Susan Temporado Cookson, MD, MPH In ternational Emergency & Refugee Health Branch

HIV Infection among Refugees: Myths and Findings

HIV Center for Clinical and Behavioral StudiesNY State Psychiatric Institute and Columbia University

December 10, 2009

Susan Temporado Cookson, MD, MPHInternational Emergency & Refugee Health BranchCenters for Disease Control and Prevention

OverviewDefinitionsEmergenciesRefugees and internally displaced personsRisk factors impacting these populationsBig 4 communicable diseasesHIVMyths, findings, and realitiesPrinciples of HIV control among refugee and internally displaced populations

Definitions of Emergencies

Emergency: unforeseen crisis requiring immediate response

Natural disaster: vast ecological breakdown between humans and their environment; such a serious or sudden event that the community needs extraordinary efforts to cope, often with outside help or international aid

Complex humanitarian emergency (CHE): large-scale human displacement with living condition deterioration caused by physical conflict, often with attempt to restructure society (e.g., genocide), leading to significant increase in mortality for limited time, but sometimes longerIndicator = 1 death /10,000 population / day

Definitions of Refugees and Internally Displaced Persons (IDPs)Both populationsVictims of conflict and violenceFled their homesFear of or persecutionRace, religion, nationality, member of social group, political opinion, genderRefugees onlyFled outside home countryUnable/unwilling to return home

Population Movements in Conflicts of Refugees and Internally Displaced Persons (IDPs)

Conflict- affected population

Refugees

Internationally Border

IDPs

Host community

Repatriate

Return

Interactions with other groups: - Armed forces/peacekeepers - Sex workers

Host community

Communicable Diseases Risk Factors among Refugees and Displaced PersonsMass population movementOngoing conflict/insecurityGender-based violenceTemporary/absence of shelterPoor nutrition/scarcity of foodPoor healthcare access/collapse of healthcareLack of medications/treatmentLack of prevention/control programsOf supplies, such as condoms or vaccinationOf programs, such as TB or HIV control

Source: Connolly MA, et al. Lancet, 2004Serbians fleeing

Communicable Diseases among Refugee and Displaced PersonsBig 4 causes of morbidity and mortalityAcute respiratory infectionsDiarrheal diseasesMeaslesMalariaMalnutritionHIV/AIDS have increasing importanceBut not top priority in emergencyPotential regional effectsDisease prevalence, including HIV

Micronutrient Deficiency and HIV CycleIncreased HIV replicationDisease progressionIncreased morbidity/mortalityMicronutrient deficienciesIncreased oxidative stressImmune suppressionInsufficient dietary intakeMalabsorption and diarrheaAltered metabolism and impaired nutrient storageModified from Semba RD and Tang AM. Brit J Nutrition, 1999Vicious Cycle of Micronutrient Deficiencies and HIV

Reasons HIV Not Top Priority in EmergenciesPerceived as development issueConcerned of discrimination against HIV-infected refugeesBasic survival: shelter, food, water, sanitationHealth actions focused on Big 4 and malnutritionEssential primary clinic services/medications

Refugees and Internally Displaced Persons, 31/12/08Total=24.9 millionInternally displaced14,405,405 Refugees10,478,621

Source: UN Refugee Agency. 2008 Global Trends. Available at: http://www.unhcr.org

Myths or Realities?Conflicts increase HIV transmission

Refugees bring HIV to the country of asylum

IDPs and refugees have the same HIV risks and prevalence rates

Effects of Conflict and Sexual Violence on HIV Transmission and Visa VersaDifficult to discernWide variety of issues involvedData can have varied quality and focus, be biasedData on prevalence on HIV and sexual violence among affected-populations scarce

1. Do conflicts increase HIV transmission?

Overlap between countries affected by conflicts and high HIV prevalenceSources: Mock NB, et al. Emerg Themes Epidemiol, 2004UNAIDS. 2008 Report on the global AIDS epidemicEpidemiology of Conflicts and HIV HIV Prevalence in Africa, 2007

, 2004

Level of Conflicts and HIV Prevalence 1991-2000Among 37 sub-Saharan African countriesArmed conflict scores vary from 0, no conflict, to 28 and 29 for Sudan and Angola, respectively15 countries with no conflict, including Botswana, Central African RepublicHIV prevalence=18.6%13 countries with armed conflict score=1-9, including Cameroon, SenegalHIV prevalence=8.3%9 countries with armed conflict score>10, including Burundi, DRC, SomaliaHIV prevalence=7.8%Source: Strand R, et al. Int J STD & AIDS, 2007

