Forced migration and the spread of HIV/AIDS

The biology of HIV/AIDS

There are a number of modes of infection for the human immunodeficiency virus (HIV). These are:

• unprotected sex
• mother-to-child-transmission (MTCT). This can be prenatally, at the time of delivery, or postnatally through breastfeeding
• use of infected blood or blood products
• intravenous drug use with contaminated needles
• other modes of transmission involving blood such as bleeding wounds.

Once the virus enters the body, the virus attacks a particular set of cells in the human immune systems known as CD4 cells. Ultimately the virus destroys immune cells quicker then they can be replaced and the number of CD4 cells falls. In a healthy person there are 1,200 CD4 cells per microlitre of blood. In an HIV infected person, the CD4 cell count falls below 200. At this point opportunistic infections begin to occur and the person is said to have acquired immunodeficiency syndrome (AIDS).

The period from HIV infection to illness and death is crucial for the analysis and planning of the epidemic’s social, economic, and political impact. It was generally believed that in the richer countries people would live on average for ten years before they began to fall ill with AIDS. Without treatment, the normal period from the onset of AIDS to death is thought to be twelve to twenty-four months. With the development of effective antiretroviral therapies, infected people can expect to live a meaningful life for a longer period of time.

The incubation period in the developing world was thought to be shorter - between six and eight years. This is based on the assumption that people in the developing world often have poorer nutrition, lower health status, and less access to health care. However, a number of studies have also found similar incubation periods to those in the developing world ( Barnett and Whiteside 2002 : 30-34). The evidence suggests that the period from the onset of AIDS symptoms to death is shorter in developing countries because of lower health status, poorer nutrition, less access to health care, and the higher prevalence of opportunistic diseases such as tuberculosis. In addition, the vast majority of people in the developing world do not have access to antiretroviral therapy which would prolong both the HIV incubation period and the time spent living with AIDS.

Responses to the disease include, firstly, prevention. This covers the provision of male and female condoms, treatment of sexually transmitted diseases (which facilitate HIV infection), the effective screening of blood products and sterilization of medical equipment, and provision of antiretroviral drugs such as Nevirapine to mothers and children during delivery to reduce mother-to-child transmission. In addition, microbicides are currently under development. These are chemical substances that could be used vaginally and which aim to kill the HIV/AIDS viruses upon entry to the body. Interventions to prevent exposure to HIV by altering risky behaviour - ‘Knowledge, Attitude and Practices and Behaviour’ (KAPB) interventions - are also a key element in HIV/AIDS prevention. However, the problem is that even if people have the knowledge, they may not have the incentive or the power to change their behaviour. It is therefore critical to recognize the structural socio-economic and political factors that increase vulnerability to becoming infected with the disease. Please see below for more details on vulnerability.

The second response is providing treatment and care for people living with HIV/AIDS. This includes the use of antiretroviral drugs which delay the onset of full-blown AIDS and therefore allow people living with HIV to lead fulfilling and productive lives. Treatment also covers opportunistic infections arising from HIV/AIDS such as tuberculosis and pneumonia. The limited ability of developing countries to purchase antiretroviral drugs, medicines to treat opportunistic infections, and facilities to ensure their adequate provision has prevented the beneficial effects of these treatments experienced in wealthier countries. Organizations such as the Treatment Actions Campaign, Médécins Sans Frontières, ActionAid, and WHO/UNAIDS have all launched campaigns to increase access to essential HIV/AIDS drugs. The response of care includes medical, nutritional, and psychosocial support for people living with HIV/AIDS, including palliative care for those close to dying of HIV/AIDS. Care and support should also be extended to orphans, the elderly, and other vulnerable surviving family members. The third response is the search for a cure and vaccine. Neither has yet been developed.

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Forced migration and the epidemiology of HIV/AIDS

Epidemiology is the study of the distribution, frequency, and determinants of health-related events in human populations. It is based on the premise that adverse health outcomes do not occur randomly within a population but rather occur in somewhat predictable patterns. It describes the social and geographical distribution and dynamics of disease, and highlights the social and economic influences that help determine the spread of health problems such as HIV/AIDS ( Hennekens and Buring 1987 ; Lilienfield and Lilienfield 1980 ). It identifies determinants that make individuals, groups, or a society more or less vulnerable to epidemic spread, and vulnerable to the adverse consequences resulting from illness and death. Barnett and Whiteside (2002: 65) note how ‘pathways of infection are mapped on to social, cultural and economic relations between groups of human beings … We all share the same world, but unequally, so are differentially exposed to disease organisms.’

