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RHO archives : Topics : HIV/AIDS

Special Focus: Refugees and HIV/AIDS

Refugees constitute one of the most difficult populations to reach with HIV/AIDS prevention and care services. In most cases, it is armed conflict that leads to the formation of large groups of refugees. When conflict subjects civilian refugees to food shortage, displacement, and poverty, a “complex emergency” is often the result. Armed conflict and the complex emergencies that result often engender the disintegration of social structures, a rupture in people’s normal sources of income, the collapse of health and educational infrastructure, and widespread sexual violence and abuse. Some refugees (or returning refugees) may also turn to injection drug use out of despair or hopelessness. The combination of these factors increases the risk to refugees of epidemic diseases. Sexually transmitted infections (STIs), including HIV/AIDS, are among the diseases to which refugees are vulnerable. The degree to which refugees are vulnerable to HIV/AIDS depends in part on the level of HIV prevalence in their country of origin and in their host country (Hankins et al. 2002; Spiegel 2004).

At the end of 2002, 40 million people were displaced due to conflict. This number included 15 million refugees who had fled across international borders and 25 million internally displaced persons. In sub-Saharan Africa, the confluence of high prevalence of HIV, conflict, and poverty has led to particularly dangerous conditions for refugees and internally displaced persons (Spiegel 2004). A recent example is the 1994 genocide in Rwanda that resulted in the death of hundreds of thousands of Rwandans, as well as the rape of huge numbers of women and children, the destruction of health networks, and the flight of additional hundreds of thousands of civilians into refugee camps in neighboring countries or camps for internally displaced persons in other parts of Rwanda (Ntakirutima and Mboyane 2004).

Vulnerable groups

As victims of armed conflict and as refugees (or internally displaced persons), women and children are particularly vulnerable to sexual violence and abuse, and therefore to STIs. Warring factions often use rape as an expression of violence and revenge against those whom they consider to be their enemies. Rape and sexual violence do not necessarily end when women and children reach refugee camps. In Rwanda, women living in camps without adult males in their households were especially at risk. Men in the camps often pursued female refugees to latrines and water taps, taking advantage of these basic needs to subject women and girls to sexual coercion (Benjamin 2001). A survey conducted among Burundians in a Tanzanian camp revealed that 26 percent of women had endured sexual violence since becoming refugees (Holmes 2001).

Approximately 6.6 million adolescents are currently displaced due to armed conflict. Many refugee adolescents and children are separated from their families and must fend for themselves and sometimes for younger siblings (Ritsema 2003). Both women and children, living as internally displaced persons or refugees, are forced by the need for survival to engage in transactional sex with other refugees, member of the host population, or a combination of the two, a further and significant risk factor for HIV transmission (Spiegel 2004).

Human rights

In responding to HIV/AIDS among refugee populations, it is important to consider the situation from a human rights perspective. Those who provide HIV-related and other health care services for refugees should resist discrimination against people with HIV or those suspected of being infected. Efforts to provide HIV/AIDS services among refugees should also respect each person’s right to self-determination, confidentiality, privacy, and information (Holmes 2001). In particular, the following measures can help protect the rights of refugees:

  • Non-restriction of access to asylum, or right of return, based on HIV status.
  • No mandatory HIV testing of displaced persons.
  • HIV testing with informed consent accompanied by pre- and post-test counseling and appropriate referral to follow-up services.
  • Informed consent for the disclosure of HIV status.
  • Non-restriction of access of refugees to public-sector HIV/AIDS services (Spiegel 2004).

Strategies for HIV prevention among refugees

Several organizations are active in HIV prevention among refugee populations, including the United Nations High Commission on Refugees (UNHCR), the International Rescue Committee (IRC), and the Women’s Commission for Refugee Women and Children (WCRWC). These organizations and others advocate the provision of a “Minimum Initial Services Package” (MISP) for emergency situations to reduce illness and death related to reproductive health. MISP activities to reduce the risk of HIV transmission include:

  • Identification of an individual and organization responsible for MISP implementation.
  • Ensuring a safe blood supply.
  • Implementation of universal precautions (to prevent HIV transmission in health care settings).
  • Availability of free condoms.
  • Prevention and management of sexual violence.
  • Planning for comprehensive reproductive health services (WCRWC 2002).

