Humanitarian Response to the Floods in Pakistan

I. Integrating HIV-related actions, Status as of 27/8/2010 Joint UN Team on AIDS Pakistan, 27/8/2010

AIDS Acquired Immune Deficiency Syndrome AJK Azad Jammu Kashmir APLHIV Association of People Living with HIV ARV Antiretroviral GB Gilgit-Baltistan HCT Humanitarian Coordination Team HIV Human Immunodeficiency Virus HR Humanitarian Response IASC Inter-Agency Standing Committee JUNTA Joint UN Team on AIDS KPK Khyber Pakhtunkhwa MCRAM Multi‐Cluster Rapid Assessment Mechanism NACP National AIDS Control Program NDMA National Disaster Management Authority NGO Non-Governmental Organization OI Opportunistic Infections PACP Provincial AIDS Control Program PDMA Provincial Disaster Management Authorities PIFERP Pakistan Initial Flood Emergency Relief Plan PIMS Pakistan Institute of Medical Sciences PLHIV People Living with HIV PPTCT Prevention of Parent-to-Child Transmission STI Sexually Transmitted Infections TCS Treatment, Care and Support UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Funds VAM Vulnerability Assessment Mapping WHO World Health Organization

2 Joint UN Team on AIDS Pakistan, 27/8/2010

1. Flood Situation and Response

Due to unprecedented monsoon rains starting from 22 July 2010 onwards, devastating floods have affected up to 20 million people in Pakistan with near to 1,600 deaths in what is now one of the country’s worst natural disaster in scale [Note: All figures presented in this working paper will be revised as new figures are confirmed]1.

Continuous rain has led to repeated surges of flood along the Indus River and its tributaries from the mountains and valleys of the North to the agricultural plains of Central and South Pakistan affecting an estimated 79 districts, some more severely than others and with the number of districts still growing. In all provinces, inundation has caused devastation and damage to communities, homes [estimates have risen from an initial figure of 281,000 households to 1.2 million by 25th August], infrastructure [roads, bridges, railway networks, and dams], communications, health and education facilities, livestock, agricultural crops, shops and work- places, and livelihoods in general.

All the Provinces and regions witnessed this devastation, including Khyber Pakhtunkhwa (KPK), Punjab, Sindh, Baluchistan, Gilgit-Baltistan (GB), and Azad Jammu Kashmir (AJK). It was initially estimated that 11,000 villages had been affected across the country, but increasingly towns and cities in southern Pakistan continued to be inundated. As of late-August, the situation continues to evolve across Sindh with the floods having reached the coastal areas. It is estimated that 8 million are in need of assistance, millions displaced and around 800,000 are, isolated and cut off from road access across the country [Reference: WFP, 25/10/2010].

The province of Khyber Pakhtunkhwa (KPK) was the most severely affected in terms of mortality and destruction especially during the first week of this disaster. Massive damage to infrastructure and property was sustained. Against a backdrop of recurrent natural and human- made calamities in this Province – including the protracted fighting and mass displacement witnessed in 2009 – the long term effects of the floods threaten to entrench food insecurity and poverty in KPK as well as in other provinces.

Yet the deluges in Punjab and Sindh have, in fact, accounted to by far the largest affected populations and vast areas in these two provinces have been submerged, with massive evacuations occurring since a fortnight from rural areas, towns and cities as the water moves even further south. Hundreds of thousands are currently either living in makeshift settlements, specific centers [school buildings, etc.] or formal camps [Note: In Sindh alone, 1,800 camps have been established]. Access remains limited as communities have been cut-off and isolated by the floods. While the international humanitarian NGOs have, in general, more experience in work in provinces such as KPK, they traditionally have less presence and access in southern Pakistan. The federal and provincial government apparatus was also largely taken by surprise by the scale of the emergency; however, in provinces such as Punjab the government has acted to mitigate the consequences of the floods. In general, it is noted that relief assistance is largely progressing in KPK and Punjab, especially for the northern regions, but still enormous challenges exist in Sindh where the floods continue to ravage southern districts.

1By 14th August, the Government of Pakistan was quoting the figure of 20 million people affected.

