Health Ministry seeks to protect mothers and infants from HIV “time bomb”

New guidelines on preventing the transfer of HIV from mother to child will come into effect from Wednesday (May 7 2014), Ministry of Health and Gender has said.

The national guideline on prevention of mother to child transmission of HIV is underpinned by a need to equip the Maldives for what the Health Protection Agency has termed an HIV “time bomb.”

Programme Coordinator for the Reproductive Health Unit Naseera Nazeed has urged all pregnant women to get tested in their first semester.

“There is very high chance of saving the baby – 90% – if they are checked,” she said.

The guidelines aim to protect women of childbearing age from HIV, advise women with HIV against pregnancy, protect HIV positive mothers from infecting their children and providing support to HIV positive mothers and their families.

The Maldives identified the first infant with HIV in 2012. In February this year, the Indhira Gandhi Memorial Hospital (IGMH) transfused a pregnant women with HIV positive blood due to a technical error. Meanwhile, local media have alleged a 19-year-old HIV patient had given birth at IGMH in early April.

Programme Manager for the National HIV AIDS programme Abdul Hameed said the spate of HIV incidents this year had raised awareness on HIV and provided a boost to healthcare efforts.

“We are sending out the public a clear message, always to be sure of their status. HIV is everywhere, you don’t have to give your name, you just have to go and get tested. The result will be in 10 minutes,” he urged.

Not prepared

Lack of prevention programmes and specialized care for population groups at risk facilitate an HIV outbreak in the Maldives, Hameed said. Sex workers, gay men and intravenous drug users are particularly at risk, he said.

“We are sitting on a time bomb. We know those key populations exist [in Maldives],” stated Hameed. “At any time it can explode.”

The Maldives does not offer prevention services for gay men or sex workers, he said.

HIV patients prefer treatment abroad due to high levels of stigma and discrimination, he said, adding: “Even in the healthcare system itself there is ingrained discriminations.”

The healthcare system is ready for an outbreak, Hameed claimed, but said there are deficiencies that could hinder response to a crisis.

“The health system is ready, but we don’t have the civil society or organization networks. We may not be prepared,” he said.

A prevention workshop—the second of its kind—is underway from Tuesday to Wednesday (May 4 to May 6) to train health professionals on the new guidelines. A total of 31 participants from regional hospitals, populous atolls, Malé, Villimalé and Hulhumalé are taking part.

The Ministry also plans to hold a series of phone conferences to all atolls to further disseminate the information.

Former Minister of Health Dr Ahmed Jamsheed Mohamed said it was only through “incredible luck” the HIV virus had not spread throughout the country.

“All the habits that may lead to the spread of HIV is excessively in practice,” he claimed referring to sexual promiscuity and intravenous drug use in the Maldives.

Since the first case of HIV was detected in the country in 1991, 19 cases of HIV have been reported among Maldivians. However, the Health Ministry estimates numbers of HIV positive persons could be between 70 and 100.


19 year-old Maldivian HIV patient gives birth

A 19 year-old woman with HIV has given birth to a child last week at the Indira Gandi Memorial Hospital (IGMH), local media have reported

According to online newspaper ‘MV Youth’ the patient was allegedly involved in a sexual relationship with a man with HIV when she was 15 years of age.

The website reported that the man who she had sex with was found guilty of having sex with the girl and sentenced to 19 lashes in 2010 by the Criminal Court. It was not confirmed whether the baby was tested positive to HIV.

Speaking to Minivan News today IGMH Spokesperson Zeenath Ali said that she had not heard of the incident.

‘’Some other news agencies had contacted me today and asked about it but I told them that only the concerned authorities such as Health Ministry and concerned persons from IGMH will have that kind of information,’’ she said.

She said she cannot confirm whether or not the information was true.

On February 27, an expatriate lab technician working at IGMH who was allegedly responsible for the transfusion of HIV positive blood to a pregnant Maldivian patient was taken into police custody.

The technician at fault reported the blood as negative despite the machine showing that it was positive for HIV.

The error was discovered when the patient came in for a routine checkup on February 18, after which the blood test report was reviewed.

The blood sample was taken from a donor found by the patient and not from the hospital’s blood bank and was not previously registered as an HIV patient.

