HIV / AIDS in Timor-Leste

HIV is a world wide health concern and East Timor has also been affected. This page includes articles and reports that discuss the important issue of HIV in East Timor .

The first report of HIV in East Timor was in 2001. In 2002 there were only six reported cases of HIV/AIDS in East Timor . The prevalence was reportedly 0.64%, however this was based upon testing done on 982 samples from blood donors. Reliable data is lacking....

For other health issues see Health in Timor-Leste.

INDEX

EAST TIMOR: Hip-Hop and Rock for Condoms Challenge Church   Inter Press Service - July 5, 2004 Sonny Inbaraj Darwin

USAID Report on HIV in East Timor February 2004 (Adobe Acrobat file: 548 kB)

HIV: East Timor Crisis December 2002

HITTING HOME How Households Cope With The Impact Of The HIV/AIDS Epidemic. From South Africa October 2002. Some potential parallels? (Adobe Acrobat file)

WHO/UNICEF/UNAIDS Epidemiologic Fact Sheet on HIV/AIDs and Sexually Transmitted Infection for Indonesia. 2002 Update.  (Adobe Acrobat file)

HIV-1 infection in foreign nationals working in East Timor Lancet 2002

Low HIV rate could easily escalate, warns health minister 8.7.2002

Transcript of an interview with Dr. Rui Maria de Araujo Minister of Health, East Timor Dili, 28 of June 2002 

East Timor move to combat AIDS 10/06/02 -- The Age

NATIONAL HIV/AIDS AWARENESS CAMPAIGN LAUNCHED BY SRSG 3 April 2002

Prevalence of Infection with Human Immunodeficiency Virus in East Timor Clinical Infectious Diseases 2001

East Timor HIV Spills Over To Australia   Dr Murphy 2001

MOH announces 24 AIDS cases in Timor-Leste, with five deaths Suara Timor Lorosa'e (STL). The Ministry of Health (MoH) released the total number of HIV/AIDS cases to the public based on data collected, which indicates that 5 out of the 24 HIV/AIDS cases in Timor-Leste have resulted in death, said Mr. Feliciano Pinto, an official in the Ministry. Mr. Pinto noted that to help prevent the spreading of the virus, the Ministry is cooperating with both international and local NGOs to distribute information on HIV/AIDS and its dangers. ETAN International and Local Media Monitoring December 03 2004

EAST TIMOR : Hip-Hop and Rock for Condoms Challenge Church

Inter Press Service - July 5, 2004 Sonny Inbaraj DARWIN

Musicians in the predominately Catholic East Timor are taking their HIV/AIDS message directly to the people by circumventing official Church policy that bans the use of condoms.

"It is sheer hypocrisy to tell youth that it is a sin to use condoms and to abstain from pre or post marital sex," Milena da Silva, a band member of the hip-hop Bibi Bulak Group, tells IPS in a phone interview.

"If you go around the capital Dili and listen to what the young East Timorese men are talking about - it's always about having sex," says Da Silva.

HIV/AIDS is spread through risky sexual behaviour such as having multiple partners, and is not confined to particular groups of people. But " most of them don't use condoms when they visit prostitutes," adds Da Silva.

"You can't control these guys and if a lackadaisical attitude is adopted towards HIV/AIDS, then we're in for some big-time trouble," she warns.

Ninety percent of East Timor 's 800,000 people are professed Catholics, although many are also animists. There are small Protestant, Muslim, Hindu and Buddhist communities in Dili. The Catholic Church in East Timor , as in many other mainly Catholic countries, opposes any kind of contraception, claiming it breaks the link between sex and procreation. Consequently, it has repeatedly refused to agree with health experts who recommend the use of condoms as protection from contracting HIV and other sexually transmitted infection (STI). Instead, it encourages abstinence and fidelity within marriage as a safe way of avoiding HIV and STI. Milena's band has just recorded 'Uza Ida Kondom' (Use a Condom) in East Timor 's national language 'Tetum'.

