When Cyclone Idai struck the port city of Beira, Mozambique, on March 15 it damaged or destroyed buildings and infrastructure and ripped the roofs off most health centers, rendering many completely unusable.
This level of damage to medical facilities would be a major public health concern anywhere in the world, but the tree-lined streets of Beira hide an added vulnerability: this city of more than half a million people is the capital of a province where one in six adults has HIV.
Since 2014, a Doctors Without Borders/Médecins Sans Frontières (MSF) HIV program in Beira has focused on assisting particularly high-risk communities: sex workers and men who have sex with men. Additionally, in Beira’s main hospital, we provide emergency care to patients with advanced HIV and life-threatening associated infections such as tuberculosis.
In the aftermath of the cyclone, MSF’s response in Beira initially focused on the most visible consequences of the storm damage, including the lack of clean water and the outbreak of cholera.
However, soon after that, the less-visible HIV-related needs became part of the response. It took almost a month before MSF’s full HIV program—including night clinics in brothels and other sex worker hotspots—was up and running again.
MSF was running an HIV program from a health center in Beira before the cyclone struck. The storm damaged the facility and cut off supplies of lifesaving HIV medicines that can also help curb the spread of the disease. More than two months after Cyclone Idai, MSF teams have resumed the HIV program, and are working to reach patients struggling to rebuild their lives in the wake of the storm.
People who are often stigmatized, such as sex workers, are particularly vulnerable to contracting HIV. Sex workers play a crucial role in MSF’s response as peer educators who inform others about the transmission and treatment of HIV and the health services available in Beira. Teodora Tongouche is a sex worker who understands the challenges faced by people living with HIV. She is also an MSF peer educator.
“Some of these people [who lost their homes] are ashamed,” she explained. “They are now living with ten [or more] other people in the same space, and they don’t want their HIV status to be known. But it has been difficult to contact them to help them manage their care because the phone and internet have not been working well.”
As the emergency phase of the cyclone response subsides and humanitarian support for people affected by the storm scales down, Tongouche’s role working with MSF to educate other sex workers on the management of HIV is more important than ever.
Filipe Francisco Luis is a sex worker and a member of MSF’s peer educator team. As an HIV-positive person himself, Filipe knows how crucial it is to ensure people can continue their HIV treatment in the midst of Cyclone Idai’s devastation. Uninterrupted treatment is important for individual health and to help keep one’s viral load—the amount of HIV in a person’s blood—low to prevent further spread of the disease.
“It is very important to find these people right now and remind them of the importance of taking their pills,” he said. “Because taking their medicines is not their biggest worry—they are worried about finding shelter, where to sleep, what to eat. We cannot abandon them, because if they go untreated their viral load will increase.”
Like hundreds of thousands of other people, Filipe also lost nearly everything during the cyclone and subsequent massive flooding. “I practically only have my clothes and a mattress,” he said. “Cyclone Idai did not leave anyone well.”
“In one of our HIV clinics in Beira, we saw an average of 125 HIV patients each day before the cyclone hit,” said Dr. Antonio Flores, an MSF infectious disease specialist. “Then the roof of the center was ripped off, and the outpatient activities more or less closed for ten days. Our team of peer educators started hearing about patients, including some sex workers, who had been unable to refill their prescriptions. That was a big concern, because some sex workers were taking the medicine as a way of keeping them safe from catching HIV [and some were on medication] to keep the level of their virus low enough to not be a risk for their health and to make sure they cannot transmit the virus to their sexual partners.”
The financial impact of the cyclone may also be exacerbating the spread of HIV.
“After natural disasters, extreme hardship often forces people to look for alternative, last resort ways to make money to survive,” says Dr. Flores. “We have heard multiple reports suggesting that transactional—or survival—sex may have increased, including [among] people who had never engaged in sex work before. HIV is an increasingly urgent priority in the post-disaster response. The HIV epidemic was claiming lives long before the cyclone and, if we overlook this medical emergency, the long-term consequences could be devastating.”
Paula [name changed to protect anonymity] is a sex worker and a patient in MSF’s HIV program. She spoke about some of the other impacts the cyclone has had on her income and safety.
“My work is more risky now,” she said. “Many of the places I used to meet clients have been destroyed by Cyclone Idai. I end up going to more dangerous places. Recently, when I left one of those places, I was approached by three armed men. I had to give them everything.”
“I have fewer clients since the cyclone,” she continued. “I think they cannot afford the same amount as they paid before. Everyone was affected by the storm.”
MSF has run an HIV program in Beira since 2014. The team provides sexual and reproductive health services, including HIV testing and treatment for vulnerable and stigmatized groups, as part of MSF’s transnational “corridor project” along transport routes between Malawi and Mozambique.
Since 2018, the team has also worked in the emergency room of Beira Central Hospital to reduce sickness and mortality in patients with advanced HIV by improving diagnosis, treatment, and continuity of care, and supporting the laboratory and pharmacy.