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									             URBAN DISPLACEMENT             1
                                  October 2010

HIV/AIDS, security and conflict:
making the connections
                                        Steve Elliott
Forced Migration Review
(FMR) provides a forum for the                                                       from the editors
regular exchange of practical
experience, information and             The interconnections between conflict and HIV/AIDS are more complex and less obvious
ideas between researchers,              than is often thought. HIV/AIDS affects the lives of many: those people caught up in
refugees and internally                 conflict, those who are the protagonists in conflicts, and those whose role it is to provide
displaced people, and those who         security during and after conflict.
work with them. It is published
in English, Arabic, Spanish and         The AIDS, Security and Conflict Initiative (ASCI) undertook research over a number of
French by the Refugee Studies           years to examine the connections, to gather evidence and to advance analysis. This special
Centre of the Oxford Department         supplement of FMR presents a selection of the ASCI case-studies alongside a number of
of International Development,           other articles on the subject which were submitted in response to an FMR call for articles.
University of Oxford.                   All 27 ASCI studies are listed on the back cover.

Staff                                   We would like to thank our Guest Editors, Pam Delargy of UNFPA and Jennifer Klot and
Marion Couldrey and
                                        Dana Huber of SSRC, for all their work and assistance in the preparation and production
  Maurice Herson (Editors)
                                        of this special supplement of FMR. We are grateful to both SSRC and UNAIDS for their
Sharon Ellis (Assistant)
                                        financial support for this supplement.

                                        The English edition is online at It is also being published
Forced Migration Review                 in French (which will be available online at
Refugee Studies Centre
Oxford Department of                    Best wishes
International Development,
University of Oxford,                   Marion Couldrey and Maurice Herson
3 Mansfield Road,                       Editors, Forced Migration Review
Oxford OX1 3TB, UK
Skype: fmreview                     Contents
Tel: +44 (0)1865 281700
                                    2      From the editors                                           18 Gendered violence and HIV in Burundi
Fax: +44 (0)1865 281730
                                           Marion Couldrey and Maurice Herson                            Hakan Seckinelgin, Joseph Bigirumwami
                                                                                                         and Jill Morris             3      Vulnerable mobile populations overlooked
                                           Leo Kenny, Manuel Carballo                                 20 Post-conflict transition and HIV
                                           and Thobias Bergmann                                          Manuel Carballo, Calixte Clérisme,
                                                                                                         Benjamin Harris, Patrick Kayembe,
                                    4      Forced migration and HIV/AIDS in Asia:                        Fadila Serdarevic and Alexandra Small
                                           some observations
                                           Nafis Sadik                                                22 Understanding sexual violence,
Disclaimer                                                                                               HIV/AIDS and conflict
                                    6      HIV/AIDS, security and conflict:                              Judy El-Bushra
Opinions in this supplement                new realities, new responses
do not necessarily reflect the             Alex de Waal, Jennifer F Klot and                          24 Mobility and power in HIV transmission
views of the Editors, the Refugee          Manjari Mahajan with Dana Huber,                              Cathy Zimmerman, Charlotte Watts, Anna Foss
Studies Centre, the University of          Georg Frerks and Souleymane M’Boup                            and Mazeda Hossain
                                    8      HIV in emergencies – much achieved, much to do             25 Addressing HIV and sex work
                                           Paul Spiegel                                                  Ann Burton, Jennifer Butler, Priya Marwah,
Copyright                                                                                                Cecile Mazzacurati, Marian Schilperoord
Any FMR print or online material    10 HIV, refugees and conflict-affected populations                   and Richard Steen
may be freely reproduced,              in Asia
                                       Ann Burton                                                     27 The price of liberation:
provided that acknowledgement
                                                                                                         migration and HIV/AIDS in China
is given to ‘Forced Migration       12 Disarmament, demobilisation and reintegration:                    Shao Jing
Review’.              opportunities in post-conflict settings
                                       Priya Marwah, Pamela DeLargy and Lara Tabac                    29 Education: critical to HIV prevention
ISSN 1460-9819                                                                                           and mitigation
                                    14 Ex-combatants as entry points for HIV education                   Marian Hodgkin and Marian Schilperoord
                                       in southern Sudan
Designed by                            Anyieth M D’Awol                                               30 HIV/AIDS, security and conflict: What do we
Art24                                                                                   know? Where do we go from here?
                                    16 Challenges for antiretroviral provision in                        Pamela DeLargy and Jennifer F Klot
                                       northern Uganda
Printed by
                                       Matthew Wilhelm-Solomon                                        32 AIDS, Security and Conflict Initiative (ASCI)
                                                                                                         resources and further reading

                                                                      Kibati camp for displaced people, DRC.
                                                                      Christian Als

                                                                      People displaced in conflict (and on return home) often find themselves in contact
                                                                      with people carrying weapons in various guises. Equally, people carrying weapons
                                                                      are themselves generally mobile, whatever their relation to a conflict or its aftermath.
                                                                      In particular, members of security forces in situations of forced displacement can be
                                                                      agents of positive change in relation to HIV and AIDS – or part of the problem.
                                               HIV/AIDS, SECURITY AND CONFLICT                                                   3

      Vulnerable mobile
      populations overlooked
      Leo Kenny, Manuel Carballo and Thobias Bergmann

      Many countries have been seemingly overwhelmed by the                            will increase – and this in turn
      speed with which the HIV epidemic has spread and its                             will impose on governments an
                                                                                       ever greater need for pro-active
      impact on forced migrants and other mobile populations.                          planning, flexibility in health policy
      Millennium Development Goal 6            forced to move as a result of war       and rapid response capacities.
      (MDG 6)1 seeks improved access           and natural disasters and people
      to HIV prevention services and           who move in search of work and          Due to the circumstances of their
      AIDS treatment, care and support,        economic opportunities. Differences     movements, forcibly displaced
      and halting and reversing the            between refugees and IDPs are not       populations, as well as migrants,
      spread of the HIV epidemic by            only limited to legal status, but       can be at a higher risk of gender-
      2015. Universal access to HIV/AIDS       also to living conditions and socio-    based violence, including rape,
      services can only be achieved if         economic opportunities, depending,      which in turn can increase the risk
      the global effort to scale up HIV        for example, on whether people          of HIV infections. Combating sexual
      prevention, care and treatment           are living in camps or not, which       violence which is a serious violation
      includes such highly vulnerable          can in turn affect their ability to     of human rights in itself, is therefore
      populations as the estimated 200         integrate into the host community.      also a key priority in order to prevent
      million people affected annually by                                              HIV transmission and to protect
      humanitarian crises (and, frequently,    There are also millions of people who   the rights of mobile populations,
      by the ensuing displacement), the        are typically referred to as economic   especially – but not only – in conflict
      approximately 50 million uniformed       migrants, but who also vary widely      settings. It is crucial that uniformed
      services personnel, and regular          in terms of their status, how they      services, such as militaries and
      and irregular migrants. UNAIDS           move and how they are received.         peacekeepers, are targeted not only
      has created a new Outcome                Some move officially, and are known     with HIV services (as they are highly
      Framework2 to galvanise support          as regular or documented migrants;      mobile groups themselves) but also as
      for key objectives which include         they have a type and degree of          agents of change, to combat gender-
      reducing sexual transmission of          access to health care that unofficial   based violence and the spread of HIV.
      HIV, improving access to treatment,      or irregular migrants, who are not
      social protection, empowering young      documented, and are often smuggled      The health and human security of
      people and combating gender-based        or otherwise travel under difficult     migrants and refugees, however,
      violence. UNAIDS is promoting            conditions, do not benefit from.        are also a function of the extent to
      the strong partnerships that can                                                 which migrants have access to, and
      deliver results on the ground.3          In coming years, changing climatic      are able to use, health and social
                                               patterns and environmental              services in the countries they pass
      Meeting MDG 6 will not be easy           conditions are expected to displace     through and settle in. In some
      for a variety of reasons. At the         many more people,4 and this will add    cases this is influenced by legal and
      end of 2008, only 42% of people in       massively to the demographic, social    administrative requirements, while
      need of treatment were receiving         and cultural complexities confronting   in others it may be more a function
      anti-retroviral therapy. While this      health planners and those responsible   of social, cultural and linguistic
      represents a significant increase        for designing HIV programmes.           factors. In most situations it is a mix
      over the previous year’s coverage                                                of all of these factors and more.
      of 33%, reaching all those still in      What all of these forms of human
      need of antiretrovirals will require     movement have in common is that         In principle, the right of refugees
      a major reallocation of human,           the backgrounds people come             and asylum seekers to health care
      financial and logistical resources.      from, the conditions under which        and to HIV services is protected
      Countries will need to take a more       they move, and the ways in which        by international conventions, and
      comprehensive view of demographic        they are received and resettled         documented migrants are also
      realities in order to ensure inclusion   (even for temporary periods)            likely to be assured of access to the
      of IDPs, refugees and migrants.          can influence both their physical       same health care as nationals. The
                                               health and their psychosocial well-     extent to which undocumented
      Mobile populations                       being, and can affect patterns of       migrants are able to or feel free to
      Among those who have traditionally       incidence of HIV, TB and other          access services, including for HIV,
      not been reached by HIV (as well as      diseases. If the gap between rich       in the countries where they live
      other health) interventions, mobile      and poor countries, and between         and work varies considerably. In
      populations rank especially high.        rich and poor people, continues to      general, undocumented migrants
      These vulnerable groups are growing      grow and as transportation and          have come to constitute a particularly
      in both number and diversity and         information options improve, the        marginalised group in most parts of
      comprise a varied mix of people          speed with which people move            the world, and have far more limited
4                                                                  HIV/AIDS, SECURITY AND CONFLICT

                                                                   long, or that the needs of newcomers      and a key item on the agenda of
                                                                   will prove to be no different from        the international community.
                                                                   those of their host populations. As
                                                                   a result, migrants and refugees are       Leo Kenny (
                                                                   being overlooked everywhere, even         is Team Leader, Security and
                                                                   though they may be made all the           Humanitarian Response, and Thobias
                                                                   more vulnerable to HIV because            Bergmann (

                                          IRIN/Manoocher Deghati
                                                                   of the work they do and the type          is Humanitarian Response Adviser, at
                                                                   of lives they are forced to live          UNAIDS (

                                                                                                             Manuel Carballo (mcarballo@
                                                                   Today the question of how to
                                                                                                    is Executive Director
                                                                   achieve greater and better access
                                                                                                             of the International Centre for
                                                                   to prevention, care and treatment
                                                                                                             Migration Health and Development
    access to health care services than                            for HIV looms large. It is unlikely
    other types of people on the move.                             that MDG 6 will be met without
                                                                   far more outreach to all forms of         1. To combat HIV/AIDS, malaria and other diseases.
    Many countries have not had the                                displaced populations and migrants,
                                                                                                             2. Joint action for results: UNAIDS Outcome Framework,
    time or the insight to develop the                             regardless of their status, and to the    2009-2011, available at:
    policies and programmes needed                                 uniformed services that in many           OutcomeFramework

    to reach newcomers adequately.                                 cases interact with them. Specially       3. Partnerships especially with WHO, UNHCR, UNFPA,
                                                                                                             WFP, UNICEF, UNDP, UNODC, ILO, IOM, and ICMHD.
    Others have simply chosen to neglect                           tailored programmes to ensure             4. See FMR 31, Climate change and displacement at
    the question of HIV and mobile                                 universal access to vulnerable groups and in
                                                                                                             particular ‘Health challenges’ by Manuel Carballo,
    populations, in some cases assuming                            must become an integral part of           Chelsea B Smith and Karen Pettersson at http://www.
    or hoping that people will not stay for                        national HIV policies and strategies,

    Forced migration and HIV/AIDS
    in Asia: some observations
    Nafis Sadik
    Although most of Asia has not suffered from a generalised HIV                                            same time they have lost access to
    epidemic, there is reason to be concerned about how forced                                               information and means of prevention.
    migration and economic crisis-related migration may increase                                             Over the past decade there has
    the risks.                                                                                               been a great deal of conflict-related
    A thorough discussion of how and                               to the rights, needs and protection of    displacement in the region. Civil
    why forced migration can increase                              migrants. Over the past decade, there     war or insurgencies in Afghanistan,
    risks of HIV transmission in the                               has been significant progress in HIV      Nepal, Myanmar, Sri Lanka,
    region would require reviewing                                 awareness and adoption of ever more       Indonesia, Pakistan, India and the
    a myriad of social, cultural,                                  progressive and effective policies and    Philippines and across Central
    economic and even physiological                                programmes by many governments.           Asia have created large numbers of
    dynamics. So I will focus on a                                 A good example of recent change is        refugees and IDPs who have required
    few issues of particular relevance                             the lifting of immigration restrictions   humanitarian support. Although
    – HIV in humanitarian settings,                                based on HIV status by China, setting     HIV prevention, as a part of the
    security-related programme                                     a good example for other countries.       minimum package of reproductive
    developments, and the special needs                                                                      health services, was adopted as a
    of the millions of Asians who, out                             But there remains much room               critical component of humanitarian
    of desperation, find themselves                                for improvement when it comes             response in 19941, resource
    exploited and unprotected as                                   to widespread establishment of            constraints and social and cultural
    labourers in foreign lands.                                    effective, rights-based policies and      factors have impeded universal
                                                                   programmes for HIV prevention and         access to information and means of
    In my capacity as Special Envoy,                               care. There are particular needs for      prevention among these populations.
    I have advocated for stronger                                  more attention to those at risk due to    (It should also be pointed out that
    prevention, better care, and                                   being displaced. There are millions       for some people the first information
    destigmatisation of HIV/AIDS                                   of Asians who have left their homes       they ever received on HIV was
    throughout the region. I have also                             and areas of origin and are living,       from humanitarian agencies.)
    worked for the recognition that                                often without their families or other
    migration within and outside                                   social support, in new communities.       Some types of conflict or
    the region plays an important                                  Many are facing circumstances             displacement have brought much
    epidemiological role and that there                            which make them more vulnerable           more particular risks of HIV infection.
    must be much greater attention paid                            to contracting HIV while at the           For example, long years of refugee
                                                 HIV/AIDS, SECURITY AND CONFLICT                                                   5

