Marian Schilperoord

Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review

BACKGROUND Violence and rape are believed to fuel the HIV epidemic in countries affected by conflict. We compared HIV prevalence in populations directly affected by conflict with that in those not directly affected and in refugees versus the nearest surrounding host communities in sub-Saharan African countries. METHODS Seven countries affected by conflict (Democratic Republic of Congo, southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia, and Burundi) were chosen since HIV prevalence surveys within the past 5 years had been done and data, including original antenatal-care sentinel surveillance data, were available. We did a systematic and comprehensive literature search using Medline and Embase. Only articles and reports that contained original data for prevalence of HIV infection were included. All survey reports were independently evaluated by two epidemiologists to assess internationally accepted guidelines for HIV sentinel surveillance and population-based surveys. Whenever possible, data from the nearest antenatal care and host country sentinel site of the neighbouring countries were presented. 95% CIs were provided when available. FINDINGS Of the 295 articles that met our search criteria, 88 had original prevalence data and 65 had data from the seven selected countries. Data from these countries did not show an increase in prevalence of HIV infection during periods of conflict, irrespective of prevalence when conflict began. Prevalence in urban areas affected by conflict decreased in Burundi, Rwanda, and Uganda at similar rates to urban areas unaffected by conflict in their respective countries. Prevalence in conflict-affected rural areas remained low and fairly stable in these countries. Of the 12 sets of refugee camps, nine had a lower prevalence of HIV infection, two a similar prevalence, and one a higher prevalence than their respective host communities. Despite wide-scale rape in many countries, there are no data to show that rape increased prevalence of HIV infection at the population level. INTERPRETATION We have shown that there is a need for mechanisms to provide time-sensitive information on the effect of conflict on incidence of HIV infection, since we found insufficient data to support the assertions that conflict, forced displacement, and wide-scale rape increase prevalence or that refugees spread HIV infection in host communities.The epidemic its prevention and its consequences require coordinated responses of all institutions and sectors involved in municipal development. While municipalities may need further guidance through national programmes to know how to respond the municipal management has to ensure that appropriate measures are being implemented on the ground. HIV and Aids has been widely perceived as a health issue for some time but the impact of the epidemic on the development goals of municipalities is now becoming increasingly obvious. This contribution is the first in a series of articles discussing the many dimensions of HIV and Aids for local government ranging from impact to response and from legal and policy frameworks to examples of local responses as well as national and international developments. (excerpt)

Six rapid assessments of alcohol and other substance use in populations displaced by conflict

BackgroundSubstance use among populations displaced by conflict is a neglected area of public health. Alcohol, khat, benzodiazepine, opiate, and other substance use have been documented among a range of displaced populations, with wide-reaching health and social impacts. Changing agendas in humanitarian response-including increased prominence of mental health and chronic illness-have so far failed to be translated into meaningful interventions for substance use.MethodsStudies were conducted from 2006 to 2008 in six different settings of protracted displacement, three in Africa (Kenya, Liberia, northern Uganda) and three in Asia (Iran, Pakistan, and Thailand). We used intervention-oriented qualitative Rapid Assessment and Response methods, adapted from two decades of experience among non-displaced populations. The main sources of data were individual and group interviews conducted with a culturally representative (non-probabilistic) sample of community members and service providers.ResultsWidespread use of alcohol, particularly artisanally-produced alcohol, in Kenya, Liberia, Uganda, and Thailand, and opiates in Iran and Pakistan was believed by participants to be linked to a range of health, social and protection problems, including illness, injury (intentional and unintentional), gender-based violence, risky behaviour for HIV and other sexually transmitted infection and blood-borne virus transmission, as well as detrimental effects to household economy. Displacement experiences, including dispossession, livelihood restriction, hopelessness and uncertain future may make communities particularly vulnerable to substance use and its impact, and changing social norms and networks (including the surrounding population) may result in changed - and potentially more harmful-patterns of use. Limited access to services, including health services, and exclusion from relevant host population programmes, may exacerbate the harmful consequences.ConclusionsThe six studies show the feasibility and value of conducting rapid assessments in displaced populations. One outcome of these studies is the development of a UNHCR/WHO field guide on rapid assessment of alcohol and other substance use among conflict-affected populations. More work is required on gathering population-based epidemiological data, and much more experience is required on delivering effective interventions. Presentation of these findings should contribute to increased awareness, improved response, and more vigorous debate around this important but neglected area.

