The Maldives still has very few people living with HIV and AIDS. However, with considerable vulnerability and risk, there is a potential for a concentrated HIV epidemic. The country has high rates of hepatitis B and C, while STI rates are average for the region. Stigma and taboos related to sex work and MSM are widespread, putting the Maldives at risk of spread of STIs, HIV and hepatitis. With few resources currently required for treatment, the Maldives has the opportunity to focus on better understanding risk factors, such as unsafe sexual practices and drug use, and focus on prevention among the most at risk populations. It can also address accessibility to health services, linking HIV with other STIs, and improve action in the ongoing HIV/AIDS program.
State of the Epidemic
The state of the epidemic in the Maldives is characterized by low overall prevalence but considerable vulnerability and risk, i.e. high epidemic potential. The most likely trigger for an HIV epidemic in the Maldives is injecting drug use, because of the ‘efficiency’ of sharing contaminated needles as an HIV transmission route compared to sexual transmission, the relatively large number of Maldivians using drugs, the apparently increasing share of drug users shifting towards injecting rather than smoking, and the high prevalence of needle sharing (according to the BBS 2008).
The first case of HIV in the Maldives was reported in 1991. UNAIDS estimated in 2009 that less than 100 people were infected with the virus. However, through 2009, 13 HIV‐positive cases had been reported among Maldivians (11 male, 2 female) and 245 cases among expatriates. All have been identified through case reporting and all infections were reportedly acquired through heterosexual transmission. Eleven of the 13 HIV‐positive Maldivians developed AIDS; of those, ten died. Of the 13, 10 were seamen, two were spouses of the sailors, and one was a resort worker. In 2008, the first Bio‐Behavioral Survey (BBS) was conducted in the Maldives (Corpuz AC, October 2008, 2008 Biological and Behavioral Survey (BBS) and HIV/AIDS, Republic of Maldives). A total of 1,791 serologic samples were taken across five groups: female sex workers (FSW), men who have sex with men (MSM), injecting drug users (IDU), occupational cohorts of men (OCM – including seafarers, construction workers and resort workers) and youth, across Male, Addu and Laamu atolls. One HIV infection was identified in a male resort worker. It is not clear via which risk behavior he became infected, but it may indicate that tourism is a factor to be taken into account. The survey found high rates of STI and Hepatitis. Data collected on sexual behavior and drug injecting behaviors, show wide ranging and closely interconnected sexual networks across survey groups.
Risk Factors and Vulnerability
Mobility: Many Maldivian citizens go abroad for education and work and are away from their families for long periods of time. More information is needed on the risk behaviors that these citizens may engage in while they are away from the support of their families.
Sexual Practices: The bio behavioral survey in 2008, showed the following risk pattern: Female Sex Workers and their clients: FSW [N=94] reported a median of 4 clients per week in Male and 2 clients per week in Addu. FSW reported very low consistent condom use (12% in Male and 2% in Addu); male construction workers reported 0% condom use. This contrasted with the reported condom use of the occupational cohort males: 67% of seafarers and 41% of resort workers reported to consistently use condoms. 9‐12% of FSW reported expatriate clients in the past 12 months; one FSW in Male had worked as a sex worker in Malaysia. 83% of seafarers, 3% of resort workers and 2% of construction worker clients reported sex with an expatriate FSW.
Nearly all (98%) FSW in Addu and 88% in Male reported unsafe sex with a client in the past 7 days; 100% and 80% reported unsafe sex with a regular partner in the past 7 days, indicating a clear potential pathway for HIV into sexual networks in which monetary exchange plays a role.
Men who have Sex with Men: The mean age of sexual debut of MSM [N=126] was 16 and 17 in Male and Addu, respectively. One out of five MSM in Male reported their first sexual experience with another male was forced upon them. MSM were found to have a wide range of sex partners. 93‐94% reported consensual sex with a male in the past 12 months and about two thirds in both Addu and Male also had had sex with women in the past year. Selling sex to a man was reported by 18% and 44% in Addu and Male, respectively; buying sex from a man (18% and 29%), selling sex to a woman (5% and 29%) and buying sex from a woman (16% and 49%) were also significant risk behaviors. MSM in Addu and Male used condoms consistently in 21% and 36% of their encounters with men and in only 2% and 17% of their sexual encounters with women, respectively.
