28 November 2013

Timor-Leste in danger of moving from "low-level" HIV/AIDS epidemic to "higher prevalence" as public health policies fail

ETLJB 28 November 2013 -A review of the East Timor Health Sector Response to HIV/AIDS and STI program was conducted from 18 February 2013 through to 01 March 2013 by Dr. Po-Lin Chan, Mr. Freddie Mawanda, Ms. Ravipa Vannakit and Dr. G. Weerasinghe with the support of WHO and USAID.

ETLJB has previously published critiques of the HIV/AIDS public health policy in East Timor previously and statistics have shown an increasing number of HIV infections in recent years. (See also the links to posts at the end of this article.)

While most developed nations formulated public health policies, laws and public education programs early in the stages of the HIV/AIDS epidemic which have been very successful at reducing and minimising the transmission of HIV as well as developing drug treatments and availability that have rendered HIV practically a manageable chronic illness rather than a fatal disease, the report on the review of East Timor's health sector response has highlighted numerous deficiencies and that there is a growing trend that the HIV epidemic may be evolving from “low-level” to higher HIV prevalences.

Some observations in the report are worth noting. For example, the report states that "[s]ex between men is not uncommon.

Unprotected anal sex carries a high risk of HIV and STI infection, beside vaginal sex and needle use/injecting drug use. In the 2004 study, 12% of soldiers and taxi drivers, and 5% of male students, had anal sex with another man in the previous year. Over 40% of those men had also recently had sex with a woman. The authors noted that irrespective of how people think of themselves as heterosexual, homosexual or transgender, they are in practice behaviorally bisexual. These “bisexual” individuals can act as a bridge by which HIV and STI can pass from groups with higher risk behaviour to others with lower risk behaviour (termed “sexual mixing”). (at page 46).

Next, the report notes that "despite the increasing coverage of prevention interventions for both FSWs and MSMs including the related groups of clients of sex workers and an emerging at-risk group of ‘clients of MSM’ - quality of prevention interventions is inadequate. This is reflected by inconsistent condom use across the at-risk groups, very low risk perception for HIV and STI infections including inadequate knowledge of where to access condoms when the need arises. Sexual mixing i.e. at-risk groups and MARPs (Most At Risk Populations) having multiple partnerships, regular and casual partners including ‘lower risk’ partners such as wives, increases the risk of HIV and STI transmission within the population. (at page 47).

It also reports that "[l]evels of unprotected vaginal and anal intercourse are high among sex workers, with only 16% and 12% of women using condoms 100% of the time for vaginal and anal intercourse, respectively, with a paying client in the previous 12 months." (page 44)

In regard to condom use, the report finds that:

"Stakeholders report that a major challenge in the promotion of condom use is religious sensitivities, with resultant conflicting messages. This finding is apparent also in discussions with MARPs who belong to the religion. The MOH and NAP have engaged faith-based leaders and the Church in lengthy discussions, and the consensus seemed to follow the edict of Pope Benedict XVI which is “it is acceptable to use a prophylactic when the sole intention was to ‘reduce the risk of infection’ from AIDS. Contraception interferes with the creation of life, but using a condom to preserve life and avoid death could be a responsible act – even outside marriage”. This messaging, however, has not been widely disseminated and thus confusion reigns within service providers and community what the appropriate message should be."

There is no allocated budget for HIV prevention activities within the prison system. (page 49)

The report concludes, inter alia, that "[t]he growing body of data available on HIV/STI in the last few years suggests that the HIV epidemic may be evolving from “low-level” to higher HIV prevalences, possibly in geographical “pockets” and sub-groups of the population. Risk behaviours exist and unsafe sex is occurring across sub-groups within the population. Untreated STIs particularly within at-risk groups constitute an emergency which need attention and action. STI and HIV are symbiotically-related: they accelerate the transmission of one another."

It recommends, among other things, "[p]rotection of human rights and stigma/discrimination: Strengthen stigma and discrimination laws and policies including redressal mechanisms and protection for PLHIV and MARPs (including injecting drug users, men who-have-sex-with men, sex workers).

One of my principle objections to this report is the use of the term "men who have sex with men" as constituting one of the "Most At Risk Populations" and the abject failure to identify homosexual men as a separate "Most at Risk Population". I have raised this criticism in previous commentaries as an exercise in obscurantism and pandering to the deep seated homophobia on East Timorese society.

Men who have sex with men are not necessarily homosexual or do not identify as homosexuals. Some of the men who have sex with men referred to in this report have wives and families whereas homosexual men do not. Men who have sex with men do not engage in as much homosexual activity as homosexual men and therefore constitute a "less-at-risk" population than homosexual men. The failure to distinguish these two groups in policies and education programs is a fundamental failure of the report and of the government's public health policy on HIV/AIDS.

Those men who have sex with men who have wives need different counselling and education than men who just have sex with other men. Wives need to be educated about the risk of their husbands engaging in high-risk unprotected sex with other men (whether their sexual partners be "men who have sex with men who are not homosexuals" or homosexuals) and those women obviously face much higher risks of infection from their husbands who have unprotected sex with other men.

As for the recommendation regarding protection of human rights and stigma/discrimination and the strengthening of  stigma and discrimination laws and policies including redressal mechanisms and protection for PLHIV and MARPs (including injecting drug users, men who-have-sex-with men, sex workers); this is pathetically short on detail and fails to realise that there are no existing discrimination laws and policies or protections for PLHIV or "MARPS"; in particular, homosexual men and women. There are no laws protecting PLHIV or homosexuals from discrimination or vilification. There are no "redressal" mechanisms. Furthermore,there is no discussion in the report at all of homophobia and how homophobia contributes to the transmission of HIV/AIDS or how public policy and laws should resolve the social problem of homophobia. This is a critical failure in the report and a reprehensible omission by the researchers.

Reference: East Timor Health Sector Response to HIV/AIDS and STI 18 February 2013- 01 March 2013 by Dr. Po-Lin Chan, Mr. Freddie Mawanda, Ms. Ravipa Vannakit and Dr. G. Weerasinghe. This article written by by Warren L. Wright

The full report may be dowloaded from here 

Post Script
On 22 October 2013, the Government of East Timor at the meeting of the Council of Ministers approved  Law Decree that approves the creation of the Timor-Leste's National Commission for Combating HIV/AIDS (CNCS-TL) and its Statute

This law approves National Commission for Combating HIV/AIDS and defines its structure, composed of the National Council (plenary body that sets the policies) and the Secretariat (executive body who is responsible for technical and administrative management and promotion of activities to combat HIV/AIDS).

The establishment of the National Commission for Combating HIV/AIDS is an integral part of the macro - policy strategy approved in 2003, which sets out the Government's objectives in the medium and long term as to combat and control the spread of the AIDS virus in Timor-Leste. Thus, in 2006, the government approved the National Strategic Plan for HIV/AIDS and appointed the Chairman of the National Commission for Combating HIV/AIDS.

The Commission depended directly from the Ministry of Health and faced several difficulties associated with the definition and implementation of Government policies to control diseases and raising funds to fight HIV/AIDS, so it became essential to establish an independent Commission policy advice and support the implementation of strategies to combat HIV/AIDS established by the Government.

Related posts
Timor Leste Red Cross Excludes Homosexuals From HIV-AIDS Program
HIV/AIDS Services for Timorese Inmates
HIV-AIDS and Homophobia in East Timor
Homosexuality in East Timor
Catholic propaganda obscures the true toll of HIV in East Timor

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