Written evidence submitted by RAISE
October 2009
The Reproductive Health Access, Information
and Services in Emergencies (RAISE) is developed by Columbia University's
Heilbrunn Department of Population and Family Health in the Mailman
School of Public Health and Marie Stopes International (MSI).
The initiative aims to address the full range of RH needs for
refugees and internally displaced persons (IDPs) by building partnerships
with humanitarian and development agencies, governments, United
Nations (UN) bodies, advocacy agencies and academic institutions.
This enquiry provides us the opportunity to address the pressing
reproductive health (including HIV/AIDS prevention, care and support)
needs of refugees and Internally Displaced Persons (IDPs).
1. INTRODUCTION
1.1 In 2006 there were 24.7 million people
with HIV in sub-Saharan Africa, the region of the world experiencing
the highest concentration of global emergencies.[33]
In sub-Saharan Africa, 57% of adults with HIV are women, and young
women aged 15 to 24 are more than three times as likely to be
infected as young men.[34]
1.2 HIV and STIs spread—and kill—most
quickly in populations affected by poverty, social unrest and
lack of health infrastructure; factors commonly present in humanitarian
emergencies. There may be an increased vulnerability of refugees
and Internally displaced persons (IDPs) to HIV/AIDS due to specific
factors such as:
— movement of people and mix with populations
with high and low prevalence;
— opportunistic infections are unlikely
to be treated when health resources are lacking;
— urgent needs for blood transfusions and
lack of universal precautions;
— scarce health resources and supplies;
and
— increased sexual violence that enhance
the risk of HIV and STI transmission.
1.3 Studies have shown that the risk of
HIV among women who have experienced intimate partner violence
may be up to three times higher than among those who have not.[35]
According to UNAIDS, in the Democratic Republic of Congo, HIV
prevalence "varies from 1.7% to 7.6% depending on the region,
and may be as high as 20% among women who have suffered sexual
violence in areas of armed conflict.[36]
1.4 For people living in emergency settings,
services for prevention and treatment of HIV/AIDS are often limited.
Antiretroviral therapy (ARV) and Prevention of Mother to Child
Transition (PMTCT) programs for HIV positive pregnant women can
be harder to access or unavailablein humanitarian settings, which
increases the risks of childbirth for the woman and the risk of
transmission to the child.
1.5 Male and female condoms can prevent
unwanted pregnancy and protect against the transmission of HIV/STIs.
Access to condoms and family planning services allow those affected
and unaffected by HIV to prevent unwanted pregnancies, reduce
further HIV transmission.
1.6 Skilled attendance at delivery is one
of the indicators of progress towards achieving MDG5, the most
off track of all MDGs. Encouraging women to deliver in a health
facility to ensure access to PMTCT may increase the number of
institutional deliveries and hence contribute to efforts to reduce
maternal morality.
2. POLICY AND
FUNDING ENVIRONMENT
FOR RH INCLUDING
HIV/AIDS IN EMERGENCIES
2.1 According to a study of disbursements
of official development aid (ODA) for RH activities in 18 conflict-affected
countries between 2003 and 2006, there is an inequity of RH ODA
disbursement between conflict-affected and non-conflict-affected
countries. An annual average of 4.4% of all ODA disbursed to sampled
conflict-affected "least-developed countries" (LDCs)
was allocated to RH activities, compared to 8.9% in sampled non-conflict
affected.[37]
2.2 Of the annual average of $509.3 million
ODA for RH, only 1.7% was disbursed to support family planning
activities compared to 46.7% to support HIV/AIDS control efforts.[38]
2.3 A review of the policy environment of
RH in emergencies showed that policies related to gender-based
violence and HIV/AIDS are well represented, compared to those
related to family planning and emergency obstetric care.[39]
2.4 The Ugandan Policy for the Reduction
of Mother-to-Child HIV transmission in Uganda (May 2003)[40]
refers to the following:
(a) Women with HIV infection who are pregnant
should be treated with either: Nevirapine at the onset of labour
and Nevirapine syrup to the baby within 72 hours of birth; Zidovudine
from 36 weeks of gestation until one week after delivery and syrup
to the baby for the first week after birth.
(b) Voluntary Counselling and HIV Testing within
the antenatal clinic is recommended for pregnant women, with at
least two laboratory tests: one for screening and another for
confirmation.
2.5 The SRH policy of Congo (2004)[41]
refers to PMTCT. The more recent Congolese SRH policy (2008) is
very strong on PMTCT especially in well equipped facilities.
2.6 The National RH strategy of Sudan (2006)
refers to PMTCT, one of the objectives is scaling up PMTCT services
from 5 to 45 sites by 2010.[42]
3. PMTCT IN CONFLICT
AFFECTED SETTINGS—FINDINGS
FROM SELECTED
FACILITIES
3.1 Although there is a "facilitating"
policy and funding environment for HIV/AIDS services in conflict
affected settings (see point 2 above) a baseline study of selected
service delivery sites in 2007 showed VCT and PMTCT services were
severely lacking. As part of baseline activities, RAISE supported
partners conducted assessments of the status of health services
available at all sites identified for support through the RAISE
Initiative. Assessments were conducted in Uganda, DRC and Sudan.
