Subject: HIV: East Timor Crisis

magazine article re HIV/AIDS, then comment

from HIV Australia magazine vol.2 no.2 Nov/Dec 2002 "Focus on the Asia Pacific"

"Preventing Crisis in East Timor" - HIV is an important issue facing the East Timor Government as the nation struggles to rebuild itself after 425 years of colonial rule. Joe Thomas looks at the government's response so far.

East Timor is emerging from the shadow of about 425 years of colonial rule and more than 2 decades of occupation by the Indonesian government. It was only on May 20th this year that East Timor became a fully independent nation. Along with the challenge of nation building, the East Timor government has to address the issue of HIV/AIDS.

The East Timorese people are eager to engage in a rapid social development program and the country's political leaders have identified HIV prevention as a key aspect of nation building. Addressing the challenges of HIV transmission forms part of the National Development Plan.

There are some unique challenges and opportunities in developing an effective national response to HIV/AIDS in East Timor. The general perception shared by many international agencies is that HIV prevalence is currently low in East Timor and there are other public priorities requiring urgent attention. However this perception may be a validation of the non-existent HIV surveillance facilities which are contributing towards complacency among many international agencies.

Senior members from the Ministry of Health and the East Timor Cabinet of Ministers have joined the Prime Minister and President in indicating the need for early action to prevent an uncontrolled HIV transmission rate and the associated consequences.

East Timor is one of the poorest countries in the world. With a population of about 750,000, the GDP per head was US$378 in 2001, with more than 40% of the population living below a poverty line of US55cents a day. The literacy rate is around 40%, life expectancy is 57 years, and there is high unemployment especially amongst youth in Dili.

Coupled with this, there is a high incidence of disease in East Timor, particularly Tuberculosis, Malaria, Dengue and Japanese Encephalitis, which are endemic. For every 1,000 births there are 125 deaths, and the maternal mortality rate is 890 per 100,000 births. Malnutrition is rife with 3-4% of children aged 6 months to five years diagnosed as acutely malnourished and 20% chronically malnourished.

The health system is inadequately staffed to cope with these problems - let alone the challenge of HIV/AIDS. There are less than 24 Timorese doctors in East Timor and only a very few qualified lab technicians. In an attempt to offset these shortages, the World Bank led Trust Fund is currently employing 25-30 internationally recruited doctors for the districts and sub-districts, and 15-20 specialists for hospitals, as well as some technicians.

Because HIV/AIDS strikes people in their most productive age, the economic and social consequences are profound. Couple with the opportunistic infections facing many people living with HIV/AIDS, the health budget is under severe strain.

The social factors that might exacerbate the spread of HIV in East Timor include massive social dislocation, cross border migration, a high level of unemployment, an ineffective HIV/AIDS awareness program, inadequate health facilities, and a low awareness about HIV/AIDS.

The country's violent past may also impact on its ability to control the transmission of HIV/AIDS. Modvig and colleagues (2002) reported the results of a national psychosocial needs assessment carried out in post-conflict East Timor to assess the extent of torture and trauma and its health impact on the population. From the 1,033 households surveyed (7,500 individuals) 57% of respondents claimed they had experienced at least one form of torture including psychological torture (40%), physical beating or mauling (33%), and beating the head with or without helmet (26%). Rape and other forms of sexual violence were also reported during the conflict. Data and experience from other conflict zones around the world indicates that social conflict and violence could fuel the epidemic.

At present, a limited number of Ministry of Health (MoH) staff are trained in clinical recognition of AIDS, and appropriate pre and post test counselling and care. Confidentiality remains a concern and is addressed in the official guidelines for management of suspected HIV/AIDS cases released by the MoH in December 2001.

Awareness of HIV/AIDS and knowledge of transmission and prevention is low. The first case of confirmed AIDS was reported in Dili National Hospital in December 2001, and the spouse and one of the two children of this 'index case' also tested positive for HIV.

Although accurate data on HIV prevalence is inadequate, recent surveys jointly carried out by the MoH and the World Health Organisation estimate HIV in East Timor at 0.64% of the population (MoH ETG 2002 HIV/AIDS summary report).

Foreign nationals may also contribute to the spread of HIV/AIDS. Huffam and colleagues (Lancet 3 Aug 2002) from the NT Health Services, reporting on the incidence of HIV-1 infection in foreign nationals working in East Timor, noted that more than 10,000 foreign nationals from countries with endemic rates of HIV-1 have worked for the UN and NGOs in East Timor since June 1999. Foreign nationals working in East Timor visit medical practitioners in Darwin when their contracts end or when on leave. Since October 1999, 12 of the 20 HIV-1 notifications in Darwin have been in foreign nationals working in East Timor.

Speaking at the first National AIDS conference, (7-8 June 2002), President Xanana Gusmao said: "The disease isn't yet a big issue in East Timor but there are risk factors. It's now established that in Cambodia, UN peacekeepers actually contributed to the spread of the virus. But no education program was given to the thousands of UN workers in East Timor who've come and gone".

