Challenges

Increasing resources and commitment

The global response to HIV/AIDS generally has expanded significantly in the past few years. However these developments do not match the epidemic’s scale or pace. There is an urgent need to boost prevention programmes, and antiretroviral treatment coverage remains dismal in sub-Saharan Africa overall ( UNAIDS/WHO 2003a : 4). Assistance for displaced people and in conflict situations is particularly scant ( Lubbers 2003 ; Smith 2002 ; Lawday and Webb 2002 ; ICG April 2004 ; De Cock et al. 2002 ).

According to a report commissioned by Save the Children, the ‘lack of international funding is the single largest obstacle to reducing the spread of HIV in conflict situations. Without a greatly enhanced response and funding, conflict-affected countries will not meet their UN commitments on HIV/AIDS to meet basic needs and provide prevention, care and support, to alleviate the impact and to assist children affected by HIV/AIDS’ ( Lawday and Webb 2002 : 1).

The Global Fund for AIDS, Tuberculosis, and Malaria (GFATM, http://www.theglobalfund.org/en/) represents the largest multi-lateral funding agency for HIV/AIDS. However it has been criticized for failing to take into account the needs of displaced persons ( Spiegel 2004b ). For example, in the first round of disbursements by GFATM in early 2002, conflict-affected countries were largely bypassed, with only Burundi, Rwanda, and Cambodia receiving funds for HIV/AIDS prevention and care work. In a study of funded projects up to the third GFATM funding round, of twenty-nine countries with refugee populations of more than 10,000 in Africa, twenty-three had approved proposals with an HIV/AIDS component for the GFATM. However, only five included refugees in their proposals and of those five only three gave specific details of activities with refugees ( Spiegel and Nankoe 2004 ). For example, Uganda and Thailand, widely viewed models of best practice, both failed to include displaced persons in GFATM-approved projects worth over $157,000,000 despite having 236,041 and 121,715 displaced persons respectively (Please see below for links for funding provided by GFATM to specific countries, and for numbers of displaced persons.) Funding by the World Bank’s Multi Country AIDS Programme fares a little better (for map, see http://www.worldbank.org/afr/aids/map.htm). Of the twenty-nine countries with refugee populations of more than 10,000 in Africa, sixteen were funded, but only eight gave specific details of activities with refugees ( Spiegel 2004b ). Ruud Lubbers, the UN High Commissioner for Refugees, noted that ‘not only are refugees accused of spreading HIV and other diseases, but they are often excluded from multi-million dollar HIV/AIDS programmes … The development of integrated HIV/AIDS strategies would be given an enormous boost if donor governments would loosen current restrictions on funding so money can be used more flexibly to provide HIV/AIDS programmes to both refugees and local communities’ ( Lubbers 2003b ).

The US administration’s ‘President’s Emergency Plan for AIDS Relief’ (PEPFAR, http://www.state.gov/s/gac/rl/or/c11652.htm), which as of July 2004 had pledged $15 billion over five years to fight HIV/AIDS, has also failed to take into account the needs of displaced peoples, and has incurred the anger of many within the HIV/AIDS community because of its faith-based policies, particularly the prioritization of abstinence over condoms to prevent HIV/AIDS. At the time of the XV International AIDS Conference in Bangkok in July 2004, Dr Peter Piot, Executive Director of UNAIDS, declared that ‘we know condoms save lives. We are not in the business of morality. Condom promotion should be part of education about sexuality for young people.’ Poul Nielson, the EU’s Commissioner for Development and Humanitarian Aid, criticized US administration for ‘preaching one line only and denying people’s rights by trying to push them into abstinence. It will weaken the battle against Aids, and the unfortunate reality is that it will directly endanger the lives of millions of women’ ( http://observer.guardian.co.uk/international/story/0,,1258589,00.html).

