Situational Analysis of HIV in Haiti Post Emergency Recommendations for response to HIV in an emergency context Background Country context Haiti is a mountainous country which suffers from extensive deforestation. The country lies in the hurricane belt and the natural catastrophe risk index (flooding, cyclones) is one of the highest in the world. The country has a population of about nine million with a life expectancy of 52 years. Almost 80% of people live on less than US$2 a day. Sustained corruption and misuse of public funds have resulted in a decline of all public services. Haiti’s health statistics are amongst the worst in the Americas. Vaccine coverage does not exceed 33.5% of the country. Lack of clean water and sanitation, poor housing, the absence of adequate health care and environmental disasters contribute to poor health conditions. Over 75% of births take place without qualified assistance, child deaths comprise a third of all deaths in Haiti and half the population can be categorised as ‘food insecure’. 24% of children under five are chronically malnourished. Violence and crime are rampant in Haiti and women and children are greatly affected. A weak legal environment and easy access to weapons contribute to violence and insecurity. Social cohesion mechanisms and community support networks have deteriorated, in particular in rural areas, and in some cases have completely disappeared (urban environments). Entire geographical areas have become increasingly isolated and militarised. Children are vulnerable to being recruited into armed gangs and women are often targets of kidnapping, rape and theft. Existing vulnerabilities towards HIV HIV prevalence Haiti has the highest HIV prevalence rates in Latin America and the Caribbean and the worst AIDS epidemic outside Africa. HIV prevalence, at 2.2 %, is generalised among the population, although slightly more women than men are affected and rates are higher in urban than in rural areas. Among the groups considered most at risk of HIV are young people, commercial sex workers, migrants (both to urban areas and cross-border), men having sex with men (MSM), police, prisoners and truck drivers. Whilst Haiti-wide statistics on these particularly vulnerable groups are lacking, some smaller studies have been tracking key indicators and some also have been collecting biological samples: the preliminary results of a survey in 2004 to determine drug use and HIV infection rates among former soldiers entering into police service found that 30% of the soldiers tested were HIV positive1. 1 WHO, 2005 Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 The primary means of HIV transmission is through sexual contact, followed by vertical (mother to- child) transmission. Transmission from injecting drug use or blood transfusions is said to be negligible since the introduction of a blood safety programme by the Haitian Red Cross in 1986. Only 29% of young women and 43% of young men used condoms during their last high-risk sexual contact2 There are indications that the prevalence rate has been falling over recent years, due to the introduction of a safe blood policy and some – but still insufficient – positive behaviour change among high risk groups as well as some helpful PEPFAR funding. Before the January earthquake this year there were approximately 120,000 people living with HIV (PLHIV), of whom around 19,000 people were estimated to be on Anti-Retroviral Treatment (ART) Incidence of sexually transmitted infections (STIs) is high in urban areas: 50% of the women of Cité Soleil (slum) are affected by at least one STI, and 58,000 are living with HIV3. Urbanisation and migration Although much of the population still lives in the rural areas, urbanisation has been accelerating over the years. The urban population is estimated at 3.2 million inhabitants, 50% of whom live in slums and shantytowns4. The impact of soil erosion and land fragmentation on agricultural productivity coupled with the increase in natural disasters has forced more and more people to migrate to the capital Port au Prince (PaP) and overseas in search of work. This has had an effect on traditions and culture as more and more people are taking on urban life without the traditionally relied on extended family and cooperative labour as a means of taking care of each other. An increased exposure to an ‘American lifestyle’ being the closet influential western country has added to this. A growing middle class has increased the gap between rich and poor as can be seen in PaP. Over one million native-born Haitians live overseas; an additional 50,000 leave the country every year, predominantly for the United States but also to Canada and France. Approximately 80% of permanent migrants come from the educated middle and upper classes, but very large numbers of lower-class Haitians temporarily migrate to the Dominican Republic and Nassau Bahamas to work at low-income jobs in the informal economy. As men are often predominantly the ones that migrate, it means women are left at home to look after the household, potentially increasing their vulnerability. Trafficking and Restaveks Trafficking of women and girls and forced repatriation of women at the Haitian-Dominican Republic border often includes sexual violence and rape. The majority of trafficking cases are found among the estimated 90,000 to 300,000 restaveks in Haiti and the 3,000 additional restaveks who are trafficked to the Dominican Republic. A restavek is a child in 2 Samuels, F. and Spraos, S., HIV and Emergencies Haiti Country Case Study, ODI:2008 UNAIDS 2010 4 UNAIDS 2010 3 Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 Haiti who is sent by their parents to work for a host household as a domestic servant because the parents lack the resources required to support the child. Poor, mostly rural families, send their children to cities to live with relatively wealthier “host” families, whom they expect to provide the children with food, shelter, and an education in exchange for domestic work. While some restaveks are cared for and sent to school, most of