HIV Epidemiology amongHIV Epidemiology amongConflict-affected andConflict-affected and

Displaced PopulationsDisplaced Populations

Paul Spiegel MD,MPH

United Nations High Commissioner

for Refugees

Mock NB, Duale S, Brown LF, et al. Conflict and HIV: A framework for risk assessment to prevent HIV in conflict-affected settings in Africa. Emerg Themes Epidemiol 2004;1(1):6.

Overlap between HIV and ConflictOverlap between HIV and Conflict

HIV Prevalence by Asylum Country HIV Prevalence by Asylum Country and Country of Origin by Regionand Country of Origin by Region

0

1

2

3

4

5

6

7

HIV

pre

vale

nce

*

Africa (N=29) Asia (N=17)

Region**

Country of Asylum

Country of Origin

* Weighted means: country of asylum by population size, country of origin by refugee population size

** N refers to countries of asylum with >10,000 refugees

HIV Prev. of Refugees and Host Communities HIV Prev. of Refugees and Host Communities in Selected Sites, 1998-2005in Selected Sites, 1998-2005

HIV Prevalence in N. Uganda vs. HIV Prevalence in N. Uganda vs. National Data and Other Selected Sites*National Data and Other Selected Sites*

0

5

10

15

20

25

30

35

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

HIV

pre

va

len

ce

(%

)

Gulu

Moyo

Arua

Kitgum

Pader

National

Mbarara

Kampala

* For the Northern Uganda sites, Gulu, Moyo, and Arua used ANC data,20 while Kitgum and Pader use prevention of mother-to-child transmission programme data with acceptance rates by pregnant women of >97%;54 the non-Northern Ugandan sites of Kampala and Mbarara used ANC data)

• Reduction in mobility• Reduction in accessibility• Slowing down of

urbanisation• Increase in resources and

services in host country

HIV Risk Factors for HIV Risk Factors for Conflict-Affected PopulationsConflict-Affected Populations

• Behavioural change• Gender violence/

transactional sex• Reduction in resources

and services (e.g. health, education, community services, protection, food)

• Area of origin HIV prevalence• Surrounding host population (pop.) HIV prevalence

• Level of interaction bw DP and surr. host pop.• Type and location of DP env. (e.g. urban vs. camp)

• Phase of emergency• Length of time: conflict, existence of camp

Increased Risk Decreased Risk

Key Factors

Modified from Spiegel PB. HIV/AIDS among Conflict-affected and Displaced Populations: Dispelling Myths and Taking Action. Disasters 2004;28(3):322-39.

Behavioural Surveillance Survey (BSS) Behavioural Surveillance Survey (BSS) Study: Objective and MethodologyStudy: Objective and Methodology

• To evaluate quality of BSS in HEs and post-conflict situations and provide recommendations to NGOs and Gov'ts on how to improve quality

• 31 BSS evaluated between 1998-2005 in 14 countries classified as reproducible if pop. based sampling:

– Defined sampling frame– Used probabilistic sampling (incl. PPS

for cluster sampling)

ResultsResults • Settings

– Conflict: 8 (25.8%)– Post-conflict: 9 (29.0%)– Refugee settings 14 (45.2%)

• Organisations– NGOs 23 (74.2%)– CDC 4 (12.9%)– UN agencies 3 (9.7%)– Gov’ts 1 (3.2%)

• Sample size – Mean: 1,261, median: 549, range: 148-7,484

Results contResults contSampling Method Frequency (%)

Random sampling 23 (74.2)

Convenience 4 (12.9)

Not mentioned 4 (12.9)

31 (100)

If random what type? Simple random 4 (17.4)

Systematic 7 (30.4)

Cluster sampling 8 (34.8)

Not mentioned 4 (17.4)

23 (100)

All eligible person in hhold surveyed

yes 31 (100)

Sampling Frame yes 23 (74.2)

Reproducible yes 14 (45.2)

Behavioural Surveillance Surveys Behavioural Surveillance Surveys (BSS) for Displaced Persons (DP) (BSS) for Displaced Persons (DP)

and Host Communitiesand Host Communities

• Modified questionnaire incl. pre-displacement, displacement and post-displacement/interaction modules with strong gender-based violence component developed*

• Undertaken in both DP and host communities• Development of BSS manual to improve quality

of BSS undertaken in field

* UNHCR, World Bank (GAMET), CDC, FHI and IRC

ConclusionsConclusions• Complex relationship between HIV and conflict

– Findings not support contention that conflict increases HIV transmission regardless of magnitude of prev. when conflict began

– Refugees had lower or similar prev. than surr. pop.– Analysis is context-specific and no assumptions

should be made

• Need to examine (and program for) interactions between DPs and host pop. as well as returnees and those persons in area of return

• Need for improved biological and behav. data• Data can and should be used for advocacy and

programming purposes