The impact of Mozambique's cyclones on its HIV population

BEIRA, Mozambique — When Cyclone Idai hit Mozambique’s coastal city of Beira in March, heavy winds and torrential rain tore off roofs and destroyed buildings across the city. Many of the city’s residents, particularly those in informal settlements, were forced to flee their homes in search of shelter.

Three months later, the mark of the storm on the city is still present. Tent clusters host people who have lost their homes, buildings sit without roofs, school buildings lay in shambles, roads are cracked, and uprooted trees lay twisted on their sides.

Less visible is the impact the cyclone had on those living with HIV. Cyclone Idai marked the first time a major natural disaster has hit a country with a high prevalence of HIV. Mozambique has the eighth highest HIV rate globally and in Beira, 1 in 6 adults lives with the virus.

In the aftermath of the cyclone, health workers said they were concerned that patients lost access to treatment for HIV and opportunistic infections, as well as services and medical records. There are also some patients that have been out of touch since the storm. The economic devastation brought by Cyclone Idai and a second cyclone in April could also lead to more new cases of HIV amid growing instances of transactional sex, health workers said.

“The main difficulty that beneficiaries met during the emergency is that suddenly the health system for them concerning HIV, and all the services we were providing to them, disappeared,” said Giulia D’Odorico, patient and community support manager for Médecins Sans Frontières’ Key Population HIV program.

In the months after the cyclone, there’s been about a 25% increase in the number of advanced-stage HIV cases at the Munhava health center in Beira, according to Quezia Monteiro, an MSF medical activity manager, who runs an advanced HIV program at the center.

“I will have more advanced HIV patients because I wasn’t able to control the HIV in these patients during this period,” she said. “My concern is that for sure this number will increase.”

Lapses in treatment

MSF’s work at the Munhava health center focuses on early detection of advanced stages of HIV and treatment of the disease, as well as of opportunistic infections such as tuberculosis and cryptococcosis. At the emergency unit of Beira Central Hospital, MSF focuses on lifesaving interventions for patients with late stages of the disease.

“If someone is in the advanced stage of the disease and has opportunistic diseases, we need to identify or diagnose and start the treatment as soon as possible,” said Joaquim Guinart, coordinator for MSF’s Beira Sexual Reproductive Health and HIV programs.  

In the aftermath of the storm, all MSF health workers were thrown into the emergency response, including responding to a cholera outbreak. Because of this, for about two weeks MSF’s HIV programming was halted. There is also concern that when the storms hit communities, HIV and opportunistic infection medication was lost as homes were destroyed and people were displaced.   

A lapse in treatment and access to services could lead to deterioration of the health of some patients, or lead to resistance to treatment, MSF health workers said.

“If a person with HIV stops their treatment, we might expect that opportunistic disease or the development of AIDS will move from the controlled treatment of HIV,” Guinart said. “This can put someone in a very severe condition.”

The cyclones also destroyed many crops, which is expected to create prolonged food insecurity in the country. Having access to food is critical to the HIV treatment plan, said Rute Dos Santos, head of programs for VSO International in Mozambique.  

“These people need to eat so they can take their [antiretroviral treatment], because the [antiretroviral treatment] is strong,” she said. “If they don’t eat, they don’t take their [antiretroviral treatment], then their conditions get worse and worse.”

A disruption in many family planning services also means people aren’t getting access to condoms. Dos Santos worries this could lead to an increase in cases of reinfection, which happens when HIV positive people contract new strains of the virus, which has the potential to increase the progression of the disease.

Compounding all of this, many patients’ medical histories were lost in the storm.

“The doctors, without files, without papers, without anything, just prescribed the [antiretroviral treatment] and gave them to the patients,” Monteiro said.

“But it was really complicated because I had no control if the patient is receiving the correct [antiretrovirals] or not. We had to just listen to them and try to figure out which kind of treatment they were using. It was really complicated.”

New cases

With the storms exacerbating poverty, Guinart said he expects to see more people turning to transactional sex.

In one of its other HIV programs in Beira, MSF works with people that have a high risk of HIV exposure including sex workers and men who have sex with men — providing HIV prevention, treatment and sexual reproductive health services.

In the past, MSF provided these services in a personalized way, meeting with people at a decided-upon location, such as their homes. The storm made this logistically impossible because many people were displaced or lost their cellphones, making it difficult for health workers to locate them.

So MSF switched its approach, setting up mobile clinics in different parts of the city each day, using pop-up tents and the back of their trucks to meet with patients.

But there have been challenges. One is making sure the populations they work with are aware of the new way they can access services.

Lucas Sefo, a 22-year-old transgender woman that lives in Beira, had been receiving home visits once a month from MSF since 2015. While she is HIV negative, MSF routinely tests her for the virus and other sexually transmitted diseases and provides her with contraceptives. But she hasn't been visited since the cyclone.

"I haven't heard from them since the storm. I was a little bit concerned and was looking for them," she said. "I wanted to call, but I lost the number."

The organization is trying to get the word out through peer educators to inform the populations they work with about where they will provide services on any given day.

The next crisis

In order to improve HIV programming in the event of future disasters, HIV testing and treatment should be provided in displacement camps and HIV care should be provided in cholera treatment centers, said Caroline Rose, head of the MSF mission. In the aftermath of the cyclone, some of the patients in the cholera treatment centers were dying due to HIV.

Preparedness and evacuations before storms hit are also key to protecting HIV positive populations, as well as all populations, she said.

There are still many unknowns, but MSF health workers said they expect to have a clearer picture of how the cyclone impacted those living with HIV in the coming months.