Susan Temporado Cookson, MD, MPH In ternational Emergency & Refugee Health Branch

1. HIV Infection among Refugees: Myths and FindingsHIV Center for Clinical and Behavioral StudiesNY State Psychiatric Institute and Columbia UniversityDecember 10, 2009 Susan Temporado Cookson, MD, MPH International Emergency & Refugee Health Branch Centers for Disease Control and Prevention

2. Overview • Definitions • Emergencies • Refugees and internally displaced persons • Risk factors impacting these populations • Big 4 communicable diseases • HIV • Myths, findings, and realities • Principles of HIV control among refugee and internally displaced populations

3. Definitions of Emergencies Emergency: unforeseen crisis requiring immediate response Natural disaster: vast ecological breakdown between humans and their environment; such a serious or sudden event that the community needs extraordinary efforts to cope, often with outside help or international aid Complex humanitarian emergency (CHE): large-scale human displacement with living condition deterioration caused by physical conflict, often with attempt to restructure society (e.g., genocide), leading to significant increase in mortality for limited time, but sometimes longer Indicator = 1 death /10,000 population / day

4. Definitions of Refugees and Internally Displaced Persons (IDPs) • Both populations • Victims of conflict and violence • Fled their homes • Fear of or persecution • Race, religion, nationality, member of social group, political opinion, gender • Refugees only • Fled outside home country • Unable/unwilling to return home

5. Population Movements in Conflicts of Refugees and Internally Displaced Persons (IDPs)

6. Communicable Diseases Risk Factors among Refugees and Displaced Persons • Mass population movement • Ongoing conflict/insecurity • Gender-based violence • Temporary/absence of shelter • Poor nutrition/scarcity of food • Poor healthcare access/collapse of healthcare • Lack of medications/treatment • Lack of prevention/control programs • Of supplies, such as condoms or vaccination • Of programs, such as TB or HIV control Serbians fleeing Source: Connolly MA, et al. Lancet, 2004

7. Communicable Diseases among Refugee and Displaced Persons • Big 4 causes of morbidity and mortality • Acute respiratory infections • Diarrheal diseases • Measles • Malaria • Malnutrition • HIV/AIDS have increasing importance • But not top priority in emergency • Potential regional effects • Disease prevalence, including HIV

8. Vicious Cycle of Micronutrient Deficiencies and HIV Insufficient dietary intake Malabsorption and diarrhea Altered metabolism and impaired nutrient storage Micronutrient Deficiency and HIV Cycle Increased HIV replication Disease progression Increased morbidity/mortality Micronutrient deficiencies Increased oxidative stress Immune suppression Modified from Semba RD and Tang AM. Brit J Nutrition, 1999

9. Reasons HIV Not Top Priority inEmergencies • Perceived as development issue • Concerned of discrimination against HIV-infected refugees • Basic survival: shelter, food, water, sanitation • Health actions focused on Big 4 and malnutrition • Essential primary clinic services/medications

10. Refugees and Internally Displaced Persons, 31/12/08 Total=24.9 million • Internally displaced • 14,405,405 • Refugees • 10,478,621 Population * 1,000,000 Source: UN Refugee Agency. 2008 Global Trends. Available at: http://www.unhcr.org

11. Myths or Realities? • Conflicts increase HIV transmission • Refugees bring HIV to the country of asylum • IDPs and refugees have the same HIV risks and prevalence rates

12. Effects of Conflict and Sexual Violence on HIV Transmission and Visa Versa • Difficult to discern • Wide variety of issues involved • Data can have varied quality and focus, be biased • Data on prevalence on HIV and sexual violence among affected-populations scarce

13. 1. Do conflicts increase HIV transmission?