The lyrics centre around a young East Timorese man who decides to get a tattoo from a tattooist who never changes his needles. The young man then decides to visit a prostitute and has unprotected sex with her. Then the young man's uncle also goes to the same girl and refuses to wear a condom when having sex. This uncle later goes back home to his village and dies of AIDS some time later. The song ends with the funeral of the young man who also succumbs to AIDS.

According to Family Health International (FHI), which started work in East Timor in April, this ongoing risk behaviour in the fledgling nation is worrying.  

"Among groups of men who have cash and are frequently away from their families, visits to sex workers are quite common," says FHI's East Timor Programme Officer Rui Carvalho.

"These individuals are choosing not to abstain or be faithful to a spouse, they are not choosing to protect themselves or their partners by using condoms," adds Carvalho.

A World Health Organisation (WHO) assessment team that visited post-conflict East Timor in November 2000 concludes in a report that "condom use is still a sensitive issue and does not get the support from the Catholic Church. 

"There is no policy on condom promotion; thus there is no definitive protocol for the whole system of condom procurement, logistics and monitoring," the WHO report adds.

For 25 years, East Timor was occupied by Indonesia . The Timorese in a United Nations-sponsored referendum opted for independence in late August 1999 and became independent in May 2003, after a two-year interim administration led by the United Nations.

"The topic of HIV/AIDS and condom usage makes people very uncomfortable here," Bibi Bulak's coordinator Yohan York tells IPS. "We're testing the waters in the country, to gauge whether the local community radio stations will play 'Uza Kondom'," he says.

York says new forms of emerging music in East Timor - like hip-hop, reggae, ska and rock - are important mediums for social messages.

"Bibi Bulak is willing to push the conservative boundaries to save young peoples' lives through our music," says the Canada-born musician. "Music is a powerful tool because it also entertains."

Domingus da Silva Lay, one of the founder members of the popular rock band Vi Almaa X, agrees with York . "The entertainment element draws people and when you get an audience you preach the message -- and that goes down well," Lay tells IPS. The Vi Alma X bassist reveals the sexual realities in the country.

"You've got to be kidding if you say everyone is faithful to their spouses and there's no sleeping around in Catholic East Timor," he tells IPS.

The rock band recorded 'HIV/AIDS' in Tetum last year and performed it publicly a t the National Stadium on World AIDS Day in December 2003.

"I think the mainstream media has let us down in not giving us enough information about AIDS. So that's the reason we decided to record 'HIV/AIDS' to reach out the East Timorese youth who consider it not macho to wear condoms when they have sex," says Lay.

In East Timor , only a handful of people have tested positive for HIV, but healthcare workers say poor monitoring and the widespread stigma is probably masking the true picture. Reports from international organisations do not have categorical information on HIV/AIDS in East Timor .

"People don't know who is infected, but they are scared. Of course, if they hear that HIV positive people are being treated at a clinic, they would run away from that clinic," says FHI's Carvalho.

The WHO assessment report warns that the components for an HIV epidemic already exist in East Timor - a problem exacerbated by many East Timorese moving around locally and back and forth across the common border with Indonesia-administered West Timor province.

"There is a HIV problem but no one knows how extensive it is because we don't do testing," says Dan Murphy, a medical doctor running the Bairo Pite Clinic in Dili.

While the extent of HIV remained invisible, Murphy tells IPS his clinic frequently treats men suffering the more obvious sexually transmitted diseases, such as gonorrhaea, from visiting sex workers and having multiple partners.

"If unchecked, I fear a major blow out in HIV among the conservative Catholic population resistant to condom use and sexual discussion," he says.

From: 040705 IP040709  

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ANNAN WELCOMES PACT ON LOWERING AIDS DRUG PRICES IN DEVELOPING COUNTRIES

New York , Oct 24. 2003  5:00PM: United Nations Secretary General Kofi Annan today welcomed an agreement between former President Bill Clinton's foundation and four pharmaceutical companies in developing countries to halve the price of anti-retroviral drugs used to treat HIV/AIDS and he said he hoped other drug manufactures would follow suit. 

