HIV and Conflict-affected HIV and Conflict-affected Populations: Populations:

Overview and the ChallengesOverview and the Challenges

Paul Spiegel MD,MPH

United Nations High Commissioner

for Refugees

OverviewOverview

1. Definitions

2. Numbers

3. Key players

4. Epidemiology

5. Key Guidelines and policy documents

6. Challenges

7. Constraints

DefinitionsDefinitions

Complex Emergency

• Humanitarian crisis in country, region or society with total or considerable breakdown of authority resulting from internal or external conflict that requires int. response which goes beyond mandate or capacity of single agency and/or ongoing UN country programs IASC, December 1994

• Acute situations affecting large civilian populations, usually involving combination of war or civil strife, food shortages, and population displacement, resulting in significant excess mortality CDC MMWR, 1992

Definitions contDefinitions contRefugee • Any person who owing to well-founded fear of being

persecuted for reasons of race, religion, nationality, membership of particular social group or political opinion is outside the country of his nationality.…

Refugee convention, 1951

Internally Displaced Person (IDP): • Persons who flee their homes for similar reasons as

refugees but who remain inside their own countries

Displaced Persons (DPs) • Refugees and/or IDPs

Displacement CycleDisplacement Cycle

NumbersNumbers

Conflict-affected, 2005• Refugees (13.4 m; 9.2m UNHCR, 4.2 m UNRWA)• IDPs (25 m)• 50% under 18 yrsSource: UNHCR and UNRWA, 2006

• ? X m affected by conflict but no displaced

Disaster-affected, 2005• 157 m affected (floods, droughts)• 245,000 deaths (90% tsunami)Source: EM-DAT, CRED, 2006

Key PlayersKey Players

1. DPs

2. Surr. host population

3. Host government

4. Non-governmental organisations (NGOs)

5. UN agencies

6. Other international org.

7. Military

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.

HIV and Conflict Epidemiology: HIV and Conflict Epidemiology: Overlap between HIV and ConflictOverlap between HIV and Conflict

HIV Prevalence by Asylum Country HIV Prevalence by Asylum Country and Country of Origin by Regionand Country of Origin by Region

0

1

2

3

4

5

6

7

HIV

pre

vale

nce

*

Africa (N=29) Asia (N=17)

Region**

Country of Asylum

Country of Origin

* Weighted means: country of asylum by population size, country of origin by refugee population size

** N refers to countries of asylum with >10,000 refugees

• Reduction in mobility• Reduction in accessibility• Slowing down of

urbanisation• Increase in resources and

services in host country

HIV Risk Factors for HIV Risk Factors for Conflict-Affected PopulationsConflict-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)

• Phase of emergency• Length of time: conflict, existence of camp

Increased Risk Decreased 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.

The Sphere Project,1997The Sphere Project,1997

• Humanitarian Charter • Universal minimum

standards in core areas

Aim:

• Quality of assistance

• Accountability

• HIV is cross-cutting issue

HIV Interventions in EmergenciesHIV Interventions in Emergencies

• Guidelines for HIV/AIDS Interventions in Emergency Settings, IASC, 2003

• Matrix in 3 phases – Emergency Preparedness– Minimum Response (to be

conducted even in emerg.)– Comprehensive Response

(Stabilised Phase)

By sector

Post-emergency, 2005Post-emergency, 2005

1. Integrate refugee issues into national HIV programs and policies

2. Implement sub regional (cross-border) initiatives

3. Combine humanitarian and development funding

Challenge #1: Challenge #1: Inclusion of DPs into Inclusion of DPs into Country Policies and InterventionsCountry Policies and Interventions

^ NSP- National HIV Strategic Plans; * countries in Africa in 2004 with >10,000 refugees

un-known

21% n=6

Yes79% n=23

Existence of NSP^(N=29)*

Yes65%n=15

No35% n=8

NSP Mentions Refugees (N=23)

NSP State Activities For Refugees (N=23)

Yes43% n=10

No57% n=13

Challenge #2: Challenge #2: Integrating HIV and ProtectionIntegrating HIV and Protection

• HIV status has no influence on :– Access to asylum

– Refoulement

– Right of return

• Improved mechanisms to ensure confidentiality

• HIV prevention and care integrated into voluntary repatriation operations

• Ensuring resettlement countries improving counselling and testing procedures

Challenge #3:Challenge #3:Subregional ApproachSubregional Approach

• Provide access to prevention and care for

mobile populations including DPs

• Ensure continuity of care

• Improve efficiency and lower costs

• Leverage additional funding

Other Major Lessons Learned Other Major Lessons Learned and Challengesand Challenges

• Coordination at global, regional, country

and site levels

• Provision of antiretroviral therapy

Also relates to funding mechanisms

• Gathering reliable data

• Operational research

Some ConstraintsSome Constraints

• Staffing

• Short-term view

• Technical expertise

• Funding

• Competing interests

More information: www.unhcr.org/hiv-aids