Asia's longest-running conflict has created the perfect environment for an AIDS epidemic to flourish in Sri Lanka, but surprisingly, decades of war have brought only a slow spread of the disease in vulnerable groups.
AIDS activists said the fallout from the protracted ethnic conflict could be an explosion in the numbers contracting the disease, as more people were uprooted from their homes in war zones, military camps sprang up amid civilian populations, and refugees travelled to and from neighbouring India, where AIDS figures were high.
Twenty years after the first case of the disease was detected here, the island still has a low HIV prevalence rate, according to Health Ministry officials.
AIDS affects less than 0.1 percent of the general population, and less than one percent of high-risk groups, such as men who have sex with men, commercial sex workers and returnee migrants. Official estimates show that some 5,000 Sri Lankans are living with HIV.
Do the numbers lie?
However, the potential under-documentation of the number of HIV-positive people has sparked the fears of activists, concerned that infected people might be missed, particularly in the north and east where Tamil Tiger rebels are fighting for a separate state.
"The question that has to be asked now is, 'Are we still a low-prevalence country?'" said Kamanee Hapugalle, executive director of Community Development Services, a reproductive and sexual health non-governmental organisation engaged in AIDS prevention.
"We have all the factors that could cause an epidemic here: internally displaced people, increased militarisation of societies in conflict zones, women selling sex in exchange for security, an increase of men having sex with men, and even the lack of access to health services in the conflict areas."
Hapugalle said other elements, such as internal and external migration for employment and education, and more incidents of women and child abuse, also threatened the low incidence of the disease.
"In countries like Vietnam and Cambodia, where there have been similar situations, it is well documented that the rise in HIV/AIDS was a direct consequence of conflict," she added.
Dr Nimal Edirisinghe, who heads the government's sexually transmitted disease (STD) and AIDS control programme, commented: "My personal view is that we will not have a general epidemic in this country. It is true that there are conflict-related factors, but we don't have large numbers of injecting drug users. That is the deciding factor."
He pointed out that countries which had experienced a sudden spike in HIV/AIDS cases were those where injecting drug use had gone up.
Different strokes?
Other factors contributing to the low infection figures in Sri Lanka were comparatively low levels of casual sex, good access to health services, successful STD control programmes and the generally better social position of women.
The lack of a "bridging population", or network of contacts, between high-risk groups, such as commercial sex workers and men who have sex with men, and the general populace was another mitigating factor.
"As for returning migrants and refugees, if they get the disease ... they tend to pass it on to their spouses or partners and it ends there. They usually don't have multiple partners," Edirisinghe said, responding to fears that the island's close proximity to India and the large numbers of Sri Lankans employed in the Middle East could threaten its low-prevalence status.
 We usually say Sri Lanka is sitting on a time-bomb, or on top of a volcano; otherwise, AIDS will not be taken seriously |
In the first quarter of this year, 24 cases of HIV had been reported, while some 112 patients were being treated with free antiretroviral drugs provided by the government.
"What we have now are pockets where the disease has been detected. Of course, if these clusters increase we could have an epidemic, and that is what we want to prevent," he added.
A health professional, who works closely with AIDS patients and high-risk groups, said: "There are certain socio-demographic patterns and cultural behaviours - like the low usage of condoms - which are a threat, but it is not going to erupt in an epidemic.
"We usually say Sri Lanka is sitting on a time-bomb, or on top of a volcano; otherwise, AIDS will not be taken seriously," said the health worker, who did not want his name used. "It is difficult enough for us to convince sex workers to get their clients to use condoms."
With patterns of sexual behaviour changing among young people, the National STD/AIDS Control Programme's primary focus in its new five-year plan, beginning this year, is on awareness and prevention.
An international conference on AIDS in Asia and the Pacific, to be held in August in Colombo, the Sri Lankan capital, is expected to focus on issues such as voluntary versus mandatory testing, discrimination and the rights of people living with the virus.
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