The HIV/AIDs in Somaliland: the Social, Demographic Effects of HIV/AIDS on Somaliland – What should Somaliland learn from the rest of the Sub-Saharan countries to combat the spread and the infection of HIV/AIDS? By Ahmed Isse, Bsc (Hons) and MSc in Social Science.

This study will be serialised on the Somaliland media in the next coming weeks. Key parts of the study will be carried out every Mondays.

In this week’s part 3 of my studies into HIV/ AIDs in Somaliland, it will be further looked into preventative intervention in combating the infection and the spread of the HIV/AIDs.  I hope you will enjoy reading it, and I will appreciate to have your feedback directly send to: isseahmed@hotmail.com

Introduction to part 3

In this section the study explores around the preventative measures, and in particularly discusses the discourse of condom distribution and marketing by the international NGOs as an effective prevention form to combating the spread and the infection of the HIV/AIDS in Somaliland.  However, there are strong opposition to condom supply to the country from religious scholars and as well as from the general public who views it as a sin, and to encourage promiscuity.

On the Contrary, the international NGOs in the past years have been pushing the distribution of condoms to make available for anyone who needs it. The case of the Somaliland in the distribution and marketing of condoms experienced similar opposition if not stronger than it had been the case in Uganda in 1990 in which INGOs faced strong opposition from Uganda Catholics (University of Bradford, 1991). The perspectives of the international NGOs tents were to use condom as a tool to prevent and reverse the raising trend of infection rate of the HIV/AIDs in Uganda at the time. INGOS argued that by distributing condoms was to constructing it to be a distinctive contribution to the public health as a discourse that separates the safe guarding of the public health and discourse erecting the traditional Christian morality as argued by (Barnedtt and Blaikie, 1992).

 

In the case of the Somaliland despite the opposition to the supply of condom from the religious scholars and the public, however there is strong evidence showing that the country to have high prevalence rate of HIV/AIDS infection that should not be ignored. In studies into HIV zero-prevalence in major hospitals across the country, and   mobile laboratories testing carried out across the periodically since 2000 have shown Somaliland to have above 1% of HIV/AIDs prevalence rate (UNAIDS, 2010).  With above 1% marks prevalence, Somaliland appears to be a HIV/AIDS generalised country. The UNAIDS report in 2012 have shown that Somaliland and Ethiopia to have same prevalence rate of 1.4%. Ethiopia through effective preventative measure it has stabilised the infection rate of the HIV but mobile laboratory testing targeting female sex workers in 40 border towns of major transport corridor  linking into Addis Abba have shown this social cohort to have 25.3% HV/AIDS prevalence rate (Ethiopian Country Report, 2010:16).   In Somaliland as of the Ethiopia, the country has not got the capacity to carry out similar studies and reliant on INGOs. The INGOs stated that the prevalence rate of Female Sex Workers in Somaliland is 17% (UNAID, 2010). However, this study was short of substance as it has not  inseminate the methodology, how and when and where the tests were carried out i.e. not elaborated the demographic profile of Somaliland Female Sex workers.

Furthermore, the high level of  HIV infection rate  posed a serious public health concern, the International Non-Governmental Organisation (INGOs) have rolled out the distribution of the Condoms not only Somaliland but also to Somalia, which has been flooded with troops from the  African Union.  It was documented these soldiers that had been dispatched to help the Somalia return to stability after 22 years of anarchy, HIV/AIDs are endemic in their countries.  More often, armed forces are generally ranked one of the social cohorts at most risk of the HIV infection. Therefore, the INGOs increased the condom supply to Somaliland and Somalia from 900,000 in 2009 to 14,447,126 according (UN AIDS Report, 2012:28) to what appears to be safeguarding the local community. In Somaliland a 72 years old German International Agency worker in 2011 was arrested and was found to be running a large prostitution ring in Hargeisa, the capital city of Somaliland that surprised the public and the government. Those situations reinforced the arguments that the supply of condom is imperative to combat the spread and the infection of HIV against increased risk exposed to the local communities in those above prevalence circumstance within and between societies.

 

 Therefore, Part 3 of the study of this week concludes the preventative intervention measures in combatting HIV/AIDs:

 

 

1. 3.      The preventative modes of HIV infection:

3.1 preventative mode of an individual

It is reduced to targeting the way in which an individual behaves, and to predict their behaviours to move further with the hope of diminishing this disease. This approach emphasises the health belief as argued by (Rhodes, Hartnoll citing  Rosenstock, 1974), Self –efficacy (Broder, 2010)) and motivation and skill as argued by (Hacker, 2004) The authors have also argued that all individual decision making is based on the perceived cost and benefit factors. But in fact, all elaborated that these social groups appear to have the knowledge to make choices.

