Driving the global theme ‘Hands Up for HIV Prevention’ forward, Sri Lanka is currently hoping to prevent an HIV epidemic, by reshaping its goals and redefining its strategies to meet the United Nations Sustainability and Millennium goals for 2030. Already, several strategies have been put in place to fast-track those goals with Sri Lanka so as to achieve them ahead of 2030, by 2020. These far sighted strategies have put our tiny country ahead of her immediate neighbouring countries in reaching those goals.
At a recent discussion with the media at the Health Education Bureau, officials from the National STD/AIDs Control Program (NSACP) outlined some of these strategies and interventions and their outcomes, citing statistics based on the most recent surveys by the NSACP.
Excerpts:
Current situation in Lanka
Consultant Epidemiologist NSACP Dr Sriyakanthi Beneragama discussing the current situation of HIV/AIDS in Sri Lanka underlined the importance of eliminating HIV which could eventually lead to AIDS. “HIV is incurable. Once infected with it a person will remain infected for the rest of his /her life.
However, today, unlike in the past, we have medications - Antiretroviral (ARV) which is available to prolong life and enable the infected persons to lead normal lives. But, they do NOT cure the disease, as many believe”, she reiterated.
Q. What about people who while being on ARV for HIV assumed they could engage in unprotected sex in the belief that the disease could not be transmitted to their sexual partner (man of woman)?
A. It is definitely a possibility, because there are those who are infected and capable of infecting others without having symptoms or knowing they had the disease”.
Q. So how does the disease act on the body’s immune system?
A. HIV multiplies inside CD4+ cells, destroying them. As CD4+ cell count decreases and viral load increases, the immune defences are weakened. HIV infected people then become vulnerable to opportunistic infections which can eventually kill them.
Q. How can this be prevented?
A. With ARV treatment only. Without this, HIV will progress to symptomatic disease and AIDS.
Q. How is the infection transmitted in the first place?
A. Unprotected sexual intercourse with an infected partner. Vertical transmission (from mother to child), injection drug use from infected syringes.
Q How does a mother transmit the infection to her baby?
A. In utero, during delivery, breast milk, from tears, sweat drops.
The speaker also cited the following estimated statistics of persons living with HIV/AIDS in Sri Lanka:
2015 - People living with HIV/AIDS -
Adults over 15 years totalled 4,100
Children below 15 years – 100
New infections in 2015- 1,000
AIDS deaths in 2015- below 100
Adult HIV Prevalence rate at present – 0.1% which was the lowest in South Asian countries.
On probable mode of transmission among reported HIV cases in 2015, she said, “The highest number were hetero sexual, followed by male to male sex.
Age wise and gender wise a survey had revealed that the highest age group comprised young males from 15- 24 and 25- 49- people in the prime of their lives whose illness was a burden to the entire family who were not only deprived of their only income, but had to become their sole care gives as well, speakers disclosed.
Drivers of the HIV Epidemic in Asia? Responding, Dr Beneragama said, those mainly responsible for transmitting HIV in Asian countries and in Sri Lanka were: Female Sex Workers (FSW) and their clients, Males who had sex with men (MSM) and Injecting Drug Users who share contaminated needles and syringes.
Q. How many sex workers are there in Sri Lanka?
A. According to national estimates in 2013, the number ranged from 12,329 to 15,935 who operated on an average 3-5 days a week.
Q. Men having sex with men (MSM). How many of them are to be found in Sri Lanka?
A. Once again, according to our National Estimates, in 2013 the numbers ranged from 6,547 to 8,554. The average number of male partners was nine per year.
Mother to Child Transmission Elimination
In her discussion on this topic, Coordinator of the Elimination of Mother to Child Transmission of HIV (EMTCT) Dr Lilani Rajapaksa highlighted a very tragic outcome of HIV- Children with HIV and how a mother was responsible for this tragedy.
Displaying charts and visuals, she said, by the end of 2015, the estimated number of children with HIV was 100, with seven new cases discovered in the same year. This year (2016) the number had dropped to two - largely due to improved control measures and strategies introduced to prevent transmission from mother to child, by the NSACP.
“Sri Lanka aims to achieve Elimination of Mother to Child Transmission of HIV by the end of 2017 , and we are confident we can reach that goal provided all HIV infected mothers cooperate with us and report to our clinics for regular screening so that the baby can be treated early,” she said.