Despite increasing concern over potentially rapid increases in HIV/AIDS prevalence in post-conflict situations, there remains a weakness in factoring in AIDS into conflict resolution activities. Peter Piot stated to the UN Security Council on 17 November 2003 that ‘I do note with some regret, however, that the Security Council has not taken the opportunity to expressly address AIDS in a number of recent resolutions establishing and extending UN missions, especially given that some of these missions are operating in regions which already have major HIV epidemics’ (quoted in Elbe 2003 :67). Analysts must take more seriously the growing burden of widespread illnesses such as HIV/AIDS when surveying the contemporary strategic landscape and the implications this may have for forced migration ( Elbe 2003 : 67).

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Increasing support of host governments

The capacity of governments to respond to the overall HIV/AIDS crisis is clearly limited, with many countries struggling to provide adequate services to their own populations, particularly in post-conflict situations. The need to support host governments and encourage strong leadership in their HIV/AIDS programmes is paramount ( DFID 2004 : 24-30, http://www.dfid.gov.uk/Pubs/files/HIVAIDStakingaction.pdf). A study by Kennedy et al. revealed that despite the high risk of rapidly rising HIV/AIDS prevalence rates, Liberia ‘is in a stage of vague awareness … regarding HIV/AIDS-related activities … there is a critical need to acquire adequate resources and build capacity to implement effective HIV/AIDS-related programming services’ ( Kennedy et al. 2004 : 169-80).

It also appears that many host countries often do not view refugee health programmes as within the scope of their national aids control programmes, relying instead upon UNHCR to look after the welfare of these populations ( Salama and Dondero 2001 : 15 (suppl. 3), S8). In a UNHCR study of twenty-two African countries with over 10,000 refugees, only fourteen HIV/AIDS National Strategic Plans mention refugees, and only ten have any specific activities aimed at refugees ( Spiegel 2004b : p.713). Spiegel ( Spiegel and Nankoe 2004 : 23) notes that ‘Refugees have been systematically excluded from many host countries. HIV/AIDS National Strategic Plans … improving HIV/AIDS interventions for refugees in an integrated manner with the surrounding host population will invariably improve services for both communities.’ Rudd Lubbers, the High Commissioner for Refugees noted that ‘host countries should stop excluding refugees from their AIDS programmes. It is highly discriminatory and totally counter-productive … these individuals have been neglected for too long’ ( Lubbers 2004 ).

Thailand, Uganda, and Senegal have all developed relatively successful HIV surveillance and prevention systems and yet virtually no specific data exist about the HIV status of their large forced migrant populations ( Salama and Dondero 2001 : S4-S12). The danger is that as a result, their needs will be largely ignored. De Waal (2003: 1-23) also notes that regional government initiatives such as the ‘New Partnership for Africa’s Development’ (NEPAD) ‘include scant reference to HIV/AIDS as a public health problem and none at all to its development impact - or the impact upon conflict and security’.

The failure of governments to incorporate displaced persons into their national AIDS activities and surveillance systems has implications for HIV/AIDS funding for displaced persons - particularly where governments take the main management role. In a study by Brugha et al. (2004: 95-100) of experiences to date with the GFATM, one representative in Tanzania noted that ‘there is an imbalance of power in favour of [government], which is talking only on behalf of government …’. The result is that agencies representing displaced persons are marginalized from the main sources of AIDS funding. In Tanzania, there are no specific activities mentioned for displaced persons in any of the three accepted GFATM projects which total over US$109,707,298 in approved funds. This is despite the fact that Tanzania has an estimated 649,940 displaced persons within its borders. Please see below for links for funding provided by GFATM to specific countries, and for numbers of displaced persons.

Governments also need to work hard to change the atmosphere of discrimination against both displaced peoples and those with HIV/AIDS, and to reduce social and economic vulnerability by promotion inclusion and participation. They must also ensure that HIV/AIDS testing is voluntary, and that HIV/AIDS status will not affect the legal status of refugee and its associated benefits. Without such assurance, displaced persons will inevitably avoid government services.

