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Forced Migration & HIV Transmission
Forced Migration and Transmission of HIV and Other Sexually Transmitted Infections: Policy and Programmatic Responses
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Introduction
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Definition of Terms
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Background on Reproductive Health for Refugees
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The Data on STIs/HIV/AIDS in Forced Migration Settings
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transparent imageMigration and Displacement in Refugee and IDP Settings
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transparent imageMilitary Presence
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Policies Regarding HIV/AIDS and Persons Affected by Armed Conflict
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transparent imageUNHCR and Relief Agencies
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transparent imageUnited Nations
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transparent imageGovernments
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transparent imageNGOs
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Programmatic Response to HIV/AIDS in Conflict Settings
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Discussion and Next Steps
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Notes
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References
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Tables
Table 1.Program Response Guiding Principles
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Table 2.Strategies Specific to Reducing the Transmission of HIV in the Stable Phase
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Table 3.Addressing HIV Transmission in Refugee Settings: Country Examples
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Introduction
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Sexually transmitted infections (STIs) and HIV/AIDS have become urgent concerns for populations affected by armed conflict and migration (both forced and voluntary). Poverty, powerlessness, and social instability affect the spread of STIs and HIV. These conditions are characteristic of the lives of most refugees and internally displaced persons.

This chapter briefly describes the history of reproductive health for refugees (used in this article to refer to both refugees and the internally displaced) and presents the available evidence on the effects of conflict on the spread of HIV. It then describes policy and program responses recommended by multilateral, governmental, and nongovernmental organizations. It concludes with recommendations for future directions. It is expected that, from this chapter, the reader will gain:

  • an appreciation of the importance of reproductive health services for displaced populations

  • awareness of the need to focus on STI and HIV/AIDS prevention and response in conflict settings

  • awareness of the policy and program advances that have occurred, and a recognition that additional effort is required to address the problem

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Definition of Terms
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A refugee is defined as a person who has fled his or her country and is unable or unwilling to return because of persecution based on race, religion, nationality, membership in a particular social group, or political opinion. The term also includes those fleeing war, civil strife, famine, and environmental disasters.(Note a)

Internally displaced persons (IDPs) have been forced from their homes, usually by civil strife, but remain within the borders of their own countries. Because countries in conflict are often unable or unwilling to provide needed health and social services to their citizens and because the international community may be averse to overstepping the sovereign rights of states, IDPs often receive little international attention, and may go unprotected and unassisted.

As of mid-2001, there were an estimated 14 million refugees and 21 million IDPs worldwide.(1) Violent conflicts in 1999, including in East Timor, Chechnya, and the Democratic Republic of Congo, led to a significant increase in the numbers of refugees and IDPs. Three countries--Sudan, Afghanistan, and Angola--continue to account for over one-fourth of the world's entire uprooted population.(2)

Complex humanitarian situations involving armed conflict and population displacement are often divided into phases for guidance in determining program needs and setting priorities. The exodus or emergency phase, which may last up to six months, is followed by the postemergency and stabilization phases, which often last for years. Some refugees eventually return home, others are resettled in another country, while still others remain displaced for extended periods.(3)

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Background on Reproductive Health for Refugees
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The movement to adequately address reproductive health in refugee settings can be traced back to 1993 and early 1994, when the Women's Commission for Refugee Women and Children, a nongovernmental advocacy organization, conducted a global assessment of reproductive health services in refugee and internally displaced sites. The result was the seminal report Refugee Women and Reproductive Health Care: Reassessing Priorities.(4)

The National Council for International Health's(Note b) annual meeting in June 1994 broadened the debate on reproductive health for refugees. Both the report mentioned above and the ensuing debate demonstrated that, historically, health care for refugees and IDPs followed the relief model, providing only those medical services considered to be "life-saving," regardless of the stability of the setting. This model tended to neglect reproductive health care services that save lives as well. In short, the rights and needs of refugees and IDPs were not being met adequately.

Over the past seven years, following the publication of the report and the June 1994 meeting mentioned above, there has been significant progress in this area. The November 1994 International Conference on Population and Development in Cairo gave refugee women their first international forum to voice their own needs and concerns regarding reproductive health. The conference's Programme of Action,(5) with its emphasis on women-centered health and development, is widely regarded as a milestone for humane and effective health and population programs.(6-8)

In 1998, the Interagency Working Group on Reproductive Health in Refugee Situations elaborated a list of supplies and equipment for use in crises. The list was published as The Reproductive Health Kit for Emergency Situations;(9) UNFPA packaged the items into units ready for deployment.

