# FOREWORD
The ICRC exists to protect the lives and dignity of victims of armed conflict and other situations of violence and to provide them with assistance. The rationale for its commitment to respond to HIV/AIDS thus springs from the increasing prevalence of HIV in those situations in which the organization is active.
The 28th International Conference of the Red Cross and Red Crescent, held in Geneva in 2003, adopted the Agenda for Humanitarian Action in which the components of the International Red Cross and Red Crescent Movement resolved, among other things, to enhance the protection of victims of armed conflict and other situations of violence and to reduce the risk and impact of diseases. 1 General objective 4 of the Agenda aims to reduce the devastating consequences of HIV/AIDS and other diseases faced, in particular, by groups that are stigmatized, discriminated against or socially marginalized because of their situation or circumstances and often lack access to comprehensive prevention, treatment, care and support.
HIV risk and vulnerability can be exacerbated by armed conflict. This may be because levels of sexual violence increase, because the displacement of communities leads to the breakdown of families and community norms or because communities are cut off from public health messages and services. During armed conflict, people living with HIV/AIDS, like other people with chronic and life-threatening illnesses, may be deprived of health services and require assistance to restore or maintain their health. In keeping with its mission to work as closely as possible with the people affected by conflict or violence, the ICRC needs to ensure that attention to issues of HIV/AIDS vulnerability, risk and care is included in its assessments, planning and ongoing work.
This field guide provides the ICRC with a flexible tool for making decisions about how and when the organization needs to incorporate attention to HIV/AIDS into its work, with emphasis on a multidisciplinary approach enabling coordination between health programmes, wider assistance programmes and protection programmes. The type of response will depend on the nature of the conflict, on the extent of HIV/AIDS infection in the population and on the availability of support from other stakeholders.
This field guide should be kept on hand as a working tool. It is hoped that it will enhance ICRC interventions in the countries where it is working, resulting in more effective protection of the victims of armed conflict.

# Pierre Krahenbuhl Director of Operations
1.1 About the field guide

# Purpose of the guide
The field guide is designed to assist the ICRC in responding to HIV/AIDS as an integral part of its core health activities. It provides: > guidance and decision-making tools to help delegations decide what to do in response to HIV/AIDS among specific populations in a given context; > guidance on how to integrate HIV/AIDS into core health activities.
Annex 1 contains a series of Action Guides that summarize information on key topics and options for action. These need to be read in conjunction with more detailed technical resources, references to which are provided in each Action Guide.
The guide is also designed to help delegations find strategic entry points to respond to HIV/AIDS as part of the work they do in a given setting and, over time, to build the whole organization's capacity to respond to HIV/AIDS as an integral part of its work.

# Scope and audience
The field guide sets out ways in which the ICRC can integrate HIV/AIDS into its core health activities by adopting strategies to reduce the spread of HIV or to address the impact of HIV/AIDS on its target populations. Its primary focus is HIV/AIDS. Tuberculosis (TB) is covered to the extent that it relates to HIV, as a common co-infection among people living with HIV/AIDS. Guidance on TB programming, particularly with respect to detention, already exists. 2 The aim of the HIV/AIDS Field Guide is to achieve a consistent approach when considering an HIV/AIDS response in each setting, not uniformity of the response in all settings.
A multi-sectoral approach is essential to address vulnerability to and the impact of HIV/AIDS effectively. Addressing the complex issues surrounding HIV/AIDS requires the cooperation of people from a range of disciplines and coordination between health programmes, wider assistance programmes and protection programmes. For example, ensuring safe access to potable water, adequate shelter and economic security reduces vulnerability to HIV/AIDS infection. Existing resources already deal with these issues, although they may not mention that such efforts contribute to reducing vulnerability to HIV/AIDS. 3 The content of this field guide is aimed primarily at ICRC health coordinators, delegates and field officers, but it is also relevant for delegation management staff, technical support staff and others involved in planning and implementing the work of the ICRC.

# How to use the guide
The field guide will: > assist delegations in: understanding HIV/AIDS in their specific contexts;  making strategic decisions about what they are best  placed to do to respond to HIV/AIDS, particularly in the framework of the ICRC's annual Planning for Results (PfR) exercise; responding to HIV/AIDS as an integral part  of their core activities; > assist the Health Unit's heads of sector in:
ensuring HIV/AIDS is being taken into consideration  when assessing delegations' annual PfR plans; incorporating attention to HIV/AIDS in  the monitoring and planning undertaken through the Equipes Regio nales de Coordination and other relevant processes; > provide staff of the Health Unit at ICRC headquarters with guidance in and resources for delivering technical assistance to the field. 

# ICRC policy
A number of key policy documents provide the foundations for this guide. 4 In the Declaration and Agenda for Humanitarian Action adopted by the 28th International Conference of the Red Cross and Red Crescent in December 2003, the Movement committed to undertake specific actions to "reduce the impact of HIV/AIDS and other infectious diseases with regard to vulnerable people". 5 The proposed actions relevant to the ICRC's work are to: > undertake operational measures aimed at ensuring continuous progress in the availability of treatment and care for people living with HIV/AIDS, with an emphasis on reaching marginalized groups that do not have ready access; > carry out awareness and education activities aimed at creating a positive, socially inclusive workplace environment for staff, volunteers and beneficiaries; > implement socially inclusive prevention and health care interventions appropriate for displaced and marginalized populations; > address, in a multi-sectoral and coordinated manner, the problems associated with HIV/AIDS in armed conflict, disasters and emergencies, recognizing the special vulnerability and capacity of displaced populations, host communities, military and peacekeeping personnel; > address the special needs and vulnerabilities of people affected by HIV and AIDS in emergency situations, with special attention to food security; > implement polices and operational measures in prisons to create a safer environment and reduce the risk of transmission of HIV, TB and other diseases among detainees, prisoners and staff. 6 The ICRC Assistance Policy Doctrine 49 provides broad guidance, including a strategic approach, and defines the core areas of assistance work. 7 The following core health activities set out in the doctrine are particularly relevant to HIV/AIDS: > supporting a minimum package of primary health care (PHC) activities, including maternal and child health (MCH) and outpatient curative care using essential drugs; > support for victims of sexual violence; > emergency hospital care; > health in detention.
The ICRC's Operational framework in regard to HIV/AIDS for victims of armed conflict, endorsed in 2004, forms part of the organization's Assistance Policy and provides a basic framework for responding to HIV/AIDS in conflict settings. In this document, there is a clear emphasis on working with national HIV/AIDS programmes and on ensuring that the ICRC's contribution to these programmes is in line with its core assistance and protection functions. The framework is supported by supplementary guidelines on HIV/AIDS in prisons, which call for an in-depth local assessment of the nature and extent of HIV/AIDS in a prison setting before decisions are made about possible interventions and for the adoption of a public health approach that is integrated with national efforts. 8

# HIV/AIDS and conflict
The rationale for the ICRC's commitment to respond to HIV/ AIDS as an integral part of its work is the increasing prevalence of HIV in the contexts in which the organization works. Many of the world's conflict zones are also places where the burden of HIV/AIDS is very high. In addition, existing HIV epidemics are fuelled by factors that exist in conflict settings, including: > the forced displacement of communities; > increased levels of sexual violence and exploitation of women and girls; > increased incarceration and overcrowding of prisoners and detainees; > the breakdown of community and State structures and services.
The ICRC is active in a context at the very time that the potential exacerbation of HIV transmission takes place, and the people most affected by it are those that the ICRC is seeking to assist and protect. The presence of HIV/AIDS also affects the ability of a community or nation to recover from a conflict, as illness and death from HIV/AIDS depletes the workforce, erodes community capacity and places an additional strain on public health and welfare systems.
Conflict does not always exacerbate the spread of HIV. Reduced mobility to high prevalence urban areas and the isolation and inaccessibility of some populations, such as internally displaced persons (IDPs), can in some cases offer temporary protection from surrounding epidemics. 9 In such cases, integrated HIV prevention nonetheless becomes necessary as people's isolation decreases and displaced communities come in contact with surrounding host populations.
The ICRC has a unique role in prisons and other detention settings. Even in countries with a low HIV prevalence, detention settings are often where an HIV epidemic is concentrated.
In fragile States, living conditions in places of detention are It is anticipated that the universal access agenda will fundamentally change the way that HIV/AIDS treatment and care are delivered. Systems for drug pricing and procurement are being reviewed and strengthened. Treatment and care access points are expanding in many countries, in an effort to increase the number of people who are aware of their HIV status and able to access treatment and care. As the global effort increases, more people with HIV/AIDS will be on antiretroviral therapy (ART) and their access to treatment and medical care will need to be ensured, to avoid increased morbidity and mortality and the development of drug-resistant strains of the virus.
DEcIDInG wHAt to Do -ASSESSmEnt AnD pLAnnInG

# Introduction
Section 2 sets out a process for deciding when and how to respond to HIV/AIDS from within the ICRC's core work in countries affected by armed conflict or violence.
Assess the environment that the ICRC is working in:
The The contexts in which the ICRC works are complex and diverse. There are many different factors that influence both the need to respond to HIV/AIDS and the feasibility of doing so. The landscape is often extremely dynamic. Situations can change rapidly and opportunities for intervention come and go. What is clear is that ICRC policy commits the organization to take into account how HIV/AIDS affects the populations it works with and to take action to address the vulnerability of these populations to HIV infection and the impact on them of HIV/AIDS.
The conflict and humanitarian environments constitute the overall context within which a more detailed consideration of the HIV/AIDS environment takes place.

