Conflict, displacement, food insecurity and poverty offer fertile ground for the spread of HIV/AIDS. Many of the 20 million persons of concern to UNHCR worldwide live in such conditions. As their physical, financial and social insecurity erodes habitual caring and coping mechanisms, refugees are often rendered disproportionately vulnerable to HIV/AIDS. While refugees do not necessarily have high HIV prevalence rates, they are inextricably linked to any successful effort to combat the catastrophic pandemic in the countries that host them.
Throughout history, marginalised populations have been blamed for the spread of disease. Often inadequate living and working conditions render them more vulnerable to various illnesses. Theories of disease causation versus the actual reality of a disease feed upon each other as "the poor get not only the blame, but also the disease."(1) Such a self-fulfilling prophesy has also characterised the HIV/AIDS pandemic. Refugees are often doubly discriminated against: firstly for simply being refugees and secondly for being falsely accused of bringing HIV/AIDS with them into host countries of asylum.
In order to reduce stigmatisation and to ensure that the whole population have access to HIV/AIDS prevention and care interventions, UNHCR is working to ensure that refugees are integrated into host government HIV/AIDS policies and programmes.
UNHCR's HIV/AIDS and refugees strategic objectives
HIV/AIDS prevention and impact mitigation are essential components in the overall protection of refugees. In 2002 UNHCR introduced its 2002-2004 Strategic Plan on HIV/AIDS and Refugees(2). Based on a human rights framework, it has three main objectives:
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to ensure that refugees live in dignity, free from discrimination, with their human rights respected
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to ensure that a minimum and coordinated package of HIV/AIDS programmes is provided in refugee emergency situations (safe blood supply; adherence to universal medical precautions; condom distribution; basic health care including treatment of sexually transmitted infections and contact tracing; HIV information-education-communication (IEC) materials; orphan tracing and protection and care of survivors of sexual violence).
- to implement multi-sectoral and comprehensive HIV/AIDS pilot programmes in more stable situations that link prevention to care and reinforce surveillance, monitoring and evaluation.
These objectives are being implemented using a phased approach. In situations where there are few resources, only the first two strategic objectives can be achieved. Although UNHCR is conducting HIV/AIDS activities globally, we concentrate our interventions in Sub-Saharan Africa, the region most affected by the pandemic. In each region, a standardised assessment is undertaken with our implementing partners. UNHCR's Refugees and HIV/AIDS Assessment and Planning Tool looks at:
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policy: existing national AIDS control programme guidelines or manuals; refugees specifically included as a vulnerable population under national AIDS control programme policy
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protection: no mandatory HIV testing of refugees under any circumstances; no denial of access to asylum procedure, refoulement or denial of right to return on basis of HIV status; when required by resettlement countries, HIV testing conducted in accordance with established standards (i.e. accompanied by pre- and post-test counselling and appropriate referral for follow-up support and services); no laws or regulations prohibiting refugee access to public sector HIV/AIDS programmes in country of asylum; specific programmes in place to combat stigma and discrimination against refugees living with HIV/AIDS; programmes in place to prevent and respond to Sexual and Gender-Based Violence (SGBV) (3)
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coordination and supervision: regular meetings among implementing partners in the field and in the capital; HIV/AIDS programmes specifically included in planning, implementation, monitoring and evaluation stages of programme cycle; regular attendance at meetings of UN Theme Group on HIV/AIDS and associated technical working groups at capital level
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prevention: safe blood supply; universal precautions; condom promotion and distribution; behavioural change and communication (including development of educational/awareness materials in appropriate languages; programmes for in-school and out-of-school youth, peer education, youth centres, sports/drama groups, programmes aimed at reducing teen pregnancy and combating SGBV); Voluntary Counselling and Testing (VCT)(3); Prevention of Mother-to-Child Transmission (PMTCT); prophylaxis for opportunistic infections; and Post-Exposure Prophylaxis (PEP)
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care and treatment: Sexually Transmitted Infections (STIs)(3); opportunistic infections including tuberculosis; nutrition(3); home-based care; people living with HIV/AIDS; orphans
- surveillance, monitoring and evaluation: behavioural surveillance surveys; AIDS clinical case and mortality reporting; blood donors; syphilis among antenatal clinic attendees; STIs (by syndrome); condom distribution; opportunistic infections including tuberculosis; VCT; PMTCT; SGBV; PEP; and SGBV
This standardisation has proved invaluable in ensuring that all areas of HIV/AIDS are assessed as well as allowing for comparison between programmes and countries.
Following the assessment, UNHCR and its implementing partners strategically plan for the following year using the same categories.
What have we learned?
Evaluation and planning missions to Kenya, Tanzania, and Uganda were undertaken between June and October 2002 culminating in a tri-country HIV/AIDS and Refugees workshop in December 2002 in Entebbe, Uganda. Key findings have included:
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wide variation of standards, quality and comprehensiveness among HIV/AIDS programmes being implemented in refugee situations
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lack of basic and culturally appropriate IEC materials in local languages
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high levels of HIV discrimination and stigma against, as well as within, refugee communities
- lack of funding and technical expertise which severely hampers HIV/AIDS programmes in refugee situations.