The Reproductive Health for Refugees (RHR) Consortium was established in February 1995 by five relief and reproductive health agencies to conduct collaborative and multidisciplinary work in the field. The consortium has since expanded to seven member agencies.(Note c) In 1997, the consortium published a set of needs assessment tools for use in refugee and IDP settings.(10) The consortium also produced one- and five-day training manuals for reproductive health in refugee situations.(11,12) In 1999, the consortium established a Web site (http://www.rhrc.org) that hosts the resources mentioned above and provides links to other sites focused on improving refugee reproductive health. In December 2000, the consortium hosted Conference 2000: Findings on Reproductive Health of Refugees and Displaced Populations,(13) the first large international forum on the topic. About 250 people from some 30 countries participated.

A United Nations symposium on reproductive health in refugee situations was held in Geneva in June 1995. The symposium mandated a follow-up mechanism that became the InterAgency Working Group on Reproductive Health in Refugee Situations. Also in 1995, a refugee reproductive health-focused position at the United Nations High Commissioner for Refugees (UNHCR) was created and staffed.

A draft version of the InterAgency Field Manual on Reproductive Health in Refugee Situations was produced and field-tested around the world in 1995 and 1996. A revised manual, incorporating feedback from the field test, was published in 1999.(14) This manual is a basic guide to support the delivery of quality reproductive health services and has been endorsed by over 30 relief and reproductive health agencies.

The InterAgency Field Manual on Reproductive Health in Refugee Situations, which guides agencies in their field work, identifies the following important components of reproductive health for refugees:

  • prevention and care of STIs, including HIV/AIDS

  • comprehensive safe motherhood programming, including emergency obstetric care

  • protection from and response to sexual and gender-based violence

  • a full range of family planning services (as field conditions permit)

  • the reproductive health of adolescents

  • a Minimum Initial Service Package (MISP) of interventions to be implemented at the onset of a humanitarian emergency

The factors that underlie conflict, particularly those in high HIV prevalence regions, are similar to those that are known to exacerbate HIV transmission: poverty, powerlessness, social instability, and marginalization. War destroys health, education, transportation, and communications infrastructure; separates families; alters gender roles; and creates psychological, as well as physical, trauma. The effects of these changes continue after active fighting ends; indeed, they may be felt for decades. These factors contribute to the spread of STIs and HIV/AIDS, and render response more difficult. To assist appropriately, therefore, those working in relief communities must begin by understanding the scope of the problem.

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The Data on STIs/HIV/AIDS in Forced Migration Settings
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There are several characteristics of refugee life that would logically increase the risk of acquiring STIs, including HIV. Zwi and Cabral identified five ways in which populations may become high risk during low-intensity conflict: displacement, military activity, economic disruption, psychological stresses, and increased migration.(15) The available data suggest that STI and HIV transmission is indeed greater among people in forced migration settings as compared to stable populations and that movement and interaction with the military exacerbate the situation. The effects are not limited to refugees themselves, but extend to all those in the conflict or postconflict setting.

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Migration and Displacement in Refugee and IDP Settings
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Displacement, which promotes exposure between high- and low-prevalence populations, rather than refugee status itself, appears to be a critical factor in the spread of STIs. Indeed, the association of STIs with population movement--whether voluntary or not--is long-standing.

Several assessments of point prevalence of HIV or other STIs have been conducted in refugee and IDP settings. A 1989 prospective study of 179 pregnant Vietnamese refugees in Hong Kong by King et al found 3.4 percent prevalence of syphilis and no gonorrhea.(16) The same syphilis rate was found in 1998 in Kakuma Refugee Camp, Kenya, among 876 pregnant Sudanese and Somali women.(17) The studies cited do not provide premigration nor local population prevalence rates for comparison, but their findings are nonetheless troubling.

