Sexually Transmitted Infections, including HIV/AIDS

Key Messages

• The 2005 Human Development Report identified AIDS as the factor inflicting the single greatest reversal in human development history.[1]
• In most settings, sexually transmitted infections (STIs), including HIV, spread fastest where there is poverty, powerlessness and instability, all characteristics of displaced settings.[2]
• Refugees and displaced persons are especially vulnerable to STIs, including HIV, due to poverty, food insecurity, lack of access to health services, mobility and lack of protection against violence and/or exploitation by military, peacekeeping forces and others.[3]
• HIV transmission among conflict-affected and displaced populations is complex. The common assumption that these populations’ increased vulnerability necessarily translates into more HIV infections is not supported by data. Various competing and interacting factors affect HIV transmission during conflict and displacement.[4]
• Recent research indicates that numerous factors such as decreased mobility and access to and from displaced populations, possibly due to forced migration, insecurity, destroyed infrastructure and diminished resources, may be protective against the spread of HIV among displaced populations in some contexts.[5]
• Violence and discrimination increase women’s risk factors for HIV infection. HIV-positive women are ten times more likely to have encountered male violence than their HIV-negative counterparts.[6]
• The power imbalances that make girls and women disproportionately vulnerable to the infection become more pronounced during conflict and displacement. Gender-related factors, such as breakdown of social and community structures and increased gender-based violence, can contribute to the spread of HIV in these settings.[7]
• While behavioral and biological data on HIV in situations of forced migration is slowly increasing, limited information is currently available to help design, implement and evaluate HIV/AIDS programs.[8]
• Even in the context of a complex emergency, effective HIV/AIDS interventions are possible and necessary. At the onset of a new crisis, it is possible to guarantee the availability of free condoms and enforce respect for universal precautions against HIV/AIDS. Longer term, public awareness campaigns can lead to the reduction of HIV/AIDS by changing sexual behavior patterns.
• The passing of UN Resolution 1308 in July 2000 urged UN agencies and member states to develop effective HIV/AIDS prevention strategies in peacekeeping missions. As a result, most peacekeeping missions now have HIV/AIDS policy advisors and progress has been made in controlling the effect of HIV/AIDS in conflict zones.[9] However, gender units in peacekeeping missions are often lacking and agencies still need to adequately address the link between HIV/AIDS and women.[10]

Overview

The relationship between conflict and vulnerability to STIs, including HIV/AIDS, is complex. Typically, all STIs thrive under crisis conditions, which coincide with limited access to the means of prevention, treatment and care.[11] In complex emergencies, refugees and internally displaced persons are especially vulnerable to STIs, including HIV. However, new findings from conflict settings show that in some circumstances where displaced people have been isolated and less mobile HIV prevalence is lower than that of neighboring countries.[12]

At the same time, it is possible that STIs, including HIV, if not addressed or checked, may spread rapidly among displaced populations for many reasons. The disturbance of community and family life among displaced populations may disrupt social norms governing sexual behavior. Adolescents may begin sexual relations at an earlier age, take sexual risks, such as having sexual intercourse without using a condom, and face exploitation in the absence of traditional socio-cultural constraints. Women and children may be coerced into having sex to obtain their survival needs. During civil strife and flight, displaced persons, especially women and girls, are at increased risk of sexual violence, including rape. Proximity to peacekeeping forces, military and police, a population which has long been associated with higher rates of STIs, can facilitate the spread of HIV in refugee and internally displaced settings.[13] Finally, populations from low HIV prevalence areas may mix with populations from high prevalence areas, increasing the overall HIV rate in the region. In conclusion, there is insufficient data to determine how conflict and displacement affect HIV prevalence.[14]

