Gender, HIV/AIDS and Emergencies
by Lyn Elliott, HIV/AIDS Policy Advisor, Research & Development Unit, Save the Children Fund UK June 2003

HIV/AIDS is often neglected in emergency and displaced situations where agencies concentrate on providing basic needs, shelter and the treatment of disease. However, from the war zones of Rwanda, Bosnia and Sierra Leone to the stigmatised migrant communities of the industrialised North, there is a body of evidence linking war and forced migration to the spread of HIV/AIDS. [1] The impact of this is particularly acute on women and children as they make up the largest proportion of refugee and displaced people.

HIV prevalence and gender issues

While there are a number of modes of transmission, sexual intercourse and intravenous drug use account for the majority of HIV infection globally. Estimates available at the end of 1997 show that over 30 million people are living with HIV/AIDS worldwide. Although almost every country in the world is touched by HIV the virus spreads very differently in different regions of the world; 90 per cent of people living with HIV are in the developing world. Due to limited access to counselling and testing nine out of 10 people who are HIV positive do not know their status. [2]

For every four men infected with HIV, six women are infected. While women and young children are physically more vulnerable to HIV/AIDS, it is now recognised that HIV/AIDS is a wider social and economic issue firmly rooted in power imbalances in gender relations in all social classes. [3] These power imbalances are more acute in resource-poor countries and regions.

Gender and HIV/AIDS in emergency and displaced situations

Equally, these power imbalances become more acute when women and children loose their social and economic base and access to basic needs and services in emergency situations throughout the world. Factors that contribute to the spread of HIV in emergency situations with a particular gender emphasis are:

  • sexual and gender-based violence;
  • breakdown in social and community structures and lack of physical and legal protection;
  • lack of health infrastructure;
  • lack of basic needs and economic opportunities;
  • lack of education and skills training;
  • paramilitary, combatants, military and peacekeeping forces (related to sexual and gender-based violence; also use of intravenous drug use by these groupings as a coping mechanism).

Sexual and gender-based violence

There are various forms of sexual and gender-based violence, rape being the most common.

In complex emergencies sexual violence has been used as a weapon of war, for example in Bosnia, Mozambique, Rwanda, Liberia, Sierra Leone, and more latterly Kosovo. Although data are not available for many conflicts, elevated rates of HIV infection followed the wars in Mozambique and Angola. During in the war in Bosnia 30–40,000 women were raped where it was a deliberate policy to rape young women to force them to bear the enemy’s child. [4]

In the camps in Tanzania research with women in 1995 indicated that an increasing number of pregnancies were occurring among young women and many girls who lived without the protection of their parents. In addition, the frustrations and idleness of refugee men in the camp environment and their drinking habits contributed to more violence and sexual abuse against women. Most of the populations in the camps in Tanzania were from Rwanda where HIV rates were high prior to the conflict. [5] Many refugee women sold sex to people outside the camps and many refugee men visited local sex workers. Yet HIV/AIDS was not prioritised as an issue and very few interventions were developed.

Sexual violence also occurs in complex emergencies when refugees and displaced people move from one location to another. Girls and women are raped in this context and in camp situations where ‘marauding groups’ sexually abuse them; this includes those who are supposed to be guarding them. [6] In such situations, although the military are aware of the dangers, many do not use condoms as protection against HIV/AIDS.

There are a number of measures that can be adopted in the short term and long term in camp settings to offer protection and support to women and children.

Lack of access to basic needs, basic services and economic opportunities

In complex emergencies the majority of refugees leave home with very few possessions. The first priority then is food, shelter, treatment for any illness or disease, and tracing family members. Under these circumstances with few resources and little money, refugee women and girls often will exchange sex with the military or combatants for money, food, shelter, water, fuel and protection.

Refugees and displaced people need access to gender sensitive education on HIV/AIDS, the means to prevent it and access to services for the treatment of sexually transmitted diseases (STDs) and HIV/AIDS. In the camps in Tanzania, refugees who were HIV positive presented with green cards provided by support services in Rwanda for care, and asked to live in the hospital (and not the tents) and for better food. NGOs were unprepared for this and were unsure how to respond. [7]

The response in the camps of Tanzania is possibly one of the better documented on providing prevention and care for HIV/AIDS. The African Medical Research Foundation (AMREF) was providing STD treatment within one month of the camps being set up. CARE responded with HIV/AIDS prevention, and AMREF, CARE and two other agencies set up a home-based care project for people living with HIV/AIDS.8 However, with the exception of AMREF, the responses were after the event, virtually no agencies had integrated HIV/AIDS into their needs assessment before developing an intervention, and few of these interventions acknowledge the gender dynamics that are so fundamental to the spread of HIV/AIDS. [8]

The military

An HIV positive member of the military in Uganda suggested that the military and combatants should be kept as far away from civilians as possible. [9] In a complex emergency this is difficult to achieve. It is also difficult when combatants either live in communities or when the military are the guardians of refugees and displaced people. There needs to be specific thought about how this can be achieved in different situations and whose role it is to negotiate this.

