The first HIV positive case in the Maldives was reported in 1991. Since then a total of 14 positive cases among locals and over 250 cases in expatriates have been reported according to the official statistics. Looking into the mode of transmission among the local population, it is believed that all 14 cases acquired the infection through heterosexual contact. Maldives still remains an HIV low prevalent country and we all would like to keep it that way. However, there is a high prevalence of multiple high-risk behaviours in the Maldives that might change this low prevalent status!
HIV is transmitted mainly by three routes; sexually, via blood and blood products and from mother to foetus. Sexual promiscuity, especially with high-risk people and intravenous drug use are most important modes of transmission, which is most relevant to the Maldives like the rest of the world.
Maldivians have always been sexually very active and promiscuous community. We have a very high divorce and re-marriage rate, which increases the number of sexual partners any individual have over the lifetime. It is also a known fact that despite being a Muslim community, a lot of Maldivians have multiple extramarital relationships.
Prostitution is much more widely being practiced in the Maldives than many of us would imagine. It is believed that there is frequent and regular commercial sex work going on in almost all the population centers and larger islands. It is also common knowledge that we have a lot of massage parlors and business entities registered under various names where sex work is widely practiced. A lot of sex workers who work in these places are expatriates on tourist visa and it is likely that there are HIV positive people among them. In fact, the first documented evidence of this came in 2009 when an expatriate working in such a place was tested and found positive. Though deported from Maldives, this woman was arrested a second time while working in a similar place! There is also an increasing population of call girls, both local and expats who operate in the Maldives. It is also believed that there is a group of prostitutes who operated between Maldives and Sri Lanka, on a rotational basis; working on tourist visa!
We have been getting reports of alarmingly increasing number of rape and sexual abuse cases. Victims of sexual violence are at a very high risk of getting infections transmitted sexually, including HIV.
There is a subgroup of the population, from all works of life, who are clients of commercial sex workers and has very frequent and usually unprotected sex with them. This happens both abroad and in the Maldives.
However much we deny, there is a significant number of gay men in the Maldives, a lot of who are married and having bisexual relationships. There is also reason to believe that the gay community in the Maldives is increasing and becoming more organized and open about their sexual orientation.
Maldives may perhaps be having the highest number of substance abuses victims for the size of the population. What many of us do not know or do not think about is a silent but gradually increasing number of IV drug users (IDU).
The condom prevalence rate in the Maldives is very low and on a negative curve, though this data comes from married couples, it is significant when talking about HIV risk for some of the reasons (eg: extramarital sex among married people) I have discussed earlier. Studies also show that condom use by the high-risk groups (commercial sex workers, men having sex with men, clients of sex workers) is also very low. Condom is the most effective preventative tool we have to protect from HIV transmission through sexual intercourse.
The increasing IDU population, with no needle exchange programme and multiple barriers for getting disposable/clean needles, usually opt for sharing the needle among friends and continue reusing it for several days. This further increases risk of HIV transmission by several folds.
With all these extremely high risk factors, it could be said that we are sitting on a ticking bomb for an explosive HIV epidemic. It’s a matter of time for the virus to be introduced to the high-risk circle, especially the IV drug users. Unless we escalate our preventive efforts and introduce new and more effective measures, the low HIV prevalence in the Maldives might change to a very high prevalence in no time.
I will share my thoughts and views on the preventive measures and options in a separate blog post.