During 1992-1993, Cossa et al carried out a study of 1,728 displaced pregnant women living in accommodation centers in Mozambique's Zambezia Province.(18) Syphilis was confirmed in 12.2 percent of the women and HIV in 2 percent. The authors note the relatively low HIV rate, surprising in view of the high syphilis rate, and suggest recent introduction of HIV or absence of cofactors for transmission as possible explanations. Earlier studies of rural displaced persons in other areas of the country, cited by the authors, found HIV prevalence of 3.4 percent in 1987 and 4.6 percent in 1990, considerably higher than the 0.9 percent rate in the general adult Mozambican population in 1987. The authors describe a 1983 study that showed a syphilis rate among pregnant Mozambicans in eight provinces of 6.3 percent, and note that it is not possible to determine whether the apparent increase between 1983 and 1992-1993 is the result of the effects of displacement, geography, or time. The 1992-1993 study showed no correlation between syphilis or HIV seropositivity and duration of displacement.

Immediately following the massive movement of refugees from Rwanda to Tanzania in mid-1994, Mayaud et al. carried out a rapid assessment of STI prevalence in refugee camps.(19) Over eight days, 239 male clients of the camp's outpatient clinics, 289 men from the refugee community and 100 pregnant camp antenatal clinic attenders were interviewed and examined clinically. Over 60 percent of the women had some form of reproductive tract infection (RTI) (when candidiasis, bacterial vaginosis, and trichomoniasis were included). Gonorrhea was found in 3 percent of women and syphilis in 2 percent. Among men, prevalence of gonorrhea was 1 to 2 percent and urethritis about 3 percent in both outpatient and community samples; syphilis was 6 percent in the male outpatients, the only male group tested for syphilis. The authors note that the RTI and STI levels found within the refugee population were generally consistent with those found in an earlier study among Tanzanian residents in neighboring Mwanza Region.

Two studies by Rey and colleagues in refugee camps for Rwandans in Goma, Zaire, in 1994 found HIV prevalence at 6 percent among 48 adult controls and 19 percent among 48 adult patients presenting with "fever of unknown origin," and 4.9 percent among 143 orphans, suggesting a problem of substantial magnitude.(20,21)

Studies of resettled or immigrant populations in developed countries have also been undertaken, again demonstrating that no single pattern emerges. In London, a retrospective study published in 1998 of 196 patients from the former Yugoslavia and age-matched British controls showed 34 percent of the immigrants and 27 percent of the controls had an STI.(22) A study published in 1995 found an HIV prevalence of 6.3 percent among 5,234 African and Haitian refugees in France attending a dispensary for foreign nationals.(23) Vietnamese refugees in Japan were tested for syphilis within one month of resettlement during 1989-1991; 0.7 percent tested positive, a rate unchanged from earlier cohorts of Vietnamese refugees.(24)

Studies have linked the spread of HIV and other sexually transmitted infections to migration, both voluntary and conflict-induced. In many countries, HIV has been most visible in the early stages of the epidemic along truck routes, in trading towns, and in border areas where populations are highly mobile.(25) Mobility itself has been identified as a risk factor for HIV infection, as data suggest that HIV spreads along migration routes.(26) HIV prevalence was particularly high at the border crossing points and along transport routes in mainland Southeast Asia (Cambodia, Laos, Malaysia, Myanmar [Burma], Thailand, Vietnam, and southern China)(27) and along the heavily traveled corridor in West Africa between Abidjan, Côte d'Ivoire, and Ouagadougou, Burkina Faso.(28) South Africa's high HIV rate has been attributed in part to its long history of male labor migration.(29)

Although family disruption, marginalization, poverty, and/or insecurity often result from the movement of individuals or groups, these effects may be most severe among those forced to flee because of conflict at home. Data from Rwanda provide some evidence that mixing populations with different HIV prevalence rates increases HIV prevalence overall.(30) A 1997 survey found 11 percent HIV prevalence in both rural and urban areas. This contrasts with prewar levels that were low in rural areas (estimated at 1 percent) where approximately 95 percent of the population resided, and high in urban areas (over 10 percent of women attending antenatal clinics). Following displacement and return, seroprevalence among those who had lived in refugee camps in Tanzania or Zaire was 8.5 percent, representing a six- to eight-fold increase over the rates in the rural areas from which they came. The increase was even greater, however, for the internally displaced--those who remained in Rwanda during the conflict years. Of the IDP women who survived rape, 17 percent were HIV-positive.