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Towards a more comprehensive provision of services

The difficulties faced by staff of humanitarian agencies in such complex emergency situations are considerable, and concerns exist as to whether work on HIV is beyond their organizational remit, and whether the particular skills required by emergency programming are suited to addressing HIV-related issues. Lawday and Webb, of Save the Children, note that ‘humanitarian efforts to tackle HIV/AIDS have concentrated on preparing guidelines that field staff have often lacked the capacity and confidence to implement’ ( Lawday and Webb 2002 : 2). Staff are also hampered by the lack of data and information on effective HIV interventions in emergency settings. The attitudes of local authorities have had a detrimental effect upon agencies’ abilities to provide such services ( Smith 2002 : 23).

HIV/AIDS services to displaced persons appear to be caught in the debate between humanitarianism and development, with some humanitarian agencies seeing it as the work of specialist development and HIV/AIDS practitioners, whilst development and HIV/AIDS practitioners commonly see any services for displaced persons as purely humanitarian. Despite the links between emergencies and HIV vulnerability, agencies’ humanitarian emergency operations have tended to focus on meeting basic needs, providing shelter and food, and treating infectious diseases such as measles, cholera, and dysentery ( Smith 2002 ). Whilst some emergency health interventions may address immediate, biomedical aspects of HIV/AIDS vulnerability and transmission, by their very nature they generally fail to address the underlying social and economic issues related to HIV and displacement that a longer-term development approach would be more suited for.

In addition, the context of conflict situations has changed over the past decade - camp scenarios are no longer the norm since populations are often dispersed among local communities. In many conflict situations, ongoing war has led to ‘chronic emergencies’ affecting entire countries and with long rehabilitation phases such as have occurred in Afghanistan, Angola, Somalia, and the DRC. In such situations longer term HIV/AIDS work is essential as the increased risk and prevalence of the disease presents major threats to the long-term health of these populations.

The result appears to be that some agencies are failing adequately to provide HIV/AIDS services. A September 2000 study by the Women’s Commission for Refugee Women and Children indicated that of the eighty agencies surveyed, only eight had a reproductive health for refugees policy or guidelines. Among US-based international NGOs included in the study, only 22 per cent were addressing HIV/AIDS programming ( Women’s Commission 2000b ). In a survey of refugee settings worldwide, UNHCR found that Voluntary Counselling and Testing (VCT) is not available in most programmes ( UNHCR, HIV/AIDS and Refugees: UNHCR’s Strategic Plan 2002-2004, Geneva, 2004 ). Similarly, STI services are still neglected, despite their relative simplicity and strong evidence for effectiveness in reducing HIV/AIDS transmission in refugee settings ( Mayaud 2003 ; Mayaud et al. 2001 : 121-4). Mother-to-child transmission (MTCT) prevention programmes also do not seem to be universally applied, despite evidence suggesting that MTCT can be higher during complex humanitarian emergencies ( Khaw 2000 ). A 1999 study by MERLIN revealed that out of thirteen HIV/AIDS programmes for displaced people, only three provided home-based care for terminally ill people and only one included income-generating activities to support orphans ( Young 1999a ). UNICEF have also reported failures in developing programmes for young people ( UNICEF 2000 ; UNICEF/USAID/UNAIDS 2002 ). A report by Save the Children notes that ‘humanitarian agencies operation in most conflict settings are failing to respond adequately to the threat of HIV/AIDS. Struggling to provide for basic needs, humanitarian agencies are neglecting their responsibility to provide refugees and displaced peoples with access to HIV prevention and treatment services’ ( Lawday and Webb 2002 : 1). The active participation of displaced people, particularly vulnerable groups, in supporting programme activities would also appear to be paramount.