these children are subjected to involuntary domestic servitude. These restaveks, 65 percent of whom are girls between the ages of six and 14, work excessive hours, receive no schooling or payment and are often physically and sexually abused. Gender inequality and sexual gender based violence (SGBV) Women are often said to seek alliances with men as a means of ensuring survival for themselves and their families, reflecting the unequal gender relations that operate within society. This same reality is likely to encourage casual sex work, as well as occasional transactional sex in return for certain favours such as a job5. Recurrent gender-based violence, multiple sexual partners for both men and women, and women’s inability to negotiate condom use with men are all factors which are contributing to HIV transmission. Violence against women is a serious problem in Haiti and rates of sexual violence are high. In the month of January 2009 alone, Kay Fanm (‘House of Women’), a women’s organisation, recorded 79 cases of rape. In general, 30% of women in Haiti suffer physical, emotional or sexual violence from their partners, according to a study by the Ministry of Women Affairs and Women’s Rights in Haiti. The ‘dating game’ and teenage pregnancies Young people become sexually active early (15% of young women and 43% of young men before the age of 15). It has been suggested that poverty is likely to force women into an early sexual debut and multiple partners6 and that their economic dependency on men means that they are unlikely to be able to negotiate the terms on which the relationship takes place. During discussions with World Vision staff in February 2010 it became clear that there is an unwritten rule around dating amongst youth. There is an expectation that a transaction will take place; with girls expecting gifts and boys expecting sex in return. The average women in Haiti will have approximately 4 children by the end of her reproductive age. Of those, according to the WHO survey in 2005, approximately 1.6 was reported to be unwanted fertility. Young mothers 2% of women aged between 15 and 19 were reported to be pregnant with their first child7. Young mothers are often found to have children who have different Fathers. Teenage pregnancies in rural areas are higher however many girls are lured to the city by men who after they are pregnant leave them for other women. The consequences are that young mothers face bringing up their children with little help from an extended family. The majority of women (75%) deliver at home and low birth weight is common as is anaemia in pregnancy with 52% of pregnant women reported to be anaemic8. This does 5 Spraos, H., Perceptions of Urban Violence in Haiti: the case of St Martin, unpublished MSc dissertation, 2007 Hempstope, H. et al. HIV/AIDS in Haiti: A literature Review, 2004 7 WHO, 2005 8 WHO, 2005 6 Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 not bode well for the well being of the child economically and socially particularly concerning issues around child development and nutrition. This may contribute to the high incidences of under five malnutrition found in the country. Post Earthquake On January 12, 2010 a 7.0 (Richter scale) earthquake struck Haiti. The Haitian Government reported that over 220,000 people died and an estimated 300,000 were injured with at least 1.7 million displaced. Hospitals and primary health care were crippled with 46 hospitals and clinics being destroyed and severe damage to 38 more. There were over 600 camps in PaP hosting internally displaced people that were in need of shelter, health, and water and sanitation services. The main needs initially were from the affects of trauma and currently there are many cases of communicable diseases and malnutrition as well as psychosocial affects from the trauma. Post emergency vulnerabilities towards HIV Migration and split families In the confusion that arose immediately after the earthquake buses were laid on by the government to ferry people out of the danger. Many people found themselves in rural areas where they stayed in temporary shelter often without all the members of their family. Many families were split up and this temporary arrangement ended up being more permanent as many people are still lodging with host families in the rural areas. This of course makes people very vulnerable without the support of their family in a strange environment with disrupted access to basic services. Many families who were able, went overseas often again splitting up their family. Increase in promiscuity There is general consensus that consensual and transactional sex is likely to occur in the emergency phase as people are living in temporary shelters. In Haiti, where this type of sex was common before, is an indication that this behaviour will be exacerbated with the increase in vulnerabilities such as a shortage of goods and services caused by the emergency. Increase in promiscuity is likely to increase because of a number of factors; mixing of people increasing curiosity in sexual encounters, seeking comfort from the trauma people face, lack of role models/traditional leadership, limited activities to be engaged with so boredom may increase levels of sex and limited opportunities to earn a livelihood increasing the chance of transactional sex. In the World Vision mobile clinics in the camps, one of the highest incidences of illness reported in the second month post earthquake was vaginal discharge most likely indicating that there was an increase in STIs caused by an increase in unprotected sex. Increase in SGBV From previous studies of Haiti during conflict and periods of political unrest, sexual violence, including rape and gang rape increased. It is highly likely that during this current emergency sexual violence also Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 increased during the chaotic period when there was looting and general unrest and services, particularly law and order, were disrupted. In one of the biggest camps, Champ de Mars, according to Amnesty International there were 19 women and