Refugees have not always had high rates of HIV infection, nor higher rates than local populations. In an examination of 398 blood samples from Mozambican refugees in two camps in Swaziland in 1993, Van Rensburg et al found 10.8 percent HIV prevalence in the camp located near Swaziland's two major cities and 1.2 percent prevalence in an isolated camp in a sparsely populated area further south.(31) The authors conclude that greater interaction with the Swazi population, which had an estimated seroprevalence of 18 percent, was responsible for the higher prevalence in the first camp.

The location of the refugees, rather than refugee status per se, was also important in an examination by Santos-Ferreira et al of the spread of HIV infection in Angola in 1987 and 1988.(32) Serum samples were tested for a total of 1,695 apparently healthy individuals and patients (seeking treatment for STIs, tuberculosis, and other illnesses) in six provinces; among them were 250 displaced men in three provinces. The authors found that "The highest rates of seropositivity were found among patients and healthy people in the northern areas near the Zaire Republic, among refugees in the most affected war zones, and among army personnel." Proximity to a war zone appeared to be more important than refugee status as seropositivity among the displaced varied substantially by province: 20.2 percent in a central, war-affected area (Huambo); 8.1 percent in Kuando-Kubango in the southeast, far from the fighting in the north; and zero among refugees in Luanda arriving from the south. The authors concluded, "The war certainly promotes dissemination of HIV by heterosexual (usual in armies for STI) and parenteral [perinatal] transmission."

The importance of STIs and their association with war and movement is noted not only by researchers but also by community members. In a qualitative study by Palmer of reproductive health in communities affected by war in southern Sudan in 1999, STIs were the problem most consistently identified by community members.(33) Settled and displaced residents had similar opinions on the prevalence of STIs but differed in their views on treatment and impact. The importance of STIs was confirmed by health statistics: STIs accounted for 13 percent of consultations at the main hospital and were the fourth most common reason for attendance. Men and women in all age groups attributed STIs to "movement of people and the war."

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Military Presence
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Another characteristic of forced migration settings is the exposure and interaction with military personnel. Military presence has been shown to facilitate STI transmission. During conflict, rape and other forms of sexual violence are often used as weapons of war by combatants. In postconflict settings, forced sex perpetrated by combatants and by civilians continues. However, it is not only through rape that military presence contributes to STI and HIV transmission. Several factors promote unprotected sexual activity by military personnel, including those assigned to peacekeeping operations in postconflict zones: service requires long periods away from home and family; the military culture values risk-taking; most military personnel are young men, a group at high risk of HIV; military staff are often better paid than the local population; and military installations demand and attract the commercial sex industry.(34) In most conflict settings, both the demand for sex by the military and the (mostly female) commercial sex industry that expands in response are perceived as routine and acceptable.

The military have long been associated with high STI rates(35) and with high-risk behavior. In interviews with men in various occupations in northern Thailand in 1991, VanLandingham et al found that soldiers were more likely than other men to visit a prostitute in the last six months (71 percent of soldiers vs. 38 percent of total sample, which included soldiers; students; and municipal, construction, and department store workers) and less likely to always use a condom with prostitutes (42 percent of soldiers vs. 53 percent of the total sample).(36) In a 2001 unpublished study in Sierra Leone in which a convenience sample of 202 United Nations peacekeepers and soldiers from the national army were interviewed, only 23 percent of respondents could spontaneously cite at least three routes of AIDS transmission; 38 percent reported not being worried about AIDS; and only 39 percent used a condom at last sex.(37)

In Cameroon in 1994, HIV seroprevalence rates were 3.2 percent in the general population and 6.3 percent among the military.(38) Analysis of 1999 HIV data by Quan and colleagues in Vietnam found much lower HIV rates overall but similarly high differentials: seroprevalence was 0.12, 0.20, and 0.61 percent, respectively, among women attending ANCs, blood donors, and military recruits.(39) In the U.S. in 1998, syphilis incidence was two to three times higher in the Marines (9 per 100,000 population), Army (7 per 100,000), and Navy (5 per 100,000) as compared to the U.S. population overall (3 per 100,000); only the Air Force rate was lower (2 per 100,000).(40) Condom use at last sex in all branches of the U.S. military in 1998 was under 45 percent, and did not meet the Department of Defense goal of 50 percent.(41)

In a 1990 examination of the distribution and spread of HIV infection in Uganda during the 1980s, Smallman-Raynor and Cliff linked the pattern of military recruitment in the post-Amin years and the geographical spread of the epidemic.(42) They concluded, "...the classic association of war and disease substantially accounts for the presently observed geographical distribution of reported AIDS cases in Uganda."

