Treatment and Prevention of HIV and TB Disease in Emergency

Situations Introduction

Rafik Hanna, MDSt. Luke’s Roosevelt Hospital Center

Global Health Fellowship Lecture Series

Refugees and IDPs

• A refugee, according to UNHCR is someone who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country."

• The Internal Displacement Monitoring Center defines internally displaced persons as "persons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border."

UNHCR

• The Office of the United Nations High Commission for Refugees was established in December of 1950 by the UN General Assembly.

• The agency has a mandate to lead and co-ordinate international action to protect refugees and resolve refugee problems worldwide.

• Its primary purpose is to safeguard the rights and well-being of refugees.

*UNHCR.org

UNHCR Statistics

• UNHCR estimates a total of about 43 million people have been displaced by conflict or persecution.

• At the beginning of 2011, 10.4 million refugees were of concern of UNHCR. More than 50% are in Asia and approximately 20% are in Africa.

(http://www.unhcr.org/pages/49c3646c1d.html)

• Approximately 27 million of the 43 million people are IDPs. Slightly less than 50% of these are in Africa.

• A 2006 estimate reveals that approximately 1.8 million people with HIV were also affected by conflict.

(Overseas Development Institute – 3/2009)

Marginalization

• Refugees and displaced persons are as a group frequently marginalized and discriminated against.

• Some of the more vulnerable groups may include women, children, the elderly, and the disabled. These may also include religious, ethnic, and political minorities.

HIV

• HIV patients are also a group of people who are frequently stigmatized.

• As a result, HIV seropositivity may pose a serious problem with regard to human rights.

• As poor sanitary conditions usually already exist in the refugee and IDP context, the protection of HIV positive individuals will often become necessary.

HIV

• No study has ever shown that displaced persons have either a higher or lower risk of contracting HIV.

• Even though the risks are not higher, given the uniqueness and special needs of HIV patients, all efforts should be undertaken to insure treatment of patients and contain further transmission of the disease.

Constraints

• Malnutrition and other acute infectious diseases.• Breakdown of normal systems of screening and

universal precautions.• Social, political, and cultural disruption.• Difficulties for planning longterm programs.• In light of these issues and the uniqueness of

HIV needs, the matter will deserve special attention.

Ethical Considerations

• Since displaced persons are often held in suspicion in regard to health issues, particularly in regard to communicable diseases, they may be suspected of introducing epidemics into a host country, or destabilizing an already precarious situation, or of receiving better assistance than the local population.

• They may be then suspected as a source by the local community, with manipulation of health data and using it against them politically.

Further Constraints and Ethical Considerations: HIV AND IDPs

UNAIDS, UNHCR and WHO POLICY BRIEF• Moving populations• Providing outreach: some IDPs may not want to reveal their HIV status for

fear of retaliation or discrimination. This factor, combined with other protection issues, makes outreach difficult.

• Accessing services: in some areas, access will be limited due to increased insecurity, restrictions due to lack of identity cards or requirement for payment of services.

• Deteriorating Community and Health infrastructure• Estimating the size and location of the displaced

population in order to develop important indicators such as rates, service coverage and accessibility to services.

• Developing technical capacity and specific expertise on HIV in emergency and humanitarian settings.

• Monitoring and evaluating the impact of HIV interventions.

Ethical Considerations

• Given the usual unstable situation of displaced persons and the aforementioned issues related to HIV, it is then imperative to focus on HIV prevention and treatment among refugees and IDPs to also affect its prevention and treatment in the host countries.

• Approximately 30% of all displaced persons live in Africa, which has by far the highest rate of HIV.

Ethical Considerations

• Strict confidentiality, especially given crowded conditions and lack of privacy.

• HIV testing for individual diagnosis should be avoided unless the patient is properly informed and has given consent, strict confidentiality is guaranteed, and comprehensive management of the patient is insured, with constant access to healthcare.

• Ordinary mass screening should be avoided.• Safety of blood products is crucial.

HIV behavioural surveillance among refugees and surrounding host communities

in Uganda, 2006

• “The high mobility and frequent interactions of these two populations suggest that integrated HIV programs should be developed and would be an efficient use of resources.”

• “Female refugees may be at elevated risk for HIV infection, due to forced sex, transactional sex and other vulnerabilities.”

*Harrison, Kathleen McDavid et al. HIV behavioural surveillance among refugees and surrounding hostcommunities in Uganda, 2006. African Journal of AIDS Research 2009, 8(1): 29–41.

Forced Sex and HIV Prevalence in Conflict

• Rape increases the risk of an individual woman contracting HIV.

• There is insufficient evidence that displacement and wide-scale rape increased HIV prevalence across an entire population. (Spiegel, PB. Prevalence of HIV infection in confl ict-aff ected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007; 369: 2187–95; similar findings in Haiti.)

UNAIDS, UNHCR and WHO Government Recommendations for IDPs and HIV

• Incorporate IDPs into national HIV policies, strategic plans and proposals and ensure they have equal access as nationals and other persons in the country to HIV services.

• Ensure that HIV is integrated into emergency preparedness and contingency planning.• Ensure policies and programs are designed, implemented, monitored and evaluated

with the participation of internally displaced persons.• Ensure that appropriate laws, policies and programs, including those related to HIV, are

adopted towards the full realization of the rights of all IDPs.• Ensure HIV programs are rights and evidence-based tailored to the epidemiological

context.• Integrate HIV into assessments done among internally displaced persons across key

sectors such as health, protection, nutrition, food and education.• Ensure internally displaced children and young people have full access to information

on HIV as part of the education curriculum as well as in the informal educational sector.• Provide culturally and linguistically appropriate HIV prevention, treatment, care and

support programs that are adapted to the needs of IDPs.• Implement information and education programs that aim to dispel misconceptions and

counter discrimination and social exclusion of IDPs and people living with HIV among IDPs.