Hepatitis E outbreak, Dadaab refugee camp, Kenya, 2012.

To the Editor: Hepatitis E virus (HEV) is transmitted through the fecal-oral route and is a common cause of viral hepatitis in developing countries. HEV outbreaks have been documented among forcibly displaced persons living in camps in East Africa, but for >10 years, no cases were documented among Somali refugees (1,2). On August 15, 2012, the US Centers for Disease Control and Prevention (CDC) in Nairobi, Kenya, was notified of a cluster of acute jaundice syndrome (AJS) cases in refugee camps in Dadaab, Kenya. On September 5, a CDC epidemiologist assisted the United Nations High Commissioner for Refugees (UNHCR) and its partners in assessing AJS case-patients in the camp, enhancing surveillance, and improving medical management of case-patients. We present the epidemiologic and laboratory findings for the AJS cases (defined as acute onset of scleral icterus not due to another underlying condition) identified during this outbreak. Dadaab refugee camp is located in eastern Kenya near the border with Somalia. It has existed since 1991 and is the largest refugee camp in the world. Dadaab is composed of 5 smaller camps: Dagahaley, Hagadera, Ifo, Ifo II, and Kambioos. As of December 2012, a total of 460,000 refugees, mainly Somalians, were living in the camps; >25% were recent arrivals displaced by the mid-2011 famine in the Horn of Africa (3). Overcrowding and poor sanitation have led to outbreaks of enteric diseases, including cholera and shigellosis (4); in September 2012, an outbreak of cholera occurred simultaneously with the AJS outbreak. During July 2–November 30, 2012, a total of 339 AJS cases were reported from the camps and 2 nearby villages: 232 (68.4%) from Ifo II, 57 (16.8%) from Kambioos, 26 (7.7%) from Ifo, 12 (3.5%) from Dagahaley, 10 (3.0%) from Hagadera, and 1 each (0.6%) from the nearby Kenyan villages of Biyamadow and Darkanley. The epidemic curve of the outbreak is shown in the Figure. Figure Cases of acute jaundice syndrome, Dadaab, Kenya, July–November 2012. The arrow indicates the point at which outbreak control measures (e.g., construction of new latrines and hygiene messaging) were initiated by health authorities. Of the 339 AJS case-patients, 184 (54.3%) were female. The overall median age was 23.5 years (range 1 month−91 years). The median age among female and male residents was 24 years and 20 years, respectively. Among the 134 women of reproductive age (15−49 years), 72 (53.7%) reported being pregnant; the median gestational age was 17.4 weeks (range 8.7−35.3 weeks). Death was reported for 10 of the 339 case-patients (case-fatality ratio 2.9%), 9 of whom were postpartum mothers (case-fatality ratio 12.5%) and 1 a 2-year-old child. Serum samples were obtained from 170 (50.1%) AJS case-patients for testing at the Kenya Medical Research Institute/CDC laboratories in Nairobi, Kenya. Of the 170 samples, 148 were tested for hepatitis E virus (HEV) IgM by using an ELISA (Diagnostic Systems, Saronno, Italy), and 93 were tested for HEV RNA by using the GeneAmp Gold RNA PCR Reagent Kit (Applied Biosystems, Foster City, CA, USA). Of the 170 samples tested, 131 (77.1%) were positive for HEV IgM, HEV RNA, or both: 120 (81.1%) of 148 tested for HEV IgM and 48 (51.6%) of 93 tested for HEV RNA were positive. In response to the outbreak, UNHCR and partners initiated control measures, including training of health care workers, increasing community awareness, improving hygiene promotion activities, and hastening latrine construction. The outbreak also affected refugee resettlement to the United States and other countries. At the onset of the outbreak, ≈100 Dadaab refugees per month were scheduled for US resettlement. The incubation period for HEV is 15–60 days (5); thus, there was concern that refugees could become ill in transit or within weeks of US resettlement. Acute HEV infection, including progression to fulminant hepatitis, had been reported among travelers returning from regions where the disease is endemic (6). As a precaution, the International Organization for Migration and CDC conducted heightened AJS surveillance during pre-departure and arrival health screenings. As of February 2013, no cases of AJS were reported among refugees from Dadaab who resettled in the United States. Dadaab has faced grave insecurity: aid workers were abducted from the camp in late 2011, and Dadaab has experienced numerous blasts from explosive devices (7). Thus, UNHCR and CDC have been limited in their capacity to collect data and conduct a thorough outbreak investigation to identify risk factors. An earlier study in the Shebelle region of Somalia suggested an increased incidence of HEV during the rainy season and elevated risk for infection in villages dependent on river water (8). Further evaluation is needed to identify the risk factors for HEV transmission and HEV-associated deaths in this region, including the role of person-to-person transmission. UNHCR and CDC investigations of HEV outbreaks in refugee camps in southern Sudan may provide data to answer these questions. HEV is believed to have infected humans for centuries (9); however, the reemergence of the disease in refugee camps is a major concern because of the difficulty in implementing effective preventive measures under camp conditions. Point-of-care tests will be useful for rapidly detecting outbreaks and could potentially save lives. The progress made in developing effective vaccines is encouraging (10). Once available, HEV vaccination should be prioritized in this population, especially for pregnant women.

