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HIV / AIDS in Sri Lanka
A Profile on Policy an
Practice
July 2007

HIV / AIDS in Sri Lanka
Profile on Policy and
Practice
July 2007

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The Centre for Policy Alternatives (CPA) is an independent, non-pa issues of governance and conflict resolution. Formed in 1996 in the society to the public policy debate is in need of strengthening, CP and advocacy through which public policy is critiqued, alternatives id
Address: 24/2 28th Lane, off Flower Road
Colombo 7 Telephone: +94 (11) 2565304/5/6 Fax: +94 (11) 4714460
Web www.cpalanka.org Email info@cpalanka.org

n independent, non-partisan organization that focuses primarily on . Formed in 1996 in the firm belief that the vital contribution of civil d of strengthening, CPA is committed to programmes of research critiqued, alternatives identified and disseminated.
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Table of Contents
Acronyms
Introduction
Overview of the socio-economic situation in Sr
1 HIV / AIDS situation in Sri Lanka
2 Vulnerability factors and groups
3 Review of Laws and Policies on HIV / AIDS
3.1 Constitutional and Legal Framework 3.2 National Legislation with regard to HIV/AIDS 3.3 International Obligations 3.4 Commitments made by Political Leaders 3.5 National Policies on Health and HIV/AIDS 3.6 National Strategic Plan
4 Institutional structures in relation to HIV / AID
4.1 The National AIDS Council 4.1 The National AIDS Committee (NAC) 4.3 The National STD and AIDS Control Programme 4.4 Overall response
5 Stigma and discrimination
5.1 Health Care 5.2 Education 5.3 Employment 5.4 Family Life 5.5 Housing 5.6 Social Life
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ble of Contents
5
6
nomic situation in Sri Lanka 7
ri Lanka 8
groups 10
icies on HIV / AIDS 12
mework 12 ard to HIV/AIDS 12 14 tical Leaders 14 nd HIV/AIDS 15 16
relation to HIV / AIDS in Sri Lanka 18
18 ee (NAC) 18 Control Programme 19 19
n 21
21 22 22 22 23 23
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6 Access to medication and treatment
7 Initiatives by Other Actors in relation to HIV/A
7.1 The Role of Civil Society & NGOs 7.2 Role of the Private Sector 7.3 Role of the Media 7.4 Initiatives by International Organisations and Donors
8 Conclusion
9 Recommendations
1. Formulating a National HIV/AIDS Policy 2. Legislation in relation to HIV/AIDS 3. Issues associated with the Strategic Plan 4. Proactive leadership 5. Strengthening of the NSACP 6. Prevention Activities 7. Treatment, care and support 8. Initiatives by Non Governmental Actors
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d treatment 24
rs in relation to HIV/AIDS in Sri Lanka 25
GOs 25 26 26 ganisations and Donors 26
31
34
olicy 34 34 ic Plan 34 35 35 35 35 ctors 36
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Acronyms
AIDS Acquired Immunodeficiency Syndrome
ART Antiretroviral Treatment ARV Antiretroviral Medication
CBO Community Based Organisation
CPA Centre for Policy Alternatives CSW Commercial Sex Workers
FTZ Free Trade Zone GFATM Global Fund against AIDS, TB and Malaria
HIV Human Immunodeficiency Virus
IDH Infectious Diseases Hospital ILO International Labour Organisation
I/NGO International/ Non-Governmental Organization IOM International Organisation for Migration
MDG Millennium Development Goals
MOH Ministry of Health NAC National AIDS Committee
NSACP National STD/AIDS Control Programme NHAPP National HIV/AIDS Prevention Project
OI Opportunistic Infections
PEP Post-exposure Prophylaxis PLWHA People Living with HIV/AIDS
STD Sexually Transmitted Diseases TB Tuberculosis
UN United Nations
UNAIDS UN Programme on HIV/AIDS UNDP United Nations Development Programme
UNFPA United Nations Population Fund UNGASS UNGASS Declaration of Commitment 2001
UNICEF United Nations Children’s Fund
UP Universal Precautions VCT Voluntary Counseling and Testing
WHO World Health Organization
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ronyms
drome
d Malaria
n
l Organization
ration
ramme oject
gramme
ment 2001
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Introduction
This paper discusses the status of HIV/AIDS in Sri Lanka, with a special f practical issues such as the prevalence of stigma and discrimination, lack o Lanka is a low prevalence country, several factors such as poverty, conflic pled with vulnerable groups as listed in this document, could result in the p In such a situation, it is vital that the response to HIV/AIDS is targeted, tim nerabilities of people living with HIV/AIDS (PLWHA), their families and friend
also maps out the role played by civil society, religious leaders, media, t donors and particular initiatives undertaken by these actors in their respon mendations for future action combining a multisectoral approach and a righ
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troduction
Lanka, with a special focus on laws, policies, institutional structures and nd discrimination, lack of adequate resources and infrastructure. While Sri such as poverty, conflict, low awareness levels and low condom use cou- ent, could result in the possibility of an outbreak of HIV/AIDS in the future. IV/AIDS is targeted, timely and effective, recognising the needs and vul- their families and friends, communities and vulnerable groups. This paper
gious leaders, media, the private sector, international organisations and
e actors in their response to HIV/AIDS. Finally the paper sets out recom- oral approach and a rights based framework.
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Overview of the socio economic situation in Sri Lanka
Having been ravaged by a civil war for over two decades, the people of Sr the Ceasefire agreement in 2002. However, peace was not forthcoming an continues as fiercely as before. In 2004, the Sri Lankan coastal line was d continuing conflict has severely affected the development of Sri Lanka.
With low levels of development, poverty in Sri Lanka persists. While pove addressed, it is yet to be adequately addressed in the rural and estate s water and sanitation are scarce and inadequate in many rural areas in Sr areas and overseas.
Sri Lanka boasts of a high literacy rate 91.1% and attributes it to free ed the main reason children drop out of school. Limited resources continue t the lack of basic services such as education, health, sanitation and water h such as women.
Health care is financed by the Government as well as by private persons times, there has been a surge in the use of private hospitals due to overcro
However, since most of the population cannot afford the high private h hospitals for services, many of which have insufficient resources, infrastruc
The lack of good infrastructure has excluded poor communities from Gender inequality is another barrier. In order to empower such communitie
that infrastructure and basic facilities are provided to the poor and vulne must be given to the role women play as the heads of households and as and social equality to be successful and impact the lives of all citizens, the that are rights based and effectively implemented.
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verview of the socio- onomic situation in i Lanka
cades, the people of Sri Lanka saw a glimmer of hope with the signing of was not forthcoming and today the violence in the North East of Sri Lanka nkan coastal line was devastated by the tsunami. This together with the pment of Sri Lanka.
ka persists. While poverty in urban areas receives attention and is being the rural and estate sectors. Basic services such as education, health, many rural areas in Sri Lanka, resulting in increased migration to urban
d attributes it to free education. Yet it is important to note that poverty is d resources continue to affect those who live below the poverty line and , sanitation and water have heightened the vulnerability of various groups
ll as by private persons through direct out-of-pocket payments. In recent hospitals due to overcrowding, long waits and queues at public hospitals.
fford the high private hospital charges, they continue to rely on public nt resources, infrastructure and staff.
or communities from enjoying the benefits of economic development. ower such communities and to bring about gender equality it is essential
to the poor and vulnerable communities. Further, adequate recognition of households and as breadwinners. For economic growth, development e lives of all citizens, there must also be a framework of laws and policies
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HIV / AIDS situation in Sri Lanka
Although the official number of cases of Sri Lankans living with HIV is 862 stigma, discrimination and fear associated with HIV/AIDS. Furthermore, th unaware that they are infected. Therefore, the actual number of people liv 5,000. UNAIDS/WHO has classified Sri Lanka as a low HIV prevalence co
adult prevalence rate of less than 0.1%.2
The Western Province accounts for 60% of HIV infections, with the Centr
for 8%, and the North East Province 7%.3 A point to remember is that thi reflect estimated cases. While the Western Province has a substantial num high number of HIV tests done in the area. For example, although migrant generally done in the Western Province. Further, poverty results in migratio testing facilities in the Western Province results in a higher percentage of more cases reported from the Western Province. Nearly 90% of the reporte
The majority of HIV-positive people (96%) acquired HIV/AIDS through sexu through heterosexual/bisexual relations only a few cases of prenatal tra ported.
The number of women with HIV/AIDS is increasing, with 50% of these w ployed abroad.6 The current ratio of HIV-positive men to women in Sri Lank
Despite the current low prevalence rate, Sri Lanka is vulnerable to an imp the country has large numbers of at risk groups such as sex workers, m placed Persons (IDPs), refugees and drug users and a high incidence of dom use and escalating rates of STDs.
Poverty which has led to prostitution and trafficking has resulted in women
trafficked being vulnerable to HIV/AIDS. Poverty is usually the primary “roo the poorest and most marginalized households are the most susceptible does not lead to prostitution and/or trafficking but often places individuals
viduals to leave their place or residence in search of work or better opportu community, these people are vulnerable to prostitution and/or trafficking.
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HIV / AIDS situation Sri Lanka
s living with HIV is 8621, the actual figure is much higher as a result of the /AIDS. Furthermore, there are probably countless others who are simply al number of people living with HIV/AIDS is estimated by UNAIDS to be low HIV prevalence country in the South Asia region, with an estimated
fections, with the Central and North Western Provinces each accounting
to remember is that this merely reflects the reported cases and does not e has a substantial number of infected cases, this may also be due to the mple, although migrant workers come from other provinces, HIV tests are verty results in migration to urban areas. Having better infrastructure and a higher percentage of infections being detected. Consequently there are early 90% of the reported HIV infections are within the 15-49 age group.4
HIV/AIDS through sexual transmission.5 While the majority of them were cases of prenatal transmission or through blood transfusion were re-
, with 50% of these women being migrant workers who have been em- en to women in Sri Lanka is reported at 1.4 to 1.
is vulnerable to an impending epidemic due to a number of risk factors: such as sex workers, migrant workers, military personnel, Internally Dis- nd a high incidence of unsafe sexual practices, which includes low con-
has resulted in women and children who are in the sex trade and/or are
usually the primary “root cause” of prostitution and trafficking. Those from re the most susceptible to prostitution and/or trafficking. Poverty alone often places individuals in other vulnerable situations. It often forces indi-
f work or better opportunities. Once away from the familiarity of their own ion and/or trafficking.
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Gender-based discrimination is perpetuated at both the family and commu vient role to that of men and not challenge their authority. This creates a so
of women being susceptible to the coercive and deceptive tactics wielde gender based violence and woman having minimum power to negotiate heightens women’s vulnerability to STDs and HIV/AIDS.
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h the family and community level. Women are expected to play a subser- hority. This creates a social atmosphere in which men control women and
deceptive tactics wielded by predominantly male traffickers. Additionally, m power to negotiate sex (as well as negotiate using condoms) further IDS.
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Vulnerability factors and groups
A) Low Condom Use Condom use in Sri Lanka is reported to be low, with a prevalence of only tion of approximately 10 million, the condom availability is 1.2 condoms p among sex workers is heightened by low condom use and the high pr
which make a person more susceptible to contracting HIV/AIDS. In one st tiple STIs, and 70% of male patients at STI clinics reported frequenting se kept in mind is whether women have the power to negotiate condom u
Though the general picture is bleak, there are various initiatives undertak the use of condoms through awareness programmes and training.10
B) Commercial Sex Workers and Clients It has been estimated that there are over 45,000 commercial sex worker due to the deteriorating socio economic conditions and prevailing poverty. sex workers in Sri Lanka.
