hiv in emergencies: from research to strategies, policies and results

HIV in Emergencies

Paul Spiegel MD,MPHDeputy Director, DPSM

United Nations High Commissioner for Refugees

from research to strategies, policies and results

2001 to present

Outline of Presentation• Assumptions• Research

– HIV prevalence – Magnitude of issue– Behavourial change and communication– Antiretroviral therapy (ART) adherence

• Strategies and Policies • Results

UNGASS* 200112. “Noting that armed conflicts and natural disasters also exacerbate the spread of the epidemic;”

75. “By 2003, develop and begin to implement national strategies….recognizing that populations destabilized by armed conflict, humanitarian emergencies and natural disasters, including refugees, internally displaced persons, and in particular women and children, are at increased risk of exposure to HIV infection; and where appropriate, factor HIV/AIDS components into international assistance programmes;”

* UN General Assembly Special Session (Declaration of Commitment on HIV/AIDS)

Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet 2007;369(9580):2187-95.

What was the evidence at the time (2002-07)?

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.

Overlay bw Conflict and HIV prevalence

Strand RT, Fernandes DL, Berstrom S, Andersson S. Unexpected low prevalence of HIV among fertile women in Luanda, Angola. Does war prevent the spread of HIV? Int J STD AIDS. 2007 Jul;18(7):467-71.

Relation of Armed Conflict and HIV Seropositivity in sub-Saharan Africa

HIV Prevalence by Asylum Country and Country of Origin by Region

* 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

Spiegel PB. HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action. Disasters 2004; 28(3): 322-39.

Methodology


• Refugees: original UNHCR antenatal care (ANC) sentinel surveillance data

• Nationals: Nearest ANC sentinel surveillance data from UNAIDS and WHO (in-country and non-conflict surrounding country)

• Lit search: 7 conflict countries with 65 original datasets

• Uppsala databased for dates of conflict

Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet2007;369(9580):2187-95.

Spiegel PB, Bennedsen AR, Claass J, et al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. Lancet2007;369(9580):2187-95.

Byumba site, 2002, (host) 6.7% (95%CI: 4.7-9.4)

Gihembe camp, 2002 (refugee) 1.5% (95%CI: 0.4-3.8)

Lukole camp, 2003, (refugee) 1.6%

Kagera region, 2003, (host) 3.7%

Limitations

• Different methods to collect data among refugee, host community and country of origin pop. w/ variable quality of data

• Data for surrounding host pop. or region within country of origin was not always available; proxies used

• Comparisons could be biased due to different contexts and years

• Trend data often unavailable or did not include same sites

Conclusions1. Individual vulnerabilities and risks exist for

persons affected by conflict; this does not appear to translate into increased HIV infection at population (pop) level

• All situations must be examined according to context2. Refugees often have lower or similar HIV

prevalence to that of host communities; refugees may be vulnerable to HIV infection

3. Could HIV infection spread more post-conflict?

INCREASING RISK:

Behaviour change/coping mechanisms Gender-based violence Transactional sex Reduction in resources

and services

DECREASING RISK:

Reducing mobility Slowing of urbanization Increasing resources Increased access to

services in host area

HIV prevalence at origin HIV prevalence in host area Length of time: conflict, existence of camp

HIV Risk Factors for Conflict-Affected Populations

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

Presenter

Presentation Notes

Risk of HIV is the likelihood that a person will become infected with HIV either due to his or her own actions (knowingly or not) or due to another person’s action. Unprotected sex with multiple partners and sharing contaminated needles are risky activities that increase the probability of HIV infection. Vulnerability to HIV is a person’s or a community’s inability to control their risk of infection. It may be attributed, inter alia, to poverty, disempowering gender roles or migration.

Magnitude of the Issue

Estimates of HIV Burden in Emergencies: 2003, 2005, 2006 and 2013

• Objective: – Quantify proportion of people living with HIV (PLHIV)

who are affected by emergencies (ERs)

• Methods: – Country-specific estimates of pop affected by ERs

were developed based on 8 and 11 databases (2003/05/06 & 2013, respectively)

– Combined with UNAIDS HIV database to estimate numbers of PLHIV (all years)

Lowicki-Zucca M, Spiegel PB, Kelly S, Dehne KL, Walker N, Ghys PD. Estimates of HIV burden in emergencies. Sex Transm Infect 2008; 84 Suppl 1: i42-i8.

Diagram of Development of Estimates, 2003, 2005,2006

Methods cont

Lowicki-Zucca M, Spiegel PB, Kelly S, Dehne KL, Walker N, Ghys PD. Estimates of HIV burden in emergencies. Sex Transm Infect 2008; 84 Suppl 1: i42-i8.