# Assessing the conflict environment
The stage and degree of a conflict determine the kinds of intervention that are desirable and feasible in a given context. The degree of insecurity and the stage of the conflict, whether in its early stages, protracted or transitional, affect what can and needs to be done and how the ICRC is positioned to contribute and exert influence. The nature and stage of the conflict also influence the level of the ICRC's involvement in a country and this in turn affects the opportunities for and barriers to taking up particular issues.
The degree of stability and the extent to which a State is functioning and its infrastructure is affected by conflict are further critical factors in determining what the ICRC can do and the modes of action it will choose.

# Assessing the humanitarian environment
Generally, in planning ICRC programming, consideration will be given to: > the target population size and demographics; > the death rate; > the leading causes of preventable illness and death; > existing resources and services for target populations in respect of: health;  nutrition;  water, sanitation and habitat;  food and economic security;  protection.  Assessing basic needs and planning how to address them are the foundations of more complex preventive and curative interventions. The next stage is to identify the leading causes of preventable illness and death and to map the services and programmes available to the ICRC's target populations and which organizations are already active in this area. Doing so will assist the ICRC in determining its most appropriate role in the multi-sectoral response. Participation in HIV/AIDS and health-sector-wide coordination bodies is essential for the ICRC to make the most appropriate contribution over time.
Once the above assessments have been carried out, consideration should be given to the most appropriate modes of action to address the needs identified. This field guide sets out a range of services and programmes that need to be in place in order to respond effectively to HIV/AIDS. Depending on the context, decisions will be made as to whether the ICRC's role will be to support existing health services, to mobilize others to fill gaps in services or to persuade the government to fulfil its responsibility to meet the needs of the target populations. Often a combination of these modes of action is required. This field guide introduces the concept of strategic substitution. This involves the provision of goods and services on a shortterm basis, combined with specific action to address obstacles to the provision of these goods and services by the government or other providers. This approach recognizes the need to strike a balance, particularly in relation to HIV/AIDS, between shortterm health gains and long-term sustainability.

# Assessing the HIV/AIDS environment
In addition to assessments of the conflict and humanitarian environments, an assessment of the HIV/AIDS environment is needed to examine: > the extent of the HIV/AIDS problem; > risk factors of particular relevance in a given setting; > the response to HIV/AIDS -both in terms of policy commitments and the services and programmes available in a given context.

# What is known about the number of people living with HIV/AIDS
Even though reliable data on HIV prevalence at population level or among specific populations, such as IDPs and detainees, are not always available, some assessment of the burden of disease from less formal data sources will usually be possible and is critical to decision-making.

# What is known about who is becoming HIV infected and why?
Good programming requires an understanding of the factors driving HIV transmission in a country and within specific populations and settings. For example: > The movement of people into camps or dispersed in communities often disrupts livelihoods, increasing poverty and breaking down the cohesion of communities and the social norms that regulate behaviour. > Inadequate food and shelter can force women and girls into situations where they engage in transactional sex to meet their basic needs. > Consensual or non-consensual unprotected sex between men, as well as injecting drug use, in prisons increases HIV transmission in an environment where HIV is often already concentrated. > Where injecting drug use is common prior to the onset of conflict, HIV risk transmission can increase due to sharing of needles > Unemployment and boredom in IDP camps often increase men's alcohol intake and affect their ability to protect themselves and their families from HIV infection.
The table below sets out the key issues to examine in an assessment of the HIV/AIDS environment, guiding questions and examples of the data sources that may help to answer these questions.
Most countries have a national AIDS policy or strategy that guides the government's response. Many are guided in part by a Country Coordinating Mechanism (CCM) or national AIDS council or authority. These structures may or may not be functioning, depending on the extent and nature of the conflict. If they do not exist or are not functioning, there is usually an informal mechanism in place, often involving donors and international agencies.
HIV/AIDS policy commitments and coordinating mechanisms provide key leverage for the ICRC to ensure that people in conflict-affected areas have access to HIV prevention, treatment and care equivalent to those available in unaffected areas of a country. The ICRC's agenda for improving such access needs to be consistent with, and support the achievements of, national HIV/AIDS policy and programme priorities. 

# Elements of a comprehensive HIV/AIDS response
The map of available services, developed as part of the assessment of the HIV/AIDS environment, needs to be compared with the range of interventions required for a comprehensive health sector response to HIV/AIDS in order to identify the critical gaps in services and programmes for the ICRC's target populations.
The table below provides a summary of the key elements of a health sector response to HIV/AIDS. This will ensure a strategic and informed approach that enables the ICRC to take on a role in responding to HIV/AIDS in a given context in a way that addresses the critical gaps in services for its target populations and enables it to choose the responses or approaches that it is best placed to provide. It will also ensure that the ICRC's role is an integral part of national and local responses to HIV/AIDS, promoting consistency and sustainability and minimizing duplication.
Responding effectively to HIV/AIDS is a complex, multi-sectoral task. Working in partnership with others is essential to avoid duplication and achieve the level of coverage and reach that will make prevention and care initiatives successful. Sustainability is more likely if assistance is in line with national plans, policies and procedures. 

# Introduction to the Planning Guides
This sub-section takes the ICRC's three main target populations -sick and wounded, people internally displaced by conflict, and people deprived of freedom -and sets out a mechanism for prioritizing the integration of HIV prevention and care initiatives for each one according to the status of the conflict.
The Planning Guides are intended as tools for discussion, debate and planning. The sample Planning Guides given here are examples of how they might look when completed. Blank planning templates are also provided for delegations or subdelegations to use when considering what to do to respond to HIV/AIDS for specific populations of concern (see Annex 2). These can be used as part of the ICRC's PfR process, tailored to a particular context.
When using these templates, the following issues need to be kept in mind: > Overlap in target populations: People deprived of freedom are also members  of the community affected by the conflict. They are released into the community and they have families who live in the community. IDPs are sometimes living in camps and are sometimes  dispersed in the general community affected by the conflict. They are sometimes sick or wounded. > Conflicts do not usually follow a linear pattern from crisis to chronic crisis to post-crisis. They are generally dynamic, with periods of relative calm and recovery interspersed with periods of acute conflict or warfare. > The crisis, chronic crisis and post-crisis phases will vary in duration, from months in some cases to many years in others. > A different blend of strategic substitution, support and persuasion is required to solve different problems and this blend changes over time according to the circumstances.
The Action Guides in Annex 1 complement the Planning Guides. They provide more detailed guidance in each of the main intervention areas and should be used in conjunction with the planning templates when deciding what to do in a given context.
The starting points given in each Planning Guide for the integration of particular prevention and care initiatives are indications only. They are meant to prompt a consideration and an examination of the need for and feasibility of providing that particular intervention, at that level of the system, at that time in the conflict or transition. The approach that is eventually taken will depend on circumstances, and the narratives accompanying each Planning Guide cover the range of possible approaches and circumstances. 

# Crisis Chronic crisis Post-crisis
The Planning Guide for sick and wounded suggests what to consider and when in responding to HIV/AIDS in providing for the sick and the wounded, whether it is in field hospitals or through support to existing hospitals.

# Surgical and medical care for the war-wounded
The entry points for setting up care of the sick and the wounded vary enormously. At the height of the conflict, emergency surgical and medical care for combatants and civilians is the highest priority. As conflict subsides, the priority shifts to assisting in the restoration of inpatient and outpatient services (see below).

