13. HIV

The HIV/AIDS epidemic has been increasing steadily on a global scale. According to UNAIDS, an estimated 33.2 million people world-wide were living with HIV/AIDS as of 2007. The groups most at risk of contracting HIV are women, children, mobile populations and rural poor people.

There is a direct link between poverty and HIV/AIDS, because the disease flourishes where there is deep-seated inequality and widespread denial of basic human rights. Major drivers of the epidemic include gender norms and inequality, perceptions of what are appropriate sexual norms and practices, and HIV-related stigma and discrimination that further marginalise key vulnerable populations and limit their access to various services.

The rise in HIV/AIDS dramatically affects both demographics and economics. The HIV epidemic is eroding the economic capacity of those nations seriously afflicted with the disease. At a household level, primary and secondary income earners are falling sick, and are no longer able to support the family’s household expenditures. In many cases, one or both parents have died from AIDS, orphaning their children and leaving them to be cared for by others, including the elderly. According to UNAIDS, 15.2 million children were orphaned by AIDS in 2005. These children are at increased risk of poor health, lack of educational opportunities, poverty and forced recruitment into warfare.

For international NGOs, HIV/AIDS is a challenging cross-cutting issue to solve. What was once thought of exclusively as a health issue today is considered for its influence on education, livelihoods, gender inequality and food security.

In the initial crisis situation, there are a few key reproductive health (RH) interventions that programmes should ensure are available, and these do not require an assessment. The Minimum initial service package (MISP) for reproductive health (RH) in crisis situations outlines the initial response necessary and includes the minimum activities for HIV/STI (sexually transmitted infection) prevention and treatment, and is a standard included in the 2004 revision of the Sphere handbook, Humanitarian charter and minimum standards in disaster response for humanitarian assistance providers. The Sphere Manual, Interagency Field Manual (IAFM) for RH in Emergencies and the 2005 Interagency Standing Committee (IASC) Guidelines for HIV in Emergencies are all under revision; however, they will most likely contain most of the following interventions for the initial emergency response to HIV:

1. Prevention of HIV transmission in health care settings by ensuring universal precautions are adhered to
2. Ensuring access to condoms;
3. Providing PEP for treatment of rape survivors, and for other non-occupational and occupational exposure to HIV;
4. Management of sexually-transmitted infections;
5. Management of opportunistic infections and interventions to prevent illness;
6. Continuing anti-retroviral treatment (ART) for those under treatment as quickly as possible

Checklist

Background information

• Obtain the most recent seroprevalence rates of HIV in displaced populations and surrounding communities.
• Obtain the prevalence and types of STIs.
• Assess the level and quality of available health services for testing and treatment of HIV, and for providing blood transfusions.
• Assess if the affected populations already had access to anti-retroviral treatment (ART)s and prevention of mother to child transmission (PMTCT).
• Identify those on ART.
• Assess the level of existing risks and factors that make the risk groups more vulnerable to HIV infection (risk groups usually include women, children and adolescents, single-headed households, certain ethnic and religious groups, minorities, people with disabilities, and drug addicts).

Security and access

• Determine the existence of ongoing natural or human-generated hazards.
• Determine the overall security situation, including the presence of armed forces or militias.
• Determine the access that humanitarian agencies have to the affected population.

Establish HIV/AIDS surveillance

Existing baseline data may include:

• Voluntary blood donor testing
• STI incidence and trends
• Sentinel surveillance of pregnant women
• Voluntary counselling and testing (VCT) for HIV
• Prevention of maternal to child transmission (PMTCT) including counselling and testing of pregnant/delivering women of unknown status
• Trends in condom usage
• Incidence and trends of gender-based violence (GBV)
• Number of clients receiving ARTs
• Number of family planning clients
• Number of women receiving drugs for PMTCT
• Number of newborns receiving PMTCT prophylaxis.

Available resources

• Determine the capacity of and the response by the ministry of health of the country or countries affected by the disaster.
• Coordinate with international experts such as UNAIDS.
• Determine the status of national health facilities and their capacity to provide HIV counselling and testing, treatment and PMTCT services.
• Determine the availability of standardised protocols, ART and PMTCT drugs, supplies, and equipment for all HIV services listed above.
• Review existing referral systems.
• Determine the status of the existing health information system (HIS).
• Determine the capacity of existing logistics systems to procure, distribute and store HIV related drugs, testing kits and other supplies.

Refer to Chapter 8.5 Health, for details relating to health system capacity.

Consider data from other relevant sectors

• Nutritional status
• Environmental conditions
• Food and food security.

Source: Adapted from IASC 2004. Guidelines for HIV/AIDS interventions in emergency settings-currently under revision (2008); RHRC. Minimum initial service package (MISP) for reproductive health (RH) in crisis situations.

The prevention and treatment of HIV/AIDS must be approached from a multi-sectoral perspective in an emergency response. Section 3.1 provides an outline on how this may be achieved.

The following recommendations are adapted from the 2004 IASC’s Guidelines for HIV/AIDS  interventions in emergency settings (Note: these guidelines are under revision and the final version is expected in May 2009, check the following website for updates, http://www.aidsandemergencies.org/cms/index.php?option=com_content&task=view&id=17&Itemid=34)

• Interventions aimed at improving the welfare of orphans must not exclude children whose parents are still alive, though ailing.
• Compromises should not be taken in regard to condom quality. Good-quality condoms are essential both for the protection of the consumer and the credibility of the relief programme. If the condoms are of good initial quality, are protected with impermeable foil packaging and are properly stored (protected from rain and sun, in particular), they are likely to retain much of their original quality.
• Not being aware of the culturally sensitivities of the beneficiaries can lead to inappropriate services, which are more likely to cause negative reactions rather than achieve the desired impact.
• Treatment for patients should not be withheld until they attend with their partner. Patients should be counselled to tell their partner(s) to come for treatment.
• There is no justification for excluding drug users from HIV/AIDS treatment. Drug users should have equitable access to the same HIV/AIDS treatment and care offered to other individuals infected with HIV.
• There should be no discrimination against workers on the basis of real or perceived HIV status. Discrimination and stigmatisation of people living with HIV/AIDS inhibits efforts aimed at promoting HIV/AIDS prevention-if people are frightened of the possibility of discrimination, they may conceal their status and are more likely to pass on the infection to others. Moreover, they are not likely to seek treatment and counselling.

A specialist should be sought when the CO does not have adequate technical capacity in its team to be able to meet the HIV/AIDS needs of the emergency. International technical expertise can be requested through the CERT mechanism (refer to the chapter on Human resources).

Remote technical support and advice is available from the Senior Sexual and Reproductive Health/HIV Advisor in Emergencies, based at CARE International in Geneva and the Technical Advisor based with CARE USA (contact details at the start of this chapter).

With over 60 years of experience assisting communities to address development challenges, improve their livelihoods and reduce their vulnerability to emergencies, CARE is uniquely positioned to address the global HIV and AIDS epidemic. CARE has an institutional commitment to tackle underlying causes of poverty through multi-sectoral programme approaches, and continues to strengthen its responses and strategic partnerships as a key strategy to improve the lives of people affected by HIV and AIDS.

From a single project started in 1987, CARE now addresses HIV and AIDS in over 40 countries with support from a range of public and private donors. CARE’s strengths in responding to the AIDS crisis include broad geographic coverage, multi-sector poverty alleviation expertise, technical HIV and AIDS expertise, and decades of experience in strengthening the capacity of community-based organisations and linking communities to health care and other services.

A full capacity statement detailing CARE’s approach to HIV/AIDS programming is available at Annex 9.3.4 CARE’s HIV and AIDS Capacity Statement.