*11/19/2010 policy brief.

UNAIDS, UNHCR and WHO Recommendations for Civil Society

Regarding IDPs and HIV• Provide culturally and linguistically appropriate

HIV prevention, treatment, care and support programs that are adapted to the needs of internally displaced persons.

• Implement information and education programs that aim to dispel misconceptions and counter discrimination and social exclusion of internally displaced persons and people living with HIV among internally displaced persons.

*11/19/2010 policy brief

UNAIDS, UNHCR and WHO Recommendations for International Donors,

NGOs Regarding IDPs and HIV• Integrate and include responses to the HIV needs of IDPs in

humanitarian action plans as well as emergency preparedness and contingency planning.

• Advocate with governments and donors to ensure IDPs are included in national HIV strategic plans, HIV policies and HIV funding proposals.

• Fund and help implement HIV prevention, treatment, care and support services for IDPs.

• Ensure that HIV policies and interventions are mainstreamed into: conflict-prevention activities, peacekeeping operations, disaster preparedness plans, humanitarian responses to crises across all of the humanitarian clusters, post-conflict and post-disaster reconstruction planning, implementation, monitoring and evaluation.

*11/19/2010 policy brief.

UNAIDS, UNHCR and WHO Recommendations for International Donors,

NGOs Regarding IDPs and HIV• Advocate for flexibility in HIV and humanitarian funding

approaches for the HIV needs of IDPs.• Work in partnership with governments and civil society to

respond to the changing needs of IDPs as they move through the phases of displacement and recovery.

• Support strong coordination and communication with government and civil society to ensure HIV-related services are available to IDPs until a durable solution is established.

• Improve implementation of humanitarian coordination through better linkages between existing coordination mechanisms.

*11/19/2010 policy brief

UNHCR HIV/AIDS Strategic Objectives

• Protection• Coordination and Integration• Prevention• Care, Support, and Treatment• Durable Solutions• Capacity Building• Assessments, Surveillance, Monitoring and

Evaluation, and Operational Research.

Myths

• Conflict always increases HIV• Displaced persons engage in high-risk behavior.• High mobility among displaced persons prohibit

good adherence.• Providing care will bring on a flood across the

border.• Displaced persons never have support

structures.• Conflict is limited to a short period.

Key Considerations Governing the Provision and Use of ARVs in UNHCR Operations

• Refugees often live for years in relatively stable settings in their host country. By the end of 2003, refugee populations remained in their host country for an average of 17 years.

• A minority of refugees in numerous countries are already finding their own innovative ways to begin ARVs.

• The increase of ARV resistance by stopping and then re-starting the therapy in a controlled fashion is not considered to be more of a risk for populations that have been displaced by conflict than other populations. The largest threat to developing ARV resistance remains persons taking ARVs in an incorrect manner; this threat is no larger for forcibly displaced populations than other populations (?)

Principles Governing the Provision and Use of ARVs in UNHCR Operations

• Planning for and including HIV in the earliest possible stages of an emergency response is necessary.

• Continuity of ART.• Refugees should receive equivalent services as those

available in the surrounding community.• Interventions are to be initiated only where and once the

minimum criteria to implement such activities are met.• Diagnostic and treatment protocols should follow those

of the host community unless they are ineffective.• Sustainability of ART (minimum of one year).• “Pilot” programs should be implemented in line with

national policies.

WHO Guidelines from the Interagency Standing Committee

ODI: Collaboration between faith-based communities and humanitarian actors when

responding to HIV in emergencies• Faith-based communities provide 40-50% of

healthcare in developing countries. • Their role is often underutilized because other

humanitarian organizations may not value their role, often out of fears related to ideology (warranted or not) or possible misconceptions about that.

• Some have noted that faith-based health providers may supply better services than government facilities (Global Health Council 2005) - http://reliefweb.int/sites/reliefweb.int/files/resources/52AFFEC58662EDD249257730001B6656-Full_Report.pdf

ODI: Collaboration between faith-based communities and humanitarian actors when

responding to HIV in emergencies• Collaboration between ODI, World Vision, and

Tearfund in 2009• Possible advantages of church involvement: can

provide treatment for marginalized communities; can maintain treatment during times of insecurity; can be a place of physical and spiritual refuge because they are often trusted more than governments.

• Possible disadvantages include: some misinformation about HIV; occasional pastors tell patients to stop their ARVs; interdenominational competition.

ODI: Collaboration between faith-based communities and humanitarian actors when

responding to HIV in emergencies• Even though few FBCs had sufficient preparedness for

HIV response during emergencies, the church’s role has often been critical particularly in being able to rapidly mobilize short-term funds through networks.

• Churches have often provided shelter during emergencies, such as in Kenya and have often played important roles in registering people.

• Mission clinics and hospitals can stay open and increased their capacities at times when government facilities shut down.

• FBCs are often flexible and resources were transferred to priority areas including rape response and HIV testing.

• “The study shows the continuous presence of churches during conflict builds trust amongst local communities.”

ODI: Collaboration between faith-based communities and humanitarian actors when

responding to HIV in emergencies Recommendations

• Provide training for FBCs to include HIV emergency preparedness and disaster risk reduction intiatives.

• Mobilize the Church to address the stigma and detrimental cultural practices associated with HIV.

• Scale-up intiatives for children and youth.• Mobilize FBCs to tackle gender-based sexual

violence.• Invest in faith-based youth teams and community

outreach.• Strengthen inter-denominational bodies.

Next Lectures

• More focus on specifics of HIV treatment amongst refugees/IDPs.

• Similar focus on TB.