1. Conflict and HIV: A Framework for Risk Assessment to Prevent HIV in Conflict Settings International Studies Association March 26, 2002 New Orleans, La. 700112 Nancy Mock, Dr. P.H. and Ellen Mathys, M.P.H. Tulane University

2. Conflict and HIV:Background Since its discovery in the early 80’s, we are only now seeing any detectable evidence that HIV prevention strategies are having ANY impact on HIV incidence After 20 years, the epidemiology of HIV in Sub-Saharan Africa is still poorly understood There was a deliberate policy decision taken by the donor community to collect highly limited information on population-level HIV status Until very recently, HIV prevention/care strategies were stove-piped in the health sector Until now, conflict management strategies have been stove- piped into humanitarian assistance and “transition” programs

3. Why business as usual will not work Collective wisdom says that traditional HIV prevention/management programs take decades to work and have limited effects Current data suggest that HIV epidemic progression can be explosive when the isolating effects of conflict are removed Relief/transition/development stove-piping misses the windows of opportunity to attack the driving forces of HIV, which are always accentuated in conflict settings

5. African Population Database: 1990 Population Density Distribution Source: UNEP/GRID

6. Africa: Major Routes

7. Figure 1: Conceptual Framework of Principal Causes of HIV Risk in Conflict- Affected Populations Violent Conflict Social Ecology of HIV Population Vulnerability to HIV HIV Hazard/ Exposure Opportunity Population HIV Risk

8. Conflict-associated factors that increase and decrease HIV risk Decrease –Increased isolation of communities –Increased death rates among high risk groups –Increased death rates among HIV-infected –Decreased casual sex associated with trauma and depression –Disruption of sexual networks Increase –Increased interaction among military/combatants and civilians –Increased levels of commercial sex –Decreased availability of STI and other health services –Decreased utilization of health services –Increased levels of malnutrition –Decreased access to knowledge and means to prevent HIV transmission –Large internal or regional population movements –Emergence of norms of sexual predation and violence

9. Risk and Vulnerability Assessments Identify distinct high risk and vulnerable groups Map the dynamics of population mixing both internal and external to the system Identify key leverage points for prevention Repeating the process over time based on impact assessment Anticipate risk as far out as possible, ie. early warning

10. SecuritySurvivalGovernanceSustainable Development US Military USAID/OFDA USAID/OTI USAIDCOMMERCE Active Gunfire And Fighting Humanitarian Cycle Community and Societal Cooperation Long-term Economic Development Source: Lyerly, W., 1999 Model of US Government Response to Conflict and Complex Emergencies

11. Implications for Programming Prevention initiatives must be aggressive during active conflict and transition Interventions should be risk-reduction driven Integration of HIV prevention into other sectoral/programs to create synergies Intervention strategic planning should consider and include regional and micro-ecological factors

12. A Note on the Need for Information-Driven Action Large scale household survey programs such as the Demographic and Health Survey Program can now be used to generate population-based seroprevalence levels and most transition countries implement DHS The humanitarian community is increasingly applying rapid probability surveys in active conflict contexts. These can be utilized as vehicles for serostatus assessment where appropriate Early warning systems are emerging in a variety of areas. That will facilitate the rapid development of geospatial information

14. MozambiqueEritreaEthiopiaSierra Leone AngolaSomalia Poverty Pop. below $1 a day37.9 (1996)25.3 (1996)31.3 (1995)57.0 (1989) Adult Illiteracy Male - % ages 15 and over in 1999 413357 Female - % ages 15 and over in 1999 726168 KAP % Heard of HIV82.280.684.754.036.6 % Know no ways to prevent HIV 65.824.231.588.3 % Know condom use 15.434.633.527.02.8