3 Joint UN Team on AIDS Pakistan, 27/8/2010

The most pressing needs remain clean water, food, shelter, health and sanitation. The main causes of morbidity and mortality from the floods, at present, are outbreaks of water-borne diseases including acute diarrhea, gastro-enteritis, skin infections, acute respiratory tract infections, typhoid fever, malaria, and viral conjunctivitis. Particularly alarming has been the increasing number of cases of acute diarrhea being reported. There is a concern with the situation of children, pregnant women, elderly and other vulnerable populations whose immune systems are compromised. To this effect, provision of food rations helps prevent further nutritional decline. Through government health services and the Health Cluster, the Disease Early Warning System (DEWS) has been established and mobile and fixed service points are providing consultations, including to where internally displaced population (IDP) camps are in place, though coverage does not meet the need. Given that many health services outlets have themselves been destroyed or affected by the floods, the need for medicines and health care is immense. Emergency health and reproductive health kits are being made available according to the existing distribution capacities.

The immediate prolonged phase of the Humanitarian Response (HR) is largely focused on reaching communities with assistance that are isolated, homeless and displaced because of the floods. While the needs for relief assistance vary for the 20 million affected, the most urgent already mentioned above include safe drinking water, food, shelter, and basic medical care. Rural communities have preferred to stay in or close to their home, lands and livestock to the extent possible, but massive numbers have had no choice and were displaced from the areas adjacent to the river beds and the path of the floods to other areas. Three types of camp settings of varied size now exist, including those located in public building such as schools, make-shift camps alongside roads or in designated relief camps.

As the floods recede, the scale of the damage unfolds and the new demographic landscape emerges as some populations return home while others remain displaced, the focus of the HR will partially shift to community restoration and early recovery although there will be need to continue relief assistance. Other than embarking on the longer-term efforts to address the damaged infrastructures, protection and various forms of social services and psycho-social support are urgently needed to address vulnerabilities faced by all the flood-affected populations as well as those who remained in their localities including issues such as post-trauma stress and specific risks [e.g. drug use, violence or exploitation, etc.]. Other essential aspects of normal lives will also need to be re-established, including education as the school year starts and return to livelihoods.

Coordination of the HR on the government side is managed through the National Disaster Management Authority (NDMA) and its provincial branches, with the support of the UN and International Non-Governmental Organizations (NGOs). To enhance coordination and assistance, regional hubs have been set-up in Peshawar, Multan, Sukkur and now Hyderabad. The rescue operations were initially mainly being undertaken by the Pakistan Armed Forces, but given the extent of air-lifting and rescue needs other commercial, civilian and military forces are now contributing. In the provinces and districts, networks of local NGOs, private charities and community groups have been mobilized to contribute to the response.

4 Joint UN Team on AIDS Pakistan, 27/8/2010

Since 30 July, the Humanitarian Country Team (HCT), including UN agencies and International NGOs has convened regularly. Key clusters have been activated with a focus on Food, Shelter, Water Sanitation and Hygiene, and Health, under the lead of the designated agency. As of 27th August, the Community or Early Restoration Cluster has also been convened.

2. Funding of Flood Emergency

The ‘Pakistan Initial Floods Emergency Response Plan’ (PIFERP) was launched on 11th August for USD 460 million. It focuses on the initial relief phase of the HR. The plan was formulated with a certain level of urgency and based on the assessment data available at the time, and taking into account that the situation of the floods continues to evolve. As is common practice, the Response Plan will be revised within 30 days based on more detailed assessments of the ground situation and a breakdown of the estimated requirements of implementing partners in the form of projects. By the end of August, commitments have been made by an increasing number of countries of up to USD 800 million for Pakistan, including covering 70% of the PIFERP. The costs related to rebuilding the destroyed infrastructure and damages to the economy reaches in the billions of dollars but this is difficult to estimate at this stage as the full scale of the flood consequences and needs are not known.

3. HIV Situation

Pakistan has a ‘concentrated’ HIV epidemic since the early 2000s mostly visible in larger urban centers and, in particular, affecting socially and economically marginalized populations, such as injecting drug users (IDU), transgender community and male and female sex workers. HIV prevalence among IDUs and transgenders has been documented to be much higher than among the wider population: 21% and 6% respectively. Transmission is increasing from those with risk behaviors to their spouses and, in some cases, from mothers-to-children.