C) Drug Use
According to the Dangerous Drug Control Board, there are 400,000 heroin with 7.5% estimated to be injecting drug users.12 Although there is only o nous drug use, this group is at high risk because of needle-sharing and ca AIDS.
D) Refugees and Internally Displaced Persons (IDPs) Internally Displaced Persons and refugees living in camps can be conside due to the conditions they face namely a breakdown of essential services, sexual violence, rape and coercion.
E) Military Forces and Police Military forces and the police are considered a vulnerable group mainly due military personnel and the sex worker/partner at risk.
F) Youth and Adolescents The lack of information on HIV/AIDS among youth is another serious pro found that very few were aware of STIs and HIV/AIDS.13 Due to cultural leaves school children ignorant on the matter, and hence vulnerable. .
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Vulnerability factors d groups
th a prevalence of only 3%.7 Accordingly, with an estimated adult popula- bility is 1.2 condoms per adult per year.8 The risk of HIV/AIDS spreading use and the high prevalence of sexually transmitted infections (STIs),
ing HIV/AIDS. In one study, 45% of female sex workers experienced mul- reported frequenting sex workers.9 An additional element that should be to negotiate condom use, when they have little say in negotiating sex.
ous initiatives undertaken by private organizations that have encouraged es and training.10
commercial sex workers (CSW) in Sri Lanka.11This number is increasing and prevailing poverty. There is also an upswing in the number of foreign
here are 400,000 heroin users and 200,000 cannabis users on the island Although there is only one reported case of HIV infection through intrave- f needle-sharing and can be recognized as a population vulnerable to HIV/
(IDPs) camps can be considered as a group at high risk to HIV/AIDS and STIs n of essential services, a disruption of social structures and support and
erable group mainly due to risky sexual behaviour , which leaves both the k.
is another serious problem. In a study contacted by the UNICEF it was IDS. 13 Due to cultural reasons, there is little or no sex education, which ence vulnerable.
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G) Worker in Free Trade Zones Workers in the Free Trade Zones have been identified as a vulnerable gr proximately 96,000 workers of which a majority are women.14 The shift fro style and the lack of a social network or protection leaves female workers v
H) Migrant Workers Women who travel overseas as migrant workers have been identified as a their families and communities, they undergo lifestyle changes and further h
I) Workers in Tea Plantations Women in plantations have limited access to health care facilities and due to migrate to other areas including traveling overseas. Changes in lifestyle health care have all contributed to the group being considered as a vulnera
J) Men Having Sex with Men (MSM) Men having sex with men (MSM) are another group that has been identifie a growing number of beach boys who are vulnerable to STDs and HIV/AID due to homosexual transmission.15
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ified as a vulnerable group and it has been estimated that there are ap- e women.14 The shift from rural to urban areas results in a change in life- leaves female workers vulnerable.
ve been identified as a high risk group as they do not have the support of le changes and further have no support networks.
care facilities and due to a dearth of employment options many have had eas. Changes in lifestyle, lack of awareness, as well as limited access to considered as a vulnerable group to HIV/AIDS.
that has been identified as being vulnerable to HIV/AIDS. There are also le to STDs and HIV/AIDS. 11% of the reported HIV infections have been
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Review of Laws and Policies on HIV / AIDS
3.1 Constitutional and Legal Framework16
The Constitution of Sri Lanka does not have a specific provision on health sures that all people are equal before the law and are entitled to the equa person shall be subject to any disability, liability, restriction or condition on sex. The Government of Sri Lanka has made international commitments health care to all citizens without discrimination.17
The 13th Amendment to the Constitution devolves health to the Provincia especially with regard to health, is that it introduced an additional layer of g
devolving power to a smaller unit that is closer to the people.
The current health structure is set up under the Health Services Act of 1
Provincial Councils (Consequential Provisions) Act of 1989 . Under these policy as well as the training and management of special and teaching ho for health care in their respective areas. However there are marked dispar inces and even between different districts within provinces. This can be a that the concentration of resources and industrial development in the We system.
Financial Allocation Mechanisms within the country: The main source of fi grants made by the Central Government. In disbursing these funds, the ommendations of the Finance Commission. It must be noted however tha to be within the limits indicated by the Treasury. Further, the Provincial Cou but are only passive recipients of the funds doled out. Another criticism o cient to address the needs of the hospitals.
3.2 National Legislation with regard to HIV/AIDS
There are no laws that specifically deal with HIV/AIDS in Sri Lanka. A notab AIDS in Sri Lanka is the Draft Health Care of Public Act (1996) which aim sue. The Bill emanated from the Legal and Ethical Affairs Subcommittee of tion from various quarters.
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Review of Laws and licies on HIV / AIDS
l Framework16
cific provision on health. Under the present Constitution, Article 12 (1) en- are entitled to the equal protection of the law. Article 12 (3) states that no striction or condition on the grounds of race, religion, language, caste or rnational commitments, which make the State responsible for providing
health to the Provincial Councils. A criticism of the 13th Amendment, an additional layer of governance, expenditure and bureaucracy, without
e people.
ealth Services Act of 1953, the Provincial Councils Act of 1987 and the
of 1989 . Under these Acts, the Central Government is responsible for pecial and teaching hospitals. Provincial health ministries are responsible here are marked disparities in the provision of health care between prov- rovinces. This can be attributed to a 'rural-urban' divide, as it is alleged development in the Western Province is partly due to an over-centralised
: The main source of financing for the Provincial Councils is through the rsing these funds, the Central Government and Treasury act on the rec- t be noted however that the Finance Commission recommendations have rther, the Provincial Councils have no role to play in the finance allocations out. Another criticism of the system is that the funds allocated are insuffi-
regard to HIV/AIDS
S in Sri Lanka. A notable landmark in the law and policy reaction to HIV/ c Act (1996) which aimed at establishing an Authority to deal with the is- ffairs Subcommittee of the MOH. The Bill was not passed due to opposi-
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The Bill, which was never enacted, was subject to much criticism on the towards the issue, and made little reference to human rights and ethical co
example, there was no reference to the dignity of persons living with HIV against such persons. In a manner which some would describe as being c heavily focused on establishing a National Authority for the Prevention and to Ministries) and delineating its powers and functions as opposed to ad fairness, it must be noted that the Bill states that one of the responsibilitie protect the rights of HIV and AIDS patients and prevent HIV and AIDS an given as to what such measures should be.
It must be noted that MOH officials strongly argue that this was but a pre that it was 'leaked'. However, it has been argued in response that the for
gressed beyond the preliminary stages. Even if the Bill as was discussed least as of that time) of certain sections of the government towards the issu
The debate on whether there should be a separate law dealing with HIV/A for some time. A law with a strong emphasis on the rights of PLWHA, whic help to a great extent in reducing stigma and discrimination.
However, in order to protect the rights of PLWHA it is extremely important transparent and participatory manner. As indicated by several studies 1 , du of society, there is a high level of stigma and discrimination towards PLW
these points into consideration, the resultant law could be discriminatory, d them. It is also worth noting that there is no judicial review in the Sri Lan amend laws passed by the legislature. In such a context where there is a
among law makers could result in law that is discriminatory, bureaucrati adequate protection provisions may draw more attention to people living w tion.
Sri Lanka does not have cases decided by the national courts that suppor with issues such as consent, confidentiality, or the right to work. Therefore, laws to protect the rights of PLWHA, nor judicial activism on the subject. sionals and officials are largely unaware of the basic rights of PLWHA.
There are several discriminatory laws not specific to HIV/AIDS that underm
Penal Code of Sri Lanka19 continues the ‘criminalisation of homosexuality, acts of gross indecency’. Penal sanctions against such acts when commit sidered reasonable or just in a liberal society. These laws also undermine p other STIs since they drive marginalized people further underground.
The Vagrants Ordinance20, which targets “every common prostitute”, defi makes it difficult to reach commercial sex workers in order to educate the importance of practising safe sex. Furthermore, the public and the police it more difficult for these individuals to seek redress when necessary.
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much criticism on the grounds that it typified a very narrow approach an rights and ethical concerns that form an integral part of the issue. For
persons living with HIV/AIDS or any provisions to prevent discrimination uld describe as being characteristic to Sri Lankan legislation, the Bill was y for the Prevention and Control of AIDS (composed mostly of secretaries ions as opposed to addressing some of the more substantive issues. In ne of the responsibilities of the Authority is ‘to take effective measures to revent HIV and AIDS and related diseases’, though there is no guidance
that this was but a preliminary draft and several officials were displeased in response that the format of the Bill indicates that the drafting had pro-
Bill as was discussed was not the final draft, it portrays the attitude (at rnment towards the issue of HIV/AIDS.
law dealing with HIV/AIDS and the rights of PLWHA has been going on rights of PLWHA, which binds both private and public institutions, would mination.
is extremely important that any legislation on HIV/AIDS be introduced in a by several studies18, due to misinformation and prejudice among sections rimination towards PLWHA. Hence if a law is formulated without taking
uld be discriminatory, depriving the rights of PLWHA instead of protecting ial review in the Sri Lankan legal system, making it extremely difficult to ontext where there is a possibility that misinformation, prejudices and fear
criminatory, bureaucratic and/or weak. Furthermore, such a law without ention to people living with HIV/AIDS and lead to their further marginalisa-
ional courts that support the rights of PLWHA, nor are there any that deal right to work. Therefore, we are in a situation where there are no adequate ctivism on the subject. As a result, the general public, health care profes-
rights of PLWHA.
o HIV/AIDS that undermine efforts to control the spread of the virus. The
ation of homosexuality, carnal intercourse against the order of nature and uch acts when committed by consenting adults in private cannot be con- laws also undermine programs aimed at the prevention of HIV/AIDS and her underground.
mmon prostitute”, defines soliciting as a criminal offence. This provision in order to educate them on HIV/AIDS and other STIs as well as on the e public and the police often harass the groups mentioned above, making
when necessary.
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3.3 International Obligations
Sri Lanka is a signatory to many international conventions and treaties s Government of Sri Lanka participated in a SAARC Health Ministers confer ence a SAARC Regional Strategy was launched which focuses mainly on p
expertise and pharmaceuticals and producing affordable medicines. It is t mented in Sri Lanka.
UNGASS implementation
Sri Lanka has yet to follow up on many of the commitments made at the on HIV/AIDS (UNGASS) Declaration of Commitment in 2001. The Declarati and sustained response to HIV/AIDS. Currently there are initiatives by the
donor community and others to achieve UNGASS targets. However, effo sharing of information. UNGASS also recognises that stigma, silence, dis undermine prevention, care and treatment efforts, and these need to be ad tives made for equal access to medication and voluntary testing in all hea ated by and involving communities and religious leaders.
Millennium Development Goals
As a country committed to achieving the Millennium Development Goals (M
is a halt to the spread of HIV/AIDS and begin to reverse its spread. A MDG istries, government agencies and international and national organisations, The Sri Lanka Millennium Development Goals Report 2005 states that Sr year 2015, increasing the present level of 40% condom use among CSW workers from 30% to 70% by the year 2015. The Report further identified numbers of military personnel, low condom use, high incidence of STDs, e with men, beach boys and commercial sex tourism, free trade zone worke
identifies challenges such as improving prevention programmes targeting pitals, the need to have a multi-sectoral approach in tackling HIV/AIDS, en society as well as a stronger political leadership.
