HIV Epidemiology among Conflict-affected and Displaced Populations Paul Spiegel MD,MPH United Nations High Commissioner for Refugees

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 2004;1(1):6. Overlap between HIV and Conflict

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 >10,000 refugees

HIV Prev. of Refugees and Host Communities in Selected Sites,

HIV Prevalence in N. Uganda vs. National Data and Other Selected Sites* * For the Northern Uganda sites, Gulu, Moyo, and Arua used ANC data,20 while Kitgum and Pader use prevention of mother-to-child transmission programme data with acceptance rates by pregnant women of >97%;54 the non-Northern Ugandan sites of Kampala and Mbarara used ANC data)

Reduction in mobility Reduction in accessibility Slowing down of urbanisation Increase in resources and services in host country HIV Risk Factors for Conflict-Affected Populations Behavioural change Gender violence/ transactional sex Reduction in resources and services (e.g. health, education, community services, protection, food) 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 Key Factors Modified from Spiegel PB. HIV/AIDS among Conflict-affected and Displaced Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):

Behavioural Surveillance Survey (BSS) Study: Objective and Methodology To evaluate quality of BSS in HEs and post-conflict situations and provide recommendations to NGOs and Gov'ts on how to improve quality 31 BSS evaluated between in 14 countries classified as reproducible if pop. based sampling: –Defined sampling frame –Used probabilistic sampling (incl. PPS for cluster sampling)

Results Settings –Conflict: 8 (25.8%) –Post-conflict: 9 (29.0%) –Refugee settings 14 (45.2%) Organisations –NGOs 23 (74.2%) –CDC4 (12.9%) –UN agencies 3 (9.7%) –Govts1 (3.2%) Sample size –Mean: 1,261, median: 549, range: 148-7,484

Results cont Sampling MethodFrequency (%) Random sampling23 (74.2) Convenience4 (12.9) Not mentioned4 (12.9) 31 (100) If random what type?Simple random4 (17.4) Systematic7 (30.4) Cluster sampling8 (34.8) Not mentioned4 (17.4) 23 (100) All eligible person in hhold surveyed yes31 (100) Sampling Frameyes23 (74.2) Reproducibleyes14 (45.2)

Behavioural Surveillance Surveys (BSS) for Displaced Persons (DP) and Host Communities Modified questionnaire incl. pre-displacement, displacement and post-displacement/interaction modules with strong gender-based violence component developed* Undertaken in both DP and host communities Development of BSS manual to improve quality of BSS undertaken in field * UNHCR, World Bank (GAMET), CDC, FHI and IRC

Conclusions Complex relationship between HIV and conflict –Findings not support contention that conflict increases HIV transmission regardless of magnitude of prev. when conflict began –Refugees had lower or similar prev. than surr. pop. –Analysis is context-specific and no assumptions should be made Need to examine (and program for) interactions between DPs and host pop. as well as returnees and those persons in area of return Need for improved biological and behav. data Data can and should be used for advocacy and programming purposes