# Universal precautions
When establishing a stand-alone field hospital, guidelines for universal precautions (also known as infection control), supplies and expertise would need to be included in the set-up in order to minimize the risk of HIV transmission during surgery and care. When supporting a district hospital, it may be necessary to substitute supplies until government supply systems can be restored. Building hospital services up from the ground will also usually involve the development of guidelines, staff training and supervision, and the provision of PEP to reduce the risk of HIV transmission during care.

# Safe blood supply
Safe blood is required for acute care, and in the crisis phase of a conflict, supplies will usually come from family members and other patients. ICRC protocols provide guidance for the testing and use of donated blood. 11 The timing of the reintroduction of a more formal blood transfusion service will depend on need, available resources and the status of the conflict. All donated blood will need to be screened for HIV and other infectious diseases.
Further information and guidelines are provided in Action Guide 1: Universal precautions and safe blood supply.

# Restoration of inpatient and outpatient services
As the intensity of the conflict decreases, the priority shifts to restoring general inpatient and outpatient services for the civilian population. This involves rebuilding infrastructure, drug and consumables supply and management systems, pharmacy services, and diagnostic and laboratory services.
The staged incorporation of MCH services (including PMTCT and STI services), services for victims of sexual violence (including PEP and HIV counselling and testing), and HIV/AIDS treatment and care (including ART) will strengthen HIV/AIDS prevention and care significantly at this point. It will require assistance in identifying or developing guidelines and protocols, strategic substitution of drugs and supplies, persuasion to re-establish the flow of drugs and supplies from the government, and staff training and support (see the references and resources in the related Action Guides).
For a discussion on district planning and coordination and national persuasion, see the narrative accompanying the IDP Planning Guide. 

# PHC services in the crisis phase
When conflict is acute, the focus of PHC will be on providing or supporting the provision of basic health care, including MCH, with attention to safe birthing and universal precautions (see Action Guide 1: Universal precautions and safe blood supply). As it is common for rape to be used as a method of warfare, support to victims of sexual violence, including emergency contraception and presumptive treatment of STIs, will often need to be considered at an early stage. PEP to prevent HIV transmission can be undertaken without knowledge of the victim's HIV status, so it is not dependent on the availability of HIV counselling and testing but on the availability of antiretrovirals for PEP (see Action Guide 5: Supporting victims of sexual violence).
Where people are already on antiretrovirals and the supply is interrupted by the conflict, immediate action will be needed. Initially, this may involve strategic substitution, through the inclusion of antiretrovirals and PEP in drug kits. This would need to be combined with persuasion to re-establish drug supplies (see Action Guide 6: HIV/AIDS treatment, care and support).
STI prevention and treatment services can be commenced once basic health services have been re-established, because there is no need to know a person's HIV status in order to provide such services.

# Strengthening inclusion of HIV/AIDS in PHC as conflict subsides
As the intensity of the conflict decreases, attention will need to be paid to the progressive incorporation of HIV counselling and testing, of PMTCT into MCH services and of access to HIV/ AIDS treatment and care for people living with HIV/AIDS, including ART in clinical services. The capacities and availability of health staff (clinical officers and nurses) will be crucial in determining what can be done in this respect.

# Supporting district planning and coordination
The ICRC is often one of the few organizations able to work in an environment of acute conflict. If it has a good understanding of the HIV prevention and care needs of IDPs, the ICRC can assist the district health administration in identifying needs and setting priorities for HIV/AIDS services for this population and in ensuring their inclusion in the planning of such services.
As the conflict eases and the landscape becomes more crowded with service providers and donors, the district health administration will be in a better position to ensure strategic use of resources and coordinate service delivery efforts. The ICRC will also be well placed to coordinate the different actors, as more become involved in providing services for IDPs, and to ensure effective referral to services provided by others.

# National effort
Despite the existence of national HIV/AIDS plans committing to the provision of HIV/AIDS-related services, IDPs are often a neglected population. Persuasion will be needed to ensure that governments take steps to meet the needs of IDPs as an integral part of the national response. Obstacles to meeting the HIV/AIDS-related needs of IDPs will likely give rise to specific issues that need to be addressed at national level, such as identifying, developing or improving protocols for HIV counselling and testing, PMTCT, ART, establishing or re-establishing access to drugs and resolving drug supply issues, and ensuring health workers have access to national staff training programmes. 

# Crisis Chronic crisis Post-crisis
The Planning Guide for people deprived of freedom plots what to consider and when in responding to the HIV/AIDS-related needs of people deprived of freedom.

# Initial focus on basic needs
The ICRC's work with people deprived of freedom combines the efforts of the organization's assistance and protection divisions.
In the initial engagement in prisons, issues of basic health take first priority; water, sanitation, living conditions, nutrition and safety are paramount. As the ICRC's relationship with the government and prison authorities develops, opportunities arise to work on strengthening health services in particular prisons and to work with the national prison health service as a whole.

# Strengthening services that assist in HIV prevention and care
It may be more practical and feasible to focus in the first instance on support to a set of services that do not require HIV counselling and testing, as a way to ensure that HIV prevention outcomes and general health care are strengthened from the outset. Such services include: > access to basic health care; > general administration of co-trimoxazole to reduce morbidity and mortality from PCP (pneumocystis jiroveci pneumonia, formerly pneumocystis carinii pneumonia) and other OIs in settings of high HIV prevalence; > TB prevention and treatment; > STI prevention and treatment, including condom distribution; > MCH services for female detainees and their children; > support to victims of sexual violence; > access to drug substitution, drug treatment or sterile injecting equipment for drug users.
(See Action Guide 3: Strengthening HIV/AIDS prevention and care in detention settings.)
Once these services have been established, they can be followed by support for HIV counselling and testing, OI treatment and prophylaxis, ART, and expanded MCH, including PMTCT for female detainees.
Where delegations are seeking to integrate attention to HIV/AIDS into existing prison health support, early efforts will be needed to secure ART access for those already on ART when entering the prison system. It is also very important to develop strategies to secure confidentiality for HIVpositive people.
Collaboration across programmes is particularly important in the detention environment. It requires support and persuasion for the coordination of national TB, HIV/AIDS and malaria programmes and support for local coordination between prison health and community health services.
It is also important that delegations and sub-delegations work together to combine local support with a national support and persuasion agenda to strengthen the whole prison health service. This will ensure that the services supported in individual prisons have the back-up they need in terms of policies and guidelines, financial resources, consistent supply of drugs and other supplies, and the human resources needed to carry out their work.
For a discussion on district planning and coordination and national persuasion, see the narrative accompanying the Planning Guide for IDPs.
SEctIon 3: monItorInG AnD EVALUAtIon

# National targets
Most countries will have in place a set of commitments and indicators that guide their HIV/AIDS response. These will be contained in the national strategy, in Global Fund documents, as a sub-set of the Millennium Development Goals, or in their UNGASS reports.
Under the universal access agenda, governments have committed to work towards universal access to HIV/AIDS prevention and care for all their citizens who need them. The ICRC's target populations are often the most difficult to reach with these programmes, so measurement of the ICRC's contribution to achieving this increased access is extremely important.
The ICRC can assist governments in measuring their progress against these goals by ensuring that ICRC programmes measure outputs and outcomes in a way that is consistent with the indicators and goals and that they support services to monitor and evaluate their work accordingly.

# National HIV/AIDS programme indicator guidelines
There In practice, the indicators used need to be SMART. Therefore, it will be necessary to determine a specific target for each indicator, for example the percentage increase in the level of PMTCT access over a specific period of time.

