Fighting HIV in a chronic emergency

Severe food shortages and continuing conflict in large parts of war-scarred Somalia have stretched people's coping strategies to breaking point, but for those who are HIV positive every day brings another struggle to survive. "The country is in the grip of a severe drought at the moment, which means millions of Somalis are going without food - they have to move from place to place with their animals to find pasture and water," said Ulrike Gilbert, HIV project officer for the Somalia office of the UN Children's Fund (UNICEF). About 400,000 internally displaced people are now living in camps, where they depend on their host communities and relief agencies for food and protection. The few health services that exist are stretched to capacity, and populations on the move in search of pasture and water may find there are no health services at all. Water shortages have heightened the risk of waterborne infections, and resisting and recovering from diarrhoeal diseases is much harder for people living with HIV, so progression from infection to AIDS can be greatly accelerated. Women and children living in the camps are also at greater risk of HIV infection. "Displacement and conflict have damaged these people's support networks, exposing them to the risk of sexual exploitation, which in turn exposes them to HIV/AIDS," Gilbert pointed out. When women and children are raped or abused, access to emergency post-exposure prophylaxis is limited, and trauma counselling rare. To make matters worse, there is little basic education about how to avoid HIV/AIDS. Discussions about sex are traditionally taboo and conservative Somalis have been in denial about the existence of HIV and its ability to affect them for years. "At first we thought that AIDS was a foreign disease, but we now know that AIDS is here," said Sheikh Mahamud Aw Abdulle, a senior religious scholar in the capital, Mogadishu. HIV diagnoses are becoming increasingly common. "We see HIV positive people at the hospital - many more than we did years ago. Increasingly we see AIDS patients, who obviously contracted the virus several years ago, before we knew we had a problem," said Dr Mohamed Mahmud. "Our geographical position, and the fact that our populations are very mobile - travelling around the region, where HIV is more prevalent - means we need to be on guard about the epidemic growing here [in Mogadishu]," he added. An estimated 350,000 Somali refugees live in neighbouring countries, with millions more in the diaspora. UNAIDS estimates the HIV prevalence rate in Somalia at 0.9 percent, well below that of its east African neighbours, such as Ethiopia with 4.1 percent and Kenya with 6.7 percent. However, according to UNAIDS, Somalis are "approaching a generalised epidemic". Some cultural practices have also aggravated the situation, according to human rights activists. "AIDS is spreading in Somalia. One of the main factors is the continued practice of FGM [female genital mutilation] on our young girls," said Marian Hussein Awreye, co-director of the country's largest rights group, the Ismail Jumale Human Rights Centre. Close to 100 percent of Somali girls undergo FGM, traditionally seen as a rite of passage into womanhood, and perceived as a procedure ordained by the Koran. It is rarely carried out in a hospital, and unsterilised instruments are often used to cut several girls. Deep-rooted stigma is an underlying reason for the continued failure to recognise HIV/AIDS as a problem. "Somali people do not like to hear about AIDS, and that is why they are always negative towards HIV-positive people, simply because they believe that such an 'immoral' disease befalls only those do not comply with Islamic religion," said Mohamed Abdi Osobleh, a musician. "Nobody dares to disclose his/her HIV status to people for fear of humiliation, so they continue to infect others, unidentified." In a frank acknowledgement of the problem, Dr Mahmud noted: "When these people come and discover they are HIV-positive I do not know where to send them ... We have no VCT [voluntary counselling and testing] services; we have no ARV [antiretroviral] services at the hospital." Financing for HIV/AIDS programmes is slowly beginning to arrive. The Global Fund to Fight AIDS, Tuberculosis and Malaria has provided funding - with UNICEF as the principal recipient - to implement a "framework" for the prevention and control of HIV/AIDS and sexually transmitted infections. "In areas where there is relative stability we are able to provide some services - Somaliland and Puntland both established AIDS commissions in 2005 to coordinate the effort in those regions," Gilbert said. "Most recently, the government and partners established the South Central AIDS Commission, in March, in an effort to deal with the pandemic." The northeastern self-declared autonomous region of Puntland and the northwestern self-declared republic of Somaliland are relatively stable compared to the southern and central regions of the country, where the drought is worst and factional fighting continues to disrupt the flow of humanitarian aid to those most in need. "We now have one site providing ARVs in Hargeisa [capital of Somaliland], and have two more planned by June in Puntland and the central-south region," said Gilbert. "We have set up four VCT sites around the country and have trained counsellors to expand the services." UNICEF has also established child protection prgrammes in the camps to shield orphans and vulnerable children from potential abuse. Other measures include basic steps like ensuring that bathrooms and toilets, which are outdoors, are well lit to ward off potential attackers.