      camp life and lack of employment           were among the first countries           migration has not been considered
      or recreational opportunities have         to recognise the need to provide         as forced. I would like to challenge
      contributed to intravenous drug use        comprehensive HIV prevention             that notion in the case of much of
      in Afghanistan and Pakistan border         programmes within the security           the labour migration within and
      areas; this is a driving factor in the     sector (national militaries, police      from Asia today. The severity of the
      epidemic in these countries just as        and other uniformed services) and        economic and social crises in the
      it is in Central Asia. The destitution     they have shown the way for many         region has led thousands to leave
      of Burmese refugees in Thailand            other countries in the world. The        their families and homes to go to
      has led to widespread ‘survival sex’       Thais, as in so many other aspects       foreign lands and engage in low-
      which has driven the infection in that     of HIV prevention, pioneered peer        wage labour with little protection
      sub-region. The sexual violence used       education and condom distribution        from exploitation, no legal rights
      as a weapon of war in Timor Leste,         programmes for uniformed services.       and inadequate access to even basic
      Central Asia, Sri Lanka and other          The MAITRI programme in India            social services. This must surely
      conflicts has undoubtedly increased        was one of the first programmes          be considered not as a lifestyle
      HIV risks. And although it is often        established to support military          choice but as something forced on
      not considered an armed political          families and dependents, not just        the migrant by circumstance. The
      conflict, the horrific levels of social    individual members of the military,      conditions of such migrants are such
      and interpersonal violence in Papua        with comprehensive health and            that their risks of harm, including of
      New Guinea are also thought to be          HIV education and counselling            HIV infection, are multiplied. And
      important factors in the epidemic          as well as other social support.3        yet their resources for protection
      there. Throughout the region, there                                                 are sparse. This is an area in which
      is not only need to ensure that HIV        With the support of UNAIDs, UNFPA        I would like to encourage much
      prevention and care services are           and others over recent years, there      more documentation and analysis
      provided for displaced populations         has been good progress in the            to inform policy advocacy.
      but there is also need for serious         region among national uniformed
      analysis of the HIV impact of the          services, groups who are important       Thousands of Asian women are
      conflicts and for the inclusion of the     both because of their risk factors       working as domestic workers or in
      special needs of the displaced in          (age, mobility, etc) and because         the service industries, particularly
      every national AIDs action plan.           they can serve as role models in         in the Middle East and Europe, and
                                                 their societies. It is particularly      there are daily and sometimes horrific
      The Asian region suffers more              important that members of militaries     examples of exploitation and sexual
      natural disasters, especially floods       and police in the region have both       abuse, including HIV infection. Yet
      and earthquakes, than any other            knowledge of HIV and prevention          these workers are without consular
      region in the world. The displacement      skills because Asian countries           oversight or legal protection in the
      of millions due to such events is a        provide a very large proportion of       countries where they are working.
      regular annual occurrence. In many         international peacekeeping forces and
      places, such as Pakistan, Indonesia        so are deployed all over the world,      To compound the problem, if they
      and Sri Lanka, populations have            including to places with higher HIV      do become infected with HIV, they
      suffered both conflict- and disaster-      prevalence. Pakistan, Bangladesh         are deported and thus left without
      related devastation. In addition to        and India are the largest contributors   a livelihood. This has implications
      the trauma of the disaster and the         to UN peacekeeping, sending on           not only for their own health but
      difficulties of living in temporary        average over 10,000 peacekeepers         for their families and communities
      shelter, the loss of livelihoods and       a year; Thailand, Nepal, Australia,      and countries of origin who must
      assets accompanying natural disasters      New Zealand, China, Indonesia,           then provide care. In some cases
      can affect families and communities        Fiji, Malaysia, Nepal, Sri Lanka,        in the past, when the country
      for years, leaving them destitute and      Mongolia, the Philippines and Korea      of origin has protested at such
      vulnerable to sexual exploitation          are also significant contributors.       policies, the receiving country has
      or even trafficking. There is some         Since the adoption of UN Security        simply responded by suspending
      evidence that domestic violence also       Council Resolution 1308 on HIV/          or restricting labour migration
      increases in post-disaster periods.        AIDS in 2000, the UN has established     from that country, which can have
      All of these are risk factors for HIV      HIV prevention programmes in all         enormous negative consequences
      infection. While provision of HIV          peacekeeping missions. For some          for others seeking work.
      education and basic prevention             troops from countries without
      measures, including condom                 national programmes, their first         At the same time, many countries
      distribution, are part of the minimum      exposure to reliable information is      in and outside the region require
      standards for humanitarian                 during peacekeeping deployment.          HIV testing for work permits and
      response2, full implementation                                                      immigration (and sometimes even
      of these standards has not been            Migration due to economic                for a visit) and reject applicants
      accomplished due to resource               and social crises                        based on their HIV status. So even
      constraints, or stigmatisation, or both.   Within migration studies there has       if a person is under treatment and
                                                 long been a hearty debate about the      healthy, they will not be able to take
      HIV and the security sector                ‘push’ and ‘pull’ factors determining    up a job for which they are qualified.
      Many Asian countries have been             individual decisions to migrate and      This stigmatisation and the denial
      leaders in the area of HIV and             what constitutes forced or voluntary     of travel and employment rights
      security. Thailand and India               migration. Traditionally, labour         are issues that have been taken up
6                                           HIV/AIDS, SECURITY AND CONFLICT

    by UNAIDs and the International         the health and well-being of those        1. UNHCR, WHO and UNFPA, Field Manual on
                                                                                      Reproductive Health for Refugees, 1996. Now revised
    Labour Organization as well as by       who are forced to work abroad.            as Inter-Agency Field Manual on Reproductive Health
                                                                                      in Humanitarian Settings, 2010.
    parliamentarians seeking to change                                      
    laws in countries such as India and     Nafis Sadik is Special Advisor to         2. Sphere Project, Humanitarian Charter and Minimum
    Australia. While these are welcome      the UN Secretary General and Special      Standards in Disaster Response, 2004. www.sphereproject.
                                                                                      org and IASC, Guidelines for HIV/AIDS Interventions in
    developments, there remains             Envoy of the UN Secretary General         Emergency Settings, 2003.
    much to do in the region both to        for HIV/AIDs in Asia and the Pacific.     3.
    alleviate the conditions leading        She can be contacted through
    to such migration and to protect or

    HIV/AIDS, security and conflict:
    new realities, new responses
    Alex de Waal, Jennifer F Klot and Manjari Mahajan with Dana Huber,
    Georg Frerks and Souleymane M’Boup

    Ten years after the HIV/AIDS epidemic itself was identified as                     Post-conflict transitions are both a
    a threat to international peace and security, findings from the                    period of heightened vulnerability
                                                                                       to HIV transmission and a
    three-year AIDS, Security and Conflict Initiative (ASCI)1 present                  neglected element in HIV and
    evidence of the mutually reinforcing dynamics linking HIV/AIDS,                    AIDS policy and programming.
    conflict and security.
                                                                                       Greater policy attention and
    ASCI’s findings reveal that a            HIV and AIDS can threaten the
                                            ■■                                         service continuity are needed in
    number of earlier, more alarmist,        operational capability of armies          post-conflict situations to respond
    relationships assumed to exist           primarily at the tactical level           to increased population mobility,
    between national-level state security    of operations. HIV/AIDS can               demobilisation of combatants,
    and the HIV/AIDS epidemic were not       affect combat effectiveness, unit         disruptions in humanitarian
    borne out. Under-examined risks in       cohesion, morale and discipline.          assistance to displaced persons in
    humanitarian emergencies and post-                                                 camp settings, and the excessive
    conflict transitions are highlighted,    Command-centred approaches
                                            ■■                                         demands on health and social
    as well as threats posed by HIV/         to HIV prevention – i.e. that put         services in areas of return.
    AIDS to the operational capacity of      responsibility for HIV policy
    armies and across the uniformed          and practice within the army              Disarmament, demobilisation
    services (such as police, prison         command rather than on medical            and reintegration (DDR)
    and border authorities). ASCI’s          services alone – are likely to be         programmes are an important
    gender analysis exposes flawed           more effective in reducing the            and consistently overlooked focus
    assumptions that continue to guide       risk of HIV infection and sexual          for HIV and AIDS prevention
    epidemiological and behavioural          violence among the rank and               and response, especially among
    approaches to HIV/AIDS prevention        file than relying solely upon             military and extended families,
    and response in conflict situations      education and training based on           and women and children
    and fragile states. By focusing on       individual behavioural, medical           associated with armed forces.
    intermediary levels of interaction –     or human rights approaches.
    between macro-level assumptions                                                    Forced sex may increase
    and micro-level behavioural and          HIV prevention efforts have
                                            ■■                                         individual risk of HIV acquisition
    biomedical approaches – ASCI             neglected police and other                for different scenarios of coercion
    offers a new agenda for action.          law enforcement and uni-                  based on genital trauma,
                                             formed services, including the            relative probabilities of HIV
    Summary of findings                      customs, naval, immigration               and other sexually transmitted
     Prevailing indicators of state
    ■■                                       and prison services.                      infections, and inadequate
     fragility fail to capture the impact                                              access to health services.
     of HIV/AIDS on local governance,        The
                                            ■■ risks of HIV transmission,
     human resources, service delivery       especially in epidemics                  Key recommendations
     and community survival.                 concentrated among injecting             1.	 Sexual violence needs to be
                                             drug users and sex workers, are          recognised as a physiological and
     Prevalence of HIV within the
    ■■                                       influenced by law enforcement            social factor in HIV transmission.
     uniformed services is related to        practices and by the drugs               Consistent with UN Security
     age, rank, time in service, maturity    trade, human trafficking and             Council Resolutions addressing
     of the epidemic, patterns of            those who control sex work               women, sexual violence and HIV/
     violence, military sexual trauma        – pimps, ‘protectors’, traffickers       AIDS (1308, 1325, 1820, 1882, 1888
     and command structures.                 and long-term clients.                   and 1889), sexual violence and HIV
                                             HIV/AIDS, SECURITY AND CONFLICT                                                  7

      prevention efforts must be more        5.	 DDR provides important entry        for injecting drug users, policing
      closely aligned in conflict-affected   points for HIV/AIDS prevention,         sex work and trafficking, and
      environments, including through        testing, care and treatment.            decriminalising homosexuality
      urgently needed consensus on           A new approach to voluntary             are all central to this. A global
      definitions and measurement.           counselling and testing, before         programme of collaborative
                                             and after deployment, should            learning on law enforcement and
      2.	 A command-centred approach         incorporate care and treatment          HIV/AIDS is recommended.
      (CCA) to HIV prevention and            not only for demobilising soldiers
      AIDS treatment and care within         but also for their families. The        9.	 Borders should be a special focus
      uniformed services and UN peace        UN, the World Bank and bilateral        for HIV prevention efforts. Cross-
      operations is needed. This should      donors should support national          border issues, including trafficking
      entail institutional and operational   governments to clarify policies and     of women and drugs, and sexual
      assessments of the potential impact    include Voluntary Counselling           exploitation and abuse at border
      of HIV/AIDS within security            and Testing/Care and Treatment          crossing points are all related to
      institutions and development of        Plus (VCT-CTP) in the context of        risks of HIV transmission. The role
      mechanisms of accountability,          DDR and security sector reform.         of some groups of law enforcement
      discipline and enforcement.                                                    personnel as core-group
      Tools developed for ASCI,              6.	 HIV/AIDS policies for the           transmitters needs examination.
      including a Military Institutional     uniformed services should be            Bilateral, regional and multilateral
      Audit and a Force Capabilities         reflected in pension and retirement     exchange and cooperation
      Framework2, can support a CCA.         schemes, funeral and survival           are vital. Linkages across the
                                             benefits, compassionate leave,          international trade in illegal drugs,
      3.	 The integration of HIV/AIDS        disability and medical discharge        related sex-trafficking activities,
      prevention and response in peace       benefits as well as entitlements        drug use and the emergence of
      operations – including in relation     for children born out of wedlock        narco-states in several parts of
      to pre- and post-deployment            and/or as a result of rape.             the world demand attention.
      testing, care and treatment,
      and inclusion of HIV-positive          7.	 ASCI recommends greater             10.	 There is a major response gap
      people within the uniformed            dialogue on mandatory HIV/AIDS          during post-conflict transitions,
      forces – should fit more realisti-     testing and the establishment of        a time when transmission
      cally with operational demands         health criteria for deployment.         risks can be heightened due
      and the capacities of troop-           Mandatory testing is practised          to discontinuities between
      contributing countries. Building       by most armies but has been             emergency and reconstruction and
      on the operational tools of CCAs,      inadequately justified in the context   development efforts. International
      ASCI proposes that HIV/AIDS            of national HIV/AIDS policies and       policy frameworks and practices
      and sexual violence security risk      human rights principles. Some           put limits on HIV/AIDS-related
      assessments be carried out in          militaries provide incentives to        assistance to post-conflict countries,
      peacekeeping environments.             encourage voluntary testing and         as these often fail to meet funding
                                             require sero-negative test results      criteria which may require
      4.	 A universal standard for HIV/      as a prerequisite for deployment        conditions of stable governance.
      AIDS prevention, treatment and         and promotion. Others frame             More refined approaches are
      care should be developed across        their policies in terms of medical      recommended, paying particular
      all troop-contributing countries       fitness in general, leaving scope       attention to a variety of gender-
      and in alignment with regional and     for discretion on how to utilise        related factors that shape HIV
      international approaches. In line      soldiers who test HIV-positive. Both    risk during transitions.
      with the global goal of universal      principled and practical arguments
      access, HIV and AIDS treatment         for and against mandatory testing       11.	 The linkages between
      should be extended to UN               should be aired. International          psychosocial recovery and HIV
      peacekeepers as a matter of policy.    humanitarian law and the right of       risk are among the most under-
      ASCI recommends increased              states to suspend certain human         explored. The psychosocial effects
      dialogue among bodies and              rights provisions during national       of war, conflict, displacement,
      institutions with complementary        security emergencies should be          torture and violence have
      peacekeeping/peacemaking               discussed alongside the resource        repercussions for interpersonal,
      mandates (e.g. the UN Security         constraints of armed forces.            family and household relationships.
      Council, the African Union
      Peace and Security Council and         8.	 ASCI identified the pressing        12.	We also need to better
      other regional mechanisms, the         need for HIV/AIDS interventions         understand how notions of
      Peacebuilding Commission and the       within the police and other law         masculinity and femininity are
      UN Department of Peacekeeping          enforcement institutions. Law           shaped by conflict and its aftermath,
      Operations) to address the             enforcement practices, especially       so that appropriate interventions
      heightened risk of HIV exposure        in relation to stigmatised and          can be designed for men and
      during post-conflict peacebuilding     criminalised activities and             women, boys and girls. Policy
      and to ensure the continuity of        groups, influence the trajectory of     successes need to be recognised
      HIV prevention efforts during          national and regional epidemics.        and sustained, including best
      post-conflict transitions.             Issues such as harm reduction           practices in HIV/AIDS response
8                                            HIV/AIDS, SECURITY AND CONFLICT

    to populations in refugee and            decentralisation can alter patterns      Director and Jennifer F Klot (klot@ssrc.
    IDP camps and the strengthening          of HIV transmission for the better.      org) its Senior Advisor for HIV/AIDS,
    of health infrastructure in                                                       gender and security. Manjari Mahajan
    post-conflict settings.                  Conventional indicators of conflict      ( is an SSRC
                                             and epidemiological and behavioural      research fellow. Dana Huber (dhuber@
    Conclusion                               models of HIV transmission fail to is a Research Assistant at
    The relationship between HIV/AIDS        capture the relevant dimensions          the Social Science Research Council.
    and state fragility is highly complex    of social disruption and related
    and non-linear. ASCI’s findings          trauma for gender relations, family      Georg Frerks, Professor of Conflict
    lead to a call for a reassessment of     structures, local government and         Prevention and Conflict Management
    current measures of state fragility      social services. We need more            and Director of the Centre for Conflict
    to take into account key elements of     finely tuned indicators that are         Studies, Utrecht University, and
    local government, including human        sensitive to these social and gender     Souleymane M’Boup, Professeur,
    resources, health sector delivery        dimensions. Analytical frameworks        Laboratoire de Bacteriologie Virologie,
    and community resilience. ASCI’s         and measurement tools need to            Université Cheikh Anta Diop, Dakar,
    research highlights the many ways        consider local variations in sexuality   Senegal, are co-chairs of ASCI.
    in which the HIV/AIDS epidemic           and violence, and assessments of the
    puts stress on local government          drivers and impacts of HIV/AIDS             The full report of which this is a
    institutions, hindering effective        should complement aggregated                summary is available at:
    representation and contributing          national-level indicators with more
    to poor service delivery. Such           contextualised measures of family,
    weaknesses undermine efforts to          community and social dynamics.
                                                                                      1. ASCI is a research partnership between the Social
    achieve universal access to HIV/AIDS                                              Science Research Council (New York) and the
    prevention care and treatment. Local     Alex de Waal (alex_dewaal@harvard.       Clingendael Institute for International Relations (The
    government reforms and national-         edu) is the Social Science Research
                                                                                      2. See
    level commitment to genuine              Council’s HIV/AIDS Programme