In October 2012, the then Minister of Health Dr Ahmed Jamsheed Mohamed claimed it was only through “incredible luck” that HIV had not spread across the Maldives, considering the prolific levels of unprotected sex and intravenous drug use.

Jamsheed at the time spoke of the risks of promiscuity in the society, referring to the 2010 case where police arrested an HIV positive prostitute. He stated that the same prostitute had been identified in the Maldives as being HIV positive in the year 2009 as well.

Since the first case of HIV in 1991, 19 cases of HIV have been reported among Maldivians, while the estimations of HIV positive persons are as high as 70 – 100.

The Health Ministry has previously warned about a possible explosion of HIV/AIDS in the country, with high risk behavior such as drug use and numerous sexual partners a concern.


Maldives identifies “first” child HIV infection

Senior health figures have called on the government, NGOs and members of the private sector to help step up attempts to promote AIDS prevention in the country after authorities discovered that a two year-old child had tested HIV positive earlier this year.

While accepting that HIV infection rates remained relatively low in the Maldives, Minister of State for Health Lubna Zahir Hussain said that efforts needed to be increased across all sectors of society to tackle attitudes towards high-risk behaviours that allow the virus to be transmitted.

Lubna heads the National Drug Agency (NDA). Her comments followed the hosting of a special NDA workshop on HIV prevention held on December 1 to commemorate World AIDS Day. The workshop was focused particularly on the HIV infection through drug abuse.

Though statistics indicate HIV infection rates have been limited in the Maldives over the space of the last two decades, health officials in the Maldives have begun to raise concerns about the risk of cases spreading across the country.

In October Minister of Health Dr Ahmed Jamsheed Mohamed claimed it was only through “incredible luck” that HIV had not spread across the Maldives, considering the prolific levels of unprotected sex and intravenous drug use.

Addressing concerns raised by Health Minister Jamsheed about the potential scope for HIV to spread beyond high-risk communities such as drug users, Lubna said greater effort was needed to address attitudes of the general public to the spread of the virus.

“I think what the health minister was saying is that it is not only people living bad lifestyles that are at risk [of HIV infection],” she said, reiterating concerns about the number of young people engaged in intravenous drug use and potentially dangerous sexual practices.

She spoke about a child who was suspected of having been infected from her mother at birth.

“We were first made aware of the case in April 2012 and as far as I know, this is the first case [of a child in the Maldives being born HIV positive],” she said. “However, I think it is important for the public to know the reality of the situation right now, whilst respecting [the child’s] privacy and well being.”

Lubna said she was ultimately encouraged by the work of the country’s health authorities in trying to address the HIV risk from national attitudes towards sex and drug use in the country, yet warned against complacency.

“This doesn’t mean that we continue to work at this pace to try and address attitudes towards AIDS and its spread,” she said.

Lubna called on civil society, the business community and government to speed up efforts to hold awareness and education events about the dangers posed through unprotected sex and intravenous drug use, and to promote preventative measures to reduce the national HIV risk.

Attempts have been made to work with local drug NGOs such as Male’-based Journey on running special outreach programs and blood tests to try and monitor and manage infection rates.

However Lubna said that drug use was not the only area of concern in trying to curb HIV infection.

“Prostitution is another area that needs to be looked into. Awareness work in this area needs to be seen immediately,” she said.

She said greater awareness was needed not just among the general public, but by government authorities and law enforcement agencies.

First Lady’s concerns

During the NDA workshop, First Lady Ilham Hussain stressed that growing numbers of the country’s youth were subjected to dangerous habits that could potentially lead to HIV infection.  She highlighted recreational drug use in particular as the leading cause of the virus spreading nationally.

“Incredible luck”

Speaking earlier this year on the issue of HIV infection rates, Health Minister Jamsheed said that although the Maldives had remained on the HIV less-prevalent category since the first HIV positive case was found in 1991, “all the habits that may lead to the spread of HIV is excessively in practice here,” stating that it was only through “incredible luck” that the disease had not already spread widely throughout the country.

“What has always worried me most is that there is a large drug community, and that the virus might find its way into this group, especially the IV drug users. Once it does, it will spread like wild fire,” he said at the time.

