HIV VULNERABILITY WITHIN THE HUMANITARIAN SITUATION This session should be used for longer 2-day workshops only. 60 minutes HIV VULNERABILITY WITHIN THE HUMANITARIAN SITUATION

HIV and AIDS, Crisis and Vulnerability 2  Bi-directional relationship Vulnerability to HIV infection: Emergencies generate situations of high risk to HIV infection Vulnerability to crisis: HIV and AIDS undermines existing coping strategies and may reduce social stability and available services and resources This slide explains how vulnerability relates to HIV and emergencies. Emergencies amplify or intensify vulnerability to HIV infection – especially for groups like women and children, or marginalised groups. High HIV infection rates increase the vulnerability of a population to external shocks and stresses (including drought, civil unrest and conflict). Emergencies can increase the risk of HIV infection by disrupting social order (i.e. in civil unrest) or by forcing vulnerable women and children to engage in transactional sex in exchange for food or security. b) Emergencies can undermine existing strategies for positively coping with HIV and AIDS, for instance by disrupting social networks that provide support and care for HIV infected people, or by overwhelming or destroying essential public services (for example health services). Inter-related issues - gender & culture; climate & conflict should be considered… 2

The linkage… 3 Emergencies can have significant impact on HIV and AIDS-related vulnerability: Heightened risk of exposure to HIV infection: Negative coping mechanisms Sexual and gender-based violence Disruption of social networks Inaccessible HIV prevention commodities Most at risk group Increased vulnerability of PLHIV and affected populations Disruption of health care services Disruption of care and support services e.g. food & livelihoods to ART/TB patients; HBC and OVC Impact of humanitarian situation on HIV affected households. HIV vulnerability is a person’s or a community’s inability to control their risk of infection. It may be attributed, inter alia, to poverty, disempowering gender roles or migration Risk of HIV is the likelihood that a person will become infected with HIV either due to his or her own actions or due to another person’s action. Unprotected sex with multiple partners and sharing contaminated needles are risky activities that increase the probability of HIV infection. A humanitarian crisis may lead to heightened risk of exposure to HIV infection by possibly increased transactional sex, increased sexual violence, and inaccessible HIV prevention commodities (condoms, safe injecting equipments etc.) particularly for the most-at-risk groups. A humanitarian crisis may increase vulnerability of PLHIV and affected population due to disruption of health care services, discontinuation of care and support services (patients on ART and those who are chronically ill), and disruption of social support networks and limiting livelihood options. The hidden slides at the end of the presentation may be inserted to demonstrate how HIV-related services have been disrupted during crisis in Burkina Faso and DRC. If local data is available, use it to demonstrate how HIV services have been disrupted or maintained during the most recent crisis. 3

Guidelines for Addressing HIV in Humanitarian Settings, 2010 4 Growing multisectoral action to include HIV considerations in essential humanitarian preparedness More understanding of HIV service provision, i.e. ART, in fragile and crisis scenarios Improvements in humanitarian coordination and achieving quality HIV programming when resources and personnel are pooled led to Matrix: MIR regardless of context The IASC Guidelines begin to explain how to structure an effective multi-sectoral response in humanitarian settings. The guidelines have been updated to reflect progress in humanitarian HIV preparedness and understanding of HIV service provision. The Guidelines also reflect our improvements in coordination. 4

How/when to use the guidelines? 5 The Guidelines apply to any emergency setting within any HIV context Integrated HIV action is an urgent priority to avert even greater HIV impacts Collapse of health services/ infrastructure can increase HIV transmission, if guidelines not applied. In emergency settings with high HIV infection rates This slide underlines reasons for applying the guidelines in any setting. In emergency settings with high HIV infection rates, integrated HIV & AIDS action is an urgent priority to avert even greater HIV and AIDS impacts. Some of the interventions described apply primarily to countries with generalized epidemics and a high HIV prevalence, where large numbers of PLHIV struggle to cope with the additional stress created by the humanitarian crisis. These interventions may include large scale treatment programmes, food support and livelihood assistance to HIV-affected families and care and support of orphans. However, in emergency settings with low HIV infection rates, HIV is still a priority. For example, even in low prevalence settings, a collapse/breakdown in the health infrastructure can increase transmission of HIV if health care workers do not follow universal standards against blood-borne diseases. Although HIV may not be given as high a priority in low prevalence settings, this does not justify complacency about the issue. Even in low prevalence settings, the minimum initial response is the required response by the humanitarian community. In emergency settings with low HIV infection rates 5