With this in mind, Garry Stimson and Martin Donoghue argue that there are limitations to the extent of the behavioural change to the individuals and whilst they are being provided the knowledge and means to steer them away from risk behaviour that get them infected, it will be likely to fail in particular observations made on among drug users (Rhodes and Richards Hartnoll, 1992:7). In the case of the Somaliland, street children, locally called Darbi jiif, are prevalent in the street, although there are provisions provided by the local NGOs. There have not been studies into the street children (Darbijiif) to ascertain the problems that are catapulting into the streets and their behavioural issues. With regards to the street children in Somaliland, there seem to be susceptible to substance of misuse.  In the absence of studies, what makes these children street borne is either the source of assistance drying up or the addiction is coercing back into streets (Bor, 1994). However, this is an area of interest for academics to look into, as the locally grown academics in every discipline are on the rise in Somaliland.

3.2 The Preventative mode of the Community

Community action intervention is based on one to one, an intervention to reach out to the community at large. The distinction between the two is that a community intervention is aimed at adequately reaching out the specific community groups to impede the individual at risk, however individual behavioural changes are only limited to the individual as this does not encourage the social condition in which avails individual’s wide range of choices (Jose,199).  It is therefore, the community changes that bring about the change of the norms and practices, which strives for safer behaviour overall as argued by Brent, 2010.

In Somaliland, the so called Guddiga Xumaan Reebista iyo Wanaag Farista. It is a local voluntary community group that exists across the country, which translates into English – The Committee on the Elimination of Bad Practices and Promulgation of Good Practices. This committee headed by local religious scholars along with local volunteers work  with local police in cracking criminal behaviour, including, mugging, prostitutions and alcohol. According the Somaliland press this group has been very successful in meeting their objective. Paradoxically, it appears that Khat which is a psychotic drug and classified as class B drug and has been documented to encourage prostitution and causes mental illness, serious liver damage and cardiac arrest is acceptable drug. The  study contributes that it could not imbued why the Somaliland  public accept the use of KHAT, which  have been banned  in North America,  Europe with exception of UK and all Muslin countries excluding Yemen.

 

 

3.3 Preventative mode of mother to child transmission

In Somalia (including Somaliland) there are 34 centres providing PMCT. Of these, 20 centres are in Somaliland. The PMTCT centres provide ART for PLWA 96 babies that had been exposed to HIV infection during pregnancies. In addition to this, this service provided 20,397 women counselling and testing services in Somalia (including Somaliland). Furthermore, it identified of 3,091 HIV positive women that are in need of the PMTCT. Of these, only 3% benefited from the services according to the country report of (UNAIDS Country Report, 2012:25). However, this service is common with other services aimed at combating HIV/AIDs in Somalia (including Somaliland) and is by far short of services that adequate to need. This conclusion is supported by the Somali HIV/AIDS stakeholders.

3.4 Islam as Preventative mode to HIV/AIDs

Although HIV/AIDs are inextricably linked to poverty, the variables of education and religion are empirically documented to their negativity to HIV/AIDS. In Somaliland, as a Muslim society the message of the religion to everyone is ‘you should abstain from sex until you are married’. In observing this guidance, it is likely that HIV infection could be controlled to a certain extent as seen by the empirical evidence of the ABC in page 4. However, this does not mean if you are Muslim, you are immune from HIV infection for two reasons. Firstly, there are people who do not observe this restriction and get into risky behaviour that exposes them to HIV infections. With this regards,   there are large Muslim populations in the world infected by the HIV infection.  Secondly, HIV is not exclusively spread by sex, for example one could get infected through blood transfusion. With the Islamic religion, there has been empirical evidence supporting there to be effective preventative options and  being Muslim will reduce the chances  of one being infected by HIV as argued by (Brent, 2010, P.54 cited in Brent, 2006) and further elaborated that the greater the share of the population that was Muslim, the lower the country’s HIV infection rate.