Strand R, et al. Int J STD&AIDS, 2007Spearman rank correlation, =-0.41, p=0.012

Why do conflicts seem to delay HIV epidemic?Two stages of conflictConflictSurvivalAccess Post-conflictServices and employment Access

Conflict StageSurvival of HIV-infected personsDifferential mortality among high-risk populationsIn addition, poor nutrition and lack of servicesIsolationDestroyed transport, unsafe travel, disrupted commerceLevel of sexual activityMarked reductionKABP among Rwandan refugees, Tanzania 1994Decreased libidoDepression and post-traumatic stress symptoms

Source: Mayaud. Trans Roy Soc Trop Med & Hyg, 2001

Post-conflict StageIncreased HIV incidence , post-conflictMaputo, Angola (9.9% in 1998, 13.2% in 2000, 20% in 2004)Service may be slowQuality of medical servicesSupplies, equipment/vaccines, and medications Universal precautions, safe medical equipment and blood may lagLevel and type of employmentDemobilization of forces and female head of householdsAccessUrbanization and increased level of sexual activity

Source: UNAIDS/WHO. AIDS epidemic update. Geneva: UNAIDS/WHO, 2004

2. Do refugees bring HIV to the country of asylum?

HIV/AIDS: Epidemiology among Refugees* Weighted means: country of asylum by population size, country of origin by refugee population size

Source: Spiegel PB. Disasters, 2004 HIV prevalence among refugees appear lower than host population Country of origin compared with country of asylum

HIV Prevalence Data among RefugeesSurveillance during conflict impracticalSurrogate dataAdults: chronic diarrhea, fever of unknown origin, recurrent pneumonia, STIs, TB, wastingChildren: chronic diarrhea, developmental delays, failure to thrive, recurrent bacterial infectionsDirect HIV testing resultsBlood supply: no systematic surveillanceAntenatal care centers

UN Refugee Agency Health Information System (HIS)In 1999, began developmentIn 2006, 16 countries with stable refugee campsData collected: Blood supply activities: no results

VCT (PICT), PMTCT, And ART program activitiesEvaluation in Sept-Nov 2008: Issue with data quality

Source: UNHCR. Health Information System (HIS) toolkit Available at: http://www.unhcr.org/4a3374408.html

Assess HIV Prevalence Rates, AfricaMethodAnonymous, unlinked, cross-sectional surveys (UAT)Attendees public antenatal clinics, including in refugee campsFirst timeBlood for syphilis testingOften no informed consentConcerns of selection/participant biasDe-identified, except for Age, parity, marital status , educational level , and clinic location (or urban versus rural)In refugee camps: refugee versus host statusRapid, diagnostic tests and/or dried blood spots

Reliability of HIV Testing: Rapid Tests vs. EIAGray RH, et al. BMJ, 2007, in Rakai, Uganda: 43.7% (129/295) false positive results0.3% (4/1,222) false negative resultsUNHCR, 2006/07, Kenya

PMTCT rapid testsEIA at National Public Health LabHIV positiveHIV negativeTotalDadaab refugee camp, Aug-JanRapid test algorithm positive101Rapid test algorithm negative910321041Total 1010321042sensitivity=10%; specificity=100%; PPV=100%; NPV=99.1%Kakuma refugee camp, Kenya, Sept-JanRapid test algorithm positive71320Rapid test algorithm negative911361145Total 1611491165sensitivity=43.8%; specificity=98.9%; PPV=35%; NPV= 99.2%

RefugeesPrevalence (95% CI*)YearHost populationPrevalence (95% CI)YearSomalis in Dadaab camp, Kenya0.6% (0.01-1.1)2003Garissa, Kenya26.0%20021.4% (0.5-2.2)200511.0%20041.0% (0.6-1.6)2006/7Sudanese in Kakuma camp, Kenya5.0% (3.5-7.0)2002Lodwar, Kenya18.0%20021.2% (0.6-2.1)2006/7Immediately surrounding3.6% (1.9-6.0)2006/7Sudanese in Palorinya settlement, Uganda1.0% (0.3-1.8)2004Immediately surrounding5.9% (1.7-10.1)20045.4% (3.6-7.2)2005Immediately surrounding6.9% (3.9-13.4)2005Sudanese in Kyangwali settlement, Uganda2.7% (1.3-4.0)2004Immediately surrounding2.8% (1.0-6.6)2004Hoima, Uganda4.6%2004Burundis in Lukole camps, Tanzania3.1%2002Kagera region, Tanzania3.7%20031.6%2003Burundis in Mtabila and Muyovosi camps, Tanzania4.5%2003Kigoma region, Tanzania2.0%2003DRC refugees in Lugufu and Nyaragusu camps, Tanzania2.5%20021.8%2003Kagera region, Tanzania3.7%2003DRC refugees in Gihembe camps, Rwanda1.5% (0.4-3.8)2002Byumba, Rwanda6.7% (4.7-9.4)2002