“I don’t think this is too far off now. We have already identified one IV drug user who has been infected with HIV. What’s left is to see how much this has spread,” Jamsheed revealed.

Jamsheed said that he believed there were issues which needed to be opened to a “national debate” in order to move forward and take stronger preventive measures.

“We can simply stay inactive and keep talking for any amount of time by assuming the moral highground,’ Jamsheed said at Sunday’s press conference.

“That is to claim that we are Muslims, and by living in a Muslim state in Muslim ways we are doubtless protected from this disease. But that is never the reality anywhere in the world,” he said.

Jamsheed said it was unrealistic to assume all Muslims to live as “perfect Muslims”, and that even if they were, there was still a chance of infection. He stated that HIV is not transferred through sexual activity or visits to prostitutes alone.

In 2011, a total of 18 HIV positive cases were reported, out of which one was of a local. Between 1991 and 2011, 15 HIV cases were reported among Maldivians, while 168 cases of expatriate workers were also filed. Two out of the 15 cases were female, and all patients cited heterosexual transmission as the cause of infection.


Male’ festival aims to clear HIV “misconceptions” among migrant population

A “HIV Awareness Festival” being held this weekend in Male’ aims to provide free advice and medical examinations, alongside activities for those interested in learning about HIV/AIDS in a friendly environment, organisers have said.

According to the United Nations Development Programme (UNDP), the main organiser of the festival, the aim for the event is to promote HIV/AIDS awareness amongst a rapidly growing migrant population in the Maldives – identified as one of the most vulnerable groups to contract the deadly virus.

It is an opportunity to connect migrant workers to the available HIV preventive and curative services in the Maldives as well.

“The festival will create a platform for migrant workers to obtain information on prevention of HIV/AIDS and clear misconceptions through activity-based interaction in their native languages,” a press statement about the event read.

The festival will begin at 4:00pm in Sultan Park and throughout the event, stalls will be providing basic healthcare checks, for dental and eye health, voluntary counselling and testing for HIV/AIDS – all free of charge.

A jumble sale will also take place, while snacks and music will reflect the different food and cultures of migrant populations.

According to the organiser, the stall activities are supported by various foreign embassies and civil society organisations.

HIV situation in Maldives

Compared to many countries in the region, the Maldives had been found to have a low prevalence of HIV.

As of December 2011, state figures reveal a total of 15 HIV cases were detected among Maldivians, while 289 were identified among the expatriate migrant labour force.

However, the challenge remains to maintain the low prevalence rates amid widespread high risk behaviours.

Heath Minster Dr Ahmed Jamsheed has contended that these high risk behaviours – including unsafe injecting, unprotected sex with multiple partners, serial monogamy, group sex, gang rape, commercial sex, and unprotected male-to-male sex – have put Maldives at the brink of an HIV/AIDs explosion.

Recent studies suggest that migrant construction workers, injecting drug users, female sex workers, men who have sex with men, seafarers, resort workers and young people are the seven groups at the most risk for contracting deadly virus.

An unknown number of 80,000 to 110,000 foreign workers – almost one-third of the total local population – is estimated to be working in Maldives – primarily in the construction and service sectors.

Thousands of them are undocumented workers who have entered the country illegally, possibly escaping the mandatory HIV screening process.

Through the Global Fund Supported Programme in the Maldives, health authorities and UN agencies are working to run outreach programmes on HIV, targeting the groups most vulnerable to contracting HIV and strengthening national HIV preventive mechanisms.


High-risk behaviour leaves Maldives at risk of HIV/AIDS “explosion”

A new report has revealed that the health authorities detected 18 HIV positive cases and over 400 cases of Sexually Transmitted Infections (STIs) in last year – a “significant” finding which has highlighted the need for additional research to understand the prevalence of STI’s and HIV in the Maldives.

The report, “Annual Communicable Disease 2011” from the Centre for Community Health and Disease Control (CCHDC), revealed that among the 31,016 people tested under the Voluntary Counseling and Testing (VCT) program last year, a total of 438 cases of STIs were reported, out of which 97 percent affected females.