3.4 Commitments made by Political Leaders
Former President Chandrika Bandaranaike Kumaranatunge in her 2004
working with civil society, the private sector and the international commu former Prime Minister and current President Mahinda Rajapakse highlighte ple and the need for a multi-sectoral response to address the problem in h
Furthermore, the former Prime Minister instituted the ILO code of ethics at In his “Mahinda Chinthana” proposals24 in 2005, he also had a separate Sevana” programme. This programme contains a component focused o
“country” from the “serious threat” of HIV/AIDS. Cabinet spokesman and that more work needs to be done to address the lack of awareness on H
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ventions and treaties specifically related to HIV/AIDS. Most recently the Health Ministers conference in June 2006 in Bangladesh. At this confer- ich focuses mainly on preparing an action plan on cooperation in medical
rdable medicines. It is to be seen how the regional strategy will be imple-
mitments made at the United Nations General Assembly Special Session t in 2001. The Declaration recognises the need for an urgent, coordinated ere are initiatives by the Government, civil society, the private sector, the
targets. However, efforts should be made for better co-ordination and hat stigma, silence, discrimination, denial, and lack of confidentiality can nd these need to be addressed. Furthermore, there should also be initia- luntary testing in all health institutions. There needs to be more work initi-
ders.
Development Goals (MDGs), Sri Lanka must ensure that by 2015, there
erse its spread. A MDG country group, working closely with relevant min- national organisations, is working to ensure that all MDGs are achieved.21 ort 2005 states that Sri Lanka is on track with tackling HIV/AIDS by the dom use among CSW to 80% and the use of condoms by clients of sex eport further identified risk factors such as large numbers of CSWs, large gh incidence of STDs, external migration, presence of men who have sex , free trade zone workers and the large youth population. The Report also
programmes targeting vulnerable groups, improving infrastructure in hos- in tackling HIV/AIDS, encouraging greater participation by CBOs and civil
Political Leaders
ranatunge in her 2004 AIDS Day message stressed the importance of
he international community to improve the situation in Sri Lanka22 while a Rajapakse highlighted the lack of awareness on HIV/AIDS among peo- dress the problem in his message on World AIDS day 2004.23
e ILO code of ethics at the work place to combat HIV/AIDS in July 2004. e also had a separate section focusing on good health called the “Suva component focused on immediate steps to save the “youth” and the
abinet spokesman and Minister for Health, Nimal Siripala de Silva, stated ack of awareness on HIV/AIDS and promised that the government would
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initiate programmes to address awareness and other related issues.2 Th HIV/AIDS policy is directly related to the interest taken by the present Gove
3.5 National Policies on Health and HIV/AIDS
(A) Health Policy
Until the late 1980s, there was no comprehensive national health policy do the Ministry of Health. In 1992, a Presidential Task Force formulated a Na taken forward however due to the change of government, which resulte Presidential Task Force on National Health Policy was set up in 1997. The situation. The Poverty Reduction Strategy paper and Vision 2002 also com drafted a Health Master Plan, and the first draft was released in Novembe
to criticism that stakeholder participation was minimal. The final docume through all these changes of government, there were principles common cost effectiveness, multisectoral co-operation, maximisation of efficiency a of services in remote areas, respect for the dignity of patients, and the inv tation process.
(B) National HIV/AIDS Policy27
Background
Currently, there is no finalised national policy on HIV/AIDS. In October 2005
and was circulated among a select few for comments. This follows a prev among a few individuals and organisations. Though feedback was sent there was no final document, which was widely circulated or made publ frame as to when the document will be finalised. The MOH convened a m cuss an updated version of the National HIV/AIDS Policy. This version of t ported that the draft policy discussed below is presently being amended mentary Advisory Committee for approval before being presented to the
meets every quarter and the next meeting will be after the ICAAP Conferen
The Draft Policy
The draft policy places a heavy emphasis on medical-science as the p framework is very weak. This is unfortunate as a rights-based approach
dance with human rights norms and would therefore be more successfu place emphasis on rights of PLWHA and vulnerable groups, women's rig information on sex and sexuality for all individuals.
The policy looks at issues such as prevention, monitoring, testing, counse behaviour. However, the policy has left out several issues that should be policy on HIV/AIDS. These include:
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her related issues.25 The present interest in the formulation of a National en by the present Government.
lth and HIV/AIDS
ational health policy document, although there were guidelines issued by Force formulated a National Health Policy for the first time. This was not ernment, which resulted in new policy documents in 1994 and 1996. A as set up in 1997. The change of government in 2001 again altered the nd Vision 2002 also commented on health policy.26 The Ministry of Health s released in November 2003. This was however quickly withdrawn due
mal. The final document is to date not available to the public. However, ere principles common to all the different documents. They were mainly: imisation of efficiency and quality of service, equitability and accessibility of patients, and the involvement of people in the planning and implemen-
/AIDS. In October 2005, a draft policy was presented at an NAC meeting
nts. This follows a previous draft policy (Draft 1), circulated in early 2004 h feedback was sent to the subcommittee on legal and ethical issues, irculated or made public. Further, the Government has not given a time he MOH convened a meeting with stakeholders in January 2006 to dis- Policy. This version of the draft policy is discussed below. It has been re- sently being amended by the MOH and is to be presented to the Parlia- being presented to the Cabinet. The Parliamentary Advisory Committee
ter the ICAAP Conference, at the end of August 2007.
dical-science as the primary mode to HIV/AIDS prevention. The rights rights-based approach would inform and empower individuals in accor-
fore be more successful in HIV/AIDS prevention. The policy should also le groups, women's rights, adolescents' rights and the right to complete
itoring, testing, counselling, care, treatment and the promotion of positive l issues that should be addressed in a comprehensive and multi-sectoral
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• The involvement of PLWHA in the formulation and implementation
• Confidential reporting of HIV/AIDS in medical terms and in the me
• Recognising and promoting informed consent and counselling wi
• Promoting safe practices including Universal Precautions (UP) and
•
Carrying out programmes on behavioural change and communica
• Including provisions on basic standards for the work place and ed
• Developing care and support for PLWHA
The draft policy has been circulated among certain individuals and organ
only sent to selected persons, many people are unaware that such a poli consulted on any programs, plans and strategies that are formulated, as th the most knowledgeable on what is required.
3.6 National Strategic Plan28
The National Strategic Plan for Prevention and Control of HIV/AIDS in Sri national response. In the absence of a HIV/AIDS policy, the Strategic Plan initiatives are undertaken in the response towards HIV/AIDS.
The goals of the Plan are:
1) To maintain the low HIV prevalence amongst risk groups and the 2) To increase the quality of life of those already infected.
Six strategies have been identified in the Plan to achieve the above goals. T
1) Increase coverage and quality of prevention interventions
2) Increase coverage and quality of care, support and treatment inte 3) Improve generation and use of information for planning and policy 4) Increase involvement of relevant sectors and levels of governmen 5) More supportive public policy and legal environment for HIV/AIDS 6) Improve management and coordination of the response
The Strategic Plan has identified the following areas as needing attention-
• Prevention
• Treatment, care and support services for PLWHA and their families
• Work with civil society including NGOs, CBOs, religious groups and
tor prevention and care services
• Mainstream HIV response by relevant non health ministries
• Develop a national monitoring and evaluation framework and related
• Strengthen the institutional and human capacity of the NSACP
• Develop sectoral policies and laws including sensitisation, capacity and decrees.
Prevention is still the primary focus, yet the present Strategic Plan has take of existing PLWHA.
The Strategic Plan also recognizes the importance in working with non-g sector. It also mentions working closely with UNAIDS and other UN age use. This is evident with the UN Theme Group actively engaging various m
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tion and implementation of the policy ical terms and in the media
sent and counselling with testing sal Precautions (UP) and Post-exposure Prophylaxis (PEP) change and communication r the work place and educational institutions
n individuals and organisations for comments. Since the draft policy was
aware that such a policy exists. Health staff across the country must be hat are formulated, as they are involved in day-to-day procedures and are
ntrol of HIV/AIDS in Sri Lanka for 2007-2011 (Strategic Plan) guides the olicy, the Strategic Plan provides the framework within which government
IV/AIDS.
gst risk groups and the general population
dy infected.
hieve the above goals. They are:
n interventions
port and treatment intervention
for planning and policy development nd levels of government in the response vironment for HIV/AIDS control f the response
as needing attention-
WHA and their families
s, religious groups and the private sector to complement the public sec-
ealth ministries n framework and related activities
city of the NSACP sensitisation, capacity building, monitoring and enforcement of such laws
t Strategic Plan has taken on board the importance of treatment and care
in working with non-government actors, religious actors and the private IDS and other UN agencies to mobilise resources and co-ordinate their ely engaging various ministries and organisations in identified areas.
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The Strategic Plan has several positive aspects. These are:
• It identifies vulnerable/risk groups such as CSW, Clients of CSW, tegic Plan and the draft policy, it seems that the Strategic Plan h able groups as well as groups at risk.
• It recognises the importance of a multi sectoral approach, with pa CSW, MSM and drug users.
•
It includes a component on the respect for human rights includin tive rights, non discrimination based on gender, disease status, s
of informed consent and confidentiality.
• It has an emphasis on the involvement of communities and PLWH services.
•
There is identification of communication strategies and media as a
• It sets out greater engagement with relevant ministries and depar
While the Strategic Plan has positive aspects, there are several areas that come shift in recognising the importance of a rights based approach but it be practiced in Sri Lanka with the existence of discriminatory laws and h that the government will take the lead in amending discriminatory laws, p actors.
Further, while involvement of all relevant governmental actors is vital includ
levels of engagement, facilitating an effective engagement and response. especially of local authorities, provincial AIDS committees, district AIDS co mittee will be funded. As noted in this document, there are several proble
wards HIV/AIDS. For an effective strategy, involving greater engagement o ment must ensure sufficient funds and expertise is available.
National framework:
The lack of a strong HIV/AIDS policy has impeded the response to HIV/AID the Strategic Plan provides an overall guidance in the response to HIV/AI out goals and strategies of the government towards the response. Therefo work is introduced, providing guidance to an effective, targeted and sustain
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ese are:
CSW, Clients of CSW, MSM and drug users. When comparing the Stra- hat the Strategic Plan has a broader approach and identifies both vulner-
ctoral approach, with participation from all stakeholders including PLWHA,
r human rights including the respect and dignity of sexual and reproduc- ender, disease status, sexual behaviour or sexual orientation, importance
communities and PLWHA in the design, implementation and evaluation of
trategies and media as an effective tool in prevention activities.
nt ministries and departments and local government.
are several areas that need consideration. The Strategic Plan has a wel- s based approach but it is to be seen how such a rights framework could criminatory laws and high rates of stigma and discrimination. It is hoped discriminatory laws, policies and regulations, working closely with other
ntal actors is vital including local authorities, there needs be clarity in the
gement and response. It is also of concern on how such engagement,
ittees, district AIDS committees and the Colombo Municipal AIDS com- there are several problems in capacity of local actors in the response to-
greater engagement of local actors and relevant ministries, the govern- available.
the response to HIV/AIDS, leaving a vacuum on the policy direction. While the response to HIV/AIDS, this is not a policy document but merely sets s the response. Therefore it is vital that a policy based on a rights frame- ive, targeted and sustained response.
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Institutional structure in relation to HIV / AIDS in Sri Lanka
4.1 The National AIDS Council
The National AIDS Council is the highest government body in the respons
President. The members of the Council include members of relevant minis highest leadership to the response. It is perceived by many in the governm Council provides greater space and encouragement for the involvement of
the Council is expected to provide leadership to the response, it is yet to has been effective since it has only met once.
