In-depth: ART on the frontline

AFRICA: Treatment is feasible but needs careful implementation

Photo: IRIN
IDPs camp in Ituri, northeastern DRC
JOHANNESBURG, 25 October 2006 (IRIN) - Providing HIV/AIDS treatment and care in countries at peace is hard enough; extending those services to people on the run from conflict or disaster seems, on the face of it, hopelessly complicated.

But even during the height of the fighting in war-wracked eastern Democratic Republic of Congo (DRC), the medical relief group Médecins Sans Frontières was doing it in two clinics in Bukavu, capital of South Kivu Province, developing a model that has been replicated in other conflict areas.

The rationale is straightforward: crisis-affected people have the same right to HIV/AIDS services as the general population. That entitlement extends to refugees, with a series of international protocols upholding their right to a minimum standard of assistance.

There are an estimated 31 million refugees and displaced people in the world, but when demobilising ex-combatants and communities "in transition to recovery" are added, the number of people at risk balloons to over 80 million. An additional 120 million are deemed vulnerable in Southern Africa due to the special circumstances of extremely high HIV infection rates, large pockets of food insecurity and poverty, and weak public services.

"We're not talking about a marginal group of people. Somewhere in the region of 80 to 90 countries - half the number of countries in the world - have got siginificant populations of humanitarian concern, so this is mainstream business," Mukesh Kapila, UNAIDS technical director of a programme for scaling-up HIV/AIDS services, told IRIN/PlusNews.

Kapila heads a consortium of nine UN agencies working to clear away the organisational and technical hurdles that prevent populations of concern benefiting from HIV/AIDS assistance. The goal is the inclusion of their specific needs in humanitarian and development programmes, with a related focus on the protection of women and girls from sexual violence.

"It has been shown, even in the most difficult circumstances, that one can provide reliable and safe treatment opportunities," said Kapila. "The costs of bringing this to all vulnerable populations has significantly decreased over the years ... to the point where we can contemplate taking this on."

Conflict, displacement, food insecurity and poverty make affected populations more vulnerable to HIV transmission; providing treatment and care not only directly helps the traumatised victims of disasters and emergencies, but also benefits wider society.

A joint UNHCR and UNAIDS report, 'Strategies to support the HIV-related needs of refugees and host populations', makes the point that failure to provide HIV/AIDS services for refugees, "hinders effective HIV prevention and care for host country populations. Since refugees now remain, on average, in their host country for 17 years, the implications for both refugee and host populations are very serious."

There are similarities between providing treatment for tuberculosis - which is routine - and making antiretroviral therapy (ART) available in humanitarian emergencies; there are also distinct differences. "These include more complicated diagnosis and follow-up, life-long treatment and significantly more funding," Paul Spiegel, senior HIV technical officer with the UN refugee agency, UNHCR, said in a study that has guided some of the new thinking on HIV/AIDS and vulnerable populations.

Minimum services - treatment for sexually transmitted diseases, condom distribution and AIDS education programmes - must be in place before more complicated interventions like prevention of mother-to-child transmission and antiretroviral therapy (ART) are initiated, Spiegel noted.

"Although people have a universal right of access, it doesn't mean that it would be feasible to start everybody on treatment," said Kapila, who is also HIV/AIDS Special Representative of the Secretary General of the International Federation of Red Cross and Red Crescent Societies. "There are indicators for the right type of interventions for the right type of target groups."

Providing HIV/AIDS services to vulnerable populations has long-term developmental advantages. Refugee camps, for example, are usually far from urban-based programmes. "Improving HIV/AIDS interventions in an integrated manner for the refugees and surrounding host population will invariably improve services for both communities," Spiegel said in his influential study, 'HIV/AIDS among conflict-affected and displaced populations'.

And, after years of AIDS education programmes, repatriated refugees and homeward-bound displaced families arrive back in their communities with an awareness that can potentially shape attitudes. "Conflict and disasters represent an opportunity for new paradigms and new ways of thinking," said Kapila.

But there are serious ethical and safety concerns in providing ART to crisis-affected groups. When the disaster is over, people often return home to smashed and looted hospitals, under the nominal care of governments without the capacity to provide basic social services: ideal conditions for treatment interruption and, inevitably, drug resistance.

Simplified treatment protocols and community-based ART programmes can provide some of the answers, but challenges remain in delivering support to national HIV/AIDS efforts for the longer-term integration of resettling people.

The UNAIDS/UNHCR study stressed that "host countries, humanitarian and development agencies and donors need to continue to seek new ways to address the cross-border realities of the AIDS epidemic". But the needs of populations of concern can only be met if significant additional funding is made available.

"We have to speak, as UN agencies, NGOs and others working in emergencies, with one voice to advocate with donors to support ART in emergencies in an appropriate and sustainable manner," said Laurie Bruns, UNHCR's senior regional HIV/AIDS coordinator in Southern Africa.

"Global targets towards universal access for HIV services will not be achieved if populations in emergency settings are excluded," she added.
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