The HIV response faces difficult challenges under ordinary circumstances. Humanitarian crises, however, can push HIV prevention, testing, treatment and care services to the brink of failure.
In March 2019, Intense Tropical Cyclone Idai, one of the southern hemisphere’s worst tropical storms on record, caused catastrophic damage in Malawi, Mozambique and Zimbabwe (36). A month later, Intense Tropical Cyclone Kenneth made landfall in Mozambique as the strongest tropical cyclone the country had experienced since record-keeping began (37). The second storm exacerbated an already serious humanitarian crisis:
more than 1.5 million people were affected, with more than 1600 injured and 600 dead.
The twin disasters left many rural and urban dwellers with the barest minimum of health care. The cyclones reduced access to HIV services and added to HIV risks: with the breakdown of social order and accepted codes of behaviour—and in the absence of community protection mechanisms—many women and girls were exposed to sexual and gender-based violence.
Mozambique’s Ministry of Health, public health workers, community health workers, community activists and development partners worked tirelessly to re-establish life-saving HIV services, and to trace and link people living with HIV to health services and psychosocial support.
Their efforts highlight the importance of a people-centred approach. The situation encouraged mainstreaming HIV and tuberculosis services into the ongoing response to the acute threat of cholera, malaria and food insecurity. In addition to addressing the crisis, longer-term social–structural issues that increase vulnerability to HIV and threaten people living with HIV will require greater attention. This includes tackling broader gender inequalities, stigma and discrimination, and lack of confidentiality in health-care facilities and other settings.
At the same time as Mozambique is experiencing natural disasters and their aftermath, Venezuela’s economic and political crisis has led to the
displacement of millions of people. As of June 2019, there were 4 million Venezuelan refugees and migrants in countries across Latin America and the Caribbean, one of the largest displacements of people in the history of the region (38).
Some countries maintained open borders for Venezuelans and provided shelter and support for migrants and refugees, but the demand was often beyond what they could manage. The International Organization for Migration (IOM) and the United Nations High Commissioner for Refugees (UNHCR) created the Regional Inter-Agency Coordination Platform, which developed the Regional Refugee and Migrant Response Plan to support the efforts of national authorities in 16 host countries (39, 40).
Physical, cultural and social limitations can prevent migrant people living with HIV from accessing health services. Sexual orientation may create additional risks in countries where same-sex sexual relationships are highly stigmatized or criminalized (41). UNAIDS developed two sets of recommendations for governments, civil society
The injured feet of a Venezuelan man who walked hundreds of kilometers from Venezuela to Tumbes, at the border between Ecuador and Peru, to escape the crisis in his country.
Credit: Santiago Escobar
THE CASCADE FROM HIV TESTING TO VIRAL SUPPRESSION
COMMUNITIES IN ACTION
organizations, international organizations, migrants, refugees, and host communities that are specific to the care of migrants and displaced people living with HIV:
An Initial Minimum Response: what is required to cope with emergencies that prompt a mass exodus of people, such as that from Venezuela.
An Expanded Response: a process to integrate migrants and refugees into national response planning.
In 2018, UNAIDS and the Pan American Health Organization (PAHO) developed a three-year Master Plan for Strengthening the Response to HIV, Tuberculosis and Malaria in Venezuela. A scale-up strategy was implemented by United Nations agencies and, at the end of 2018, funding was made available to support the distribution of 60 000 rapid HIV tests and 100 000 syphilis tests in eight hospitals in Caracas and two major states, as well as training for health workers. By May 2019, all
Ministry of Health pharmacies had received 300 000 bottles of combination antiretroviral medicines, with a further 300 000 due in the following months.
Civil society in Venezuela is monitoring delivery of donated antiretroviral medicines and helping people living with HIV navigate the health system to guarantee timely access to services and antiretroviral treatment.
UNAIDS is also supporting survivors of rape by training 90 health workers in four border areas to provide comprehensive services to survivors of sexual violence.
UNHCR is supporting a national protection network providing assistance and counselling to persons in transit and safe spaces for survivors of sexual and gender-based violence and children at risk. The safe spaces provide confidential case management, counselling, psychosocial support, medical assistance and legal services.
Damage from cyclones that hit Mozambique in early 2019.
Credit: Shutterstock
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