Conflict and HIV: A Framework for Risk Assessment to

Prevent HIV in Conflict Settings

International Studies Association

March 26, 2002

New Orleans, La. 700112

Nancy Mock, Dr. P.H. and Ellen Mathys, M.P.H.

Tulane University

Conflict and HIV:Background• Since its discovery in the early 80’s, we are only now seeing

any detectable evidence that HIV prevention strategies are having ANY impact on HIV incidence

• After 20 years, the epidemiology of HIV in Sub-Saharan Africa is still poorly understood

• There was a deliberate policy decision taken by the donor community to collect highly limited information on population-level HIV status

• Until very recently, HIV prevention/care strategies were stove-piped in the health sector

• Until now, conflict management strategies have been stove-piped into humanitarian assistance and “transition” programs

Why business as usual will not work

• Collective wisdom says that traditional HIV prevention/management programs take decades to work and have limited effects

• Current data suggest that HIV epidemic progression can be explosive when the isolating effects of conflict are removed

• Relief/transition/development stove-piping misses the windows of opportunity to attack the driving forces of HIV, which are always accentuated in conflict settings

African Population Database: 1990 Population Density Distribution

Source: UNEP/GRID

Africa: Major Routes

Figure 1: Conceptual Framework of Principal Causes of HIV Risk in Conflict-Affected Populations

Violent Conflict

Social Ecology of HIV

Population Vulnerability

to HIV

HIV Hazard/ Exposure

Opportunity

Population HIV Risk

Conflict-associated factors that increase and decrease HIV risk

• Decrease– Increased isolation of

communities

– Increased death rates among high risk groups

– Increased death rates among HIV-infected

– Decreased casual sex associated with trauma and depression

– Disruption of sexual networks

• Increase– Increased interaction among

military/combatants and civilians

– Increased levels of commercial sex

– Decreased availability of STI and other health services

– Decreased utilization of health services

– Increased levels of malnutrition

– Decreased access to knowledge and means to prevent HIV transmission

– Large internal or regional population movements

– Emergence of norms of sexual predation and violence

Risk and Vulnerability Assessments

• Identify distinct high risk and vulnerable groups• Map the dynamics of population mixing both

internal and external to the system • Identify key leverage points for prevention• Repeating the process over time based on impact

assessment• Anticipate risk as far out as possible, ie. early

warning

Security Survival Governance SustainableDevelopment

US Military USAID/OFDA USAID/OTI USAID COMMERCE

Active GunfireAnd Fighting

HumanitarianCycle

Community andSocietal Cooperation

Long-term EconomicDevelopment

Source: Lyerly, W., 1999

Model of US Government Response to Conflict and Complex Emergencies

Implications for Programming

• Prevention initiatives must be aggressive during active conflict and transition

• Interventions should be risk-reduction driven • Integration of HIV prevention into other

sectoral/programs to create synergies • Intervention strategic planning should consider

and include regional and micro-ecological factors

A Note on the Need for Information-Driven Action

• Large scale household survey programs such as the Demographic and Health Survey Program can now be used to generate population-based seroprevalence levels and most transition countries implement DHS

• The humanitarian community is increasingly applying rapid probability surveys in active conflict contexts. These can be utilized as vehicles for serostatus assessment where appropriate

• Early warning systems are emerging in a variety of areas. That will facilitate the rapid development of geospatial information

Mozambique Eritrea Ethiopia Sierra Leone

Angola Somalia

Poverty

Pop. below $1 a day 37.9 (1996) 25.3 (1996) 31.3 (1995) 57.0 (1989)

Adult Illiteracy

Male - % ages 15 and over in 1999

41 33 57

Female - % ages 15 and over in 1999

72 61 68

KAP

% Heard of HIV 82.2 80.6 84.7 54.0 36.6

% Know no ways to prevent HIV

65.8 24.2 31.5 88.3

% Know condom use

15.4 34.6 33.5 27.0 2.8