Adherence to antiretroviral therapy and treatment outcomes among conflict-affected and forcibly displaced populations: a systematic review

A bstractBackgroundOptimal adherence to highly active antiretroviral therapy (HAART) is required to promote viral suppression and to prevent disease progression and mortality. Forcibly displaced and conflict-affected populations may face challenges succeeding on HAART. We performed a systematic review of the literature on adherence to HAART and treatment outcomes in these groups, including refugees and internally-displaced persons (IDPs), assessed the quality of the evidence and suggest a future research program.MethodsMedline, Embase, and Global Health databases for 1995–2011 were searched using the Ovid platform. A backward citation review of subsequent work that had cited the Ovid results was performed using the Web of Science database. ReliefWeb and Médecins Sans Frontières (MSF) websites were searched for additional grey literature.Results and conclusionWe screened 297 records and identified 17 reports covering 15 quantitative and two qualitative studies from 13 countries. Three-quarters (11/15) of the quantitative studies were retrospective studies based on chart review; five studies included <100 clients. Adherence or treatment outcomes were reported in resettled refugees, conflict-affected persons, internally-displaced persons (IDPs), and combinations of refugees, IDPs and other foreign-born persons. The reviewed reports showed promise for conflict-affected and forcibly-displaced populations; the range of optimal adherence prevalence reported was 87–99.5%. Treatment outcomes, measured using virological, immunological and mortality estimates, were good in relation to non-affected groups. Given the diversity of settings where forcibly-displaced and conflict-affected persons access ART, further studies on adherence and treatment outcomes are needed to support scale-up and provide evidence-based justifications for inclusion of these vulnerable groups in national treatment plans. Future studies and program evaluations should focus on systematic monitoring of adherence and treatment interruptions by using facility-based pharmacy records, understanding threats to optimal adherence and timely linkage to care throughout the displacement cycle, and testing interventions designed to support adherence and treatment outcomes in these settings.

Improving mental health care in humanitarian emergencies

Climatic and geological hazards con-tinue to take their toll, as seen recently following the devastating earthquake in Nepal, cyclone in Vanuatu and flooding in China, Malawi and Myanmar.Although estimated rates of mental disorder after conflict vary due to differ -ences in context and study methods, a meta-analysis of methodically stronger surveys indicate average rates of 15–20% for depression and post-traumatic stress disorder.

