British Medical Journal (BMJ) rapid response article.

http://bmj.bmjjournals.com/cgi/eletters/330/7482/59#92036

Mainstream HIV prevention into `Tsunami' response
10 January 2005

Dr.Joe Thomas, Convenor, APPACHA ,
Dr.Mridula Bandyopadhyay, The University of Melbourne, Victoria 3010

The direct and indirect impact of the `Asian Tsunami' is staggering.
The latest estimates of deaths are over 146 000 (anticipated to rise
over 185 000), with over 525 000 injured, over 20 000 missing, close
to 1.6 million displaced, and over 1 million estimated homeless
(Moszynski, 2005).

The initial governmental and community response to this terrible
disaster was to organise an immediate relief operation consisting of
food, shelter and medical attention. The global response was
extraordinary. Even, aid recipient country such as India, declined
bilateral aid, so that aid could go to other needy countries and
deployed 32 warships, over 80 aircrafts, unmanned aerial vehicles and
17,500 members of the army to locate and aid the survivors and victims
and pledged US$25 million aid to the Tsunami affected neighbouring
countries.

As we are gradually moving into the next phase (the long term) of the
Tsunami disaster response, it is imperative to mainstream HIV/AIDS
prevention and care programs as part of a long term re-reconstruction
of the affected communities and individuals.

Though natural calamities do not transmit HIV, however, some of the
post disaster situations may provide a fertile environment which would
enhance vulnerability of individuals to HIV. Although, a systematic
analysis has yet to be undertaken on how natural disasters could
enhance vulnerability to HIV, based on our understandings about the
social context of HIV vulnerability, we could safely predict that the
post Tsunami situation could lead to insecure conditions, exacerbating
the spread of HIV/AIDS. The Tsunami disaster could contribute to
inadequate safe blood, shortage of clean injecting equipments for
injecting drug users, an insufficient supply of condoms and health
care; and the vulnerability of displaced people, especially women and
children to sexual abuse and violence. In addition, during the periods
of population displacement, HIV/AIDS prevention and care is often
disrupted.

The HIV epidemic presents key challenges to both humanitarian and
development assistance, and to the interface between them. The
challenges raised by the HIV pandemic in the Asia Pacific are only
beginning to be fully realised now, and HIV is clearly a massive
crisis in all the Tsunami affected areas and can be described as an
emergency.

HIV/AIDS has profound humanitarian consequences, both by directly
causing illness and death, and in terms of the wider impact it has on
societies. These consequences will develop over decades. The existing
models of humanitarian response to natural calamities may not be
appropriate in understanding and integrating an effective HIV
response. Equally, existing models of development assistance are
likely to prove inadequate in developing an HIV response.

There is ample evidence to advocate for mainstreaming an effective HIV
response to the Tsunami Disaster response. Elsey and Kutengule (2002)
defined mainstreaming HIV/AIDS into disaster relief as the process of
analysing how HIV/AIDS impacts on post disaster situations and
developing appropriate responses, including the impact of the disaster
on people who are already living with HIV/AIDS and survived the disaster.

Mainstreaming HIV programming into humanitarian responses is to
determine how each sector should respond based on its comparative
advantage. In this context the specific organisational response may
include: putting in place policies and practices that protect staff
from vulnerability to infection and support staff who are living with
HIV/AIDS, whilst also ensuring that training and recruitment takes
into consideration future staff depletion rates, and future planning
takes into consideration the disruption caused by increased morbidity
and mortality. Humanitarian organisations must ensure those infected
and affected by the pandemic are included and are able to benefit from
their activities. Agencies must also ensure that their activities do
not increase the vulnerability of the communities to HIV/STIs, or
undermine their options for coping with the affects of the pandemic.

The "Tsunami response" is now moving from the immediate humanitarian
response to developmental phase. The UNAIDS Working Definition of
Mainstreaming AIDS (2004) into development work is more illuminating
"Mainstreaming AIDS is a process that enables development actors to
address the causes and effects of AIDS in an effective and sustained
manner, both through their usual work and within their workplace".

`Development actors' are all the people and institutions involved in
development, including all sectors and levels of government, the
business sector, civil society, and international agencies. Whilst
`usual work' is the work that development actors are supposed to do as
set forth by their mandate, mission or business interests.

Based on current experiences aimed at mainstreaming HIV/AIDS at
different levels, five simple principles have emerged that attempts to
provide a comprehensive framework to analyse where and when to
introduce and implement HIV/AIDS mainstreaming (UNADS/GTZ 2002).

Principle 1 underscores the importance of developing a clearly defined
and focused entry point or theme for mainstreaming HIV/AIDS in order
to maintain the critical focus necessary to make an impact.

Principle 2 maintains that, at the country level, mainstreaming does
not take place outside of the existing national context. Thus National
Policies or Strategic Frameworks for HIV/AIDS should be used as the
frame of reference. Mainstreaming efforts should be located within
existing institutional structures.

Principle 3 necessitates advocacy, sensitisation and capacity building
in order to place people in a better position to undertake
mainstreaming. Mainstreaming cannot be expected to develop of its own
accord.

Principle 4 asserts the need to maintain a distinction between two
domains in mainstreaming: the internal domain or workplace, where
staff risks and vulnerabilities are addressed; and the external
domain, where the institution undertakes HIV/AIDS interventions based
on its mandate and capacities in support of local or national
strategic efforts.

Principle 5 highlights the importance of developing strategic
partnerships based upon comparative advantage, cost effectiveness and
collaboration.