Spiegel P, Bennett R, Doraiswamy S, Karmin S, Kobayashi, A, 2015 (unpublished)

Diagram of Development of Estimates, 2003, 2005,2006

Visual description of Interaction of Databases, 2013

ResultsYear # persons affected

by ERs (millions)[range]

# of PLHIV and affected by ERs(millions)[range]

% PLHIV affected by ERs / overall PLHIV

2003* 349.5 2.6 [2.0-3.4] 7.9% (1 in 13)2005* 168 1.7 [1.4-2.1] 5.1% (1 in 20)2006* 185.5 1.8 [1.3-2.5] 5.4% (1 in 19)2013+ 314 [295-330] 1.6 [1.2-1.9] 4.5% (1 in 22)

*Lowicki-Zucca M, Spiegel PB, Kelly S, Dehne KL, Walker N, Ghys PD. Estimates of HIV burden in emergencies. Sex Transm Infect 2008; 84 Suppl 1: i42-i8.+Spiegel P, Bennett R, Doraiswamy S, Karmin S, Kobayashi, A, 2015 (unpublished)

• For 2013• 67 million [61-73] (21%) people were displaced • Majority PLHIV affected by ERs were in Sub

Saharan Africa; 1.3 million [1.0-1.6] (81%) • 1,000,000 [0.9-1.3] PLHIV not have access to

antiretroviral therapy (ART)

Limitations

• Estimates do not represent trends• Estimating non-displaced persons affected

by ERs is complex• Numerous overlapping of databases; thus

used [range]• Duration of ER and length of service

disruption• National HIV estimates and treatment

coverage applied to areas of ERs

Presenter

Presentation Notes

In developing these numbers, several data limitations were identified. Estimating the number of people affected by conflict but NOT displaced proved to be challenging (see methodology section) because no database captures these figures. In order to develop an estimate, several databases were used and data overlaid in order to come up with the best figures. Though efforts were made to prevent double counting, and to match varying data sources, this is a limitation in the work. One possible suggestion coming out of this research is for a database to capture these figures – conflict affected, not displaced. No database captures the duration of the impact of the emergency and hence length of service disruption in the various emergencies. The assumption is that the level of service disruption is uniform across all emergencies. This could either underestimate or overestimate the magnitude of the problem. Food insecurity is not considered in this paper and yet we know that food security is critical to adherence and retention for people living with HIV. Follow up on linking food security and HIV would be a welcome step. National HIV prevalence was applied to the numbers of people affected by emergencies to estimate the number of people living with HIV affected by emergencies in 2013. In some instances the numbers were under-estimated because prevalence was higher in emergency affected areas. In other cases, the prevalence was over-estimated because emergencies occurred in areas with prevalence lower than the national average. In developing the numbers of PLHIV affected by emergencies, the full range of uncertainties was used. The figures were calculated using a low and a high estimate, but not an estimate using “high lows” and “low highs” making uncertainty bounds tight. National treatment coverage was applied to the emergency population. Similar to the limitations on estimating HIV prevalence using national figures, emergency affected areas may have higher or lower treatment coverage. This figure does not show disruptions in access to treatment, which is a critical issue in emergency response.

Conclusions• Large numbers of PLHIV affected by ERs;

to ‘get to zero*’ need to address this pop• Ethical, moral and public health issue• Concentrate on sub-

Saharan Africa• Sub-national HIV

estimates and ART coverage needed

• Now is the time!* Zero new HIV infections, zero discrimination,

zero AIDS-related deaths

Behavioral Change and

Communication

Behavioral Surveillance Surveys (BSS) for Displaced Persons and

Host Communities

• Need to understand knowledge, attitudes and practices of displaced persons, host communities and interactions

• Developed standardised BSS w/ displ & post-displ modules incl core indicators, and methodology

• Undertake in both displaced and host communities (baseline and follow-up surveys)

Description• BSS undertaken separately among refugees

and surrounding communities in Kenya, Tanzania and Uganda (Dahab 2013)– 6 paired sites (11,582 persons; 6,448

baseline in 2004/05, 5.134 follow-up 2010/11• Analysis of 27 BSS in 10 countries among

displaced persons and hosts (24,219 persons) bw 2004-2012 (Spiegel 2014)

• Descriptive data analysis and multivariable logistic regression to identify high risk sex, displacement and interaction

Dahab M, Spiegel PB, Njogu PM, Schilperoord M. Changes in HIV-related behaviours, knowledge and testing among refugees and surrounding national populations: a multicountry study. AIDS Care 2013; 25(8): 998-1009.