# AnnEx 1:
How to Do It -ActIon GUIDES

# Using the Action Guides
These Action Guides provide information on how HIV prevention and care interventions can be integrated into health services. They are not intended to be guides to stand-alone short-term projects but to assist in ensuring that attention to HIV prevention and care becomes a routine part of the planning and implementation of ICRC programmes. The Action Guides are to be used in conjunction with the Planning Guides for each of the ICRC's different target populations set out in Section 2.
Each Action Guide contains some basic technical information and options for action. There are also links to resources and guidelines where more detailed technical information can be found. The web version provides hyperlinks to these resources. For the printed version, the HIV/AIDS Field Guide is reproduced in full on the accompanying CD, with hyperlinks to enable easy access to these further resources.
In order to reduce the likelihood of this field guide becoming out of date, specific information such as treatment protocols is provided in the expanded versions of the Action Guides. For the printed version, these expanded Action Guides can be found on the accompanying CD. For the web version, they are provided in separate PDFs available with this guide on the ICRC's website. Thus, the expanded Action Guides can be easily updated as the protocols change over time. Where additional information is available in an expanded Action Guide, the field guide refers to the accompanying CD or PDF versions.
More technical information on HIV/AIDS in the ICRC context is also contained in the ICRC publication HIV/AIDS: Everything you need to know. 12 ActIon GUIDE 1:

# UNIVERSAL PRECAUTIONS AND SAFE BLOOD SUPPLY

# Universal precautions
Universal precautions are a set of standard procedures to be applied with all patients at all times to minimize the risk of transmission of blood-borne pathogens. They eliminate the need to know whether a particular patient is carrying a bloodborne pathogen and provide protection for staff and patients.
In a conflict setting, an interruption in the availability of supplies, the absence of trained staff and the disruption of normal procedures brought about by the emergency can result in a lack of attention to universal precautions and an increased risk of HIV transmission to both staff and patients.

# Key actions
 Ensure that clear universal precaution guidelines are available and that staff are trained in their use. > Promote hand washing and have hand-washing facilities consistently and widely available in all care areas. > Ensure an adequate and consistent supply of sterile injecting equipment, sterile intravenous equipment, gloves, masks, gowns, disinfectant, cleaning materials and other supplies to promote adherence to universal precautions. > Promote the availability and use of safe systems for the disposal of sharps. > Ensure that sterilizers are functioning and that they are used properly. > Ensure the safe disposal of all human waste, including through the availability of incinerators.
Adherence to universal precautions needs to be closely monitored in all care settings, and staff training and supervision are essential to ensure consistent good practice. Staff and patients also need access to PEP in case of accidental exposure to HIV in a health care setting. 

# Generic guidelines on universal precautions

# Safe blood supply
The ICRC Blood Transfusion Guidelines need to be adhered to when collecting and administering blood in emergency settings. A transfusion of HIV-infected blood is extremely likely to result in HIV infection for the recipient. The timing of the reintroduction of more formal blood transfusion services will depend on need, available resources and the status of the conflict.

# Key actions
 Avoid unnecessary use of blood transfusion. > Screen donated blood for HIV and syphilis (and if possible for hepatitis C and hepatitis B), and screen donors for recent HIV-risk behaviour. > De-link HIV results from donors, unless referral to VCT services is available. > Introduce a system to track the use of blood products.

# Next steps
Reintroduce standard blood transfusion guidelines and practices including: Where the ICRC's work in PHC involves strengthening MCH services, there are important opportunities to contribute to preventing HIV transmission from mother to child and facilitating women's access to primary HIV prevention services and HIV/AIDS treatment, care and support when required. 14 HIV transmission from mother to child may occur during pregnancy, labour or delivery or as a result of breastfeeding.
Children exposed to HIV either before or during delivery or through breastfeeding have a roughly 3 in 10 chance of becoming infected. About 15 -25% of infants born to HIVpositive women will be infected during pregnancy or delivery and an additional 5 -20% as a result of breastfeeding. 15 A comprehensive approach to the prevention of HIV infection in infants requires: > primary HIV prevention for women; 16 > prevention of unintended pregnancies among women living with HIV/AIDS; > prevention of HIV transmission from HIV-positive mothers to their infants; > treatment, care and support for mothers living with HIV/ AIDS, their children and families. 17 Existing resources provide detailed guidance on most of the above aspects of a comprehensive approach (see Resources). This Action Guide focuses on information and the ICRC's options for action that ensure PMTCT is addressed as an integral part of MCH.
The information in this field guide supersedes that on PMTCT in the ICRC's Antenatal Guidelines for Primary Health Care in Crisis Conditions. 18 The current WHO guidelines are summarized in the present guide. 19

# Access to MCH
Experience has shown that in many resource-poor settings the biggest obstacle to access to PMTCT is the low proportion of pregnant women who have access to basic antenatal care, which is the most likely entry point for PMTCT. In the contexts where the ICRC implements many of its PHC programmes, access to basic antenatal care is often very limited. This adds weight to the argument for prioritizing the restoration of antenatal care in the immediate post-conflict environment. Access to HIV counselling and testing HIV counselling and testing for pregnant women, as early as possible in their pregnancy, provides a critical entry point for PMTCT and treatment, care and support for those who need it. Supporting MCH to provide HIV testing requires attention to: key issues of confidentiality; counselling that enables people to understand their own risk of HIV infection/risk to others; disclosure of results; access to appropriate HIV prevention information, services and commodities; and ART, care and support for women diagnosed as HIV positive. 20 (See Action Guide 7: HIV counselling and testing.)

# ART for pregnant women living with HIV/AIDS
Where treatment is indicated, access to ART for pregnant women living with HIV/AIDS both promotes the health of the woman and is a highly effective form of PMTCT. Illness or death of the mother is likely to undermine any improvements in survival of the child achieved as a result of antiretroviral prophylaxis to prevent mother to child transmission of HIV. The survival of the mother is a strong predictor of the child's survival. (See Action Guide 6: HIV/AIDS treatment, care and support.)

# Prevention of mother to child transmission
PMTCT requires attention to delivery, safe birthing, including safe blood transfusion, antiretroviral prophylaxis, and counselling on infant breastfeeding. Elective caesarean section can reduce mother to child transmission where the woman is not on ART. However, this is likely to be of limited relevance in the contexts in which the ICRC works, unless there are also complications in childbirth that indicate an emergency caesarean section is necessary. 21

# Antiretroviral prophylactic regimens
Where pregnant women do not have access to ART or treatment is not indicated, the antiretroviral prophylactic regimen for PMTCT recommended by WHO is set out below. 22 The recommended regimen at the time of writing is discussed in order to provide a clear overview of this complex area of policy and practice. It is important to check whether this regimen remains current at the time of use.

# Recommended regimen
Mother Pregnancy:
Labour:
Postpartum:
Azidothymidine (AZT) from 28 weeks of pregnancy or as soon as possible thereafter- AZT and lamivudine (3TC) plus a single dose of nevirapine (NVP) AZT and 3TC x 7 days

# Infant
Single dose NVP and AZT x 7 days - If a course of less then four weeks of AZT has been given to the mother during pregnancy, it is necessary to give the infant AZT for four weeks.
The WHO guidelines recognize that operational contexts vary considerably and, where capacity is limited, it may be necessary to use alternative regimens. These options, and the advantages and disadvantages of each option, are provided in the expanded Action Guide 2. (For the printed version, see the CD accompanying this field guide. For the web version, see the separate PDF accompanying the web version.)
The WHO guidelines make it clear that a single dose of NVP for both mother and child is the absolute minimum and should be considered as a temporary measure while steps are taken to identify and address the specific obstacles to the provision of more effective regimens. Therefore, it is important to understand the disadvantages of this regimen, particularly that it is less effective than the recommended regimen and that there is a high risk of the patient developing resistance to NVP, thereby limiting future treatment options. The ICRC has a clear role to play in persuading governments to improve PMTCT protocols as ART becomes more widely available in countries affected by conflict.
Where women living with HIV/AIDS have not received ART or antiretroviral prophylaxis during pregnancy, several prophylactic regimens have been shown to have an impact on reducing mother to child transmission during labour and postpartum. The recommended regimen is the same as the recommended regimen in the table above, except the AZT for the infant is given for four weeks instead of one. There are also alternative regimens for women seen only in labour and only postpartum. 23

# Considerations for informed treatment decisions
Pregnant women living with HIV/AIDS will need to have sufficient information, based on local realities, to give informed consent to treatment. The choice between giving ART and antiretroviral prophylaxis will depend on the availability of ART, the woman's current level of HIV illness and the quality of the prophylaxis available. It may be better for her to take ART earlier than indicated by her HIV disease than to take a sub-optimal antiretroviral prophylaxis.

