HIV Infection among Refugees: Myths and Findings HIV Center for
Clinical and Behavioral Studies NY State Psychiatric Institute and
Columbia University December 10, 2009 Susan Temporado Cookson, MD,
MPH In ternational Emergency & Refugee Health Branch Centers
for Disease Control and Prevention Slide 2 Overview Definitions
Emergencies Refugees and internally displaced persons Risk factors
impacting these populations Big 4 communicable diseases HIV Myths,
findings, and realities Principles of HIV control among refugee and
internally displaced populations Slide 3 Definitions of Emergencies
Emergency: unforeseen crisis requiring immediate response Natural
disaster: vast ecological breakdown between humans and their
environment; such a serious or sudden event that the community
needs extraordinary efforts to cope, often with outside help or
international aid Complex humanitarian emergency (CHE): large-scale
human displacement with living condition deterioration caused by
physical conflict, often with attempt to restructure society (e.g.,
genocide), leading to significant increase in mortality for limited
time, but sometimes longer Indicator = 1 death /10,000 population /
day Slide 4 Definitions of Refugees and Internally Displaced
Persons (IDPs) Both populations Victims of conflict and violence
Fled their homes Fear of or persecution Race, religion,
nationality, member of social group, political opinion, gender
Refugees only Fled outside home country Unable/unwilling to return
home Slide 5 Population Movements in Conflicts of Refugees and
Internally Displaced Persons (IDPs) Slide 6 Communicable Diseases
Risk Factors among Refugees and Displaced Persons Mass population
movement Ongoing conflict/insecurity Gender-based violence
Temporary/absence of shelter Poor nutrition/scarcity of food Poor
healthcare access/collapse of healthcare Lack of
medications/treatment Lack of prevention/control programs Of
supplies, such as condoms or vaccination Of programs, such as TB or
HIV control Source: Connolly MA, et al. Lancet, 2004 Serbians
fleeing Slide 7 Communicable Diseases among Refugee and Displaced
Persons Big 4 causes of morbidity and mortality Acute respiratory
infections Diarrheal diseases Measles Malaria Malnutrition HIV/AIDS
have increasing importance But not top priority in emergency
Potential regional effects Disease prevalence, including HIV Slide
8 Micronutrient Deficiency and HIV Cycle Increased HIV replication
Disease progression Increased morbidity/mortality Micronutrient
deficiencies Increased oxidative stress Immune suppression
Insufficient dietary intake Malabsorption and diarrhea Altered
metabolism and impaired nutrient storage Modified from Semba RD and
Tang AM. Brit J Nutrition, 1999 Vicious Cycle of Micronutrient
Deficiencies and HIV Slide 9 Reasons HIV Not Top Priority in
Emergencies Perceived as development issue Concerned of
discrimination against HIV- infected refugees Basic survival:
shelter, food, water, sanitation Health actions focused on Big 4
and malnutrition Essential primary clinic services/medications
Slide 10 Refugees and Internally Displaced Persons, 31/12/08
Total=24.9 million Internally displaced 14,405,405 Refugees
10,478,621 Source: UN Refugee Agency. 2008 Global Trends. Available
at: http://www.unhcr.org Population * 1,000,000 Slide 11 Myths or
Realities? 1.Conflicts increase HIV transmission 2.Refugees bring
HIV to the country of asylum 3.IDPs and refugees have the same HIV
risks and prevalence rates Slide 12 Effects of Conflict and Sexual
Violence on HIV Transmission and Visa Versa Difficult to discern
Wide variety of issues involved Data can have varied quality and
focus, be biased Data on prevalence on HIV and sexual violence
among affected-populations scarce Slide 13 1. Do conflicts increase
HIV transmission? Slide 14 Overlap between countries affected by
conflicts and high HIV prevalence Sources: Mock NB, et al. Emerg
Themes Epidemiol, 2004 UNAIDS. 2008 Report on the global AIDS
epidemic Epidemiology of Conflicts and HIV HIV Prevalence in
Africa, 2007, 2004 Slide 15 Level of Conflicts and HIV Prevalence
1991-2000 Among 37 sub-Saharan African countries Armed conflict
scores vary from 0, no conflict, to 28 and 29 for Sudan and Angola,
respectively 15 countries with no conflict, including Botswana,
Central African Republic HIV prevalence=18.6% 13 countries with
armed conflict score=1-9, including Cameroon, Senegal HIV
prevalence=8.3% 9 countries with armed conflict score>10,
including Burundi, DRC, Somalia HIV prevalence=7.8 % Source: Strand
R, et al. Int J STD & AIDS, 2007 Slide 16 Strand R, et al. Int
J STD&AIDS, 2007 Spearman rank correlation, =-0.41, p=0.012
Slide 17 Why do conflicts seem to delay HIV epidemic? Two stages of
conflict Conflict Survival Access Post-conflict Services and
employment Access Slide 18 Conflict Stage Survival of HIV-infected
persons Differential mortality among high-risk populations In
addition, poor nutrition and lack of services Isolation Destroyed
transport, unsafe travel, disrupted commerce Level of sexual
activity Marked reduction KABP among Rwandan refugees, Tanzania
1994 Decreased libido Depression and post-traumatic stress symptoms
Source: Mayaud. Trans Roy Soc Trop Med & Hyg, 2001 Slide 19
Post-conflict Stage Increased HIV incidence, post-conflict Maputo,
Angola (9.9% in 1998, 13.2% in 2000, 20% in 2004) Service may be
slow Quality of medical services Supplies, equipment/vaccines, and
medications Universal precautions, safe medical equipment and blood
may lag Level and type of employment Demobilization of forces and
female head of households Access Urbanization and increased level
of sexual activity Source: UNAIDS/WHO. AIDS epidemic update.
