# Presentation: 731097

## HIV/AIDS and Complex Emergencies: Challenges and Progress

**HIV/AIDS and Complex Emergencies:**** ****Challenges and Progress**

- Peter Salama MD MPH
- Summer Seminar Series
- USAID Washington, August 2004

## Total: 38 million 

**Adults and children estimated to be living ****with HIV/AIDS as of end 2002**

**Total: 38 million**** **

**Western Europe**
**580 000**

**North Africa**
**    ****& Middle East**
**480 000**

**Sub-Saharan Africa**
**25 million**

**Eastern Europe ****& Central Asia**
**1.3 million**

**South **
**& South-East Asia**
**6.5 million**

**Australia **
**& New Zealand**
**32 000**

**North America**
**1 million**

**Caribbean**
**430 000**

**Latin America**
**1.6 million**

**East Asia & Pacific**
**900 000**

## HIV Prevalence in Adults in Sub-Saharan Africa, 1986-2001

**20 – 39%**

**10 – 20%**

**  ****5 – 10%**

**  ****1 – 5%**

**  ****0 – 1%**

**trend data**** ****unavailable**

**outside region**

**1986**

**1991**

**1996**

**2001**

*Source: UNAIDS Report on the Global HIV/AIDS Epidemic, July 2002*

## Between 1990 and 2003, sub-Saharan Africa’s population of children 

**Between 1990 and 2003, sub-Saharan Africa’s population of children **
**orphaned by AIDS increased from less than 1 million to more than 12 million**** **

## In 11 countries in sub-Saharan Africa, more than 15% of all children were orphans in 2003

**In 11 countries in sub-Saharan Africa, more than 15% of all children were orphans in 2003**

## The worst is yet to come:Epidemic curves, HIV/AIDS & orphans

**0**

**10**

**20**

**30**

**40**

**Millions**

***Source:  ******UNAIDS/UNICEF, 2003, adapted from Whiteside, A. and C. Sunter, 2000 ***

**HIV Prevalence**

**The worst is yet to come:****Epidemic curves, HIV/AIDS & orphans**

## Global Trends

**Female face of HIV/AIDS**
**Population-based surveys**
**Access to treatment **
**Integrated prevention and care**
**Going to scale: OVC, PMTCT etc**
**Increased donor interest**
**Coordination and the 3 ones**
**HIV and governance/security**

## Context

**Dramatic increase in resources for HIV/AIDS:**
**(1 to 7 billion USD from 2000-2005)**
**Focus on treatment and increasingly on care**
**President’s emergency plan for AIDS relief:**
**15 billion USD to 2008**
**Goals: **
**   ****2 million people treated **
**   ****7 million HIV infections prevented and **
**   ****10 million people cared for**

## Complex Emergencies

**A situation that affects large civilian populations and usually involves a combination of war or civil strife, food shortages, and population displacement resulting in significant excess mortality (Toole, MJ. 1997)**
**13.5 million refugees and approx. 20 million IDPs**
**Divided into two phases: **
**Emergency **
**Post emergency**
**Two types of environments - camp setting and unstable civil conflict or post-conflict environment**

## Possible Forced Migration in Conflict Situations

- Spiegel P, UNHCR; Brennan R, IRC, 2003

## Complex Emergencies

**Major causes of death in emergency phase:**
**Measles**
**Diarrhea**
**ARI**
**Malaria**
**Malnutrition**
**Surveillance systems:**
**emphasize tracking mortality rates**
**diseases of acute epidemic potential**
**rely on sensitive clinical case definitions that don’t require functioning labs**

## Causes of Increased HIV risk in Complex Emergencies

**Mass population displacement**
**Disruption of societal structures and mores**
**Disruption of family units**
**Disruption of sexual networks**
**Sexual interaction with military**
**Economic vulnerability of women and UAC**
**Commercial sex work**
**Sexual violence/coercive sex**
**Psychological trauma**
**Disruption of preventive and curative services**
**Unsafe transfusion practice**
**Increase intravenous and other drug use**
**High prevalence of STIs **

## Reduction in mobility
Reduction in accessibility
Slower urbanisation
Increase in resources and  services in host country

- Reduction in accessibility
- Slower urbanisation
- Increase in resources and  services in host country

**HIV Risk Factors for Conflict ****and Displaced Persons**

- 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 pop. HIV prevalence
- Length of time: conflict, existence of camp

** ****Increased Risk**

**Decreased Risk**

** ****Key Factors**

## Challenges

**Collection of reliable data**
**Implementation of effective, equitable and sustainable programmes**
**Inclusion into proposals and interventions**
**Protection**
**Operational research**
**Coordination**