14. Epidemiology of Conflicts and HIV Overlap between countries affected by conflicts and high HIV prevalence , 2004 HIV Prevalence in Africa, 2007 Sources: Mock NB, et al. Emerg Themes Epidemiol, 2004 UNAIDS. 2008 Report on the global AIDS epidemic

15. Level of Conflicts and HIV Prevalence 1991-2000 Among 37 sub-Saharan African countries • Armed conflict scores vary from 0, no conflict, to 28 and 29 for Sudan and Angola, respectively • 15 countries with no conflict, including Botswana, Central African Republic • HIV prevalence=18.6% • 13 countries with armed conflict score=1-9, including Cameroon, Senegal • HIV prevalence=8.3% • 9 countries with armed conflict score>10, including Burundi, DRC, Somalia • HIV prevalence=7.8% Source: Strand R, et al. Int J STD & AIDS, 2007

16. Strand R, et al. Int J STD&AIDS, 2007 Spearman rank correlation, г=-0.41, p=0.012

17. Why do conflicts seem to delay HIV epidemic? Two stages of conflict • Conflict • Survival • Access • Post-conflict • Services and employment • Access

18. Conflict Stage • Survival of HIV-infected persons • Differential mortality among high-risk populations • In addition, poor nutrition and lack of services • Isolation • Destroyed transport, unsafe travel, disrupted commerce • Level of sexual activity • Marked reduction • KABP among Rwandan refugees, Tanzania 1994 • Decreased libido • Depression and post-traumatic stress symptoms Source: Mayaud. Trans Roy Soc Trop Med & Hyg, 2001

19. Post-conflict Stage • Increased HIV incidence , post-conflict • Maputo, Angola (9.9% in 1998, 13.2% in 2000, 20% in 2004) • Service may be slow • Quality of medical services • Supplies, equipment/vaccines, and medications • Universal precautions, safe medical equipment and blood may lag • Level and type of employment • Demobilization of forces and female head of households • Access • Urbanization and increased level of sexual activity Source: UNAIDS/WHO. AIDS epidemic update. Geneva: UNAIDS/WHO, 2004

20. 2. Do refugees bring HIV to the country of asylum?

21. HIV/AIDS: Epidemiology among Refugees • HIV prevalence among refugees appear lower • than host population • – Country of origin compared with country of • asylum • * Weighted means: country of asylum by population size, • country of origin by refugee population size • Source: Spiegel PB. Disasters, 2004

22. HIV Prevalence Data among Refugees • Surveillance during conflict impractical • Surrogate data • Adults: chronic diarrhea, fever of unknown origin, recurrent pneumonia, STIs, TB, wasting • Children: chronic diarrhea, developmental delays, failure to thrive, recurrent bacterial infections • Direct HIV testing results • Blood supply: no systematic surveillance • Antenatal care centers

23. UN Refugee Agency Health Information System (HIS) • In 1999, began development • In 2006, 16 countries with stable refugee camps • Data collected: • Blood supply activities: no results • VCT (PICT), PMTCT, And ART program activities • Evaluation in Sept-Nov 2008: Issue with data quality Source: UNHCR. Health Information System (HIS) toolkit Available at: http://www.unhcr.org/4a3374408.html

24. Assess HIV Prevalence Rates, Africa Method • Anonymous, unlinked, cross-sectional surveys (UAT) • Attendees public antenatal clinics, including in refugee camps • First time • Blood for syphilis testing • Often no informed consent • Concerns of selection/participant bias • De-identified, except for • Age, parity, marital status , educational level , and clinic location (or urban versus rural) • In refugee camps: refugee versus host status • Rapid, diagnostic tests and/or dried blood spots

25. Reliability of HIV Testing: Rapid Tests vs. EIA • Gray RH, et al. BMJ, 2007, in Rakai, Uganda: • 43.7% (129/295) false positive results • 0.3% (4/1,222) false negative results • UNHCR, 2006/07, Kenya

27. Refugee vs. Host Populations HIV Prevalence • Spiegel PB, et al. Lancet, 2007 plus newer data (2006/07) • Data <1 year for both populations • Kenyan camps • Somali refugees, 2003,’’05, ‘07, rate <10-fold vs. nearby town • Sudanese refugees, 2002 , ‘06/7, rate <3-fold vs. town or surrounding • Uganda settlements • Sudanese refugees , 2004, and ‘05, rate <4 fold vs. town or surrounding • Tanzania camps • Burundi refugees, 2002 , ‘03, rate variable (<2-fold in 1 camp in ‘02, ‘03 ; >2-fold in 2 camps in 2003) vs. nearby town • DRC camp refugees • Rwanda and Tanzania, 2002 and ‘03, respectively, rate <2-fold vs. towns

28. 3. Do IDPs and refugees have the same HIV risks and prevalence rates?