Possibly the most reasonable solution for members of the military, including UN peacekeeping forces, would be to:

  • provide information and education on HIV/AIDS;
  • create awareness of human rights instruments and the violations that are particularly pertinent to sexual abuse and exploitation;
  • provide condoms and regular STD screening, treatment and care.

The response: what can agencies do?

Appropriate needs assessments

It is imperative that the issue of HIV is addressed at the needs assessment stage of any agency response. In general, lack of preparedness makes it more difficult to set up a relevant response and obtain funding for it. The issue of gender needs to be addressed within this context to reflect the fact that the majority of refugees are women and children (75 per cent of the 40 million refugees and displaced worldwide), and women and girls are particularly vulnerable to HIV both biologically and socially in an emergency context.

Three activities should be carried out immediately prior to any assessment in any new refugee situation (including emergency): [10]

  • guarantee availability of free condoms;
  • enforce respect for universal precautions against HIV/AIDS transmission in healthcare settings; [11]
  • identify a person responsible for the coordination of activities.

As a general rule field staff should act on the assumption that sexual and gender-based violence is a problem unless they have conclusive proof that it is not the case.

The needs assessment should include the collection of information on the following issues: [12]

  • the prevalence of STDs and HIV in the host and home country, area, region;
  • specific risk situations within the refugee settlement which should be targeted for various interventions;
  • the cultural beliefs, attitudes and practices concerning sexuality, reproductive health, STDs and HIV/AIDS through formative (qualitative) research using focus groups and interviews;
  • are intravenous drugs used and if so, by whom?
  • what forms of gender-based violence are occurring? In what circumstances? Who are the perpetrators?
  • do women, children and young people have the opportunity to develop skills and educational opportunities? Are there any ways of earning an income except by exchanging sex for money and resources?

Other important factors to consider include questions on the status of women in the host country; the physical layout of the camp in terms of accessing food and water; how many female protection officers are in camps; how many agency members are familiar with guidelines on HIV/AIDS and sexual violence; how many medical staff are trained on HIV/AIDS and sexual violence; are there same sex staff available in services; are post-coital contraceptives available; are girls treated differently from women and do they need a specific response?

The need for a holistic response

To avoid the escalation of HIV/AIDS in emergency and displaced settings it is necessary to have a holistic response and address all the factors that contribute to the spread of HIV in emergencies. Unless the problem is dealt with comprehensively by addressing causal factors, agencies are simply dealing with the symptoms. Core to this holistic approach is a multi-sectoral response involving the:

  • protection, legal rights and human rights issues for women, girls and boys;
  • gender-sensitive camp layout and access to food, water, fuel and resources;
  • provision of reproductive health services, including gender sensitive HIV/AIDS education and condom distribution, and care for people living with HIV/AIDS;
  • education, skills training and social and economic opportunities directed at women, children and young people;
  • separation of the military and combatants from civilian populations where possible;
  • adoption of universal precautions against HIV/AIDS.

Staff training

Agency staff need to be aware of HIV/AIDS, how it is transmitted, the need for protection, and the specific vulnerabilities of all refugees and displaced people to HIV/AIDS but in particular those of women and girls. Agency staff need relevant guidelines and policies within which to respond; they also need to be aware of the role played by the military, combatants, camp leaders and guardians in possible violations of protection. Staff also need to be aware of their own personal vulnerability to HIV/AIDS as many posts are unaccompanied, sexual relationships are quite common, and staff may be dealing with contaminated blood and equipment.

If all these factors are addressed in emergency and displaced settings then it is more likely that the transmission of HIV/AIDS will be challenged significantly in these situations, and that women and girl’s vulnerabilities will be recognised and responded to.

Notes

[1] Migration & HIV: War, Oppression, Refugee Camps Fuel the Spread of HIV in The Bridge no 5, 3 July 1998, pp 4-5.

[2] Current Status of Epidemic and Global Response, USAIDS progress report 1996-1997, pp8-9, USAIDS, Geneva.

[3] Ibid 2

[4] Ibid 1

[5] Community Participation in a Refugee Emergency – Focusing on Community Mobilisation, Women and Youth, a Report from the Rwandan Camps in Kagera Region of Tanzania, Rädda Barnen, Swedish Save the Children, Stockholm 1995.

[6] Ibid 1

[7] Personal Communication MSF Switzerland, Kagera, Tanzania, 1995.

[8] Report of the Seminar on NGO Action, UK NO AIDS Consortium, London, October 1996.

[9] Maj. R Ruranga, Joint Clinical Research Committee, Uganda. ‘The Military & Guardians‘ in Report of the Seminar on NGO Action, UK NO AIDS Consortium, London, October 1996.

[10] Reproductive Health in Refugee Situations: An Inter-Agency Field Manual, 1995, UNHCR Geneva.

[11] Specific detail on this is available in the Guidelines for HIV Interventions in Emergency Settings, UNAIDS/UNHCR/WHO, 1996, UNAIDS, Geneva.

[12] Taken from a combination of Reproductive Health in Refugee Situations: An Inter-Agency Field Manual, 1995, UNHCR Geneva, and Guidelines on the Protection of Refugee Women, 1991, UNHCR, Geneva.

RRN Network Paper 30, Protection in Practice, also deals with this issue.

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