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HIV in Emergencies: From research to strategies, policies and results
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Transcript of 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
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.
• 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. Lancet 2007;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.
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.
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
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.
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.
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
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.
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
Results cont4. Increased funding for emergencies
5. Increasing awareness of issue and recognition of need to act
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.
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.
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
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