Refugee vs. Host Populations HIV PrevalenceSpiegel PB, et al. Lancet, 2007 plus newer data (2006/07)Data

3. Do IDPs and refugees have the same HIV risks and prevalence rates?

Additional Differences between Refugees and Internally Displaced Persons (IDPS)Level of interface withMilitary and peacekeeping forces, and humanitarian aid workersProtection1951 Refugee Convention1967 ProtocolServicesImplementing partners vs. host population

HIV Prevalence Studies on Internally Displaced WomenLuanda, Angola, 2000, at antenatal care and family planning clinics1.8% HIV-infected among 1,035This prevalence rate lower than most urban settings in Africa and Angola52.6% of infected vs. 36.8% infected women engaged in business (NS)Usually street vendors

Source: Strand R, et al. Int J STD & AIDS, 2007

Internally Displaced (IDWs) vs. Surrounding Population Women Congo River area, DRC, 2005, in household survey 7.6% (95% CI 4.1, 11.0) vs. 3.1% (CI 2.1, 4.1) HIV prevalenceFewer married (84.7% vs. 95.4%, NS), lived without partners (13.9% vs. 6.2% , p

North Uganda , 2005, at antenatal clinic for protected camp vs. surrounding population6.0% vs. 11.6%, p

Context means everythingAngola: IDWs very low HIV prevalenceDRC: IDWs with higher HIV prevalence vs. surrounding womenGreater history sexual violence and STIsNorth Uganda: IDWs with lower HIV prevalence vs. surrounding womenProtected campsGreater risk associated with usual factors

IDWs, Surrounding Population, or Refugee Women

HIV: Key Risk Factors among Refugees HIV prevalence of country of originHIV prevalence of surrounding host population Level of interaction between two populationsType and location of refugeesPhase of emergency (conflict, post-conflict, development)Length of time: conflict, camp and services Key FactorsModified from Spiegel PB. Disasters 2004

HIV: Factors Increasing Refugees RiskBehavioural changesGender-based violence/ transactional sexReduced services (health and community services, protection, food)Reduced education Increased RiskHIV prevalence of country of originHIV prevalence of surrounding host population Level of interaction between two populationsType and location of refugeesPhase of emergency (conflict, post-conflict, development)Length of time: conflict, camp, and services Key Factors

HIV: Factors Decreasing Refugees RiskDecreased mobilityReduced accessibilitySlowing down of urbanizationIncreased services and resources in host countryDecreased survival of sick persons Increased Risk Key FactorsDecreased RiskBehavioural changesGender-based violence/ transactional sexReduced services

Reduced education HIV prevalence of country of originHIV prevalence of surrounding host population Level of interaction between two populationsType and location of refugeesPhase of emergency (conflict, post-conflict, development)Length of time: conflict, camp, and services

HIV in Emergencies: Prevention and ControlProvide early interventions to prevent spreadUse Minimum Initial Service Package (MISP)Coordinate and implement MISPPrevent sexual violenceReduce HIV transmissionPrevent excess maternal and neonatal mortality and morbidityPlan for comprehensive reproductive health servicesPromote ABC, especially CAvailable at: http://misp.rhrc.org

HIV in Emergencies: Additional Prevention and Control

Additionally protect vulnerable sub-populationsLayout camp conducive to protectionDistribute of essential items: Easy access to cooking fuelTreat sexual transmitted infections (STIs)Interaction with STIs, especially ulcerativeUse HIV and STI emergency guidelines TB and HIV requires integrated programs

GUIDELINESfor HIV/AIDS interventions in emergency settingsThe sectors are:CoordinationAssessment and monitoringProtectionWater and sanitationFood security and nutritionShelter and site planningHealthEducationBehavior communicationchange (BCC)HIV/AIDS in the workplace

Available at: http://www.unfpa.org/upload/lib_pub_file/249_filename_guidelines-hiv-emer.pdf

Overall HIV Planning for Conflicts Prevention and ControlInclude HIV/AIDS in humanitarian action plansEstablish coordination mechanismCollect baseline data, analyze and monitor situationPrevent and respond to sexual violence and exploitationProvide education material and condoms to population and aid workersEnsure universal precautions and safe blood supplyIntegrate programming with water/sanitation, nutrition, reproductive health, TB