The price reductions by the four companies "will not only make HIV treatment more affordable to many of those who could previously not afford them, they should also act as a further incentive for Governments, particularly in countries heavily affected by HIV/AIDS, to establish national treatment plans as part of their comprehensive prevention and care emergency strategies," Mr. Annan's spokesman told a news briefing.

"The Secretary-General hopes the initiative will encourage other pharmaceutical manufacturers to review their pricing policies and evaluate what further price reductions they can make to render these vital medicines more accessible to those who need them most," spokesman Fred Eckhard said. 

According to the Clinton Foundation, the four manufacturers in the agreement are Aspen Pharmacare Holdings Ltd. of Johannesburg, South Africa, Cipla Ltd. of Mumbai, India, Ranbaxy Laboratories Ltd. of Delhi , India , and Matrix Laboratories of Hyderabad, India. The annual cost of drugs for each infected person is expected to fall to as little as $140. 

Mr. Annan said he trusted that a synergy would be created between the initiative launched by the Clinton Foundation and such efforts as President Bush's Emergency AIDS Plan, the project by the World Health Organization.

http://www.who.int/mediacentre/statements/2003/statement13/en/index.html

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HIV: East Timor Crisis

HIV Australia magazine vol.2 no.2 Nov/Dec 2002 

"Focus on the Asia Pacific" 

www.afao.org.au and http://www.etan.org/et2002c/december/22-28/00hiv.htm

"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 particular 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 "National 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, follow-up 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.

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 Government'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 will 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 achievements of the vision.

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 Timor, 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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HIV-1 infection in foreign nationals working in East Timor

S Huffam , B J Currie, P Knibbs, J Savage, V Krause 

The Lancet 2002; 360: 416

Sir - Darwin , Australia , has been the major site for medical support to East Timor since the beginning of the United Nations Mission in 1999. We believe East Timor has been at risk of an HIV-1 epidemic since that time. In April, 2002, the United Nations Transitional Authority in East Timor (UNTAET) launched a campaign to raise public awareness of HIV/AIDS and avoid the kind of epidemic that has crippled other developing nations. 1 

Since June, 1999, at any one time there have been 10 000 or more foreign nationals working for the UN 2 and around 70 non-governmental organisations in East Timor . Many of the foreign nationals are from countries where endemic rates of HIV-1 infection are higher than 25% in the 15-49-year age-group. 3

Foreign nationals working in East Timor visit medical practitioners in Darwin , about a 1 h flight from the capital, Dili, 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 . Three cases of HIV-1 infection in Darwin were acquired through contact with foreign nationals from countries with high HIV-1 prevalence.

Although limited data are available, HIV-1 seroprevalence in East Timor is believed to have been extremely low before 1999. 4 In Darwin in October, 1999, 51 East Timorese evacuees who had tuberculosis were all HIV-1 negative.

The potential HIV-1 impact from peace-keeping was recognised in July, 2000, when the UN Security Council voted to intensify AIDS education among UN peacekeepers. 5 At around this time an interagency assessment mission, involving various local stakeholders, including the Catholic Church, was done in East Timor, and a national HIV-1 working party was formed. The Catholic Church is a powerful religious and social agent in East Timor , and its leadership and recognition of the potential risk of an HIV-1 epidemic is vital for the success of prevention programmes.

Hopefully, an HIV-1 epidemic of the scale seen in Cambodia after the 1992 UN mission can be avoided. There, by late 1999, more than 4% of adults aged 15-49 years were infected. 3 HIV-1 prevention must be an earlier priority in future peace-keeping missions.

*S Huffam, B J Currie, P Knibbs, J Savage, V Krause AIDS/STD Unit and Infectious Diseases Unit Royal Darwin Hospital, Department of Health and Community Services, Darwin, Northern Territory, Australia (e-mail: sarah.huffman@nt.gov.au )

References

1 UN. National HIV/AIDS awareness campaign launched by SRSG. http://www.un.org/peace/etimor/DB/db030402.htm (accessed June 5, 2002 ).