# Infant breastfeeding
Breastfeeding is vital to the health of children, reducing the impact of many infectious diseases and preventing chronic diseases. The UN recommends that infants be exclusively breastfed, that is, fed with nothing but breast milk, for the first six months of life. 24 However, 5 -20% of infants born to HIV-positive women acquire HIV infection through breastfeeding. 25 Exclusive breastfeeding for up to six months has been shown to decrease the risk of transmission of HIV threeto fourfold compared with non-exclusive breastfeeding.
Exclusive formula feeding has also proved an effective way to prevent postnatal mother to child transmission, but this may not be a viable option in settings where there is not a continuous supply of formula, fuel and clean water.
Pregnant women need to know their HIV status in order to make informed decisions about infant feeding, as well as all the options for addressing their own health needs. Where women do not know their HIV status or know they are HIV negative, it is recommended that they breastfeed exclusively for six months and continue breastfeeding combined with complementary feeding 26 after six months.
UN guidelines recommend that when formula feeding is acceptable, feasible, affordable, sustainable and safe, women with HIV/AIDS do not breastfeed. Where these preconditions are not met, women should either: > exclusively breastfeed, stopping as soon as formula feeding is possible; or > exclusively breastfeed for six months and continue breastfeeding combined with complementary feeding after six months, weaning for as short a time as possible. Women living with HIV/AIDS need to be supported in making informed decisions on infant feeding options. This means providing counselling based on a local assessment of the benefits and risks of the available options, taking into consideration factors such as cultural, economic or social barriers or fear of stigma that might make formula feeding unacceptable. Access to a continuous supply of formula and all the ingredients necessary to prepare formula, including fuel and clean water, are also key considerations. 27

# Options for action
In deciding what to do to prevent mother to child transmission, consider: > How are MCH services functioning? > What is the background prevalence of HIV ? (see Section 2) > Does a national protocol for PMTCT exist and are antiretrovirals for prophylaxis and ART available in the country? > Where is PMTCT supposed to be delivered in the health system? > What are the obstacles to access to PMTCT for the ICRC's target populations? > How can these obstacles be addressed?
It is likely that national protocols for PMTCT exist and there will be some availability of ART and antiretrovirals for prophylaxis in the country, although consistency of supply and availability of drugs in the settings in which the ICRC works are likely to be obstacles that need to be addressed. The steps the ICRC can take to promote access to PMTCT for its target populations will depend on the level in the health system at which the ICRC is supporting MCH services. HIV is an issue of particular concern in prisons. In many countries, rates of HIV infection are much higher among detainees than in the general population. 28 Unsafe injecting practices are a key driver of many HIV epidemics, and injecting drug users are overrepresented in prisons. HIV-risk behaviours, including unsafe injecting practices and tattooing, often occur in detention. The prison environment can also increase HIV-transmission risk through unprotected consensual and non-consensual sex and poor access to means of prevention (condoms). This affects both men and women and includes sex between men. Detention settings are often characterized by overcrowding, which increases transmission of TB and OIs, and by lack of access to clean water, good nutrition, and medical care and treatment. This contributes to HIV-related morbidity and mortality.

# Level Actions
National
All these factors underscore the need for focused efforts to prevent the spread of HIV in prisons and to address the impact on detainees living with HIV/AIDS.
The general aim of an ICRC intervention with respect to HIV/AIDS in prisons is to provide detainees with access to HIV prevention, care, treatment and support equivalent to that available to people in the community outside prison. 29 Even in non-conflict settings, it has proved difficult to achieve the principle of equivalence. Acknowledging that HIV-risk behaviour occurs in prisons has been difficult for many governments and providing access to means of prevention has presented significant challenges. Yet there is compelling evidence for what works to prevent the spread of HIV and how best to address the HIV/AIDS-related health needs of detainees for sterile equipment and other supplies. 30 To work towards equivalence with services available in the community: > Examine the national AIDS policy and local HIV/AIDS treatment and care policy and practice and compare these with what detainees receive. > Work with the prison health system and other organizations to identify a set of priorities for detainees and take action to address their basic health needs, HIV prevention, HIV counselling and testing, and HIV/AIDS treatment, care and support.

# Address basic health needs
The ICRC's Health in Detention Practical Guide sets out a framework for assessing health-related issues in prisons. 31 Attention to the basic issues of shelter, sanitation, water and nutrition remains a high priority, as these factors also significantly affect HIV/AIDS morbidity and mortality.
People with HIV/AIDS have compromised immune systems, so overcrowding, poor ventilation and a lack of isolation areas for people with infectious illnesses exposes them to TB and life-threatening OIs. Poor nutrition also contributes significantly to HIV/AIDS morbidity, so improvements in general nutrition will have a positive impact.
Poor access to health services will adversely affect the health of all detainees, and will certainly increase morbidity and mortality for detainees with HIV/AIDS. Improving the regularity and quality of health services for detainees is an important place to start. Strengthening TB programmes, malaria prevention and treatment programmes in malaria-prone areas, and access to medical services in prisons will have a positive impact on morbidity and mortality for undiagnosed people with HIV/AIDS.

# HIV prevention
The WHO/UNODC/UNAIDS policy brief on reducing HIV transmission in prisons sets out four key areas of intervention that have been extensively studied: > the provision of bleach to clean syringes and needles between use; > the provision of sterile needles and syringes; > substitution treatment programmes; > condom availability. 32 These form the cornerstone of effective responses in HIV prevention programming in prisons and can be supported by: > the incorporation of STI diagnosis and treatment in prison health clinics; > communication on risk reduction; > services for victims of sexual violence; > access to HIV counselling and testing and to partner notification and family support; > universal infection control policy and procedures.
HIV prevention in prisons is challenging. This often leads to the choice of single specific interventions, such as behaviour change communication in the form of information, education and communication materials or peer education for detainees, which are more acceptable to prison authorities. Supporting detainees in understanding their own HIV risk and in developing the knowledge and skills to protect themselves is of little value if they do not have access to means of prevention -condoms, sterile needles and syringes, sterile razors and sterile tattooing equipment. 33 Knowledge about how HIV is transmitted, without the power and the means to apply that knowledge, will not prevent HIV transmission.

# WHO/UNODC/UNAIDS, Policy Brief: Reduction of HIV Transmission in Prisons,
Evidence for action on HIV/AIDS and injecting drug use, 2004. 33 UNODC/WHO, HIV/AIDS in places of detention: A toolkit for policy makers, managers and staff, 2007.
A combination of the above strategies that address people's knowledge, power and access to means of prevention is needed to prevent the spread of HIV.
Behaviour change programmes, as part of a comprehensive approach to HIV prevention in prisons, have a role to play in promoting safer sexual and injecting behaviours. Behaviour change interventions need to support detainees in understanding their own risk and in gaining the knowledge, skills and commodities to protect themselves and others from infection. Information is often best delivered by peers, particularly because there is greater trust among peers than towards the prison authorities.
For further information on incorporating the HIV prevention strategies outlined above into practice, see: > Action Guide 1: Universal precautions and safe blood supply > Action Guide 4: Strengthening HIV prevention through the integration of STI treatment into PHC > Action Guide 5: Supporting victims of sexual violence > Action Guide 7: HIV counselling and testing

# HIV counselling and testing as a gateway to care
Knowledge of HIV status can improve health outcomes by assisting health staff in providing the most appropriate treatment regimens for OIs and by acting as a gateway to accessing HIV/AIDS treatments. However, it has particular ramifications for people in detention. For the individual, it can increase the psychological burden of detention and can lead to discrimination, violence and exclusion from health services, as confidentiality in the detention environment is difficult to protect.
The introduction of access to HIV testing has to be carefully planned and provided only where knowledge of HIV status will enable improved care, such as treatment of OIs and the provision of ART. HIV counselling and testing should be provided in accordance with the principles set out in Action Guide 7: HIV counselling and testing.
The three Cs -counselling, confidentiality, consent -are essential in prisons, just as they are in the community. Yet mandatory HIV testing -testing detainees without their consent -remains a common practice. Mandatory testing should be opposed and all efforts made to persuade prison authorities that coercive approaches are unethical and ineffective. In many countries where mandatory testing in prisons has been practised, it has later been abandoned because it is both costly and inefficient. 34 

# Incorporating attention to HIV issues in TB programmes
TB is a common co-infection in people with HIV/AIDS. The presence of HIV in a community exacerbates a TB epidemic, just as the presence of HIV/AIDS in individuals can cause a relapse of latent TB or their compromised immune systems can make it easier for them to contract TB. HIV not only increases the number of TB cases, but also alters the clinical course of TB disease.
As HIV-related immunosuppression increases, the clinical pattern of TB disease changes, with increasing numbers of smearnegative pulmonary TB and extra-pulmonary TB cases. TB is more likely to be disseminated and more difficult to diagnose as immunosuppression progresses. 35 Whilst access to high-quality laboratory diagnostic services is important for the management of this group, revised diagnostic algorithms are available to speed diagnosis and commencement of treatment. Linking people to community services post-detention Key strategies include: > working with other agencies to link detainees to outside services immediately before and then following release; > attention to issues of disclosure to family members and of testing, treatment and care of family members; > transfer to external drug treatment programmes for drug users on substitution therapy; > working with the families of detainees.