Post-Conflict StageIntegrate refugee issues into national HIV programs and policiesImplement sub-regional HIV initiativesCombine humanitarian and development funding

National HIV Strategic Plans (NSP), 2004 in African Asylum Countries** with >10,000 refugees in 2004

Source: Spiegel PB, et al. Int Conf AIDS, 2004, Jul 11-16, 15, abstract D12361 with modificationAvail able NSP(N=29) NSP mentioned refugees (N=23)NSP stated activities for refugees (N=23)Unknown21% (6)

Yes 79% (23)

No35% (8)

Yes65% (15)

No57% (13)

Yes43% (10)

Reports approved

26

3

yes90% (n=26)

no10% (n=3)

Data 8-9-04

National Strategic Plan on HIV/AIDSGlobal Fund for HIV/AIDS, Tuberculosis and MalariaWorld Bank-MAP

CountryPlan exists 1=yes; 2= no; 3=unknownPlan incl. ref to refugees 1=yes; 2=no; 3=not applicablespecific activites 1=yes; 2=no; 3=N/AApproved 1=yes; 2= noRoundPlan incl. ref to refugees 1=yes; 2=no; 3=N/Aspecific activites 1=yes; 2=no; 3=N/AApproved 1=yes; 2= noPlan incl. ref to refugees 1=yes; 2=no; 3=N/Aspecific activites 1=yes; 2=no; 3=N/ACountryNSP SourcesNAP SourceWB Source

Algeria3331Round 3222Angola"Plano Estrategico Nacional para as Doenas Sexualmente Transmissiveis, VIH e SIDA em Angola (2000-2002)"

Angola1221Round 4112Burundi"Consultation Thematique--Plan d' Action National de Lutte Contre le VIH/SIDA 2002-2006"

Burundi1111Round 112111CameroonPlan Strategique de Lutte Contre le SIDA au Cameroun, 2000-2005 (Document Provisoire, 31 Aout 2000)

Cameroon1221Round 3 and Round 42212Central African RepublicPlan Cadre Strategique de Lutte Contre le SIDA de la Republique

Central African Republic1111Round 2 and Round 42212don't have NSPChadPlan d'Action du Groupe Thematique du Systeme des nations Unies sur le VIH/SIDA/MST au Tchad 1999-2001

Chad1221Round 31112pdf couldn't scan text, eye scan insteadCongoCadre Strategique de Lutte contre le VIH/SIDA/IST en Republique du Congo 2003-2007

Congo-B11123312Cote d'IvoirePlan Strategique National de Lutte Contre le VIH/SIDA 2002-2004

Cote d'Ivoire1121Round 2 and Round 3 (only round 3 covers refugees)112Democratic Republic of CongoPlan Directeur 2002-2004 Republique Democratique du Congo, Ministere de la Sante, Programme National de Lutte contre le SIDA (PNLS)

Democratic Republic of Congo1121Round 312111Djibouti

Djibouti3331Round 4122Egypt

Egypt3332332EthiopiaStrategic Framework for the National Response to HIV/AIDS in Ethiopia (2001-2005) June 2001

Ethiopia1111Round 2 and Round 422111Gabon

Gabon3331Round 3222Gambia

Gambia3331Round 322111Ghana

Ghana1221Round 12212GuineaCadre Strategique national de Lutte Contre les IST/VIH/SIDA en Guinee 2003-2007

Guinea1111Round 212112KenyaThe Kenya National HIV/AIDS Strategic Plan 2000-2005 Popular Version National AIDS Control Council, October 2000 (hard copy)

Kenya1221Round 1 and Round 22212Liberia

Liberia1121Round 2222Libyan Arab Jamahiriya

Libyan Arab Jamahiriya2322332NamibiaThe National Strategic Plan on HIV/AIDS (Medium Term Plan II) 1999-2004

Namibia1111Round 2112Namibia NSP y--but only refers to "displaced populations" not refugees put in annex later.RwandaNo title page, National Strategic Plan of Rwanda 2002-2006

Rwanda1111Round 1 and Round 3 (reference to ref's only in round 1)22111Senegal

Senegal1121Round 122111Sierra Leone

Sierra Leone1221Round 411111South AfricaHIV/AIDS & STI Strategic Plan for South Africa 2000-2005

South Africa1221Rounds 1, 2 and 3222SudanThe National Strategic Plan for the Prevention and Control of HIV/AIDS in the Sudan 2003-2007, prepared Jan 2003

Sudan1121Round 3 and Round 4122Togo

Togo1221Round 2, Round 4222Uganda"the national Strategic Framework for HIV/AIDS Activities in Uganda 2000/1-2005/6, prepared March 2000