2 UN. Transitional administration in East Timor . http://www.un.org/peace/ etimor/etimor.htm (accessed May 31, 2002 ).

3 UNAIDS epidemiological fact sheets. http://www.unaids.org/hivaidsinfo/statistics/ fact_sheets/all_countries_en.html#k (accessed May 31, 2002 )

4 Chevalier B, Carmoi T, Sagui E, Pierre C. Prevalence of infection with human immunodeficiency virus in East Timor .  Clin Infect Dis 2001; 32: 991-92. 

5 UN Security Council. Actions taken by the security council in 2000: 17 July SC/6890 HIV/AIDS. http://www.un.org/Docs/scres/2000/ res1308e.pdf (accessed July 22, 2002 ).

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Low HIV rate could easily escalate , warns Health Minister

from http://www.etan.org/et2002c/july/07-13/09HIV.htm

8.7.2002

East Timor`s minister of health has said that his country has all the conditions necessary for the outbreak of an Aids epidemic and urgent measure are needed to prevent this. Rui Araujo, currently attending a world conference on HIV/AIDS in Barcelona , said that Timor possessed "all the ingredients" needed for a serious epidemic. Poverty, street children, unemployment and prostitution all existed in Timor , and the present HIV rate of 0.64 percent was just "the tip of the iceberg", Araujo told ABC Radio in Australia on his way to Barcelona . 

Dili's health minster said that this figure was based on inadequate analysis and limited research. The Timorese health authorities were making all efforts to involve the whole nation, including the church, parliament and even the president in an awareness raising measures, said Araujo.

The Timorese health ministry will shortly launch a nationwide campaign, including the distribution of condoms, a voluntary testing and counseling service and a case notification program, said Araujo.

The Dili representative of the United Nations Development Program, Phillips Young, said last week that as Timor was "a country practically not affected by Aids", it had "a priceless opportunity to avoid a major epidemic". 

The first Aids case was notified in Dili in December, 2001. Currently, there are six confirmed cases in Timor: three of AIDS (one death) and three HIV poistive, according to Dili`s health authorities.

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East Timor move to combat AIDS 

10/06/02 -- The Age

East Timorese planners have begun work to combat the spread of AIDS. At the newly independent country's first conference on the issue, the UN Secretary-General's new head of mission, Kamalesh Sharma, said that because East Timor was beginning afresh, "policy-makers have a unique opportunity to learn from other countries". He pledged that his office would draw up a prevention program for UN peacekeepers and civilians. Joe Thomas, adviser on HIV/AIDS to East Timor's Ministry of Health, said that since last September seven cases had been recorded nationally, resulting in one death. For many, the UN promise of a program for its own staff comes late. 

A peak in HIV infection figures in Darwin in 2000 suggested that they might be a source of infection. Eight cases were detected among UN staff on leave from East Timor , resulting in the infection of two local people. 

Jan Savage, head of Darwin 's AIDS program, warned "it is quite plausible that HIV will be transmitted to the East Timorese from the foreign workers". The rate of infection during the Indonesian period is not known. However, Health Minister Rui Maria Araujo said some infections might have dated from then because of prostitution and "the great mobility with which Timorese traveled to other areas of Indonesia ". But he added that the UN had "not succeeded in regulating matters" during the transition period, "which will probably contribute to the spread of the epidemic". He said of prevention measures among peacekeepers: "We still are in a phase of a mass international presence, with around 5000 internationals, so it's never too late." Estimates give the infection rate as a low 0.64 per cent of the population. Health workers fear it may climb, given the international presence and the increase in prostitution.

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NATIONAL HIV/AIDS AWARENESS CAMPAIGN LAUNCHED BY SRSG

3 April 2002

UN Transitional Administrator Sergio Vieira de Mello and East Timor 's Vice Minister for Health, João Martins, launched today a national campaign to raise public awareness on HIV/AIDS and help prevent the kind of epidemic that has crippled other developing nations.

Martins said his ministry's preliminary estimate on the rate of HIV infection in East Timor is 0.64 percent of people of reproductive age. By comparison, regional countries Cambodia , Thailand and Myanmar have HIV rates of more than 1 percent, according to UNAIDS.