Until recently, HIV/AIDS programs were frequently excluded in relief agencies’ immediate response to complex emergencies. However, the humanitarian community now understands that an HIV/AIDS intervention must begin immediately at the onset of an emergency as well as involve a multi-sectoral approach; the updated Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response Handbook also recognizes HIV/AIDS as a cross-cutting issue. New evidence demonstrates the effectiveness of providing basic HIV/AIDS information and prevention methods among displaced populations. These essential HIV programs should be developed in adherence to the Inter-agency Standing Committee Guidelines for HIV/AIDS in Emergency Settings. In addition, HIV programs for internally displaced persons should be integrated with host governments and follow host government protocols, guidelines and strategic plans.[15]

The most common route of HIV transmission is through sex. The World Health Organization (WHO) states that the presence of an untreated STI can greatly increase the risk of HIV transmission during sexual contact.[16]

Facts

Global Statistics

• Globally, an estimated 340 million curable STIs are contracted per year.[17]
• In less developed countries, STIs and their complications are among the top five diseases for which adults seek health care.[18]
• In women of reproductive age, STIs are the second leading cause of disease, death and healthy life lost.[19]
• The presence of an STI can increase both the acquisition and transmission of HIV ten-fold.[20]
• In 25 years, HIV has spread to almost every country in the world, infecting 65 million people and killing 25 million.[21]
• An estimated 38.6 million people worldwide were living with HIV in 2005; of these, 24.5 million people were living in sub-Saharan Africa.[22]
• Research suggests that by 2015, in the 60 countries most affected by AIDS, the total population will be 115 million less than it would be without the impact of AIDS.[23]
• In 2005 approximately 4.1 million people became newly infected with HIV.[24]
• Over 90 percent of those infected with HIV do not know their status.[25]
• Almost one in three people living with HIV globally reside in southern Africa. About 43% of all children (under 15 years) living with HIV are in this sub-region as are an estimated 52% of all infected women (15 years and older).[26]
• Of those who are infected with HIV, an estimated 64 percent live in sub-Saharan Africa. Almost nine out of ten children with HIV live in sub-Saharan Africa, where more than 12 million children were been orphaned by AIDS in 2005.[27]
• Although more men than women were infected with HIV/AIDS ten years ago, the percent of infected women worldwide has grown from 41 percent to 50 percent in the past six years.[28] About 75 percent of all infected women live in sub-Saharan Africa.[29]
• An estimated 59 percent of the 24.5 million people with HIV/AIDS in sub-Saharan Africa are women.[30] Poverty, inequality, violence, and lack of education and power are among the key factors contributing to the spread of HIV/AIDS among women, according to UNIFEM.[31]
• Adolescent girls are increasingly affected by the HIV/AIDS pandemic. Globally, about half of people living with HIV are female, but 75 percent of affected young people in sub-Saharan Africa are female.[32]
• In Africa, where the majority of new HIV infections are among the young, the risk for girls (aged 15 to 24) compared with boys is two to one. In sub-Saharan Africa, infected young women outnumber infected young men 3.6 to one.[33]
• About one-third of those currently living with HIV/AIDS are aged 15 to 24. Most of them do not know they carry the virus.[34]
• The Declaration of Commitment on HIV/AIDS aimed for 90 percent of young people to be knowledgeable about HIV by 2005; however, studies demonstrate that less than 50 percent of young people achieved comprehensive knowledge.[35]
• The “virgin myth”, the belief that infected men can cure themselves of HIV/AIDS if they have sex with a virgin, has helped fuel the spread of HIV in Botswana where nearly 40 percent of the adult population has the virus.[36]
• Globally, 65 million girls are denied an education, making them at greater risk for contracting HIV/AIDS due to increased vulnerability to poverty, hunger, violence, abuse, exploitation and trafficking. Twenty-four million of girls not in school reside in sub-Saharan Africa.[37]
• Around 9 percent of children (under 15) in sub-Saharan Africa have lost at least one parent to AIDS, and one in six households with children is caring for at least one orphan.[38]
• Countries in Eastern Europe and Central Asia are experiencing the fastest-growing AIDS epidemic in the world – this is a twenty-fold increase in less than ten years. Between 2003 and 2005, infection rates among adults and children increased by more than one-third.[39]
• HIV prevalence is increasing in Ukraine, Russian Federation, China, Indonesia, Papua New Guinea and VietNam, and there are signs of HIV outbreaks in Bangladesh and Pakistan.[40]
• Swaziland continues to have the highest prevalence rate in the world at 42.6 per cent. The prevalence of pregnant women between the ages of 25 and 29 was reported to be 56.3 percent.[41]
• Human Rights Watch has reported that Uganda’s lack of effective domestic violence laws has increased Ugandan women’s risk of contracting HIV.[42]
• Studies from Uganda demonstrate that a child who drops out of school is three times more likely to contract HIV in her/his twenties than a child who completes basic education.[43]
• Approximately 38.5 percent of women ages 15 to 49 attending antenatal clinics in Botswana were HIV prevalent in a two-year study.[44]
• Intimate partner violence has been shown to increase the risk of HIV in a survey of 1,366 women attending antenatal clinics in Soweto, South Africa. Significantly higher rates of HIV infection were found in women who were physically abused, sexually assaulted, or dominated by their male partners. Some possible explanations for these findings include these women’s prolonged exposure to their intimate partners (potentially HIV transmitters), their inability to refuse sex or to negotiate condom use, and the connection between intimate partner abuse and increased likelihood of HIV risk behavior.[45]
• Abstinence-based only HIV/AIDS prevention programs fail to consider a variety of factors in women’s lives, including the possibility of coerced sex, partner infidelity, rape, exchanging sex for resources, and the refusal of her partner to wear a condom. Abstinence-based only initiatives do not protect women and girls from contracting HIV/AIDS.[46]
• Research in sub-Saharan Africa show the net impact of HIV/AIDS on countries’ gross domestic product to be around 1 percent yearly; figures are significantly lower for countries with lower HIV prevalence.[47]

