IRIN Web Special on Civilian Protection in Armed Conflict

In a humanitarian emergency, HIV/AIDS prevention and reproductive rights are not likely to be seen as a priority.

But Africa's refugees and displaced face the prospect of a life of poverty, powerlessness and social instability: conditions that increase their vulnerability to HIV/AIDS.

"Refugees and IDPs [internally displaced persons] are often at a higher risk of HIV/AIDS, but often in crises, reproductive health is put on the backburner," Helen Jackson, regional HIV/AIDS advisor for the UN Population Fund (UNFPA) told PlusNews.

Southern Africa's current humanitarian crisis that threatens 14 million people has been marked by a growing realisation of the devastating impact of the epidemic. The explosive combination of acute food shortages and HIV/AIDS has called for new ways of dealing with this emergency.

Hunger and diminished access to health services, including reproductive health care, are taking a heavy toll on women, adolescents, and other vulnerable groups across a region that has the world's worst HIV/AIDS prevalence figures.

Reproductive health can no longer be sidelined, humanitarian officials warn. UN agencies and NGOs are now faced with the challenge of addressing this in their relief responses for the people in six southern African countries who have been pushed to the edge by successive crop failures, government policy errors and poverty.

"We have to take it extremely seriously, especially in this context [the Southern Africa emergency]," Jackson said.

According to Dr Gebreamlak Ogbaselassie, a UNFPA regional adviser on sexual and reproductive health, poverty and the food insecurity crisis is having a "nightmare" effect on maternal health in particular.

Malnutrition makes pregnant women more susceptible to infection, miscarriage and premature labour, and increases the likelihood that pregnant and lactating women who are HIV-positive will transmit the virus to their children.

To make matters worse, food shortages and high poverty levels are contributing to a decrease in the number of women seeking family planning services and antenatal care. The number of home deliveries is also on the rise, as the constant search for food for their families leads women to neglect their own health, he added.

Family planning services are especially important when war has destroyed the health system on which people depend.

Angola has one of the highest maternal mortality ratios in the world, estimated at 1,500 per 100,000 compared to neighbouring Namibia at 370 per 100,000. But the HIV/AIDS epidemic has not yet reached its peak. Infection rates appear to be a modest 8.6 percent, compared to rates of 20 percent and upwards in the region.

Increased population movements within the country, however, will contribute to the rising prevalence rate. "The impact of HIV/AIDS does have the attention of humanitarian agencies, now the challenge is for us to translate this into action," CARE assistant country programme director, Robert Bulten, told PlusNews.

Despite considerable strides made in improving the health care of women and children in IDP and refugee camps, Bulten admitted that until recently, relief organisations had done "very little" about HIV/AIDS prevention.

"The provision of condoms is a very recent development, and we still have a long way to go in education and awareness," he said.

"This issue has not been addressed adequately, because of competing demands, technical capacity, and funding issues, noted Mary Otieno, the reproductive health (RH) technical advisor for the International Rescue Committee.

"I believe that over the past 10 years, a lot has improved with regard to RH services for displaced and war affected populations, as shown in a recent study. This study compared the reproductive health outcomes among displaced and war affected in 52 refugee settings/camps, in seven countries, with those of host populations and country of origin populations," she said.

"The study concluded that refugees had better health outcomes than the host and country of origin populations," Otieno added.

Nevertheless, refugees were often left out of HIV/AIDS prevention campaigns run in host countries, and condom distribution in refugee camps has remained "alarmingly low", Albert Edgar Manyuchi, project officer for the Jesuit Refugee Services told PlusNews.

"You need the right personnel on the ground to educate people because the policies are there, it is just a matter of implementation, " he said.

UNAIDS has recommended a number of ways in which the problems facing refugees and the displaced can be overcome.

A "minimum package" for the prevention and care of HIV/AIDS in an emergency setting includes a safe blood supply, the provision of supplies for universal medical precautions, condoms and basic HIV/AIDS information. The physical protection of refugees and displaced people from violence and abuse was also essential for reducing the risk of HIV/AIDS.

When refugees are already HIV-positive, "comprehensive care should be seen as a component of basic care in any refugee situation", a UNFPA field manual on refugee conditions, warned.

Nutritious food is the first line of defence for people living with AIDS (PWAs). In emergencies, supplementary feeding for PWAs is often neglected. For Ogbaselassie at UNFPA, the solution lies in inter-agency collaboration.

Working with food distributors such as the World Food Programme will ensure that the special nutritional needs of lactating mothers and HIV-positive people are addressed, he said.

According to UNAIDS, the provision of treatment is also an essential HIV/AIDS intervention in refugee camps, but the realities are different.

Dukwi refugee camp in northeastern Botswana is home to around 4,000 refugees from 16 countries. A system of peer educators, based on refugee volunteers, was introduced in 2001 by the Botswana Red Cross, but failed due to a lack of motivation. The educators, who were supposed to provide HIV/AIDS instruction and support within the community, received no incentives in terms of payment or increased food rations.

Similarly, there was little inducement for the refugees to get tested or declare their status. "People are ready to go for voluntary testing, the problem is once they have tested HIV-positive there is no assistance. They don't receive any extra food or antiretroviral drugs," one of the peer educators told IRIN.

Condoms are available at the camp's dispensary, but the process of obtaining them is bureaucratic. This is a common problem in most refugee camps, Manyuchi noted.

"There is a general reluctance to dispense them. The camp officials have this idea that handing out condoms will create chaos ... little do they know that withholding them [condoms] will be the reason for the chaos," Manyuchi added.

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