1. HIV among Conflict- Affected Populations and Refugees Paul Spiegel MD, MPH Chief, Public Health and HIV Section United Nations High Commissioner for Refugees

2. 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

3. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95.

4. Democratic Republic of Congo, 2003/04 Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95. Overall HIV prevalence of 4.9% [4.3-5.6]; W DRC 4.1% [3.6-4.7] and E DRC 4.9% [4.3-5.6] (ANC SS)

5. Other Conflict-Affected Countries Angola3.9% in 2003 (ANC SS) Liberia1.5% in 2007 (pop.-based-DHS) Mozambique2.9% in 1992/93 and 4.5% in 1997 (both ANC data) Sierra Leone0.9% 2002 and 1.5% in 2004 (pop.-based); no signif difference Somalia0.9% in 2004 (ANC SS) S Sudan2002/03 (pop.-based) –Rumbeck town0.4% –Yei town4.4% –Yei rural0.7%

6. “The HIV prevalence observed among pregnant women was roughly 8 times higher than that reported 7 years ago in Mozambique. The isolation of Mozambique during years of the civil war from 1976 to 1992 probably limited the spread of HIV epidemic. Since the end of this period, the opening of the borders, the return of refugees, and widespread prostitution have contributed to a dramatic increase in HIV prevalence.” Melo J et al. HIV and HTLV Prevalences Among Women Seen for Sexually Transmitted Diseases or Pregnancy Follow-Up in Maputo,,Mozambique. Journal of Acquired Immune Deficiency Syndromes. 2000: 23:203–207Mozambique

7. Angola “The level of armed conflicts was found to be inversely related to HIV prevalence. The low HIV seroprevalence in Luanda is in sharp contrast to the capitals of neighbouring countries. While the spread of HIV may have been hampered by the long armed conflict in the country, it is feared to increase rapidly with the return of soldiers and refugees in a post-war situation. The challenge for preventive actions is urgent. This example may be relevant to other areas with a recent end-of-war situation.” Strand RT et al. Unexpected low prevalence of HIV among fertile women in Luanda, Angola. Does war prevent the spread of HIV? Int J STD AIDS 2007;18:467-471

8. Multi-Country Study in Africa “Data from these countries [ * ] did not show an increase in prevalence of HIV infection during periods of conflict, irrespective of prevalence when conflict began. Prevalence in urban areas affected by conflict decreased in Burundi, Rwanda, and Uganda at similar rates to urban areas unaffected by conflict in their respective countries. Prevalence in conflict-affected rural areas remained low and fairly stable in these countries.” Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub- Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95. * Burundi, Sierra Leone, Rwanda, DRC, Liberia, Sudan and Uganda

9. HIV Prevalence by Asylum Country and Country of Origin by Region * Weighted means: country of asylum by pop. size, country of origin by refugee pop. size ** N refers to countries of asylum with >10,000 refugees

10. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict- affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95. “Of the 12 sets of refugee camps, nine had a lower prevalence of HIV infection, two a similar prevalence, and one a higher prevalence than their respective host communities.”

11. Reduction in mobility Reduction in accessibility Slowing down of urbanisation Increase in resources and services in host country HIV Vulnerability and Risk Factors in 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) Type and phase of emergency (e.g. slow vs. quick onset nat. dis.) Length of time: ER, existence of camp Vulnerability & Risk Key Factors Modified from Spiegel PB. HIV/AIDS among Conflict-affected and Displaced Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):322-39.

12. Limitations 1.Cross sectional retrospective data a)Associative not causative 2.? Confounders 3.Known limitations of ANC and population-based surveys for HIV prevalence 4.Lack of trend data in many conflict and post conflict countries 5.Lack of reliability of data during conflict; reliance on post-conflict data to reflect conflict situations

13. Conclusions 1.HIV transmission in conflict-affected countries is generally lower than in surrounding countries not in conflict, regardless of magnitude of prevalence when conflict began 2.HIV prevalence may decrease during conflict (limited data; more study needed) 3.Refugees in camps have lower or similar HIV prevalence than surrounding host populations 4.HIV transmission appears to rise in post conflict settings

14. Recommendations 1.Advocacy important but must reflect latest data 2.HIV and AIDS are still important issues in conflict and must be addressed at beginning of conflict 3.HIV programmes during post conflict must be priority for Governments, UN agencies, NGOs and donors 4.Interactions bw refugees and host pop. important due to differences in HIV prevalence and need joint programs 5.Further research a)Refugees not in camps b)Internally displaced persons c)Effects of refugees returning home on HIV transmission d)Behavioral surveillance surveys among these populatoins

16. Rwanda 1994 genocide caused substantial increase in HIV in rural pop. due to massive pop. displacement, pop. mixing and wide scale rape –17.8% urban and 1.3% rural (1986)* –11.6% and 10.8% rural (1997, unpublished but AIDS conf abstract)** Good methodology but purposeful sampling primarily in urban and peri-urban areas * Rwanda HIV Seroprevalence Study Group. Nationwide community-based serological survey of HIV-1 and other human retrovirus infections in a central African country. Lancet 1989;333: 941–44. ** National AIDS Control Programme. National population-based serosurvey. Kigali, Rwanda, 1997

17. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95.