    HIV in emergencies – much
    achieved, much to do
    Paul Spiegel

    Entrenched misconceptions about HIV/AIDS in humanitarian                          in areas affected by conflict. Since
    emergencies have been refuted but there is still work to do to                    refugees and IDPs would be
                                                                                      displaced from these same areas,
    ensure that HIV is adequately and appropriately addressed.                        they would have a higher HIV
    A decade ago, HIV/AIDS in                to be included in humanitarian           prevalence than surrounding host
    humanitarian emergencies was not         emergencies. Around the same             communities, and consequently be
    considered a priority in either the      time, Médecins Sans Frontières           vectors of transmission. Although
    HIV or humanitarian worlds but was       (MSF) began advocating for and           counter-intuitive, research has
    rather thought of as a development       providing ART to persons affected        shown this generally not to be the
    issue. Provision of antiretroviral       by humanitarian emergencies. In          case, although it is context specific.2
    therapy (ART) for displaced people       2003, the Inter-Agency Standing
    was thought to be inappropriate,         Committee (IASC) created a Task          Factors in reducing HIV transmission
    and adequate guidelines for HIV          Force for HIV in Humanitarian            during conflict compared with what
    in humanitarian situations did           Situations.1 These efforts, and          would normally be seen during
    not exist. Furthermore, it was           many others, have helped ensure          peacetime include isolated and
    widely believed both that conflict       that HIV is no longer considered         inaccessible populations and reduced
    exacerbated HIV transmission             solely a development issue but an        urbanisation as well as reduced
    and that displaced people brought        important matter to be addressed         migration and transportation due
    HIV with them and spread the             in humanitarian emergencies.             to insecurity and destruction of
    virus to host communities.                                                        infrastructure. This knowledge
                                             HIV is a complex and ‘political’         has helped reduce stigma and
    Progress                                 disease that clearly goes beyond         discrimination towards HIV-affected
    The HIV and humanitarian worlds          the health sector. Human rights          persons displaced by conflict and
    have come far in the past decade. In     and protection interventions are         has been used to advocate for their
    2002, two large UN agencies – the        major components of addressing           inclusion in policies, strategies
    World Food Programme and UNHCR           HIV in all populations, especially       and funding proposals. It has
    – became co-sponsors of UNAIDS           those affected by conflict. A decade     also highlighted the need for the
    and started advocating for HIV           ago, it was commonly believed that       international community to focus
    strategies, policies and interventions   HIV transmission would increase          on post-conflict situations.
                                                HIV/AIDS, SECURITY AND CONFLICT                                                                             9

      MSF led the way in advocating for
      access to ART for all as a basic right.

                                                                                                                                              UNHCR/F Noy
      It showed that provision of such
      essential medications and acceptable            Therapeutic
                                                nutritional centre
      levels of compliance were possible             in Cameroon
      in conflict and post-conflict settings.    where both local
      ART policies and guidelines                populations and
      followed. Although not always                refugees with
      simple, the continuation of ART in         and malnutrition
      the acute phase of conflict and the             are treated.
      need to provide more comprehensive
      HIV services including ART in
      protracted and return situations
      is now considered the norm.
                                                access and other targets set out in      provides an opportunity for clarity
      Shortcomings                              Millennium Development Goal 6.5          in coordination and response of
      The HIV and humanitarian                                                           HIV in non-refugee humanitarian
      communities, as well as                   Human rights violations have also        emergencies. This needs to be
      governments, still have a long            not been sufficiently addressed in       coordinated with the IASC at a senior
      way to go to ensure that HIV is           humanitarian emergencies and             level to ensure that the humanitarian
      adequately and appropriately              there have been few protection           reform process also addresses this
      addressed in humanitarian                 interventions. Gender-based violence     issue in a clear manner that will
      emergencies and post-conflict             – and its individual and community       result in an integrated HIV response
      settings. In 2001, the UN General         effects on the transmission of HIV –     within the cluster approach.
      Assembly Special Session passed           is an important issue that still needs
      a Declaration of Commitment on            much more political commitment           Conclusion
      HIV/AIDS3 which aimed by 2003 to          and practical field intervention.        Recent research has confirmed the
      “develop and begin to implement           Mandatory HIV testing for refugees,      effectiveness of HIV interventions
      national strategies that incorporate      migrants and other displaced persons     in post-conflict settings. As societies
      HIV/AIDS awareness, prevention,           is still relatively common in many       begin to recover from the trauma
      care and treatment elements               parts of the world and those found       of conflict, factors that did not
      into programmes or actions that           to be positive are routinely forcibly    exist during conflict – such as
      respond to emergency situations,          returned (refouled). The recent          the rebuilding of infrastructure,
      recognizing that populations              US decision to stop undertaking          increased urbanisation, wide-
      destabilized by armed conflict,           mandatory HIV testing for refugees       scale migration and an improving
      humanitarian emergencies and              accepted for resettlement is welcome     economy – may provide a fertile
      natural disasters, including              and it is to be hoped that other         environment for the spread of HIV.
      refugees, internally displaced            governments will follow its lead.        At this stage, as well as during
      persons, and in particular women          This measure needs to be augmented       the ‘transition’ phase between
      and children, are at increased risk       by robust public health measures         emergency and post-emergency
      of exposure to HIV infection; and         to ensure that on their arrival in       settings, when a breach in funding
      where appropriate, factor HIV/            the US resettled refugees have the       mechanisms for HIV interventions
      AIDS components into international        opportunity to choose to be tested       may occur, appropriate funding and
      assistance programmes”.                   and receive ART if indicated.            interventions for HIV in post-conflict
                                                                                         settings are neglected priorities.
      Sadly, this commitment has yet            In 2005, UNAIDS developed the
      to be met. Refugees and IDPs are          Technical Support Division of            Paul Spiegel (
      generally excluded from national          Labour6 in an attempt to simplify        is UNHCR’s Chief of Public Health
      HIV strategic plans or proposals          HIV support at the country level and     and HIV (
      to the Global Fund to Fight AIDS,         provide improved accountability.
      Tuberculosis and Malaria. In its          This development was followed by         2. Spiegel P B et al. ‘Prevalence of HIV infection in
      2009 annual list of the top ten           the humanitarian reform process          conflict-affected and displaced people in seven sub-
                                                                                         Saharan African countries: a systematic review’, Lancet
      ignored humanitarian crises,              that aimed to provide increased          2007;369 (9580); Plewes K et al. ‘Low seroprevalence of
      MSF included inadequate donor             predictability and accountability        HIV and syphilis in pregnant women in refugee camps
                                                                                         on the Thai-Burma border’. International Journal of STD
      support for AIDS treatment.4              to conflict and natural disaster         & AIDS 2008;19 (12); Strand RT et al: ‘Unexpected low
      Besides the legal obligations of          response.7 Unfortunately, the two        prevalence of HIV among fertile women in Luanda,
                                                                                         Angola. Does war prevent the spread of HIV?’
      those governments that have signed        processes were not coordinated           International Journal of STD & AIDS 2007;18 (7).
      the 1951 Refugee Convention,              and there has never been sufficient      3.
      there is a public health imperative       clarity on HIV response in non-          4.
      to include all groups affected by         refugee humanitarian situations.         5. See
                                                                                         also article pp3-4.
      conflict in HIV national strategic        Thus, HIV coordination and response
      plans and funding proposals as well       in humanitarian emergencies (and         DivisionOfLabour/default.asp
      as to develop contingency plans.          natural disasters) remains incoherent    7. See FMR 29 Humanitarian reform: fulfilling its
      It is essential for their inclusion       and ad hoc. The current revision         promise?
      if we are to achieve universal            of the UNAIDS Division of Labour
10                                            HIV/AIDS, SECURITY AND CONFLICT

     HIV, refugees and conflict-affected
     populations in Asia
     Ann Burton

     Evidence-based experience, good assessment and a readiness                         refugees but only 18% mentioned
     to adapt programmes to local realities have been key to tackling                   activities for refugees; and only two
                                                                                        of the nine countries with more
     HIV in Asia.                                                                       than 10,000 IDPs acknowledged
                                                                                        them in their plans – and none had
     UNHCR’s HIV activities in                While progress has been                   activities directed towards IDPs.
     Asia – which began in earnest in         made, experience in the region            Displaced populations, especially
     2005 – were based on approaches          has highlighted a number of               refugees, often lack advocates
     outlined in its 2005-2007 and 2008-      challenges at different stages.           during strategic plan development
     2012 Strategic Plans but adapted                                                   processes and development of other
     to accommodate factors specific to       Emergency phase                           national HIV initiatives, such as
     the Asia region. These included the      It is now widely recognised               Global Fund Proposals, as they
     low-level and concentrated nature        that for HIV to be adequately             are viewed as politically sensitive.
     of epidemics in most countries (with     addressed in humanitarian settings        However, some progress is being
     HIV infection concentrated around        interventions need to begin early         made, with both Sri Lanka and
     unprotected paid sex, the sharing of     on in the response and expand as          Thailand acknowledging displaced
     contaminated injecting equipment         the situation stabilises. However,        people in their more recent NSPs.
     and unprotected sex between men);        there is inadequate attention given to
     the fact that most Asian countries are   the need to prioritise interventions      Considerable experience has been
     not signatories to the 1951 Refugee      based on what is feasible and what        accrued globally and in the region
     Convention or its 1967 protocol1;        will have the most impact in the          on addressing HIV in camp-based
     and the significant population           early phase – given competing             refugee settings. In Asia there are
     movements within the region (both        priorities. Furthermore, there is still   large numbers of refugees who
     conflict and non-conflict related).      inadequate understanding of the           are living in non-camp settings
                                              multisectoral response to HIV in the      including in urban areas – such
     Achievements over the last               region and the role that key sectors      as in Iran and Malaysia. Refugees
     five years include:                      such as shelter, protection, water        in such settings present many
                                              and sanitation have in reducing           challenges in the delivery of services,
      expanded access to prevention
     ■■                                       HIV vulnerability and risk.               including HIV services. They are
      services2 for most-at-risk                                                        often scattered geographically, have
      populations with 55% of sites           In addition, existing national HIV        minimal contact with UNHCR or
      in 2009 addressing at least one         programmes in countries affected          its partners, and receive health and
      key population – an increase            by conflict and displacement are          HIV-related services from a number
      from no sites in 2005                   often slow to adapt to the changes        of providers, including private
                                              associated with displacement and          providers. Information about the
      increased access to key
     ■■                                       the need for prioritisation. This is      services they access and their specific
      HIV services for refugee                compounded by the fact that those         HIV and health-related needs is
      populations in 66% of sites             UN agencies with a development            often scarce. As a result a variety of
                                              focus are often unwilling to adapt        interventions is needed to reach non-
      considerable progress in the
     ■■                                       their long-term strategies to meet        camp, including urban, refugees.
      availability of antiretroviral          the more immediate and rapidly
      treatment (ART): of those countries     evolving needs. Finally, but crucially,   Improving access to sexual violence
      hosting more than 10,000 refugees       in conflict situations insecurity         services has been challenging.
      in the region, 100% of them offer       invariably hampers response. In 2008      Access to specialised centres may
      refugee populations access to ART       in Sri Lanka the national HIV quality     be limited for refugees and other
      where it exists for local populations   assurance scheme for HIV testing          forced migrants and where national
                                              had still not extended to the conflict-   laws oblige health providers to
      increased availability of HIV-
     ■■                                       affected North-East although all other    report survivors of sexual violence
      related information with 66%            regions of the country were included.     to the police, health providers
      of refugee sites at the end of                                                    are unable to offer confidential
      2009 having standard HIV                Post-emergency phase                      services. Furthermore, national
      information systems in place            In the post-emergency phase there         gender-based violence programmes
                                              are other challenges. Refugees            are often very poorly developed.
      expanded evidence base on HIV
     ■■                                       and IDPs are often not included           Post-exposure prophylaxis for
      vulnerability and risk amongst          in National HIV Strategic Plans           HIV is not part of many countries’
      conflict-generated internally           (NSPs). In relevant countries in Asia     responses to sexual violence.
      displaced persons (IDPs).               in 2006 45% of NSPs mentioned
                                                      HIV/AIDS, SECURITY AND CONFLICT                                                                                      11

      While significant progress has been
      made in programming this has

                                                                                                                                                        UNHCR/I M Bayzid
      not been matched by progress in                   A refugee visits
      behavioural or biological surveillance              health worker
      in those most-at-risk amongst                          Zafor Ullah
      conflict-affected populations in                      (right) in his
                                                             home for a
      the region. In refugee and related
                                                           fresh supply
      settings it has been difficult starting              of condoms,
      HIV interventions for most-at-risk                       Nayapara
      groups because of factors such as                         camp for
      the closed nature of many settings                       refugees,
      and the considerable stigma and                      Bangladesh.
      discrimination these populations face
      over and above their displacement
      status. Other challenges include
      small sample sizes and ethical                  programming at country level.             in Asia need to target those most at
      considerations. Furthermore, there              However, while a national policy          risk of infection, such as sex workers
      is a dearth of both biological and              may be supportive of refugee              and their clients, men who have sex
      behavioural data amongst urban                  access, refugees often have special       with men and injecting drug users.
      refugees. Progress has been made,               needs which may hinder uptake             General population interventions
      however, in qualitative approaches              of services. These include different      such as mass awareness activities,
      such as participatory learning and              language and cultural backgrounds         though appearing to reach more
      action which has been used to                   from those of the host community,         people, will have less impact.
      identify risks and vulnerabilities              lower literacy levels than the host
      associated with sex work amongst                community, fear of harassment             It is possible to reach marginalised
      urban refugees in Delhi. Rapid                  and arrest, and uncertainty about         and highly stigmatised populations
      assessments have been done                      their rights. All of these need to        with HIV-related services in a closed
      in relation to substance use in                 be taken into consideration.              setting, even in the presence of
      Thailand and Pakistan, resulting                                                          strong socio-cultural constraints.
      in improved programming.                        HIV prevention activities amongst         Building trust with the concerned
                                                      refugees and other persons of             community may take time but
      Lessons                                         concern in the region must target         is necessary to facilitate uptake
      Inclusion of refugees and displaced             those most at risk of infection.          of services - and it is essential
      populations in national HIV                     Refugees and IDPs are often seen as       that this trust be maintained.
      initiatives is a necessary first step           homogeneous populations whereas,          Working with peers and trusted
      but as an isolated measure will                 like all populations, they contain        community gatekeepers will assist
      not guarantee access to services.               persons with varying degrees of risk.     in reaching most-at-risk persons.
      Advocacy for the inclusion of                   In keeping with regional guidance on
                                                                                                Proper assessment of HIV risk and
      refugees and related populations                addressing HIV in low prevalence/
                                                                                                vulnerabilities and the operating
      in national HIV initiatives is a                concentrated epidemic settings, HIV
                                                                                                environment in each population
      key component of UNHCR’s HIV                    interventions for persons of concern
                                                                                                of concern is necessary to design
                                                                                                appropriate interventions. Each
                                                                                                context is different and a ‘one size
        Innovative approaches in Malaysia                                                       fits all’ approach is not appropriate.
        Malaysia hosts over 70,000 refugees, mostly from Myanmar/Burma, who are mainly          Local assessment is needed to
        scattered throughout the Klang Valley area (incorporating Kuala Lumpur). At the end     determine which interventions are
        of 2009, there were 124 refugees receiving ART supported by the Ministry of Health      most appropriate and why, and to
        and UNHCR. Following expressions of concern regarding adherence to ART amongst          identify possible barriers to planned
        refugees, a number of measures to support refugees on ART and to facilitate their       activities and potential solutions.
        adherence to treatment programmes were introduced, with considerable success.
                                                                                                Ann Burton (
        A multi-level approach at home, community and facility level was adopted. Home          was the Senior Regional HIV/AIDS
        interventions included dosage boxes, mobile phone alarms and support for adequate       Coordinator with UNHCR in Bangkok
        nutritional intake. Community activities included assigning people living with HIV to   from 2005 to May 2010 and is
        a community counsellor, mobile phone ‘hotlines’ and treatment support groups.           now Senior Public Health Officer
        All refugees access services at one hospital, Sungoh Bulai, in Kuala Lumpur,            with UNHCR in Dadaab, Kenya.
        which has structured its services to meet the needs of refugees. All new and
        follow-up appointments for refugees, for example, are scheduled on the same day         The author would like to acknowledge
        of the week to facilitate access to interpreters in appropriate languages and           the contribution of Susheela
        trained counsellors.                                                                    Balasundaram of UNHCR Malaysia.
                                                                                                1. Signatories to the 1951 Refugee Convention in Asia
        Following these interventions, medical providers reported that average viral load       include Cambodia, China, the Philippines and Iran.

