Nearly 15 months since the Ebola virus began its burn through Guinea, Sierra Leone, and Liberia, the deadly hemorrhagic fever continues to infect and claim lives. But with almost 10,000 deaths and more than 23,000 total cases throughout the three hardest hit countries, thousands have walked out of treatment centers deemed Ebola free.
The battle against Ebola, however, does not end when an individual recovers, as many survivors report medical complications such as problems with eyesight and body pain well after they test negative for the virus. But perhaps one of the most talked about unknowns of the healing process is whether or not the disease can be transmitted sexually after recovery.
Studies from past outbreaks have shown that levels of the virus can remain in a person's semen and vaginal fluids for up to 90 days after they have otherwise tested negative for Ebola. For this reason, survivors are advised to abstain from sex during the three-month period and, in the event abstinence proves difficult, 90 condoms have become a staple in take-home packages when a patient is discharged.
While most experts agree the virus is present in bodily fluids at this point, there is no current evidence that indicates whether the disease can be sexually transmitted during this time period. But, just as it has been the case throughout this unprecedented outbreak, the unknowns of Ebola instill fear and scrambling in affected communities.
Without a roadmap guiding decision makers on how to deal with these patients and their potential to transmit the virus, local communities and individuals have taken it upon themselves to handle the situation. In some cases, for example, men have decided not to return home to their wives for fear they will not be able to abstain from sex. But more alarmingly, the World Health Organization (WHO) told VICE News that some local districts in Sierra Leone have taken more punitive approaches — in some cases throwing people that are believed to have infected their partner through sex in jail.
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"It's been an issue in a number of districts where survivors are accused of infecting their partners," Pieter Desloovere, a WHO communications officer in Sierra Leone, told VICE News, stressing that there is no evidence proving that this can actually occur. Left to find their own solutions, he said a few districts have acted harshly in these instances, particularly in Bombali, where "survivors got actually imprisoned."
The WHO said it has been working closely with the government of Sierra Leone to prevent punitive reactions. At the national level, the ministries of health and justice recently issued clear instructions ordering all districts to immediately release anyone who has been imprisoned, explaining there are no grounds to throw someone in jail.
While Sierra Leone's government has condemned jail time for survivors, officials have expressed concerns that keeping people from having sex would be impossible. This has led to some attempts at developing what Desloovere called "out of the box" solutions, many of which immediately raised eyebrows and were never implemented.
Some media reports last week suggested that "concentration camp" like situations had been implemented in parts of the country to prevent survivors from having sex. WHO said these reports were inaccurate. According to Desloovere, one option Sierra Leone authorities floated was putting these individuals to work on agricultural projects, also a necessity as the outbreak has diminished the labor pool. But the WHO advised against this, keeping the potentially inhumane option out of the realm of possibility.
Fears of sexually transmitted Ebola have only added to the ways in which survivors have become stigmatized during the largest and deadliest outbreak of the fever in its nearly 40-year history. "There has been a lot of fear from the community. Integration of most survivors back into the community is not that easy," Desloovere added.
As the virus appears to be burning itself out in Liberia, with less than 10 total cases in the country during the last 21 days, compared to 235 in Sierra Leone, it is common to hear stories about patients returning home only to be rejected by their families.
James Cassidy, the West Africa regional director of US-based Christian organization Young Life, told VICE News about the struggle many survivors he has worked with have experienced. Cassidy used the already established network to establish makeshift contact tracing teams in both Liberia and Sierra Leone, while also creating mechanisms to monitor new cases and survivors. He described situations in which survivors have been denied water at community pumps, shunned from their homes, or refused important medical care. The WHO has reported similar cases in Sierra Leone, where survivors in cities such as Port Loko have joined together as a team to support each other and educate others.
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While these countries continue to grapple with the stigma — and the virus itself — providing continued psychological and medical support will be crucial to integrating survivors into public health and containment efforts. The WHO says it will work to establish longterm care clinics for survivors, as well as psychosocial support.
"Today we can say we are on the verge [of stopping Ebola], it's not yet over, but we have made gains" Cassidy said. "We have to rehabilitate and reintegrate these survivors back into the community. Ebola also comes with conflict issues, but how do we mitigate those conflict issues so that Ebola survival will be peaceful?"
Follow Kayla Ruble on Twitter: @RubleKB