Since 2019, male-to-male transmission has become the leading mode of human immunodeficiency virus (HIV) transmission in Sri Lanka and given that anal sex carries the highest risk for HIV transmission, it is pivotal to direct targeted preventive measures toward men who have sex with men (MSM) within the 15-24-year age group.
These concerns were raised and recommendations were made in an editorial on ‘A silent surge of HIV infection among Sri Lanka’s youth’ which was authored by Specialist Community Physician, Professor in Community Medicine at the Peradeniya University and the Co-Editor of the Sri Lanka Journal of Medicine, Samidi Navaratna, and published in the said Journal's 34th Volume's Second Issue, in August 2025.
Screening for HIV and STIs
In Sri Lanka, HIV screening is carried out through several targeted approaches aimed at early detection and prevention. These screening efforts represent a strategic public health initiative to prevent and control HIV transmission across the country.
The National Blood Transfusion Service tests all donated blood to identify HIV infections to ensure safety. All antenatal clinic attendees are screened for HIV to prevent mother to child transmission. Screening is also incorporated into tuberculosis (TB) care programmes, given that individuals living with HIV are approximately 30 times more likely to develop TB. Furthermore, samples from key populations at increased risk, such as MSM, female sex workers (FSWs), prison inmates, beach boys, and people who inject drugs, are regularly screened. Individuals attending sexually transmitted disease (STD) clinics for other sexually transmitted infections (STIs) are tested due to overlapping risk factors, and selected hospital patients and private sector patients may undergo HIV screening based on clinical indications and assessments.
While the FSWs population in Sri Lanka is estimated to be around 30,000 (20,000-35,000), A. Manathunge, J. Barbaric, T. Mestrovic, S. Beneragama and I. Bozicevic's ‘HIV prevalence, sexual risk behaviours and HIV testing among FSWs in three cities in Sri Lanka: Findings from respondent-driven sampling surveys’, which was a study conducted in the Western Province (WP), showed that FSWs were more likely to uptake HIV testing while people who inject drugs were the least likely.
Over one million HIV tests were conducted in Sri Lanka in 2023, and the seropositivity rate was the highest among STD clinic attendees (0.6%), followed by the key population screening (0.4%). Of the key populations, MSM were identified as the group with the highest HIV positivity rate in 2023. National Guidelines in England recommend that MSM should be screened every three months, as M. Desai, S.C. Woodhall, A. Nardone, F. Burns, D. Mercey and R. Gilson's ‘Active recall to increase HIV and STI testing: A systematic review’ has proved this to be cost-effective in detecting new HIV cases.
Despite these screening efforts, many young people remain unaware of their status due to a decline in clinic visits and a reliance on self-testing kits, which may lack accuracy. The WP has been particularly affected, with males disproportionately represented in the new case data.
Apart from the youth in the general population, K. Mahindarathna and I. Ratnayake's ‘An exploratory study on career challenges of spa therapists in Sri Lanka’ highlights the dire need for screening other vulnerable groups, such as internal and external migrant workers and their families, individuals involved in the tourism sector including tour guides, three-wheeler drivers, spa therapists and their clients, and personnel from the tri-forces.
Sexual health promoting interventions
Sexual health is a holistic concept that acknowledges the sexual rights of persons to have safe, respectful, and pleasurable sexual experiences free from coercion, discrimination, and violence, and encompasses physical, emotional, and social wellbeing concerning sexuality. It goes beyond the absence of mere disease, dysfunction, or infirmity, and achieving sexual health requires access to accurate, updated knowledge and supportive environments.
According to the Integrated Biological and Behavioural Surveillance Survey among Key Populations at Higher Risk of HIV in Sri Lanka, 2018 data, condom-less sex during the last sexual encounter was reported among MSM at 18%, FSWs at 17%, transgender individuals at 24%, beach boys at 25%, and people who inject drugs at a notably high rate of 75%. C. Free, I.G. Roberts, T. Abramsky, M. Fitzgerald and F. Wensley's ‘A systematic review of randomised controlled trials of interventions promoting effective condom use’ has proven that while effective condom use leads to dual protection against STIs/HIV and unwanted pregnancies, reliable evidence on the effectiveness of condom promotion intervention trials is lacking. To improve the impact of condom promotion programmes, it is recommended that they be integrated with other sexual health-promoting interventions (N. Hearst and S. Chen's ‘Condom promotion for Acquired Immuno-Deficiency Syndrome prevention in the developing world: Is it working?’).
EMTCT of HIV and syphilis
Sri Lanka has adopted an integrated strategy for the elimination of the mother to child transmission (EMTCT) of HIV and syphilis infections. In November 2019, Sri Lanka was officially recognised by the Global Validation Advisory Committee of the World Health Organisation (WHO) as the third country in South Asia to have successfully eliminated the MTCT of HIV and congenital syphilis (L. Rajapaksa, G. Weerasinghe, A. Manathunge, J. Elwitigala, I. Nilaweera, K. Kasturiaratchi, L. Siriwardena and A. Karunaratne's ‘Eliminated MTCT of HIV and syphilis in Sri Lanka; WHO confirms’). However, to ensure the sustainability of this milestone, it is imperative to address the HIV-related challenges faced by youth.
Future of HIV and STI prevention
As Prof. Navaratna opines: “While no new technology will be able to beat the effectiveness of abstinence and being faithful to one equally faithful sexual partner in preventing HIV, it’s not realistic to expect all young adults to adhere to such behaviour.”
Therefore, multipurpose preventive technologies seem to be the way forward for HIV and STI prevention. Hence, developing all-in-one, single, mostly female-directed products that will prevent multiple STIs, HIV, related malignancies, and co-morbidities, as well as unwanted pregnancies, makes sense. However, they need to cater to the needs of MSM as well.
It is imperative that the status of the low incidence and prevalence of HIV and eliminated MTCT be maintained. To achieve meaningful impact, related programmes should be employed to address stigma, increase awareness and encourage safer practices.