# Options for action
At national level, persuasion will be needed to ensure people deprived of freedom are explicitly included in the national HIV/AIDS plan and that the plan commits to the provision of HIV/AIDS-related services equivalent to those available in the community.
This Action Guide addresses the detention setting, while most other Action Guides address specific types of services or programmes that also need to be provided in prisons. See each of these Action Guides for options for action at national, prison hospital and prison clinic levels: Studies show that for each episode of unprotected vaginal sex, the risk of HIV transmission for women increases 10 to 50 times in the presence of an ulcerative STI and the risk for men increases 50 to 300 times. 40 Inflammatory STIs such as gonorrhoea or chlamydia also increase the viral load (concentration of HIV) in genital fluids. Increased viral load in semen has been estimated to increase the likelihood of HIV transmission during unprotected vaginal sex by 8 to 10 times. 41 So, reducing the burden of STIs in a community can contribute significantly to HIV prevention and can provide a relatively quick and simple starting point for a more comprehensive HIV prevention effort.

# STI-related morbidity and mortality
There are other good reasons for early incorporation of STI diagnosis and treatment into the recovery of PHC systems in post-conflict environments and into the PHC services provided to IDPs during conflict.

# Reducing sexual transmission of HIV
STI prevention and control is a significant HIV prevention strategy that fits well within the ICRC's core activity of assisting in the rebuilding of PHC services and within the ICRC's core competencies. It can later be complemented with other longer-term prevention initiatives such as behaviour change communication and condom social marketing that are difficult to achieve in the immediate post-conflict environment and that may be better carried out by other agencies as they require longer-term programming and community development strategies to ensure maximum effectiveness. 42 42 Global HIV Prevention Working Group, Proven HIV Prevention Strategies Fact Sheet, 2006.
Persistent undiagnosed STIs seriously compromise women's health Infertility: - Gonorrhoea and chlamydia are the main preventable causes of infertility. Between 10 and 40% of women with untreated chlamydial infection develop symptomatic pelvic inflammatory disease (PID). Post-infection tubal damage is responsible for 30 -40% of cases of female infertility.

# Cervical cancer: 
Human papilloma virus (HPV) infection results in approximately 500,000 cases of cervical cancer annually. It is the second most common cancer in women after breast cancer, causing about 300,000 deaths yearly, mostly in resource-poor settings.

# STIs are major causes of adverse pregnancy outcomes
Ectopic pregnancy: - Women who have had PID are 6-10 times more likely to develop an ectopic (tubal) pregnancy than those who have not; 40 -50% of ectopic pregnancies can be attributed to previous PID.

# Stillbirth: 
In pregnant women with untreated early syphilis, 25% of pregnancies result in stillbirth and 14% in neonatal death -an overall perinatal mortality rate of about 40%.

# Premature delivery: 
Up to 35% of pregnancies among women with untreated gonococcal infection end in spontaneous abortion or premature delivery and up to 10% in perinatal death.

# Infant blindness: 
In the absence of prophylaxis, 30 -50% of infants born to mothers with untreated chlamydia or gonorrhoea develop ophthalmic neonatorum, which can lead to blindness.

# Adapted from WHO/SEARO, Regional Strategy for the Prevention and Control of Sexually Transmitted Infections, 2007-2015.
Incorporating STI prevention and control into primary health care services

# Starting point: syndromic management
There is no need to wait for laboratories to be up and running to treat STIs. Many STIs and reproductive tract infections (RTIs) can be successfully identified and treated on the basis of characteristic symptoms and signs. Symptoms, the things the patient complains of, and signs, the things that the health worker observes, can be grouped together into syndromes. Syndromic management of STIs/ RTIs is an approach that involves the presumptive treatment of STI/RTI symptoms and signs based on the organism most likely to be causing the problem.
Algorithms combining symptoms, signs and risk assessment are used to guide the health worker in managing the seven most common STI/RTI syndromes -urethral discharge, genital ulcers, vaginal discharge, lower abdominal pain, scrotal swelling, inguinal bubo and neonatal conjunctivitis. This means that the patient is treated on the spot, avoiding loss to follow-up, and that the treatment can be offered even in settings where basic laboratory services are not available. Having consistent and locally adapted algorithms also allows for task-shifting from doctors to PHC nurses, increasing access to treatment in settings where doctors are not consistently available. Obviously, syndromic management misses asymptomatic STIs, and efforts to strengthen local diagnostic capacity will improve overall STI management.
Many countries have their own adapted algorithms in place. These are preferable to generic algorithms as they contain local drug treatment information and tailored risk assessment questions. Generic algorithms and training materials are available at www.who.int/reproductive-health/stis/training.htm. A sample algorithm is provided in the expanded Action Guide 4. (For the printed version, see the CD accompanying this field guide. For the web version, see the separate PDF accompanying the web version.)

# Options for action
Strengthening the capacities of PHC services is a gradual process. In most settings, it will require a blend of mobilization and support. ActIon GUIDE 5:

# SUPPORTING VICTIMS OF SEXUAL VIOLENCE

# Context
Conflict environments are characterized by increased sexual violence and exploitation of women and girls, the breakdown of health and social welfare systems, disruption of livelihoods, and the weakening of the social norms and cohesion of communities that regulate behaviour. The nature, extent and impact of sexual violence, including rape, forced prostitution and sexual slavery, perpetrated against women and girls in armed conflict and its aftermath are well documented. 43 Men and boys are also subject to sexual violence, particularly in detention settings, underscoring the need for support to victims of sexual violence in prisons.
The ICRC's primary health care work includes supporting victims of sexual violence and provides important opportunities to contribute to preventing HIV transmission and ensuring women have access to HIV counselling and testing and to HIV/ AIDS treatment, care and support where required.
Comprehensive health care for victims of rape requires compassionate and confidential services that include: > the preparation of victims for medical examination; > medical examination, including documentation and treatment of injuries, collection of forensic evidence, assessment of HIV and other STI risk and pregnancy risk; > emergency contraception; > treatment or preventive treatment of STIs; > psycho-social counselling and social support; > PEP to prevent HIV transmission; > HIV counselling and testing; > access to HIV/AIDS treatment, care and support where required.
Existing resources provide detailed guidance on most of the above aspects of a comprehensive programme (see Resources). This Action Guide focuses on information and the ICRC's options for action to ensure HIV is addressed as an integral part of support to victims of sexual violence. 44 Treatment or preventive treatment of STIs
Treatment or preventive treatment for STIs is an integral part of health care for victims of sexual violence. A person with an STI is at far greater risk of contracting HIV during unsafe sex than a person without an STI. So STI treatment and preventive treatment also contribute to HIV prevention. (See Action Guide 4: Strengthening HIV prevention through the integration of STI treatment into primary health care.)
Post-exposure prophylaxis 45 PEP is a short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure. It should be commenced as soon as possible after the rape occurs, within the first 4 hours where possible, and no later than 72 hours after the assault. There is no conclusive evidence of the effectiveness of PEP in preventing HIV transmission after rape. However, based on experience with occupational exposure and PMTCT, it is considered beneficial. PEP is recommended as part of a minimum response after rape. 46

# Assess risk
Health care providers must assess the risk of exposure and discuss this with victims of sexual violence to enable them to make an informed decision about whether to undertake PEP. In assessing risk, consider the circumstances of the assault, including the number of assailants, whether there was penetration, injuries sustained and HIV prevalence in the region. There is increased risk of transmission if: > there is more than one assailant; > the victim has torn or damaged skin or mucosa; > the assault was an anal penetration; > the assailant is known to be HIV positive; > the HIV prevalence in the region is high.

