This document discusses HIV in emergency settings and outlines research conducted from 2001 to present on this topic. It begins with assumptions and outlines research conducted on HIV prevalence, the magnitude of the issue, behavioral change and communication, and antiretroviral therapy adherence. It then discusses strategies, policies, and results, including increasing inclusion of refugees in national HIV plans, more refugees accessing antiretroviral therapy, and decreased high-risk sexual behavior. The document also summarizes several studies conducted on HIV prevalence in conflict-affected populations, behavioral surveillance surveys, and antiretroviral adherence.

1. HIV in Emergencies
Paul Spiegel MD,MPH
Deputy Director, DPSM
United Nations High Commissioner
for Refugees
from research to strategies, policies
and results
2001 to present

2. Outline of Presentation
• Assumptions
• Research
– HIV prevalence
– Magnitude of issue
– Behavourial change and communication
– Antiretroviral therapy (ART) adherence
• Strategies and Policies
• Results

3. UNGASS* 2001
12. “Noting that armed conflicts and natural disasters also
exacerbate the spread of the epidemic;”
75. “By 2003, develop and begin to implement national
strategies….recognizing that populations destabilized by
armed conflict, humanitarian emergencies and natural
disasters, including refugees, internally displaced persons,
and in particular women and children, are at increased risk
of exposure to HIV infection; and where appropriate, factor
HIV/AIDS components into international assistance
programmes;”
* UN General Assembly Special Session (Declaration of Commitment on HIV/AIDS)

5. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-
Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95.

6. What was the evidence
at the time (2002-07)?

7. Mock NB, Duale S, Brown LF, et al. Conflict and HIV: A framework for risk assessment to prevent HIV in
conflict-affected settings in Africa. Emerg Themes Epidemiol 2004;1(1):6.
Overlay bw Conflict and HIV prevalence

8. Strand RT, Fernandes DL, Berstrom S, Andersson S. Unexpected low prevalence of HIV among fertile women in Luanda,
Angola. Does war prevent the spread of HIV? Int J STD AIDS. 2007 Jul;18(7):467-71.
Relation of Armed Conflict and HIV
Seropositivity in sub-Saharan Africa

9. HIV Prevalence by Asylum Country and
Country of Origin by Region
* Weighted means: country of asylum by population size, country of origin by refugee population size
** N refers to countries of asylum with >10,000 refugees
Spiegel PB. HIV/AIDS among conflict-affected and displaced populations: dispelling myths and
taking action. Disasters 2004; 28(3): 322-39.

10. Methodology
Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced
people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95.
• Refugees: original UNHCR
antenatal care (ANC) sentinel
surveillance data
• Nationals: Nearest ANC
sentinel surveillance data from
UNAIDS and WHO (in-country
and non-conflict surrounding
country)
• Lit search: 7 conflict countries
with 65 original datasets
• Uppsala databased for dates
of conflict

11. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced
people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95.

12. Spiegel PB, Bennedsen AR, Claass J, et
al. Prevalence of HIV infection in conflict-
affected and displaced people in seven
sub-Saharan African countries: a
systematic review. Lancet
2007;369(9580):2187-95.

13. Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected
and displaced people in seven sub-Saharan African countries: a systematic review. Lancet
2007;369(9580):2187-95.
Byumba site,
2002, (host) 6.7%
(95%CI: 4.7-9.4)
Gihembe camp,
2002 (refugee) 1.5%
(95%CI: 0.4-3.8)
Lukole camp, 2003,
(refugee) 1.6%
Kagera region,
2003, (host) 3.7%

14. Limitations
• Different methods to collect data among refugee,
host community and country of origin pop. w/
variable quality of data
• Data for surrounding host pop. or region within
country of origin was not always available;
proxies used
• Comparisons could be biased due to different
contexts and years
• Trend data often unavailable or did not include
same sites

15. Conclusions
1. Individual vulnerabilities and risks exist for
persons affected by conflict; this does not
appear to translate into increased HIV infection
at population (pop) level
• All situations must be examined according to context
2. Refugees often have lower or similar HIV
prevalence to that of host communities;
refugees may be vulnerable to HIV infection
3. Could HIV infection spread more post-conflict?