Uganda1111Rounds 1, and 3 (round 3 no mention of ref's)1112United Republic of Tanzaniaational Multi-Sectoral Strategy on HIV/AIDS 2003-2007

United Republic of Tanzania1111Round 1 and Zanzibar Round 2, Round 3, Round 42212ZambiaHIV/AIDS/STD/TB Strategic Framework 2001-2003--Summary, October 2000

Zambia1111Round 1 Funding for 4 different groups, Round 4 - ART funding22111

NATIONAL STRATEGIC PLANS

have a planrefs mentionact f/ refs

Answer2923232929179

YES231510261161798

NO6813315201281

Unknown or Not Applicable03301220

Refugees mentioned

0.4230769231

0.5769230769

yes42% (n=11)

no58% (n-15)

Refugee activities incl.

0.2307692308

0.7692307692

yes23% (n=6)

no77% (n=20)

Chart3

23

6

Summary data 12-12-04

NSP# of countries%ageNSPs incl refs%ageRef activities described%age

292323

yes2379%1565%1043%

no621%835%1357%

unknown0%00%00%

GFATM# of countries%ageGFATMs incl refs%ageRef activities described%age

3rd Rd292626

yes2690%1142%623%

no310%1558%2077%

unknown00%00%00%

MAP# of countries%ageMAPS incl refs%ageRef activities described%age

Feb '0429179

yes1759%953%889%

no1241%847%111%

unknown00%1271%2069%

Reports approved

26

3

yes90% (n=26)

no10% (n=3)

Data 8-9-04


































Answer2923232929179

YES231510261161798

NO6813315201281


Refugees mentioned

0.4230769231

0.5769230769

yes42% (n=11)

no58% (n-15)


0.2307692308

0.7692307692

yes23% (n=6)

no77% (n=20)

Chart3

23

6

Yes79% (n=23)

No21% (n=6)

Chart4

15

8



292323

yes2379%1565%1043%

no621%835%1357%

unknown0%00%00%


3rd Rd292626

yes2690%1142%623%

no310%1558%2077%

unknown00%00%00%


Feb '0429179

yes1759%953%889%

no1241%847%111%

unknown00%1271%2069%

Reports approved

26

3

yes90% (n=26)

no10% (n=3)

Data 8-9-04


































Answer2923232929179

YES231510261161798

NO6813315201281


Refugees mentioned

0.4230769231

0.5769230769

yes42% (n=11)

no58% (n-15)


0.2307692308

0.7692307692

yes23% (n=6)

no77% (n=20)

Chart3

23

6

Yes79% (n=23)

No21% (n=6)

Chart4

15

8

Yes65%(n=15)

No35% (n=8)

Chart6

10

13



292323

yes2379%1565%1043%

no621%835%1357%

unknown0%00%00%


3rd Rd292626

yes2690%1142%623%

no310%1558%2077%

unknown00%00%00%


Feb '0429179

yes1759%953%889%

no1241%847%111%

unknown00%1271%2069%

Global Fund Approved Proposals with HIV/AIDS Components in African Asylum Countries*Approved proposals (N=29)Proposals mentioned refugees (n=26) Proposals stated activities for refugees (n=26)Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria; 4th round inclusive * with >10,000 refugees

Source: Spiegel PB, et al. Int Conf AIDS, 2004, Jul 11-16, 15, abstract D12361 with modification

Yes 90% (26)

No 10% (3)

No58% (15)

Yes 42% (11)

Yes 23% (6)

No77% (20)

Chart4

26

3

Data 8-9-04


































Answer2922142929158

YES22 (76%)1410261161587

NO1 (3%)84315201471

Unknown or Not Applicable6 (21%)71603301421

Chart5

0.4230769231

0.5769230769

yes42% (n=11)

no58% (n-15)

Chart7

0.2307692308

0.7692307692

yes23% (n=6)

no77% (n=20)



292214

yes2276%1464%1071%

no13%836%429%

unknown621%00%00%


3rd Rd292626

yes2690%1142%623%

no310%1558%2077%

unknown00%00%00%


Feb '0429169

yes1655%956%889%

no1345%744%111%

unknown00%00%00%

Chart4

26

3

yes90% (n=26)

no10% (n=3)

Data 8-9-04


































Answer2922142929158

YES22 (76%)1410261161587

NO1 (3%)84315201471


Chart5

0.4230769231

0.5769230769

Chart7

0.2307692308

0.7692307692

yes23% (n=6)

no77% (n=20)