Refugee/Internally Displaced/Conflict-affected Statistics

• Countries impacted by complex emergencies have 27 percent of all HIV deaths globally.[48] However, evidence also suggests that complex emergencies may reduce HIV/AIDS transmission due to factors such as a reduced population, reduced trade and transportation, famine, and disruption in rural and regional migration.[49] Other data suggests that the effects of the epidemic are simply delayed until post-conflict.[50]
• Only 35 percent of the 29 African countries that host more than 10,000 refugees have specific activities for refugees in their HV/AIDS National Strategic Plans.[51] Moreover, urban refugees are often undocumented and therefore do not receive support from UNHCR, while internally displaced persons are often barred from their government’s HIV/AIDS programs.[52]
• Conflict has displaced up to 400,000 people in Nepal, which may be accelerating the country’s HIV epidemic due to severely curtailing the ability of nongovernmental organizations to provide HIV prevention services.[53]
• Post-conflict Cote d’Ivoire has the highest HIV prevalence in West Africa at 7.1 percent.[54]
• According to a UNDP survey, the majority of HIV-positive men and women in southern Sudan are between 20 and 29 years old. Forty-one percent of the general population in southern Sudan has no knowledge of HIV/AIDS prevention methods.[55]
• STIs were the problem most consistently identified by community members in a 1999 reproductive health qualitative study conducted in war-affected communities in southern Sudan.[56]
• The HIV prevalence among Rwandan girls aged 15 to 19 is estimated at 4.8 percent. Of 964 Rwandan youth surveyed by GTZ, 47 percent believed it is possible to know someone’s infection status by simply looking at her/him; almost half did not know how to use a condom; and 41 percent believed that having sex with a child will cure an infected man while a mere five percent thought this belief was “totally wrong”.[57]
• In Burma 360,000 children and adults were living with HIV in 2005.[58]
• After an HIV/AIDS public awareness campaign in a refugee camp in northwestern Kenya, the infection rate was found to be 5 percent in the camp, compared to 18 percent in the area surrounding the camp, demonstrating the effectiveness of providing basic HIV/AIDS information and prevention methods among conflict affected populations.[59]
• Approximately 5 percent of population of the Democratic Republic of the Congo was HIV-positive before the war, whereas an estimated 20 percent of the population is infected in the war-ravaged eastern parts of the country. Less than one percent of Liberia’s population was inflected before the onset of the war in 1989; approximately 8 percent was infected a decade later and 16 percent in 2003.[60]
• Although three percent of the general population of Angola is infected with HIV, between 40 and 60 percent of the Angolan military is HIV-positive. In Zimbabwe, the HIV-infection rate in the military is twice that of the general population.[61]
• In conflict-affected Burundi, the HIV/AIDS growth rates have reached 20 percent in urban settings and 7.5 percent in rural areas.[62]
• Burma (Myanmar) has the highest HIV/AIDS rate in south-east Asia.[63] In a survey of Burmese refugees (233 men and 492 women) in Thailand, only 15 percent of women had seen a condom, and less than half knew that birth control pills do not prevent HIV transmission. Less than 2 percent of the women and approximately 13 percent of men reported using a condom at least once. Only 27 percent understood that their own HIV status could be determined with a blood test.[64]
• A survey of 976 refugees living in camps in Guinea's forest region showed that 26 percent thought that HIV could be transmitted by touching and 22 percent of interviewees said that eating good food will protect against contracting HIV.[65]
• Sixty-three percent of HIV-positive women in Burundi who had tried the female condom preferred it to the male condom and over three-quarters thought that it empowered them to prevent unwanted pregnancy. Burundi has an approximately 11.3 percent HIV-prevalence rate among adults.[66]
• War-torn Haiti has the highest number of persons living with HIV in the region.[67]