        suppression in refugees had improved significantly and was comparable to nationals.     2. Including STI management, male and female
                                                                                                condom provision, clean needles and syringes, peer
        Refugee satisfaction with the support received was high.                                outreach, peer support groups and behaviour change
12                                              HIV/AIDS, SECURITY AND CONFLICT

     Disarmament, demobilisation
     and reintegration: opportunities
     in post-conflict settings
     Priya Marwah, Pamela DeLargy and Lara Tabac

     The international community has learned much over recent years                       Ethiopian military health authorities,
     about the need and potential for integration of HIV awareness into                   for example, believed that the
                                                                                          return of HIV-infected conscripts/
     the disarmament, demobilisation and reintegration process.                           combatants to their communities
     A number of converging factors can         mobility patterns and their conflict      after the end of the Eritrean war of
     make post-conflict settings high-risk      experiences. The risk-taking attitudes    independence war in 1991 was an
     environments for the spread of HIV.        of members of armed forces and            important transmission factor in
     The loss of access to basic health care,   groups are also known to increase         the epidemic in Ethiopia. Based on
     education and information during an        their probability of exposure. If         that experience, during the 1998-
     armed conflict can leave communities       sexual violence or other forms            2001 border war with Eritrea they
     without adequate knowledge or              of sexual exploitation have been          adopted an intense HIV prevention
     means of HIV prevention when               factors in the conflict, then female      campaign within the military. Then,
     warfare ends. A number of welcome          ex-combatants, women associated           prior to post-war demobilisation,
     developments in terms of national          with armed forces and groups,             they trained demobilising troops
     recovery – the opening up of trade         dependants and abductees are also         to serve as HIV educators and
     and transport, the return of displaced     frequently at high risk of HIV and        change agents in their communities
     populations and ex-combatants to           other sexually transmitted infections     upon return. In Mozambique, it
     their communities, and improved            (STIs). Disarmament, demobilisation       was found that giving vouchers
     access for humanitarian and                and reintegration (DDR) processes,        for food, shelter and training to ex-
     development programmes – also              which help reintegrate ex-combatants      combatants provided a better basis
     bring new patterns of population           to civilian life, can be designed         for their reintegration into civilian
     interaction (including possible            such that they both help identify         life than giving cash payments.
     exploitation) and new HIV risks.           and diminish HIV risks and                Cash is often quickly spent by ex-
                                                also reinforce national and local         combatants, and sometimes on things
     Although armed violence may                prevention and care programmes.           directly increasing HIV risks such
     have ended, shattered economies                                                      as drinking or commercial sex – as
     are slow to recover, leaving many                                                    was seen in the badly managed early
     communities in deep poverty. In              A disarmament, demobilisation and       days of the Liberian DDR process.1
     post-conflict settings, the new hopes        reintegration (DDR) programme is        In Timor Leste, where ex-combatants
     for peace and recovery may exist             designed to help ex-combatants          initially had few employment
     side by side with unemployment,              return to civilian life and to help     opportunities, their frustration
     destitution and despair, with people         prevent security problems which         with their lot contributed to alcohol
     turning all too often to alcohol             could arise when combatants are         and drug use as well as increased
     or drug abuse and other risky                left without livelihoods and support    levels of domestic violence – all risk
     behaviours. Where women have                 networks during the transition from     factors for HIV. When livelihood
     assumed new decision-making roles            war to peace. Disarmament includes      and credit programmes were
     while men were off fighting, the             the collection and disposal of arms,    introduced, the situation improved.
     return of men to civilian life (and          ammunitions, explosives and light
     often to unemployment) is sometimes          and heavy weapons. Demobilisation       By 2000, when the Security Council
     associated with increased domestic           entails the formal and controlled       passed Resolution 1308 on HIV and
     violence. All of these factors can           discharge of armed forces and groups.   Security2, it was widely recognised
     drive an HIV epidemic, adding to             Reintegration is the socio-economic     that post-conflict periods were
     the already daunting challenges of           process by which ex-combatants          critical points for HIV interventions.
     peacebuilding and reconstruction.            gain sustainable employment and         The Resolution emphasised the
                                                  income back in their communities.       importance of HIV awareness and
     Yet there are also unique                                                            prevention within both peacekeeping
     opportunities in post-conflict                                                       and demobilisation processes. In
     environments to mitigate such an           HIV awareness in DDR programmes           the same year, Security Council
     epidemic. Ex-combatants (either in         Two decades of national                   Resolution 1325 on Women, Peace
     formal militaries or non-state armed       demobilisation experiences in HIV-        and Security3 emphasised the specific
     groups) and women and children             affected countries have helped to         HIV risks faced by women and girls
     associated with armed groups are           inform the establishment of norms         in conflict situations and brought
     considered especially at-risk groups       and standards for HIV prevention          attention to the previous neglect
     for HIV due to their age range, their      in today’s DDR programmes. The            of women, girls and children in
                                               HIV/AIDS, SECURITY AND CONFLICT                                                              13

      demobilisation processes. Over the       such as reproductive health, gender,      children associated with armed
      next few years, as the UN became         gender-based violence, community          forces as in the case of Sudan.
      involved in an ever larger number        security and livelihoods must be
      of peacebuilding and recovery            strengthened in order to ensure           Successful interventions in Sierra
      situations, the importance of            a comprehensive multi-sectoral            Leone, Liberia, Niger, Nepal, Sudan
      integrating both gender and HIV          approach at the national and local        and Côte d’Ivoire have shown that
      awareness within DDR programmes          levels. To build the knowledge base       having dedicated staff capacity within
      became clear. A number of health         for such programming, UNDP,               a coordinated national DDR response
      screening and training programmes        UNFPA and DPKO, in partnership            greatly improves the successful
      sprang up, with different agencies       with the Sonke Gender Justice             integration of HIV concerns.
      involved in different countries,         Network and the International Center
      but these were not evidence-             for Research on Women, are currently      While there has been progress
      based and the quality (or even           conducting operational field studies/     in integrating HIV into the
      availability) was highly variable.       reviews in four or five countries.        demobilisation phase, the reinte-
                                               This research initiative (June 2010       gration phase of DDR remains the
      Integrated DDR Standards                 to December 2011) is supported by         most challenging. Why? Barriers
      In an effort to consolidate lessons      the European Commission, among            include a lack of dedicated technical
      about DDR and to establish basic         others, which is a good sign that         expertise on the ground; lack of HIV
      standards, the UN Inter-Agency           donors are beginning to appreciate        awareness among key policymakers;
      Working Group (IAWG) on DDR was          the importance of the HIV linkages        limited financial resources; and
      established in 2005 to develop an        with security sector initiatives.         poorly articulated linkages between
      integrated approach to DDR across                                                  DDR-HIV programmes and national
      the UN system. The IAWG worked           Lessons, achievements and                 HIV strategies. It is critical to
      for over a year to collect and analyse   challenges                                mainstream the needs of demobilised
      lessons and then launched the            Many of the lessons learned thus far      personnel and their dependants
      Integrated DDR Standards (IDDRS)4        are not surprising. Experience has        within national HIV frameworks.
      in December 2006. The IDDRS are          shown that ‘cantonment’ periods           All too often, newly established
      a set of comprehensive guidelines        (when ex-combatants are gathered          national HIV/AIDS commissions
      covering all aspects, both operational   together after disarmament and            completely neglect the security sector.
      and technical, of a DDR process.         before return to civilian life) can
      They include modules for a number        provide time and space for critical       The DDR process provides an
      of ‘cross-cutting’ aspects, including    health screening and education            opportunity to reach out to
      gender, human rights and HIV. The        efforts, including awareness raising      vulnerable groups, contributing to
      HIV policy guidance reinforces the       about HIV and provision of basic          effective recovery and strengthening
      idea that DDR programmes are a           prevention packages. Community            long-term development. Integrating
      critical entry point for addressing      reintegration policies work best if       HIV/AIDS within DDR processes is
      HIV, and shares key lessons from         they incorporate HIV prevention as        vital for the well-being of male and
      initiatives in various countries.        a priority not only for ex-combatants     female ex-combatants, women and
                                               but also for host communities and         girls associated with armed groups,
      Since the adoption of the standards,     returning refugees; such programmes       and their receiving communities.
      the Gender, HIV and DDR Sub-             can even create some common ground        With the right engagement and
      Working Group5 has been working          among groups with widely differing        training on HIV issues, ex-combatants
      with a number of UN missions to          wartime experiences. It is also           do have the potential to become
      address gender and HIV within DDR        becoming ever clearer that training       ‘change agents’, assisting their
      processes. Funding was secured           and employment programmes which           communities to prevent infections.
      from UNAIDS, the British and Irish       ensure livelihoods are not only
      governments and the European             critical for national economic recovery   Priya Marwah (marwah@unfpa.
      Commission to implement HIV-DDR          but are also a key to HIV prevention      org) is Programme Specialist at the
      programmes in several countries,         since they offer alternatives to sex      Humanitarian Response Branch/
      including Sudan, Côte d’Ivoire,          work and lessen the prevalence            Programme Division, UNFPA and
      Nepal, Colombia, Liberia, Sierra         of other high-risk behaviours.            Pamela DeLargy (
      Leone and DRC. While political and                                                 is Senior Advisor in the Arab States
      operational factors heavily determine    Experience also shows that                Regional Office at UNFPA (http://
      the progress of DDR overall and          responding to HIV during the DDR Lara Tabac ((lara.
      impede its smooth progress, there        process has a catalytic effect and is Programme
      has been significant progress            can be an entry point for addressing      Coordinator, Development Planning
      in use of the guidelines and in          several other sensitive issues such as    and Mainstreaming, HIV Practice,
      ‘mainstreaming’ HIV considerations       gender-based violence and gender          Bureau for Development Policy with
      into many DDR processes.                 inequality among armed forces and         UNDP (
                                               groups. Including HIV activities
      Experience thus far also indicates       in reintegration programmes has           2.
      that the reduction of HIV risks          also had the collateral benefit of        3.
      requires coordination with even          raising awareness of the needs of         4.
      more sectors than previously thought     female combatants and women and           5. chaired by UNDP and UNFPA and including DPKO,
      and that linkages to other areas                                                   UNIFEM, UNICEF, UNAIDS, WHO and ILO
14                                           HIV/AIDS, SECURITY AND CONFLICT

     Ex-combatants as entry points for
     HIV education in southern Sudan
     Anyieth M D’Awol

     Disarmament, demobilisation and reintegration (DDR)                                                 HIV prevalence is between 2 and
     interventions provide potential avenues to help reach those who                                     4% of the population, while a 1996
                                                                                                         study at antenatal clinics suggested
     are most vulnerable to HIV transmission.                                                            HIV prevalence was 5%. Amongst
     Southern Sudan has been affected        urban areas or displacement camps                           different tribes various names are
     by conflict since the 1950s. The        with better service provision.                              given to HIV/AIDS, making data
     Comprehensive Peace Agreement           Widespread gender-based violence                            collection more difficult. Despite the
     (CPA), signed on 1 January 2005,        in both rural and urban areas has                           lack of precise data, the high-risk
     brought an end to the second civil      both been the cause of increased                            post-conflict environment, combined
     war, and the process of development     HIV infection and has posed                                 with the lack of infrastructure,
     and recovery is underway. Efforts       challenges for HIV interventions.                           has presented both the necessity
     to develop coherent HIV policies,       Severe gender inequalities exist,                           to establish and implement HIV
     however, are in their infancy. In       and concurrent sexual relationships                         prevention and mitigation policies
     a vast area devoid of almost all        exist as a result of transactional sex,                     – and the difficulties in doing so.
     infrastructure, the challenges          inheritance of multiple wives and
                                                                                                         The SPLA – the army of the
                                                                                                         Government of South Sudan (GoSS),
                                                                                                         previously the armed wing of the
                                                                                                         main southern Sudanese rebel
                                                                                                         movement (the SPLM) – is in the
           Returning                                                                                     process of transforming from a
           Sudanese                                                                                      guerrilla army to a professional
            refugees                                                                                     military force. Challenges during
         information                                                                                     the transition include ambiguity
         on HIV/AIDS                                                                                     surrounding command structures,
      and landmines                                                                                      and increased cultural variation
         at UNHCR’s
      way-station on
                                                                                                         among soldiers (as all other armed
       the Sudanese                                                                                      groups, based on mainly tribal
                                                                                                         identity, had to be absorbed into
                                                                                       UNHCR/P Wiggers