Presenter

Presentation Notes

Dahab 2013 Spiegel 2014 At follow-up, prevalence of risky sex was generally higher among participants who visited neighbouring community at least once per month compared with those who did so less frequently. We noted consistent decreases in reported multiple and casual sexual partnerships in previous 12 months bw baseline and follow-up that generally persisted across age and gender subgroups regardless of length of residency in camp Coupled with dramatic increases in HIV testing levels as well as improvement of comprehensive HIV knowledge These positive changes may reflect intensified HIV prevention programming, but we cannot know extent that this contributed In Kenya and Uganda, refugees did not report significantly higher levels of risky sexual partnerships than surrounding community residents – not supporting widely held notion that refugees have higher levels of risky sexual behaviours than nationals Comprehensive HIV Knowledge: Having one uninfected, faithful partner to prevent HIV/AIDS Using condoms to prevent HIV/AIDS Cannot get HIV/AIDS from mosquitoes Cannot get HIV/AIDS from sharing food with infected person A healthy-looking person can have HIV/AIDS

Spiegel PB, Schilperoord M, Dahab M. High-risk sex and displacement among refugees and surrounding populations in 10 countries: the need for integrating interventions. AIDS 2014; 28(5): 761-71.

Presenter

Presentation Notes

Comparison of never displaced, internally and externally displaced S Sudanese Juba residents never forcibly displaced or who were IDPs in Juba reported lowest levels of multiple sexual partnerships and casual sex, as well as lowest levels of HIV testing Unexpectedly, refugees in Hoima, Uganda and Kakuma, Kenya had signif lower levels of comprehensive HIV knowledge than those never displaced or IDPs in Juba

Forced Sex

• Prevalence of forced sex was similar in paired sites, with intimate partner violence being the most frequent, ranging bw 1-4.6% in camps and 0.8-3.6% in communities• Exception of Nepal (10.8% and 9.8%,

respectively)

Spiegel PB, Schilperoord M, Dahab M. High-risk sex and displacement among refugees and surrounding populations in 10 countries: the need for integrating interventions. AIDS 2014; 28(5): 761-71.

Conclusions1. Data showed no consistent difference in levels

of risky sexual behavior and there was much variation among different groups• Prevention strategies should be targeted in highly

integrated manner for both communities2. Forced sex among women was similar levels

among refugees and nationals with intimate partner violence most common• These findings should reduce stigma and

discrimination against refugees3. Possible to measure change over time but

difficult to attribute to interventions

Presenter

Presentation Notes

In the largest study of paired sites of refugees in protracted refugee camps and surr nationals, data showed no consistent difference in levels of risky sexual behaviour and there was much variation among different groups Prevention strategies should be targeted in highly integrated manner for both communities Forced sex among women was reported at similar levels among refugees and nationals, with intimate partner violence being most common These findings should reduce stigma and discrimination against refugees

Antiretroviral Adherence

Methodology

Mendelsohn JB, Schilperoord M, Spiegel P, Ross DA. Adherence to antiretroviral therapy and treatment outcomes among conflict-affected and forcibly displaced populations: a systematic review. Conflict and health 2012; 6(1): 9.

ResultsMendelsohn JB, Schilperoord M, Spiegel P, et al. Is forced migration a barrier to treatment success? Similar HIV treatment outcomes among refugees and a surrounding host community in Kuala Lumpur, Malaysia. AIDS Behav 2014; 18(2): 323-34.

Mendelsohn J, Spiegel P, Grant A, Doraiswamy S, Schilperoord M, Larke N, Burton J, Okonji J, Zeh C, Muhindo B, Njogu P, Mohammed I, Mukui I, Sondorp E, Ross D. Similar treatmen outcomes among refugees and host nationals accessing antiretroviral therapy in a Kenyan refugee camp.

Presenter

Presentation Notes

Kenyan study results – not published: Among eligible clients, 86% (73/85) of refugees and 84% (86/102) of Kenyan adults participated at baseline; 60% (44/73) and 58% (50/86) of these were present at follow-up. Similar proportions of refugees and host nationals on treatment for ≥25 weeks tested <5000copies/mL at baseline (58% vs 43%, p=0.10) and follow-up (74% vs 70%,p=0.66) with improvement observed at follow-up in both groups (p=0.04; p=0.03). Mean adherence at baseline was similar between groups. Refugee status was not associated with viral suppression in multivariable analysis. Among treatment failures, 9/13 exhibited resistance mutations. Virologic outcomes among refugees and host nationals were unacceptably low but improved slightly by a remedial intervention. Virologic monitoring is important for identifying underperforming ART programs in remote facilities that serve refugees together with host nationals.

