|Guidelines for HIV Interventions in Emergency Settings (UNAIDS - UNHCR - WHO, 1996, 59 p.)|
During any emergency when political, social and security structures break down, human rights may be violated in ways that either increase the risk of infection with HIV or increase the impact that HIV/AIDS has on infected people and their families, or on people merely suspected of infection.
In terms of increased risk of infection, people are able to avoid infection to the degree that they have access to HIV/AIDS prevention information, education, health (STD and reproductive) services and means of prevention (condoms); and are able to use these to avoid infection. During emergencies, people will have less access to such information and services, either because they are not available or accessible or because they are denied by those in power at the time. The degree of access will of course change over time as the emergency moves from the acute phase to phases of increased stability. Thus, in the context of the provision of assistance during emergencies, the provision of HIV/AIDS education and services should be seen as a part of meeting peoples basic rights to life, health, education and information.
Marginalized or disadvantaged groups will have less access than they usually do to such information and services. In the context of the activities described in this guide, special measures, such as providing targeted outreach programmes, should be taken so as to ensure that particularly vulnerable and disadvantaged groups have access to HIV/AIDS prevention information and condoms during emergencies. Among emergency populations and refugee populations, such groups include women, children, minorities, indigenous peoples, migrants, the illiterate, the poor, men having sex with men, sex workers and injecting drug users.
People should also be able to avoid sex that threatens them with infection. With the breakdown of family, social and security structures that occurs during emergencies, this is more difficult than usual because of the increase in sexual and gender violence. Such violence includes all coerced or non-consensual sex, including rape inside and outside marriage, sexual abuse, exploitation of prostitution, trafficking in women and children, sexual bartering, and female genital mutilation. Such sexual violence involves a higher likelihood of infection because the person coerced cannot protect him/herself from unsafe sex and because the virus can be transmitted more easily if bodily tissues are torn during violent sex.
Thus, measures taken during emergencies and armed conflict to protect those vulnerable to sexual violence will also protect them from increased risk of HIV transmission. Those particularly vulnerable are women, children, the elderly, detainees and prisoners.
Non-consensual sex includes people giving sexual favours in exchange for essential goods and services, such as food/water, shelter, fuel, security. Therefore, to the degree possible the loci in which women/children intereact with authorities for access to these essential goods should be monitored, as should all places of detention, including local jails. POW detention centres and refugee camp detention centres. Furthermore, HIV/AIDS prevention education and issues of sexual abuse should be targeted to those in the community who have authority, such as refugee camp officials, refugee leaders, national military units and peacekeeping forces, staff of international and nongovernmental organizations, truck drivers, vendors of household goods and brothel owners. (For further steps to take, see UNHCR documents: Sexual Violence against Refugees - Guidelines on Prevention and Response, 1995; Refugee Children - Guidelines on their Protection and Care, 1994; Guidelines on the Protection of Refugee Women, 1991.)
The human rights of those infected or suspected of infection should also be respected both to protect their dignity and to enable them to cope with the disease. Coercive or discriminatory measures which may be taken (often in the name of public health) include mandatory testing of individuals or groups; publication of HIV status; isolation or segregation of people infected with HIV/AIDS; and denial of asylum, health care, employment and/or assistance because of HIV status. Such measures violate the rights of people living with HIV or suspected of it and do not prevent the spread of HIV/AIDS.
Mandatory testing is sometimes a reaction by authorities if they fear that a displaced or refugee population may infect a local population. However, mandatory testing in such situations does not stop the spread of infection from one population to another because:
· HIV/AIDS is already present in all populations; testing itself does not stop the spread of the disease; testing diverts resources from programmes for prevention education and information, STD management, and condom distribution, all of which are more effective in reducing the spread.
· Testing does not identify all those infected because of false results and/or because of the window period during which a person may be infected and highly infectious but the antibodies to the disease have not yet developed and do not register on the test; furthermore, a person who tests negative may become infected any time after the test.
Since testing cannot identify all HIV-positive people, every person receiving health care should be regarded as a potential carrier of HIV, hepatitis B and other bloodborne infections; and universal precautions by health workers should be observed at all times.
Mandatory testing not only has no public health justification; it also violates the rights of people, including the rights to privacy and security, as well as the ethical principles of autonomy, informed consent and confidentiality. If HIV status is made known, HIV-positive people may be subject to discrimination, stigma, ostracism, harassment and physical abuse. Thus, HIV/AIDS status should be kept confidential by health care workers and other authorities who may have access to it.
Furthermore, in the provision of health care during emergencies, medical tests and treatment, including those related to HIV/AIDS, should be conducted with the informed consent of the patient. All the positive and negative consequences of testing or treatment should be explained to the patient. With regard to pregnant women, there should be no routine or hidden testing of such women. Rather, as part of prenatal care, they should receive information and counselling concerning HIV/AIDS so that they may make informed and voluntary decisions, concerning testing, pregnancy, treatment and breast-feeding. Protocols to obtain informed consent and ensure confidentiality should be developed.
The establishment of voluntary testing and counselling programmes is not a priority during an emergency. Available resources for HIV testing should be devoted, first and foremost, to ensuring a safe blood supply for transfusions. As the emergency or refugee situation stabilizes, voluntary testing and counselling programmes should be made available to the affected population to the extent that they are available in the community at large. As with any voluntary counselling, pre- and post-test counselling should be provided, with informed consent being obtained during pre-test counselling.
In order to be able to cope most successfully with HIV/AIDS during emergencies, people who are infected with HIV or have AIDS should remain in their homes, communities, refugee camps and health care facilities, as appropriate, where they should have equal access to available care and support. They should not be segregated into special areas, nor should access to assistance and health care be denied due to HIV status. The right to seek and enjoy asylum should also not be denied on account of HIV/AIDS status, actual or presumed.