However, some agencies have managed to overcome these challenges and are providing A more comprehensive range of reproductive health and HIV/AIDS services. Agencies such as ARC, IRC, and UNHCR are conducting surveillance, VCT and prevention of MTCT activities in their respective programmes with displaced and conflict-affected populations in Kenya, Uganda, Tanzania, and Sierra Leone. The benefits of providing services in refugee camps were highlighted by results from the study by Kabagabo et al. (1999) of HIV sero-survey. This revealed an overall HIV prevalence of 11.1 per cent compared to people who had been displaced in camps outside the country (10.5 per cent) with the lowest rates among returning long-term exiles (9.7 per cent). It appeared that rates were lowest amongst those returning from camps in Tanzania (compared to Zaire or Burundi), where HIV/AIDS prevention and STI interventions had been greater ( Mayaud 2001 : 121-4). Results from an HIV/AIDS prevention project run by ARC also indicate the benefits of implementing such activities in post-conflict settings ( ARC/RHRC 2003 , see http://www.rhrc.org/pdf/ARCSLPostInterventionSurvey.pdf). To ensure such progress becomes more widespread, ‘there is a need to increase advocacy efforts aimed at humanitarian agencies to encourage their support of HIV/AIDS programming’ ( Purdin et al., 2001 ). In addition, governments and donors need to support agencies in the scaling up of HIV/AIDS services.

It is critical to ensure that such work is integrated and coordinated with HIV/AIDS programmes by local health authorities for the host population. If longer-term support is going to be provided by agencies, it inevitably requires the consent and support of the host government. It is crucial that the needs of the previously under-served minority groups are recognized and that more equitable and appropriate access to health services is ensured, in order to avoid a continuance of problems (that may have led to the conflict or displacement itself).

Care and treatment

There is considerable debate over the provision of antiretroviral treatment for HIV/AIDS for displaced persons, with concerns raised over costs, and the ability to maintain provision and access for treatment due to population movement and return. There is also the possibility of reduced treatment efficacy if drug-resistance rises as a result of non-compliance. This is particularly pertinent as displaced persons may repatriate to areas where ARV treatment is not available. The potential effects of increasing drug resistance could have quite serious public health implications. UNHCR are currently developing a strategy to address this issue.

There is also concern that the increasing focus on treatment will undermine prevention, and lead to a remedicalization of HIV/AIDS, and so distract from attempts to recognize and address the social and economic determinants of the disease ( Barnett and Whiteside 2002 : 364). There is debate regarding the treatment of tuberculosis (which as an opportunistic infection accounts for over a third of AIDS deaths worldwide) for displaced persons due to concerns over treatment continuity and drug-resistance arising from halted treatment regimes.

However, others question the ethics of denying treatment to displaced persons whilst settled populations are increasingly provided with it. The declaration by the Ugandan government to provide free antiretrovirals could prove a test case with regard to the large numbers of refugees and IDPs residing there. Examples already exist of the provision of antiretrovirals in conflict areas by humanitarian agencies, with MSF (Holland) providing antiretrovirals in the DRC. The apparent scaling up of antiretroviral treatment generally, as a result of initiatives such as WHO’s 3X5, the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM), and the (US) ‘President’s Emergency Plan for AIDS Relief’ (PEPFAR), would suggest that it is likely that an increasing number of displaced persons will be receiving treatment prior to displacement. Humanitarian agencies and host governments may therefore be required to provide for the continuation of such people’s treatment.

Protection

Fundamental to protecting the human rights of people living with HIV/AIDS are the issues of stigma and discrimination. HIV/AIDS-related stigma can be described as a ‘process of devaluation’ of people either living with or associated with HIV/AIDS ( UNAIDS 2003b ). This often stems from the underlying stigmatization of sex and intravenous drug use - two of the primary routes of HIV infection. HIV/AIDS-related stigma builds upon, and reinforces, existing prejudices. It also plays into, and strengthens, existing social inequalities - especially those of gender, sexuality, and race. The risk is that where stigma exists people may prefer to ignore their real or possible HIV status. This can increase the risk of faster disease progression for themselves as well as the risk of spreading HIV to others.