                                                                                                         the SPLA). The SPLA plans to
                                                                                                         downsize through the DDR process,
                                                                                                         which presents an opportunity
                                                                                                         for HIV interventions as soldiers
                                                                                                         make the transition to civilians.
     are enormous. The limited data          the encouragement of early marriage
     available reveal that HIV is            and polygamy. Scarification with                            During the years of conflict, SPLA
     prevalent across southern Sudan,        non-sterile tools and the view of                           soldiers were constantly told they
     but the exact extent is unknown.        circumcision as taboo also increase                         were the instruments for repopulating
                                             HIV risk. Most people lack access                           southern Sudan. Unsurprisingly,
     This article presents the findings      to basic services, and infrastructure                       therefore, soldiers forgo protection
     of research focusing on the Sudan       for managing HIV policies is largely                        with commercial sex workers. For
     People’s Liberation Army (SPLA) as a    absent. Interventions for HIV                               their part, vulnerable and lacking
     high-risk group which, with its close   prevention need to be innovative                            a normal community life, women
     community links, is a potentially       and applicable without reliance on                          seek refuge with soldiers, and often
     effective entry point for responsive    basic health services. Many southern                        engage in transactional survival
     HIV policy development during           Sudanese have never heard of HIV, or                        sex. HIV interventions must address
     the disarmament, demobilisation         do not know how it is transmitted or                        these realities if communities
     and reintegration (DDR) process.        prevented. Additionally, protection                         are to be able to move away from
                                             through behaviour change is                                 environments where HIV can thrive.
     The post-conflict context               a choice many do not have.
     The post-conflict environment                                                                       The DDR process provides a valuable
     in southern Sudan is unstable           Accurate data on HIV/AIDS                                   opportunity to screen a high-risk
     and constantly changing. People         prevalence in southern Sudan is                             group while still in DDR sites,
     are returning to the region after       almost non-existent, though a few                           creating a unique entry point where
     decades of forced displacement          studies have been conducted to try to                       people who will soon be part of a
     both internally and across borders,     determine the extent of the epidemic                        civilian community can be addressed.
     and many of them come from              in the region. One study showed that                        DDR provides an opportunity for
                                                    HIV/AIDS, SECURITY AND CONFLICT                                                   15

      those who are dependent on the army           to coordinate HIV policy efforts,        to be promiscuous or engage in
      to receive clear, targeted and relevant       was developed in 2001 but was            concurrent relationships. For policies
      reintegration opportunities and               unsustainable due to insufficient        to be effective, the SPLA and SSAC
      HIV interventions to encourage self-          funding and institutional support. As    should identify all groups that need
      sufficiency and reduce vulnerability          a result, scattered HIV policies were    access to HIV prevention materials,
      for themselves and others. Additional         generally put in place by independent    including often overlooked groups
      populations such as child soldiers            NGOs, which were both short-term         such as widows. Policies must
      and women associated with armed               in focus and limited in scope. In        also address the instability of the
      forces and groups should also benefit.        June 2006, the Southern Sudan AIDS       post-conflict region, with special
                                                    Commission (SSAC) was established        consideration for formerly displaced
      However, progress towards                     in partnership with the GoSS at state    people returning to the region.
      demobilisation of SPLA personnel              and county levels. Both the SSAC
      has been slower than anticipated,             and the SPLA have created long-          Recommendations and next steps
      with problems relating to staffing and        term plans intended to implement         Despite the volatile environment,
      technical assistance. While the CPA           HIV/AIDS prevention policies.            there are many opportunities for
      envisaged that DDR support would              Specifically, the SSAC has partnered     HIV interventions, particularly
      be given for 180,000 southern and             with key stakeholders to develop the     within the SPLA, which must match
      northern combatants, it was reported          Southern Sudan HIV/AIDS Strategic        their rhetoric with action. Military
      by the UN in July 2010 that only 23,700       Framework (SSHASF) for 2008-2012.        leadership must be at the forefront of
      have completed DDR programmes1                                                         efforts to tackle the epidemic within
      – and of these only 6,000 have been           Both the SPLA and the SSHASF             the institution, implementing and
      demobilised in southern Sudan.                agree on key policy areas:               enforcing a code of conduct – and
                                                                                             also protecting others associated
      The final milestone of the CPA                ■■creating an enabling environment       with barracks. Funding should be
      is the forthcoming referendum                   for a sustained financial, legal       consistent to implement programmes,
      scheduled for January 2011 which                and institutional framework            and mandatory testing – accompanied
      will determine whether Sudan is to              for HIV interventions                  by confidential counselling and
      remain one country or be split into                                                    treatment – should be encouraged for
      north and south Sudan. This has               ■■emphasis on prevention to              the SPLA to understand the scale of
      become the overarching priority for             reduce new infections                  the epidemic within its forces. The
      all government institutions and donor                                                  SPLA can use its command structure
      communities since uncertainties               ■■care, treatment and impact             to reach a very high-risk group,
      regarding security and indeed risk of           mitigation to improve the quality      encouraging responsible behaviour
      renewed war following the results (for          of life for people living with HIV     and reducing new infections through
      unity or secession) could mean that                                                    discipline and a holistic approach.
      current efforts in DDR may be undone.         ■■mitigating exposure to and impact      DDR is also an opportunity to
                                                      of HIV among emergency-affected        teach new skills –in agriculture, for
        “...I don’t want protection. All these        populations during the post-           example – for future self-sufficiency.
        years we have been suffering, we have         conflict and reconstruction phase      Only known family members
        not produced and some of our children                                                should be allowed near military
        even got lost. We need to produce           ■■capacity building to strengthen,       barracks, in order to eliminate
        children... and if we were to die, we         decentralise and sustain a             dependency and survival sex.
        would have died in the bush. AIDS             national HIV response
        doesn’t kill...” SPLA soldier, April 2008                                            Post-conflict conditions pose a
                                                    ■■monitoring and evaluation              real challenge and threaten to
                                                      to strengthen evidence-based           compromise progress made to date.
      HIV policy development                          management of national multi-          Interventions must reach the majority
      The SPLA has made HIV                           sectoral HIV response at all levels.   and must affect behaviour amongst
      prevention a priority but it is                                                        people with little or no access to
      unclear if these messages have                This response appears to be              resources. That said, the simple ‘ABC’
      been absorbed throughout the                  comprehensive but many challenges        approach – Abstain, Be faithful,
      ranks. It has a voluntary testing             still exist in creating relevant         Condomise – will not work in the
      and counselling policy, and an                frameworks and fine-tuning policies      region, and HIV policies must take
      HIV/AIDS Secretariat, established             across each of these thematic areas.     into account cultural practices.
      in 2006, which is responsible for             These difficulties include policy
      the oversight and implementation              coordination between the SPLA            The SSAC should take the lead in
      of an army-wide HIV response.                 and SSHASF and maintaining               maintaining a political commitment
      The lack of sufficient command,               consistent budget allocations for        to improve conditions for HIV
      however, remains a challenge for              the management of HIV response.          interventions, and lobby for line
      the SPLA’s war against HIV.                   In addition, it needs to be better       ministries that affect the socio-
                                                    understood that the determinants         economic drivers of the epidemic. The
      Additional attempts to create HIV             that place people at risk of HIV         SSAC should identify areas where
      policy have been met with varied              relate more to the socio-economic        traditional behaviours are high risk,
      success. The New Sudan National               and cultural factors in people’s lives   and should target groups such as
      AIDS Council (NSNAC), formed                  than to the desire of individuals
16                                              HIV/AIDS, SECURITY AND CONFLICT

     midwives, healers and chiefs as entry      prevention strategies involving            Anyieth M D’Awol (msdawol@hotmail.
     points to discuss unhealthy practices.     education, sensitisation and advocacy      com) is an independent researcher
                                                will have limited impacts because of       based in southern Sudan and
     Although post-conflict analysis            gender inequalities, absence of rule of    Executive Director of the Roots Project
     offered in the fuller study is non-        law and weak governance structures.        (
     exhaustive, it reveals a range of          The potential for effective HIV
     challenges that can weaken intended        intervention is high; there is a large       This article is extracted from a longer report
     HIV policy direction if it is not          and captive audience within DDR              written for ASCI which is available at:
     evidence-driven, practical and             programmes, and these individuals  
     realistic. Vulnerability to HIV/AIDS in    present important entry points for
     the region is high, and many typical       reaching many at the individual level.     1.

     Challenges for antiretroviral
     provision in northern Uganda
     Matthew Wilhelm-Solomon
     Uganda faces major challenges to ensure the continuity and                            patients. However, there has been a
     sustainability of treatment programmes for IDPs returning home.                       definite impact on patient retention
                                                                                           and missed appointments, which
     Northern Uganda is in a phase of           Research in northern Uganda                has strained resources. Adherence
     momentous transition. The end              between 2006 and 2009 into ART             and patient retention data is mostly
     of hostilities between the Lord’s          programmes implemented by the              lacking for state health services in
     Resistance Army and the Ugandan            AIDS Support Organisation (TASO)2,         northern Uganda, though interviews
     government in 2006 paved the               St Mary’s Hospital Lacor3 and the          suggest similar problems.
     way for the return of hundreds of          Ugandan Ministry of Health indicates
     thousands of IDPs. The challenges          that, for those who have been able to      Uncertainties for patients
     of treating HIV in the post-conflict       access it, ART is helping transform        and providers
     phase are almost as formidable             HIV infection from a terminal to           Many of those living with HIV
     as during the conflict itself.             a chronic illness. Antiretrovirals,        faced significant anxiety around
                                                and associated treatments for              the return period, often choosing to
     A 2004-05 study by Ugandan Ministry        opportunistic infections, have brought     remain in camps or towns as long as
     of Health suggested in 2006 that           about substantial improvements             possible. The burdens of return may
     northern Uganda had an HIV sero-           in the health of those with HIV. In        be severe and include reconstructing
     prevalence rate of 8.2%. There are         addition, the frequency and intensity      homesteads, restarting agriculture,
     indications based on this sample that      of stigmatisation, especially linked to    moving to areas where service
     northern Uganda has the highest            fears of transmission, have declined.      provision is weak, and the withdrawal
     rates of recent HIV incidence in the       ART has saved thousands of lives           of food assistance. As Nighty Acheng,
     country1, though reliable data from        and created new possibilities for          an HIV-positive woman in Pabo
     rural areas and camps is scarce, and       friendship, family and productivity.       camp, explained in 2008, “when we
     the validity of the evidence disputed.                                                go back to the village you don’t have
     In 2007, St Mary’s Hospital Lacor,         Provision of ART was started in            the strength to dig anymore. And
     a surveillance site, recorded an           2002 in Gulu, the region’s main            there are cases where some of us have
     antenatal sero-prevalence figure of 9%.    urban centre, and from 2004 was            been neglected by our families.”
     Recent data from other health facilities   extended to other towns, and from
     suggests that prevalence has been          2005, to some rural areas and IDP          ART requires rigorous life-
     increasing over the last three years.      camps. By March 2010, there were           long adherence. Unmanaged
                                                over 22,000 HIV-positive people on         interruptions to treatment can lead
     Antiretroviral therapy (ART) to            ART – mostly free or at low cost – in      to treatment failure, as well as the
     conflict-affected communities is           previously conflict-affected districts.4   emergence of drug-resistant viral
     now being promoted and viewed              High adherence rates to treatment          strains. Monitoring adherence was
     as feasible by governmental and            have been shown for the TASO and           relatively simple in displacement
     non-governmental institutions in           St Mary’s Lacor programmes, using          camps. Many people could be
     northern Uganda and internationally,       community-based strategies.                reached easily and even during
     including Médecins Sans Frontières                                                    the conflict provision was rarely
     (MSF) and UNHCR. However, it is            Over the period of return, data            interrupted. Support groups were
     important to prepare for the post-         does not show a significant impact         also created in the camp environment,
     conflict transition and the return         on treatment adherence for TASO            providing networks of care.
     of the displaced in order to ensure        and St Mary’s, though field workers
     continuity and sustainability              claim that food scarcity may be            Return movements, and the opening
     of treatment programmes.                   affecting the adherence of some            of trade routes, have made continuity
                                               HIV/AIDS, SECURITY AND CONFLICT                                                                                    17

      of treatment much more complicated.      provision and monitoring using                    follow patients as rigorously as in the
      The scattering of the population         motor cycles was very effective when              camps. One of them, Simon Omara
      and increased distances between          populations were static – but came                of Comboni Samaritan, reported,
      patients and their nearest health        under strain when patients moved                  “the major difficulties I face are that
      centre have created difficulties for     further away. In the first two quarters           the distances are far, most people
      patients and providers. Some are so      of 2008, over 10% of patients were lost           take their medication at eight o’clock
      sick they cannot come to collect their   in each quarter. However, a strategic             when it is already dark, and you
      medication and those who have lost       shift to using community members to               may find it has started to rain. You
      all their relatives have nobody to       monitor and track patients, as well as            may encounter drunkards on the
      collect their medication for them. All
      programmes have had to contend
      with patients who miss appointments

                                                                                                                                        Matthew Wilhelm-Solomon
      or who give up attending.

      The potential challenges of the
      return period for HIV treatment were
      generally under-estimated during
      the conflict. For instance, Ministry
      of Health ART was expanded to
      some rural health centres in 2005
      with no contingency plan for
      return and often little capacity for
      treatment monitoring. Coordination
      between programmes and sharing
      of experience were also problematic.
      The Health, Nutrition and HIV/
      AIDS cluster meetings chaired by
      the World Health Organisation
      focused on the more immediate
      challenges of transition, such as the               A newly formed HIV support group in a return area of Oyam district, Uganda.
      hepatitis E and malaria outbreaks,
      and were not appropriate forums
      to develop longer-term approaches        decentralised treatment distribution              way who disturb you, and another
      or monitoring capacity for patient       points in rural areas, allowed TASO               problem is if you have to cover a long
      retention in HIV as well as TB           to radically reduce lost patients to              distance that makes you weak.”
      programmes. State health services        under 1% in the second half of 2008.
      have suffered from severe shortages                                                        While some organisations like
      of staff and drugs as returns have       St Mary’s Hospital Lacor shifted                  TASO are shifting to livelihoods
      placed more strain on services.5         to a community-based monitoring                   programmes, there were few
                                               strategy from the outset of their                 programmes supporting those
      Selected rural health centres with       programme, with the help of the                   with HIV in the transition from
      ART provision were supported by          community organisation Comboni                    displacement to return. All the
      different branches of MSF, which         Samaritan – a strategy which has                  programmes also have HIV
      included community support,              proven very effective in ensuring                 prevention components to them,
      although these faced staff and           continuity of treatment. Extensive                although the St Mary’s programme
      supply-line challenges once MSF          networks of community-based                       do not provide condoms, thereby
      withdrew. In late 2006, the five-year    treatment monitors were chosen                    limiting patients’ reproductive
      Northern Uganda Malaria AIDS/            from different geographic areas and               health options particularly in
      HIV and Tuberculosis Program             few patients were lost during the                 rural areas where other services
      (NUMAT) was established to assist        return period, never exceeding 2%                 were not easily available.
      state health services with supply        in a quarter. The success of St Mary’s
      lines, community support and             shows that extensive community                    Recommendations
      the decentralisation of treatment.       networks can be as effective as                   Experience in northern Uganda is of
      This was a welcome development           decentralising treatment provision                relevance to other situations in which
      though in places community               in ensuring ART continuity.                       large numbers of people have been
      support started after the return                                                           displaced for long periods. Among
      movements. Treatment is still            Community-based adherence                         the lessons to be learned is the
      unavailable in a number of rural         monitors employed by most HIV                     importance of working with national
      health centres, though coverage          programmes are themselves mostly                  health ministries and NGOs to:
      has improved significantly since         HIV-positive and are also battling
      the cessation of hostilities.            with the difficulties of transition. The          ■■acknowledge that post-conflict
                                               small stipends provided are often                   return processes can pose
      Even relatively well-resourced NGOs      inadequate to cover even their time,                significant challenges to HIV
      have come under severe strain.           and community monitors across                       treatment programmes as a result
      TASO’s strategy of home-based            programmes said they were unable to                 of increased distances between
18                                           HIV/AIDS, SECURITY AND CONFLICT

       service providers and often           ■■ensure that data collection in           circumstances. The long-term
       mobile HIV-positive populations         post-conflict situations focuses         sustainability of ART relies on the
                                               not just on adherence but                fostering of strong communication
     ■■acknowledge the reality that            also on patient attrition.               and support between donors, civil
       state-provided ART programmes                                                    society, national health authorities,
       are under-resourced                   In addition, data from well-resourced      patients and local providers.
                                             non-governmental programmes
     ■■decentralise treatment and fund       cannot be viewed as representative         Matthew Wilhelm-Solomon (matthew.
       community-based support to help       of all programmes; there is a need is a
       ensure continuity of treatment        in northern Uganda, and elsewhere,         doctoral candidate in the Department
                                             for an assessment of more poorly           of International Development,
     ■■recognise the burdens placed on       resourced state antiretroviral             University of Oxford. He is the author
       community-based ART adherence         programmes. While treatment                of ’Stigmatisation, Disclosure and
       monitors, especially those who        provision can be successful to conflict-   the Social Space of the Camp’, AIDS
       are themselves HIV-positive           affected communities, the transitional     and Society Research Unit, Working
                                             phase poses a new set of challenges        Paper 267.
     ■■target support to HIV-positive        which have affected patients and           publications/working-paper/2010/267
       patients so that while they           may have increased the chances
                                                                                        1. Mermin, J et al (2008) ‘Risk Factors for Recent HIV
       are struggling with transition        of drug resistance developing.             Infection in Uganda’, JAMA, 300(5) http://jama.ama-assn.
       they are also helped with                                                        org/cgi/content/full/300/5/540
       treatment adherence                   Those living with HIV in northern
                                             Uganda – as in other post-conflict
                                                                                        4. AIDS Control Programme, Ministry of Health, Status of
     ■■ community workers
       use                                   contexts – show a remarkable               Antiretroviral Therapy in Uganda, Quarterly Report for
       to help patients overcome             capacity to adapt to the difficulties      January to March 2010.
                                                                                        5. Interview with Dr Elizabeth Namagala (July 2009).
       anxiety over the return period        of return by forming new support           National ART Coordinator, Ministry of Health. Interview
       through providing information         groups. However, they remain               with Dr Solomon Woldetsadik (August 2008), Head of
                                                                                        World Health Organisation, Gulu Sub-office.
       about treatment options               vulnerable and live in fragile