Q. How has the response been so far?
A. Good, as more women are now coming to our clinics for treatment for themselves and their babies. We are hoping that our coverage of HIV testing of pregnant women will exceed 95% and by 2020 be 200%.
Q. Do you think you can achieve this target?
A. We started scaling up our EMCTC program from 2012 and have initiated new strategies to prevent EMCTC. They include:
* HIV testing of pregnant women at the first booked visit
* Starting them on Antiretroviral Treatment (ART) as soon as possible to prevent the baby from becoming infected.
* Guidelines to manage obstetrics
* Counselling mothers on infant feeding
* Starting the baby on ART for 6/52 weeks
Q. Has the number of pregnant women tested for HIV from 2012 -2015 also seen a parallel increase?
A. Yes. The estimated number by 2015 end was around 70%, but we hope to increase this number to over 90% by 2017.
Q. What was the outcome of pregnancies of mothers who received such treatment prior to having their babies?
A. Since 2011, all babies of mothers who received EMTC services are negative.
Q. What does that imply?
A. That early diagnosis, early services, will eliminate the risk of mother to child transmission of HIV.
Consultant Venereologist Dr G.Weerasinghe discussed the national reponse to HIV epidemic in Sri Lanka while outlining strategies for the future.
History
Tracing the history of the NSACP he said it was established in 1988, shortly after the first report of HIV/AIDS in Sri Lanka. Screening donor blood for HIV was also started in the same year. In 1990, HIV surveillance systems were introduced for the first time in the country.
The Sri Lanka College of Venereologists was set up in 1995, followed by the development of infrastructure for STD/HIV/AIDS control and prevention which led to a nation wide awareness and advocacy program.
Q. When was ART introduced?
A. A free ART program was introduced with World Bank funds in 2004. This was followed by a Behavioural Surveillance Survey, conducted in 2005/6, also with World Bank funding. By 2016 our programs have been funded entirely by the government of Sri Lanka with technical support from the World Bank.
Dr Weerasinghe also quoted statistics regarding the HIV cases detected and followed up in 2016, as well as the number on ART.
* Cumulative No. of HIV cases detected – 2,436
* No. of HIV positives followed up in clinics – 1,050
* Total number of Sexually Transmitted Diseases (STDs) diagnosed islandwide – 13,852.
Reiterating the words of Dr Rajapaksa, he said, “No HIV positive baby was delivered by any of known HIV mothers since 2011. The number of known HIV positive children remains unchanged since 2011.
Q. Transmission through blood?
A. We have no reported cases of transmission of HIV through blood. Last year we carried out over a million tests (1,121,663), which is a huge jump from just 422,071 in 2011.
Q. From where are the samples collected?
A. Blood donors, Private hospitals and private labs, antenatal clinics, STDF clinics, prisons and from TB screening. The highest number of samples was from blood donors – 399,500 which shows that more people are coming forward to donating their blood voluntarily. All samples of donated blood are screened. Donor blood testing has now reached 100%..
Q. The accelerated targets for 2020 to end AIDS is 90-90-90. What are they? What are your future strategies to this end?
A. 1) That 90% of people living with HIV ( PLHIV) know their status by 2020.
2) On December 1, donor blood testing was introduced in all antenatal clinics across the country.
3) Also, on December 1, we introduced HIV testing guidelines.
4) We are also in the process of normalizing HIV tests (events based and strategically planned
5) We have begun routine offers of HIV tests to all STD attendees, TB patients, pregnant mothers and Hepatitis B&C patients.
6) Community based HIV testing targeting key populations will also be carried out.
7) We are also outreaching with testing services to vulnerable communities, while improving infrastructure and logistics of district level STD clinics.
8) Another thing is that we will be doing follow up cases of all HIV known positive cases, as some have disappeared after their first visit. They need to be found and treated. If not they can be a risk to the rest of society.
Q. Is Rapid HIV testing another new strategy? What are its benefits?
A. Rapid HIV tests will be introduced and promoted by 2017. The advantage is that these tests can detect the virus in a positive patient within 20-30 minutes.
Q. Any new strategies for promoting condom use?
A. At present an estimated 58% of males use condoms and 90- 93% of women according to an IBBS survey. Although the number of males using condoms has increased over the past, we need to push these figures much higher.
We will be looking at social marketing of HIV/AIDs / STD services as we earlier lacked a social marketing strategy. Now, we will market our services, possibly from January 2017, to help us achieve our target by 2025. We hope the media will support us to get across our messages to the target groups, and also help us overcome the stigma against HIV AIDS patients.