Discrimination follows stigma and is the unfair and unjust treatment of an individual based on his or her real or perceived HIV status. Discrimination occurs when a distinction is made against a person that results in their being treated unfairly and unjustly on the basis of their belonging, or being perceived to belong, to a particular group. When applied to displaced persons, both stigma and discrimination can become particularly pronounced in both the new area of settlement and upon return to the area of origin. It can occur at the social and economic level with reduced access to health and education services, and employment opportunities. It can also occur at the political level, with governments applying or threatening to apply compulsory HIV/AIDS testing, and resultant refusal of entry or repatriation dependent on the test result. Such policies breach fundamental human rights as well as leading displaced persons to avoid the authorities, including health services, for fear of repatriation. This risks faster disease progression for people living with HIV/AIDS and increasing the spread of HIV/AIDS to others ( All Party Parliamentary Committee on HIV/AIDS 2003 ).

Concerns exist that the immediate, biomedical aspects of HIV/AIDS still dominate, and that insufficient emphasis is being placed on protection issues and vulnerability of women at risk from gender-based violence and rape, and orphans and children separated from their parents during conflict and displacement ( Smith 2002 ; Ward and Brewer 2004 ). Whilst there is increasing recognition of protection issues in HIV/AIDS policies and guidelines for displaced persons, it would appear that much remains to be done ( Beatty et al. 2004 ; Ward and Brewer 2004 ; Ward 2002 ).

Surveillance, research, and evaluation

Despite the difficulties of conducting HIV/AIDS surveillance (see section 2.2 ^X), methodologies do exist for use in both an acute emergency phase and the post-emergency phase. This should ideally include both biological (or serological) surveillance which looks at biologically recorded rates of HIV/AIDS and HIV/AIDS-related diseases such as STIs, tuberculosis and other opportunistic infections, and also behavioural trends (behavioural surveillance). Examples of effective surveillance include programmes by ARC in Sierra Leone and UNHCR in Rwandan refugee camps in Tanzania. Surveillance methodologies can also be found at UNAIDS, including guidelines for resource-constrained settings (please see below for web links). However, there remains a dearth of HIV/AIDS behavioural and biological data in situations of forced migration. Refugees and IDPs frequently remain excluded from national HIV surveillance systems, and those forced migrants that are able to access these sites are not necessarily representative of the entire forced migrant population ( Salama and Dondero 2001 : S4-S12; Spiegel 2004b : 11). IDPs and urban refugees not living in camps are particularly poorly documented and so often excluded from governmental and non-governmental assistance programmes ( Spiegel 2004b : 713). Such data, especially serial data to establish trends, are essential in directing, monitoring, and evaluating HIV/AIDS programmes. Such data will also improve the current, limited understanding of how conflict and displacement affect the spread of HIV/AIDS.

There is a need for a better evidence base on HIV/AIDS interventions for displaced persons, with NGO staff expressing frustration at the lack of evaluation and information on effective HIV interventions in emergency settings ( Smith 2002 : 23). Potential areas of investigation include:

• methods to improve integration of HIV/AIDS programmes among displaced and non-displaced populations
• policies and programmes to reduce HIV/AIDS stigma and discrimination towards displaced populations from local communities/governments
• findings on the provision of antiretroviral treatment to displaced persons
• interactions between armed groups, conflict-affected populations and surrounding communities
• cost-effectiveness analysis of HIV/AIDS interventions among displaced persons
• the impact of HIV/AIDS on people’s desire to return to their home area.

Informed consent in combination with the active participation of community members in the design and implementation of surveillance systems are critically important safeguards in reducing prejudice and stigma against those with HIV/AIDS ( Salama and Dondero 2001 : S11). The limited levels of power and control of refugees and IDPs when participating in medical research means that ethical research standards need to be strongly respected.

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