Treating STIs is a particularly important strategy for HIV prevention in emergency situations (Khaw et al. 2000).

To help protect against sexual violence:

  • Refugees, especially women, should participate in the design of camp layouts.
  • Women, children, and men should be properly registered (especially female heads of households).
  • Female refugees should have access to camp services and essential goods, including food, fuel, and water.
  • Camps should establish a committee to help prevent sexual violence. (WCRCW 2002).

One of the earliest studies of knowledge, attitudes, behaviors, and prevalence related to HIV and other STIs within an African refugee population was conducted in 1992. The study took place in the Dimma refugee settlement in southwestern Ethiopia, and focused on Sudanese refugees and Ethiopian sex workers. The investigation found that knowledge of HIV/AIDS and condom use were extremely low among Sudanese refugee women, and that sexual contact between Sudanese refugee men and sex workers was common. HIV and STI prevalence among the study population was high. In addition to yielding this information, the study was one of the first of its kind to underscore the importance of conducting a situation analysis, establishing baseline data, and carrying out a survey on knowledge, attitudes, and behaviors as preliminary steps to designing a program to respond to HIV/AIDS among refugees and other mobile populations (Holt et al. 2003).

Working with refugee populations in Kenya

UNHCR is working with several non-governmental organizations (NGOs) in Kakuma, Kenya, to provide HIV/AIDS services to refugees. Approximately 82,000 refugees, mainly from Sudan, Somalia, and Ethiopia, live in the Kakuma area. The International Rescue Committee helps provide health services to refugees in Kakuma. NGOs have adopted different behavior change communication strategies for different groups, including adolescents, young women, and commercial sex workers. To increase the effectiveness of these strategies, UNHCR has recommended:

  • The use of multi-channel communication, including print, electronic, and traditional means.
  • Participatory development of advocacy packages for abstinence, faithfulness, and condom use.
  • Testimonials from people living with HIV/AIDS.
  • Community education and counseling through peer educators.
  • Timely and accurate treatment of sexually transmitted infections.
  • Prophylaxis to prevent tuberculosis and pneumonia among people living with HIV/AIDS.
  • Carrying out HIV behavioral and biological surveys every two years, to measure behavior change and HIV prevalence.
  • The involvement of camp bars and bar personnel in HIV prevention efforts (UNHCR 2002).

Working with returning refugees in Sierra Leone

Returning refugees are also in need of HIV/AIDS services. The American Refugee Committee (ARC) has been working with Sierra Leonean refugees returning to Port Loko since 2001. Nearly half of Sierra Leone’s 4.5 million inhabitants fled either to other parts of the country or across international borders from 1991 to 2001. After returning home, former refugees had to contend with a near complete absence of health infrastructure.

ARC has responded to the threat of HIV/AIDS in Sierra Leone through a project that uses posters, billboards, newsletters, tabloids, and radio jingles to spread prevention messages. Sponsoring events and workshops about condom use and negotiation, HIV transmission and prevention, and prevention and treatment of other STIs, the ARC project has helped distribute 50,000 condoms per year and assisted in the improvement of STI treatment. It has focused particularly on members of the military, commercial sex workers, young people, and ex-combatants.

Prior to launching the Port Loko project, the ARC conducted a baseline survey on knowledge, attitudes and behaviors related to HIV/AIDS and other STIs. After two years of project operation, a follow-up survey took place. This survey found that among respondents from the target population:

  • Correct knowledge of three or more means of HIV transmission increased from 10 percent to 50 percent.
  • Knowledge of three or more effective means of avoiding HIV infection increased from 6 percent to 54 percent.
  • The ability to name three or more condom sources increased from 12 percent to 56 percent.
  • Reported use of condoms at last intercourse increased from 26 percent to 53 percent (ARC 2003).

Lessons learned

Although work to respond to HIV/AIDS among refugees and internally displaced persons has only begun in earnest in the last several years, some preliminary lessons have emerged from the experience:

  • Refugees are in need of HIV-prevention efforts and high quality health care.
  • Refugees living with HIV/AIDS would benefit from the availability of antiretroviral drugs.
  • Governments should stop obstructing aid to marginalized and displaced populations.
  • The standards, quality, and comprehensiveness of HIV/AIDS programs conducted among refugees vary widely.
  • Basic and culturally appropriate communication materials are often lacking in local languages.
  • A high level of HIV-related stigma and discrimination exists within (and toward) refugee populations.
  • Funding and technical expertise for HIV/AIDS programs in refugee populations are lacking (IRC 2004; Spiegel and Nankoe 2004).