The report says among the 426 females with STIs, 395 involved vaginal discharge cases and 31 ulcers. Meanwhile, males with STIs were reported significantly low at 12 – eight cases of urethral discharge and four cases of ulcers. The report does not specify the age group, however all participants in the study were volunteers.

CCHCDC director Director Moomina Aboobakuru told local media that the authorities are deeply concerned about the increased detection of STIs such as chlamydia and gonorrhea – both conditions that can cause infertility if left untreated.

As the surveillance is limited to the number of people volunteering to take the tests, and with no nationwide survey, Aboobakuru believes that more people are likely to be living in with STIs “undetected”.

Meanwhile, Dr Ahmed Jamsheed, public health expert and former Director General of the CCHDC, argued that it could not necessarily be deduced from the report that the sexually transmitted diseases are on the rise in the Maldives.

He explained that as this was the first published general finding on STIs in the Maldives, there was no reference to determine whether cases were on the rise nationwide without previous data to compare it with.

“But certainly there is an urgent need for additional research for STI’s , including HIV to understand the prevalence of these diseases in the country,” Dr Jamsheed asserted.

Risk of HIV/AIDS ‘explosion’

Jamsheed and CCHDC officials fear that increasing rates of “high risk behaviour” risk the historically low rate of HIV prevalence in the Maldives, putting selective groups such as drug users, resort workers and people travelling abroad at greater risk.

Meanwhile, a total of 18 HIV positive cases were reported last year alone – including 17 expatriates and one local.

Between 1991 and 2011, 15 HIV cases were reported among Maldivians, compared to 168 among expatriate workers. Of the Maldivian cases 13 were males, and two females, and all patients cited heterosexual transmission as the cause.

Despite the country’s conservative exterior, Dr Jamsheed wrote on his blog in June 2011 that Maldivians have always been sexually very active: “High divorce and re-marriage rate, which increases the number of sexual partners any individual have over the lifetime. It is also a known fact that despite being a Muslim community, a lot of Maldivians have multiple extramarital relationships.”

Human trafficking for purposes including sexual entertainment has put more locals at risk, while in 2010 police arrested an HIV-positive prostitute.

Further risk factors include falling rates of contraceptive use, Dr Jamsheed wrote, particularly among high risk groups.

“The condom prevalence rate in the Maldives is very low and on a negative curve, though this data comes from married couples. Studies also show that condom use by the high-risk groups (commercial sex workers, men having sex with men, clients of sex workers) is also very low. Condom is the most effective preventative tool we have to protect from HIV transmission through sexual intercourse,” Dr Jamsheed wrote.

Furthermore, “However much we deny, there is a significant number of gay men in the Maldives, a lot of who are married and having bisexual relationships. There is also reason to believe that the gay community in the Maldives is increasing and becoming more organized and open about their sexual orientation,” he wrote.

Without any formal sexual education in schools and a general stigma around purchasing condoms, the basic defenses against HIV transmission are low.

“With all these extremely high risk factors, it could be said that we are sitting on a ticking bomb for an explosive HIV epidemic,” Dr Jamsheed warns.

“It’s [only] a matter of time for the virus to be introduced to the high-risk circle, especially the IV drug users. Unless we escalate our preventive efforts and introduce new and more effective measures, the low HIV prevalence in the Maldives might change to a very high prevalence in no time.”


Comment: Intravenous drug use raises AIDS spectre in Maldives

Thirty years since the first reported cases of acquired immunodeficiency syndrome (AIDS) in 1981, the response to the HIV/AIDS epidemic has been unprecedented, especially in terms of global and national initiatives.

Substantial progress has been made, such as a 31 percent reduction in the number of new infections between 2001 and 2009 in South-East Asia. A revolutionary new approach to treatment endorsed by UNAIDS and WHO, which includes improved, lower-cost drugs, simplified HIV diagnostic technologies, improved delivery systems, and innovations  in prevention of HIV infection, give hope for achieving universal access to prevention, care and treatment of HIV/AIDS, even in resource-constrained settings.

Yet, the challenge is far from over. HIV still remains a formidable foe, affecting 33.3 million people globally, including 2.5 million children. Despite years of concerted global efforts and investments, there is still neither a cure nor an effective vaccine for the disease.