4.1 The National AIDS Committee (NAC)
The National AIDS Committee (NAC) co-ordinates activities on HIV/AIDS a to the MOH. The NAC is composed of several other ministries including
bour, Women’s Affairs, Tourism, Youth Affairs, Defence and Sport. It also merce, UN Theme Group, Lanka + and a NGO representative. The NAC is
Decisions by the Council are conveyed to the NAC which is expected to fo of Reference set out the following functions for the NAC:
• advise the Government on policy regarding the prevention and th
• facilitate inter-sectoral co-ordination; monitor the implementation
•
bring to the notice of the National Health Council (NHC) difficultie of changes in the prevailing situation.29
While the NAC is meant to play a larger role on policy related issues, in pra essential that the NAC takes the responsibility of guiding and monitoring t
bogged down by operational issues.
The composition of the NAC is also an issue. It is extremely important tha tive of all sectors in society, especially PLWHA. Though Lanka+ is a mem representation of PLWHA as well as other vulnerable groups such as drug workers.
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Institutional structures relation to HIV / AIDS Sri Lanka
cil
ent body in the response to HIV/AIDS in Sri Lanka, and is chaired by the
mbers of relevant ministries. The Council was established to provide the by many in the government sector that having the President chairing the t for the involvement of non health ministers towards the response. While
e response, it is yet to be seen whether the establishment of the Council
ittee (NAC)
activities on HIV/AIDS at the national level and is chaired by the Secretary her ministries including Finance, Education, Justice, Social Services, La-
fence and Sport. It also has representation from the Chamber of Com- resentative. The NAC is meant to meet twice a year.
which is expected to follow up and implement such decisions. The Terms NAC:
g the prevention and the control of HIV/AIDS; itor the implementation of activities related to the NSACP; and Council (NHC) difficulties in the implementation of any activities as a result
cy related issues, in practice it has played more of an operational role. It is uiding and monitoring the response to HIV/AIDS rather than getting itself
extremely important that the NAC and its subcommittees are representa- ough Lanka+ is a member of the NAC, there needs to be a high level of le groups such as drug users, men who have sex with men, and migrant
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Though collaboration of line ministries and other stakeholders is meant to This is because negotiations at the NAC are limited to the secretaries of th
of the Ministers. Therefore coordination and interest on HIV/AIDS is most o to ensure greater participation from the various ministries.
4.3 The National STD and AIDS Control Programm
In 1992, the Government initiated the National STD and AIDS Control Prog torate of Health Services in the MOH, and implemented in collaboration w clinics, and the National Blood Transfusion Service (NBTS). The Director o Health Services through the Deputy Director General, Public Health Ser WHO, UNICEF, and JBIC have provided financial and technical assistanc dollars in support annually for the STD control programme through the He used to support capacity building measures at the STD clinics.
The NSACP is responsible for co-ordinating and supporting the national r
Lanka. Since its inception, the NSACP has made significant progress in im meeting staffing and equipment needs, and establishing outreach camps. blood safety through screening transfusions for HIV and upgrading blood and knowledge of HIV/AIDS among the general population.
At present, there are 26 STD district committees and 8 provincial committ underway to decentralise prevention and control activities to the provincial
One of the key problems facing the NSACP is that many STD clinics hav skilled professionals to manage STDs and HIV/AIDS. For example, in Jaffn
HIV/AIDS. Furthermore, there is no consultant specialising in HIV/AIDS in treating STD patients.
Even at the Infectious Diseases Hospital (IDH), the lab and X-Ray facilities only the Colombo hospital is providing ARV treatment, but it would be very two or three more hospitals in the country. Upgrading of the facilities is a the IDH do not have all the facilities needed, so we have to go to other h lematic for us”30. As a result of the ongoing conflict, the North and East P health care and infrastructure. There is a dearth of trained health staff bas testing equipment are lacking with reconstruction and development efforts
The STD Clinics have not limited their activities to treatment but also inc Various actors, including the STD Clinic itself and individual health profess
For example, the STD Clinic carried out sensitisation and awareness prog HIV/AIDS Prevention Project (NHAPP) has contracted the creation of med sion, a private media group. These programmes are currently being aired o
4.4 Overall response
This section has set out the governmental actors involved in the national
the NAC and the NSACP. While both the Council and NAC are meant to interest by the relevant leaders has been slow and sporadic, resulting in
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akeholders is meant to take place at the NAC, this is not always the case. to the secretaries of the respective ministries, with limited/no involvement
t on HIV/AIDS is most often limited and this needs to be rectified in order istries.
IDS Control Programme
and AIDS Control Programme (NSACP), which is managed by the Direc- nted in collaboration with the provincial directors of health services, STD (NBTS). The Director of the STD Clinic reports to the Director General of eral, Public Health Services. Multilateral and bilateral agencies, such as and technical assistance. The IDA has been providing about one million gramme through the Health Services Project (1997-2002). This has been STD clinics.
upporting the national response for prevention and control activities in Sri
ignificant progress in improving STI services by refurbishing health clinics, ishing outreach camps. In addition, the programme has helped to ensure V and upgrading blood banks. It has also raised the level of awareness pulation.
nd 8 provincial committees. As stated in the Strategic Plan, initiatives are tivities to the provincial and district levels.
t many STD clinics have inadequate infrastructure, human resources and S. For example, in Jaffna there is no doctor trained to deal with STDs and
cialising in HIV/AIDS in Kandy, and it is the general practitioners who are
lab and X-Ray facilities are inadequate. As a PLWHA stated, “presently, nt, but it would be very easy if they could provide the medicine in at least ing of the facilities is also essential. Some of the main hospitals such as e have to go to other hospitals to get our tests done which is very prob- t, the North and East Provinces have been severely affected in terms of trained health staff based in Jaffna and basic facilities such as adequate nd development efforts progressing at a slow pace.
treatment but also include prevention work through raising awareness. individual health professionals, have carried out awareness programmes.
on and awareness programmes targeting religious leaders. The National ted the creation of media programmes on HIV/AIDS to Young Asia Televi- e currently being aired on national television in all three languages.
involved in the national response towards HIV/AIDS namely the Council,
and NAC are meant to provide leadership to the response, initiatives and sporadic, resulting in the absence of a strong message by the govern-
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ment. It is also noted that NAC, which is meant to be a body deciding on issues. Such haphazard leadership in policy results in ambiguities and lack
and interest taken by particular individuals within the MOH and NSACP, t improvement, there is still much more improvement needed in areas incl structure and expertise.
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be a body deciding on policy is in practice more a forum for operational in ambiguities and lack of direction. With the development of the NSACP,
he MOH and NSACP, the response has improved. While there has been nt needed in areas including policy direction, increased resources, infra-
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Stigma and discriminatio
In a study conducted by the Centre for Policy Alternatives (CPA) in 2005, and discrimination faced by PLWHA due to the lack of knowledge and t volved in the health care, employment and education sectors as well as several issues highlighting the stigma and discrimination in the specific a PLWHA and their family members.31
5.1 Health Care
With regards to health care it was found that PLWHA faced many difficulti identified as:
• Lack of confidentiality
• Lack of informed consent
•
Discrimination against the patients and their families by the hospit
• Lack of basic services
•
Refusal to treat
“This incident occurred in a private hospital. The patient had been tested the hospital. When the test result returned positive, prior to informing the p patient’s brother-in-law. Furthermore, the test results had been leaked by t staff learnt about it. The patient stated that the immediate family was only found out. People outside the hospital, such as van drivers parked near t driver was from the same village as the patient and spread the news of the led to various acts of discrimination – people wanted them to leave the vill the child’s school, which in turn led to complications at school.”
“At a government hospital, a patient was operated on by hospital staff wit family. After the operation, the patient’s mother had informed the doctor th behaved respectfully towards the patient and family, the attendants and m badly. The mother of the HIV+ person, when interviewed, stated that the resulted in stigmatization and discrimination. She went on the mention tha sheets on the patient’s bed.”
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5
Stigma and discrimination
rnatives (CPA) in 2005, it was found that there were high levels of stigma ck of knowledge and the misconceptions by people including those in- tion sectors as well as family and society at large. This section captures ination in the specific areas, case studies demonstrating experiences of
A faced many difficulties when obtaining medical treatment. These were
eir families by the hospital staff
Page 17
atient had been tested there since his brother-in-law was employed by prior to informing the patient, the doctor had passed the result on to the ts had been leaked by the hospital lab, and as a result, the entire hospital ediate family was only notified after everyone in the hospital had already n drivers parked near the hospital, were told of the case. One such van spread the news of the patient’s HIV+ status throughout the village. This ed them to leave the village, making derogatory comments and informing s at school.”
on by hospital staff without any testing or consultation with the patient’s informed the doctor that the patient was HIV+. Though the doctor had ly, the attendants and minor staff had treated both the patient and family viewed, stated that the health staff were ignorant of HIV/AIDS and this
ent on the mention that the hospital staff had even refused to touch the
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“A similar case of discrimination occurred at a government hospital, wher had refused to touch her sheets and had insisted that the patient change birth and was unable to move from her bed. After the birth, a nurse had p tious disease. When the people from the village saw it, people made dero mother had been sent offensive letters. The same patient experienced dis pital in Colombo, where her child was warded. The nurses had not allow that it put the other children at risk for HIV. They had not permitted the pa separate bathroom and space to wash her clothes.”
5.2 Education
Pertaining to stigma discrimination in the sphere of education, it was found tion had taken place. There was no mistreatment on the part of the educa
by parents of other students towards children of parents living with HIV/AID
5.3 Employment
The majority of people interviewed during the study were unemployed, an those who were employed and whose HIV/AIDS status was made known much discrimination and had to face the lack of regard for confidentiality pe
“A qualified computer operator (SF) who was found to be HIV+ was sack was that they just could not employ an infected person in their establishm found that every interview he went for he was rejected because his previo and informing every interview panel of his ailment.”
5.4 Family Life
(a) Positive Aspects The majority of interviewees have only shared knowledge of their HIV+ sta ents or siblings. It is only in a few cases that they have
revealed it to others.
(b) Negative Aspects
There were situations where things turned out more negatively. PLWHAs f edge of HIV/AIDS, and that disclosure would result in stigmatization and members stigmatising and discriminating PLWHA. Until society becomes HIV/AIDS, they are unwilling to disclose their status to outsiders.
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ernment hospital, where the patient had given birth. The nurses on duty that the patient change them herself. This was soon after she had given the birth, a nurse had put a sign up saying that the patient had an infec- w it, people made derogatory remarks about her and her family, and her patient experienced discrimination at the Lady Ridgeway Children’s Hos- e nurses had not allowed the child to play with other children, claiming ad not permitted the patient to use the common bathroom, giving her a .”
education, it was found that there were very few cases where discrimina- n the part of the educational institutions but objections and discrimination
rents living with HIV/AIDS.
y were unemployed, and a few were self-employed. It was reported that atus was made known to their employers and co-workers were subject to
ard for confidentiality pertaining to their HIV/AIDS status.
d to be HIV+ was sacked from his post overnight and the reason given erson in their establishment. He then applied to other organisations and cted because his previous employer somehow was keeping track of him
ledge of their HIV+ status with their close family: spouses, children, par- ave
e negatively. PLWHAs felt that people were not aware or had little knowl- lt in stigmatization and discrimination. There were reports of close family Until society becomes more aware and accepting of people living with to outsiders.