While East Timor has so far avoided an epidemic, both Vieira de Mello and Martins warned that several social factors might exacerbate the spread of HIV in the soon-to-be-independent nation: massive social dislocation; cross-border migration; high unemployment; illiteracy among the rural population; and low awareness about HIV and other sexually transmitted diseases.

“The United Nations, in partnership with the East Timorese transitional government, is fully committed to develop necessary programmes to address the causes and consequences of HIV infection in East Timor ,” said Vieira de Mello, the Special Representative of U.N. Secretary-General Kofi Annan.

“Indeed, East Timor has a unique opportunity to prevent an epidemic of HIV/AIDS, but only if all the key stakeholders act together in a coordinated manner. This is the only way to make sure that this epidemic – which is already ravaging other parts of Southeast Asia – will not take a strong hold in East Timor ,” he added.

The campaign – spearheaded by UNTAET's Office of Communications and Public Information and the Ministry of Health – employs UNTAET's television, radio and publications units to promote general awareness on how to prevent the spread of HIV/AIDS.

It will also promote ongoing HIV/AIDS-related initiatives by the government, UN agencies and NGOs. A national HIV/AIDS working group has been set up and is advising the government on HIV/AIDS-related matters. The Ministry has also already initiated priority, short-term interventions among marginalized youth and sex workers. The stakeholders are now working on an HIV testing and counselling policy; a national HIV/AIDS situation assessment; and a national strategic plan. Also, a National AIDS Conference has been planned for 29-30 April.

Both the Vice-Minister and Vieira de Mello applauded the Catholic Church for its cooperation in the fight against HIV/AIDS. The influential church has established a programme to raise HIV/AIDS awareness through health clinics run by the international NGO Caritas.

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Transcript of an interview with Dr. Rui Maria de Araujo,  

Minister of Health, East Timor Dili, 28 of June 2002

East Timor at present can count itself fortunate: so far it appears to have avoided the kind of HIV/AIDS problem that has ravaged many other developing nations. This means it has a rare opportunity to prevent an HIV/AIDS epidemic, learning from the lessons of other less fortunate nations to build a healthier future for its people. UNDP is supporting the East Timorese government in their efforts to create a programme that will bring about that future, by facilitating the drafting and discussion of a National Strategic Plan, and by sending the new Minister for Health, Dr Rui Maria de Araujo to Barcelona, so that East Timor can for the first time as a nation join the international dialogue on responding to the HIV/AIDS issue. But Timor is a small and very poor nation with many, many other problems - is it really in a position to seize the opportunity it now has? In this exclusive interview, Dr. Rui Maria de Araujo tells UNDP why and how East Timor can handle the HIV/ AIDS issue

How important is it to East Timor to deal with the issue of AIDS/HIV?

"I think for East Timor it's very important, because we do realize that the AIDS epidemic is going to be a real challenge, the biggest trap for the economic development of this country. We understand that looking at the examples we have – in Papua New Guinea for example, the most recent outcry, the spread of the disease has affected the whole country, particularly the workforce. That's why we do realize that HIV/AIDS is very important, it's one of our highest priorities and we are doing all that we can to get the involvement of everyone in the country – civil society, the church, parliament and right up to the president himself because we realize it's very important to get people at the top involved."

At present, East Timor has a very low recorded prevalence of HIV/AIDS and that means that you have the opportunity here to prevent that kind of epidemic. Are you confident that that can be achieved?