In early 2003 similar missions undertaken in South Africa, Zambia, Namibia and Angola showed the epidemic to be more mature and the problems deeper and more complicated. Current developments in Southern Africa reveal the unfolding scenario of impending catastrophe in East Africa and the Horn of Africa. There are significant numbers of predominantly male urban refugees with HIV/AIDS who are suffering terribly. UNHCR's self-reliance strategy for urban refugees in South Africa may need to revert to a care and maintenance phase as more refugees become vulnerable. Angolan refugees returning from such high HIV prevalence host countries as Zambia and Namibia may bring HIV/AIDS with them and increase the relatively low HIV prevalence in Angola.
Angola: repatriation and HIV/AIDS
HIV/AIDS protection and advocacy must be pursued vigorously to reduce discrimination against those returning to Angola. Promotion of the right of return as a basic human right is crucial. We must insist there should be no mandatory HIV testing, and avoid any form of discriminatory treatment and stigmatisation of refugee returnees due to HIV/AIDS.
Behavioural surveillance surveys found that refugees had better HIV/AIDS knowledge than non-displaced Angolans. Camp refugees have trained health and community workers, teachers, and peer educators who will benefit Angola upon their return. UN agencies are working with the Angolan Government to accredit their training in countries of asylum. Comprehensive HIV/AIDS plans to improve the HIV/AIDS programmes for Angolan refugees as well as returnees have been developed and funded. Within camps existing programmes have been strengthened with new focus on prevention interventions. For those returning to Angola, HIV/AIDS prevention measures, condom promotion and peer education are being combined with landmine awareness training. Returning health and community workers are being provided with condoms to distribute.
HIV/AIDS programmes need to be directed towards all Angolans in refugee returnee municipalities, including non-displaced populations and IDPs. These programmes need to begin with the provision of basic HIV/AIDS interventions and then expand to more comprehensive activities.
Refugees excluded from national HIV/AIDS initiatives
Countries of asylum are ultimately responsible for the protection and well-being of people living on their soil, including refugees. However, refugees have been systematically excluded from many host countries' HIV/AIDS National Strategic Plans (NSPs) and their needs have not been addressed in proposals submitted to major donors. Refugees and local populations interact on a daily basis. Their systematic exclusion is not only discriminatory but it also undermines effective HIV/AIDS prevention and care efforts.
Of the 29 countries in Africa that host more than 10,000 refugees, UNHCR has been able to review 22 NSPs. While 14 mention refugees, 8 fail to do so. Of those that do mention refugees, 10 NSPs mention specific activities for refugees, while 4 NSPs fail to do so. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM - a multilateral financial instrument established by the Secretary-General of the UN, Kofi Annan)(4) and the Multi-Country HIV/AIDS (MAP) Programmes of the World Bank(5) have funded HIV/AIDS projects in 25 of these 29 refugee-hosting sub-Saharan states. Only a minority of proposals include refugees. In the 23 states with approved GFATM proposals only five programmes have included activities for refugees. Eight of the 15 approved World Bank MAP projects have refugee-specific components.
The way forward
UNHCR and our partners have realised the need to:
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accept that each refugee situation is unique: HIV/AIDS programmes in low resource settings need to be adapted to local circumstances
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ensure that host countries always include refugees and all other vulnerable groups in their efforts to combat HIV/AIDS
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promote sub-regional approaches to address the constant movement between countries
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improve cooperation and coordination between UNHCR and other UN agencies, NGOs and governments in both host countries and countries of origin
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provide more vigorous support to such regional initiatives as the Great Lakes Initiative for HIV/AIDS(6) and West Africa's Mano River Union Initiative(7) on HIV/AIDS
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ensure that donors such as the GFATM and the World Bank include refugees and IDPs in all HIV/AIDS programmes and funding proposals
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encourage donor governments to learn from experience in Uganda and ease conditions preventing funds being simultaneously used for resident and displaced populations
- ensure that refugees are not excluded as antiretroviral medications become more widely available in developing countries.
Paul Spiegel is UNHCR's Senior HIV/AIDS Technical Officer. Email: spiegel@unhcr.ch.
Alia Nankoe is UNHCR's HIV/AIDS Programme Officer. Email: nankoe@yahoo.com.
Notes:
- J N Hays The Burdens of Disease: Epidemics and Human Response in Western History, Rutgers University Press, 1998, p3
- Available upon request from UNHCR: spiegel@unhcr.ch
- This has prevention as well as care and treatment components.
- See: www.theglobalfund.org/en/about/road/history/default.asp
- See: www.worldbank.org/afr/aids/map.htm
- See: www.onusida-aoc.org/Eng/GLIAEN.htm
- See: www.onusida-aoc.org/Eng/Mano%20River%20Union%20Initiative.htm