Regarding sexual networking, IDU, similar to MSM, have a wide ranging sexual network. In Addu and Male, 97% and 90% of IDU had sex in the past 12 months; 65% and 74% had a regular sex partner (of whom only 1% and 2% were also injecting); 54% and 55% had a non‐regular partner, 52% and 38% bought sex; 4% and 16% sold sex; 2% of male IDU sold sex to another man in both locations and 1% and 2% of IDU reported consensual sex with another man. Importantly, 59% of IDU reported unsafe sex in the past 12 months.
Drug Use: A 2003 UNDP rapid situation assessment of drug abuse in the Maldives revealed that drug abuse is on the increase in the country and is initiated at a young age. Opioids, primarily brown sugar, hashish oil, and other cannabinoids, are the most frequently seized and most frequently abused drugs. In the outer atolls, reports of use of cologne, inhalants, and alcohol are also common. Drug use is a risk factor for HIV infection for two reasons: drug users may sell sex to earn money, and injecting drug users may share needles/syringes. Female drug users in the Maldives are apparently sometimes involved in sex work. In addition, sex occurs between male and female drug users as well as between male drug users; 3% of sexually active drug users reported same‐sex experiences in a 2002 UNDP assessment of drug use.
Injecting Drug Users: The mean age of debut of drug use of current injecting drug users [N=276] is 16 in Male and 17 in Addu (2009, BBS). In both locations, the median age at which current IDU had shifted to injecting drugs is 22. A third (31%) of IDU in Male and 23% in Addu reported sharing an unsterilized needle at the last time of injection. Cleaning of needles occurred but often using inappropriate and unsafe techniques. Most IDU in both locations did not carry syringes with them for fear of being arrested. A fifth (20%) of IDU in Male and a smaller number (6%) in Addu had travelled to other places to inject, mainly in the Maldives but Bangladesh and India were also mentioned. A bit less than a third (30‐26%) of these ‘mobile’ IDU reported unsterilized needle sharing, indicating an important potential entry route for HIV into networks of Maldivian drug injectors.
A large majority (86%) of IDU in Male had been in jail. Two thirds (64%) of them used drugs while in prison and a third (32%) reported injecting drugs while in jail. A third of drug‐using rehab clients in Male reported injecting while in rehab.
Awareness: Respondents of a 2004 reproductive health survey had fairly high general levels of awareness (e.g. 99% had heard of HIV/AIDS; 91% knew at least one mode of HIV transmission) however, only 50% agreed that condoms can protect against HIV and 34% did not know that a healthy looking person can have HIV.
Dispersed Population: Maldivians inhabit 200 of the 1,200 islands and atolls that make up their country. This dispersed population creates barriers to educating people on HIV, distributing condoms, and treating people for STIs that increase transmission of HIV.
Tourism Employment: The Maldivian tourist economy employs about 5,000 immigrant workers, mainly from India and Sri Lanka. These workers, far from their support systems, families, and usual sexual partners, are vulnerable to participating in high‐risk behaviors such as sex without a condom and sex with commercial sex workers. More research is needed to better understand the risk behaviors of immigrant workers and to tailor existing HIV programs to their needs without introducing stigma against foreigners.
External Tourism: In 2004, about 600,000 tourists visited the Maldives, almost double the entire population of the Maldives. Although sex tourism is not present in the Maldives, the great influx of people from all over the world represents a potential route of introduction of HIV and high‐risk behaviors such as injecting drug use and unsafe sex.
Stigma and Discrimination: As in other South Asian countries, HIV‐related stigma and discrimination are barriers to effectively addressing HIV and AIDS. Stigma is especially strong against men who have sex with men.