Conflict increases the spread of sexually transmitted infections, including HIV/AIDS, at least through displacement and military presence, which are inevitable results of war. Other analyses suggest that the economic disruption and psychological stress that accompany forced migration also contribute to increased HIV risk. For example, limited educational and economic opportunities for both men and women in the aftermath of conflict may lead to migratory labor patterns among the men, economic dependence among the women who stay behind, and alienation and despondency across the population. Such disruption contributes to the supply and use of commercial sex.(43)

The effects are felt not only by refugees and the displaced themselves but by the "war-affected," who include the local residents in the host area and the military personnel themselves. The direction of spread is not inevitably from refugees to local residents, but depends on the relative prevalence levels in the area of origin and destination.

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Policies Regarding HIV/AIDS and Persons Affected by Armed Conflict
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Although this paper does not examine the details of international law, there are three bodies of international law relevant to persons affected by armed conflict:

1.Refugee law: the Convention on the Status of Refugees (1951) and its Protocol (1967).

2.Human rights: for example, Universal Declaration of Human Rights (1948); the International Covenant on Economic, Social and Cultural Rights (1966); the Convention on the Elimination of All Forms of Discrimination Against Women (1979); and the Convention on the Rights of the Child (1989).

3.Humanitarian law: the four Geneva Conventions (1949) and their two Additional Protocols (1977).

These three interrelated fields form the framework on which to build policies addressing the needs and rights of conflict-affected persons.(44)

Evidence from programs that have had some success in addressing HIV/AIDS in less developed countries indicates the pivotal role played by leadership at the highest levels. One easily observable indicator of high-level commitment within organizations is the existence of formal HIV/AIDS policy statements. Until the late 1990s, such policy statements concerning HIV/AIDS among conflict-affected persons were rare.

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UNHCR and Relief Agencies
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One exception was the 1988 memorandum issued by the Office of the United Nations High Commissioner for Refugees (UNHCR), "Policy and Guidelines regarding Refugee Protection and Assistance and Acquired Immune Deficiency Syndrome (AIDS)."(45) During the year preceding this policy statement, nations had begun to consider instituting HIV screening for international travel and for refugee resettlement. The 1988 UNHCR policy, derived from the agency's protection mandate, stated:

"In every refugee situation in which AIDS or HIV infection is an issue, both human rights and protection principles oblige States and UNHCR to co-operate in the avoidance of individual tragedy. This involves recognition of the fact that exclusion is no solution, and that responses must be geared to the dual objectives of combating the disease and protecting the refugee. These objectives further entail the highest degree of inter-State and inter-agency co-operation, substantial contributions to the development of national, schemes in receiving countries, and a readiness to offer resettlement programmes which include those presently in need of care, as well as those who test HIV seropositive."

One of the tenets of international refugee law is that refugees should have nondiscriminatory access to care and services in countries of asylum. However, some governments, including the United States, have limited eligibility for visas if a person "is determined to have a communicable disease of public health significance, which shall include infection with the etiologic agent for acquired deficiency syndrome."(46) Although U.S. law provides a process whereby an otherwise eligible refugee can apply for a waiver of inadmissibility, such waivers were rarely granted prior to June 1999. At that time, the Immigration and Naturalization Service (INS) lowered the economic barriers for refugees diagnosed with HIV. HIV-positive refugees are still deemed "inadmissible" to the U.S. and they must still apply for a waiver, but they now face a more simple waiver process.

In 1992, UNHCR issued a statement of policy and guidelines regarding refugee protection and assistance and HIV/AIDS, which affirmed that refugees should not be subject to mandatory HIV testing.(47) In 1998, UNHCR issued an updated "Policy regarding Refugees and Acquired Immune Deficiency Syndrome (AIDS)."(48) By then, HIV/AIDS had reached pandemic proportions with disastrous results in Africa, which was also the home of tens of millions of conflict-affected persons. The revised policy states:

"While the status of being a refugee need not be equated with an increased risk of HIV, [emphasis in original] it is most important to emphasize that the nature of a refugee environment may increase the vulnerability of the population, especially women, young people and children, to HIV/AIDS. Vulnerability to HIV/AIDS is often created by societal, economic, and cultural factors that can affect any given population. HIV spreads fastest in conditions of poverty, powerlessness and social instability--conditions that are often at their most extreme during the refugee life cycle."