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Annotated bibliography

Please note that PDF files require Adobe Acrobat Reader software, which can be downloaded for free at www.adobe.com/products/acrobat/readstep.html.

American Refugee Committee. Post-intervention Survey Report: HIV/AIDS/STI Knowledge, Attitudes and Practice (KAP) Survey Among Commercial Sex Workers, Military and Youth in Port Loko, Sierra Leone. Minneapolis: ARC International; 2003. Available at: www.rhrc.org/pdf/ARCSLPostInterventionSurvey.pdf.
This report discusses the results of a program implemented by the American Refugee Committee (ARC) among returning refugees in Port Loko, Sierra Leone. In 2001, ARC began work with members of the military, commercial sex workers, young people, and ex-combatants. Prior to launching the Port Loko project, the ARC conducted a baseline survey on knowledge, attitudes, and behaviors related to HIV/AIDS and other STIs. After two years of project operation, a follow-up survey took place. This survey found that among respondents from the target population: correct knowledge of three or more means of HIV transmission increased from 10 to 50 percent; knowledge of three or more effective means of avoiding HIV infection increased from 6 to 54 percent; the ability to name three or more condom sources increased from 12 to 56 percent; and reported use of condoms at last intercourse increased from 26 to 53 percent.

Benjamin J. Women, war and HIV/AIDS: West Africa and the Great Lakes. Presented at: The World Bank, March 8, 2001; Washington, D.C. Available at: www.rhrc.org/resources/sti/benjamin.html.
This presentation examines the effects of armed conflict and HIV/AIDS on women in West Africa and the Great Lakes region. The author maintains that women and children constitute 70 to 80 percent of 40 to 50 million displaced persons. Violence against women both during armed conflict and in camps for refugees or internally displaced persons is an important risk factor for HIV/AIDS. Women are vulnerable both to rape and to the need to sell sex for survival. Women and girls are often at risk in camps when going to use latrines or to fetch water, where men wait for and coerce them into sex. The author recommends training of peacekeeping forces in human rights law, gender awareness, prevention of gender violence, and HIV/AIDS prevention, as well as making condoms and STI treatment available to troops, refugees, displaced persons, and local populations.

Hankins C, Friedman SR, Zafar T, Strathdee SA. Transmission and prevention of HIV and sexually transmitted infections in war settings: implications for current and future armed conflicts. AIDS. 2002;16(17):2245-2252. Available at: www.unhcr.ch/cgi-bin/texis/vtx/home/opendoc.pdf?tbl=PROTECTION&id=4073cc494&page=protect.
The authors of this article investigate the direct effects of war on sexual transmission of HIV and other STIs; transmission of HIV and other infectious agents through injection drug use; and interacting sub-epidemics of HIV. They also examine the indirect effects and the after-effects of war on HIV epidemics. They recommend the implementation of the “Minimum Initial Service Package” during complex emergencies; universal precautions among health care workers; promotion of condom use and availability; income-generation strategies for refugees and internally displaced persons; and needle exchange programs.

Holmes W. HIV and human rights in refugee settings. The Lancet. 2001;358(9276):144-146.
This brief article suggests that a human rights framework is a useful basis for understanding and responding to the vulnerability of refugees to HIV/AIDS. Women are particularly vulnerable to sexual violence and coercion, and therefore to HIV transmission. The traditional roles and responsibilities of women and men change drastically in the context of displaced populations. Men and women should have the opportunity to meet in culturally acceptable ways, and they also need the opportunity to engage in meaningful activities. In refugee settings, it is important to safeguard people’s right to self-determination, confidentiality, privacy, information, and non-discrimination.