292214

yes2276%1464%1071%

no13%836%429%

unknown621%00%00%


3rd Rd292626

yes2690%1142%623%

no310%1558%2077%

unknown00%00%00%


Feb '0429169

yes1655%956%889%

no1345%744%111%

unknown00%00%00%

Chart4

26

3

yes90% (n=26)

no10% (n=3)

Data 8-9-04


































Answer2922142929158

YES22 (76%)1410261161587

NO1 (3%)84315201471


Chart5

0.4230769231

0.5769230769

yes42% (n=11)

no58% (n-15)

Chart7

0.2307692308

0.7692307692



292214

yes2276%1464%1071%

no13%836%429%

unknown621%00%00%


3rd Rd292626

yes2690%1142%623%

no310%1558%2077%

unknown00%00%00%


Feb '0429169

yes1655%956%889%

no1345%744%111%

unknown00%00%00%

Antiretroviral Therapy (ART) in Conflict-affected SettingsRATIONALE

Life saving, essential treatment available in Africa (universal access)Shown to be feasible in conflict-affected settings60% of refugees are in camps >10 years (2008)

INTERVENTIONS

Post-exposure Prophylaxis PMTCTTherapeutic, long termPEPFAR supportRwanda, Tanzania, and Kenya beginning 2008/09DRC and Burundi not yet

Source: Julius Kasozi, UNHCR, personal communication, Nov 2009Source: US Committee for Refugees and Immigrants. World Refugee Survey 2009.

HIV Care and Treatment Implementing ART among Refugee and Displaced PersonsEmergency phase over (mortality:

SummaryHIV risk factors increase during conflictsRisk does not mean transmissionIf populations are isolated and HIV levels are low, conflict may be protectiveHIV risk factors increase post-conflict Opening up trade, but still unemployment, and accessing previously isolated populationsEarly interventions needed to prevent explosive spreadInteraction with STIs, TB and other diseases requires integrated interventions HIV, STI and TB emergency guidelines available

Thank You

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers of Disease Control and Prevention.

I want to thank you for inviting me to come speak about HIV infection among refugees,Myths and finding*Over the next 45 minutesI will first explain some of the terms that I will be using throughout the rest of this talkSuch as what are emergenciesandWho are refugees and internally displaced persons, the vulnerable populations that are created as a result of these emergencies

Then give a brief background of the conditions impacting these vulnerable populations, giving the basic communicable diseases and then for the rest of the talk concentrating on HIV

Presenting possible myths or realitiesAnd available findings and possible reasons for these findings depending on the phase of the emergency

And finally look at principles for HIV control again depending on the phase of the emergency*So lets first look at emergencies

In general , an emergency is an unforeseen crisis requiring immediate response

They can be divided into two major types

Natural disaster: vast ecological breakdown between humans and their environment, such a serious or sudden event that community needs extraordinary efforts to cope, often with outside help or international aid

Complex humanitarian emergency (CHE): large-scale human displacement with living condition deterioration caused by war or attempt to restructure society (e.g., genocide), leading to significant increase in mortality for limited time, but sometimes longer

We use the indicator of >=1 death /10,000 population/ day to define that the situation is in an emergency phase

*But now let define the terms of refugee and internally displaced persons or IDPs

Both are victims of conflict and violence

Both have had to flee because of fear or actual persecution on the basis of

RaceReligionNationalityBeing a member of a social group Having a political opinion orGender

Internally displaced persons remain within their country of home

But refugees have fled to outside their country and because of being a victim of persecution are unable or unwilling to return home*This schematic helps explain the difference between refugees and internally displaced persons or IDPs

As you can see both are affected by the conflict

However, IDPs do not cross the international border and refugees do.

IDPs who interact with the host community, are interacting with people of their same nationality

For refugees, any interaction with the host community would be with persons of a different nationality

In regard to HIV transmission, in addition to interacting with the host community these persons can also have interactions with other key groups such as armed forces and UN peacekeepers sex workers

In the post-conflict phase, IDPs return to their homes in the same country For refugees, they would repatriate back to their home country or country of origin or integrate into the host population**So what are the communicable diseases risks among these personsMost suffered from mass population movement, as so well seen in the Balkans in the 1990s

Many have experienced Gender-based violenceThey live in Temporary shelter or can even lack any shelter, as seen among the Sudanese youth in the 1980s and 1990s

As a result they have a Poor nutritional status and scarcity of food

In addition, there is poor access to healthcare or a collapse of the healthcare system, leading to lack of medications and treatmentLeading to a Lack of prevention and control programsWith Low immunization coverage and lack of vaccinationLack of condoms or vaccinationLack of TB and HIV/AIDS control