Although still grounded in the protection mandate, the revised policy was much more practical in nature, recognizing that UNHCR's responsibility for many thousands of people who were HIV-positive and for millions at risk of contracting the virus. The 1998 policy articulates HIV/AIDS programmatic responsibilities in emergencies, stable settings, and resettlement situations and refers to several documents that provide more detail on what programs should include. It emphasizes the imperative that HIV/AIDS be tackled in cooperation with host countries' national AIDS control efforts and in partnership with other intergovernmental organizations, nongovernmental agencies, and local communities.

Humanitarian relief agencies began implementing HIV/AIDS programs along with other reproductive health programming efforts in the mid-1990s. Two guideline documents served to promote action, even though they did not offer specific policy guidance: UNAIDS' Guidelines for HIV Interventions in Emergency Settings(49) and the InterAgency Field Manual on Reproductive Health in Refugee Situations, previously noted.

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United Nations
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The arrival of AIDS on the agenda of the U.N. Security Council during 2000 prompted a spate of policy documents from U.N. agencies, many of which apply to conflict situations. In March 2000, a U.N. report recognized the high risk of the contraction and transmission of HIV by peacekeeping forces.(50) In April 2000, a World Health Organization working group prepared Controlling the Spread of HIV/AIDS in Complex Emergencies in Africa(51) for the InterAgency Standing Committee of the U.N. Office of Coordination of Humanitarian Affairs' Sub-Working Group on HIV/AIDS in Complex Emergencies. On July 17, 2000, the U.N. Security Council passed resolution 1309 (2000)(52) stressing that the HIV/AIDS pandemic, if unchecked, could pose a risk to stability and security and recognizing the need to incorporate HIV/AIDS prevention skills in training for U.N. peacekeeping personnel.

Policy papers continued to be issued during the first half of 2001 in anticipation of the U.N. General Assembly Special Session on HIV/AIDS, held June 25-27, 2001. In a February 2001 preparatory document, the UNHCR Executive Committee reviewed the impact of the HIV epidemic on refugee situations.(53) It concluded that:

"UNHCR owes it to the people of concern to the Office to give priority to HIV/AIDS prevention and care, so that the trauma of exile and displacement is not compounded by this terrible disease. The response, to be effective, can only come through partnership at all levels and through the full and active support of all concerned..."

In March 2001, UNAIDS drafted strategies to respond to the HIV epidemic in the context of peacekeeping operations.(54) In June 2001, a final statement of commitment was adopted at the U.N. General Assembly Special Session on HIV/AIDS.(55) This document specifically highlights HIV/AIDS in conflict-affected regions and pledges to:

"...implement national strategies that incorporate HIV/AIDS awareness, prevention, care and treatment elements into programmes or actions that respond to emergency situations, recognizing that populations destabilized by armed conflict, humanitarian emergencies and natural disasters, including refugees, internally displaced persons and in particular, women and children, are at increased risk of exposure to HIV infection; and, where appropriate, factor HIV/AIDS components into international assistance programmes;

...call on all United Nations agencies, regional and international organizations, as well as non-governmental organizations involved with the provision and delivery of international assistance to countries and regions affected by conflicts, humanitarian crises or natural disasters, to incorporate as a matter of urgency HIV/AIDS prevention, care and awareness elements into their plans and programmes and provide HIV/AIDS awareness and training to their personnel;

...address the spread of HIV among national uniformed services and consider ways of using personnel from these services who are educated and trained in HIV/AIDS awareness and prevention to assist with HIV/ AIDS awareness and prevention activities including participation in emergency, humanitarian, disaster relief and rehabilitation assistance;

...ensure the inclusion of HIV/AIDS awareness and training, including a gender component, into guidelines designed for use by defence personnel and other personnel involved in international peacekeeping operations while also continuing with ongoing education and prevention efforts, including pre-deployment orientation, for these personnel."