16. INCREASING RISK:
 Behaviour change/coping
mechanisms
 Gender-based violence
 Transactional sex
 Reduction in resources
and services
DECREASING RISK:
 Reducing mobility
 Slowing of urbanization
 Increasing resources
 Increased access to
services in host area
 HIV prevalence at origin
 HIV prevalence in host area
 Length of time: conflict, existence of camp
HIV Risk Factors for
Conflict-Affected Populations
Modified from Spiegel PB. HIV/AIDS among Conflict-affected and Displaced
Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):322-39.

17. Magnitude of the Issue

18. Estimates of HIV Burden in Emergencies:
2003, 2005, 2006 and 2013
• Objective:
– Quantify proportion of people living with HIV (PLHIV)
who are affected by emergencies (ERs)
• Methods:
– Country-specific estimates of pop affected by ERs
were developed based on 8 and 11 databases
(2003/05/06 & 2013, respectively)
– Combined with UNAIDS HIV database to estimate
numbers of PLHIV (all years)

19. Lowicki-Zucca M, Spiegel PB, Kelly S, Dehne KL, Walker N, Ghys PD. Estimates of HIV burden in
emergencies. Sex Transm Infect 2008; 84 Suppl 1: i42-i8.
Diagram of Development of
Estimates, 2003, 2005,2006

20. Methods
cont
Lowicki-Zucca M, Spiegel PB, Kelly S,
Dehne KL, Walker N, Ghys PD. Estimates
of HIV burden in emergencies. Sex Transm
Infect 2008; 84 Suppl 1: i42-i8.
Spiegel P, Bennett R, Doraiswamy S,
Karmin S, Kobayashi, A, 2015
(unpublished)
Diagram of Development of Estimates, 2003, 2005,2006
Visual description of Interaction
of Databases, 2013

21. Results
Year # persons affected
by ERs
(millions)[range]
# of PLHIV and
affected by ERs
(millions)[range]
% PLHIV affected
by ERs / overall
PLHIV
2003* 349.5 2.6 [2.0-3.4] 7.9% (1 in 13)
2005* 168 1.7 [1.4-2.1] 5.1% (1 in 20)
2006* 185.5 1.8 [1.3-2.5] 5.4% (1 in 19)
2013+ 314 [295-330] 1.6 [1.2-1.9] 4.5% (1 in 22)
*Lowicki-Zucca M, Spiegel PB, Kelly S, Dehne KL, Walker N, Ghys PD. Estimates of HIV
burden in emergencies. Sex Transm Infect 2008; 84 Suppl 1: i42-i8.
+Spiegel P, Bennett R, Doraiswamy S, Karmin S, Kobayashi, A, 2015 (unpublished)
• For 2013
• 67 million [61-73] (21%) people were displaced
• Majority PLHIV affected by ERs were in Sub
Saharan Africa; 1.3 million [1.0-1.6] (81%)
• 1,000,000 [0.9-1.3] PLHIV not have access to
antiretroviral therapy (ART)

22. Limitations
• Estimates do not represent trends
• Estimating non-displaced persons affected
by ERs is complex
• Numerous overlapping of databases; thus
used [range]
• Duration of ER and length of service
disruption
• National HIV estimates and treatment
coverage applied to areas of ERs

23. Conclusions
• Large numbers of PLHIV affected by ERs;
to ‘get to zero*’ need to address this pop
• Ethical, moral and public health issue
• Concentrate on sub-
Saharan Africa
• Sub-national HIV
estimates and ART
coverage needed
• Now is the time!
* Zero new HIV infections, zero discrimination,
zero AIDS-related deaths

24. Behavioral
Change and
Communication

25. Behavioral Surveillance Surveys
(BSS) for Displaced Persons and
Host Communities
• Need to understand knowledge, attitudes and
practices of displaced persons, host communities
and interactions
• Developed standardised BSS w/ displ & post-displ
modules incl core indicators, and methodology
• Undertake in both displaced and host
communities (baseline and follow-up surveys)

26. Description
• BSS undertaken separately among refugees
and surrounding communities in Kenya,
Tanzania and Uganda (Dahab 2013)
– 6 paired sites (11,582 persons; 6,448
baseline in 2004/05, 5.134 follow-up 2010/11
• Analysis of 27 BSS in 10 countries among
displaced persons and hosts (24,219 persons)
bw 2004-2012 (Spiegel 2014)
• Descriptive data analysis and multivariable
logistic regression to identify high risk sex,
displacement and interaction

27. Dahab M, Spiegel PB, Njogu PM, Schilperoord M. Changes in HIV-related behaviours, knowledge and testing
among refugees and surrounding national populations: a multicountry study. AIDS Care 2013; 25(8): 998-1009.