     Gendered violence and
     HIV in Burundi
     Hakan Seckinelgin, Joseph Bigirumwami and Jill Morris

     Pre-existing gender relations changed for the worse during the                     This is a limited way of thinking
     conflict and interventions to promote disarmament, demobilisation                  about gender and conflict. Groups
                                                                                        in conflict are linked in many
     and reintegration (DDR) failed to address the dynamics which                       other ways and these linkages
     shape the spread of HIV.                                                           do not necessarily allow a sharp
     Conflict has scarred Burundian          gendered hierarchy of decision-            distinction between protagonists in
     society since independence in 1962,     making which disempowers women;            a protracted conflict as in Burundi.
     although in recent years a still        and legal restrictions on women’s
     fragile peace has emerged from          ownership of land. These structural        Rather than attempting to prove
     a series of ceasefire agreements        gender norms and vulnerabilities,          or disprove the existence of a clear
     signed by armed groups.                 remaining as constraints on                link between conflict and the spread
                                             women’s role in society, have              of HIV/AIDS, it is more productive
     A series of interviews with men,        facilitated the spread of HIV/AIDS.        to think about how both processes
     women, youth, ex-combatants, IDPs                                                  create gendered vulnerabilities.
     and sex workers highlighted the         In the literature on HIV/AIDS
     extent of conflict-related changes      and conflict, it is often stated that      Gender context
     in Burundian society and how            conflict increases the likelihood          The interviews produced evidence
     HIV prevention efforts must take        of spreading HIV. However, the             to suggest that while it is possible
     these changes into account. Each        possible links between conflict            to argue that the conflict intensified
     interview aimed to elicit a narrative   and HIV/AIDS are complex. The              and worsened gender disparities by
     of experiences before, during           literature largely focuses on the          exposing women to more violence,
     and after the conflict in order to      military, often simplistically relying     the particular forms of violence
     understand gender relations and         on a single causal link between            and deprivation during the conflict
     perceptions of HIV/AIDS. They           men and women. ‘Military’ implies          were shaped by pre-existing gender
     explored the traditional role of        a male gender position while               disparities. One of the things that
     women as household care-givers          the use of ‘general population’            has changed as a result of conflict
     and agricultural producers; the         suggests a female gender position.         is people’s sexual behaviour; for
                                               HIV/AIDS, SECURITY AND CONFLICT                                                            19

      example, extra-marital relations         the conflict this mechanism was         vulnerable during the conflict.
      were formerly regarded as shameful       much more pronounced as a way           Women coming out of the bush,
      and an acute embarrassment to            of obtaining sexual favours.            or who were pushed out of their
      the family if publicly known but                                                 communities, were not integrated
      have now become commonplace.             Most of the ex-combatant informants     in a way that allowed them to
                                               reported hearing nothing about HIV/     become functioning members
      HIV has further exacerbated the          AIDS during the conflict. The fact      of society and they remain
      vulnerability of women. Even when        that a large and powerful group         vulnerable to sexual violence.
      women are responsive to HIV/AIDS         remained unsensitised added to the
      training and prevention messages,        vulnerability of women over whom        Conclusions
      their capacity to deal with them in      they exercised sexual control.          In Burundi and elsewhere, the
      their everyday lives at present seems                                            relationship between conflict and
      to be constrained. Many interviewees     Conflict created an environment         HIV/AIDS is complex and mediated
      stated that men always blame women       within which existing gender            by gender norms and values that pre-
      for their HIV status. Although           vulnerabilities were exacerbated,       date the conflict. Prolonged conflict,
      most women stated that they were         pathways to transmission were           displacement and restrictions on
      sexually active only with their          opened and the scope for talking        movement damaged social relations
      husbands, men generally terminate        about HIV or mass sensitisation         and traditional livelihood options,
      relationships on learning of their       was reduced. Burundi was not            creating increased vulnerability
      positive status. This leaves women       able to participate in early regional   to HIV. In this prolonged conflict,
      without husbands and unable to           efforts to contain the epidemic and     both within the household and
      access land and other resources.         the increase in risky male sexual       outside, women were the most
                                               behaviour during the conflict           vulnerable, while pre-conflict
      Gender and conflict                      has made it additionally harder         gender relations had also created
      After 1993, conflict occurred between    for Burundi to catch up. Post-          expectations among females from
      the government and multiple              conflict interventions have been        early childhood that they should
      armed groups. As the conflict            implemented with limited capacity       be voiceless and submissive.
      became prolonged, women became           and insufficient resources. There
      increasingly impoverished and            has been a tension between raising      All interventions dealing with
      exposed, left to defend themselves       awareness and providing treatment.      the spread HIV/AIDS, before
      and to look after their families. The                                            and after conflict, need to take
      interviews indicated that when           DDR insensitive to gender               account of the sociological context
      women joined armed groups to             vulnerabilities                         of a particular conflict as well as
      increase their chances for survival      Demobilisation camps are integral       structural gender characteristics
      they were ill-treated. Those who         to DDR, the first point at which ex-    – and must acknowledge how the
      went into IDP camps were also            combatants have an opportunity          various actors are interlinked.
      exposed to violence. General             to receive information on HIV/
      militarisation meant that many           AIDS. Informants stated that while      DDR processes should not focus
      households lost adult males, while       sensitisation and testing were          solely on military and armed
      the situation for those women who        important there was insufficient        groups. Given the nature of the
      did not have a formal marriage           time for many ex-combatants to          conflict and the extent of violence
      was particularly precarious. The         digest information and reflect on       experienced by so many people,
      relationship between wives who           the personal implications for their     DDR initiatives must address the
      had been left behind and their in-       behaviour as they prepared to return    underlying causes of violence,
      laws and male relatives changed          to communities from which many          especially gendered violence.
      as the conflict continued. Often         had been absent for many years. HIV     If they do not, they can become
      male in-laws sought to get rid of        programmes did not reach either the     part of the HIV/AIDS problem,
      sisters-in-law in order to absorb        few women in demobilisation camps       rather than assist the response.
      property back into the family.           or the greater number of female
                                               ex-combatants who reportedly            Hakan Seckinelgin (M.H.Seckinelgin@
      As women came to be regarded as          demobilised themselves. During is a senior lecturer in the
      dispensable many had no option           DDR, female combatants were             Department of Social Policy at the
      but to engage in transactional sex.      tested, but testing in general took     London School of Economics
      Their vulnerability is very much         place in environments that did not      ( Joseph
      related to the collapse of well-         cater for their particular needs as     Bigirumwami (
      negotiated family relations and          women and as female combatants.         is a professor in the African Language
      this search for security. Poverty,       If found to be positive they were       and Literature Department of the
      powerlessness and male expectations      generally condemned by men upon         University of Burundi. Jill Morris
      of female meekness made it hard          their return, and forced to fend for    ( is an
      for women to resist advances by          themselves while men were taken         independent consultant.
      armed combatants. Traditionally,         care of by families and relatives.
      once women are approached even                                                     This article is extracted from a longer report
      casually to talk, it becomes difficult   In Burundi, the DDR process was           written for ASCI which is available at:
      for them to refuse the advances          located within traditional gender
      of a powerful man. In the case of        structures that made women
20                                               HIV/AIDS, SECURITY AND CONFLICT

     Post-conflict transition

                                                                                                                                 IRIN/Neil Thomas
     and HIV
     Manuel Carballo, Calixte Clérisme, Benjamin Harris, Patrick Kayembe,
     Fadila Serdarevic and Alexandra Small
     Research in Bosnia, the Democratic Republic of Congo, Haiti
     and Liberia has highlighted worrying neglect of HIV issues in the
     aftermath of conflict and displacement.
     The last half century has seen a            surveyed where there was a clear
     dramatic increase in the number of          end to open hostilities, there were no
     conflicts and complex emergencies.          large-scale interventions designed to
     Most have occurred in settings              ensure the long-term human security
     where conflict further weakened             of the populations concerned. Nor
     already inadequate national health,         was there much evidence of any
     educational and other public                targeting of population groups whose       conflict. This was particularly evident
     services. The growth in frequency of        vulnerability was due to or had been       in Haiti and DRC where displaced
     conflicts and the number of people          exacerbated by the conflict. Whatever      women said they were living in
     affected by them has prompted a             recovery and social reconstruction         constant fear that they or their
     strong commitment to emergency              have occurred or are now occurring         daughters would become infected
     relief in the acute phase of crises         in all four countries appear to have       with HIV and they complained
     but, by comparison, interest in post-       been coincidental and have largely         that whatever HIV interventions
     conflict transition to recovery and         bypassed many of the people who            had been mounted had not taken
     reconstruction has been much more           bore the brunt of the conflicts.           them or their needs into account.
     limited in both vision and scope.
                                                 This neglect of people whose               In all four countries concern about
     Bosnia, Haiti and Liberia have all          reinsertion into society is essential      HIV among displaced women
     gone through protracted conflicts, and      for recovery and reconstruction is         was linked to what they saw as
     hostilities continue in eastern DRC.        creating a new marginalisation (real       their continued, if not increased,
     A research project undertaken by the        and perceived) from health and social      vulnerability to rape. In DRC, Haiti
     International Centre for Migration          services, including much-needed HIV        and Liberia, displaced women said
     Health and Development (ICMHD)1             initiatives. As well as placing lives at   they felt the risk of being raped
     and its research collaborators as part      risk, this neglect could have serious      had increased with the decreased
     of the AIDS, Security and Conflict          implications for public health and         presence of outside relief groups and
     Initiative (ASCI) focused on how the        future social and political stability.     there was a general perception that
     transition from conflict is experienced                                                little if anything was being done to
     by different groups of people and           The prevalence of HIV among people         provide them with the assistance
     the effect it has on their attitudes to     aged 15-49 in Bosnia, DRC, Haiti           (physical and psychosocial) needed
     HIV and sexual and gender-based             and Liberia in 2007 was estimated          to deal with the aftermath of rape.
     violence (SGBV). In DRC, Haiti and          to be 0.1%, 1.5%, 2.2% and 1.7%            There was a consensus that not only
     Liberia HIV remains a large and still       respectively but the lack of good          did they not know where to go to
     growing problem. In Bosnia, where           data makes accurate estimation             report rape but they did not believe
     the epidemic has been far less evident,     very difficult and in the three latter     anything would be done about it
     the growth in the number of reported        countries the situation may have been      because there was no real interest in
     cases of TB may be indicative of            significantly worse. To what extent        them or their welfare. They mentioned
     underlying, poorly diagnosed and            patterns of incidence and prevalence       that having been raped, knowing
     unreported HIV. All four countries          of HIV were influenced by conflict         someone who had been raped, or
     saw conflict produce extensive,             is not clear for the same reason.          fearing rape has become a major
     repeated displacement of people and                                                    psychological barrier to going back
     extensive sexual and gender-based           What is clear is that displaced and        to their families and communities of
     violence, and in DRC and Liberia            sexually abused women conspicuously        origin. In all the countries displaced
     there was also widespread mutilation        failed to benefit from post-conflict       women said they felt more socially
     associated with that violence.              HIV and other health interventions.        isolated after the conflict because of
                                                 In none of the four countries did          the social stigma associated with rape.
     Post-conflict donor neglect                 cessation of or reduction in hostilities
     Our research suggests that in general       bring much improvement to their            Feelings of social isolation were
     the international community has             lives. Indeed, displaced women in          also associated with the knowledge
     given relatively little attention, either   DRC, Haiti and Liberia reported that       that they had lost their homes and
     conceptually or programmatically,           their situation worsened and they          that housing was not a part of any
     to the transition from conflict to          felt more at risk of being exposed         reintegration initiatives they had
     recovery. In three of the countries         to HIV after conflict than during          heard about (and which in any event
                                                 HIV/AIDS, SECURITY AND CONFLICT                                                                 21

      they did not see as applying to them).     situations, by virtue of their lifestyles   The post-conflict process often sees
      Fear of being left without a roof          and their willingness to sell sex           displaced women, especially those
      and means of income generation in          in order to satisfy non-essential           who have been raped and otherwise
      DRC and Liberia led many of the            needs. Despite this, ex-combatants          violated, socially isolated and
      interviewees still living in camps to      in all four countries agreed on the         unable to benefit from whatever HIV
      say that no matter how poor these          importance of women to society              prevention and treatment initiatives
      camps were, they offered far more          and the need to protect them. In this       are put in place. Their re-entry into
      security than what they thought            regard they frequently mentioned the        society and the reconstruction process
      awaited them outside. Many women           need for more efficient prosecution         is hindered by this isolation and the
      said they would prefer to be given         of perpetrators of rape and the             fact that the stigma attached to rape (or
      building materials to construct their      need for greater discipline in civil        suspected rape) assumes even greater
      own shelters and stay “in the bush”.       society as well as in the military.         importance than during conflict.