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Governments
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Most national government policies regarding refugees and HIV/AIDS relate to access to services and resettlement. As noted above, international policy documents declare the rights of refugees to health services on a par with nationals, as well as their right to nondiscrimination because of HIV status. Yet national policies and practices do not always support these rights for refugees. Most aid agencies that fund programming for refugees and other war-affected persons, however, do support activities addressing HIV/AIDS; these agencies include the Canadian International Development Agency (CIDA); European Community Humanitarian Aid Office (ECHO); U.S. Bureau of Population, Refugees and Migration (USBPRM); U.S. Office of Foreign Disaster Assistance (USOFDA); and U.K. Department for International Development (DFID). Some have also demonstrated their commitment by endorsing the InterAgency Field Manual on Reproductive Health in Refugee Situations.

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NGOs
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Major nongovernmental relief organizations began to prepare agency-wide HIV/AIDS policies upon recognition that the ad hoc nature of HIV/AIDS programming yielded inconsistent practice across country offices. One such organization is Médecins Sans Frontières (MSF), an international humanitarian aid organization that provides emergency medical assistance in over 80 countries. In 1996, MSF drafted an HIV/AIDS policy that was revised in late 1999 by the MSF Inter-sectional AIDS Working Group.(56) The MSF policy applies throughout the MSF network and includes the following tenets:

  • "Mandatory interventions in all MSF projects consist of rational use of blood transfusion, rational prescription of safe injections, respect of universal precautions, nondiscrimination.

  • Interventions in all general medical programmes include: prevention of HIV transmission through STIs management and health education; medical care for people living with HIV/AIDS; protection of people living with HIV/AIDS against any form of discrimination; and protection of people vulnerable to sexual violence.

  • Specific prevention programmes to prevent HIV transmission to include: health education towards high-risk groups or general population; programmes aiming at reducing maternal to child transmission; and harm reduction programmes. Specific care and support programmes for people living with HIV/AIDS to include comprehensive care across a continuum and ARV [anti-retroviral] treatment, where part of the national policy.

  • Specific lobbying and advocacy programmes: MSF advocate for no discrimination against people living with HIV/AIDS; for increased political commitment toward the HIV/AIDS epidemic and for available and accessible key drugs."

However, a September 2000 study of U.S.-based international nongovernmental organizations by the Women's Commission for Refugee Women and Children indicated that of 80 agencies surveyed, only eight had a reproductive health for refugees policy or guidelines.(57)

As noted, the issuance of a policy statement is one manifestation of the high-level commitment necessary to adequately address HIV/AIDS. There are two other actions essential to good programming that are required of leaders. One is to hold those whom the leaders support, either through funding or through position, accountable for implementing activities mandated by the policy. The second is the allocation of sufficient resources to mount an effective programmatic response.

Efforts to address HIV/AIDS among conflict-affected populations have been inconsistent and poorly resourced. Policies and guidelines are in place. Newer policies addressing recently acknowledged factors such as the potential role of peacekeepers in the spread of the disease are welcome. But the reality persists: as important as policy statements are, they are simply ink on paper until realized through effective programming.

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Programmatic Response to HIV/AIDS in Conflict Settings
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Comprehensive reproductive health care in conflict settings requires good quality services in four major technical areas: safe motherhood and emergency obstetric care; family planning; protection from and response to sexual and gender-based violence; and prevention and management of sexually transmitted infections and HIV/AIDS. Organizations typically address one or more of these technical areas in their reproductive health field programs, and efforts are often made to integrate services.

For example, HIV has been addressed by efforts to reduce sexual violence and promote gender equity during and after conflict. The vulnerability of refugee women and girls to rape and sexual exploitation as they attempt to meet their survival needs is well documented and increases their risk of exposure to HIV. An important development in improving services to refugees and IDPs was the Sphere Project, developed in the 1990s by a group of nongovernmental organizations to set minimum standards for addressing refugees' fundamental human right to security, shelter, food, water, and health services.(58) Attending to these basic needs helps stabilize refugee communities and can thereby reduce sexual and gender-based violence. Standards for reproductive health programs, including HIV/AIDS, for the emergency phase were added to Sphere in 2000 and are covered in the ongoing training that helps relief workers meet the standards.

Since 1989, several agencies, including UNHCR and the Women's Commission for Refugee Women and Children, have been addressing gender issues with particular attention to promoting the protection of refugee women and girls and their direct participation in humanitarian assistance. UNHCR's Guidelines on the Protection of Refugee Women(59) and Sexual Violence Against Refugees: Guidelines on Prevention and Response(60) and the field friendly synopses of those guidelines developed by the Women's Commission for Refugee Women and Children(61,62) are important resource materials to support the prevention of HIV/AIDS.