29. Additional Differences between Refugees and Internally Displaced Persons (IDPS) • Level of interface with • Military and peacekeeping forces, and humanitarian aid workers • Protection • 1951 Refugee Convention • 1967 Protocol • Services • Implementing partners vs. host population

30. HIV Prevalence Studies on Internally Displaced Women • Luanda, Angola, 2000, at antenatal care and family planning clinics • 1.8% HIV-infected among 1,035 • This prevalence rate lower than most urban settings in Africa and Angola • 52.6% of infected vs. 36.8% infected women engaged in business (NS) • Usually street vendors Source: Strand R, et al. Int J STD & AIDS, 2007

31. Internally Displaced (IDWs) vs. Surrounding Population Women • Congo River area, DRC, 2005, in household survey • 7.6% (95% CI 4.1, 11.0) vs. 3.1% (CI 2.1, 4.1) HIV prevalence • Fewer married (84.7% vs. 95.4%, NS), lived without partners (13.9% vs. 6.2% , p<0.01) • More reported history of sexual violence during conflict (11.1% vs. 1%, p<0.01) • More reported STI symptoms in last 12mon (60.4% vs. 52.5%, p=0.02), more active syphilis (4.0% vs. 0.5%, p<0.01) • 55 refugee women in surrounding area vs. IDWs • Reported history of sexual violence during conflict (1.8% vs. 14.2%, p=0.01) • Among refugees, HIV prevalence 7.3% (CI 0, 14.1) and active syphilis 1.8% Source: Kim AA, et al. AIDS Behav, 2009

32. Internally Displaced (IDWs) vs. Surrounding Population Women • North Uganda , 2005, at antenatal clinic for protected camp vs. surrounding population • 6.0% vs. 11.6%, p<0.01, respectively • Multivariate analysis • Older women (AOR=2, p<0.01) • Unmarried women (AOR=1.5, p=0.02) • Partner with non-traditional (modern) occupation (AOR=1.62, p<0.01) • Living outside protected camp (AOR=1.55, p<0.01) Source: Fabiani M, et al. Conflict Hlth, 2007

33. IDWs, Surrounding Population, or Refugee Women • Context means everything • Angola: IDWs very low HIV prevalence • DRC: IDWs with higher HIV prevalence vs. surrounding women • Greater history sexual violence and STIs • North Uganda: IDWs with lower HIV prevalence vs. surrounding women • Protected camps • Greater risk associated with usual factors

34. HIV: Key Risk Factors among Refugees Key Factors • HIV prevalence of country of origin • HIV prevalence of surrounding host population • Level of interaction between two populations • Type and location of refugees • Phase of emergency (conflict, post-conflict, development) • Length of time: conflict, camp and services Modified from Spiegel PB. Disasters 2004

35. HIV: Factors Increasing Refugees’ Risk Key Factors • HIV prevalence of country of origin • HIV prevalence of surrounding host population • Level of interaction between two populations • Type and location of refugees • Phase of emergency (conflict, post-conflict, development) • Length of time: conflict, camp, and services • Behavioural changes • Gender-based violence/ transactional sex • Reduced services (health and community services, protection, food) • Reduced education Increased Risk

36. HIV: Factors Decreasing Refugees’ Risk Key Factors • HIV prevalence of country of origin • HIV prevalence of surrounding host population • Level of interaction between two populations • Type and location of refugees • Phase of emergency (conflict, post-conflict, development) • Length of time: conflict, camp, and services • Decreased mobility • Reduced accessibility • Slowing down of urbanization • Increased services and resources in host country • Decreased survival of sick persons Increased Risk Decreased Risk • Behavioural changes • Gender-based violence/ transactional sex • Reduced services • Reduced education