Holt B, Effler P, Brady W, et al. Planning STI/HIV prevention among refugees and mobile populations: situation assessment of Sudanese refugees. Disasters. 2003;27(1):1-15.
This article describes one of the earliest studies (1992) of knowledge, attitudes, and behaviors related to HIV and other STIs within an African refugee population. The study, which also examined prevalence of HIV and other STIs, took place in the Dimma refugee settlement in southwestern Ethiopia, and focused on Sudanese refugees and Ethiopian sex workers. The investigation found that knowledge of HIV/AIDS and condom use were extremely low among Sudanese refugee women, while sexual contact between Sudanese refugee men and sex workers was common. HIV and STI prevalence among the study population was high. In addition to yielding this information, the study was one of the first of its kind to underscore the importance of conducting a situation analysis, establishing baseline data, and carrying out a survey on knowledge, attitudes, and behaviors as preliminary steps to designing a program to respond to HIV/AIDS among refugees and other mobile populations.

International Rescue Committee. HIV/AIDS and people fleeing armed conflict [fact sheet]. New York: IRC; 2004. Available at: http://intranet.theirc.org/docs/IRC_HIV-AIDS_Factsheet.pdf.
This fact sheet describes the reasons refugees and internally displaced persons are vulnerable to the virus. It also recommends that the international community provide these populations with preventive measures and high-quality health care; increase the availability of antiretroviral drugs; and encourage national governments to allow increased access to marginalized and displaced populations.

Khaw A, Salama P, Burkholder B, Dondero TJ. HIV risk and prevention in emergency-affected populations: a review. Disasters. 2000;24(3):181-197.
This review examines HIV transmission risks associated with complex emergencies, including rape, sex as a survival strategy, host-refugee interaction, and other STIs as cofactors. It also investigates the risk of mother-to-child HIV transmission and risks related to health care, as well as the recommended “Minimal Initial Services Package” for HIV prevention during complex emergencies and barriers to HIV prevention, such as the lack of functioning health systems and the lack of data on prevalence of HIV and other STIs in conflict-affected countries. “A coherent prevention strategy will require better baseline information, better surveillance, and more access to testing and counselling than currently exist in emergency settings.”

Ntakirutima J, Mboyane J. Fighting HIV/AIDS in Rwanda. Monday Developments. 2004;22(3):9.
This short article focuses on the effects of the 1994 genocide in Rwanda and ensuing efforts by Africare to respond to HIV/AIDS among refugees, internally displaced persons, and those returning to their homes. Africare focuses primarily on young people in Gikongoro Province, aiming specifically to raise awareness about HIV/AIDS and promote prevention and care. The organization has learned that young people appreciate the opportunity to discuss sex, sexuality, and prevention in “safe” spaces. Voluntary counseling and testing services for HIV have also proven essential in Africare’s efforts to respond to the epidemic in Rwanda.

Ritsema S. Partnering with Local Organizations to Support the Reproductive Health of Adolescent Refugees: A Three-Year Analysis. New York: Women’s Commission for Refugee Women and Children, Reproductive Health Project; 2003. Available at: www.womenscommission.org/pdf/EBP_Final.pdf.
Focusing on adolescent refugees in Africa, Asia, Europe, Latin America, and the Middle East, this report examines three years of work sponsored by the Eleanor Bellows Pillsbury Fund for Reproductive Health Care and Rights for Adolescent Refugees. From 2000 to 2003, the fund helped more than 61,000 adolescents “attend events offering reproductive health training and education on issues such as condom use, prevention and treatment of STIs, family planning techniques, and protection against gender-based violence.” The fund found that peer-to-peer adolescent reproductive health education strategies provide meaningful opportunities for adolescent participation. It is important to vary approaches, depending on cultural settings. Conflict-affected communities are highly motivated to improve adolescents’ reproductive health, but are in need of capacity building. Adolescent reproductive health networks “are a promising way to close gaps in service provision and strengthen limited capacity.”