However, over time, the profile of the HIV epidemic is evolving from a life threatening to a chronic disease, thanks to availability of more effective drugs and efficacious service delivery models involving communities and people living with HIV/AIDS. With changing realities, it is time, then, to reflect and re-strategize in the long-drawn war against HIV/AIDS. Fundamental to success is acknowledging that HIV/AIDS is a social and developmental issue as much as a health one.

The impact on women and children is devastating. An estimated 1.3 million women aged 15 and above currently live with HIV in the WHO’s South-East Asia Region (Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste).

The estimated number of children living with HIV has increased by 46 percent during 2001 – 2009. Of the 448 million cases of sexually transmitted infections that occur globally, 71 million are in South-East Asia. Due to low coverage of the prevention of mother-to-child transmission (PMTCT) programme in the South-East Asia Region, a large number of babies born to HIV-positive mothers acquire HIV infection in the womb.

Despite considerable diversity in the HIV epidemic among the countries of the Region, unsafe sex and injecting drug use are the main drivers. Five countries -India, Indonesia, Myanmar, Nepal and Thailand – account for a majority of the disease burden. Sexual transmission accounts for the majority of cases in Bhutan, India, Myanmar, Sri Lanka, Thailand and Timor-Leste.  The HIV epidemic among people who inject drugs is significant in Indonesia, Myanmar, Nepal, Thailand, and some regions of India.

The Maldives has a growing threat of the HIV epidemic due to injecting drug use.

The evolution of the epidemic from life threatening to a chronic disease, with better drugs and better access to drugs, has resulted in prolonging survival and quality of care for people living with HIV/AIDS. This necessitates evolution of an HIV care model that is in line with chronic disease management, with primary care providers playing an important role.

The spectrum of HIV care needs to evolve into a comprehensive primary care model that has an integrated, patient-centered approach, and is linked to specialist care where and when needed. It also needs to address the various socio-cultural issues that take the response beyond the health sector into the families and communities.

Other key challenges include late diagnosis of HIV, stigma and discrimination faced by people with HIV and most-at-risk population; limited capacity of health systems; high prices of antiretroviral drugs especially the second line drugs, and lack of sustained finances.

The health sector can only overcome these challenges if it collaborates with other sectors in order to tackle the social, economic, cultural and environmental issues that shape the epidemic and access to health services.

WHO’s  Health Sector Strategy on HIV for South-East Asia has been endorsed by all the eleven Member States of the Region. It envisions “Zero new HIV infections, zero AIDS-related deaths and zero discrimination in a world where people living with HIV are able to live long, healthy lives.”

The four strategic directions to achieve the goal include: optimising HIV prevention, care and treatment outcomes; strengthening strategic information systems for HIV and research; strengthening health systems to ensure that the expanded response to HIV will build effective, efficient and comprehensive health systems in which HIV and other essential services are available, accessible and affordable; and fostering supportive environment to ensure equitable access to HIV services.

WHO continues to work with countries to achieve universal access to comprehensive HIV prevention, treatment and care and to contribute to health-related Millennium Development Goals (MDGs), particularly MDG 6 (combat HIV/AIDS, malaria and other diseases). Together, we hope to move closer to a world free of AIDS.

Dr. Samlee Plianbangchang is the Regional Director of the World Health Organisation for the South-East Asia Region.

<em>All comment pieces are the sole view of the author and do not reflect the editorial policy of Minivan News. If you would like to write an opinion piece, please send proposals to [email protected]</em>


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IMF warns restoring salaries will “jeopardise” international financing

The International Monetary Fund (IMF) has warned that international funding to the Maldives would be threatened if civil servant salaries are restored to former levels.

“One of the primary drivers of the large fiscal deficit has been government spending on public wages, which has more than doubled between 2007 and 2009, and is now one of the highest in the world relative to the size of the economy,” said Rodrigo Cubero, IMF mission chief for the Maldives.

“Measures that would substantially raise the budget deficit, such as a reversal of previously announced wage adjustments, would also put the program off track, jeopardising prospects for multilateral and bilateral international financing,” he warned.