28. Spiegel PB, Schilperoord M, Dahab M. High-risk sex and displacement among refugees and surrounding populations in 10
countries: the need for integrating interventions. AIDS 2014; 28(5): 761-71.

29. Forced Sex
• Prevalence of forced sex was similar in
paired sites, with intimate partner
violence being the most frequent, ranging
bw 1-4.6% in camps and 0.8-3.6% in
communities
• Exception of Nepal (10.8% and 9.8%,
respectively)
Spiegel PB, Schilperoord M, Dahab M. High-risk sex and displacement among refugees and
surrounding populations in 10 countries: the need for integrating interventions. AIDS 2014;
28(5): 761-71.

30. Conclusions
1. Data showed no consistent difference in levels
of risky sexual behavior and there was much
variation among different groups
• Prevention strategies should be targeted in highly
integrated manner for both communities
2. Forced sex among women was similar levels
among refugees and nationals with intimate
partner violence most common
• These findings should reduce stigma and
discrimination against refugees
3. Possible to measure change over time but
difficult to attribute to interventions

31. Antiretroviral Adherence

32. Methodology
Mendelsohn JB, Schilperoord M, Spiegel P, Ross DA. Adherence to antiretroviral therapy and
treatment outcomes among conflict-affected and forcibly displaced populations: a systematic
review. Conflict and health 2012; 6(1): 9.

33. Results
Mendelsohn JB, Schilperoord M, Spiegel P, et al. Is
forced migration a barrier to treatment success? Similar
HIV treatment outcomes among refugees and a
surrounding host community in Kuala Lumpur,
Malaysia. AIDS Behav 2014; 18(2): 323-34.
Mendelsohn J, Spiegel P, Grant A, Doraiswamy S,
Schilperoord M, Larke N, Burton J, Okonji J, Zeh C,
Muhindo B, Njogu P, Mohammed I, Mukui I, Sondorp E,
Ross D. Similar treatmen outcomes among refugees and
host nationals accessing antiretroviral therapy in a Kenyan
refugee camp.

34. Conclusions
1. Conflict –affected and forcibly displaced
persons had good adherence (87-99%)*
2. ART adherence similar among refugees
and nationals
3. Need for systematic monitoring of
adherence linked to displacement cycle
and context-specific support for
adherence/treatment outcomes
* Not including Malaysia and Kenya study

37. 2003 2004 20062005 2007

38. 2009 2010 20122011 2013 20142008

39. Results
1. Increased inclusion of refugees in HIV
National Strategic Plans
– 48% in 2009 to 87% in 2013
2. Increasing number of refuges on ART
– Access to ART at similar level as nationals
increased from 79% in 2010 to 97% in 2014
– For PMTCT was 95% in 2014
3. Decrease in high risk sex and increased
HIV knowledge and testing

40. Results cont
4. Increased funding for emergencies
5. Increasing awareness of issue and
recognition of need to act

42. Cameroon Refugees

44. AIDS, conflict and the media in Africa:
risks in reporting bad data badly
• Headline: "HIV/AIDS soars in war-torn northern Uganda"
– Reuters. Wallis D, 2004
• Headline: "GUINEA: Refugee influx adds fuel to AIDS crisis
in southeast Guinea“
– IRIN. Guinea, 2004
• "Infection rates are particularly high among vulnerable
groups, such as internally displaced persons (IDPs) and
refugees"
– WN.com. Telemans D: Sudan, 2004
Lowicki-Zucca M, Spiegel P, Ciantia F. AIDS, conflict and the media in Africa:
risks in reporting bad data badly. Emerging themes in epidemiology 2005; 2: 12.