National Response to HIV/AIDS
Government: The National AIDS Program, part of the Ministry of Health and Family (MOHF), is in charge of the overall coordination of the national response to HIV. It has successfully advocated for HIV related issues, including the drafting of a new Drugs Bill and the Global Fund Grant Round 6. It has established relationships with other parts of the MOHF, with other Government partners (Ministry of Education (MOE), Ministry of Islamic Affairs (MOIA), police, etc.) and with civil society/NGOs. The National Strategic Plan 2007‐2011 aims to limit HIV transmission, provide care for infected people, and mitigate the impact of the epidemic through seven strategic directions:
1. Provide age‐and gender‐appropriate prevention and support services to key populations at higher risk: drug users, sex workers and men who have sex with men.
2. Reduce and prevent vulnerability to HIV infection in adolescents and young people.
3. Provide HIV prevention services in the workplace for highly vulnerable workers.
4. Provide treatment, care and support services to people living with HIV.
5. Ensure safe practices in the healthcare system.
6. Build and strengthen capacity and commitment to lead, coordinate and provide a comprehensive response to the epidemic.
7. Strengthen the strategic information system to respond to the epidemic.
The government carries out a high level of screening, including mandatory screening of all its citizens when they return from an overseas stay of more than a year.
Nongovernmental Organizations (NGOs): UNDP reports that there are few NGOs in the Maldives. Those that are active have provided educational services such as weekly radio programs, peer education, and seminars.
Donors: The main donor in the Maldives is the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). UNDP is the Principal Recipient (PR) and the NAP is one of three sub‐recipients (SR). The objectives of the GFTAM support are to:
1. Prevent HIV transmission among young people who inject drugs or are at risk of injecting drugs.
2. Prevent HIV transmission among populations at risk such as migrant, seafarers, and resort workers.
3. Increase awareness and knowledge about STIs and HIV among young people.
4. Expand access and coverage of quality HIV testing and counseling.
5. Strengthen the prevention and control of STIs.
6. Strengthen health service capacity to provide quality care, support and treatment for people living with HIV.
7. Strengthen health systems capacity for prevention of HIV and other transfusion transmittable infections through blood and blood products.
8. Strengthen the strategic information system for HIV.
9. Strengthen the multi‐sectoral response to HIV/AIDS.
The Global Fund grant was prepared by the Country Coordinating Mechanism (CCM) which has 22 members (41% government, 39% NGOs and UN agencies – WHO, UNFPA, UNICEF, UNDP). The GFATM is the only financing mechanism in the country, and the main funder of the NAP. UNDP has a support role as principal recipient of the grant.
WHO and UNFPA have provided funding and technical assistance for HIV/AIDS awareness and prevention programs. The Government of Italy, through UNDP, funded a drug abuse‐prevention program. The UN Theme Group on HIV/AIDS carried out a situational analysis in 2006 of HIV/AIDS in the Maldives in collaboration with the National HIV/AIDS Council and the Ministry of Health in order to increase the multi‐sectoral response. UNODC has supported an Opioid Substitution Therapy (OST) pilot in Male, and the plans are to scale up comprehensive harm reduction, including OST.
Issues and Challenges: Priority Areas
Creating an enabling policy environment in order to increase access and use of prevention services among vulnerable groups at highest risk for HIV and other STIs.
Strengthen Involvement of NGOs and CBOs. The Maldives need to build capacity among NGOs and CBOs in order to reach the most at risk populations and smaller islands. Already a social mapping and size estimation is underway to better plan for targeted interventions among the most at risk populations.
Strengthen the Evidence Base. Overall national capacity in STI and HIV/AIDS program monitoring, surveillance and research should be strengthened. The first social mapping of high risk groups is underway to better understand risk factors such as drug use, serial monogamy, and the pattern of male‐to‐male sex. Once more is known about these practices, increasingly effective prevention programs can be developed. There is also a need to evaluate piloted programs for the prevention of HIV among injecting drug users, including OST pilot, to inform policy and strategy options for the Maldives.
World Bank Response
The World Bank has responded to a request from the Government of Maldives to assist in the development of a strategic action plan for 2010‐11. The planning process started with World Bank participation in a joint review in 2009, with other development partners, which identified the priorities and critical funding gaps. This was followed up by World Bank support to a costing workshop resulting in an Operational Plan for 2010, with a costed strategic action plan and costing capacity of the national AIDS team. A study to do social mapping and size estimation of high risk groups is ongoing. A Maldivian team of surveyors have been trained to conduct the mapping.