Action Framework (Matrix) 6 Response Preparedness Minimum Initial Response Expanded Response HIV awareness & community support Health Action Sheets: MIR and Expanded Response Protection Food security, nutrition& livelihood support Education HIV awareness and community support was captured under BCC and IEC in the last version. Health – much is new here. Reflects advances in treatment, includes PEP and aspects of care for PLHIV, as well as PMTCT. Protection – looks more broadly at human rights violations than 2004 version FS – contains livelihood components and also targets the specific vulnerabilities and needs of HIV+ women. Education – a new approach Shelter – more specific and detailed on what and how to do it CCM – the 2004 version tended to focus on overall coordination while this Guideline is specific of how to establish safe camp environments WASH – also become more specific on what and how to do it Shelter Camp Coord & Mng WASH HIV in the workplace 6

Case Study 1: Drought in Kenya (2011) Within KNASP III; guided by IASC Guidelines; coordinated by National Steering Committee on HIV in emergency settings under NACC leadership Rapid Needs Assessment – identify HIV needs and adequacy of HIV humanitarian response: Increase in transactional sex; school drop outs and early marriages Insecurity and lack of protection for vulnerable groups Population mobility – rural-urban and rural-rural Access to services hampered by lack of resources (services mainly in urban settings) High stigma – low uptake of services Findings informed EHRP 2012; contingency planning, policy and guidance for HIV in emergency settings

Case Study 2: Floods in Mozambique (2007/8) 20,000 households displaced; HIV concerns: inaccessible HIV services; breakdown of social norms and safety nets; increase in GBV, risk of sexual violence & transactional sex; and vulnerability of OVCs Response: Provision of services in resettlement centres (awareness, condoms, VCT, ART) Addressing GBV through paralegals and community leaders Local partnerships and coordination for sustained response Lessons: Temporary shelter opportunity to provide services; integration of HBC and ART loss to follow-up; community engagement and participation in addressing GBV; local partnerships and coordination for sustainability beyond emergency

Case Study 3: Displacement in Kenya (2008) Post election crisis - >400,000 displaced Trans Nzoia region – 13 camps hosting 6,500 people supported by Handicap International HIV Focus – social mobilisation & community dialogue; mobile VCT; condom programming; young people and GBV link GBV Focus – Gender Desks: medical (+ PEP); legal; psychosocial care; community dialogue for prevention; protection services Disability Focus – orthopaedic and physiotherapy services as entry point for HIV prevention, care and support services Lessons – preparedness strategies; community engagement (including disaster risk reduction and mitigation); coordination are essential for successful responses to HIV in emergency settings; Gender Desks as a good practice for reaching vulnerable members of community

Case Study 4: Food security & Livelihoods in Eastern and Central Africa Mix of conflict, post-conflict, drought and floods in Central and Eastern Africa 67 million people undernourished; 3.5 million people living with HIV in the region Junior and Adult Farmer Field and Life Schools programme reaching 81,000 people in 6 countries: Comprehensive package of training on HIV, gender inequalities, nutrition & agricultural topics plus agricultural and livestock inputs Partnerships and coordination central to achievement of goals IASC Guidelines provided framework, lessons integrated in revision of Guidelines Lessons: participatory & community driven support systems for vulnerable populations; comprehensive approach to empowerment – from their fields to their lives

Case Study 5: Returnees to Angola – 2004 onwards Zambia – high HIV prevalence, high access to information and services Angola – Low HIV prevalence, low access to information and services IOM supported HIV Prevention program for returnees: Zambia – training of peer educators Angola – follow-up and continued support to peer educators in areas of return; integrated within ‘Community Revitalisation Program’ aimed at supporting re-integration and reconstruction efforts (infrastructure, livelihoods). Evaluation and KAP studies – high awareness and reported condom use among target populations compared to others Lessons: continuity of programs in areas of return; working with local authorities and communities essential for success and sustainability

Conclusions Integration of emergency preparedness and concerns in National AIDS Plans and response mechanisms Integration of HIV into emergency preparedness and humanitarian response mechanisms Coordination among humanitarian and AIDS actors essential for resource allocation and response Needs assessments essential to inform response Local partnerships and community engagement in response for success and sustainability Cross-border collaboration and continuity of services and support for mobile populations and returning refugees IASC Guidelines provide framework for emergency response in line with national response policies and guidance