Differences in HIV-related behaviors at Lugufu refugee camp and surrounding host villages, Tanzania.

BackgroundAn HIV behavioral surveillance survey was undertaken in November 2005 at Lugufu refugee camp and surrounding host villages, located near western Tanzanias border with the Democratic Republic of Congo (DRC).MethodsThe sample size was 1,743 persons based on cluster survey methodology. All members of selected households between 15–49 years old were eligible respondents. Questions included HIV-related behaviors, population displacement, mobility, networking and forced sex. Data was analyzed using Stata to measure differences in proportions (chi-square) and differences in means (t-test) between gender, age groups, and settlement location for variables of interest.ResultsStudy results reflect the complexity of factors that may promote or inhibit HIV transmission in conflict-affected and displaced populations. Within this setting, factors that may increase the risk of HIV infections among refugees compared to the population in surrounding villages include young age of sexual initiation among males (15.9 years vs. 19.8 years, p = .000), high-risk sex partners in the 15–24 year age group (40% vs. 21%, χ2 33.83, p = .000), limited access to income (16% vs. 51% χ2 222.94, p = .000), and the vulnerability of refugee women, especially widowed, divorced and never-married women, to transactional sex (married vs. never married, divorced, widowed: for 15–24 age group, 4% and 18% respectively, χ2 8.07, p = .004; for 25–49 age group, 4% and 23% respectively, χ2 21.46, p = .000). A majority of both refugee and host village respondents who experienced forced sex in the past 12 months identified their partner as perpetrator (64% camp and 87% in villages). Although restrictions on movements in and out of the camp exist, there was regular interaction between communities. Condom use was found to be below 50%, and expanded population networks may also increase opportunities for HIV transmission. Availability of refugee health services may be a protective factor. Most respondents knew where to go for HIV testing (84% of refugee respondents and 78% of respondents in surrounding villages), while more refugees than respondents from villages had ever been tested (42% vs. 22%, χ2 63.69, p = .000).ConclusionThis research has important programmatic implications. Regardless of differences between camp and village populations, study results point to the need for targeted activities within each population. Services should include youth education and life skills programs emphasizing the benefits of delayed sexual initiation and the risks involved in transactional sex, especially in the camp where greater proportions of youth are affected by these issues relative to the surrounding host villages. As well, programs should stress the importance of correct and consistent condom use to increase usage in both populations. Further investigation into forced sex within regular partnerships, and programs that encourage male involvement in addressing this issue are needed. Program managers should verify that current commodity distribution systems ensure vulnerable womens access to resources, and consider additional program responses.

Changes in HIV-related behaviours, knowledge and testing among refugees and surrounding national populations: a multicountry study.

To our knowledge, there is currently no published data on the prevalence of risky sex over time as displaced populations settle into long-term post-emergency refugee camps. To measure trends in HIV-related behaviours, we conducted a series of cross-sectional HIV behavioural surveillance surveys among refugees and surrounding community residents living in Kenya, Tanzania and Uganda, at baseline in 2004/2005 and at follow-up in 2010/2011. We selected participants using two-stage cluster sampling, except in the Tanzanian refugee camp where systematic random sampling was employed. Participants had to reside in a selected household for more than weeks and aged between 15 and 49 years. We interviewed 11,582 participants (6448 at baseline and 5134 at follow-up) in three camps and their surrounding communities. The prevalence of multiple sexual partnerships ranged between 10.1 and 32.6% at baseline and 4.2 and 20.1% at follow-up, casual partnerships ranged between 8.0 and 33.2% at baseline and 3.5 and 17.4% at follow-up, and transactional partnerships between 1.1 and 14.0% at baseline and 0.8 and 12.0% at follow-up. The prevalence of multiple partnerships and casual sex in the Kenyan and Ugandan camps was not higher than among nationals. To our knowledge these data are the first to describe and compare trends in the prevalence of risky sex among conflict-affected populations and nationals living nearby. The large reductions in risky sexual partnerships are promising and possibly indicative of the success of HIV prevention programs. However, evaluation of specific prevention programmes remains necessary to assess which, and to what extent, specific activities contributed to behavioural change. Notably, refugees had lower levels of multiple and casual sexual partnerships than nationals in Kenya and Uganda and thus should not automatically be assumed to have higher levels of risky sexual behaviours than neighbouring nationals elsewhere.