Case Studies

Turning misconceptions into enthusiasm in Liberia
Momoh is a 19-year-old refugee boy in Liberia who had previously denounced an NGO’s peer counselors and refused to attend any of the youth programs because he felt that the NGO did not want young people to have sexual intercourse. Upon the recommendation of a peer counselor, Momoh was invited to attend a reproductive health workshop for youth. During the pre-test, Momoh stated that gonorrhea could be contracted through riding a bicycle and engaging in other strenuous exercises. At the end of the workshop, Momoh scored the highest grade in the post-test and commented that his misconceptions about STIs had been cleared. After the workshop, he regularly began to participate in the youth shows and use condoms. He encouraged many of his peers to participate in the shows and to also use condoms.

Commercial sex workers and condom use in Sierra Leone
Sea is a 33-year-old Sierra Leonean refugee woman who is married with two children. During the war, her husband became sick and was paralyzed three weeks after Sea gave birth to their second child. This made life very difficult for Sea. By default she became the breadwinner for the family. Sea never completed school and could not secure a job easily. She turned to prostitution to earn a living for her family. Initially, Sea never believed in using condoms and felt that with condoms, she would not be able to command a good price for her work. Sea initially ran a palm wine bar supplied by Zainab, the group leader who would help her and other commercial sex workers find clients. The palm wine bar provided an opportunity to meet clients, and as such Sea was not happy when an a staff person from the American Refugee Committee (ARC) went to her palm wine bar to talk about HIV/AIDS and condoms, thinking this would discourage clients.

Sea gradually gained confidence in ARC and accepted the use of condoms with her clients. After hearing health education messages over time, she even volunteered to distribute condoms among her colleagues. Sea was also one of 25 commercial sex workers who benefited from ARC’s micro-credit loan scheme. This has brought some positive changes in Sea's life. With a small loan, Sea was able to establish a "table market" to sell food, and she has stopped selling palm wine and reduced her sex work.

Resources

Click here for more resources on STIs and HIV/AIDS.

Updated September 2006

References

Note: Links provided only if resource is available to public.