by Commander Bhanu Abeygunawardhana
Published on The Morning on 11th September 2024.
It is important to highlight that, the Medical and Civil Rights Professional Association (MCPA) of Doctors in Sri Lanka has illustrated on 19th August 2024 that based on the percentage of individuals who are both found and undetected, the island should have a minimum of 5,000 patients suffering from Acquired Immunodeficiency Syndrome (AIDS) and only 3500 patients have been identified. Also, MCPA highlighted that there were 700 new cases of AIDS diagnosed on average every year. More specifically, MCPA indicated that approximately 0.03 cases of AIDS were diagnosed for every million people by the year 2018. On the other hand, they have further noticed that the figure had climbed significantly to 0.1, or more than 300 per cent. The virus known as the Human Immunodeficiency Virus (HIV) targets the immune system and AIDS manifests at the highest point of infection. As explained by the World Health Organization (WHO), HIV can spread through bodily fluids such as blood, breast milk, semen, and vaginal secretions from an infected individual. However, it cannot be transmitted by sharing meals, hugs, or kisses. Moreover, it can pass from a mother to her child.
Nat’l security point of view
Indeed this situation is essential to address from the national security point of view in the country because due health security of the community may face dangerous situations in the future whilst increasing the number of AIDS-infected populations in the country. On the one hand, vice versa it will affect the country’s economic security as well when considering the provision of long-term free medicine and the loss of workforce due to AIDS infection. For instance, the most common method of HIV transmission is through sexual conduct, with heterosexual relationships accounting for the majority of infections. In particular, notably, this mode of transmission is greatly aided by risky sexual behaviours including commercial sex. In particular, several conditions and behaviours increase a person's risk of HIV infection such as having sex without the use of a condom during anal or vaginal sex, contracting another STI, such as bacterial vaginosis, syphilis, herpes, chlamydia, gonorrhoea, or chlamydia. Also, it can be spread by abusing alcohol or drugs during sexual behaviour, sharing contaminated needles, syringes, or other injecting equipment, getting unsafe injections, blood transfusions, or tissue transplantation and undergoing medical procedures that involve sterile cutting or piercing or needle stick injuries, including even among health workers.
Furthermore, due to their line of work, female sex workers (FSWs) frequently partake in a variety of high-risk sexual practices, such as multiple sexual partners, unprotected sex, and high mobility. Indeed, because of the aforementioned reasons, as explained by Tang H & Lv F (2007), “Role of bridge population in the transmission of human Immunodeficiency” they are considered a "bridge population" for the spread of HIV from high-risk populations to the broader population and a population that is vulnerable to the virus. It was identified that stigma, aggression, and a lack of social support are major obstacles to stopping HIV transmission among sex workers. Furthermore, because they operate in foreign nations, migrant FSWs are more vulnerable to HIV transmission than local FSWs. For instance, there are a significant number of migrated FSWs operating in Sri Lanka. It is required to intimate that, HIV prevention poses more of a challenge for migrated FSWs because of several reasons including poor negotiation skills during work, a lack of legal rights, higher mobility, and language barriers.
HIV-risk behaviours
On the other hand, it was identified that HIV risk behaviours, such as condom-free intercourse, are influenced by social and environmental factors in addition to personal ones. For instance, as highlighted by the MCPA the disease is more common in sex workers, gays, and those in the travel and tourism sector in Sri Lanka. Indeed, since the Sri Lankan economy is highly dependent on tourism, the community engaged in the tourism sector is highly vulnerable to HIV spreading. More specifically, it is important to highlight that reports of cases of the disease among university students and kids have also been made in Sri Lanka and it is significant to address immediately.
It is important to highlight that, with the rapid improvement of social media access in the country, it has begun to play a prominent role in finding sex partners in various ways. In particular, social network elements are crucial in promoting or preventing HIV transmission. Indeed, a social network is an assembly of people connected by a variety of social ties. Furthermore, any kind of relationship can be considered a part of a network, including those with spouses, relatives, friends, bosses, and subordinates. In particular, the network functions include helping and impeding impacts in terms of emotions, materials, or information. On the other hand, most of the population in Sri Lanka at present use social media for various purposes.
More importantly, a huge number of social media groups operate in Sri Lanka either covertly or overtly for various purposes. It is important to highlight that, within those groups, there are high possibility of finding commercial sex workers or temporary sex partners for a short term. In contrast, these unknown sex partners and unprotected sexual behaviours are significant to spread the of HIV/AIDS in the country. In particular, there are various opportunities available on various social media platforms including various websites to contact sex workers in Sri Lanka overtly even though prostitution is legally prohibited in the country by law. In contrast, this easy access of sex workers through social media and websites becomes more vulnerable to the spread of HIV in the community. On the one hand, the significant use of social media groups under various themes provides a vulnerable platform for temporarily creating bonds to fulfil sexual requirements with unknown sex partners even married men and women who have families. Importantly, this kind of temporary relationship buildup for the fulfilment of sex requirements can be observed island-wide and it is highly vulnerable to the spreading of AIDS within the Sri Lankan population.