Brent stated in his research in 2006 when he had looked at the negativity of Islam to HIV/AIDs, with his religious discourse on HIV/AIDS, he took an example of Niger, which approximately 95% proportion of Muslims, with a HIV prevalence rate of less than 1%. Its national income was low and female school enrolment was less than most of SSA.  This in contrast to South Africa, which had the highest HIV rate of above 20%, sounds extortionate. By contrast South Africa was one of the richest in Africa, it had higher income, higher levels of female in school enrolment and less than 5% percentage of its populations were Muslim.  Although the author argued that this finding was counterintuitive, and found paradoxically that the higher income and higher education enrolment to positively contribute to HIV infection. Therefore, the study explains that education and wealth alone do not reduce the HIV infection but highlights the negative correlation of Islam with HIV infection and spread. (Brent, 2006) concluded to the fact the higher the income and education perspectives are meant a country to having lower HIV infection. However, Islam is a strong variable when determining the HIV/AIDs. Below is a table shown the higher the income a country the lowest HIV/AIDs prevalence, however, Islam is in breach of this order. Therefore, when taken out the variable of Islam this alone stands fact.

 

The study was based on how to reduce the impact of HIV/AIDS in developing countries, and a sample of 72 countries, covering a mixture of African and Latin American countries was focused on. It was found that the national income i.e. gross national products per person had a negative impact effect on the HIV prevalence rate. This is in line with the widely expected intuitive to HIV/AIDs that it is a poverty entrenched disease (Brent, 2010). Therefore, this support the norms of HIV and behavioural aspects which stated that poor people cannot afford to have nutritious diet and poor women will strayed into risky sex for cash for their own survival. However, there appear countries with large Muslim population which breaches this very principle and could not be explained. The intuition of what had been the casual negativity to the HIV of the religion was an anomaly (UNAIDS, 2012). Furthermore, the result of Latin America as having a higher income than those in SSA countries appears to have lower HIV infection rates (Brent, 2010:54).  Therefore, when the equation was brought into Western Europe as being high income countries, in comparison to Latin America as being middle income countries it was found that Latin America had a lower HIV prevalence rate. Hence, the more developed a country, the lower HIV prevalence with the exception of countries with a predominant Muslim population (Brent, 2010).

 

Furthermore, in six out of seven surveys carried out to determine the role of Islam in the prevention of HIV, there was a significant negative relationship between HIV prevalence in following the Muslim faith argued in (Brent, 2010 Cited in 2010:64).  Brent also looked at the HIV/AIDs prevalence in 31 SSA countries, and held the same view of that of Gray who did not need to undertake detailed statistical analysis to establish the positive correlations between Islam and HIV in Africa.

Geographical Mapping of HIV is of a higher proportion in Africa, as compared with the percentage of the population of Muslims in the region. In delineating the relationship of Islam and HIV/AIDs, North Africa with predominantly Muslim countries, have by far the lowest HIV standing at 0% to 2%. In West African countries HIV prevalence rate is between 2% to 5% where there are predominately none Muslims. By contrast, central and East Africa, where the Muslim percentage is a minority, has a HIV/AIDs prevalence rate of 5% to 15%. The prevalence of HIV is by far greater in Southern African countries nations, which stands at 15 to 37%, which has the smallest margin of the Muslim population in African (Brent, 2010, P.64). The question is now raised of why there happens to be a negative relationship between Muslims and the prevalence rate of HIV. Few examples argued by Brent, (2010:65) help in this understanding, stating that the Islamic prohibition of alcohol, which he evidenced-empirically to indirectly increase the HIV prevalence rate through impairment of sexual decision making abilities, controls the ability to refrain from sexual behavioural with strangers. With this in mind, the person loses the ability to use condoms routinely and under the influence of alcohol, commercial sex workers would find their co-workers more attractive if one was drunk.

Following this, Brent also argues in favour of the male circumcision, which the Muslim faith prescribes and is the precept of Koran. Through the religious submission, a Muslim male undergoes a practice that is empirically held to have a contributor to the low prevalence of HIV infection. (Brent, 2010 cited in Drain et al., 2006) argues that looking at 46 countries with high HIV male circumcision rate of greater than 80% dominance, the means of the percentage of the Muslims was 69% and the means percentage of Christian was 16%. However, the question is to what extent does male circumcision lower the HIV occurrence? The study also contributes to the literature beyond the physical evidence that the Muslim faith contextually prevents HIV, which is the psychological commitment to full submission of the faith that impinges the risk behaviour. This psychological belief puts off believers of sex before marriage, for example sex before marriage (faithful to wife/wives) and substance of misuse.  Therefore, in the case of Somaliland and generally the rest of the Somali speaking countries, there have not been studies if following Islam has reduced the exposure to HIV infection and could have been worse without following this religion. However, looking at the UNAIDs report of Ethiopia, the Somali states of Ethiopia has the lowest prevalence rate of HIV/AIDs within the nine regions of Ethiopia (Ethiopia Country Report, 2010).