"Let me start a little bit back from that. Yes prevalence is low but the vulnerability is there. All the necessary ingredients for a tragedy are there. Poverty, drug use is on the increase although we don't have the exact figures, we have street children out there, we have prostitution out there, we have jobless people and at the other side of the coin, we have a huge presence of expatriate people here with a great capacity of buying things, including buying sex, and that is a great risk. Obviously because the prevalence is low, according to the testing up to now, even though on that side I'm a little bit pessimistic because the cases that we've found indicated that contact with the disease happened already during the Indonesian times. We had an AIDS case who died two months ago and just doing the counting, simple math's, that means that guy was exposed five or ten years ago, which means he was exposed during Indonesian times. Now, to what extent has that exposure affected East Timor ? I think the low prevalence that we're talking about is just the tip of the iceberg. Obviously that does not discount the focus that we need to give to the prevention side, and particularly on the health promotion. Spreading the information to all communities in order to make them aware. We've been doing this for the last one, one and a half years – direct intervention with at risk groups to raise the sensitivity, the awareness about the prevention of the disease, and the response has been quite good. Now, to what extent that kind of information is going to change people's behaviour, that remains to be answered, but although this might seem a very optimistic view I think we can do something on that. "

It is very difficult to know what the incidence rate is in Timor . Are there any plans for a systematic research programme?

"Well, not systematic research, but the start of the Strategy plan, one of the activities that is first going to be activated is to set up a testing and counselling unit, and to set up a surveillance system for HIV/AIDS in the main hospitals, in the blood transfusion unit, to get the real picture. From now onwards we are planning to establish that as part of the national HIV/AIDS programme, and possibly it's going to be at the national hospital – they are now doing the proposal for the implementation of that. And with the voluntary testing and counselling unit and the surveillance system we will be able to get more data about the incidence rate. In the past we have also based on screening of blood for transfusion and based on some screening samples for people going to the police force and army, we came up with a prevalence rate we are now using of 0.64. The plan for the voluntary testing and counselling unit is to have pre-test counselling, and then post-test counselling in case we find out people are positive and we need to have the network to follow up once people are positive. So these are the principles that led to the founding of this centre, but it will take another few months. We need psychologists, blood technicians and social workers in order to make that centre functional. Obviously that is from the supply side. From the demand side, we may end up with people not coming for testing because it's something scary for people, even if they know that they've had a risky life in the past it is scary for them. Once they are fully aware of the connotations that are attached to that disease, on the demand side, we may face this problem. But we are doing our best on the supply side to make it an appropriate centre."

You are of course well aware that in East Timor, any HIV/AIDS campaign has to work with the Church, who are enormously influential here and whose views on approaches to HIV/AIDS are very different to those of many HIV/AIDS experts. How are you going to tackle that difference in viewpoint?

"Well, on the prevention side, one thing that's becoming a huge challenge is the possible tension between government prevention in terms of providing or making available condoms to people that want them, and the views of the Catholic Church. That is a very real potential tension that might jeopardize our prevention activities. We are now on the ground working with the Catholic Church, having a dialogue with the Church, and we have come to the conclusion that the government has the responsibility to provide all the information available about the effectiveness of prevention to people, and the people will have to make their own choice based on their religious beliefs. Let's make the choice available and let them make the choice – that is more or less the informal agreement we have with the church."

Are you confident that that relationship can work in the context of the church out in the districts, as opposed to with the religious leadership in Dili?

"At the moment, I'm not very confident of this. But I believe that as long as the government is frank in its discussions and as long as the risks of not embarking on that policy are made clear to the Church, not only to the hierarchy but at the community level, I think they will be aware. Because the main concern of the Church is of the risk of increasing promiscuity with the campaign of using condoms. Obviously we can produce scientific evidence showing that that's not the case, but in moral terms, there is a huge reluctance to openly advocate the use of condoms. But they do realize that the use of condoms is one way to prevent AIDS. It's not the only way, it's one way. And the dialogue that we are having revolves around the three main effective ways of prevention, ABC – A, Abstinence, B, Be Faithful and C, use a condom. Now A and B fit perfect with the Church's views. Obviously we are all human beings and there have to be choices, when the moral method doesn't work any more, then you have to provide information to people. Condoms should be last call. For people with the catholic faith, A and B are very important."

The ministry has now adopted a National Strategic Plan. Can you explain what that plan involves and what your first steps will be to implement it?

