|Guidelines for HIV Interventions in Emergency Settings (UNAIDS - UNHCR - WHO - OMS, 1996, 59 p.)|
HIV spreads fastest in conditions of poverty, powerlessness and social instability - conditions that are often at their most extreme during emergencies. Moreover, in situations of war and civil strife there is a strong likelihood that AIDS control activities, whether undertaken by national governments or NGOs, will have been severely disrupted or have broken down altogether. Thus people are left with very little scope for protecting themselves - no matter how well-informed or well-intentioned they are - at a time when they are especially vulnerable.
The following are some of the factors that encourage the spread of HIV during emergencies:
· In situations of war and civil strife particularly, women and children are at increased risk of violence, including rape. In some conflicts rape is used as a method of persecution in systematic campaigns of terror and intimidation against certain population groups, and indeed may be the root cause of flight from home. But even where this is not the case, displaced women and girls are vulnerable to sexual abuse at every stage of their flight, and many find themselves coerced into sex to gain access to basic needs such as food, water, shelter or security. If either partner in the sex act is HIV-infected, the risk of passing on the virus to the other is especially high since coercive sex is likely to result in tears or other injuries to the genitals.
· Displaced men and boys may also be powerless and therefore vulnerable to physical abuse. They may be subjected to similar forms of sexual violation as well. Prisoners and captives are at special risk.
· The disintegration of community and family life means the break-up of stable relationships and the loss of mutual support, as well as the loosening of cultural and familial controls on behaviour. Fleeing populations generally have a high proportion of unaccompanied minors, particularly single females. According to UNHCR, roughly 75% of the worlds refugees are women and children.
· Experience from refugee camps shows that children with too little to occupy themselves, uncertain of their future, and often with no one to account to for their behaviour, tend to become sexually active at an earlier age than they would under normal conditions.
· People cut off from their normal sources of income and basic needs, may find that selling sex is one of very few survival strategies open to them. The experience of many refugee camps has been that the sex industry has flourished, becoming part of the interaction between the refugee population and the local people in the host country.
· Forced migration often entails people from rural areas moving to heavily-populated areas on the outskirts of towns. Rural areas generally have a significantly lower HIV prevalence than urban areas; as rural populations are less aware of means of prevention, the risks of infection increase dramatically.
· Drug injecting as a vector for the spread of HIV is rivalling sexual transmission in some countries. If a population containing many drug injectors flees an area, traffickers and dealers will flee as well, taking any portable wealth (i.e. drugs) with them. Experience suggests that injectors without the drug of their choice will inject anything - from opium to disinfectant.
· In emergency settings, the risk of HIV transmission through the transfusion of contaminated blood may be high. More transfusions than usual may be needed, especially in situations of war and civil strife and given the poor nutritional status of women and children; the displaced people may come from a high-prevalence area; and resources and infrastructure for screening may be lacking. Despite the difficulties, ensuring a safe blood supply is a priority in these settings.
These factors are part of the complex dynamic of HIV/AIDS in emergency situations and need to be understood by local authorities and the donor community, when they are deciding where and how to intervene.
To the extent possible, new activities should be integrated into what is already being done and local resources should be used. This is an early priority: failure to establish trust and a working relationship with those in authority has so often led to obstruction and delays - to vital supplies being held up at ports for want of customs clearance; to duplication of activities; or to materials being shipped in from outside when they are available locally.