Prevalence is the most commonly used epidemiological measurement of HIV/AIDS and refers to the percentage of the population which exhibits HIV or AIDS at a particular point in time. There is an important difference between prevalence rates and mortality rates because of the long cycle of progression from HIV to AIDS (and the variation in the onset of AIDS to death). For example, South Africa has a prevalence rate of around 20 per cent amongst the adult population, whilst the annual AIDS death rate (mortality rate) over the next decade is projected to be between 1.5 per cent and 4 per cent of the adult population (UNAIDS, ‘Report on the Global HIV/AIDS Epidemic’, July 2002 - http://www.unaids.org/EN/resources/publications/corporate+publications/report+on+the+global+hiv_aids+epidemic+2002+.asp).

The mass movement of people is commonly understood to be a key factor in the geographic spread of communicable disease, including HIV/AIDS ( Minas 2001 ; Smith 2002 ; UNAIDS February 2001; UNAIDS June 2000 ). Similarly, the negative impact of political violence upon health, and the influence of different typologies of conflict upon health, is increasingly well recognized ( Murray et al., 2002 ; Richard et al. 1999 ; Noji 1997 ; Connolly and Heymann 2002 ; Levy and Sidel 1997 ).

However, it is virtually impossible to provide a standardized picture of morbidity and mortality in forced migrant populations. This is because of the wide variation in the availability and quality of health services in the conflict-afflicted and host countries, as well as in levels of wealth, epidemiological conditions, the type of settlement, and the prevalence and nature of the political violence. In addition, the epidemiological evidence on the link between HIV/AIDS and forced migration remains scarce and often subject to high levels of bias ( Hynes et al. 2002 ; Salama and Dondero 2001 ; Spiegel et al. 2001b ). This is largely due to the inherent difficulties associated with operating in a complex emergency situation. For example, the population movement means it is difficult to identify whether changes in prevalence rates are due to changes in risk factors, or fluctuating numbers of people (denominators). Many poor countries also lack reliable health registration systems, making it particularly difficult to get baseline demographic and health data, and denominators to determine the extent of HIV-related mortality and morbidity amongst displaced peoples. Refugees and internally displaced persons are also frequently not systematically included in HIV surveillance systems, and those forced migrants that are able to access these sites are not necessarily representative of the entire forced migrant population. For example, sentinel surveys to estimate HIV prevalence are also usually carried out in antenatal clinics and centres for treating sexually transmitted infections (STIs). In areas affected by conflict, these are most often not functioning. Such data collection is further impeded by insecurity, political involvement, restricted access to areas of conflict and sources of information, public fear and mistrust, lack of infrastructure, and lack of trained people to carry out the survey. HIV/AIDS may also be an underlying cause of mortality from diseases such as pneumonia and tuberculosis but is frequently not recorded as such. Lastly, displaced persons are very often left off the agenda of host governments. Even in more stable countries, such as Uganda and Thailand, which are often viewed as models of best practice in HIV surveillance and prevention, virtually no data exist about the HIV status of their large forced-migrant populations ( Salama and Dondero 2001 ).

It was previously assumed that conflict itself increased HIV infection rates because of its impact upon health systems causing reduced capacity to screen blood/blood products, use of non-sterile medical equipment, reduced testing and treatment for HIV/AIDS and other sexually transmitted infections (STIs), and halting of HIV/AIDS prevention programmes. However, research at UNHCR has challenged this ( Spiegel 2002 ; Spiegel and Qassim 2003; Spiegel and Nankoe 2004 ). The research has noted that the increased risk and vulnerability encountered during conflict does not inevitably mean increased exposure and infection to HIV/AIDS. The main factor that would appear to decrease HIV transmission in conflict situations is reduced population mobility due to destroyed infrastructure, trade, and conflict in surrounding areas. There is also evidence for decreased consensual sex due to trauma and depression ( Green 2003 ). Research by the Centres for Disease Control and Prevention (CDC) confirms such findings. Prevalence rates in Sierra Leone were 0.9 per cent and in Southern Sudan, 2.3 per cent. These were both lower than all surrounding countries, many of which have not been in conflict ( Kaiser et al. 2002 ). Low HIV prevalence rates relative to surrounding countries have also been reported in Angola, which suffered from decades of civil war ( De Jong and Spiegel 2003 ). As a result, HIV prevalence rates in some areas of conflict appear lower than in more stable neighbouring areas. The majority of refugees are therefore moving from conflict countries with lower HIV prevalence rates than those in which they seek refuge ( Spiegel and Qassim 2003).