"The main view here is that we are at the right time to prevent an epidemic in this country, and the emphasis of the strategy is to enable the whole community to adopt preventative measures and that is going to be implemented through different activities, such as education campaign, such as increasing the awareness particularly of the youth, and also having civic programmes focusing on the risk population: drug users, street children, prostitutes – they will be the main focus. We have adopted that strategic document, we are now in the process of forming a National Advisory council. The next step will be to finalize the whole document and then bring it up to the council of ministers for formal approval, and then start to break it down. Who is going to manage the whole process and who will be the partners? For the sake of co-ordination, the ministry of health has taken the role of national coordinator. The implementation will come with NGOS who are working in that area, both national and international NGOS. We have international NGOs, a number of Timorese NGOs and of course the UN agencies. They will be the main players in the implementation of this Plan."

What's the composition of the Advisory Council and how will it function?

"The members of the National Council will be nominated by NGOs who are part of the National Conference of HIV and AIDS where we discussed the programme, and obviously that will involve people who are concerned about the issue, who have the right networking capabilities and I think we are foreseeing between ten to fifteen people, and the main role is going to be advising the national management team, particularly on policy issues. And when you talk about policy issues that will involve issues like condom use, they will have to come through that advisory council before we adopt anything officially. That's only one example."

What are you hoping for from the Barcelona conference?

"Well, if you are going to name them one by one it'll be a long list of hopes. But I think the main thing I'm hoping is to get in touch with a variety of people coming from all over the world and using that chance as a way of improving our networking, and also using that chance to learn from experiences in other places, particularly experiences that are relevant to our socio-economic experiences here in Timor, and I'm very interested in finding out in other places how the relationship between the government and the catholic church was developed on HIV/AIDS. Apart from that my hope is also to meet people like the head of UN AIDS and to meet NGOS, development agencies that are working throughout the world with HIV/AIDS to explore the possibility of establishing partnerships or future activities in this country. And also one other hope is to meet people that have been successful in their application to the Global Fund, the Fund that the UN is now making available to developing countries to tackle the three main diseases affecting people in the world now – HIV, malaria and tuberculosis."

Is there a stigma attached to HIV/AIDS in this country or do you think people still understand so little about the illness there is no stigma?

"The problem is we haven't had any experience of people coming out and saying look, I am HIV positive or I'm suffering from AIDS. I think the reason is the level of education and awareness here is very low and probably people are still thinking oh, HIV AIDS, it's so far away. In Indonesia they say the enemy is still miles away so hey, we can know about it but so what? Once we put it in their faces that OK, we have cases here in East Timor now, people might wake up – at least among the educated ones."

A lot of people here blame the international presence for bringing AIDS and HIV to this country. Do you think there is any validity to that, or do you think it's unhelpful and that East Timorese people need to take responsibility for themselves?

"Well, to start with, we don't have enough evidence to blame either the period of Indonesian station here or to blame the international presence at the moment. And we cannot blame the East Timorese themselves because of the conditions here, because we have prostitution, drug users, because we are poor. So it is not an issue of blame, of who is wrong, it's a question of what we can do now. And look to the facts, to the evidence: HIV/AIDS is a reality now in this country and we are exposed. Who is going to be blamed for the exposure, well, I don't think personally, as a medical community and as an East Timorese, that we should blame the internationals. But obviously we also need to increase the awareness of the internationals about their behaviour in this country. If you are coming from a developed country or a place where HIV AIDS is a reality and you are aware of the risks of unsafe sexual behaviours, then at least as a human being you should practice that. There is no need to say because you are coming from Europe , you don't give a damn about the way you behave in East Timor ."

East Timor is not a rich country and this is an ambitious programme –do you believe you have adequate resources to run it?

From the Ministry of Health point of view, due to the fact we are small country, we have less than one million people living here and most importantly due to our limited resources, we are committed to implementing this programme in a very co-ordinated way in order not to waste resources. That does not mean the Ministry and the government want to control everything and not give others space to work in this area, but it's very important to have coordination. In order to be sustainable and bring good effects to the people, we need to make the best use of the resources we have.

