(October 2001) Worldwide, millions of people who abandon their homes and communities because of drought, floods, earthquakes, war, or civil strife live in uncertain conditions either within their own countries or in foreign lands. They may end up in special camps where social structures fall apart, women and girls are abused, unsafe sexual activity is common, and access to health services limited. In such situations, uprooted people — particularly women and girls — face a heightened risk of contracting HIV/AIDS.
The U.S. Committee for Refugees estimates that more than 34 million people were living away from their homes because of one disaster or another at the end of 2000.1 Close to 15 million of them were refugees in foreign countries. More than 3 million were living in Africa, with Tanzania hosting the largest population of more than 500,000 people.
The number of people displaced within their own countries was even greater — at least 20 million, according to the Committee. In Sudan, ongoing civil war has created some four million internally displaced people, while conflict has displaced another 2.5 million people in Angola and 1.6 million people in the Democratic Republic of the Congo.
The genocide that erupted in Rwanda in 1994 increased the international community’s awareness of the need to address the HIV epidemic during emergencies. The conflict created a massive refugee crisis in the Great Lakes region of Africa, as hundreds of thousands of people fled Rwanda — where HIV was already prevalent — for countries that were also plagued with the virus.
Since then, relief agencies agree that displacement places affected populations at heightened risk of HIV infection. The virus spreads more rapidly among the poor, dependent, and powerless whose risks increase even more in situations of social instability and lawlessness — conditions that are most extreme during natural disasters, war, and conflict.2
Displaced Women Face Additional Burdens
While women and children comprise up to two-thirds of the general population in some less developed countries,3 that proportion may rise among certain refugee groups. In some refugee populations, the proportion of women and children may rise to 90 percent, when husbands or fathers die, are taken prisoner, or are drafted as combatants.4 Though proportions of female and male refugees appear to be almost 50–50 at the global level, reflecting overall population trends,5 some regional differences in the composition of refugee populations exist. For instance, the refugee population is particularly young in Africa — some 16 percent are below the age of 5 — which itself reflects the United Nations’ projections for the region’s population as a whole.6
The options and resources available to women, particularly during civil unrest or conflict, are different from those of men, many of whom may be combatants or in positions of authority. Faced with overcrowded living conditions, inadequate food and safe drinking water, women may also have the additional burden of caring for and ensuring the survival of other family members. Separated from family and communities that traditionally offered protection and security, women often are victims of violence.7
Women are also especially vulnerable to HIV infection. According to the World Health Organization (WHO), anatomical differences make transmission of the virus through sexual contact far more effective from men to women than vice versa. While research shows that male circumcision may offer a measure of protection against HIV infection,8 questions remain as to whether the practice affects women’s vulnerability to HIV infection. Even more significant though are the power relations between women and men. The Platform for Action adopted by governments at the 1995 Fourth World Conference on Women in Beijing recognizes that low social status is at the heart of women’s vulnerability to HIV.
That vulnerability is especially apparent in Africa. While women around the world comprise roughly 47 percent of the nearly 35 million adults living with HIV or AIDS, in Africa, 12 women have HIV for every 10 men with the virus, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).9
The following are among the factors that play a major role in heightening the HIV risks for refugee and other displaced women:
- Limited access to prevention and care services. Living conditions for refugees are so chaotic that even where HIV prevention and care programs exist, the services are likely to collapse during an emergency, notes UNAIDS. As a result, refugees may lack access to condoms and may be unable to protect themselves during sexual activity.
- Presence of military forces. Research has highlighted links among army personnel, unsafe commercial sex, and sexually transmitted infections (STIs), including HIV.10 In its fact sheet, “AIDS as a Security Issue,” the United Nations Special Session on HIV/AIDS held in June 2001 notes that STI rates among soldiers are an estimated two to five times that of civilian populations during peacetime. The discrepancy could be even higher during times of conflict. In some countries where HIV prevalence rates among adults are around 20 percent, estimates show that up to 50 percent of military personnel could have HIV.
- Violence and sexual exploitation. Women and children face high levels of violence and sexual exploitation during forced population movements, as the people in the military — mostly men who have been separated from their homes, communities, and partners — exert significant control over others, according to UNHCR. In some countries, the military have also used rape and forced pregnancy as tactics to destroy or defeat ethnic or racial groups.
“The harshness of refugee life for women goes far beyond the double work day and backbreaking toil,” notes Judy A. Benjamin, pointing to the Rwanda crisis as an example.11 “Many Rwandan women on both sides of the conflict were beaten, raped, and tortured. Tragically, the violence did not end when the women finally arrived at what should have been their refuge — the refugee camp.”
Women also encounter violence from partners and acquaintances. Since such violence is likely to involve sex without a condom, the sufferer is at high risk of contracting STIs, including HIV, if a partner is infected. The risks of transmission increase when genital tissues are torn during violent sex.
- Sex work. With no means to support themselves, girls and women may increase their risk of exposure to HIV by selling sex to survive. Many people fleeing emergencies are unaccompanied minors who may be lured into early sexual activity. According to UNAIDS, girls are more likely than boys to be enticed into sex by someone who is older, stronger, and can offer them money, food, shelter, and security.
- Population mixing. During emergency situations, there is often mixing among people of differing backgrounds, according to the Reproductive Health for Refugees Consortium, a grouping of seven nongovernmental organizations. Displaced people may move from rural settings where there may be lower rates of STIs, including HIV, to heavily populated cities or their outskirts where the HIV epidemic may be more widespread.