Additional factors of HIV-related vulnerability include mobility, migration, specific occupational settings [e.g. truckers, miners, etc.] and through non-adoption of safe injection practices. Given the practice of many labor importing countries, such as the Gulf States, to deport those found to be HIV positive, returning and deported persons living with HIV are also found across rural and small town communities far from specialized health services and social support mechanisms.

A number of AIDS-related NGOs provide support across the provinces and in 2007, the people living with HIV (PLHIV) themselves established an Association of People Living with HIV to advocate and address the challenges that this population faces. Treatment programs exist in the public sector for PLHIV in Pakistan since 2005 and 14 centers were established in the country. Coordination with the Treatment Centers is done through the National (NACP) and Provincial AIDS Control Programs (PACP).

While the total estimated number of people living with HIV in Pakistan is 98,000 as of end of 2009, the number actually registered at health services is around 3,000 with around 1,400 currently on Antiretroviral Treatment (ART). As in other counties of the world, there is still a wide gap between estimated number of PLHIV and those reported to the health services. The narrowing of this gap will depend on reinforcing HIV prevention, treatment, care and support

5 Joint UN Team on AIDS Pakistan, 27/8/2010 programs, including voluntary counseling and testing, wider outreach coverage of at-risk populations, reinforcement of NGOs reaching people living with HIV, prevention of parent-to- child transmission (PPTCT), and increasingly addressing stigma and discrimination. This is envisaged over the coming five years through the Global Fund Round 9 HIV grant and the Government-World Bank-DFID supported program in line with the National Strategic Framework on HIV/AIDS’ goal of scaling-up towards universal access in HIV prevention, treatment, care and support.

Within the ‘One UN’ program of Pakistan 2009-11, a ‘Joint UN Team on AIDS’ (JUNTA) exists including 13 agencies. The Joint Team functions through specific working groups and a Joint Program Component (JPC) to ensure support to national efforts to sustain and scale-up HIV prevention, treatment, care and support efforts for those at-risk, vulnerable and living with HIV [Note: Focusing on emergency affected populations is included in the JPC under Activities 2.1.1.13–14]. The ‘Joint Team’ functions through support provided by agencies to HIV or through working groups on specific topics, including one on humanitarian issues, displaced persons and refugees2.

4. HIV in the Humanitarian Response

As the consequences of the flood emergency unfolds, the Joint Team will continue to participate in humanitarian coordination mechanisms at federal and provincial level and where it has presence, including in relevant cluster or cross-cutting groups, such as Health, Protection and Gender. The HR focus has largely been on relief needs with the target of substantially increasing and scaling-up reach to populations affected and vulnerable to the consequences of the floods across geographic areas. Planning has also begun for the Early Recovery phase. While resource mobilization efforts are progressing, the HCT has emphasized the importance of prioritizing actions based on ground realities.

Beginning on 11th August, the Joint Team working group on HIV and HR convened to consider current information on the impact of the flood HIV-related vulnerabilities and services. The discussion was guided by available knowledge on the flood disaster, epidemiological and programmatic context of the AIDS response in Pakistan as well as the Inter-Agency Standing Committee (IASC) guidelines3 on HIV in HR. This resulted in recommendations for a phased approach that will also consider the overall transition from the ‘Relief’ towards ‘Early Recovery’. This approach includes:

1. Ensuring continuity of services for people living with HIV and at-risk populations.

2. Assessing HIV-related vulnerabilities for the displaced and otherwise flood-affected populations.

3. Providing HIV-related information, services and programs for those in need among the displaced and flood-affected populations.