Geneva: UNAIDS/WHO, 2004 Slide 20 2. Do refugees bring HIV to the
country of asylum? Slide 21 HIV/AIDS: Epidemiology among Refugees *
Weighted means: country of asylum by population size, country of
origin by refugee population size Source: Spiegel PB. Disasters,
2004 HIV prevalence among refugees appear lower than host
population Country of origin compared with country of asylum Slide
22 HIV Prevalence Data among Refugees Surveillance during conflict
impractical Surrogate data Adults: chronic diarrhea, fever of
unknown origin, recurrent pneumonia, STIs, TB, wasting Children:
chronic diarrhea, developmental delays, failure to thrive,
recurrent bacterial infections Direct HIV testing results Blood
supply: no systematic surveillance Antenatal care centers Slide 23
UN Refugee Agency Health Information System (HIS) In 1999, began
development In 2006, 16 countries with stable refugee camps Data
collected: Blood supply activities: no results VCT (PICT), PMTCT,
And ART program activities Evaluation in Sept-Nov 2008: Issue with
data quality Source: UNHCR. Health Information System (HIS) toolkit
Available at: http://www.unhcr.org/4a3374408.html Slide 24 Assess
HIV Prevalence Rates, Africa Method Anonymous, unlinked,
cross-sectional surveys (UAT) Attendees public antenatal clinics,
including in refugee camps First time Blood for syphilis testing
Often no informed consent Concerns of selection/participant bias
De-identified, except for Age, parity, marital status, educational
level, and clinic location (or urban versus rural) In refugee
camps: refugee versus host status Rapid, diagnostic tests and/or
dried blood spots Slide 25 Reliability of HIV Testing: Rapid Tests
vs. EIA Gray RH, et al. BMJ, 2007, in Rakai, Uganda: 43.7%
(129/295) false positive results 0.3% (4/1,222) false negative
results UNHCR, 2006/07, Kenya PMTCT rapid tests EIA at National
Public Health Lab HIV positiveHIV negativeTotal Dadaab refugee
camp, Aug-Jan Rapid test algorithm positive101 Rapid test algorithm
negative910321041 Total1010321042 sensitivity=10%;
specificity=100%; PPV=100%; NPV=99.1% Kakuma refugee camp, Kenya,
Sept-Jan Rapid test algorithm positive71320 Rapid test algorithm
negative911361145 Total1611491165 sensitivity=43.8%;
specificity=98.9%; PPV=35%; NPV= 99.2% Slide 26 Refugees Prevalence
(95% CI*) YearHost population Prevalence (95% CI) Year Somalis in
Dadaab camp, Kenya0.6% (0.01-1.1)2003Garissa, Kenya26.0%2002 1.4%
(0.5-2.2)200511.0%2004 1.0% (0.6-1.6)2006/7 Sudanese in Kakuma
camp, Kenya5.0% (3.5-7.0)2002Lodwar, Kenya18.0%2002 1.2%
(0.6-2.1)2006/7 Immediately surrounding3.6% (1.9-6.0)2006/7
Sudanese in Palorinya settlement, Uganda1.0% (0.3-1.8)2004
Immediately surrounding5.9% (1.7-10.1)2004 5.4% (3.6-7.2)2005
Immediately surrounding6.9% (3.9-13.4)2005 Sudanese in Kyangwali
settlement, Uganda2.7% (1.3-4.0)2004 Immediately surrounding2.8%
(1.0-6.6)2004 Hoima, Uganda4.6%2004 Burundis in Lukole camps,
Tanzania3.1%2002 Kagera region, Tanzania3.7%2003 1.6%2003 Burundis
in Mtabila and Muyovosi camps, Tanzania4.5%2003 Kigoma region,
Tanzania2.0%2003 DRC refugees in Lugufu and Nyaragusu camps,
Tanzania2.5%2002 1.8%2003 Kagera region, Tanzania3.7%2003 DRC
refugees in Gihembe camps, Rwanda1.5% (0.4-3.8)2002Byumba,
Rwanda6.7% (4.7-9.4)2002 Slide 27 Refugee vs. Host Populations HIV
Prevalence Spiegel PB, et al. Lancet, 2007 plus newer data
(2006/07) Data Antiretroviral Therapy (ART) in Conflict-affected
Settings RATIONALE Life saving, essential treatment available in
Africa (universal access) Shown to be feasible in conflict-affected
settings 60% of refugees are in camps >10 years (2008)
INTERVENTIONS 1.Post-exposure Prophylaxis 2.PMTCT 3.Therapeutic,
long term PEPFAR support Rwanda, Tanzania, and Kenya beginning
2008/09 DRC and Burundi not yet Source: Julius Kasozi, UNHCR,
personal communication, Nov 2009 Source: US Committee for Refugees
and Immigrants. World Refugee Survey 2009. Slide 45 HIV Care and
Treatment Implementing ART among Refugee and Displaced Persons
Emergency phase over (mortality:Slide 46 Summary HIV risk factors
increase during conflicts Risk does not mean transmission If
populations are isolated and HIV levels are low, conflict may be
protective HIV risk factors increase post-conflict Opening up
trade, but still unemployment, and accessing previously isolated
populations Early interventions needed to prevent explosive spread
Interaction with STIs, TB and other diseases requires integrated
interventions HIV, STI and TB emergency guidelines available Slide
47 Thank You Slide 48 The findings and conclusions in this
presentation are those of the author and do not necessarily
represent the views of the Centers of Disease Control and
Prevention.