The danger is that as people are forced to leave conflict-affected areas, they are placed at increased risk as they move into areas of increased HIV/AIDS prevalence. Data indicates that amongst some refugee populations HIV/AIDS rates do increase. A resultant critical issue is the post-conflict period, as displaced people with potentially higher HIV/AIDS prevalence rates return to communities with lower rates. For example, prevalence rates among Rwandan returnees from Tanzania and Zaire was found to be 9 per cent, compared to prewar rates of 1 per cent in the rural areas from which 95 per cent of them came ( Schrek 2000 ). Data from Angola also raises concerns about the risk of increased HIV rates in the general population following the return of refugees. The HIV prevalence rate in Angola is 1 to 4 per cent, whilst among Angolan refugees in neighbouring countries (Zambia and Namibia) it stands at 5 to 10 per cent, and among host communities in these neighbouring countries at 15 to 25 per cent ( Spiegel and Qassim 2003). In Mozambique, sentinel surveys show that the HIV levels of high-risk populations were relatively low until the war ended, at which point the resumption of normal patterns of social mixing occurred alongside a marked rise in prevalence rates ( UNAIDS/WHO, 2000b ). Similar concerns are also expressed about Sierra Leone ( ARC/CARE/IRC 2004 : 24-5). The risk of rapidly increasing prevalence rates in post-conflict countries rises further as trade, transport, and population mobility all increase whilst health systems and HIV/AIDS prevention work remain limited. The importance of integrating HIV/AIDS programmes in post-conflict reconstruction efforts is therefore paramount.

The risk faced by displaced persons entering areas of higher prevalence rates are inextricably linked to other issues of vulnerability and these are discussed further in the following section.

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Forced migration and increased vulnerability to HIV/AIDS

In addition to the risks of entering areas with higher HIV/AIDS prevalence rates, forced migration can increase vulnerability to becoming infected with HIV/AIDS and the effects of the disease. This includes exacerbating existing factors of vulnerability to becoming infected with HIV/AIDS such as poverty, poor access to health care, poor nutrition, lack of education, and political, economic, and social discrimination. The breakdown of social structures and networks, lack of local language and knowledge of the new environment further increase vulnerability. Forced migrant populations are frequently politically and economically marginalized groups who may not have had equitable access to health programme resources and are unlikely to have a political voice. The prejudice and stigma associated with HIV/AIDS can also become particularly virulent when combined with stigma directed at displaced persons ( Salama and Dondero 2001 ; Decosas 1995 ).

The main cause of HIV/AIDS infection is sexual transmission, and those caught up in and fleeing from complex emergencies tend to be more vulnerable to sexual transmission for a number of reasons. Firstly, increased sexual violence and rape. Combatants have frequently used rape as a weapon of war, with examples of systematic rape found from the conflicts in Mozambique, Rwanda, Liberia, Sierra Leone, Sri Lanka, Bosnia, Kosovo, and Sudan ( Elliot 1999 ; Donovan 2002 ; Amnesty International 2004 ). Increases in HIV infections amongst the general population in Eastern Democratic Republic of Congo (DRC) (HIV prevalence between 15 and 24 per cent) have been attributed to massive sexual violence by paramilitary groups and foreign militaries, as well as the general breakdown in health services ( Save the Children 2001 ). According to one UN official, rape by the military and civilians alike of refugee populations has become systematic in conflict-affected countries such as DRC, and despite the known risk of HIV, the authorities are doing little to control the epidemic (quoted in Smith 2002 : 8). A survey among Burundian refugees in a Tanzanian camp identified that 26 per cent of women had experienced sexual violence since becoming a refugee ( Holmes 2001 ). The cramped conditions and layout of refugee camps may also increase the vulnerability of women and young girls and boys to sexual abuse.

Secondly, increased use of sex as a commodity by women as a result of losing income caused by crisis and displacement. According to a 1999 WHO study in eastern and central Sudan, 27 per cent of single mothers surveyed had become sex workers to earn a living. Orphaned and unaccompanied children are particularly at risk in emergencies and often end up forced to trade sex for provisions, including to peace-keepers ( Renaud 2001 ; Lawday and Webb 2002 ).