One of the main difficulties in coordinating an effective response to HIV/AIDS and STIs (Sexually Transmitted Infections) has been the overall lack of human resources and the inadequate infrastructure of the MoH, which is compounded by competing health and development priorities.

There is limited research data to understand the nature of vulnerability to HIV, and no reliable data on the nature of sexual behaviours among the population. Awareness of HIV prevention is low and there are no effective HIV prevention initiatives focusing on the needs of remote villages.

There is an overall lack of understanding of sexual health, a lack of consensus on how to implement sexual health programs, and a lack of appropriate sexual health promotion materials. The lack of involvement of key Ministries such as Education, Transport and Communication, the Office for Promotion of Equality and others, are further barriers in the development of an effective national response to HIV/AIDS.

An all Timorese National Working Group (NWG) is directly responsible for advising the government on HIV/AIDS/STIs issues and has ensured "Timorisation" of the HIV prevention process from the beginning. NWG members have participated in various HIV/AIDS/STI related activities including training on community-based programs for the prevention of HIV/AIDS in developing countries, and the facilitation of workshops and education seminars.

The MoH hosted a "resource mobilisation for HIV/AIDS prevention and care in East Timor" workshop in December of 2001 where UN and donor agencies discussed their paricular roles on the issue. This meeting highlighted the further need for a MoH led response to avoid duplication and ensure sustainability of HIV/AIDS programming in the overall context of East Timor's health sector.

Although district level work has been minimal, a few districts have shown initiative in carrying out general awareness raising, relying mostly on collaboration with the "Natinal HIV/AIDS team" from Dili. A workshop involving the Districts was held in Dili in September 2001 and participants recommended that multi-sectoral District level working groups be established specifically to tackle the issue, mirroring the NWG model.

However, followup has been slow, and the general view from the Districts is that the government should develop a National Strategic Plan outlining a detailed work plan that can be implemented at District level.

The MoH has established a close working relationship with the Catholic Church and the Catholic Church has set up its own pastoral health care commission, which includes HIV/AIDS. In collaboration with the Catholic Youth Commission of the Dili Diocese, the Ministry of Health has coordinated a pilot peer outreach HIV/AIDS awareness campaign in the parishes of the Dili Diocese, reaching some 1,700 youths.

Government's response

The MoH has taken the responsibility of offering leadership to coordinate HIV prevention activities in East Timor. The government is deeply aware of the potential of HIV/AIDS to hinder economic and social development, and the incumbent Prime Minister in his maiden speech to the General Assembly, (26 April 2002 then as Chief Minister), stated that HIV/AIDS would become one of the new Goverment's main concerns.

A substantial achievement of the MoH was the development of a National Strategic Plan for HIV/AIDS/STI, 2002-2005, approved by the Council of Ministers on 4 September 2002. The Plan was developed through a 12 month multi-phase consultation process including input from 139 community stakeholders, 12 district-based focus group discussions, international experts, the UN, international NGOs, and bilateral donors.

The draft plan was presented at the first National HIV/AIDS/STI Conference in June 2002 which was opened by the East Timor President with opening statements from a person living with HIV/AIDS, a UN representative and the churches.

Successful implementation of this first Strategic Plan wll require strong partnership with multiple sectors including education, communication, transport, maritime, public works, finance and planning, social welfare, labour, law and judiciary, tourism, and uniformed services.

Developing an effective response to HIV/AIDS will require substantial investments in human resources, and program infrastructure and a coordinated approach mobilising external technical and financial resources. Regular consultation with international communities, bilateral donors, international NGOs, and multinational business communities is necessary to ensure achievments of the vision.

END (Views are stated to be of author only)

References 1 Modvig J; Pagaduan-Lopez J; Rodenburg J; Salud CM; Cabigon RV; Panelo CI (2000). Torture and trauma in post-conflict East Timor. Lancet, 2000 Nov 18;356(9243):1763.

2 Ministry of Health, Government of East Timor (2002). HIV/AIDS in East Timor: a situation and response analysis - summary report.

3 Huffam S; Currie BJ; Knibbs P; Savage J; Krause V (2002) HIV-1 infection in foreign nationals working in East Timo, Lancet. 2002 Aug 3;360(9330):416.

4 Key note address by His Excellency Xanana Gusmao, President of East Timor at the National AIDS Conference: East Timor responding to HIV/AIDS/STI, 7-8 June 2002.

5 Briefing to UN Security Council on 26 April, 2002 by His Excellency Mari Alkatiri, Chief Minister of East Timor.

6 Ministry of Health, Government of East Timor. (2002). National Strategic Plan for a Comprehensive and Multi-Sectoral Response to HIV/AIDS/STI. 2002-2005.

Data and information presented in this article is derived from Dr Joe Thomas's work as a HIV/AIDS Advisor to the East Timor government's Ministry of Health under the HIV/AIDS Advisory Activity of the Australian Government's Aid program. The views and opinions expressed in this article are those of the author and they may not represent the views of the East Timor Government or the Australian Government.

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