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Prevalence of Infection with Human Immunodeficiency Virus in East Timor

Benoit Chevalier, Thierry Carmoi, Emmanuel Sagui, Claude Pierre 

Clinical Infectious Diseases 2001;32:991-992

SIR: The emergence of AIDS in 1981 has disrupted the epidemiological situation for the last 20 years. The prevalence of AIDS in Asia is fairly low, although the absolute number of people infected with HIV is high because of the large population size. The prevalence of infection varies considerably both between and within countries in Asia [1, 2]. In Indonesia , where HIV infection is endemic, epidemiological surveys have shown that the prevalence of HIV infection is low [3, 4]. Surprisingly, East Timor , which was a province of Indonesia from 1975 until 1999, was never surveyed.

The French military medico-surgical unit that was part of the International Force for East Timor (INTERFET) was deployed in Dili (the capital of East Timor ) from October 1999 through January 2000. Its role was to provide the local population with medical support in the context of a humanitarian mission. During this period, blood samples for serologic testing were collected from 1285 residents (women and men aged 1549) and tested for HIV infection by use of 2 immunoenzymatic assays. No serum sample was positive for HIV.

Although these results are provisional, they suggest that the prevalence of HIV infection could be low in this country, which, at present, is perhaps free of AIDS. Consequently, preventive measures should be undertaken by international organizations to prevent the spread of the disease in this newly independent country. Volunteers, aid workers, visitors, and armed forces personnel that now reside in East Timor have a very important role to play in this challenge. An extended follow-up is necessary to survey the progression of this disease in the East Timorese population.

References

1. Utomo B , Irwanto A, Manaf S. STD/HIV trends and behavior changes in Indonesia . Presented at: UNAIDS Regional Workshop on Evidence of Behavioral Change in the Context of HIV Decline in Thailand ( Bangkok , Thailand ), 1922 May 1997. 

2. Global AIDS surveillance. Weekly Epidemiological Record 1997; 72:35772. 

3. Rao CK. Progress reports on HIV surveillance in Indonesia , 1991. Geneva : World Health Organization GPA, 1991.

4. United Nations Programme on HIV/AIDS / World Health Organization (UNAIDS/WHO) Working Group on Global HIV/AIDS and STI Surveillance. Indonesia : epidemiological fact sheet on HIV/AIDS and sexually transmitted infections, June 1998. Geneva : UNAIDS/ WHO, 1998.

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East Timor HIV Spills Over To Australia  

Dr Dan Murphy AAP/19/06/01

The HIV virus had taken hold in East Timor and spread into Australia , a Dili-based doctor said today. As many as 15 foreign workers, mostly Africans, evacuated from East Timor for treatment at the Royal Darwin Hospital , have tested positive to HIV, Dr Dan Murphy said.

A Darwin woman contracted the virus that leads to AIDS from having sex with an East Timor-based expatriate.

"There was a case of transmission from an expatriate in East Timor to a woman in Darwin ," the American volunteer general practitioner said. Territory Health Service confirmed one of the five cases of HIV reported among Darwin residents since the United Nations moved into East Timor in 1999 was contracted through heterosexual contract with a foreigner based there. That woman then infected another local.

Darwin has become a popular recreation destination for East Timor workers. Darwin sex workers report African clients refusing to use condoms. Dr Murphy said the HIV-positive expatriates detected in Darwin had probably been infected before they reached East Timor .

But these same UN and non-government organisation workers were also patronising a clandestine sex industry flourishing in East Timor .

"It's (HIV) a problem but no-one knows how extensive because we don't do testing," Dr Murphy said.

While the extent of HIV remained invisible, Dr Murphy said his Bairo Pite Clinic frequently treated men suffering the more obvious sexually transmitted diseases from prostitution such as gonorrhoea.

Unchecked, Dr Murphy feared a major blow out in HIV among the conservative Catholic population resistant to condom use and sexual discussion. AIDS would prove devastating with the high rate of tuberculosis among the East Timorese, he said.

"TB will become more active and it'll attack more strongly because with AIDS, you don't have any resistance," Dr Murphy said.

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