37. HIV in Emergencies: Prevention and Control • Provide early interventions to prevent spread • Use Minimum Initial Service Package (MISP) Available at: http://misp.rhrc.org • Coordinate and implement MISP • Prevent sexual violence • Reduce HIV transmission • Prevent excess maternal and neonatal mortality and morbidity • Plan for comprehensive reproductive health services • Promote ABC, especially C

38. HIV in Emergencies: Additional Prevention and Control • Additionally protect vulnerable sub-populations • Layout camp conducive to protection • Distribute of essential items: Easy access to cooking fuel • Treat sexual transmitted infections (STIs) • Interaction with STIs, especially ulcerative • Use HIV and STI emergency guidelines • TB and HIV requires integrated programs

39. The sectors are: Coordination Assessment and monitoring Protection Water and sanitation Food security and nutrition Shelter and site planning Health Education Behavior communication change (BCC) HIV/AIDS in the workplace Available at: http://www.unfpa.org/upload/ lib_pub_file/249_filename _guidelines-hiv-emer.pdf GUIDELINESfor HIV/AIDS interventions in emergency settings

40. Overall HIV Planning for Conflicts – Prevention and Control • Include HIV/AIDS in humanitarian action plans • Establish coordination mechanism • Collect baseline data, analyze and monitor situation • Prevent and respond to sexual violence and exploitation • Provide education material and condoms to population and aid workers • Ensure universal precautions and safe blood supply • Integrate programming with water/sanitation, nutrition, reproductive health, TB

41. Post-Conflict Stage • Integrate refugee issues into national HIV programs and policies • Implement sub-regional HIV initiatives • Combine humanitarian and development funding

42. National HIV Strategic Plans (NSP), 2004 in African Asylum Countries* NSP stated activities for refugees (N=23) NSP mentioned refugees (N=23) Avail able NSP (N=29) No 57% (13) Unknown 21% (6) No 35% (8) Yes 43% (10) Yes 65% (15) Yes 79% (23) * with >10,000 refugees in 2004 Source: Spiegel PB, et al. Int Conf AIDS, 2004, Jul 11-16, 15, abstract D12361 with modification

43. Global Fund Approved Proposals with HIV/AIDS Components in African Asylum Countries* Approved proposals (N=29) Proposals mentioned refugees (n=26) Proposals stated activities for refugees (n=26) No 10% (3) Yes 23% (6) No 58% (15) No 77% (20) Yes 90% (26) Yes 42% (11) Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria; 4th round inclusive * with >10,000 refugees Source: Spiegel PB, et al. Int Conf AIDS, 2004, Jul 11-16, 15, abstract D12361 with modification

44. RATIONALE Life saving, essential treatment available in Africa (universal access) Shown to be feasible in conflict-affected settings 60% of refugees are in camps >10 years (2008) INTERVENTIONS Post-exposure Prophylaxis PMTCT Therapeutic, long term PEPFAR support Rwanda, Tanzania, and Kenya beginning 2008/09 DRC and Burundi not yet Source: Julius Kasozi, UNHCR, personal communication, Nov 2009 Antiretroviral Therapy (ART) in Conflict-affected Settings Source: US Committee for Refugees and Immigrants. World Refugee Survey 2009.

45. HIV Care and Treatment – Implementing ART among Refugee and Displaced Persons • Emergency phase over (mortality: <1/10,000/d) • Basis needs of shelter, water, sanitation, food met • Essential clinic services and medications exist • For large part of population • Camp expected to remain stable (? length) • Commitment to control and sustain finances (? length) • Adequate laboratory, standard treatment, continuous drug supply, guarantee quality

46. HIV risk factors increase during conflicts Risk does not mean transmission If populations are isolated and HIV levels are low, conflict may be protective HIV risk factors increase post-conflict Opening up trade, but still unemployment, and accessing previously isolated populations Early interventions needed to prevent explosive spread Interaction with STIs, TB and other diseases requires integrated interventions HIV, STI and TB emergency guidelines available Summary

47. Thank You

48. The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers of Disease Control and Prevention.