girls living in their section of the camp who had been raped and sexually assaulted in the two month period post earthquake. None of them reported this abuse to the police. They were too afraid, either because the attackers were living in the camp, or in nearby areas, or because they had no other place to go. Camp life Camp life can increase the risk of sexual violence. In the first few months post the Haitian earthquake, thousands of displaced people slept in public spaces in just one square meter or even less; women were obliged to bath almost naked under the eyes of the other residents and passers-by and children slept alone at night because they were unaccompanied or their mothers were working outside the camps in order to feed them. The conditions in the camps were extremely primitive with very poor shelter, limited access to basic services and an increased population in a confined space meaning that any communicable disease spread quickly. As the rains came there was concern for the potential increase in malaria and dengue fever. This bought about an additional vulnerability for PLHIV as their immunity is lower and consequently they are more susceptible to the progression of the infection leading to AIDS. Additionally, due often to less food, limited drinking water supplies and unclean sanitary environment (both latrines and dirty water), people become more susceptible to getting diseases and infections which also leads to reduced immunity. HIV services There are a number of clinics/hospitals that provide HIV services for PLHIV including ART and Prevention of Mother to Child Transmission (PMTCT). After the earthquake most of the ART in storage was found to be in tact. PLHIV were encouraged to go back to the clinics where they normally go to continue to receive the medication. However the three most affected areas also had more than half of all the antiretroviral treatment sites, so there were some issues of accessibility. In addition many people had moved to temporary shelter or to rural areas which meant they may have not been able to access their usual clinics. The Ministry of Health estimates that less than 40% of the 24 000 PLHIV who were on treatment before the earthquake have accessed them. Immediately after the earthquake the oldest ART centre GHESKIO reported that while the clinic had suffered some damage to its structure, essential equipment and tragically also suffered human losses, staff reported that they had enough stock of ARVs to cover the immediate need. The clinic provides 6,000 people with treatment and they said they had been able to account for 80% of their clients. However one of the main centres for provision of PMTCT services, Hospital de la Paix, reported destruction of stock as well as lack of financial abilities to buy breast milk substitute necessary to PMTCT through the breast milk. Services at the clinic were only resumed 12 days after the quake. Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 Other HIV prevention services that were disrupted were VCT, HIV awareness campaigns and access to condoms. In the camps people were limited to what the services in the camps were providing and did not have the resources or means to access services outside. Unfortunately HIV prevention services were often minimal in the camps although most mobile clinics did provide condoms. However when talking to the beneficiaries many were shy or embarrassed to access the condoms from within the clinics. Currently Haiti is experiencing a critical interruption of HIV services and programmes and will need comprehensive and sustained support for the country to regain momentum towards universal access targets to HIV prevention, treatment, care, and support. Emergency coping mechanisms As Haiti is not unfamiliar to disasters there are past accounts of how people have coped during an emergency which also helps to see how these could affect HIV prevalence and increase vulnerability for PLHIV: Missing meals Move to temporary shelters to gain handouts (food, blankets, hygiene kits etc) Reliance on family and neighbour network (although due to the widespread impact of the earthquake this will be limited) Reliance on support networks for PLHIV Staying with relatives outside of PaP Sending children away to family or friends Transactional sex Begging Recommendations Post emergency It is essential that HIV awareness messages are conducted in the camps. These need to be catered for all age groups and they should address risks that have been identified such as transactional sex, unprotected sex and condom use, youth engaging in sex and sexual violence. Stigma and discrimination needs to also be discussed and considered during awareness raising Condoms need to be made available but also accessible. This may mean they need to be distributed within hygiene kits Other contraception also needs to be available in the mobile clinics Data on numbers of PLHIV who have been displaced and moved to family and friends or temporary shelter needs to be collated and accessibility to ART needs to be analysed to ensure they can access their drugs wherever they are Data should be collected on how high risk groups have been effected by the emergency and if they can access HIV prevention services. This includes; the prison population, MSM, street based sex workers, street children, police and truck drivers. VCT services should be resumed whenever possible (not in the immediate stages post emergency) Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 Treatment for STIs should be provided in all mobile clinics Malaria treatment should be provided for any suspected cases and mosquito nets should be given out to all displaced beneficiaries Access to support groups or ART clinics to provide additional food requirements for those people on ART Assistance should be given to clinics providing ART to ensure clients can access their ART. This could be in form of assistance with identification of clients in the camps, logistical assistance for clinics or short term cash transfers for clients which could go on to a more sustainable livelihood