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:
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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
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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:
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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