2 The working group includes UNICEF, UNFPA, WHO, UNHCR, IOM, UNDP, UNIFEM, and UNAIDS Secretariat. 3 IASC, Addressing HIV in Humanitarian Settings, December 2009

6 Joint UN Team on AIDS Pakistan, 27/8/2010

Based on the above, the actions below have been initiated or are proposed:

First, continuity in critical life-saving measures by non-interruption of treatment, care and support services to PLHIV and their families. A proposal has been finalized on this with national and provincial implementing partners. Funding has been mobilized through programmatic and extra-budgetary resources from the Joint Team, including by WHO, UNICEF and UNAIDS. This includes ensuring non-interruption of ART, OI treatment, care as well as providing emergency relief items according to the needs of PLHIV and their families in districts affected by the floods, including food and non food-items. The objective will be to reach an estimated 1,200 PLHIV as well as an additional 3,600 family members residing in the flood-affected districts – Expected Starting Date: 30th August, Funds mobilized: USD 200,000.

Second, identifying HIV-related risks and vulnerabilities in flood-affected communities and among displaced populations, inclusive of gender and social protection issues; This will be based on the review and analysis of data from numerous situation and needs assessments being carried out in August [e.g. MCRAM, VAM, gender and on other technical areas, etc.] as well as identifying HIV-related needs from additional field and community-level enquiries. Socio- demographic, health, gender-related indicators will be analyzed from the above mentioned instruments, as well as tracking information on settings of vulnerability of women, girls, young people, children and specific socially marginalized populations. Given that numerous situation and needs assessments are being conducted, a stand alone quantitative assessment on HIV at this point may not necessarily be effective. However, feedback from community-based organizations and field visits will be undertaken to determine nature of impact on specific populations reached under the ‘pre-flood’ AIDS response, including to what extent there has been a disruption of programs and services4 - Expected Finalization Date: 8th September.

Third, based on evidence gleaned through the above-mentioned assessments, the HIV-HR working group will develop a six-month HIV project for addressing HIV vulnerabilities affecting at-risk populations and other segments of the population, particularly among the displaced in either make-shift or designated camps. This will be submitted to the revised ‘Response Plan’ of the PIFERP for funding – Date: 17th August 2010.

Four, is to ensure HIV-related priorities are addressed in the HR through integration in health and, in particular, reproductive health kits and services for the flood-affected population – i.e. including key HIV prevention messages into health promotion efforts when and where appropriate as well as ensuring infection control, blood safety, STI prevention and treatment, condom provision, and referral to PPTCT through existing mobile or fixed health services and camps. UNFPA will be the lead in ensuring that reproductive health services include relevant HIV focus through the Health Cluster. With regard to HIV and STI prevention messages, these will be introduced in a staggered manner and as health and hygiene-related health promotion efforts are expanded through static and mobile health services for IDP. To this effect, a minimum

4 IASC, Page 9: “As already explained, essential HIV prevention, treatment, care and support services may be disrupted during a humanitarian crisis. Such emergency-specific needs should be assessed to determine which interventions are required, the nature and scale of the assistance needed, which interventions should be prioritized and how the available resources should be allocated”.

7 Joint UN Team on AIDS Pakistan, 27/8/2010 set of agreed upon adapted prevention messages will be developed for this purpose by the NACP with UNICEF, WHO, UNFPA and UNAIDS – Expected Implementation: September.

5. Partnership and Advocacy

Based on the principles that already underlay its support to the national AIDS response, all above approaches will be elaborated by the Joint Team with the NACP and its provincial counterparts, the PACPs. Implementation will be undertaken by public health services, under the responsibility of the NACP-PACPs, as well as non-governmental and community-based organizations. Included among the latter is the Association of People Living with HIV and those representing or working with specific populations such as transgender, injecting drug users (IDU), etc.

Throughout, advocacy to increase awareness on including HIV in an adapted and integrated manner into the HR will be done when appropriate in the relevant clusters, with the federal Ministry of Health and provincial Departments of Health, as well as with the leadership5.

Lastly, it should be noted that HIV-focused staff in the UN agencies are also now contributing to the wider HR over and beyond the focus on HIV. Owing to the scale of the emergency, a number of agencies have delegated this staff to work on the HR as appropriate and in accordance with their areas of competences.

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5 During a meeting of leading health actors in Pakistan on 16 th August in Islamabad to address the health consequences of the floods by the President of Pakistan, a briefing was given by UNAIDS on HIV alongside other disease specific issues that were mentioned.

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