Spiegel PB, Bennedsen AR, Claass J, Bruns L, Patterson N, Yiweza D, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007 Jun 30;369(9580):2187-95. Review.
To perform a systematic review to evaluate whether conflict in sub-Saharan Africa results in increased risk of HIV transmission, and whether refugees have a higher prevalence of HIV infection than persons in their surrounding host communities.
Studies were included if they met the following criteria: 1. data were presented from a developing country, defined by combining the World Bank categories of low-income, lower-middle income, or upper-middle income economies; 2. participants received a diagnosis of HIV or were presumed to be HIV-infected based on clinical signs and symptoms; 3. clinical treatment was provided, including treatment for opportunistic infections and antiretroviral therapy; 4. an evaluation design was employed that compared post-intervention outcomes using either a pre/post- or multi-arm study design (including post-only exposure analysis); 5. behavioral, psychological, social, care, or biological outcome(s) related to HIV prevention were presented; and 6. the article appeared in a peer-reviewed journal from January 1990 through January 2006. No language restrictions were used. When an article in a language other than English was found, it was translated into English, and then coded.
Searches were performed of PubMed, Medline, and Embase from January 1981 onwards without language restrictions, using one or more combinations of the following terms: "HIV," "AIDS," "conflict," "war," "insurgency," and "refugee." From this initial search, seven countries were identified that had a history of widespread conflict and data available on HIV prevalence during some period in the last five years. Searches were then done by combination of country names and one or more search terms. Web-based searches of governmental and non-governmental organizations were done to obtain additional published and unpublished articles. References of publications were reviewed, and authors approached for additional data if needed. Country-level and ANC HIV sentinel surveillance data were obtained from WHO and UNAIDS websites. For studies of refugees, data from ANCs that were part of sentinel surveillance through United Nations High Commission on Refugees (UNHCR) were used. The dates of "conflict" were obtained from the Uppsala database assessing armed conflicts.(1)
Two-hundred ninety-five articles and reports met initial inclusion criteria, of which 88 had original HIV data. Assessments of study quality were based on a 5-point scale using internationally accepted guidelines for HIV sentinel surveillance and population-based surveys.(2,3,4,5,6) This resulted in a total of 65 articles and reports from seven countries; 27 were peer-reviewed, 5 were from grey literature, and 33 were prevalence surveys; 20 of the 33 prevalence surveys were from 12 refugee sites in six different countries.
HIV prevalence data within conflict zones were obtained from epidemiological surveys of persons living in the Democratic Republic of Congo (DRC), southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia, and Burundi. Data from sites in eastern DRC were compared to the nearest neighboring country sites in Kenya, Tanzania, Burundi and the Central African Republic, as there were no in-country data for comparison.
Host countries with data for comparison with displaced persons within their borders included Tanzania (refugees from DRC and Burundi), Rwanda (refugees from DRC), Zambia (refugees from DRC), Sudan (refugees from Eritrea), Uganda (refugees from Sudan), and Kenya (refugees from Sudan and Somalia).
There was no intervention.
The prevalence of HIV in populations directly affected by conflict was compared to the nearest population not directly affected by that conflict, and for which data were available. Prevalence data from refugee ANCs were compared to available (usually ANC) data in the nearest surrounding host communities.
Data did not indicate that HIV prevalence increased over time during periods of conflict in the seven countries studied. In addition, HIV prevalence rates were not different from those in nearby non-conflict zones. Of the 12 studies of refugees, 9 had lower, two had similar, and one had higher prevalence rates than surrounding host communities.
The authors conclude that available data do not provide support the belief that conflict results in increased HIV transmission, or that refugees fleeing conflict have a higher HIV prevalence than their host communities. In many circumstances, comparisons of HIV prevalence in both situations show the opposite result. However, the authors point out that the data are generally insufficient to draw definitive conclusions, and that time-sensitive and well-performed surveys need to take place in these vulnerable populations.
This systematic review of prevalence data was of a high quality. The authors applied a level of rigor to their analysis appropriate to each of the 16 points of the QUOROM checklist, even when these points would really pertain primarily to a meta-analysis, rather than to a prevalence survey review.
Data collection during conflict, although possible, is fraught with difficulties and should be interpreted cautiously.(7) Such estimates need to be compared to reliable data from before and after conflict. There is a general belief that military activity, wide-scale rape, and decreased prevention services result in increased HIV transmission at a population level. However, the estimates that have been used to support this view may have been the result of poor survey methods, reliance on data from urban areas with high prevalence, and biased interpretation. It is possible that during periods of conflict, there may be less sexual activity among the population affected, so that transmission is not increased substantially.
Based on this review performed by authors from UNHCR, past assumptions that conflict and displacement increase prevalence of HIV infection are not validated by existing data. Nor can the concern that refugee populations have higher HIV prevalence levels than their host communities, and therefore pose a risk to them. However, the considerable limitations of the available information mean that definitive conclusions cannot be drawn at this time. Reliable data on changes in HIV prevalence among displaced persons over time is lacking. Information about wide-spread rape causing increased HIV transmission is based on surveys of women from antenatal clinics. Raped women may or may not be attending those clinics for a variety of reasons - they may not have become pregnant, may have had abortions, or may fear attending the clinics. Although some conclusions from the seven African countries studied here might apply to other countries affected by conflict, every situation is unique and should be examined according to context. Generalizations should be avoided.
- Uppsala Conflict Database.
- UNAIDS. Joint UN programme on HIV/AIDS. UNAIDS/WHO global HIV/AIDS online database. (Accessed April 24, 2007).
- Brown T, Grassly NC, Garnett G, Stanecki K. Improving projections at the country level: the UNAIDS Estimation and Projection Package 2005. Sex Transm Infect 2006 Jun;82 Suppl 3:iii34-40. Review.
- Grassly NC, Morgan M, Walker N, Garnett G, Stanecki KA, Stover J, et al. Uncertainty in estimates of HIV/AIDS: the estimation and application of plausibility bounds. Sex Transm Infect 2004 Aug;80 Suppl 1:i31-38.
- UNAIDS, WHO. Guidelines for conducting HIV sentinel serosurveys among pregnant women and other groups. Geneva: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2003.
- UNAIDS, WHO. Guidelines for measuring national HIV prevalence in population-based surveys. Geneva: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2005.
- Spiegel PB. HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action. Disasters 2004 Sep;28(3):322-39. Review.