Thirdly, the breakdown of family, social, and/or cultural structures and consequent loss of norms that regulate sexual activity in stable conditions can also increase higher risk sexual activity and therefore vulnerability to HIV/AIDS. For example, there may be a desire to replace lost loved ones, either by having new children or by developing relationships with new partners. In the absence of formative social structures and the constraining influence of family and community, adolescents are also more likely to engage in risky behaviour such as alcohol or drug abuse, and increased sexual activity. In environments in which war is the norm and life-expectancy is low, there is an understandable lack of concern about HIV/AIDS when there are other, much more immediate threats such as violence, malnutrition, and more immediately debilitating diseases ( Smith 2002 : 8).

Fourthly, the sexual behaviour of armed forces, including peace-keeping units, can further spread HIV/AIDS ( Smallman-Raynor and Cliff 1991 ; Hankins et al. 2002 ; Elbe 2003 ). The high-risk sexual behaviour associated with military forces and peace-keepers has resulted in prevalence rates being far higher among military personnel than the civilian population in both their countries of origin and those in which they are operating. In Cambodia surveys estimate the HIV prevalence rate for military personnel to be 8 per cent, while the rate among the Cambodian civilian population is 2.7 per cent ( UNAIDS 2000a ). According to one report, 32 per cent of peace-keepers in Sierra Leone originate from countries with HIV prevalence rates greater than 5 per cent (quoted in Elbe 2003 : 40). A 2001 unpublished study in Sierra Leone conducted interviews with a sample of 202 United Nations’ peace-keepers and soldiers from the national army, and found that only 23 per cent of respondents could spontaneously cite at least three routes of AIDS transmission; 38 per cent reported not being worried about AIDS; and only 39 per cent had used a condom during their last sexual activity ( ARC 2001 ). The effect is that armed personnel and peace -keepers act as vectors of the disease to the civilian population they are mandated to protect. Little research appears to exist on the evidence of transmission of HIV/AIDS from armed forces and peace-keepers to displaced people specifically. However, given the close proximity between displaced persons and armed forces/peace-keepers, and high rates of voluntary, paid, and coerced sexual interaction between these groups, transmission rates could be hypothesized to be high.

The nature of settlement for displaced persons is also critical when addressing levels of vulnerability. Well-organized refugee camps may offer improved protection, nutrition, health services (including for HIV/AIDS prevention, treatment of opportunistic infections and care), education, and social services ( Spiegel 2004b ). The duration time in camps is also relevant, with long-term post-emergency refugee camps generally having better preventive and curative health services than the shorter term camps, and the surrounding local host population ( Spiegel et al. 2002 ; Hynes et al. 2002 ). For example, research by UNHCR has found that there is a pattern of reduced HIV rates in camp populations. Using antenatal sentinel surveillance, HIV prevalence was measured among pregnant women in more than twenty camps housing around 800,000 refugees in Kenya, Rwanda, Sudan, and Tanzania. Results showed that the refugee populations in three of the four countries had significantly lower HIV prevalence rates than the surrounding host communities. In the fourth, the refugees and host community had comparable rates ( Spiegel 2002 ). However, the results of these studies should not be used as an argument to ignore the needs of displaced persons. As Sam Guy from Marie Stopes International (MSI) and the Reproductive Health Response in Conflict Consortium (RHRC) notes, ‘the aim of any HIV/AIDS programme is to reduce transmission and if levels are low in these settings then we have the best possible reason to step-up prevention activities to ensure that they stay low. Not only is this good public health, it also makes sense in terms of reducing costs for treatment and care in the future’ ( Guy 2004 ).

However, where camps are more open (where population movement is less restricted and interaction with the local community higher), the HIV/AIDS risk would also appear higher ( Salama and Dondero 2001 ). In situations where refugees and IDPs are dispersed the risks of contracting HIV/AIDS appear much higher because the protective factors in camps is removed and people are generally placed in environments of higher HIV/AIDS prevalence (see previous section ^X). Given that an estimated 60 to 75 per cent of Africa’s refugees may have never lived in camps, large numbers of displaced persons are therefore placed at increased risk of HIV/AIDS in their new surroundings.