Field work to address STIs and HIV/AIDS often starts with community-based knowledge, attitude, and practice surveys followed by an intervention composed of community information, education, and communication, and condom distribution. Findings from several such projects were presented at the RHR Consortium's conference on the reproductive health of refugees and displaced populations held in December 2000 in Washington, D.C. For example, CARE Rwanda discussed a 1996-2000 HIV/STI prevention project implemented with peer educators and health animators that measured positive changes in Rwandan returnees' knowledge, attitudes, and practices about HIV/AIDS. The project resulted in significant increases in knowledge and use of STI services, including condom use. A major conclusion was that more funding was required to support the volunteer health animators, for whom the dropout rate was 20 percent.(63) The evidence from several projects reported at the conference also suggested that there are an insufficient number of projects in refugee settings focused on STI management and control, voluntary counseling and testing, and provision of comprehensive care for people living with HIV/AIDS.

Current humanitarian standards include a Minimum Initial Services Package (MISP) of reproductive health activities to be provided in emergencies.(64) These activities, designed to reduce reproductive health morbidity and mortality, must be put in place prior to any site-specific assessment in new refugee situations. MISP activities to reduce the transmission of HIV include:

  • identifying an individual and organizational responsible for ensuring that the MISP is implemented

  • ensuring a safe blood supply

  • implementing universal precautions for strict infection control

  • guaranteeing the availability of free condoms

  • addressing the prevention and management of sexual violence

  • planning for comprehensive reproductive health services, including a site-specific HIV/AIDS situation analysis

The selection of additional STI/HIV prevention and management activities for implementation after the emergency phase is determined by current knowledge of the efficacy, feasibility, and cost of interventions, as well as on data gathered in the situation analysis. This information would include prevalence of HIV in the host and refugee populations; type of setting (ie, camp, noncamp, or resettled area); degree of stability and security; and health, education, and social services available from all sources.

Programs established in stable refugee and IDP settings should address both prevention and care and will likely be similar to those found in more settled populations. They should be guided by the principles listed in Table 1. Additional strategies specific to reducing the transmission of HIV in the stable phase are found in Table 2. (Also see Table 3 for country examples.)

Notwithstanding some important progress, HIV/AIDS programming for refugees and internally displaced persons must be strengthened and accelerated. Leadership on this issue is critical. The September 2000 study conducted by the Women's Commission for Refugee Women and Children cited above indicated that among U.S.-based international NGOs providing or supporting refugee reproductive health services, only 22 percent were addressing HIV/AIDS programming.(65) Clearly, there is a need to increase advocacy efforts aimed at humanitarian agencies to encourage their support of HIV/AIDS programming.

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Discussion and Next Steps
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The spread of HIV/AIDS and STIs is a major concern in all populations throughout the world. Refugees and the displaced are of particular concern, however, because the social, economic, psychological, and infrastructure devastation that occurs during and after conflict exacerbates the risk of transmission to all segments of the populations involved, and renders response more difficult. The available data are sufficient to support the findings that the spread of STIs and HIV/AIDS is worsened in forced migration populations and that focused attention is warranted. However, data on prevalence, transmission, and program effectiveness specific to particular sites or populations are still lacking.

Substantial progress in policy formulation and in program advancement has been made in the seven years since reproductive health was recognized as a missing component of services offered to refugees. Many--though by no means all--multilateral, national, and nongovernmental bodies have issued policy statements that recognize the importance of reproductive health services, and HIV/AIDS prevention and care services in particular, for refugees, as well as the obligation to provide them. The policies, however, are too often stronger on paper than in practice. The next step--incorporating the policies into the institutional culture of the organizations so that addressing STIs and HIV/AIDS becomes part of standard operations--is the current challenge.

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Notes
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a. All statistics and definitions taken from: United States Committee for Refugees. World Refugee Survey 2000. Washington, D.C.: December 1999.

b. Now the Global Health Council.

c. Reproductive Health for Refugees Consortium members: American Refugee Committee, CARE International, Columbia University's Heilbrunn Center for Population and Family Health, International Rescue Committee, JSI Research and Training Institute, Marie Stopes International, and Women's Commission for Refugee Women and Children

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