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“A male school teacher, who was married with two children was detected period of various sicknesses. Due to his ill health he couldn’t continue teac His family deserted him upon the HIV+ diagnosis. His wife left him taking h was from his elder brother who kept him in a cow shed away from home fe he didn’t have any income to buy food and attempts to get away from shed. The AIDS Coalition when informed of his plight offered to bring him relatives and he himself refused saying it will be difficult for them to visit C financial assistance to purchase food items and clothing. In 2004 he died ravaged by opportunistic infections.”
5.5 Housing
Not many PLWHAs experience stigma and discrimination with regards t stances when villagers had set fire to their houses or made living in the villa
“In 2001, after the village found out the HIV status of the husband, the wife an extent that they (school going teenagers) had to stop their schooling. Th
give it to her husband and put an end to his life. After this whole ordeal, t the family was going through and committed suicide. After the husband’s sleeping, the villagers set fire to the house. But the family managed to ru home.”
5.6 Social Life
Due to ignorance and fear, people living with HIV/AIDS and their families a of awareness on what HIV/AIDS is and how it can be transmitted has left ease. Fear and ignorance can lead to various discriminatory practices, whic
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children was detected HIV+ at a government hospital following a lengthy couldn’t continue teaching and resigned prematurely on heath grounds. is wife left him taking his children along with her. The little support he got hed away from home fearing that they might contract HIV. He starved as pts to get away from that place resulted in that he was chained to the ht offered to bring him down to Colombo and admit him to the IDH. His ficult for them to visit Colombo on a regular basis. He was provided with lothing. In 2004 he died exposed to the monsoon rains in his cowshed,
ination with regards to housing although there have been reported in- r made living in the village impossible for them.
f the husband, the wife and the children were ridiculed and tormented to stop their schooling. The wife was given poison into her hand in order to
fter this whole ordeal, the husband could not deal with the suffering that ide. After the husband’s death, while the wife and the two children were e family managed to run to safety. Since then they have not visited their
IDS and their families are often treated with insensitivity and cruelty. Lack be transmitted has left many people with misconceptions about the dis- minatory practices, which sometimes turn violent.
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Access to medication and treatment
There is clear recognition today that all persons infected with HIV/AIDS sh control the disease, and further that preventive measure and ART cannot encouraged states to acknowledge that the “prevention, care, support, HIV/AIDS are mutually reinforcing elements of an effective response and m
combat the epidemic”.33 Nevertheless, the issue is one that gives rise to de a developing country context.
In the Sri Lankan situation, the issue of treatment was brought to the fore Sri Lankan NHAPP in 2002. Initially, the grant focused only on prevent document did note that prevention and treatment were not mutually excl phasize the former over the latter.
In response to this allocation of funds, the AIDS Coalition, headed by Dr clinics at the University of California, Berkeley prepared a memorandum a
of Sri Lanka requesting that the grant include financing for treatment.3 Th moral grounds (the daily deaths attributed to lack of access to medication threaten not only the health of the Sri Lankan population but the country's
The AIDS Coalition and CPA, using the memorandum successfully lobbied Eventually, a compromised was reached and presently the NHAPP allocate
for prevention activities). Provision is made for 100 recipients to receive A noted below, there are several practical aspects that need to be considere ARVs only being provided in Colombo, making it difficult for many to acce limiting many from coming forward.38
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Access to medication d treatment
fected with HIV/AIDS should receive treatment as part of programmes to asure and ART cannot be separated.32 The U.N. General Assembly has ention, care, support, and treatment for those infected and affected by fective response and must be integrated in a comprehensive approach to
one that gives rise to debate, particularly given the cost of ARV therapy in
as brought to the fore during discussions on World Bank funding for the cused only on prevention and outreach activities, though the appraisal were not mutually exclusive but considered it more cost efficient to em-
oalition, headed by Dr. Kamalika Abeyaratne and assisted by three law red a memorandum34 addressed to the World Bank and the Government
cing for treatment.35 The document also appealed to the government on of access to medication) and practical grounds (an AIDS epidemic would lation but the country's economic health as well).36
um successfully lobbied the World Bank to allocate funds for treatment.37 ntly the NHAPP allocates US $ 1 million for treatment and US $ 11 million
recipients to receive ARV treatment at no cost as discussed below. As at need to be considered in the provision of free ARVs. These include free ifficult for many to access it and prevalence of stigma and discrimination
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Initiatives by Other Actors in relation to HIV AIDS in Sri Lanka
This section looks at initiatives by civil society, private sector, media, interna several initiatives conducted by key actors it is not an exhaustive list and response towards HIV/AIDS.
7.1 The Role of Civil Society & NGOs
Many civil society organizations such as the AIDS Coalition, Companions o Alliance Lanka, SCDF, Migrant Services Centre and TRRO have condu grammes throughout the country.
Civil society initiatives remain largely uncoordinated. Certain key actions ne of NGOs to work with vulnerable groups and of the government to systema
Organisations such as Nest, Salvation Army, Lanka +, Companions on a J support such as providing hospice services, counselling, assisting in obtain cial support. People from a cross section of society and from across Sri organisations. However, many of the organisations providing care and sup It is also notable that many people in rural areas have difficulty in accessin support services in the conflict-affected North and East of Sri Lanka. Man lombo to provide care and support if not for funding constraints. While the able, filling a vacuum that is essential in the response to HIV/AIDS, severa ning and monitoring their programmes to ensure the services are sustaina to be more attention by the government and the donors in building the c sary training and expertise in making programmes in prevention, care and s
Civil society actors have also collaborated with leaders in others areas. Fo tise religious leaders with regards to HIV/AIDS. One such programme was vention at the community level and as part of it, increasing community a underway, very few documents are available on the involvement of religious
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Initiatives by Other tors in relation to HIV/ DS in Sri Lanka
te sector, media, international organisations and donors. While it captures an exhaustive list and is only an indicator of some of the activities in the
& NGOs
oalition, Companions on a Journey, Lanka +, Salvation Army, Sarvodaya, nd TRRO have conducted effective awareness and sensitisation pro-
. Certain key actions need to be taken in order to increase the capacities government to systematically contract and fund NGOs.
+, Companions on a Journey and YMCA have programmes for care and elling, assisting in obtaining medicine and dry rations, and providing finan- ty and from across Sri Lanka are being cared for & supported by these
providing care and support services are solely funded by private donors. ve difficulty in accessing such care. For example, there are few care and East of Sri Lanka. Many organisations could travel to areas outside Co- g constraints. While the work done by these organisations are commend- se to HIV/AIDS, several of these organisations lack the capacity in plan- e services are sustainable and have the necessary funding. There needs onors in building the capacity of local NGOs and providing them neces- in prevention, care and support more effective, targeted and sustainable.
ders in others areas. For example, Sarvodaya took the initiative to sensi- e such programme was mobilizing Buddhist leadership towards Aids pre- creasing community awareness on HIV/AIDS. While such initiatives are involvement of religious leaders in the response towards HIV/AIDS.
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7.2 Role of the Private Sector
There has been growing activity among the private sector on HIV/AIDS rela have increased where sectors such as health care, employment, and the ness programmes have been conducted in the workplace under the lead
Group, Unilever and other companies. However there needs to be more p prevention and awareness raising activities.
7.3 Role of the Media
The media needs to play a more proactive role in the response towards trayal of the true facts and increased and consistent reporting. There hav
HIV/AIDS in advertisements and pictures in a very negative light. Such actio
and their families. This was especially true of an advertisement for AIDS Day body being prepared after death. Other advertisements have used fear-gene
A striking example of negative reporting is an article carried in the Sinhala la ruary of 1995 which reported an operation carried out on an AIDS patient alleged that the patient had bribed the doctors to carry out the operation, had no right to medical treatment.
Confidentiality has also been an issue in media coverage. As highlighted i issues spoke of a newspaper article on the death of a child as a result of tion of both parents, the part of the country they resided in, the previous d of the second child. From the information provided, people in the area wh important that articles in the media are sensitive to issues of anonymity con
Studies carried out among media personnel as recently as in 2000 indicat against and lack of proper awareness on HIV/AIDS40. According to this s porting on health issues in the print and electronic media in Colombo, u
good knowledge on HIV/AIDS. 41% of the group studied was of the opinio It is also noteworthy that majority of the reporting has been in English med needing to take place in the Sinhala and Tamil media. Several initiatives t sonnel have been undertaken by organisations including UNAIDS41 and Pa
7.4 Initiatives by International Organisations and
A) Initiatives by the World Bank The World Bank is the major donor to the HIV/AIDS Prevention and Contr well as the other programmes within the MOH.
The National HIV/AIDS Prevention Project (NHAPP): This project is fi initiate a variety of prevention programmes.43 Its responsibilities include lia
and setting up multi-sectoral responses by working with various actors.
44
Awareness raising & Prevention Activities: The primary focus of the NH this aspect of the NHAPP. These are:
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r
sector on HIV/AIDS related issues. Awareness and sensitisation initiatives , employment, and the armed forces are being targeted. Several aware- rkplace under the leadership of the Chamber of Commerce, John Keells
ere needs to be more participation from the private sector with regard to
the response towards HIV/AIDS, namely by accurate and informed por- ent reporting. There have been instances where the media has portrayed
egative light. Such actions have created fear and even traumatised PLWHA
ertisement for AIDS Day – it was a half page print advertisement depicting a
nts have used fear-generating phrases such as ‘AIDS Kills’.
carried in the Sinhala language independent newspaper ‘Ravaya’ in Feb- out on an AIDS patient at the Colombo General Hospital. The newspaper arry out the operation, thereby creating the impression that AIDS patients
verage. As highlighted in a CPA study,39 an organisation working on HIV of a child as a result of AIDS. The article had given details of the occupa- sided in, the previous death of their first child, and the subsequent death , people in the area where the family lived were able to identify them. It is issues of anonymity concerning people living with HIV and their families.
ently as in 2000 indicate that there is still considerable levels of prejudice . According to this study, which was carried out among personnel re- c media in Colombo, upon aggregation only 27% were found to have a
tudied was of the opinion that HIV positive persons are a threat to society. as been in English media, with much more report and awareness raising dia. Several initiatives to raise awareness among Sri Lankan media per- uding UNAIDS41 and Panos.42
al Organisations and Donors
S Prevention and Control Programme 2002-2006, funding the NHAPP as
APP): This project is financed by a World Bank grant and was set up to sponsibilities include liaising with provincial and district health authorities
with various actors.