programme. Post Exposure Prophylaxis (PEP) services should be available. All mobile clinics in camps and other temporary shelter sites need to provide post rape kits. Referrals for counselling and other services need to be put in place for women and girls who have been affected Assistance should be given for helping women and girls to report any sexual violence Staff need to be trained on SGBV to be able to recognise signs and know how to address issues. The design of any activities needs to be considered within all sectors to ensure people are not vulnerable towards HIV, examples of these are as follows: o o o o o o o o o o o WASH Latrines and washing areas need to be gender separated and well lit with culturally acceptable designs (solid doors with locks instead of canvas or plastic sheeting) Quantities of water need to considered for any household with chronically sick members Ensure water is accessible to chronically sick beneficiaries and containers can easily be carried Shelter Ensure assistance is given to beneficiaries who may not be able to erect own shelter Ensure shelters do not make people vulnerable – keep families together, if a large building is used ensure men and women are separated appropriately Ensure beneficiaries are given mosquito nets Nutrition Breastfeeding counselling and discussions on timely contraception for mothers living with HIV Discussions on balanced diet in emergency contexts when food is scarce and training on preparation and storage of distributed food Food security Ensure any food distribution criteria is inclusive of chronically sick members so to include PLHIV Consider type of food being distributed in terms of nutritional value and ability to digest the food Consider how the food is distributed and whether it can be accessed by chronically sick members or child headed households. Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 Preparedness All staff need to have a good basic understanding of HIV – this can be assessed using a staff assessment tool (attached9) All staff need to be trained on HIV in emergencies and be familiar with the programmatic check list tool (attached) as well as the new revised IASC guidelines for responding to HIV in humanitarian settings. http://www.aidsandemergencies.org/cms/documents/IASC_HIV_Guidelines_2009_En.pdf There is a need to ensure the Ministry of Health national AIDS strategy is known and documented with particular reference to emergencies Discussions with NGOs and other organizations working in the same geographical areas with ability to respond to HIV need to be conducted to ensure there is no potential duplication in response during the emergency Advance planning on stock piling of condoms. This means ensuring access to companies, UN or other such supplier is identified and numbers calculated according to beneficiaries who could be affected. Kits such as hygiene kits, cooking sets etc that are made up ahead of time could be supplied with condoms Ensure all the clinics that provide ART are mapped out and identified – including those in rural areas Ensure support networks are identified and potential needs for PLHIV that may be an issue during an emergency considered and planned for. This may entail providing extra food particularly for those on ART as well as the potential need for extra help in setting up temporary shelters Advance planning should be made on what kind of HIV awareness needs to be given in an emergency based on the need for immediate effectiveness. Resources need to be identified so that they would be ready immediately during an emergency Monitoring and evaluation indicators should be developed and made available (see IASC guidelines for M&E matrix) Longer term There is a need to address some of the underlying cultural traditions and practices such as gender inequality particularly in the rural areas Children and youth need to be taught on what the difference between love and sex is and that sex does not equal love. Discussions on dating, delaying sexual debut and other issues need to be conducted. This could be integrated into the school curriculum or within church youth groups or other such avenues There needs to be more HIV services available including ART, PMTCT, VCT and HIV awareness Better access to HIV prevention services should be made available for high risk groups Medical and school fees need to be considered for the affect they have on people’s accessibility to these services 9 Two forms are attached; one is blank that can be given to the staff member to fill out, the other form has answers to some of the questions which can be used by the facilitator running the assessment. There are some questions that do not have right or wrong answers as they ask for people’s opinions. Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010 UNAIDS in Haiti UNAIDS on their mission in February 2010 identified the following seven priority actions 1. 2. 3. 4. 5. 6. 7. Rebuild health systems (including antiretroviral and PMTCT services); Protect displaced people from HIV; Rebuild the national and local network of PLHIV; Support social protection measures; Revitalize HIV prevention programmes; Re-establish comprehensive coordination mechanisms for the AIDS response; and Develop a comprehensive monitoring and evaluation mechanism The annual national AIDS budget of Haiti was US$ 132 million prior to the earthquake. UNAIDS estimates that an additional US$ 70 million will be needed for the next six months to meet Haiti’s immediate AIDS response needs. Attachments Staff Check List for Staff Check List for Programmatic HIV responding to HIV.docresponding to HIV with answers.doc assessment check list.docx References and Further Reading Samuels, F. and Spraos, H., HIV and Emergencies Haiti Country Case Study, ODI, February 2008 Synthesis Report: Joint UNAIDS Mission to Haiti March 20-28, 2010, UNAIDS Guidelines for Addressing HIV in Humanitarian settings, IASC task Force on HIV, 2009 http://www.aidsandemergencies.org/cms/documents/IASC_HIV_Guidelines_2009_En.pdf Fiona Perry, Global HIV Advisor for Emergencies, World Vision, May 2010