1. HIV and Conflict-affected Populations: Overview and the Challenges Paul Spiegel MD,MPH United Nations High Commissioner for Refugees

2. Overview 1.Definitions 2.Numbers 3.Key players 4.Epidemiology 5.Key Guidelines and policy documents 6.Challenges 7.Constraints

3. Definitions Complex Emergency Humanitarian crisis in country, region or society with total or considerable breakdown of authority resulting from internal or external conflict that requires int. response which goes beyond mandate or capacity of single agency and/or ongoing UN country programs IASC, December 1994 Acute situations affecting large civilian populations, usually involving combination of war or civil strife, food shortages, and population displacement, resulting in significant excess mortality CDC MMWR, 1992

4. Definitions cont Refugee Any person who owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of particular social group or political opinion is outside the country of his nationality.… Refugee convention, 1951 Internally Displaced Person (IDP): Persons who flee their homes for similar reasons as refugees but who remain inside their own countries Displaced Persons (DPs) Refugees and/or IDPs

5. Displacement Cycle

6. Numbers Conflict-affected, 2005 Refugees (13.4 m; 9.2m UNHCR, 4.2 m UNRWA) IDPs (25 m) 50% under 18 yrs Source: UNHCR and UNRWA, 2006 ? X m affected by conflict but no displaced Disaster-affected, 2005 157 m affected (floods, droughts) 245,000 deaths (90% tsunami) Source: EM-DAT, CRED, 2006

7. Key Players 1.DPs 2.Surr. host population 3.Host government 4.Non-governmental organisations (NGOs) 5.UN agencies 6.Other international org. 7.Military

8. 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. HIV and Conflict Epidemiology: Overlap between HIV and Conflict

9. 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

11. Reduction in mobility Reduction in accessibility Slowing down of urbanisation Increase in resources and services in host country HIV Risk Factors for Conflict-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.

12. The Sphere Project,1997 Humanitarian Charter Universal minimum standards in core areas Aim: Quality of assistance Accountability HIV is cross-cutting issue

13. HIV Interventions in Emergencies Guidelines for HIV/AIDS Interventions in Emergency Settings, IASC, 2003 Matrix in 3 phases –Emergency Preparedness –Minimum Response (to be conducted even in emerg.) –Comprehensive Response (Stabilised Phase) By sector

14. Post-emergency, 2005 1.Integrate refugee issues into national HIV programs and policies 2.Implement sub regional (cross-border) initiatives 3.Combine humanitarian and development funding

15. Challenge #1: Inclusion of DPs into Country Policies and Interventions ^ NSP- National HIV Strategic Plans; * countries in Africa in 2004 with >10,000 refugees Existence of NSP^ (N=29)* NSP Mentions Refugees (N=23) NSP State Activities For Refugees (N=23)

16. Challenge #2: Integrating HIV and Protection HIV status has no influence on : –Access to asylum –Refoulement –Right of return Improved mechanisms to ensure confidentiality HIV prevention and care integrated into voluntary repatriation operations Ensuring resettlement countries improving counselling and testing procedures

17. Challenge #3: Subregional Approach Provide access to prevention and care for mobile populations including DPs Ensure continuity of care Improve efficiency and lower costs Leverage additional funding

18. Other Major Lessons Learned and Challenges Coordination at global, regional, country and site levels Provision of antiretroviral therapy  Also relates to funding mechanisms Gathering reliable data Operational research

19. Some Constraints Staffing Short-term view Technical expertise Funding Competing interests More information: www.unhcr.org/hiv-aids