44
rimary focus of the NHAPP is prevention. Several initiatives encompass
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a) The NHAPP supports NGOs/CBOs already working on HIV/AlDS iss groups, and it aims to improve information and knowledge exchange b
targeted at behavioural change such as encouraging the use of condoms projects is that many lack capacity in handling large project including put the NHAPP and having the adequate capacity to report, monitor and responsible for the running of the NHAPP and therefore many of the local N may be excluded from collaboration due to various issues such as the app
While the World Bank funding has strengthened the response to HIV/ previously, funding is through the MOH, and as a result may exclude o entities working in rural areas. The existing bureaucracy in the government efficient and inclusive.
b) Another aspect within the World Bank project is the media campaign to
production house, has undertaken this component, which has conducte HIV/AIDS in Sri Lanka, carried out in all three languages. While this is encouraging more radio programmes and articles in newspapers and mag
c) The World Bank project has also revived the provincial and district co managed from the provincial and district committee level, resulting in som the project is still very centralized with the MOH having a large say in how p
ARV Treatment Component: Under this grant, there is provision for 100
The present guidelines followed by the STD Clinic for the provision of ARV by the MOH and World Bank issued in January 2005. According to the
counselling is provided prior to ARV treatment. At present health profess though it remains to be seen whether they will be adhered to when the pro
One of the main problems encountered by the ARV treatment program forward to receive treatment. Stigma and discrimination against PLWH ostracised force affluent PLWHA to access treatment outside the country. a few STD clinics, particularly in Colombo, Kolubowila and Kandy many ha
The sustainability of the ARV programme also needs to be considered. Th ends this year. Hence the authorities need to consider options for the futur or subsidised drugs. It is also important to ensure access to affordable experienced exposure to HIV such as health care workers and home based
Focus on other aspects: The NHAPP contains a component to streng Disease Control Programme (NTP). The country's vulnerability to an resurgence of Tuberculosis (TB). TB is the principal killer of HIV-infected that HIV-associated TB is yet a problem in Sri Lanka, the deterioration resources and support, together with the emergence of HIV, could effect GFATM would primarily support enhanced social mobilisation and outreac involved previously in TB efforts.
Another project working closely with the NHAPP is the National Blood Tr the blood bank infrastructure and screening for HIV.
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orking on HIV/AlDS issues with the general population and vulnerable knowledge exchange between these organisations. These projects are
ng the use of condoms. An obstacle faced by NGOs in dealing with such e project including putting together proposals within the requirements of to report, monitor and evaluate ptojects. Further, the government is fore many of the local NGOs and CBOs that are doing a lot of good work issues such as the approach taken by the NGO or personality issues.
the response to HIV/AIDS, much more needs to be done. As noted result may exclude other actors involved in HIV/AIDS work, especially racy in the government structure can also prevent the process from being
the media campaign to raise awareness on HIV/AIDS. YA TV, a private TV
t, which has conducted interviews, discussions and documentaries on nguages. While this is a positive step, there should also be initiatives
newspapers and magazines.
rovincial and district committees. This has resulted in more programmes e level, resulting in some decentralization. Though this is a positive step, ing a large say in how project implementation takes place.
ere is provision for 100 recipients to receive free ARVs.
for the provision of ARVs stem from a “Guide to Anti-Retroviral Therapy” 2005. According to the guidelines used by the STD Clinic, advice and
present health professionals at the STD Clinics follow these guidelines, dhered to when the programme is expanded geographically.
RV treatment programme is that many PLWHA are reluctant to come ination against PLWHA is very high in Sri Lanka, and fears of being nt outside the country. Furthermore, since free ARVs are provided only by ila and Kandy many have difficulty in gaining access.
s to be considered. The World Bank grant is for a period of 5 years and der options for the future in order to ensure the continued provision of free access to affordable short-term ARV prophylaxis for people who have orkers and home based care providers, as well as victims of rape.
a component to strengthen the National Tuberculosis and Respiratory 's vulnerability to an HIV epidemic has heightened concerns over a al killer of HIV-infected persons worldwide. Though there is no evidence nka, the deterioration of the national TB programme due to insufficient ce of HIV, could effect a dramatic change in this situation. A grant from obilisation and outreach functions through NGOs, which have not been
s the National Blood Transfusion Service (NBTS), which aims to improve .
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While several gaps have been listed above, a significant aspect that is lac contain space to address the needs of the IDH. With the initiatives under
tients, it is unclear as to why there were no funds allocated for improving has limited space for PLWHA and therefore it has been recommended th on and care for the needs of PLWHA. It is also notable that ARVs are not ensure that patients at the IDH need not travel to Colombo to receive ARVs
B) Efforts undertaken by the UN Theme Group pertaining to HIV/AID
The UN Theme Group on HIV/AIDS is active in various spheres, working to HIV/AIDS.
• UN Programme on HIV/AIDS (UNAIDS), the lead UN agency on HIV partnering with UN agencies to address HIV/AIDS. Therefore, UN agenc
working group, consisting of technical people from all agencies draft the UN strategic plan sets out the overall framework and activities of the UN
• United Nations High Commissioner for Refugees (UNHCR) deals w North East.
• International Organization for Migration (IOM) deals with issues rela
• World Health Organization (WHO) provides technical support on ep and is also involved in the strengthening of counselling and testing and
of medical practitioners.
• United Nations Population Fund (UNFPA) primarily focuses on provid and in under-served geographic areas. It also supports women’s clinics
aims at providing technical assistance for the formulation of national health.
• United Nations Children’s Fund (UNICEF) is yet another actor in the on HIV/AIDS, issues. UNICEF has funded government projects targetin the Department of Education, Youth Services Council as well as non-g UNIFEM has initiated a program on raising awareness in relation to repro
• The International Labour Organisation (ILO) has been actively inv recent work of the ILO is the signing of the National Tripartite Declaratio Lanka both within and outside the formal and informal sectors.
Future programmes on HIV/AIDS should be the responsibility of the Gover ensuring better coordination and information sharing. This will avoid du Though the UN agencies are involved in several areas related to HIV/A attention such as more targeted interventions with groups perceived to be government actors, including provincial and district officers and with local a
Further, the UN agencies should take a stronger stand on policy initiatives. of all stakeholders in the formulation of the draft HIV/AIDS policy, especi
also be a coordinated effort by all line ministries, ensuring that the draft po UN agencies can work with the respective line ministries, ensuring active
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ificant aspect that is lacking in the World Bank project is that it does not ith the initiatives underway at the IDH, with special care available to pa-
allocated for improving infrastructure and training staff. Presently the IDH been recommended that it have a separate building that will solely focus able that ARVs are not available at the IDH. Measures should be taken to olombo to receive ARVs but can obtain them at the IDH.
pertaining to HIV/AIDS
ious spheres, working with local actors to address various issues related
ead UN agency on HIV/AIDS, has been working in Sri Lanka since 1998, S. Therefore, UN agency heads decide on funding and spending and the
m all agencies draft the proposals and follow through with the work. The and activities of the UN agencies in Sri Lanka.
gees (UNHCR) deals with issues related to displaced communities in the
) deals with issues related to tsunami-affected communities.
echnical support on epidemic surveillance and estimation to the NSACP, selling and testing and has collaborated with UNFPA in capacity building
marily focuses on providing information and services to vulnerable groups pports women’s clinics providing training and counselling. Further, it also
formulation of national strategy for adolescent sexual and reproductive
yet another actor in the UN Theme Group, which has done a lot of work rnment projects targeting children and adolescents, working closely with ouncil as well as non-governmental organisations. UNICEF working with ness in relation to reproductive health and HIV/AIDS.
) has been actively involved in HIV/AIDS and related issues. The most onal Tripartite Declaration on Prevention of HIV/AIDS at workplaces in Sri
rmal sectors.
ponsibility of the Government, working closely with all other stakeholders, ring. This will avoid duplication of effort and ensure maximum results. areas related to HIV/AIDS, there are several activities that need further groups perceived to be vulnerable to HIV/AIDS as well as more work with
officers and with local actors including NGOs and CBOs.
nd on policy initiatives. For example, there needs to be more involvement IV/AIDS policy, especially PLWHA and vulnerable groups. There should
suring that the draft policy is multi-dimensional. In this regard, the various istries, ensuring active participation. For example, the ILO should ensure
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the active participation of the Ministry of Labour in this initiative. Similarly existing relationship with the various ministries, they should actively pursue
formulate and implement action plans regarding HIV/AIDS. The same enco and other entities that require action plans in their activities. Such action p providing financial and technical assistance, since they have been workin knowledge and expertise.
C) Initiatives by Other Actors
USAID initiated a 5 year plan on prevention, focusing on several risk gr activities, working with local NGOs on topics including VCT, condo technical assistance and capacity building
Action Aid initiated a project on HIV/AIDS in February 2005, largely changes. Action Aid works in collaboration with local NGOs, attemptin to NGOs working with PLWHA. For example, LANKA + have been prov capacity building.
The Asia Pacific Leadership Forum (APLF) initiated leadership in H commissioned by APLF such as high-level leadership initiatives and me
Save the Children focuses their work on child related issues. They wer risk behaviour of children and young persons, stigma and discrimina
evaluation, and surveillance systems improvement.
There are several international organizations that work through their part
The Canadian International Development Agency (CIDA) has proj
violence and runs programs targeting groups such as migrant workers were awareness raising programmes including training on STDs and con
The European Commission in Sri Lanka is not directly involved in H
and sexual health projects which are implemented by partner organizati
The Japan International Cooperation Agency (JICA) and the Japa work with the government by providing soft loans targeting mainly inf drafting the Master Plan document as well as providing assistance on im
Gaps in Interventions by International Actors:
Coordination among international actors, local actors and governme efficient response. With the increasing number of projects and actors i exercise should be undertaken to obtain a clear picture as to who is inv yet to commence and what has been completed. This would give a cle actors and the geographic areas covered, and assist in reducing duplica
As pointed out previously, organizations may only concentrate on geo prior presence in, and may avoid working in certain geographic a International organizations should ensure that interventions take place presence should not be the determining factor on whether to get i
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n this initiative. Similarly, since the various UN agencies already have an should actively pursue encouraging ministries and government offices to
V/AIDS. The same encouragement should be offered to the private sector activities. Such action plans should be supported by the UN agencies, by they have been working in the respective areas and have the requisite
sing on several risk groups. The project is largely focused on outreach including VCT, condom promotion, communications and providing
ebruary 2005, largely focusing on capacity building and behavioural local NGOs, attempting to empower PLWHA and providing assistance NKA + have been provided with assistance for office maintenance and
itiated leadership in HIV/AIDS activities. Several activities have been ship initiatives and media programmes using popular personalities.
lated issues. They were in the process of initiating programmes on the stigma and discrimination associated with HIV/AIDS, monitoring and
t.
work through their partner organizations.
ency (CIDA) has projects on gender issues such as gender based
ch as migrant workers, prisoners and commercial sex workers. Most ining on STDs and condom use.
directly involved in HIV/AIDS projects but is involved in reproductive
d by partner organizations
(JICA) and the Japan Bank for International Cooperation (JBIC) ns targeting mainly infrastructure projects and providing assistance in
viding assistance on improving the Blood bank.
actors and government actors must be strengthened to ensure an f projects and actors involved in HIV/AIDS, a comprehensive mapping picture as to who is involved and what activities are underway, what is . This would give a clear idea of the activities related to HIV/AIDS, the sist in reducing duplication of work.
ly concentrate on geographic areas that they are working in or had a certain geographic areas that are in need of HIV/AIDS activities. terventions take place depending on need and urgency. Lack of field r on whether to get involved or not. Partnerships with local actors
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including government officials, NGOs and CBOs should ensure that act actors who know of local issues and already have a relationship with th
need to establish large field offices and at the same will build the capac
Funding and technical assistance should not solely target prevention ac and support. Certain agencies are experiencing financial constraints o
example, due to UNHCR shrinking their projects and moving to more em over to other actors such as UNICEF. In such instances, measures mu on all areas covered and that certain aspects are not abandoned.
The International Conference on AIDS in Asia and the Pacific (ICAA Sri Lanka is hosting the ICAAP in August 2007 and as a result there is an i are focusing on the ICAAP event in order to ensure that it is a success wit While acknowledging that such an international event can be beneficial in a must also be paid to the process of handling the issue and raising aware are getting involved in the event itself, there should also be attention to wh that all the actors who are involved in the conference are encouraged to s HIV/AIDS activities. All stakeholders should also keep in mind that other diverting funds year marked for HIV/AIDS work. For example, large amoun
tation work following the tsunami disaster in December 2004, resulting in sponse towards HIV/AIDS. The interest and attention generated in August keeping the response targeted and effective.