The main causes of morbidity and mortality among refugee and displaced persons areAcute respiratory infectionsDiarrheal diseasesMeasles, if the vaccine coverage is lowAnd malaria, if endemic in the area and the population nave

However, TB and HIV/AIDS have an increasing importance

Especially for children and women in regard to violence and children and the elderly with the interaction of TB with malnutrition

And all of these diseases can have regional effects in regard to the prevalence of these diseases

**As seen in this slide, micronutrient deficiencies and HIV form a vicious cycle where each condition worsens the other.A component of the

Insufficient food intake, either because of lack of appetite or lack of food and then malabsorptionLead to micronutrient deficiencies, Immune suppression andProgression of disease

This cycle results in:- Weight loss - Loss of muscle tissue and body fat- Vitamin and mineral deficiencies- Reduced immune function and competence- Increased susceptibility to secondary infections- More rapid HIV disease progression

People affected by conflict lack nutrition and micronutrients, People with HIV need more calories, protein, micronutrients than the average person in these emergencies 300 to 1000 kcal more per day and 50-100% more protein

So here is HIV not considered a top priority in emergencies

It is perceived as a development, not emergency issue

Fear exists that if addressed and people identified, there will be discrimination against HIV-infected refugees

And that basic survival needs of shelter, food, water and sanitation need to be addressed first

And the health actions focused on the big 4 and malnutrition by ensure essential primary clinic services and medications are offered*Looking at he epidemiology of these populations

the UN High Commissioner for Refugees or the UN Refugee Agency, publishes yearly data

Their most current figures from the end of 2008

Revealed 25million total of whom

14.4 million are internally displaced10.5 million are refugees

The regions where the most come are Africa, Middle East and Asia and as you know these are the regions with the most HIV

For the remainder of the talk, I will mainly focus on Africa because it is both where the majority of refugees and IDPs reside and because it has the higher rates of HIV infection

*So lets now look at some of the myths or realities surrounding these emergencies and the populations the emergencies impact

We will look at 4Conflicts increase HIV transmission among the populations affectedSexual violence during these emergencies increases the HIV prevalenceRefugees bring HIV to the country of asylum or host countryIDPs and refugees have the same HIV risk and therefore, the same prevalence rates

*I first want to start with a caveat

The effects of conflict and sexual violence on HIV transmission

Are difficult to discern

There are a wide variety of issues involved, some of which I will try to present and explain

In addition, the data can have varied quality and focus and therefore may be biased

And the data on prevalence on HIV and even more so sexual violence among these affected populations are scarce

*That said,

Number 1 do conflicts increase HIV transmission

**There have been 2 studies that have indirectly looked at this.

The first by Nancy Mock, et al showed thatWith a few exceptions,

the countries with major conflicts in 2004 like Angola, DRC, Sudan, Somalia actually have lower HIV rates and

countries with relative peace like Namibia, South Africa, Zambia have higher HIV rates.

I have shown the most recent UNAIDS HIV data of 2007 but, these trends have been true since the study was done in 2004The other study by Roland Strand looked at 37 sub-Saharan African countries over a 10 year time period

And classified each according to level of armed conflict, with scores from 0 for no conflict to a high of 28 and 29 for Sudan and Angola, showing a pattern similar to what Mock recorded

And found among the 15 countries with no conflict, such as Botswana, Central African Republic, Malawi, South AfricaHad an average HIV prevalence of almost 20%

Among the 13 countries with some armed conflict, such as Cameroon, Chad, Ethiopia, SenegalHad an average HIV prevalence of 8.3%

And among the 9 with major armed conflict, such as Angola, Burundi, DRC, Somalia and SudanHad an average HIV prevalence of 7.8%

*So looking at these data plotted out we see a significant correlation between level of conflict and HIV prevalence the greater the conflict the lower the HIV prevalence rate per country with rho = -0.41 and p-value of 0.012

*So if we assume that conflicts actually delay the HIV epidemic, the question becomes why

Well that depends on the stage of the conflict that we are talking about

Be it during the actual conflict or in the post conflict period

During the actual conflict questions of actual survival and levels of access to populations and services or even sexual activity and violence need to be asked

During the post-conflict stage, services, employment and access also need to be investigated

questions of greater access to the population and to the demobilized military forces and peacekeepers and again the level of sexual activity and transactional sexual need to be asked

*So during the actual conflict

HIV-infected persons probably have a differentially higher mortality as some other high-risk populations, such as young children and the elderlyIn addition, poor nutrition and lack of services, adds to their mortality rate