In addition, it has been deidentified that rules and regulations on functioning ‘SPA’ as well as monitoring of them by the relevant authorities need to be addressed in the country. Moreover, it has been highlighted that the filed of ‘SPA’ in country has also providing opertunity for bridge population in the transmission of human Immunodeficiency. The word "spa" refers to a broad range of activities and services; it can refer to anything from intimate facial and massage parlours to massive resorts offering endless pampering. In particular, there were many cases reported in the country misusing spa centres for prostitution even utilising foreign female workers. For instance, those spa centres become more vulnerable to the spread of HIV/AIDS in Sri Lanka. On the other hand, the number of spa centres in the country increasing day by day due to various reasons. Hence, prompt and effective action must be taken to proper monitory of workers dealing within spa sector and rules must be introduced to condut medical tests and obtain HIV-free certificates as which done by some countries.
Cultural barriers
On the other hand, it was identified that cultural barriers exist within the vulnerable communities preventing reporting to the Ministry of Health’s STD/AIDS prevention campaign for treatments. Also, unawareness of the symptoms of HIV infections causes to further spread of the virus. Furthermore, there were many cases reported in the media recently regarding gang rape and long-term time to time raping cases even from school kids to very older people representing various layers of the general population. Moreover, communities in rural areas, labourers in the tea plantation industry, illegally migrated foreign people, legally migrated foreign labourers, prisoners, uneducated community and drug-addicted people living in Sri Lanka are much more vulnerable to HIV/AIDS infection since the country doesn’t have sound screening system to detect HIV/AIDS infected patients. In fact, the population engaged in the field of textile garments is also vulnerable to the influence of HIV/AIDS due to culture, living environment and social factors. In addition, there are a considerable number of the population are serving in Sri Lanka's armed services, Sri Lanka Police, and Civil Defence Force and must introduce the conduct of HIV tests for their annual medical examination because the community is vulnerable to the spread of HIV due to high mobility.
For instance, as explained by the WHO, antiretroviral therapy (ART) can be used to both prevent and treat HIV. However, AIDS can develop from untreated HIV, frequently years later. It is important to highlight that, even though there shall be more than 5,000 patients suffering from AIDS as explained by the MCPA, the situation may be worse than estimated when considering the aforementioned facts and opportunities availed for the spread of HIV among communities. In particular, the aforementioned facts are developing a significant alarming situation for health security in the country since identified patients suffering from HIV/AIDS are similar to the visible portion of an iceberg floating on the sea. Indeed, like a below surface portion of a floating iceberg on the sea, there may be a significant number of unidentified patients infected with HIV/AIDS and shall operate as a “bridge population” for the further spread of the virus since there are many opportunities exist in the country especially based on social media as explained above for find sex partners.
Hence, the country should initiate immediate, effective and sound actions to identify HIV/AIDS-infected patients as well as control the spreading of HIV/ AIDS among the Sri Lankan population. More specifically, the government health sector shall further lead in initiating the various actions and collaborations with the WHO, private health sector, Non-Government Organizations (NGOs), Immigration & Migration department and the country's general public to identify HIV/AIDS-infected individuals and control the further spreading of HIV/AIDS. In particular proper mechanisms should be established at the earliest possible to screen the general community for identifying HIV/AIDS-infected individuals. More specifically, the conduct of a random HIV/AIDS identification test island-wide can be done as an immediate action and it is significant to identify HIV/AIDS-infected individuals, community and distribution patterns within the population. Indeed, it may require conducting Big Data Analysis (BDA) with a high rate of random tests to map the HIV/AIDS spreading pattern in Sri Lanka.
Furthermore, as explained above there are various individual social media accounts and social media groups under several social media platforms and websites that advertise or publish about sex workers overtly in Sri Lanka. Indeed, since prostitution is prohibited by the law in the country, such kind of social media accounts, groups and websites should be banned earliest as a primary step to control the spreading of HIV/AIDS in Sri Lanka. Also, monitoring those openly published sex workers and conducting HIV/AIDS tests must be carried out to identify HIV/AIDS-infected individuals since they are vulnerable to the spread of the virus.
Moreover, as illustrated above there are a considerable number of foreign sex workers operating in the country who legally or illegally migrated to Sri Lanka for various purposes. Furthermore, foreign sex workers are operating covertly in the country who have already expired their granted visa tenure. On the other hand, rules and regulations for conducting HIV/AIDS tests when people arriving in the country from abroad must be strengthened to identify HIV/AIDS-infected people and control HIV/AIDS spreading in Sri Lanka. Finally, it is understood that the number of HIV/AIDS infected population may be significantly higher than the already identified number and those unidentified HIV/AIDS infected communities can be considered as an underwater portion of the floating iceberg than the visible portion and they will further continue to spread HIV/AIDS as a “bridge population” making tangible deterrence for the country’s health security. Also, treating the health security of the country directly impacts human security as well. Hence remedial, effective, efficient and sound actions must be initiated to enhance community awareness about HIV/AIDS including school levels. Further proper mechanisms should be introduced to screening and identifying the HIV/AIDS-infected people already living within the population. In addition, effective action must be initiated to conduct HIV tests on those who are migrating to the country from various foreign nations for numerous purposes to secure the health security of the country controlling HIV/AIDS spreading within the Sri Lankan population.
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* Commander Bhanu Abeygunawardena is a Military Research Officer at the Institute of National Security Studies (INSS), the premier think tank on National Security established under the Ministry of Defence. The opinions expressed are his own and not necessarily reflective of the institute or the Ministry of Defence.