HIV and Conflict-affected Populations: Overview and the Challenges

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HIV and Conflict-affected Populations Overview
and the Challenges

• Paul Spiegel MD,MPH
• United Nations High Commissioner
• for Refugees

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Overview

1. Definitions
2. Numbers
3. Key players
4. Epidemiology
5. Key Guidelines and policy documents
6. Challenges
7. Constraints

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Definitions

• Complex Emergency
• Humanitarian crisis in country, region or society
  with total or considerable breakdown of authority
  resulting from internal or external conflict that
  requires int. response which goes beyond mandate
  or capacity of single agency and/or ongoing UN
  country programs IASC, December 1994
• Acute situations affecting large civilian
  populations, usually involving combination of war
  or civil strife, food shortages, and population
  displacement, resulting in significant excess
  mortality CDC MMWR, 1992

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Definitions cont

• Refugee
• Any person who owing to well-founded fear of
  being persecuted for reasons of race, religion,
  nationality, membership of particular social
  group or political opinion is outside the
  country of his nationality.
• Refugee convention, 1951
• Internally Displaced Person (IDP)
• Persons who flee their homes for similar reasons
  as refugees but who remain inside their own
  countries
• Displaced Persons (DPs)
• Refugees and/or IDPs

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Displacement Cycle
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Numbers

• Conflict-affected, 2005
• Refugees (13.4 m 9.2m UNHCR, 4.2 m UNRWA)
• IDPs (25 m)
• 50 under 18 yrs
• Source UNHCR and UNRWA, 2006
• ? X m affected by conflict but no displaced
• Disaster-affected, 2005
• 157 m affected (floods, droughts)
• 245,000 deaths (90 tsunami)
• Source EM-DAT, CRED, 2006

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Key Players

1. DPs
2. Surr. host population
3. Host government
4. Non-governmental organisations (NGOs)
5. UN agencies
6. Other international org.
7. Military

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HIV and Conflict Epidemiology Overlap between
HIV and Conflict
Mock NB, Duale S, Brown LF, et al. Conflict and
HIV A framework for risk assessment to prevent
HIV in conflict-affected settings in Africa.
Emerg Themes Epidemiol 20041(1)6.
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HIV Prevalence by Asylum Country and Country of
Origin by Region
Weighted means country of asylum by
population size, country of origin by refugee
population size N refers to countries of
asylum with gt10,000 refugees
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HIV Risk Factors for Conflict-Affected
Populations
Key Factors

• Area of origin HIV prevalence
• Surrounding host population (pop.) HIV prevalence
• Level of interaction bw DP and surr. host pop.
• Type and location of DP env. (e.g. urban vs.
  camp)
• Phase of emergency
• Length of time conflict, existence of camp

Increased Risk
Decreased Risk

• Reduction in mobility
• Reduction in accessibility
• Slowing down of urbanisation
• Increase in resources and services in host
  country

• Behavioural change
• Gender violence/ transactional sex
• Reduction in resources and services (e.g. health,
  education, community services, protection, food)

Modified from Spiegel PB. HIV/AIDS among
Conflict-affected and Displaced Populations
Dispelling Myths and Taking Action. Disasters
200428(3)322-39.
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The Sphere Project,1997

• Humanitarian Charter
• Universal minimum standards in core areas
• Aim
• Quality of assistance
• Accountability
• HIV is cross-cutting issue

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HIV Interventions in Emergencies

• Guidelines for HIV/AIDS Interventions in
  Emergency Settings, IASC, 2003
• Matrix in 3 phases
• Emergency Preparedness
• Minimum Response (to be conducted even in emerg.)
• Comprehensive Response (Stabilised Phase)
• By sector

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Post-emergency, 2005

• Integrate refugee issues into national HIV
  programs and policies
• Implement sub regional (cross-border) initiatives
• Combine humanitarian and development funding

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Challenge 1 Inclusion of DPs into Country
Policies and Interventions
Existence of NSP (N29)
NSP Mentions Refugees (N23)
NSP State Activities For Refugees (N23)
NSP- National HIV Strategic Plans
countries in Africa in 2004 with gt10,000 refugees
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Challenge 2 Integrating HIV and Protection

• HIV status has no influence on
• Access to asylum
• Refoulement
• Right of return
• Improved mechanisms to ensure confidentiality
• HIV prevention and care integrated into voluntary
  repatriation operations
• Ensuring resettlement countries improving
  counselling and testing procedures

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Challenge 3Subregional Approach

• Provide access to prevention and care for mobile
  populations including DPs
• Ensure continuity of care
• Improve efficiency and lower costs
• Leverage additional funding

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Other Major Lessons Learned and Challenges

• Coordination at global, regional, country and
  site levels
• Provision of antiretroviral therapy
• Also relates to funding mechanisms
• Gathering reliable data
• Operational research

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Some Constraints

• Staffing
• Short-term view
• Technical expertise
• Funding
• Competing interests
• More information www.unhcr.org/hiv-aids