Conclusions

1. Conflict –affected and forcibly displaced persons had good adherence (87-99%)*

2. ART adherence similar among refugees and nationals

3. Need for systematic monitoring of adherence linked to displacement cycle and context-specific support for adherence/treatment outcomes

* Not including Malaysia and Kenya study

2003 2004 20062005 2007

2009 2010 20122011 2013 20142008

Results1. Increased inclusion of refugees in HIV

National Strategic Plans– 48% in 2009 to 87% in 2013

2. Increasing number of refuges on ART– Access to ART at similar level as nationals

increased from 79% in 2010 to 97% in 2014– For PMTCT was 95% in 2014

3. Decrease in high risk sex and increased HIV knowledge and testing

Presenter

Presentation Notes

2012, access to ART for refugees was sustained at 93% at a level similar to that of the surrounding population In 2012, the percentage of women having access to EMTCT programmes for operations with a health information system in place increased even though only 35% of operations meet the 90% coverage standard, a 5% increase since 2008; large improvements were observed in countries such as Burundi (43% in 2008 to 98% in 2012) and Uganda (56% to 93%). Provision of post-exposure prophylaxis to rape survivors has increased in UNHCR’ programmes. For the past four years, most countries showed sustained improvement in coverage (e.g. Tanzania: 49% in 2009 to 80% in 2012, Kenya 54% in 2010 to 98% in 2012). We noted consistent decreases in reported multiple and casual sexual partnerships in previous 12 months bw baseline and follow-up that generally persisted across age and gender subgroups regardless of length of residency in camp Coupled with dramatic increases in HIV testing levels as well as improvement of comprehensive HIV knowledge

Results cont4. Increased funding for emergencies

5. Increasing awareness of issue and recognition of need to act

Presenter

Presentation Notes

We noted consistent decreases in reported multiple and casual sexual partnerships in previous 12 months bw baseline and follow-up that generally persisted across age and gender subgroups regardless of length of residency in camp Coupled with dramatic increases in HIV testing levels as well as improvement of comprehensive HIV knowledge

Cameroon Refugees

AIDS, conflict and the media in Africa: risks in reporting bad data badly

• Headline: "HIV/AIDS soars in war-torn northern Uganda"– Reuters. Wallis D, 2004

• Headline: "GUINEA: Refugee influx adds fuel to AIDS crisis in southeast Guinea“– IRIN. Guinea, 2004

• "Infection rates are particularly high among vulnerable groups, such as internally displaced persons (IDPs) and refugees"– WN.com. Telemans D: Sudan, 2004

Lowicki-Zucca M, Spiegel P, Ciantia F. AIDS, conflict and the media in Africa: risks in reporting bad data badly. Emerging themes in epidemiology 2005; 2: 12.

Headline: "HIV/AIDS soars in war-torn northern Uganda"

Reuters. Wallis D, 2004

“The rate of HIV/AIDS infection in northern Uganda is nearly double that in the rest of the country….”

UNFPA. Muleme G, 2004

HIV Prevalence and Income Inequality in Africa

Piot P, Greener R, Russell S. Squaring the Circle: AIDS, Poverty, and Human Development. PLoS Med. 2007 Oct; 4(10): e314.

Presenter

Presentation Notes

HIV Prevalence and Income Inequality in Africa The Gini coefficient has a value between 0 and 1, representing the extremes of income distribution. A zero value corresponds to the situation where everyone in the population has exactly the same income, whereas a value of 1 would correspond to extreme concentration of income in one person. A high value indicates a more unequal income distribution. Note that Figure 1 uses data from only one year and therefore cannot show any dynamic relationship between changes in income inequality (which are slow), and changes in HIV prevalence.

HIV and Poverty cont

O’Farrell N. Poverty and HIV in sub-Saharan Africa. Lancet. Feb 2001; 357;636-7.

Pearson =0.29, p=0.07

HIV Sentinel Surveillance for Refugees

• Measure pregnant women at ANC clinics • Work with Gov. authorities, use national

protocols, develop training modules, ensure supervision

• Ensure quality control: double entry, all positives and 10% negatives to reference lab

• Find funds- approx. 20-30,000 USD/survey

SS contCompleted:• Uganda 2004 and 2005• Dadaab in 2004 and begun in July • Kakuma 2002; 2006• Tanzania: 2002, 2003, 2004• Zambia: 2004Planned:• East Sudan – Showak begin Jan/Feb 2007• Uganda – 4 sites Sep/Oct 2007• Ethiopia – 5 sites – Dec-06/Jan-07• Tanzania – 3-4 sites – Dates not confirmed

Risk versus vulnerability• Risk of HIV is the likelihood that a person will become

infected with HIV either due to his or her own actions (knowingly or not) or due to another person’s action. Unprotected sex with multiple partners and sharing contaminated needles are risky activities that increase the probability of HIV infection.