Tsunami response presents an opportunity to use the community links
established through disaster relief programs to ensure that men, women
and children are aware of their rights to aid which is not conditional
on accepting sexual exploitation. The long term disaster relief staff
should have access to HIV/AIDS awareness, and to train them to
opportunities to carry out HIV education as part of the overall
disaster response.

The United Nations Inter-Agency Standing Committee Task Force on
HIV/AIDS in Emergency Settings has produced a detailed guideline for
HIV/AIDS interventions in emergency settings. The purpose of this
guideline is to enable governments and cooperating agencies, including
UN Agencies and NGOs, to deliver the minimum required multi-sectoral
response to HIV/AIDS during the early phase of any emergency situation.

These guidelines, focusing on the early phase of an emergency, should
not prevent organizations from integrating such activities in their
preparedness planning. As a general rule, this response should be
integrated into existing plans and the use of local resources should
be encouraged. A close and positive relationship with local
authorities is fundamental to the success of the response and will
allow for strengthening of the local capacity in the future

Paul Harvey (2004) analysed the relationship between livelihood and
HIV/AIDS in the context of humanitarian programming. Livelihood
insecurity due to Tsunami could increase HIV vulnerability as local
social security networks have been severely disturbed by the disaster.

Based on Harvey's and UNADS/GTZ observations the following points in
relation to humanitarian programming in the context of an HIV/AIDS
epidemic should be taken into consideration:

1. Early-warning systems and assessments need to incorporate analyses
of HIV/AIDS and its impact on livelihoods.

2. The emergence of new types and areas of vulnerability due to
HIV/AIDS should be considered in assessment. Groups such as widows,
the elderly and orphans may be particularly vulnerable, and urban and
peri- urban areas may need to be assessed.

3. Targeting and the delivery of aid must be sensitive to the
possibility of AIDS-related stigma and discrimination.

4. The HIV/AIDS epidemic reinforces the existing need for humanitarian
programmes to be gender-sensitive.

5. Emergency interventions must aim to ensure that they do not
increase people's susceptibility to infection with HIV/AIDS.

6. Food aid in the context of HIV/AIDS should review ration sizes and
types of food and assess delivery and distribution mechanisms in light
of HIV/AIDS related vulnerabilities, such as illness, reduced labour
and increased caring burdens.

7. Labour-intensive public works programmes should consider the needs
of labour-constrained households, the elderly and the chronically ill.

8. HIV/AIDS reinforces the need for health issues to be considered as
a part of any humanitarian response.

9. Support to agricultural production (including seed distribution)
and pisciculture support should recognise adaptations that people are
making in response to HIV/AIDS.

10. Micro economic impact on people living with HIV in the disaster
affected areas to be considered.

11. As part of the Tsunami disaster challenge, all the agencies must
be encouraged to explore the possibility of mainstreaming HIV
prevention into their work.

12. All long term responses must explore the possibility of
distribution of condoms, where appropriate, in line with the UNAIDS
minimum package for HIV prevention in emergencies.

13. Mainstreaming HIV response into disaster relief starts with the
concerns of the community; policy makers and institutions need to
understand these issues.

14. There is an urgent need to document the evaluation and monitoring
of mainstreaming work into Tsunami response.

15. Tsunami response must also have an enabling environment which
would provide space for sharing HIV and AIDS concerns and to propose
solutions.

16. HIV prevention and care needs to be integrated into the Tsunami
disaster needs assessment

17. Long term Tsunami response must take into account HIV prevention
and care needs of the community

18. Tsunami affected national governments must ask their national HIV
programs to assess the impact of the disaster on their HIV programs
and to respond adequately.

19. Donor agencies and humanitarian agencies must allocate line item
specific funding for integrating HIV programs into the current
humanitarian responses.

20. UNAIDS along with other key stake holders may take leadership to
establish a regional mechanism to monitor the progress of
mainstreaming HIV into humanitarian responses and for rapid diffusion
of lessons learned from each setting.

References:

Peter Moszynski (2005) Disease threatens millions in wake of Tsunami
BMJ, 330:59 (8January), doi:10.1136/bmj.330.7482.59

IASC TF (Not dated) Guidelines for HIV/AIDS interventions in emergency
settings. The Inter-Agency Standing Committee Task Force on HIV/AIDS
in Emergency Settings

UNAIDS/GTZ (2002) Mainstreaming HIV/AIDS: A conceptual framework and
implementing principles. June 2002

Elsey, Helen & Kutengule, Priscilla (2003): HIV/AIDS Mainstreaming: A
Definition, Some Experiences and Strategies. Liverpool School of
Tropical Medicine, HEARD, DFID Ghana.

UNAIDS (2004) Support to Mainstreaming AIDS in Development
Oxfam (2001) Lessons Learnt in Mainstreaming HIV/AIDS: Oxfam, Malawi.

Harvey, P., (2004) HIV/AIDS and humanitarian action. Humanitarian
Policy Group, Overseas Development Institute. UK. April 2004

Murphy. L., (2004) HIV/AIDS and humanitarian action: Insights from US
and Kenya-based agencies. Humanitarian Policy Group, Overseas
Development Institute. UK April 2004

Harvey, P., (2003) HIV/AIDS: What are the Implications for
Humanitarian Action? A Literature Review. Overseas Development
Institute, July 2003 (draft), http://www.odi.org.uk/Food-Security-
Forum/docs/Harvey.pdf


Competing interests: Dr Thomas is the convenor of Asia Pacific
people's alliance to combat HIV and AIDS (APPACHA)