Women and Girls in Complex Emergencies

Complex emergencies are situations of disrupted livelihoods and threats to life produced by warfare, civil disturbance and large-scale movements of people, in which any emergency response has to be conducted in a difficult political and security environment (WHO, 2002). Complex emergencies can also be generated from natural disasters. An estimated 200 million people are affected every year by humanitarian crises, in addition to the estimated 50 million uniformed services personnel (Kenny et al., 2010). Special consideration must be given to HIV prevention strategies in conflict situations. In northern Uganda, for example, "physical and structural violence (political repression, economic inequality, and gender-based discrimination) increase vulnerability to HIV infection. In settings of war, traditional HIV prevention that solely promotes risk avoidance and risk reduction and assumes the existence of personal choice inadequately addresses the realities of HIV transmission. The design of HIV prevention strategies... must recognize how HIV transmission occurs and the factors that put people at risk for infection. A human rights approach provides a viable model for achieving this aim" (Westerhaus et al., 2007). Conflict can exacerbate gender inequalities, property rights, and livelihoods (Seckinelgin et al., 2011).

"As of 2008, approximately 1.8 million people living with HIV were also affected by conflict, disaster or displacement, representing 5.4% of the global number of people living with HIV" (Lowicki-Zucca et al., 2008) The actual prevalence of HIV in areas of conflict is difficult to assess. Reliable information is likely to be unavailable during times of civil conflict and under repressive and hostile governments (Beyrer et al., 2007). There are insufficient data to make any conclusions about prevalence in people who are internally displaced and a review of survey data from seven countries affected by conflictDemocratic Republic of Congo, southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia and Burundifound insufficient data to support assertions that conflict, forced displacement and wide-scale rape increased HIV prevalence. 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 the host communities (Spiegel et al., 2007: 2193-94). Another study found no correlation between conflict, war and national HIV/AIDS prevalence rates (de Waal, 2010; IOM, 2011), while a recent study found that in Kenya following post-election violence in 2008, internally displaced persons were at increased risk of an HIV-related death (Feikin et al., 2010). While HIV prevalence may differ in each setting prior to, during and following conflict, there is significant evidence that women and girls in complex emergencies often experience rape and other sexual violence (Shannon et al., 2008). For example, a population-based, random sample survey of 991 households of internally displaced families (with a total representation of 9,166 individuals) living in three camps in Sierra Leone found that 9% of female respondents reported having been victims of sexual violence related to the war and 13% of all households reported some member (male and/or female) having experienced sexual violence. Thirty-three percent of those abused reported being gang raped. Respondents who reported having "face to face" contact with the Revolutionary United Front (RUF) also reported higher incidences of sexual violence than did those who came into contact with other combatant groups, 53% compared to 6%. Twenty-three percent of the women who reported sexual abuse also reported being pregnant at the time of assault (PHR and UNAMSIL, 2002). Services for rape survivors, including post-exposure prophylaxis, emergency contraception, counseling and for those who test HIV-positive, HIV treatment and care are essential.

"During the war... some women accepted sex for [a piece of cassava]" Female ex-combatant from Burundi (Seckinelgin et al., 2011: 64)One recent study in conflict-affected countries estimated that mass rape could cause approximately five HIV infections per 100,000 females per year in the DRC, Sudan, Somalia and Sierra Leone, double that number in Burundi and Rwanda and quadruple that number in Uganda. Under extreme conditions, 10,000 women and girls could be infected per year in the DRC and 20,000 women and girls be infected per year in Uganda (Supervie et al., 2010). Others, however, dispute this claiming that "it is important to dispel the myth that there is a high probability that women who have been raped will also become HIV-positive" (Spiegel et al., 2011: 391). However all agree that essential interventions for rape survivors are needed.

Public support campaigns for rape survivors and expanded services may be effective in encouraging survivors to test for HIV and access those services. Data collected between 2005 and 2007 from Malteser International, which has run a medico-social support program for rape survivors in South Kivu, Democratic Republic of Congo, registered 20,157 female rape survivors, but only a few sought medical care and psychological help, with less than 1% presenting for services before the 72 hour window when post-exposure prophylaxis can be safely used and effective. "Possible reasons include insecurity in the area, fear of stigmatization and lacking awareness about the importance of receiving timely medical treatment" (Steiner et al., 2009: 6). The percentage of women expelled from their homes after experiencing sexual violence fell from more than 12% in 2005 to 6% in 2007. This may be due to the success of awareness-raising campaigns, which aimed to lower public stigmatization and discrimination against rape survivors. With four of ten rejected rape survivors, re-integration into the family failed despite family mediation. However, between 2005 and 2007, those who had an HIV test increased from less than 2% to 57% (Steiner et al., 2009).

HIV transmission during humanitarian emergencies is influenced by the pre-existing epidemiological context. For example, if heterosexual sex is the primary mode of transmission, it is reasonable to assume that this will continue to be a primary mode of transmission during a humanitarian emergency. In such a scenario, the availability and accessibility of male and female condoms will be a key issue for the health cluster to address during the emergency response (Peltz, 2012; McGinn, 2012).

The post-conflict period may also be a very vulnerable time for HIV transmission, perhaps more so than during conflict (Spiegel et al., 2007: 2193-94). A survey conducted by IRC in 1997 found that since becoming refugees, 27% of 12-49 year old female refugees living in camps in Tanzania had been victims of sexual violence (RHR Consortium, ND). Women in conflict settings are especially at risk for missed services because, as non-nationals, they are not always covered by national health and HIV/AIDS programs (RHR Consortium, ND). Host countries for refugees, such as Botswana, exclude refugees from national antiretroviral treatment programs and prevention of vertical transmission programs (UNHCR, 2010).

Donors and governments must be aware that "countries in the throes of complex emergencies are unlikely to prepare successful funding proposals to bilateral, multilateral, private sector donors or the... Global Fund on AIDS, Tuberculosis and Malaria (GFATM) (Hankins et al., 2002: 2248). National governments also exclude refugees and internally displaced populations from national HIV plans (Spiegel, 2010). There is still a "long way to go to ensure that HIV is adequately and appropriately addressed in humanitarian emergencies and post-conflict settings" (Spiegel, 2010). For guidelines to address HIV in humanitarian settings, please see (IASC, UNAIDS, 2010). Antiretroviral therapy has been successfully provided in conflict and post-conflict settings; for more guidance on practical measures for effective care in conflict settings please see (O'Brien et al., 2010).