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should ensure that activities on the ground are undertaken by the local e a relationship with the community. Such measures would reduce the
e will build the capacity of local actors.
ly target prevention activities, but should also improve treatment, care financial constraints or limitations resulting in shrinking projects. For
and moving to more emergency work, development issues are handed tances, measures must be in place ensuring that the new actor takes not abandoned.
and the Pacific (ICAAP)
as a result there is an increase in the focus on HIV/AIDS activities. Many that it is a success with several projects planned around the same time. nt can be beneficial in addressing HIV/AIDS issues in Sri Lanka, attention ssue and raising awareness among the public on HIV/AIDS. While many also be attention to what will happen subsequent to the ICAAP. It is vital ce are encouraged to sustain their efforts and ensure continued work in ep in mind that other events may receive greater attention and thereby r example, large amounts of money were spent on the relief and rehabili-
mber 2004, resulting in less funding and attention being given to the re- on generated in August 2007, needs to be sustained by all stakeholders,
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Conclusion
The increasing attention on HIV/AIDS in Sri Lanka has resulted in the in response. While several positive changes have taken place in the last few both at the policy level and in practice. There have been encouraging sig AIDS, but statements must be converted into concrete measures. Discuss policies and plans. Attention and funds generated through international awareness and the profile of HIV/AIDS, removing myths and misconce Interest generated through international conferences need to be sustain around a particular event but is well planned, sustained, effective and targe
A significant issue that needs to be addressed is the treatment of HIV/A issue having socio-economic and cultural implications. Such a perspective actors that should be involved in the process. Consequently the response Lanka needs to progress from previous held views, recognising the debilit increased numbers of PLWHA having a strain on the income of their fa problems within and among families and communities. Loss of livelihood
social network negatively affect people and adversely impact economic gro
In addition very little attention is given to a rights based framework in r including the rights and dignity of PLWHA and their families, informed cons in decision making. For an effective response, it is crucial to have a rights principles ensuring the decentralisation of health care and decision making
Due to the low prevalence in Sri Lanka, the response has been dominated care and support. While there is a need for prevention activities and curbin side lining the importance of treatment, care and support. With HIV/A vulnerability factors pointing to a possible outbreak, the government and care and support activities. The situation of PLWHA and their families sh improvement of treatment, care and support services.
Laws and Policies
There is a limited framework of laws and policies in relation to HIV/AIDS i the rights of PLWHA and vulnerable communities are needed, it is ques stigma and discrimination, misconceptions and prejudices is prepared cognizant of the draft policy and the debates surrounding it (evidence d
science approach over a rights framework,) goes to show the thinking be Strategic Plan strives to address certain human rights and governance iss Plans, policies and regulations, there is still concern regarding the process
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Conclusion
a has resulted in the influx of more resources towards a more targeted en place in the last few years, there is much more that needs to be done e been encouraging signs from the political leadership in relation to HIV/ rete measures. Discussions and meetings need to materialise into strong d through international conferences need to be best utilised in raising g myths and misconceptions and reducing stigma and discrimination. es need to be sustained, ensuring that the response does not revolve ined, effective and targeted.
the treatment of HIV/AIDS as a health issue and not as a development ns. Such a perspective limits the scope of the response by excluding key equently the response is one sided and not as effective as it could be. Sri , recognising the debilitating impact HIV/AIDS can have on its population; the income of their families and severely affecting livelihoods, creating nities. Loss of livelihood, homes, educational opportunities, families and
ly impact economic growth and development.
based framework in relation to the HIV/AIDS response, raising issues families, informed consent, confidentiality, participation and inclusiveness crucial to have a rights based approach coupled with good governance re and decision making in relation to the response.
se has been dominated by initiatives on prevention rather than treatment, ion activities and curbing the spread of HIV/AIDS, this should not result in d support. With HIV/AIDS estimated cases numbering at 5000, with , the government and others should take steps to strengthen treatment, A and their families should also be considered in the development and es.
n relation to HIV/AIDS in Sri Lanka. While laws respecting and protecting are needed, it is questionable whether Sri Lanka with its high levels of prejudices is prepared to legislate on such a sensitive subject. Being rrounding it (evidence demonstrating the heavy reliance on the medical
o show the thinking behind the response towards HIV/AIDS. Though the hts and governance issues, and is an improvement on previous Strategic regarding the process of formulation and implementation of the Strategic
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Plan. Further, while the Strategic Plan incorporates several improvements overall response towards HIV/AIDS is still very much centralised and top
rather than a development issue.
Institutional Framework
There are several structures in place in the response to HIV/AIDS, the hig the President of Sri Lanka. While there are prominent leaders suppose lethargic and to some extent ineffective. It is to be questioned whether the motivated by international attention, conferences such as ICAAP and med AIDs Council chaired by the President of Sri Lanka and the NAC chaired play an active role in the response towards HIV/AIDS. Without strong po ICAAP, institutional structures in the response to HIV/AIDS is plagued wi While this paper recognises the positive role played by particular individuals HIV/AIDS, the government of Sri Lanka and its leaders need to take a stron response towards HIV/AIDS.
Stigma and Discrimination
The level of stigma and discrimination and its existence in the different sph and not exhaustive of the situation in Sri Lanka. While no comprehens sources and levels of stigma and discrimination, the issues captured demo as a lack of awareness of what HIV/AIDS actually is, methods of c misconceptions, prejudices and fears. Issues such as the absence o
discriminatory laws, policies and regulations that marginalise PLWHA a inadequate resources, infrastructure and trained staff and other issues a negative picture on HIV/AIDS, PLWHA and vulnerable communities. Re
raising awareness on HIV/AIDS and its profile, is important for an effective be from the government of Sri Lanka, through the National AIDS Cou government officers, I/NGOs, private sector, media and other relevant acto
Access to Medication and Treatment
The process in which free ARVs were obtained demonstrates the increased coupled with lack of coordination and poor information flow among relevan
lack of understanding of issues related to HIV/AIDS, all add up to a syste procedures and plans, and which easily forgets the human element in the r
Access to medication is an inherent right of people. This does not and sho
should have access to free ARVs. The present system, while providing ARV all PLWHA in Sri Lanka. In addition, practical difficulties and stigma and forward to access free treatment. In a country that boasts of free public h situation speedily, ensuring that PLWHA across the country have easy effective decetralisation needs to take place ensuring availability of resourc
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s several improvements in relation to human rights and governance, the ch centralised and top heavy, with many still considering it a health issue
se to HIV/AIDS, the highest having the presence of key leaders including inent leaders supposedly involved in the response, it has been slow, questioned whether the response towards HIV/AIDS by politicians is only uch as ICAAP and media blitz. A good example is the role of the National and the NAC chaired by the Secretary of Health, both which are yet to IDS. Without strong political leadership which is sustainable beyond the IV/AIDS is plagued with bureaucracy, inefficiency and lack of direction. by particular individuals in the MOH and NSACP in the response towards ers need to take a strong, consistent and enduring proactive stand in the
nce in the different spheres captured in the document is only an indicator While no comprehensive documentation has been done to study the e issues captured demonstrates certain trends in the society at large such ally is, methods of contracting, rights of PLWHA and their families, ch as the absence of rights based legislation and policies, existing
marginalise PLWHA and vulnerable communities, centralised planning, taff and other issues all add up to exacerbate the situation, drawing a rable communities. Reducing stigma and discrimination, coupled with
portant for an effective response. In this respect, the leadership needs to he National AIDS Council and NAC, working closely with the relevant and other relevant actors.
onstrates the increased bureaucracy within the system. The bureaucracy tion flow among relevant government actors as well as the possibility of a
S, all add up to a system which is weighted down with too many actors,
human element in the response to HIV/AIDS.
. This does not and should not change in relation to HIV/AIDS. All PLWHA
em, while providing ARVs to 100 is not resourced to address the needs of culties and stigma and discrimination impede many others from coming t boasts of free public health care, effort should be made to address this the country have easy access to quality treatment. In such a context, g availability of resources, infrastructure and trained staff in all STD clinics
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across Sri Lanka. The provision of medication and treatment must be responses including awareness raising campaigns that aim to reduce levels
Initiatives by Non Governmental Actors
Glancing at the initiatives underway, and the numerous actors involved,
large role in the response to HIV/AIDS in Sri Lanka. While there are s provided by the President of Sri Lanka, it is evident that there is a dep providing resources, infrastructure, expertise, knowledge and care. This c other impediments within the government system. As highlighted in this se continue to play an active and much needed role, this should not leave s the primary actor in the response towards HIV/AIDS.
It must also be noted, that non governmental actors are not free of blame.
make the response effective, targeted and timely. Leadership must be taking the initiative to introduce and sustain activities in the response towa flow within and between the specific sectors needs to be improved, with
programmes, thereby avoiding duplication of efforts.
The various actors involved in the response can also play a pivotal role awareness levels and reducing stigma and discrimination. They can also e implement rights based legislation and policies in a transparent and partic
and policies that infringe the rights of PLWHA and vulnerable groups. Le section can play a pivotal role in the response towards HIV/AIDS, actively p respect and protect the rights of PLWHA and vulnerable groups, and misconceptions related to HIV/AIDS.
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nd treatment must be planned in close coordination with prevention that aim to reduce levels of stigma and discrimination.
erous actors involved, it is evident that non governmental actors play a
nka. While there are several government actors listed, with leadership ent that there is a dependency on non governmental actors to step in, ledge and care. This could also be due to the bureaucracy, delays and As highlighted in this section, while non governmental actors can play and this should not leave space for the government to shirk its duty of being
.
s are not free of blame. As noted above, much more needs to be done to
. Leadership must be demonstrated from the specific sectoral leaders, s in the response towards HIV/AIDS. Coordination and better information s to be improved, with better planning in prevention, treatment and care
.
also play a pivotal role in projecting the true facts on HIV/AIDS, raising ination. They can also exert pressure on the government to formulate and transparent and participatory manner and to amend discriminatory laws
vulnerable groups. Leaders in the specific categories mentioned in this rds HIV/AIDS, actively promoting a rights based approach that recognise, vulnerable groups, and through their leadership dispelling myths and
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Recommendations
1. Formulating a National HIV/AIDS Policy
• A National HIV/AIDS Policy, which is comprehensive and multi-se
• The policy should have a strong rights framework, ensuring partic formulation process.
• The policy should recognise, respect and protect the rights of PL
• The policy should include a component on sensitive media report
compliance.
• The policy should state the negative implications of mandatory te voluntary testing, involving pre- and post-test counselling.
• The policy should advocate behavioural change programmes and targeting people in situations of risk as well as include standards
• The policy should include a component on building and strengthe supportive environment for PLWHA.
2. Legislation in relation to HIV/AIDS
• In the event legislation in relation to HIV/AIDS is introduced, the le formulated in consultation with all relevant stakeholders including
• Legislation in relation to HIV/AIDS should recognise, respect and
groups.