## HIV Prevalence in Refugee Camps

**Kakuma camp est. 1992, pop. ~80,000, 5%, 2002**

**Yei and Rumbeck 2.3%, 2002**

**Lodwar area 18%, 2002**

**Garissa   4%, 2002**

**Dadaab camps est. 1991, pop. ~120,000 0.6%, 2003**

**?HIV prev **

_**Legend**_
**%** refers to HIV prevalence (prev.) using antenatal sentinel surveillance
- refugee movement

**HIV Prevalence in Refugee Camps**

## National HIV Strategic Plans (NSPs) in Asylum Countries in Africa*

- * with _>_10,000 refugees

**Existence of NSP**
**(N=29) **

**NSP Mentions **
**Refugees (N=23)**

**NSP State Activities **
**For Refugees  (N=23)**

## Protection

**Many protection issues some of which include:**
**Gender violence**
**Discrimination and stigma**
**Voluntary HIV testing**
**Access to equitable services**

## HIV Testing

**No mandatory testing**
**No denial of asylum, resettlement, right of return according to HIV status**
**Appropriate pre and post-test counselling for those resettlement countries requiring HIV testing**
**Informed consent prior to further disclosure of HIV status **
**Systems for protection, HIV care and treatment available post-testing **

## HIV/AIDS in Liberia: A Situation Analysis, 2004

## HIV Prevalence in Surrounding Countries

**Mali**

**Urban     3 % ‘99**
**Rural    2.2 % ‘94**
**Overall 1.7%  ‘01**

**Urban 6.3 % ‘00**
**Rural  5.5 % ‘00**

**Urban****  3.8 % ‘00**
**Rural   ****2.2 % ‘00**

**9.6% ‘00**

**8.9% ‘00**

**8.8% ‘00**

**9.0% ‘00**

**10.3% ‘00**

**9.7% ‘00**

**unknown**

**Urban  ****2.1% ‘96**
**Rural****   1.9% ‘96**

**Cote d’Ivoire**

**HIV Prevalence in Surrounding Countries**

## Methods

**Meetings: NACP, US mission, UN agencies, IOs and NGOs**
**Field visits: Monrovia, Buchanan, Gbarnga, Ghetto**
**Interviews: ex-combatants, drug users**
**Debriefings**

## Situation Analysis: HIV 

**Prevalence unknown:**
**No formal surveillance **
**Most data sources biased**
**Blood donor prevalence: 5%**
**If 5% prevalence, 75,000 PLWHA**
**Trends show increase:**
**AIDS cases**
**Blood donor prevalence since 1994**
**High risk groups:**
**Young women, mobile men, CSWs**

## Situation Analysis: Behaviors

**Driving factors:**
**Young age of sexual debut**
**Sexual violence and coercion**
**Condom use low**
**Most know of HIV/AIDS but:**
**>80% don’t know anyone with HIV/AIDS**
**>75% think PLWHA look sick and thin**
**<50% believe avoiding multiple partners decreases risk**

## Situation Analysis: Response

**Emergency oriented **
**Not commensurate with needs**
**History of institutionalization for OVC**
**Opportunities exist:**
**Small country**
**Concentrated population**
**Church networks**
**HIV pioneers**

## Conceptual Framework

## OVC in Liberia

**1.8 million children: 230,000 (13%) orphans**
**36,000 (15%) due to HIV/AIDS**
**42,000 double orphans: **
**Most vulnerable for poor outcomes**
**Will increase because of HIV/AIDS**
**If unaddressed, threat to stability/development**
**Need OVC assessment, coordination body, monitor quantitatively**

## Recommendations

**1) Urgently gather data on HIV prevalence and risk behaviors**
**2) Scale-up specific ABC prevention strategies targeted at high risk groups **
**3) Scale-up VCT**
**4) Standardize and improve current care and treatment practices for PLWHA**

## Recommendations

**5) Expand outreach and home-based care activities for PLWHA and non-institutionalized care for OVC**
**6) Consolidation and partnership**
**7) Improve fund-raising capabilities**
**8) High level advocacy**
**9) Support capacity of NACP**

## Conclusions

**Substantial HIV/AIDS problem and important risk factors**
**International response not commensurate  **
**GF will address predominantly curative side**
**Need for expanded evidence-based response that includes: targeted prevention, strong communications, VCT, home-based care and support for PLWHA and community groups as well as advocacy**

## Acknowledgements

- Reinhard Kaiser CDC
- Paul Spiegel UNHCR