45. Headline: "HIV/AIDS soars in war-torn
northern Uganda"
Reuters. Wallis D, 2004
“The rate of HIV/AIDS infection in northern
Uganda is nearly double that in the rest of the
country….”
UNFPA. Muleme G, 2004

46. HIV Prevalence and Income
Inequality in Africa
Piot P, Greener R, Russell S. Squaring the Circle: AIDS, Poverty, and Human Development. PLoS Med.
2007 Oct; 4(10): e314.

47. HIV and Poverty cont
O’Farrell N. Poverty and HIV in sub-Saharan Africa. Lancet. Feb 2001; 357;636-7.
Pearson
=0.29,
p=0.07

48. HIV Sentinel Surveillance
for Refugees
• Measure pregnant women at ANC clinics
• Work with Gov. authorities, use national
protocols, develop training modules, ensure
supervision
• Ensure quality control: double entry, all
positives and 10% negatives to reference lab
• Find funds- approx. 20-30,000 USD/survey

49. SS cont
Completed:
• Uganda 2004 and 2005
• Dadaab in 2004 and begun in July
• Kakuma 2002; 2006
• Tanzania: 2002, 2003, 2004
• Zambia: 2004
Planned:
• East Sudan – Showak begin Jan/Feb 2007
• Uganda – 4 sites Sep/Oct 2007
• Ethiopia – 5 sites – Dec-06/Jan-07
• Tanzania – 3-4 sites – Dates not confirmed

52. Risk versus vulnerability
• Risk of HIV is the likelihood that a person will become
infected with HIV either due to his or her own actions
(knowingly or not) or due to another person’s action.
Unprotected sex with multiple partners and sharing
contaminated needles are risky activities that increase
the probability of HIV infection.
• Vulnerability to HIV is a person’s or a community’s
inability to control their risk of infection. It may be
attributed, inter alia, to poverty, disempowering gender
roles or migration.

53. Behavioural Surveillance Survey (BSS)
Study: Objective and Methodology
• To evaluate quality of BSS in HEs and
post-conflict situations and provide
recommendations to NGOs and Gov'ts on
how to improve quality
• 31 BSS evaluated between 1998-2005 in
14 countries classified as reproducible if
pop. based sampling:
– Defined sampling frame
– Used probabilistic sampling (incl. PPS
for cluster sampling)

54. The Sphere Project, 2004
• Humanitarian Charter
• Universal minimum
standards in core areas
Aim:
• Quality of assistance
• Accountability
• HIV is cross-cutting
issue

55. Guidelines for HIV Interventions in
Emergency Settings, IASC, 2003 and
2010
• Matrix in 3 phases
– Emergency
Preparedness
– Minimum Response
(to be conducted
even in emerg.)
– Comprehensive
Response
(Stabilised Phase)
By sector/cluster

56. Post-emergency, 2005
1. Integrate refugee
issues into national
HIV programs and
policies
2. Implement sub
regional (cross-border)
initiatives
3. Combine humanitarian
and development
funding

57. Consensus statement
• ART neglected but feasible
• Continuation of ART for
those on treatment
• Initiation of ART for those
meeting minimum req’ts
• Need to scale up PMTCT
• PEP for all exposed HCWs
• PEP and rape mgt for
survivors of rape
Consensus Statement, 2006

58. ART Policy for Refugees, 2007
• Need to scale up PMTCT
• PEP for all occupational and
non occupational exposure
• Continuity of ART is priority
• Initiate if minimum criteria in
place
– Availability of resources
– Sufficiently trained persons
– Protocols
– Confidentiality
– Supervision
– 12 months of funding
– Local population has access

59. Clinical guidelines for antiretroviral
therapy management for displaced
populations, 2007 and 2014
– Continuation
ART with history
– Initiation of ART
– ART continuation
upon return
– Care and support
for PLHIV

60. HIV Assessment in Emergencies,
2007
IDPs
– Comprehensive
Assessment Tool
– Key Informant
Interviews, FGD guides
field tested in 2006 and
2007
– First Global IDP
Consultation in April
2007
– Tools finalized in 2007