Spiegel P. HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action. Paper presented at: 20th meeting of the Inter-Agency Advisory Group on AIDS, United Nations High Commission on Refugees, February 9-10, 2004; Geneva, Switzerland. Available at: http://intranet.theirc.org/docs/Dispelling%20Myths%20and%20Taking%20Action%20-%20IAAG.pdf.
This paper aims to present the state of the art and correct misconceptions on HIV/AIDS among refugees and internally displaced persons, including the erroneous belief that the vulnerability of these populations to HIV necessarily leads to increasing numbers of HIV infection. The paper examines how the combination of HIV epidemiology and conflict can either slow or increase the progression of HIV in different settings, and how HIV affects different types of refugee camp situations. Vulnerable groups can include women, children, armed personnel, and humanitarian workers. The author recommends a series of principles to protect human rights and prevent HIV transmission among people affected by armed conflict, as well as coordination and integration among those responding to the needs of refugees and internally displaced persons following armed conflict. He also presents recommendations for United Nations agencies involved in the response to HIV/AIDS and armed conflict.

Spiegel P, Nankoe A. UNHCR, HIV/AIDS and refugees: lessons learned. Forced Migration Review. 2004;19:21-23. Available at: www.fmreview.org/FMRpdfs/FMR19/FMR1909.pdf.
The authors of this article discuss the recent experience of the United Nations High Commission for Refugees in responding to HIV/AIDS. They maintain that refugees are often double victims of discrimination simply by virtue of being refugees and when host countries falsely accuse them of bringing HIV/AIDS across borders. The authors present the 2002-2004 UNHCR strategic plan on HIV/AIDS, which provides for freedom from discrimination for refugees, a minimum and coordinated package of HIV/AIDS programs in refugee emergency situations, and the implementation of multisectoral and comprehensive HIV/AIDS pilot programs in more stable situations. The article maintains that the standards, quality, and comprehensiveness of HIV/AIDS programs conducted among refugees vary widely, and that basic and culturally appropriate communication materials are often lacking in local languages. The authors also observe that a high level of HIV-related stigma and discrimination exists within (and toward) refugee populations; and that funding and technical expertise for HIV/AIDS programs in refugee populations are lacking. Also provided are a series of recommendations for UNHCR and its partners to respond to HIV/AIDS in complex emergencies.

United Nations High Commission for Refugees. Assessment of HIV/AIDS Behaviour Change Communication Strategies Employed by NGOs in Kakuma Refugee Camp. Geneva: UNHCR; 2002. Available at: www.unhcr.ch.
This report summarizes the work of UNHCR with non-governmental organizations (NGOs) in Kakuma, Kenya, to provide HIV/AIDS services to refugees. Approximately 82,000 refugees, mainly from Sudan, Somalia, and Ethiopia, live in the Kakuma area. The International Rescue Committee helps provide health services to refugees there. NGOs have adopted behavior change communication strategies for different groups, including adolescents, young women, and commercial sex workers. UNHCR recommends a series of specific actions to increase the effectiveness of these strategies.

Women’s Commission for Refugee Women and Children. Refugees and AIDS: What Should the Humanitarian Community Do? New York: WCRWC; 2002. Available at: www.womenscommission.org/pdf/hiv.pdf.
This user-friendly document from the Women’s Commission for Refugee Women and Children provides suggestions for the response of the humanitarian community to refugees and HIV/AIDS. The document discusses modes of transmission of HIV, how other STIs relate to HIV, human rights, guiding principles for program responses, establishing HIV/AIDS interventions during and following complex emergencies, preventing HIV transmission, and care for people living with HIV/AIDS.

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Links to resources

Listed below are some useful resources on refugees and HIV/AIDS.

International Rescue Committee
www.theirc.org
The website of the International Rescue Committee provides information about the organization’s work in Africa, Asia, and Europe. “The IRC helps people fleeing racial, religious and ethnic persecution, as well as those uprooted by war and violence.” The IRC provides emergency assistance in the form of water, food, shelter, sanitation, and medical care. The organization also helps thousands of refugees resettle in the United States each year.

United Nations High Commission on Refugees
www.unhcr.ch
The United Nations High Commission on Refugees is the world’s foremost organization devoted to refugee assistance. The UNHCR website offers a wide variety of publications, including many that relate specifically to HIV/AIDS (www.unhcr.ch/cgi-bin/texis/vtx/home?page=search).

Women’s Commission for Refugee Women and Children
www.womenscommission.org
The Women’s Commission for Refugee Women and Children focuses on the plight of women and children refugees throughout the world. Among the commission’s publications is a user-friendly report entitled Refugees and AIDS: What Should the Humanitarian Community Do? (www.womenscommission.org/pdf/hiv02.pdf).

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