Measles Outbreak Response Among Adolescent and Adult Somali Refugees Displaced by Famine in Kenya and Ethiopia, 2011

BACKGROUND The refugee complexes of Dadaab, Kenya, and Dollo-Ado, Ethiopia, experienced measles outbreaks during June-November 2011, following a large influx of refugees from Somalia. METHODS Line-lists from health facilities were used to describe the outbreak in terms of age, sex, vaccination status, arrival date, attack rates (ARs), and case fatality ratios (CFRs) for each camp. Vaccination data and coverage surveys were reviewed. RESULTS In Dadaab, 1370 measles cases and 32 deaths (CFR, 2.3%) were reported. A total of 821 cases (60.1%) were aged ≥15 years, 906 (82.1%) arrived to the camps in 2011, and 1027 (79.6%) were unvaccinated. Camp-specific ARs ranged from 212 to 506 cases per 100 000 people. In Dollo-Ado, 407 cases and 23 deaths (CFR, 5.7%) were reported. Adults aged ≥15 years represented 178 cases (43.7%) and 6 deaths (26.0%). Camp-specific ARs ranged from 21 to 1100 cases per 100 000 people. Immunization activities that were part of the outbreak responses initially targeted children aged 6 months to 14 years and were later expanded to include individuals up to 30 years of age. CONCLUSIONS The target age group for outbreak response-associated immunization activities at the start of the outbreaks was inconsistent with the numbers of cases among unvaccinated adolescents and adults in the new population. In displacement of populations from areas affected by measles outbreaks, health authorities should consider vaccinating adults in routine and outbreak response activities.

High-risk sex and displacement among refugees and surrounding populations in 10 countries: the need for integrating interventions.

Introduction:Between 2004 and 2012, the United Nations High Commissioner for Refugees conducted behavioural surveillance surveys in 27 separate communities in 10 countries. Methods:Random systematic or two-stage cluster sampling was used among participants of age 15–49 years, using a modified standard questionnaire. We conducted descriptive data analysis and multivariable logistic regression to identify factors independently associated with multiple sexual partnerships. Results:Of 27 sites surveyed comprising 24 219 individuals, 11 refugee and surrounding communities were paired. Recent displacement comprised less than 10% of participants. Visiting neighbouring communities varied from 8.6 to 74.4%. Multiple sexual partnerships varied from 2.7% in Sudan to 32.5% in Tanzania. Condom use during last sex was low in most of the communities (<5%). The prevalence of forced sex was similar in paired sites, with intimate partner violence being the most frequent, ranging between 1.0 and 4.6% in camps and 0.8 and 3.6% in communities, with the exception of Nepal (10.8 and 9.8%). Being away from home for more than 1 month and having lived in community for less than 12 months was associated with multiple partnerships in six and five of 16 sites, respectively. Conclusion:In the largest study of paired sites of refugees in protracted refugee camps and surrounding nationals, data showed no consistent difference in levels of risky sexual behaviour and there was much variation among the different groups. The prevention strategies should be targeted in a highly integrated manner for both the communities. Forced sex among women was reported at similar levels among refugees and nationals, with intimate partner violence being the most common. These findings should reduce stigma and discrimination against refugees.

Funding for Reproductive Health in Conflict and Post- Conflict Countries: A Familiar Story of Inequity and Insufficient Data

Paul Spiegel and colleagues discuss a new study that examines funding for sexual and reproductive health programs in conflict-affected low-income countries.