• Vulnerability to HIV is a person’s or a community’s inability to control their risk of infection. It may be attributed, inter alia, to poverty, disempowering gender roles or migration.

Presenter

Presentation Notes

Risk and vulnerability are often incorrectly used interchangeably. An understanding of these terms is essential to the understanding of the dynamics of HIV and conflict. Conflict affected populations are often incorrectly described as being at high risk or a most at risk population. Conflict-affected populations are certainly more vulnerable to HIV often living in situations where they have lost their homes, means to support themselves, separated from families and traditional support structures with disruption of social services they are often unable to meet their basic needs. However this does not necessarily translate into high risk behaviour e.g. sexual, injecting or unsafe blood transfusions. Within conflict affected populations there are certainly groups at higher risk as in any population but the population as whole is not at high risk. HIV interventions in CAPs need to do more than just reduce risk; they need to address vulnerability. This will be discussed in more detail later

Behavioural Surveillance Survey (BSS) Study: 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)

The Sphere Project, 2004• Humanitarian Charter • Universal minimum

standards in core areas

Aim:• Quality of assistance• Accountability

• HIV is cross-cutting issue

Guidelines for HIV Interventions in Emergency Settings, IASC, 2003 and

2010• Matrix in 3 phases

– Emergency Preparedness

– Minimum Response (to be conducted even in emerg.)

– Comprehensive Response (Stabilised Phase)

By sector/cluster

Presenter

Presentation Notes

UNHCR- not supporting field offices and partners (e.g. Health coord in DRC not visit Aru in his 3 yrs of working with HCR) Partners- not supporting docs and others in sites from capitals -lack of training, text books, Tx algorithms, etc.. -need more consistent supervision and exchange visits bw sites (internal and with different NGOs) Both have insufficient interaction with local gov’t/hospitals At the sites: -problems with supplies (e.g. syringes, essential medications, cold chain) -problem with communications (e.g. Codans) and transport (e.g. planes and canoes) -problems with staffing: gender equality and numbers of CHWs)

Post-emergency, 20051. Integrate refugee

issues into national HIV programs and policies

2. Implement sub regional (cross-border) initiatives

3. Combine humanitarian and development funding

Consensus statement• ART neglected but feasible • Continuation of ART for

those on treatment• Initiation of ART for those

meeting minimum req’ts • Need to scale up PMTCT• PEP for all exposed HCWs • PEP and rape mgt for

survivors of rape

Consensus Statement, 2006

ART Policy for Refugees, 2007

• Need to scale up PMTCT• PEP for all occupational and

non occupational exposure• Continuity of ART is priority • Initiate if minimum criteria in

place – Availability of resources– Sufficiently trained persons – Protocols– Confidentiality– Supervision– 12 months of funding– Local population has access

Clinical guidelines for antiretroviral therapy management for displaced

populations, 2007 and 2014

– Continuation ART with history

– Initiation of ART– ART continuation

upon return– Care and support

for PLHIV

HIV Assessment in Emergencies, 2007

IDPs– Comprehensive

Assessment Tool– Key Informant

Interviews, FGD guides field tested in 2006 and 2007

– First Global IDP Consultation in April 2007

– Tools finalized in 2007

Presenter

Presentation Notes

To effectively respond to HIV and AIDS within any humanitarian context an analysis of the specific risks and vulnerabilities needs to be undertaken and measures developed to address these. UNHCR’s assessments in refugee populations are done using a standard assessment tool and programme framework. Refugee assessment tool – policy and strategy, coordination and supervision, prevention, care treatment and support and surveillance, monitoring and evaluation and including detailed assessment of HIV services Until recently there was little guidance on HIV assessments in other conflict-affected populations, such as IDPs. To address this gap UNHCR has coordinated and facilitated a number of interagency assessment missions of the response to HIV in conflict-generated IDPs. This has culminated in the development of a multisectoral assessment tool. In these tools which can also be used in refugee settings there is more emphasis on assessing vulnerability and mechanisms in place to reduce this Though developed with an IDP setting in mind they could be used in non- displaced CAP and populations affected by natural disasters with some modifications. Refugees UNHCR Programme Framework UNHCR Comprehensive Assessment tool

hiv in emergencies: from research to strategies, policies and results

Health & Medicine