The case of the MC effectiveness was further argued by (Brent Cited in  Drain et al (2004) in explaining HIV prevalence rate in 122 developing countries and in addition linking them to the developing indicators, including sexual behaviour, reproductive health, economic factors, population;  religion and circumcision  inextricably interwoven with HIV prevalence and its effectiveness in lowering the HIV prevalence.  The strongest linkage to date shown was being Muslim and being circumcised. The two were strongly linked and their effects could not be separated as determinants of HIV prevalence driving down factors in a country. Brent further argues that HIV in West Africa is less common than east and southern Africa due to the fact that in the west of Africa, male circumcision is more customary than east Africa and southern Africa but confined to Muslim communities. Brent also argued citing De Walque in examining five SSA countries and found that the higher the male circumcision in a country, the lower the HIV prevalence with or without the control for religion (Brent, 2010).

That conclusion points out that being a Muslim could reduce the chances of contracting HIV infection, and despite the  psychological conviction with the faith, the  male circumcision components is an essential requirement of the Islamic religion along with alcohol (alcohol is proved to impair sexual decision making according to (Brent, 2010)). With all countries, as discussed, the higher the income and levels of Literacy in a country the lower HIV/AIDs, however being a believer of Islam  and being financially unstable with low Literacy level is empirically proved to have lower HIV/AIDs than countries with none Muslims with higher income and low literacy rates. For example Niger is poorer and has lower literacy than South Africa. However being Islam has lower HIV/AIDs rate as empirically documented by (Brent, 2010). Therefore, the study concludes that being fully submitted to Islam could stop the practicing Muslim into transgressing what is not appropriate to faith, for example, drugs, alcohol, sex before marriage, male circumcision.  Furthermore, by the comparison African countries with a large rate of Muslim individuals, has been successfully argued by (Brent, 2010) to have lower HIV/AIDS numbers. However, the study contributes that being Muslim does not mean that you are not at risk of the HIV infection but being knowledgeable helps to be swayed from behavioural risk that places you at a reduced chance of being infected by HIV.

3.5 The Preventative mode of abstinence

Marriage is widely viewed to reduce HIV infection. In most countries abstinence is linked to with the essential precondition to marriage. It is apparent that some people follow the pattern to have sexual intercourse when married. If this pattern is adhered it is likely that HIV/AIDs will be contained to an extent. The question here arises, why an individual would delay this act until marriage. The Islamic or Orthodox Christian perspectives are that men will not marry women who have lost their virginity before marriage (Brent, 2010).

It is also difficult to explain this from the perspective of the Western lifestyle whereby marriage and family life is slowly disappearing. Nevertheless it has been argued that where marriage is strong in African countries, for example Kenya and  Zambia,  people in marriage documented that they have a higher HIV frequency rates (UNAIDS, 2005).  The report attributed in its study a gender age difference. With this in mind, the report further claims that HIV levels were 10 per cent higher among married than sexually active unmarried girls. In the rural areas of Uganda, girls within the age range of 15 to 19 years are 88% infected by  HIV for being married to older men who had been infected  by previous marriages (UNAIDS, 2004:10). The UNAID discredited the assertion that girls should abstain sex until marriage as it does not reduce the infection. However, this appears in contrast with the intuitive fact that HIV is spread through sexual contact, and abstinence should reduce the chances of getting contracted by the infection (Brent, 2010). Therefore, the study contributes to the fact that UNAID’s report does appear to hold weight when this hypothesis is empirically tested and paradoxical to preventative intervention policies that abstaining sex will not reduce the chance of becoming HIV positive. Furthermore, authors of (Barnett, 1992, P:45) in their AIDs study argues that the views held by the main religious groups of Catholic and Islam that marriage is negative to HIV if both adhere to zero grazing. However, in the case of Islam, it has been empirically evidenced that it is a negative to HIV as argued by (Brent, 2010).

However, in combating the HIV/AIDS by prevention and treatment, it diverted international aid flow. With this, the preventative and the treatment in the low and middle-classed countries are explicated to outstrip the resource that has been divulged in development (David cited in Joint United Nations Program on HIV/AIDs, 2005:1)

3.6 The preventative mode of Condom use

Many religions are against the use of the condoms and found unacceptable its circulation. Muslims and Catholics alike are both against the distribution and marketing of the initiative of condoms as they believe to encourage promiscuity (University of Bradford, 1991). However, in Uganda, despite the opposition of the religious groups, the NGOs still supplied it unnoticed and the same is happening in Somaliland and Somalia whereby the NGOs push the availability, although in the eyes of the religious groups, it appears to be a subversive and confrontational act. However, on the other hand the NGOs argue it to be a distinctive contribution to public health as a discourse that separates the safe guarding of the public health and discourse constructing the traditionally Christian morality as explained in the face of resistance (Barnett and Blaikie, 1992).