3.2 In the 60 facilities in the three countries
assessed:
— Only six women with unknown HIV status
had been tested in the past 12 months in the maternity/labour
ward in 60 facilities:
— In the 10 facilities in Uganda, four
women had been tested in the past 12 months.
— In the 29 facilities in DR Congo, two
women had been tested in the past 12 months.
— In the 21 facilities in Sudan, no women
had been tested in the past 12 months.
— Only nine mothers and nine newborns received
PMTCT during the last 12 months in the 60 facilities:
— In the 10 facilities in Uganda, five
women received PMTCT during the last 12 months.
— In the 29 facilities in DR Congo, four
women received PMTCT during the last 12 months.
— In the 21 facilities in Sudan, no women
received PMTCT during the last 12 months.
— In the 60 facilities a total of 60 staff
to provide pre and post-HIV counselling was available and in total
40 staff for PMTCT provision:
— The 10 facilities assessed in Uganda
had in total 26 staff available to provide pre and post-test counselling
and in total 14 staff to provide PMTCT.
— The 29 facilities assessed in DRC had
21 staff available to provide pre and post- test counselling and
16 staff available for PMTCT.
— The 21 facilities in Sudan had 13 staff
available for pre- and post-test counselling and 10 staff available
for PMTCT.
— Only five of the 60 facilities assessed
had nevirapine (200 mg tablets) available and only four facilities
had nevirapine (liquid/suspension) available:
— Only gwo of the 10 sites in Uganda had
Nevirapine tablets available and only two sites had nevirapine
(liquid/suspension) available.
— Only three of the 29 facilities in Congo
had Nevirapine tablets available and onltwo 2 sites had nevirapine
(liquid/suspension) available.
— In Sudan neviripine (tablets or liquid)
was not available at all.
- HIV rapid testing kits were available in 12
of the 60 facilities:
— Two of the 10 sites in Uganda had HIV
rapid testing kits available.
— Six of the 29 facilities in Congo had
HIV rapid testing available.
— Four of the 21 facilities in Sudan had
HIV rapid testing available.
— Lack of supplies, training, policy and
management issues were the main -reasons mentioned for the lack
of testing and PMTCT services.
4. DFID
4.1 DFID recognises the importance of HIVAIDS
prevention and treatment in emergency situations, noting that
the proportion of People Living With HIV (PLWH) is four times
higher in fragile states than in other low income countries, and
the capacity of these states to respond is lower (DFID 2006).
The same document highlights the need for post-conflict states
to ensure due attention is paid to HIV in both humanitarian relief
settings and during longer-term development processes.
4.2 DFID HIV/AIDS Strategy, Achieving
Universal Access (June 2008) refers to AIDS responses in fragile
states and humanitarian contexts and also refers to the DFID White
Paper (2006) in this regard. The HIV/AIDS strategy recognises
the fact that "women and children caught up in conflict face
increased risk of abuse, violence and trafficking and are at higher
risk of HIV infection".
4.3 Whilst the 2009 DFID White Paper—Building
Our Common Future makes reference to HIV/AIDS, it does not
specifically reference the need to address the challenge of HIV/AIDS
in humanitarian settings or fragile states.
5. RECOMMENDATIONS
5.1 We urge the IDC to prioritise an examination
of DFID's track record on supporting capacity building for delivering
HIV/AIDS and other essential reproductive health services in humanitarian
settings since the publication of the 2008 AIDS strategy.
5.2 DFID must support and encourage humanitarian
agencies to develop the skills and capacity required to address
the paucity of HIV/AIDS and integrated RH services in humanitarian
settings as shown by the RAISE baseline study.
33 UNAIDS/WHO (2006). "AIDS Epidemic update: December
2006". Back
34
Ibid. Back
35
The Global Coalition on Women and AIDS (2004). Violence against
Women and HIV/AIDS: Critical intersections, Intimate Partner Violence
and HIV/AIDS, WHO. Back
36
UNAIDS. "Congo". http://www.unaids.org/en/CountryResponses/Countries/congo.asp Back
37
Patel, P et al. (2009). Tracking Official Development Assistance
for Reproductive health in Conflict-Affected countries. Plos Medicine. Back
38
Ibid. Back
39
Ettema, L, Tanabe, M et al, Determining Donor Commitment
Through Policy Analysis: Examining the Policy Environment for
Reproductive Health in Crisis Settings. RAISE RH in emergencies
conference, Kampala, Uganda, 2008. http://www.raiseinitiative.org/conf2008/raise_book_of_abstracts.pdf Back
40
The Ugandan Policy for the Reduction of Mother-to-Child HIV transmission
in Uganda (May 2003) http://www.aidsuganda.org/npdf/PMTCT%20Policy.pdf Back
41
Republique Democratique du Congo Ministere de La Politique Nationale
et Plan Directeur de Development de la Sante de la Reproduction
a Sante Publique. Programme National de Sante de La Reproduction
PNSR (Juin 2004). Back
42
Republic of Sudan Federal Ministry of health The National Strategy
for Reproductive Health 2006-10 (August 2006). Back
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