And conflicts lead to isolation of the populations because of Destroyed transport, unsafe travel, disrupted commerce

sexual activity may actually decrease, as one knowledge, attitudes, behaviors and practice survey among Rwandan refugees in Tanzania in 2004 showed

And multiple studies have showed high rates of depression and post-traumatic stress symptoms that can lead to decreased libido among these populations

*Increased HIV incidence has been seen in the post-conflict stage in such countries as Angola, Mozambique and South Africa

As the conflict resolved the level of HIV prevalence has increase, it may be just the epidemic maturity or may be related to great access

Other reasons for this may beService delivery may be slowQuality of medical services that now exist may be poor, with poor access to supplies, such as condoms, equipment and medicationsLack of Universal precautions, safe medical equipment and blood may lag

Employment levels may also wane with many demobilized military forces and peacekeepers returning, there many be a large number unemployed In addition, female heads of households may need to turn to transactional or commercial sex practices

Increased access may also lead to mixing of populations with previously isolated populations going to cities and increased levels of sexual activity also leading to increased risk of HIV

*So the next question, be it myth or reality, is do refugees bring HIV with them to the country of asylum?*When we look at specific regions with at least 10 countries having refugee populations of at least 10,000 in 2004

The HIV prevalence among refugees as compared with the host population for the 3 regions with refugees

Showed that the HIV prevalence among the refugees as far as their country of origin was equal or lower than where they current reside in their country of asylum in Africa, Asia and Europe

Therefore, in spite of the lack of security and gender-based violenceLack of prevention programs, such as condoms that led to them becoming refugees

Poor healthcare assess and lack of treatment for sexually transmitted infections

The situation must be more complex and other factors must be at work

*But, first Surveillance for HIV prevalence rates during conflict are impractical

But, Surrogate data can be collectedFor Adults: chronic diarrhea, fever of unknown origin, recurrent pneumonia, STIs, TB and wastingFor Children: chronic diarrhea, developmental delays, failure to thrive, recurrent bacterial infections

In refugee settlements in Uganda, many children are on therapeutic feeding with no signs of gaining weight. Talking to the nutritionist in October last year, he felt it was because of HIV but had no way to test for it and no ARTs if he was able to test for it

Direct means of determining the HIV prevalence might be available from data during testing of the blood supply for medical use but no systematic surveillance system exists with results

In addition, VCT and PMTCT data might be available

*No possible source of these HIV prevalence data might be available from the UN High Commissioner for Refugees Health Information System

My branch began development of this system with the UN Refugee Agency in 1999

By 2006, the system has been implemented in 16 countries with stable refugee camp situations

From the HIV standpoint, HIS collects data on blood supply activities but no results of the screened blood units are collected

In addition, volunteer counseling and testing, which is actually provider initiated counseling and testing, data are collected but this does not indicate general population ratesPreventing maternal to child transmission activities and ART program activities, Are or are to be in the case of ART programs captured, but after CDC conducted with UNHCR an evaluation of the system last year, what data are available are of questionable value

*Therefore, the HIV prevalence data that are available in Africa, are from

Anonymous, unlinked, cross-sectional surveys (UAT) of

Pregnant women attending public antenatal clinics, including in refugee camps

At the time of the women's first visit to the camp, if blood is drawn for syphilis testing, left over blood is used

For refugee women in some settings, syphilis testing has had to be set up in order to have leftover blood, like Sudan

Often no informed consent is obtained because of Concerns of selection/participant bias

The womens identify is stripped except for Age, parity, marital status , educational level , and clinic location (or urban versus rural)

And in refugee camps: refugee versus host status

The method used, are Rapid, diagnostic tests and/or dried blood spots.

*And we need to remember that in refugee camp situations, the requirement of room temperature for rapid kits is often exceeded and methods for making and maintaining dried blood spots are not simple

In a recent article by RH Gray in Rakai, Uganda, in non-refugee setting

They observed almost a 45% false positive result 129 / 295 HIV positives and 4 (0.3%) of the 1,222 false negative results

For the two most recent, ANC sentinel surveillance studies of UNHCR in Kenya we found varying degrees of sensitivity and at one site a poor positive predictive value of only 35%

*Given these concerns what data are available

I do not want you to spend much time on the busy slide but, just to show you where I got the data from *So those data come from the study by Spiegel PB, et al. Lancet, 2007 plus newer data from 2006/07 of UN Refugee Agency for which I provided technical assistance

Looking only at data within 1 year for both populations

Among the 2 Kenyan camps,

For the one with Somali refugees, surveys in 2003, 05, 07, found a rate

Susan Temporado Cookson, MD, MPH In ternational Emergency & Refugee Health Branch

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