- Blood transfusions. During the early stages of an emergency, a population may lose access to essential services and needs, including housing, food, and health care. Lives may be threatened and many people may be forced to flee. According to the United Nations’ Guidelines for HIV Interventions in Emergency Settings,12 HIV infection can occur during this phase through the transfusion of contaminated blood. The Guidelines note that efforts should be made to guarantee the availability of resources and facilities for screening blood to ensure a safe supply.
The International Response
Efforts to prevent the spread of HIV/AIDS in refugee situations face major obstacles. In less developed countries, local populations have limited access to health care services. Also, programs to prevent the spread of HIV and care for those infected have not been fully developed.
At the 1994 International Conference on Population and Development (ICPD) in Cairo, governments recognized that uprooted people deserved all the rights and protections, including access to health care services, given to the rest of the world. Since then, the international community has been devising ways of ensuring the health and rights of refugees that embrace a holistic approach — one that encompasses health, social, economic, human rights, and legal issues.
In emergency situations, such a comprehensive approach must also incorporate issues of gender, to take into account the distinct experiences of women and men, says Lyn Elliott of Save the Children Fund, UK.13
Since the ICPD, UN humanitarian agencies, nongovernmental organizations, and a number of governments have devised a response to HIV/AIDS in disaster-affected communities that focuses on providing a range of reproductive health services. They have produced handbooks and training material that have been tested in various pilot programs. The response includes the 1999 guide, Reproductive Health in Refugee Situations: An Inter-agency Field Manual and the Reproductive Health Kit for Emergency Situations developed by the United Nations Population Fund (UNFPA).
Included in the inter-agency field manual is the “Minimum Initial Service Package” (MISP) that is meant to address emergency reproductive health problems in the immediate aftermath of a disaster. The MISP calls for a number of activities, including the training of health care workers, advocacy to underline the importance of integrating reproductive health into general health care, the provision of emergency supplies, and the identification of persons to coordinate reproductive health services.
MISP provides guidelines for:
- The wide availability of condoms.
- Prevention and management of sexual violence and its consequences, including the provision of emergency contraception.
- The observance of all necessary medical precautions — including frequent hand washing and use of gloves — by health workers during the emergency to reduce the risks of HIV infection.
- The reduction of complications during pregnancy and delivery through the provision of delivery kits for use by mothers, birth attendants, and midwives, and through the use of a system of referral to local clinics or hospitals in the case of obstetric emergencies.
According to the Program for Appropriate Technology in Health (PATH), the guidelines contained in the MISP have helped humanitarian agencies respond promptly to the reproductive health needs of refugees.14 However, efforts continue to refine the package. As PATH notes, finding trained workers and emergency supplies is a major hurdle to carrying out the provisions of the MISP.
UNHCR observes that relief organizations often lack the means to provide an effective response to the HIV/AIDS crisis.
“An effective response to the complex nature of HIV and AIDS requires human, material, and financial resources, as well as technical capabilities which many humanitarian organizations have not yet been able to develop,” says UNHCR’s report, The State of the World’s Refugees 2000: 50 Years of Humanitarian Action.
Yvette Collymore is senior editor at the Population Reference Bureau.
- U.S. Committee for Refugees (USCR), World Refugee Survey 2001 (Washington, DC: Immigration and Refugee Services of America, 2001): 6.
- United Nations High Commissioner for Refugees (UNHCR), The State of the World’s Refugees: Fifty Years of Humanitarian Action (Geneva: UNHCR, 2000): 253.
- United Nations, World Population Prospects: The 1998 Revision (New York: United Nations, 1999).
- Trina Markandu, “Refugee Rights,” Human Rights Defender Manual (Sydney: Australasian Legal Information Institute, February 2001).
- UNHCR, Executive Committee of the High Commissioner’s Programme, Statistics and Registration: A Progress Report (Geneva: UNHCR, February 7, 2000).
- UNHCR, The State of the World’s Refugees: 253.
- Johannes van Dam and Marie-Christine Anastasi, Male Circumcision and HIV Prevention (Washington, DC: Population Council, June 2000): 1-21.
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global HIV/AIDS Epidemic: June 2000 (Geneva: UNAIDS, June 2000): 11.
- Therese McGinn, “Reproductive Health of War-Affected Populations: What Do We Know?” International Family Planning Perspectives 26, no. 4 (New York: Alan Guttmacher Institute, December 2000): 177.
- Judy A. Benjamin, “AIDS Prevention for Refugees: The Case of Rwandans in Tanzania,” AIDScaptions III, no. 2 (Washington, DC: Family Health International, 1999).
- UNHCR, World Health Organization, and UNAIDS, Guidelines for HIV Interventions in Emergency Settings (Geneva: UNHCR, WHO, UNAIDS, 1995): 5-6.
- Lyn Elliott, “Gender, HIV/AIDS, and Emergencies,” Relief and Rehabilitation Network (RRN) Newsletter, no. 14 (June 1999): 5.
- Adrienne Kols and Maggie Kilbourne, “Meeting the Reproductive Health Needs of Refugees,” Outlook 17, no. 4 (Seattle: PATH, 1999): 1-5.
For More Information
In an interview with PRB, Judy A. Benjamin, senior technical advisor at the Women’s Commission for Refugee Women and Children, describes ways in which women and girls are at particular risk of HIV during wars and civil unrest. She draws from her own field research on refugees in Rwanda and Sierra Leone.
Reproductive Health for Refugees Consortium: www.rhrc.org/members/
United Nations High Commissioner for Refugees: www.unhcr.ch
Joint United Nations Programme on HIV/AIDS: www.unaids.org
United Nations Special Session on HIV/AIDS fact sheet, “AIDS as a Security Issue.”