicians,
government officials, medical experts, academics, people
living with HIV/AIDS, community workers, and the media, to
discuss issues facing the epidemic in this region. AIDS
activist De Rose stressed the need for ICAAP topics to
extend beyond discussions of appropriate medical treatment
to include rights-based approaches, participatory methods,
and patient care.

Comment
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11. (SBU) Considering the limited impact of previous
HIV/AIDS awareness, prevention, and stigma reduction
activities, it remains to be seen if the recent policy turn
of using more targeted behavioral change strategies towards
at-risk populations will have a greater effect. The small
numbers and areas currently targeted in pilot projects speak

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to the need for greater financial, human, and technical
resources to expand programs to reach the threshold
necessary to change attitudes and behaviors. Difficulty in
follow-up for at-risk groups due to stigma and
discrimination pose greater challenges for impact
assessments. Such evaluations are necessary for policymakers
to assess the ability of their programs to hinder the spread
of HIV through behavior change. End Comment
ENTWISTLE