COUNTRY SITUATION ANALYSIS

The national response to AIDS

Nearly two decades since reporting its first HIV infection, Sri Lanka remains one of the few countries in this region with a low-level AIDS epidemic. There is considerable evidence that Sri Lanka is vulnerable to the development of concentrated AIDS epidemics. Female sex workers are found in most of the major towns and cities, and there are networks of men who have sex with men, who have multiple partners including paying clients. Sri Lanka has a high number of heroin users and although few of them currently inject drugs, if there were a substantial change in drug-use patterns to more injecting drug use, this would result in the increase in the number of people who are likely to be exposed to HIV. However, lack of information on all of these parameters makes it impossible to predict the potential size of concentrated AIDS epidemics in Sri Lanka.

The national response is coordinated by the National STD/AIDS Control Programme (Ministry of Health), which is responsible for planning, monitoring and provision of technical guidance, as well as some implementation at decentralized levels. Coordination in 2006 included support to a number of nongovernmental organizations, leaders of faith-based groups, and government departments and ministries, and collaboration with major private-sector initiatives.

Donors include the World Bank, eight United Nations (UN) agencies and the International Organization for Migration, all of which are represented in the UN Theme Group on HIV/AIDS. The United States Agency for International Development has commenced a capacity-building initiative with selected nongovernmental organizations.

Renewed political violence in the north and east of the country continues to hinder capacity to work in those areas. The conflict has also reduced the opportunity for dialogue on issues of a sensitive nature, which is particularly detrimental to HIV prevention efforts for people whose behaviour put them most at risk, such as sex workers, men who have sex with men, and injecting drug users.

Major barriers to HIV prevention, treatment, care and support include:

• human resources, both in the medical establishment and within civil society, needed to improve the quality of and expand the response in clinical settings and in the community;
• stigmatization and discrimination, which discourage demand for counselling, testing and treatment;
• continuing very low coverage of targeted HIV prevention programmes for key people likely to be exposed to HIV (female sex workers and men who have sex with men).

Challenges and emerging issues facing stakeholders in 2007

• Formulation of the 2007–2011 National Strategic Plan should involve all stakeholders in a broad participatory process guided by the National STI /AIDS Control Programme.
• Prioritizing targeted interventions for people whose behaviour puts them most at risk of exposure to HIV, with the highest priority given to prevention efforts for female sex workers and men who have sex with men.
• Improving partnerships with engagement and encouragement of civil society and private-sector participation, with particular emphasis on capacity-building of nongovernmental organizations and the revitalization of civil society coordinating mechanisms and partnerships.
• Improving strategic information (including bridging information gaps) and establishing a monitoring and evaluation system. Information on people with high-risk behaviour is acutely needed to guide the local response.
• Access to HIV prevention, treatment, care and support services in conflict-affected areas.

WOMEN AND AIDS

By the end of 2005, women accounted for nearly half of all people living with AIDS worldwide, and represent almost 60% of infections in sub-Saharan Africa. The impact of HIV on women is also growing in Eastern Europe, Central Asia and South and South-East Asia. Moreover, young women are several times more likely than young men to contract the disease through heterosexual contact. Worldwide, 62% of infected young people are girls, and that number soars to 77% in sub-Saharan Africa. A woman's vulnerability to the virus is attributable not only to biological differences, but also to deeply entrenched socio-economic inequalities that further compound her risk. Because 70% of the world's poor are women, women have fewer economic options. They are far more vulnerable because of absolute poverty to engage in transactional sex to pay for food, school fees and other necessities. They are also vulnerable to coercive or forced sex and often unable to negotiate condom use. One in three women world-wide have been affected by gender-based violence, but poor women are even more likely to be abused. Many women, particularly married women, cannot control the circumstances under which sex takes place. Research in several countries shows that for far too many young girls, the first sexual experience is coerced or forced. Married women are especially unable to negotiate sex or condom use with their husbands who may have extramarital partners. Some research indicates that married women are in fact more at risk for HIV than unmarried women because they are more frequently exposed to intercourse within marriage. HIV-positive women may transmit HIV to their children during pregnancy, in childbirth or through breastfeeding. Today, mother-to-child transmission (MTCT) of HIV is the primary mode of acquisition of HIV for the more than 2 million children living with HIV. While antiretroviral therapy significantly reduces the risk of MTCT of HIV, prevention coverage in the 30 African countries with the highest HIV prevalence is only 5 percent. As AIDS ravages families and communities, the burden of caring for ill family members rests mainly with women and girls - many of whom may be seriously ill themselves. A woman affected by HIV/AIDS is plunged further into poverty, losing the ability to provide for herself and her children. Combined with pervasive social stigma and the collapse of traditional family and support structures, HIV/AIDS is eroding the status of women in many countries.