# Counselling
At the outset, establish whether the woman already knows her HIV status. If she is aware she is HIV positive, PEP is not necessary. While it will not do any harm, there is no benefit. These women should be referred to HIV/AIDS treatment, care and support services.
Where a woman's HIV status is negative or not known, the following issues should be raised with her to enable her to decide whether she wishes to undertake PEP: > that the level of risk of HIV transmission as a result of rape is not exactly known, but risk exists, particularly in settings where HIV prevalence is high; > the health provider's assessment of the woman's risk (see Assessing the risk above); > that the effectiveness of PEP in preventing HIV transmission after rape is not known, but experience based on prophylaxis after occupational exposure and PMTCT indicate it is likely to be effective in reducing the risk of HIV transmission after rape; > that there are common side effects of PEP drugs, such as tiredness, nausea and flu-like symptoms (these side effects are temporary and do not cause long-term harm, and most can be relieved with ordinary analgesics, such as paracetamol); > adherence to treatment is very important for the effectiveness of the treatment.
The timing of counselling regarding HIV testing needs be carefully considered. Wherever possible, HIV counselling and testing should be considered in a subsequent consultation (see PEP follow-up below). Some women may already be HIV positive prior to the assault, but are unaware of it. An HIV-positive diagnosis at this time is likely to compound the immediate trauma of rape. However, if a woman wishes to undertake an HIV test immediately, she should be free to do so and be referred appropriately.

# Preventive treatment
Commence PEP, following national PEP protocols where they exist, as soon as possible, within the first 4 hours, where possible, and no later than 72 hours after the assault occurs.
PEP usually consists of two or three antiretroviral drugs given for 28 days. In settings where triple-combination ART is widely available, it is likely that the HIV virus may be resistant to one of the drugs. In this case, three drugs need to be used. Find out which drugs are used to treat HIV locally in order to determine the choice of drugs for PEP, but never use NVP for PEP. PEP combining two antiretrovirals can be used in settings where triple-combination ART is not available.
The antiretroviral combination recommended at the time of writing this guide is set out in the expanded Action Guide 5. (For the printed version, see the CD accompanying this field guide. For the web version, see the separate PDF accompanying the web version.)
A one-week supply of PEP should be provided on the first visit, with the remainder of the medications (three weeks' supply) given at the one-week follow-up visit. For women who cannot return for follow-up for logistical or economic reasons, a full supply with clear dosing instructions should be given at the first visit.

# PEP follow-up
As part of the standard one-week follow-up visit: > assess PEP side effects and adherence; > if not supplied at the first visit, provide an additional three weeks' supply of PEP medication; > check that the woman has had an effective course of medication for STIs (usually single dose, but may be a longer course); > assess the likelihood of STIs and treat as appropriate; > counsel on baseline testing for HIV and retesting after the window period has passed; > if the woman is diagnosed as HIV positive, refer her for HIV/AIDS treatment, care and support.
See Action Guide 7: HIV counselling and testing and Action Guide 6: HIV/AIDS treatment, care and support.

# Options for action
In deciding what to do, consider: > Does a national protocol for PEP exist and are antiretrovirals for prophylaxis and treatment available in the country? > Where is PEP supposed to be delivered in the health system? > What are the obstacles to access for ICRC target populations? > How can these obstacles be addressed?
Even where a national protocol for PEP exists and there is or will be some availability of antiretrovirals for prophylaxis and treatment in the country, consistency of supply and availability of the drugs in the settings in which the ICRC works are likely to be obstacles that need to be addressed.
The steps the ICRC can take to promote access to PEP for its target populations will depend on which level/s in the health system the ICRC is supporting services for victims of sexual violence.

# Level Action
National Effective OI treatment and prophylaxis and the administration of ART have significantly altered the prognosis for people with HIV/AIDS, and whilst they do not represent a cure, they have turned HIV into a chronic, manageable illness. The development of simplified treatment and monitoring protocols means that ART can be delivered safely and effectively in resource-limited settings.
Whilst securing ongoing access to ART is the most effective determinant of long-term survival for people living with HIV/AIDS, there are still treatment, care and support initiatives that can be put in place that prolong life, reduce morbidity and increase quality of life in the absence of the availability of ART. These are the absolute minimum standard and should be available in all settings: > improvements in access to nutritious food, good shelter and clean water; > primary health care that is able to prevent or detect and treat TB co-infection and common opportunistic and concurrent infections; > home-based care to relieve symptoms and provide support; > counselling and psychological support.

# Treatment of OIs
HIV weakens the immune system and prevents the body from fighting off a range of infections that a healthy immune system can usually manage. These are called opportunistic infections. Even in an environment where HIV counselling and testing is not available, people with undiagnosed HIV will present to health services with OIs that can be effectively treated. 47 In developing countries, many people with HIV/ AIDS still die from preventable or treatable OIs. 

# Knowledge of HIV status
Knowledge of HIV status is a key link between HIV prevention and care. Access to HIV counselling and testing allows people to know their HIV status and, if HIV positive, to take steps to access treatment and prevent transmission to others, including to their unborn children. Access to HIV counselling and testing is an essential part of HIV prevention, treatment and care. See Action Guide 7: HIV counselling and testing.
Simplified ART and monitoring protocols ART, or "combination therapy" as it was once called, is a combination of drugs from several drug classes that work together to reduce viral replication and therefore the amount of HIV in the body (viral load). The guidelines for prescribing ART are quite complex, but most people with HIV/AIDS start on what is called "first-line" therapy, a relatively simple combination of drugs with few side effects. 50 If this combination stops working, they are switched to a more complex regimen (second-line therapy). Second-line regimens are more complex and more expensive, and not yet widely available in resource-limited settings. This makes it extremely important that people in resource-limited settings get maximum benefit from their first-line treatment.
ART formulations continue to improve, reducing the burden of adherence to treatment on people with HIV/AIDS. Simplified formulations and regimens make it increasingly possible to deliver ART in settings that were previously thought to be too difficult. 51 Simplified monitoring, in the absence of a CD4 count that indicates immune function, is also possible and effective. WHO advocates a public health approach that involves simplification and standardization of regimens and clinical monitoring, "task shifting" to reduce dependence on scarce doctors, and increasing the use of nurses and lay personnel in clinical follow-up and adherence support. The Clinical Guidelines on Antiretroviral Therapy Management for Displaced Populations set out a clear rationale and practical pathways for ART provision in fragile environments. 53 ART is a life-saving intervention In principle, ART should be lifelong and sustainability should therefore be key. However, even if sustainability is not guaranteed or is uncertain, immune reconstitution on ART, even for short periods, can yield significant clinical benefits.
UNHCR/South African HIV Clinicians Society, Clinical ART Guidelines, p. 6
The decision to provide or support ART in a fragile environment is a complex one. For instance, there may be little value in providing ART for a short period without any firm plan for the person to access ongoing treatment. However, a mix of strategic substitution and persuasion to secure access to ART for conflict-affected populations can be life saving.

# Adherence to treatment
HIV/AIDS treatment is for life and needs to be taken at the correct dose every day in order to avoid treatment failure and the development of resistance. This can be challenging in any environment. Resistance can be caused by skipping doses, by interruptions in supply, by OIs that reduce absorption of the drug in the gut, and by reduced dosing brought about by sharing medications with family members and others. People with AIDS on ART require information and counselling to help them manage their medications and avoid interruptions in treatment. Training community health workers and family members to support and assist people living with HIV/AIDS to maintain their therapeutic regimen has also proven effective in maintaining adherence.
Adherence is not just an issue for the person on ART. Interruptions in supply of ART, due to stock-outs at local, district or national level, or because people are cut off from treatment centres by conflict or emergencies, present significant adherence problems and can compromise health outcomes for people living with HIV/AIDS. The ICRC has a role to play in maintaining a supply when it is cut off by conflict. This requires contingency planning.

# Home-based and community care for people with HIV/AIDS
Access to ART is only part of the picture of treatment, care and support for people with HIV/AIDS. Most of their time is spent living in families and communities, and family and community support is essential to their survival. There is evidence to show that resources within communities, and support from communities, make a difference to households and individuals affected by HIV/AIDS and to HIV prevention. 54 Creating a more supportive environment for families caring for a person with HIV or AIDS at home involves working to increase acceptance and reduce fear of HIV and AIDS in communities and mobilizing the formal and informal care structures that exist -TBAs, community health workers, and the paid and unpaid people at the lowest levels of the health system. In many settings, the ultimate aim of ICRC persuasion, mobilization, substitution and support is to secure for its target populations the same standard of HIV/AIDS treatment, care and support that other people living with HIV/AIDS in the country are receiving. In the first instance, an intervention would involve strategic substitution, for example making ART available to people who are already on ART and have been cut off from access to it or preserving access to PMTCT. This would be combined with persuasion to reconnect these people to government programmes.
If the conflict continues and the services in, say, an IDP camp become more established over time, an intervention could move on to supporting HIV counselling and testing and commencing newly diagnosed people with AIDS on ART.