• Amend discriminatory laws such as the Penal Code and Vagrants
3. Issues associated with the Strategic Plan
• Implementation of the Strategic Plan should be multisectoral and
• The Strategic Plan should strengthen and involve regional STD C
• The Strategic Plan should ensure there is an effective media and
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Recommendations
/AIDS Policy
prehensive and multi-sectoral, needs to be formulated.
mework, ensuring participation, transparency, inclusiveness in the
protect the rights of PLWHA and vulnerable groups.
n sensitive media reporting, and provide for a monitoring body to ensure
cations of mandatory testing and reiterate the importance of informed test counselling.
hange programmes and communication programmes specifically
ll as include standards for the work place and educational institutions.
n building and strengthening family and community capacity to provide a
IV/AIDS
IDS is introduced, the legislation should have a strong rights framework, t stakeholders including PLWHA and vulnerable groups.
recognise, respect and protect the rights of PLWHA and vulnerable
enal Code and Vagrants Ordinance.
Strategic Plan
ld be multisectoral and with the involvement of PLWHA.
involve regional STD Clinics and other entities.
an effective media and communication strategy in place.
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4. Proactive leadership
• The National AIDS Council and the NAC need to be strong and p
• Policy decisions and direction on the HIV/AIDS response need to communicated to the NSACP and local actors.
• There should be a coordinated and concerted effort by all politica community leaders in the response towards HIV/AIDS.
5. Strengthening of the NSACP
• All STD Clinics should have trained staff who are educated and s should be available to provide information on ARV treatment, trea
• All STD Clinics and the IDH should have all necessary resources the government.
6. Prevention Activities
• There should be coordinated efforts to raise awareness on HIV/A discrimination.
• There should be programmes to increase awareness of precautio
• Prevention initiatives should be coordinated and led by Governme agencies, NGOs, CBOs, the private sector and the media.
• Prevention initiatives should involve PLWHA, marginalised and vu while at the same time empowering these groups.
• Prevention initiatives should take place in all geographic areas, bo be given to areas where there are high levels of high-risk behavio
7. Treatment, care and support
• The Government must ensure that access to medication and hea
• Resources and attention towards treatment, care and support sh government programmes.
• The Government should provide free ARTs to all PLWHA.
• Access to ARTs should extend beyond a few STD Clinic in urban
• Health staff working in all STD Clinics should be trained in providi
• Treatment for opportunistic infections should also be available to
• The MOH should ensure that all health institutions practice Unive Prophylaxis (PEP).
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eed to be strong and proactive in the HIV/AIDS response.
AIDS response need to be made at the Council and the NAC and ctors.
rted effort by all political, religious, private sector, youth, women and ds HIV/AIDS.
P
ho are educated and sensitised on STDs and HIV/AIDS. Specialized staff on ARV treatment, treatment for STDs and opportunistic infections.
ll necessary resources and infrastructure which is provided primarily by
se awareness on HIV/AIDS, which can reduce the stigma and
awareness of precautionary steps and reduce high-risk behaviour.
d and led by Government bodies with the assistance of international r and the media.
A, marginalised and vulnerable groups, ensuring inclusivity and diversity, groups.
all geographic areas, both urban and rural. Special consideration should els of high-risk behaviour/groups in situations of risk.
rt
s to medication and health care is available to all.
nt, care and support should increase in both government and non
s to all PLWHA.
few STD Clinic in urban areas and expand to other areas.
uld be trained in providing ARVs.
uld also be available to all in all health institutions.
titutions practice Universal Precautions (UP) and Post-exposure
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• Pre-test and post-test counselling must be made available to all t pre-test and post-test counselling is a policy that is adhered to by
• There should be increased assistance and resources in developin initiatives.
8. Initiatives by Non Governmental Actors
• Leaders in the respective fields should play a proactive role in rais
• There should be organizational capacity building, training and fina
on HIV/AIDS and related matters. Attention should be given to or based care, as there are a limited number of such organizations.
• There should be better coordination among the various organizat actors and the private sector should be encouraged and facilitate
• There needs to be sensitive reporting of HIV/AIDS and related sto training of journalists, editors and media personnel on methods o
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e made available to all taking an HIV test. The MOH should ensure that licy that is adhered to by all health institutions.
resources in developing and sustaining community care and support
ental Actors
y a proactive role in raising awareness and the profile of HIV/AIDS.
uilding, training and financial resources provided to organizations working
n should be given to organizations providing hospice and community
of such organizations.
g the various organizations as well as with the Government, international ncouraged and facilitated.
IV/AIDS and related stories. All stakeholders must ensure that there is ersonnel on methods of reporting a HIV/AIDS story.
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Endnotes
1Sexually Transmitted Diseases (STD) Clinic in Sri Lanka,
2 Dr. Samarakoon, Current HIV/AIDS situation in Sri Lanka and its impact o
3 Ibid.
4 Ibid.
5Ibid.
6 Ibid.
7 Ibid.
8 Ibid.
9 HIV/AIDS in Sri Lanka, The World Bank, June 2005
10 One such organization, the Community Strength Development Foundatio and conducts awareness programmes on a regular basis.
11 Sri Lanka Country Report on Follow Up to the Declaration On Commit December 2005
12 Ibid.
13 National Survey on Emerging Issues Among Adolescents in Sri Lanka, U
14 National Strategic Plan for Prevention and Control of HIV/AIDS in Sri Lan
15 Ibid.
16 For more information on laws and policies please refer to the draft paper Sri Lanka” prepared by Bhavani Fonseka, CPA to be presented on 16th Aug
17 Further, the draft policy includes a section under the subheading “Medi PLWHA to have access to treatment without any discrimination (refer to D nent on care and support which deals with treatment, care, counselling and
18 A Profile of the Stigma and Discrimination faced by People Living with HI
19 Amendment Act No. 29 of 1998, Section 365A
20 No. 2 of 1978, section 3(1)(b)
21 See http://www.mdg.lk as at January 2006
22 Daily News, 1st December 2004
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Page 33
anka,
i Lanka and its impact on the world of work, 2005
5
Development Foundation (CSDF), has access to commercial sex workers basis.
Declaration On Commitment on HIV/AIDS (UNGASS), Ministry of Health,
lescents in Sri Lanka, UNICEF 2004
l of HIV/AIDS in Sri Lanka 2002-2006
refer to the draft paper “A Critique on Policy Interventions on HIV/AIDS in e presented on 16th August 2007.
r the subheading “Medical Treatment” which states that there is a right of iscrimination (refer to Draft Policy). The Strategic Plan includes a compo- nt, care, counselling and personal support (refer to Strategic Plan).
by People Living with HIV/AIDS, CPA 2005
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23 Daily News, 1st December 2004
24 Proposals which were used at the Presidential elections, and which in These proposals are used as guiding principles by the present government
25 Speech made at the National Consultation on HIV/AIDS and Human Rig
26 The Poverty Reduction Strategy paper and Vision 2002 is a policy paper objective of restoring economic growth and eliminating poverty in Sri Lanka
27 For more information on laws and policies please refer to the draft paper Sri Lanka” prepared by Bhavani Fonseka, CPA to be presented on 16th Aug
28 For more information on laws and policies please refer to the draft paper Sri Lanka” prepared by Bhavani Fonseka, CPA to be presented on 16th Aug
29 Sri Lanka Country Report on Follow Up to the Declaration On Commit December 2005
30 Draft paper “A Critique on Policy Interventions on HIV/AIDS in Sri Lank sented on 16th August 2007.
31 More information on Stigma and Discrimination faced by PLWHA and Profile of the Stigma and Discrimination faced by People Living with HIV/AI
32 www.unaids.org
33 U.N. GAOR, Special Session on HIV/AIDS, Declaration of Commitment Doc. S-26/2 (2001), para. 17
34 Memorandum addressing the need for a treatment agenda to be include National AIDS Prevention Project, available at www.samuelsclinic.org
35 The memorandum suggested methods to address the lack of access to manufacturers for reasonable prices for AIDS drugs.
36 Attention was drawn to the Brazilian Experience, where in 1996 a polic has resulted in improved and longer lives for all persons living with HIV. Th therapy, Brazil had achieved a 50% reduction in the number of AIDS dea opportunistic infections among HIV infected patients.
37 The MOH declined to utilize the funds because it believed that such a period is complete. Nevertheless, the Ministry representatives indicated th of ARV treatment if the MOH Budget includes a line item specific for the p was rejected by the Treasury, Dr. Kamalika Abeyratne, Drug Access for Per
38 Please refer to page 23 for more information.
39 A Profile of the Stigma and Discrimination faced by People Living with HI
40 A study on HIV/AIDS among media personnel for the first time in Sri La AIDS. 2002 Jul 7-12; 14: abstract no. TuPeE5099. Sri Lanka Public Heal able at http://gateway.nlm.nih.gov/MeetingAbstracts/102253746.html
41 http://www.unaids.org/en/MediaCentre/PressMaterials/FeatureStory/200
42 http://www.panossouthasia.org/Left_read.asp?LeftStoryId=104&leftSec
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elections, and which introduce the policies of the Presidential candidate. the present government.
V/AIDS and Human Rights, 2nd December 2004.
n 2002 is a policy paper introduced by the then UNP government with the ting poverty in Sri Lanka.
refer to the draft paper “A Critique on Policy Interventions on HIV/AIDS in e presented on 16th August 2007.
refer to the draft paper “A Critique on Policy Interventions on HIV/AIDS in e presented on 16th August 2007.
Declaration On Commitment on HIV/AIDS (UNGASS), Ministry of Health,
n HIV/AIDS in Sri Lanka” prepared by Bhavani Fonseka, CPA to be pre-
faced by PLWHA and their families in Sri Lanka can be accessed in “A eople Living with HIV/AIDS” CPA, 2005.
laration of Commitment on HIV/AIDS: Global Crisis—Global Action, U.N.
nt agenda to be included in the proposed World Bank financed Sri Lanka .samuelsclinic.org
ss the lack of access to HIV medications, including negotiating with drug .
, where in 1996 a policy to provide universal free access to ARV therapy rsons living with HIV. The report notes that since the introduction of ARV e number of AIDS deaths and a 60%-80% reduction in the incidence of s.
it believed that such a program would not be sustainable once the grant esentatives indicated that they will be prepared to accept aid for the cost e item specific for the provision of drugs for HIV. However, this suggestion
e, Drug Access for Persons Infected with HIV, loose-leaf
by People Living with HIV/AIDS, CPA 2005
or the first time in Sri Lanka, Samarakoon S, Batuwantudawa R. Int Conf . Sri Lanka Public Health Women's Network, Colombo, Sri Lanka. Avail- s/102253746.html
terials/FeatureStory/20060731-srilanka.asp
eftStoryId=104&leftSectionId=1
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43 This programme has three main strategies. The first is the high–risk pop nerable groups with the assistance of organisations working on HIV/AIDS tion strategy, aims to address stigma and discrimination through actors in Youth Services Ministry, SLBFE and other government ministries and Distr also focuses on the promotion of blood safety through the National Bloo deals with care and treatment, focuses on providing medical and nursing port, as well as involving positive individuals and their families, and meeting
44 These include the National Child Protection Authority, the Sri Lanka Bur of Education, the Ministry of Labour’s Workers’ Education Unit, the Depart the Army, Navy and Air Force, Police Department, the Vocational Training liaising with provincial and district health authorities.
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first is the high–risk population strategy, which focuses on identifying vul- s working on HIV/AIDS issues. The second strategy, the general popula- nation through actors in the government sector. These include the MOH, ent ministries and District and Provincial AIDS Committees. The strategy ough the National Blood Donation Programme. The third strategy, which g medical and nursing care, psychological support, socio-economic sup-
ir families, and meeting their legal needs.
ority, the Sri Lanka Bureau of Foreign Employment, the National Institute ucation Unit, the Department of Prisons, National Youth Services Council, the Vocational Training Authority and the Ministry of Fisheries, as well as .
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