      DDR interventions of limited benefit       Conclusion                                  Ex-combatants are also being
      Disarmament, demobilisation and            Donors and humanitarian and                 neglected and by-passed by HIV
      reintegration (DDR) processes              development agencies have tended            programmes and there is a sense
      typically follow conflicts everywhere      to neglect the post-conflict phase.         that DDR initiatives have not paid
      in the world. Governments and the          Several explanatory factors can be          sufficient attention to the issue
      international community see DDR as         identified including the fact that:         of HIV or not had the time or the
      a way of decreasing the risk of new                                                    vision to use the DDR process as
      outbreaks of armed violence. Our           ■■many donor governments make               an opportunity for consolidated
      study suggests that DDR interventions        a conceptual and organisational           and targeted HIV interventions.
      have failed to incorporate HIV issues        distinction between humanitarian
      in any meaningful way. This was              relief and development                    Displaced women and ex-combatants
      especially the case in Liberia but in        assistance that is simplistic             constitute a significant proportion
      all four countries ex-combatants felt        and not based on evidence                 of post-conflict societies. They
      that not enough had been or was being                                                  come with a burden of traumatic
      done for them and that they had seen       ■■there is a common but ill-                experiences but they also represent
      little benefit from HIV programmes.          founded belief that the end of            a vital and potentially crucial part
                                                   conflict signals a time of social         of the recovery and reconstruction
      There was a general sentiment among          reconciliation, reinvestment in           process. HIV can be a window of
      ex-combatants in DRC and Liberia that        social development by national            opportunity for strengthening the
      conflict had ‘allowed’ – and in some         governments and an economic               larger health development process
      cases encouraged – them to abuse             recovery that automatically               and facilitating recovery. Indifference
      women and in doing so possibly to            benefits the general population           to the needs of these two groups
      expose them to HIV. Most perceived                                                     of people does not bode well for
      HIV as a condition for which there         ■■there is an equally non-evidence-         post-conflict reconstruction.
      was no cure and many ex-combatants           based assumption by donor
      in these two countries had a fatalistic      agencies that national governments        Manuel Carballo ( )
      approach to HIV, saying that dying           facilitate the return of trained,         is Executive Director of the International
      from HIV was ultimately the same             knowledgeable personnel or have           Centre for Migration, Health and
      as dying from a bullet, and that             the capacity to train new ones            Development (ICMHD). Alexandra
      as ex-combatants they had little                                                       Small (Alexandra.Hamilton-Small@
      or no control over the outcome.            ■■assumptions about post-conflict  was a researcher
                                                   recovery seem to have built on            at ICMHD. Calixte Clérisme (clerisme@
      Female ex-combatants felt that the end       inappropriate analogies with the is Directeur du Centre de
      of conflict had presented a number           rapid post-conflict reconstruction        Recherche pour le Developpement
      of additional problems including             of Japan, Germany and other               (CRD) at the State University of Haiti.
      resistance to their return by families       industrialised countries                  Benjamin Harris (harrisbtelekaie@yahoo.
      and communities of origin. In Haiti,                                                   com) is Professor of Psychiatry at the
      women who identified themselves as         ■■donors seem to overlook the reality       University of Liberia. Patrick Kayembe
      ex-combatants also talked about the          that developing countries typically       ( is Dean of
      hostility of local police and the danger     go into conflicts with already weak       the University of Kinshasa School
      they sensed from law enforcement             infrastructures that then became          of Public Health. Fadila Serdarevic
      personnel who still saw and treated          even weaker and see their vital           ( is the ICMHD
      them as combatants and criminals.            agricultural, educational and health      Country Coordinator in Bosnia.
                                                   systems fundamentally disrupted
      Rape in the post-conflict phase also
                                                                                                This article is extracted from a longer
      emerged as an important theme and          ■■donor fatigue and frustration have
                                                                                                report written for ASCI which is available at:
      there was widespread agreement               come to typify the international
      among ex-combatants that the risk of         response to the frequency of
      rape in post-conflict settings remained      conflicts and the seemingly
      high. In DRC many ex-combatants              slow capacity for countries to            1.
      said they thought that women often           reconstruct and move on to
      “got themselves into” vulnerable             a development trajectory.
22                                                      HIV/AIDS, SECURITY AND CONFLICT

     Understanding sexual violence,
     HIV/AIDS and conflict
     Judy El-Bushra

     A broad gender approach is needed to understand the social                                                            been associated with the genocide,
     context of HIV transmission within conflict environments.                                                             although domestic violence has
                                                                                                                           emerged as a concern more recently.
     Rates of HIV transmission are often                transmission. It is often assumed                                  During the LRA war in Uganda,
     presumed to increase in situations                 that one-off, opportunistic rape is                                army personnel allegedly perpetrated
     of violent conflict, due to high levels            the only form of sexual violence in                                widespread rape of men and women,
     of sexual violence, poverty and                    conflict contexts. However, it also                                while rebel militias were accused
     displacement which create a high                   includes other forms such as sexual                                of abducting male and female
     risk environment for the spread                    slavery and other strategic and                                    children, with girls forced to serve
     of HIV. Claims of a link between                   deliberate attacks over time. There                                as ‘wives’ of commanders. Similarly,
     sexual violence and HIV infection                  is evidence that both long-term                                    rape by military personnel (both
     have been supported by prevalence                  exposure to the virus and violent                                  from the national army and from
     data amongst specific groups who                   sexual activity are associated with                                local militias) has been widespread
     suffered a high incidence of violence              increased risk of transmission.                                    in the Democratic Republic of the
                                                                                                                           Congo (DRC) and Burundi, and there
                                                                                                                           have also been reports of coercion
                                                                                                                           ranging from abduction to violent
                                                                                                        UNHCR/A Kirchhof   force to economic enticement.

                                                                                                                           Common features found across the
                                                                                                                           region include the sheer number of
                                                                                                                           rapes, the extreme brutality of sexual
                                                                                                                           encounters, the continuation of sexual
                                                                                                                           violence after the war has ended,
                                                                                                                           including ‘civilian rape’ and the
                                                                                                                           ‘double violation’ whereby victims
                                                                                                                           encounter stigma and are disowned
                                                                                                                           by their families and communities
                                                                                                                           after suffering sexual violence. Sexual
                                                                                                                           violence in the region has attracted
                                                                                                                           media attention, contributing to
                                                                                                                           the emergence of well-funded
                                                                                                                           international interventions. Although
                                                                                                                           many individual projects have been
                                                                                                                           effective, the overall impact has
                                                                                                                           been limited. This has been partly
         Information session on HIV/AIDS for returnees from Tanzania, Mugano transit centre, Burundi.                      because of assumptions about who
                                                                                                                           the victims and perpetrators are.
                                                                                                                           There has been a narrow range of
     during war time. A study in Rwanda                 Clearly, rigorous analysis of                                      types of support offered to victims,
     found that seropositivity1 was 60-80%              available data is important in                                     poor coordination between agencies,
     among women who had been raped                     understanding sexual violence and                                  and greater focus on medical and
     during the 1994 genocide, compared                 HIV transmission within conflict                                   psychosocial recovery with less
     to 13.5% of the general population.2               environments. However, we also                                     attention to legal and economic
                                                        need a ‘gender approach’, exploring                                support. Target beneficiaries have
     However, other studies have                        the social and cultural dimensions                                 primarily been adult women,
     challenged this claim, pointing out                of sexual relationships within                                     frequently ignoring the broader range
     that conditions of violent conflict can            conflict settings to help the design of                            of victims including young women
     both raise and lower transmission                  measures for effective prevention.                                 and girls, as well as men and boys.
     rates and emphasising that high
     prevalence rates for specific at-risk              Sexual violence in the Great Lakes                                 Most damagingly, inroads have not
     groups should not be extrapolated                  During the wars which have been                                    been made into the phenomenon
     to the entire population.                          fought in the African Great Lakes                                  itself, which in many parts of the
                                                        region for the past 20 years various                               region (notably DRC) continues at
     These varying viewpoints reflect                   patterns of sexual violence have                                   similar levels to the past. Long-term
     assumptions about types of                         been identified. In Rwanda, much                                   solutions for preventing sexual
     behaviours and their impact on                     of the reported sexual violence has                                violence have not been identified,
                                                HIV/AIDS, SECURITY AND CONFLICT                                                                         23

      as the focus has been on response         men and women can be seen both             help to perpetuate the very power
      rather than prevention. Efforts at        as victims and as perpetrators.            imbalances it seeks to undermine?
      prevention, where they exist at all,      Literature on post-conflict changes
      have been focused on containment          in gender relations suggests that          A ‘gender approach’ to
      (through legal reform, for example)       where women make gains during              sexual violence in conflict
      rather than on understanding the          wartime a backlash often follows,          A gender lens can contribute
      factors that have contributed to          implying that the underlying               powerfully to strategies for
      the outbreak of sexual violence. A        values that deny women a role in           addressing HIV/AIDS, sexual violence
      possible explanation for this neglect     decision-making have deep roots.           and violent conflict. Considering
      is that the discourse around sexual                                                  gender within a socio-psychological
      violence in the Great Lakes has been      Individuals can be shaped by their         framework is more powerful than
      dominated by the notion of sexual         context and their experiences,             the current archetypal model.
      violence as a ‘weapon of war’. As         and war can have the effect of             We need to address not just the
      long as we assume sexual violence         narrowing the range of options             everyday behaviour of men and
      to be perpetrated by marauding            through which the values that              women but also the structures
      men of arms, we feel impotent             are critical to a person’s sense of        within which power relations
      to challenge or eradicate it.             identity and self-esteem can be            operate, as well as their ideological
                                                lived. If this is the case, then does      underpinnings. Such an approach
      It is beginning to become clear,          a conflict environment enhance             might lead to more holistic policies
      however, that the ‘weapon of war’         violent sexual behaviour? There            and strategies, with a broader range
      explanation is insufficient to explain    is a suggestion that in northern           of interventions, better coordination
      either the extent or the form of the      Uganda the deprivations of war             and synergy between them, and a
      phenomenon, and that much sexual          have prevented men from attaining          stronger emphasis on mechanisms
      violence in such settings is carried      their ideals of manhood, leading to        that involve agencies and local
      out not by armies or militias but by      violent behaviour towards others as        communities acting together in
      non-military civilians. This raises the   well as various forms of self-harm.3       a shared search for solutions.
      question of who the perpetrators are,     Interviews with Congolese rank-
      and what creates the conditions in        and-file soldiers suggest that, for        HIV transmission is driven by
      which they carry out these crimes.        them, the military establishment           relationships whose intimate nature
                                                provides a backdrop of suffering and       brings to the fore people’s deepest
      The archetypal aggressive male            frustration against which violence         feelings about their identity and
      The one-dimensional model of the          appears comprehensible.4 These             values. Effective HIV prevention
      aggressive male fails to provide an       findings suggest the possibility that      programmes have emphasised the
      explanation of the root causes of         perpetrators can be seen as being in       importance of building relationships
      sexual violence during and after          some way victims of their situations.      based on mutual respect. During
      conflict. It does not account for the     This would mean that strategies            conflict, when moral underpinnings
      social rejection suffered by raped        to alter these contextual factors          are compromised, these foundations
      women nor does it explain the             may help to change behaviour.              are essential for the prevention
      continuation of violence after fighting                                              of both sexual violence and HIV
      has ended. The suggestion that            Understanding the context in which         transmission. Understanding the
      ‘civilian’ men committing rape are        perpetrators grow up and are               social and cultural context describing
      demobilised soldiers having difficulty    socialised, the problems they face         these relationships is a step towards
      adjusting to civilian life is highly      and how they conceptualise them,           effective prevention, both of the HIV
      speculative. This model assumes that      the sorts of rewards and sanctions         virus itself and of sexual violence.
      sexual violence of this intensity was     they receive from those around them
      unknown before the war, although          and how these are reinforced by            Judy El-Bushra (jelbushra@
      there is virtually no firm evidence       international actors would enable is Manager
      on which to make a comparison. It is      identification of strategies that cut to   of the Great Lakes Programme
      possible that the dominance of this       the root of the problem rather than        at International Alert (http://
      model in the international response       just reacting to its consequences.
      contributes to the failure to bring
      sexual violence under control.            The image of the powerful man and            This article is extracted from a longer
                                                his vulnerable woman victim raises           report written for ASCI which is available at:
      The gender literature is divided in       the question as to whether brutal  
      its interpretation of sexual violence     and violent rape is really a separate
      in war. One view holds that war           phenomenon. Should we rather see
                                                                                           1. Showing a serological reaction indicating the presence
      is by definition ‘war on women’,          it as one end of a continuum linking       of the disease.
      and that rape in war functions as         it with other forms of coercive sex,       2. Nduwimana, F. 2004. The Right to Survive: Sexual
      part of a ‘scorched earth’ approach,      as well as with a range of other           Violence, Women and HIV/AIDS. Rights and Democracy,
      causing terror and destabilising          oppressive relationships? And is it
                                                                                           3. Dolan, C. (2002) ‘Collapsing masculinities and weak
      the social fabric and identity of a       really an issue of man versus woman,       states – a case study of northern Uganda’ in Cleaver (ed)
      community by forcing its women            or are both victims in different           Masculinities matter! men, gender and development, London,
                                                                                           Zed Press.
      into extreme vulnerability. Other         ways of the same patriarchal power         4. Eriksson Baaz, M. and Stern, M. Why do soldiers rape?
      researchers describe a more               dynamics? Does the one-dimensional         Gender, violence and sexuality in the DRC Armed Forces,
                                                                                           unpublished paper, Goteborg University.
      complex reality, in which both            depiction of ‘woman as victim’
24                                               HIV/AIDS, SECURITY AND CONFLICT

     Mobility and power in HIV
     Cathy Zimmerman, Charlotte Watts, Anna Foss and Mazeda Hossain

     Social scientists are working with epidemiologists to produce                         sex. Large and profitable networks of
     evidence that questions traditional epidemiological HIV ‘core                         arms, drug and sex traffickers make
                                                                                           it possible to traffic women very
     group’ models.                                                                        quickly to avoid detection. Under
     Epidemiological analysis and                Within classic core group theory,         these circumstances, sex workers are
     mathematical modelling have                 there is an assumption that sex           less likely to form a stable reservoir
     demonstrated the significance               workers are a homogeneous group           of the virus. Rather, this model points
     of commercial sex and high-                 with equal potential to transmit          to the role of men – especially regular
     risk behaviours as factors in the           infection. However, social science        sex clients and men who control
     widespread transmission of HIV.             research, in particular, highlights       the sex trade, including pimps and
     This has frequently singled out             the many variables indicating             those who provide ‘protection’ for
     commercial sex-workers as a focal           the heterogeneity of this group,          brothels and sex workers on the street
     point of the spread of the epidemic.        including sex worker mobility,            (a group that often includes police)
     Research in the social sciences             age, stage of progression of the          – in transmitting the virus to newly
     has spotlighted the multifaceted            disease, access to services and           recruited sex workers. We identify
     complexities of participants in sex         protection, experiences of violence       scenarios in which this group may
     work settings, describing their             and work environment (e.g. those          constitute a ‘sustaining population’,
     mobility, particular vulnerabilities        in regulated brothels compared to         because they provide a potentially
     and heterogeneities. This variation         individuals in informal settings or       more stable, long-term reservoir for
     includes the diversity of the sex           transactional and survival sex).          the virus than do the more transient
     industry in high- and low-conflict                                                    sex workers whom they infect.
     and post-conflict settings where,           Traditional core group theories
     for example, women may move to              predict that the total number of          Although there is little quantitative
     locations where military troops             people that an HIV-positive person        data on key characteristics of sex
     are based to sell sex, or where             will infect in a susceptible population   workers and those who control
     women in refugee settings may               is determined, in part, by the rate of    them to construct verifiable
     sell or trade sex to survive.               partner change. However, there is         epidemiological models, this
                                                 limited attention given to men who        theoretical model offers thought-
     Classic ‘core group theory’ proposes        are often central to sex work settings,   provoking considerations from
     that core groups (those who, when           including non-commercial or non-          which to revise current assumptions
     infected, are most likely to spread         paying users and those who control        about the core group. This revised
     HIV multiple times) spread infection        or profit from the local sex industry.    perspective suggests the potentially
     among a wider ‘bridge’ population           These are frequently men in positions     important, if not central, contribution
     of male clients who may in turn             of power, including pimps, police         of the controlling group of men
     pass the virus to their partners. The       or soldiers. Importantly, current         in sustaining HIV transmission
     identified core group is generally          theories also fail to consider how        in certain settings where there is
     the primary population targeted             mobility – the movement of groups         high sex worker mobility. Indeed,
     for HIV prevention and, as such,            in and out of a setting and the length    this group’s longer duration in a
     most likely to be stigmatised.              of time in different locations—might      setting may make their influence
     Results from our modelling exercise         influence the risk of transmission        more significant than that of sex
     on HIV core groups suggest the              and transmission patterns.                workers, versus in settings where
     potential significance of police                                                      the sex worker population is more
     and other men in positions of               We have introduced a new equation         stable and the classic theory may be
     power for HIV transmission and              to reflect both the number of             more robust. This suggests that HIV
     question the long-held assumption           sexual partners and the average           prevention policies and programmes
     that sex workers form a core                duration that an individual is            should aim to reach those who
     group of HIV transmitters.                  infectious in a particular setting.       control the sex trade by addressing,
                                                 This reconfiguration is especially        for example, their risk-taking
     Shortcomings of classic core                important in commercial sex               behaviours and their economic and
     group theory                                situations, which often have              coercive power over women and girls.
     When considering HIV prevention,            high levels of both sexual activity
     epidemiological theories can help           and mobility.                             More broadly, there is still limited
     identify priorities within HIV                                                        debate about the underlying power
     responses. Core group theory has            In particular, conflict-related sex       structures and power differentials
     offered considerable guidance in            trafficking may increase the mobility     behind sex work. Current prevention
     priority-setting, but, in its simplicity,   of sex workers while decreasing their     efforts frequently avoid questioning
     it may miss important elements.             ability to control the circumstances of   the status quo and the power
                                               HIV/AIDS, SECURITY AND CONFLICT                                                          25

      that men may have by virtue              position – such as peacekeepers,, and Mazeda Hossain
      of their employment, social or           camp staff, border control officials   (
      economic status, physical power or       and soldiers – are not sufficiently    work at the Gender Violence &
      ruthlessness. In situations of low-      professional, they may create and      Health Centre of the London School
      or high-level conflict, international    maintain situations of vulnerability   of Hygiene & Tropical Medicine
      resources may inadvertently              and exploitation and help sustain      (
      even place men in these powerful         HIV infection.
      situations and humanitarian agencies
      and donors may look the other            Cathy Zimmerman (Cathy.                 This article is extracted from a longer
      way when this power is used to , Charlotte       report written for ASCI which is available at:
      the detriment of women. If those         Watts (Charlotte.Watts@lshtm. 
      men empowered by virtue of their, Anna Foss (Anna.Foss@