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Vulnerable groups

Between 75 and 80 per cent of displaced persons worldwide are women and children ( http://www.unhcr.org/cgi-bin/texis/vtx/statistics), and amongst groups of displaced persons, women and children appear at particular risk of contracting HIV/AIDS. In sub-Saharan Africa, women are at least 1.2 times more likely to be infected with HIV than men. Among young people aged 15 to 24, women were found to be two-and-a-half times as likely to be HIV infected as their male counterparts. Women are sexually active from an earlier age than men and infected on average six to ten years younger than men, and are biologically more vulnerable to contracting HIV ( AIDS epidemic update, UNAIDS 2003a : 7). The lower social status of women also magnifies their vulnerability to being infected with HIV/AIDS, and vulnerability to its impact. The above mentioned risk of exploitation and abuse, including coercion into transactional sex for survival, is further increased in conflict situations. Many of the burdens of HIV/AIDS at the household level fall upon women, as they are the main producers of food and the main carers for children, the elderly, and the sick. The high levels of female mortality as a result of HIV/AIDS commonly result in increasing malnutrition amongst children and deterioration of household security and stability ( World Bank 2000a ).

Adolescents (aged 10 to 24) are at most risk of HIV infection, with 50 per cent of all new infections occurring amongst this age group (UNICEF, http://www.unicef.org/aids/index.html). Despite this there appear to be insufficient operational sexual health programmes targeting displaced adolescents (Women’s Commission 2000, see http://www.womenscommission.org/pdf/adol2.pdf). One study found that 30 per cent of adolescent girls aged 15 to 19 in Sierra Leone had not heard of AIDS ( UNICEF 2000 ). Many children and young people orphaned by HIV/AIDS are frequently forced to become carers instead of being cared for. Those unable to care for themselves are less able to rely on an extended family or support network because of HIV/AIDS mortality and also the stigma associated with the disease. Such children and young people are particularly at risk of undertaking commercial sex, and of joining or being abducted by local militias who offer food, shelter, and identity. This abusive use of children as soldiers and the extreme actions they are led to commit puts this group at increased risk of contracting HIV ( Lawday and Webb 2002 : 5; UNICEF/USAID/UNAIDS 2002 ; Barnett and Whiteside 2002 : 210).

Within the displaced populations, it appears that Internally Displaced Persons (IDPs) are at a greater degree of risk for several reasons. IDPs’ access to health care is often more limited, particularly as it may be offered by the government that caused their displacement in the first place. They are often far more difficult to access by humanitarian agencies and so less likely to receive health information and services, and generally suffer worse health outcomes than refugees or host populations as a result ( WHO 2000 ; Salama et al. 2001 ; Lawday and Webb 2002 : 14). Higher rates of integration into host communities may also increase HIV/AIDS transmission rates between the two groups. In a study of IDPs in Burundi, only one in twenty IDPs could identify condoms as a means of protection against HIV/AIDS ( Wexler 2003 : 11-13). A 1996 national HIV prevalence survey in Rwanda revealed an overall prevalence rate of 11 per cent, with the highest rates of 13.9 per cent found in IDPs ( Mayaud 2001 ).

Similarly, knowledge on the situation for refugees not living in camps, such as urban refugees, is limited. However, it is expected that their vulnerability is higher than those living in camps. Dispersed and urban refugees are often less documented and so receive less material support from UNHCR or other agencies, and rely upon host government services that may discriminate against them ( Bruns and Spiegel 2003 ; Spiegel and Qassim 2003: 72-4). Evidence from urban refugees in South Africa suggests they are at considerably greater risk ( Spiegel and Nankoe 2004 ).

Those who have directly suffered trauma of one sort or another are perceived as being at greater risk, and typically psycho-social programmes are used to help people cope with trauma, whether from conflict, epidemics or other distressing events. However, the notion of trauma and use of psycho-social programmes is heavily contested. It is criticized for being a Western concept that is not necessarily applicable to non-Western populations where people may have different understandings of such events and how to survive them. It is also criticized for depicting passive, vulnerable victims to events, whereas in fact most people are able to function and survive, developing coping mechanisms appropriate to their situations. ( Ager 1997 ; Bracken et al. 1995 ; Richters 1998 ; Summerfield 1996 , 1999 ; Wessells 1999 ). It is argued that a more effective way to support people who have experienced trauma is to develop on-going support structures from within a community and activities that promote a community’s well-being.

However, the degree to which people are able to cope in such circumstances and the notion of coping itself has also been questioned, particularly the ability to survive in the short term often at the expense of future well-being ( Lawday and Webb 2002 : 5; Harvey 2003 : Barnett and Whiteside 2002 : 325-7). Examples include the withdrawal of children from schools, women being forced to become sex workers, and the sale of household assets to provide additional family income and time for caring for vulnerable relatives.

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