# Scenario 2: Incorporation of access to ART in the re-establishment of PHC for IDPs and conflict-affected communities
A key element of the ICRC's post-conflict work involves persuasion, mobilization of others and direct support to the re-establishment of health services for displaced populations or for populations returning to their home communities as stability increases. In this effort, the ICRC works at several levels of the health system: at the community level with TBAs and other community carers; at PHC level in health centre; at district hospital level, rebuilding infrastructure and supporting the strengthening of health services; and at national level, in persuasion for access to national programmes for people in the ICRC's care.
At PHC level, this support would involve: > securing and maintaining a consistent supply of OI and ART medicines -either by strategic substitution followed by access to national distribution programmes, or by a direct link to national supplies; > training staff in the use of national or regional OI and ART treatment protocols; > supporting the establishment of patient monitoring systems; > assisting in the establishment of HIV counselling and testing services (see Action Guide 7: HIV counselling and testing); > supporting awareness among health staff of the need to link STI, TB, MCH and HIV/AIDS services, that is, fostering an understanding of the need to think about the comprehensive needs of the patients they are treating; > supporting community health workers, such as volunteers and TBAs, to link families affected by HIV/AIDS to the clinic and in adherence to treatment; > supporting the strengthening of home and community care, using available community resources to reduce stigma and discrimination and improve capacity to provide care. 

# Resources

# HIV COUNSELLING AND TESTING
What is HIV counselling and testing?
HIV counselling and testing is an intervention 56 that involves: > confidential counselling that enables people to assess their risk of acquiring HIV, helps them to decide whether to do the test, and provides information and support when a person receives the results; and > taking and analysing blood or body fluids for the presence of antibodies produced in response to HIV. There are many technologies available today, including high-quality rapid tests, many of which do not require laboratory services. 57
Why is it important?
HIV counselling and testing enables people to make an informed decision to test, know their HIV status and take action to protect and promote their health. For people who test positive, it provides the gateway to HIV treatment and care and assists them in preventing transmission of HIV to others. For those who test negative, it provides the opportunity to understand their likely risk of HIV infection and to take steps to avoid HIV infection in the future. When is it necessary?
The introduction of access to HIV testing has to be carefully planned and provided only where knowledge of HIV status will enable improved care, such as the treatment of OIs and the provision of ART. 

# What to consider when providing HIV counselling and testing
While access to HIV counselling and testing can bring significant benefits for the individual and community, knowledge of HIV status can also have serious negative consequences for people. HIV-related stigma and discrimination are pervasive and take many forms: violence and harassment by family members, communities, uniformed services, or service providers; loss of home and/or livelihood; or imprisonment. While the widespread availability of treatment has the potential to reduce the stigmatization of HIV, many people living with HIV/AIDS still face stigma and discrimination, regardless of whether treatment is available. HIV-related stigma and discrimination continue to prevent people from having an HIV test. This underscores the need for HIV counselling and testing to be provided in a manner that minimizes these negative consequences. While remaining committed to the "three Cs", WHO guidance on provider-initiated HIV testing recommends an "opt out" approach, whereby people must specifically decline the test if they do not wish to be tested. 59 There is debate about whether the "opt out" approach actually supports informed consent. If a person does not feel empowered to refuse, then the preconditions for informed consent may not be met. 60 Therefore, the ICRC approach, detailed below, is that the person must specifically consent to be tested. 

# Guiding principles

# Pre-and post-test counselling for pregnant women
Pre-test counselling for pregnant women should also include: > the risk of transmitting HIV to the infant; > measures that can be taken to reduce mother-to-childtransmission; including antiretroviral prophylaxis and infant feeding counselling (this can be done later); > the benefits to infants of early diagnosis of HIV.
Post-test counselling for pregnant women whose test results are HIV positive should be done in serial sessions. Also address the following: > use of ART for the woman's own health and to reduce mother to child transmission or antiretroviral prophylaxis for PMTCT; > infant feeding options and support to carry out the mother's feeding option; > childbirth plans to ensure women have access to antiretroviral prophylaxis and infant feeding support; > HIV testing for the infant and the follow-up that will be necessary; > partner testing.
(See also Action Guide 2: Integrating HIV/AIDS into maternal and child health services.)

# Partner disclosure
Encouraging and offering HIV counselling and testing for a person's partner in the course of post-test counselling can raise complex issues. The decision to disclose rests with the HIV-positive person, unless the law states otherwise.
In conflict settings, often HIV counselling and testing is provided only as an entry point to PMTCT. This results in a disproportionate number of women being identified as HIV positive, creating a culture that blames women for bringing HIV into families. This can exacerbate violence and discrimination against women.
Discussions regarding disclosure need to address the risk of violence, abandonment or discrimination. Men who have been at risk of HIV outside their primary relationship are often reluctant to disclose to their partner. Delaying or avoiding disclosure places the partner at continued risk. HIV counselling and testing protocols and training need to equip health care workers to address these realities, as well as comply with any relevant laws relating to disclosure.

# Operational issues
For the populations the ICRC serves, HIV counselling and testing is best provided as part of an integrated PHC service, for example, as part of MCH, TB, STI and prison health services.
When supporting the provision of HIV counselling and testing, there are a range of operational issues that will need to be considered and addressed. 61 The requirements will vary depending on the setting, be it a clinic, an IDP camp or a detention centre. Among the factors to be considered are: > the expected volume of clients; > the availability and capacity of staff; > the infrastructure and supplies needed; > protocols; > staff training needs; > quality assurance; > patient flow after tests; > how to assure confidentiality; > legal issues (children, adolescents).
The basic infrastructure requires private counselling space and testing areas. The supplies needed include HIV test kits, together with gloves and other medical supplies for universal precautions (see Section 2). If national HIV counselling and testing protocols exist, they should be implemented. If protocols do not exist, these will need to be developed to guide pre-and post-test counselling and the conduct of testing. A system of maintaining confidentiality of records will need to be put in place and staff trained to implement it. Staff will need to be trained in confidentiality, to conduct pre-and post- test counselling and to conduct rapid HIV tests and analyse the results. A system of quality assurance will also need to be developed and implemented.

# Summary of options for action
The actions required to support quality HIV counselling and testing are outlined in the Action Guides, where knowledge of a person's HIV status is needed, such as starting a person on ART or starting a pregnant woman on prophylaxis to prevent mother to child transmission.
Unless services are available, there is no justification for provision of HIV counselling and testing alone. The table below summarizes the actions related to HIV counselling and testing outlined in this and related Action Guides. (See: Action Guide 2: Integrating HIV/AIDS into maternal and child health services; Action Guide 3: Strengthening HIV/AIDS prevention and care in detention settings; and Action Guide 6: HIV/AIDS treatment, care and support.)

# Level Action
National These epidemiological definitions have their limitations. For instance, as data improve, it is increasingly clear that HIV epidemics in Africa are less generalized and more diverse than previously recognized. Southern Africa's epidemics are highly generalized, with HIV prevalence ranging from 15 -35%. In East Africa, for many years grouped with Southern Africa, HIV prevalence is far lower, ranging from 2 -7%. Prevalence in West Africa ranges from 1 -5%. 65 These figures underscore the need for attention to specific populations at risk, even when responding in epidemics that have been categorized as generalized.

# Sub-populations at increased risk
Conflict and displacement can contribute to increased vulnerability to HIV infection. However, not all of the ICRC's target populations are equally vulnerable.
Out of sight, out of mind ... a familiar vicious circle: no data equals no problem, no problem equals no intervention, no intervention equals no need to collect data. Within that circle, HIV can spread undetected. 66 It is important to understand both the factors that make people vulnerable to HIV infection and how marginalization of specific populations at risk often compounds this vulnerability. For example, societies disapprove of and sometimes harshly punish sex between men, marginalizing men who have sex with men (MSM). Denial of sex between men often results in a lack of data to demonstrate the need for interventions targeting MSM. Stigma and discrimination often prevent MSM from accessing mainstream health services. Where they do access services, they are unlikely to disclose that they have sex with men, and services will often fail to address their specific needs.