Up to now, seafarers have received very little in the way of advice on HIV, either in terms of prevention or their rights. This needs to change, says Dr Rob Verbist

Seafarers’ centres and ship visitors deal with seafarers in need of medical advice, on HIV/AIDS and other issues, on a regular basis. Seafarers are often reluctant to seek advice from the regular channels on the ship, as they fear that illness from any sexually transmitted disease, and HIV/AIDS in particular, may lead to the loss of their employment.

Generally seafarers do not want to discuss their sexual experiences with others, let alone with their employer. In some regions, authorities are reluctant to warn seafarers about the risks of HIV in their port in case the warning gives a negative image of the country. Suitable materials are not often available for distribution to seafarers, who are often ignorant and passive about vital health and lifestyle issues for those at sea.

Prevalence at sea The Department of Health of the Philippines, which supplies the largest number of seafarers of any country, conducted a study of HIV prevalence between January 1984 and December 2003 and found that 12 per cent of an estimated 2,001 persons who were HIV-positive were seafarers and 10 per cent were sex workers. The main mode of transmission in the majority of all cases (85 per cent) was sexual. Of the 2,001 people, 32 per cent originated from the Philippines and worked overseas, and seafarers, who accounted for 38 per cent of HIV-positive overseas workers from the Philippines, were the most affected group among them. Similarly, the Kien Giang Provincial Committee in Vietnam reported 1,239 cases of HIV-positive persons in 2002 in the province, 10 per cent of whom were seafarers. Risky behaviour All seafarers certainly do not fit the stereotype of “having a woman in every port”, but casual sexual relations can become frequent, owing to isolation, the strong sex industry presence in many ports of call, and the limited opportunities for leisure or to spend earnings in other ways while at sea. Lifestyle studies show that for the same reasons seafarers are more likely than the general population to engage in a range of risky behaviours, such as drinking, which in turn may easily lead to unsafe sex. Few seafarers are aware of the HIV-related risks which accompany drunkenness and the associated state of lost inhibition. When inebriated, people can become more courageous about visiting sex workers, lose awareness of risk, and forget to use condoms. Other risk factors are drug use and misinformation, or plain lack of information. Even when seafarers attempt to engage in healthy lifestyles and to avoid risky activities, the lack of options or access to other leisure activities may defeat them. Women seafarers regularly report sexual harassment and occasionally rape. Heterosexual relationships among seafarers aboard cruise ships are a common feature of shipboard life, and it is often on long journeys that condom use declines. Restricted and frequently non-confidential access to ships’ doctors by crew members, in keeping with the interests of seagoing employers, may be critical factors in the difficulties women seafarers face in getting diagnosed and treated for STIs, as well as for HIV. Extracts from HIV/AIDS and work in a globalizing world, ILO 2005

Trade unions, manning agencies and shipping companies, insurers and other stakeholders could all be playing an active role in informing seafarers about HIV and other health risks. Simple, straightforward messages, going to the hearts and minds of individual seafarers, may help them to change their often hazardous lifestyles.

The traditional view of seafarers as drunken men with a woman in every port is not a reflection of the reality today. Seafarers are hard working professionals who have little leisure time. Some will serve out a whole contract without once setting foot on land. In any event, port calls often mean additional work and leave them with little time, if any, for contact with the local population.

Nonetheless seafarers are mobile and migrant workers, and have the same risk level as the mobile population in general, being away from home and from their regular social control for long periods of time.

Illegal testing

The issue of HIV for seafarers starts with the pre-employment medical. In many countries, selection for employment based on HIV status is unacceptable or illegal. The purpose of maritime medical fitness assessment is purely to ensure that any medical condition does not put the ship, the cargo or other people at risk and that the individual is not at greater personal risk from the condition while working at sea.

These are the only criteria that should relate to the assessment of an individual. Nevertheless many seafarers are tested as part of their pre-employment or periodic medical examinations.

Being found HIV positive may lead not only to personal trauma for the individual, but also to discrimination, either through the denial of employment or from harassment by other workers. This is completely unacceptable and any cases should be challenged by trade unions representing seafarers with HIV.

HIV-positive seafarers who are aware of their status and have declared it need to be given a fair examination based on rational and fair criteria, which ascertain whether a seafarer is fit, unfit, temporarily unfit or restricted in their ability to work.

Guidelines

The widely used World Health Organization staging categories for HIV/AIDS (www.who.int) provide a meaningful basis for fitness criteria, and these should inform any decisions, for example on a seafarer’s temporary unfitness and whether a return to work at sea is possible after investigation and treatment.

The progression from asymptomatic infection to the AIDS syndrome, where serious complications arise, may be very slow (depending on lifestyle and treatment) and is unlikely to occur between one medical assessment and the next.

Signs and symptoms of the advanced disease such as persistent infections, significant weight loss and serious side effects from medication, will normally render the seafarer unfit to work. Guidelines are needed to assist in the determination of the possible consequences of the disease and its treatment for the time period prior to their next reassessment.

The likelihood of eventual unfitness needs to be considered within a clinical setting so that advice can be given on when a career at sea may need to be abandoned and an onshore alternative sought.

The International Committee on Seafarers’ Welfare (ICSW) is producing a package of leaflets, booklets, DVDs and posters for seafarers on HIV/AIDS and sexually transmitted diseases, as part of its Seafarers’ Health Information Project (SHIP), funded by the ITF Seafarers’ Trust. These materials are designed to be used by trade unionists or any other stakeholders in their contact with seafarers and will be downloadable early in 2007, free of charge, at www.seafarershealth.org. Their emphasis is on what the individual can do, how good ship management can assist, and on the role of the health adviser.

Dr Rob Verbist is project coordinator of the SHIP scheme, and has wide experience of dealing with the medical problems of seafarers through his practice in the Port of Antwerp and through his association with the International Maritime Health Association. He is contactable at ship@icsw.org.uk