State minister for finance Ahmed Assad confirmed that international funding might be at risk if the salaries were restored in the manner demanded by the Civil Servants Commission (CSC).

“The IMF have been saying that for a while,” Assad said, reiterating that the government was not capable of increasing civil servants salaries this month.

Permanent secretaries of various ministries had been submitting two salary sheets, he said, “so we know the difference.”

Spokesperson of the CSC Mohamed Fahmy Hassan said according to Maldivian law, the finance ministry had to pay the increased salary this month.

”For instance, if give you  work to do and say I will pay you 100rf when the work is done, after you complete the work is it fair for me to say, ‘Oh, I cant give you Rf100, I only have Rf50′,” he asked.

In response Assad said the IMF only gave economic advice, and was indifferent to a country’s law.

During talks between the CSC and finance ministry yesterday no agreements were made beyond a decision to continue negotiations.

In its statement, the IMF warned that “the Maldivian economy continues to face serious challenges. In particular, addressing the very large fiscal deficit is of paramount importance to secure a stable economy, equitable growth, and lasting poverty reduction.’

“A larger fiscal deficit would drive up interest rates, deprive the private sector of the credit it needs, and threaten growth and employment. It may also stoke inflation and erode the purchasing power of all Maldivians, including civil servants. It is to avoid such undesirable outcomes that the fiscal deficit needs to be reduced.”


Authorities warn of looming AIDS pandemic

The Health Ministry has warned of the spread of AIDS in the Maldives after an expatriate prostitute tested positive for HIV.

At a press conference yesterday, Dr Ahmed Jamsheed Mohamed, senior medical officer at the centre for community health and disease control, said prostitutes from neighbouring countries were working in the Maldives on tourist visas.

“We have some evidence now that expatriate women who came to the Maldives without a work permit on a tourist visa are involved in prostitution,” he said. “We learned that one of them was HIV positive.”

While the authorities required  medical checkups for expatriates who apply for work permits, he said, foreigners on tourist visas were not tested.

246 foreigners on work permits have been sent out of the country after testing positive since 1995, an average of 15 a day.

He added the authorities discovered the expatriate prostitute was HIV positive when she applied for a work permit.

Jamsheed said it was likely that there were more prostitutes with HIV who work at massage parlours and appealed to the public to be aware of the risks of visiting local brothels.

Prostitutes from China and Russia working in Sri Lanka often come to the Maldives when their tourist visa expires, he continued, while prostitutes in the Maldives visit Sri Lanka to re-enter the country on a new tourist visa.

“There’s a rotating group between Ceylon and Maldives,” he said. “We believe there must be a lot of HIV positive people among them.”

If AIDS begins to spread in the country, he added, there was no reason to believe it could be controlled.

Jamsheed said HIV in the Maldives was like a ticking time bomb: “Everything necessary for the disease to spread exists among us.”

A recent survey on AIDS revealed all the behavioural risks contributing to the spread of HIV, such as promiscuity, prostitution, homosexuality, rape, child abuse and sharing needles, were “widespread” in the country.

Jamsheed said responsibility had to be taken at an individual, societal and government level to avoid the country “reaching that critical stage”.

Although the survey was based on a small sample of the population, since its release one Maldivian had been found HIV positive and it was likely that more would be discovered. There are over 30 Maldivians with HIV, according to estimates said Dr Jamsheed.

Of the 14 people with AIDS known to the authorities ten have passed away, three are undergoing treatment while the others’ condition had not deteriorated to require treatment.

Asked whether recommendations in the study, such promoting the use of condoms and making clean disposal syringes available to drug addicts could be implemented in the Maldives, Jamsheed said both strategies have been successfully deployed overseas.

“The question is whether they can be brought in to our society with our Islamic principles and values,” he said, adding that the National AIDS Council had to discuss the issues.

Dr Ali Nazeem, in charge of treating HIV patients, said more voluntary counselling and testing centres (VTCs) would be established in the near future, while testing was already available in regional hospitals.

Testing is currently available at ADK hospital and the police VTC.

He added the centres will maintain anonymity and the test results would be confidential.

Earlier this week, drugs NGO Journey opened a VTC with more than 20 volunteers to offer counselling.