 

In Uganda the behavioural change was carried out by the media to control the infection of the spread of HIV/AIDs. In Uganda, it had been modelled as the prevention method ‘ABC’ as the effective form of combatting HIV/Aids, which further interprets: Abstain, Be faithful and use a condom. To this end, it was further incorporated that ABS model with high level of political commitment to HIV prevention as argued by (DAVID, 2006). Other studies have also supported that the modelling prevention carried out in Uganda of the ABC has been successful as further elaborated by Canning, (David in cited in  Cohen, 2004:10). However, attributing a single component to be effective in the prevention was difficult to measure its success as other studies elucidated. Furthermore (Brent, 2010:175) argued that certain behaviours are driving factors of the spread of the disease and gets the person infected with HIV, as well as sources of transmitting the disease to others. However, after further research, it detected that it reduces the adverse effect. With this in mind, Brent clarified that behaviour change intervention was inevitable, but entwined with monetary.

 

In clarifying the above, the question here lies, how the monetary could aid the reduction of HIV/AIDS.  As HIV/AIDS is a disease of hunger and poverty, and to this end, Brent explained that the price of condoms, commercial sex work, clean needles, Antiretroviral virus  testing all comes down to cost, which need to be evaluated for the benefit and the cost of the behavioural preventative interventions (McDonald et al (2002)).

 

The WHO and UNCEF secured funding from Stakeholders of Global Fund to fight Aids, Tuberculosis and Malaria (GFATM) to deliver HIV/AIDS service in Somalia, including Somaliland despite the opposition by the public and the religious scholar as similar to the case of Uganda.   UNCEF, which is one of the stakeholders of the Somalia HIV/AIDS, delivers condoms unnoticed.  It stated in 2010 that it had supplied 14,447,126 condoms to Somalia and Somaliland, in its country report to UNAIDS in (Somalia country report, 2010:31). However, looking at the country report submitted to (UNAIDS country report 2012), it stated to have supplied from 2005 to 2008 2.2 million condoms and furthermore in 2009, it supplied only 900, 000 condoms.  However, the UN agencies of HIV/AIDs service providers reported to have supplied that year 14,447,126 condoms according to the (Somalia country report, 2012:28). The figures appear to be unrealistic and was elaborated the huge condom supplies of an increase by 97% by comparison to the 2009 condom supply. As the Somaliland INGOs are not accountable to the Somaliland government, the relevant line ministry could not explain the huge variance in supply of condoms to the country in 2010, which had gone up.

 

Furthermore, it is understandable that the public is against the supply of condoms into the country. This initiative is spearheaded by the Islamic scholars who believe it encourages promiscuity. However, the stakeholders explained, bearing at backdrops those barriers, why it has supplied this large number to the country. However, the study contradicts that this could not have been plausible to increase by 97% at the current world economic down turn but unfortunately, there were no third party literature sources available to support or contradict to it. As Somaliland currently lacks the capacity to supervise the status of the NGOs operating in the country, their services are unregulated. However, the current Somaliland government has introduced a Development Project Plan that will not only rein INGOs activities in Somaliland, but in addition set out coherent national development plans, which projects Somaliland development plans over the next 30 years. It is a large document of 340 pages (Somaliland of National Planning and development, 2012-2012).

 However, the service provided by the stakeholder providing Somalia and Somaliland HIV/AIDs impregnate small sample case to mirror the estimate of HIV/AIDs prevalence by contrasting it to the scale of the Ethiopian and the rest of the East African countries delivery.  Furthermore, the study indulges through literature review of how the rest of the African countries deliver full HIV/AIDS services through National health services. By contrast, UN agencies providing these services in Somalia, including Somaliland is beyond their ability to deliver the service on their own due to the devoid of knowledge.  As the sample of 43 in the above table in Somaliland for a country of over 4 million, suggests reliability of the variable mirrors that is not a service with capacity to deliver HIV/AIDs service according to the literature reviewed.

 

Somaliland called HIV/AIDs the Halista Jiifta (The Dormant danger) whilst Uganda called thinner.

 

Please, follow up part 4 of the study