      Addressing HIV and sex work
      Ann Burton, Jennifer Butler, Priya Marwah, Cecile Mazzacurati, Marian Schilperoord and Richard Steen

      Sex work is an indisputable reality in humanitarian settings.                   Pillar	2: strengthening partnerships
      UNHCR and UNFPA have demonstrated the importance of                             and expanding choices through
                                                                                      working with sex workers to
      multisectoral interventions to address HIV in sex work.                         ensure supportive environments
      There is emerging evidence of how        Sex work is an important driver of     in which all sex workers can
      conflicts and disasters may lead         HIV transmission. Unprotected sex      access the services they need.
      to sex being sold or exchanged           between clients and sex workers
      for accommodation, protection,           and between clients and their          Pillar	3: reducing vulnerability
      food, gifts and other items or           intimate partners contributes to       and addressing structural issues
      services. This can be attributed         increased risk of HIV transmission.    by ensuring protection, access to
      to many factors, including high          Thus, sex workers and their clients    food, shelter and other basic needs
      levels of poverty, lack of livelihood    are critical to an effective HIV       together with related measures
      opportunities, separation of families,   response. Frequently, though, sex      to prevent GBV and minimise
      breakdown in community support           workers are marginalised and           pressure to enter sex work.
      mechanisms and an increase in            face widespread discrimination,
      gender-based violence (GBV). Yet         reducing their participation in        These pillars form the foundation
      programmes addressing HIV and            HIV prevention and their ability       for a comprehensive response to
      sex work in humanitarian settings        to access health, legal and social     HIV and sex work and inform the
      are often poorly developed. HIV          services. There is evidence that if    recommendations presented in
      programmes typically follow              sex workers are involved in the        the Technical Note on HIV and Sex
      generalised approaches, with             provision of services, both uptake     Work in Humanitarian Settings.
      insufficient attention being paid        and access usually improve. A
      to those individuals and groups          growing number of countries            Sex work in humanitarian settings
      who are most vulnerable and              that have scaled up interventions      The characteristics that define
      at highest risk of acquiring and         with sex workers have reported         humanitarian emergencies, including
      transmitting HIV and other sexually-     stabilisation, and even reversal,      conflict, social instability, poverty
      transmitted infections (STIs).           of their HIV epidemics.                and powerlessness, can also facilitate
                                                                                      the transmission of HIV. Power
      Initial steps have been taken to         Recognising these opportunities        imbalances that make girls and
      address HIV and sex work in some         and challenges, UNAIDS promotes        women disproportionately vulnerable
      refugee programmes in the East           a human rights-based, evidenced-       to HIV infection become even
      and Horn of Africa, Latin America        informed approach to HIV and           more pronounced during conflict
      and parts of Asia. Based on these        sex work based on three ‘pillars’      and displacement. There may be
      experiences, and under the overall       which have been adapted to meet        increased pressure to engage in sex
      framework of the UNAIDS Guidance         needs in humanitarian settings:        work. HIV risk for sex workers and
      Note on HIV and Sex Work1, UNHCR                                                clients may be increased due to lower
      and UNFPA have developed a               Pillar	1: assuring universal access    condom use and increased violence.
      Technical Note as guidance for field     to comprehensive HIV prevention,
      staff and programme managers             treatment, care and support through    The vulnerability of children to
      on addressing HIV and sex work           planning and preparing to maintain     sexual exploitation and abuse is also
      in humanitarian situations. The          services, implementing basic           heightened during humanitarian
      primary objective is to inform           services in the emergency phase        crises. While conditions, contributing
      humanitarian actors of steps that        and building more comprehensive        factors and programmatic responses
      can be taken to reduce risk and          services as conditions stabilise.      may overlap with those for adults,
      vulnerability related to sex work.2                                             there are fundamental and important
26                                                  HIV/AIDS, SECURITY AND CONFLICT

     differences. The UNAIDS Guidance                empowerment opportunities to                The steps set out in the box below
     Note “affirms that all forms of                 reduce their reliance on sex work.          illustrate how sex work can be
     involvement of children (defined                An important area of intervention           addressed in humanitarian settings.
     as people under the age of 18) in               is to educate law enforcement               Most activities are extensions of
     sex work and other forms of sexual              officials such as police personnel          health or protection services that
     exploitation or abuse contravene                to be agents of change within their         should be implemented as part
     United Nations conventions and                  own communities, to respect the             of the humanitarian response.
     international human rights law”.                rights of sex workers and sensitise         Additional attention to sex work
     While improving conditions related              their peers on HIV prevention.              may involve very little extra effort
     to sex work is part of the response for                                                     but can yield important results
     adults, the programmatic response               Key strategies for response                 in terms of protecting the rights
     to sexual exploitation is protection            It is important to work on multiple         of the population and averting
     and removal of the child from                   levels and across sectors to                HIV morbidity and mortality.
     the conditions of exploitation.                 reduce risk and vulnerability
                                                     related to HIV while protecting             In Kenya and Uganda, UNHCR
     Humanitarian settings present                   the safety and human rights of              and implementing partners have
     important opportunities for                     affected populations. By being              worked closely on developing
     preventing HIV transmission. Forced             aware of conditions that heighten           programmes with sex workers,
     displacement and humanitarian                   vulnerability and risk, humanitarian        based on sustainable and improved
     crises – whether associated with                actors can take steps to ensure             comprehensive services including
     conflicts or natural disasters –                services and support are in place           HIV and reproductive health,
     usually involve armed groups,                   to protect the human rights of sex          community social services and
     uniformed services and other                    workers and their clients, minimise         livelihood interventions. In both
     men from within or outside the                  risks of HIV transmission and meet          cases there is evidence that much
     community whose presence                        the broader health and social needs         can be achieved within a six-month
     often leads to an increase in sex               of sex workers. The Technical Note          period: sex worker-led organisations
     work. In these settings, some sex               outlines steps to protect populations       and peer groups were established,
     workers openly sell sex whereas                 and prevent unwanted entry into sex         confidential and respectful health-
     other sex workers prefer not to                 work. Its recommendations reflect           care services were provided and
     identify themselves as such, often              experience from many different              protection systems strengthened.
     working on a more part-time basis.              settings and are adaptable to local         These examples illustrate how the
     As in non-humanitarian contexts,                conditions and cultural contexts.           active engagement and involvement
     some sex workers will choose                    The starting point for all these            of sex workers is not only possible
     to continue in sex work while                   interventions is engagement with            but also leads to improved quality
     others would prefer economic                    sex workers and communities.                of HIV prevention measures.

       Key activities per phase
       Preparedness                                                      Stabilised phase
       1. Integrate HIV and sex work into contingency planning           6. Build supportive environments and partnerships
          • Identify existing sex worker networks and programmes            • Establish peer groups and support sex worker-led
          • Map services and develop contingency plans for rapid              approaches
             restoration if disrupted                                       • Strengthen existing women’s groups to reach non self-
                                                                              identified sex workers
       Emergency phase                                                      • Conduct rapid assessments and plan interventions
       2. Expedite registration, risk identification and protection      7. Reinforce protection
          • Identify those most at risk: single-parent, female-headed       • Strengthen prevention of GBV and sexual exploitation
            and child-headed households, unaccompanied minors               • Find ways to involve men
          • Ensure protection and establish GBV services                 8. Expand to comprehensive HIV and SRH services including
          • Promote codes of conduct                                        STI services
       3. Ensure safe shelter and access to food and basic necessities   9. Expand targeted services
       4. Provide basic SRH (sexual and reproductive health) and HIV        • Support transition of peer activities to broader community
          services                                                            mobilisation
          • Implement MISP (Minimal Initial Service Package)3               • Strengthen venue-based and special clinics for identified sex
          • Establish basic STI services within SRH and outpatient            workers
            clinics                                                         • Work with clients to reduce demand for unprotected paid sex
          • Implement basic HIV services                                 10. Provide social/economic/legal services
       5. Start outreach                                                    • Strengthen legal protection
          • Use contacts to begin mapping and engagement with               • Establish self-regulatory boards
            sex workers                                                     • Increase livelihood and educational opportunities for the
          • Identify sex-work venues, distribute condoms and                  most vulnerable
            information                                                     • Prepare for appropriate durable solutions, especially for
                                                                              most vulnerable
                                               HIV/AIDS, SECURITY AND CONFLICT                                                                          27

      In Sierra Leone, the Women in            them to have access to education,         major challenge. Although HIV is
      Crisis Movement (WICM), an               acquire skills and to increase            recognised as a cross-cutting issue, it
      NGO supported by UNFPA, is               their economic independence.              is, unfortunately, all too often seen as
      devoted to empowering war-                                                         the domain of the health sector only.
      affected adolescents and young           Conclusion
      girls through a combination of           Interventions to respond to HIV           Jennifer Butler (, Priya
      vocational training and creation of      and sex work in humanitarian              Marwah (, Cecile
      cooperative employment. WICM has         settings are both necessary and           Mazzacurati (
      developed a two-year vocational          feasible, even during an emergency.       and Richard Steen (
      training programme helping girls         In situations where comprehensive         work for UNFPA. Ann Burton (burton@
      and young women at two sites who         HIV programmes have already been and Marian Schilperoord
      actively chose to leave sex work.        established but where sex workers         ( work for UNHCR.
      Combining vocational training with       have not yet been reached, a basic set
      income-generating activities and the     of sustainable multisectoral activities   2. This guidance is being field tested and will be available
      inclusion of sexual and reproductive     can be established within six months.     for distribution by the end of 2010 on the websites of
                                                                                         UNHCR and UNFPA.
      health as an integrated component        The integration of HIV into the
      in the training programmes allowed       humanitarian clusters remains a

      The price of liberation:
      migration and HIV/AIDS in China
      Shao Jing

      Sale of blood became an attractive alternative to the rural-                       migration. Plasma in a cash-starved
      urban migration induced by economic and social hardships                           agricultural economy becomes cash
                                                                                         by virtue of the demand for the
      but has been the cause of an HIV/AIDS epidemic in China.                           albumin it renders up to a health
      Early in the 1990s, large numbers        developments have only facilitated        industry hungry for expansion.
      of commercial blood donors in            the transformation of traditional
      rural central China, most notably        labour-intensive agricultural systems     The market for blood products,
      in Henan Province, were infected         into capital-intensive enterprises.       principally albumin, was created
      with HIV. According to conservative      The value of agricultural labour          by economic reform in China’s
      estimates released by the provincial     had thus become increasingly              health sector. Public hospitals and
      government, more than 30,000             insecure, a surplus with no profit.       other health-care facilities, which
      people in this province alone were       Under these conditions, ‘rural            previously had been supported by
      infected. This ‘separate epidemic’,      residents’ in China’s agricultural        state subsidies, now had to compete
      as it is often referred to in the HIV    heartland were compelled to convert       in the market and generate revenue
      epidemiological reports in China,        their labour surplus into cash by         through the services they provided
      defied the well-recognised patterns      migrating to urban and coastal            and the drugs they sold. This
      of progression in this epidemic,         industrial centres to look for work.      arrangement encouraged serious
      particularly in terms of the male-                                                 conflicts of interest in health care.
      to-female ratio of the infected; from    When blood plasma collection began,       More expensive treatments were
      the start, it claimed both men and       it was perceived as an attractive         promoted to patients, and the prices
      women as victims in equal numbers        alternative way of generating             of the drugs became a bogus proxy
      but by a transmission route that was     revenue without migration, as it          for their efficacy. In this context,
      far more efficient than sex. Infection   seemed to only take the insubstantial     albumin quickly became a favourite
      occurred when contaminated blood         part of their blood, the part not         drug at hospitals, prescribed often in
      cells were returned to the donor         essential to their vitality, physical     the absence of any specific indications
      after the harvesting of plasma           strength and force.                       to patients who were convinced of
      from their blood, allowing the                                                     its restorative efficacy and could
      epidemic rapidly to establish itself     Many HIV-infected women                   afford to pay for this luxury.
      over several central provinces.          had returned from working in
                                               manufacturing in the cities where         The fledgling plasma fractionation
      Labour, blood and HIV/AIDS               they had worked for several years to      industry in China was boosted by
      The term ‘rural resident’ is a           build dowries. They returned, got         a ban in 1985 on all imported blood
      bureaucratic category that ensures       married and raised their children         products which was aimed at keeping
      that rural migrants who provide          in their home villages. Selling           HIV and AIDS outside China’s
      a vast source of cheap labour are        plasma gave them an opportunity to        borders. The industry grew quickly
      excluded from basic social services      continue supporting their families        in the following decade as did the
      in urban areas. In the context of        by bringing in cash that could no         demand for source plasma (i.e.
      economic liberalisation, technological   longer be obtained through out-           plasma for further manufacturing).
28                                               HIV/AIDS, SECURITY AND CONFLICT

                                                                                                 contractors’ from the villages for
                                                                                                 their supply of workers; plasma

                                                                                     Shao Jing
                                                                                                 collection centres used ‘scouts’ to
            A former
                                                                                                 recruit and transport donors; and
         commercial                                                                              infectious disease hospitals supplied
        blood donor                                                                              clinical trial data on drugs under
              in rural
      Henan, China,
                                                                                                 development with the assistance
             with her                                                                            of the same cast of intermediaries
        medications                                                                              living among HIV-positive villagers.
               for HIV
       infection and
        a persistent                                                                             This HIV outbreak and its aftermath
      co-infection of                                                                            highlight the price that China’s ‘rural
       tuberculosis.                                                                             residents’ have had to pay for their
                                                                                                 multiple experiences of ‘liberation’.
                                                                                                 A price has also been paid by
                                                                                                 women, particularly among rural
                                                                                                 communities, for their even more
                                                                                                 dubious liberation. The majority of
     In addition to exporting labour to          adherence. Nausea and vomiting                  the epidemiological subpopulation
     the coastal and urban industrial            were among the most common                      categorised as ‘commercial sex
     centres, the central provinces could        side-effects of the ARV regime in               workers’ are also rural to urban
     benefit more directly by supplying          the free government treatment                   migrants. Their entry into China’s
     them with source plasma.                    programme, resulting in loss of                 booming sex industry is aided by
                                                 appetite or inability to keep anything          that industry’s ubiquity and its
     Pathways of pathology                       down, as well as dizziness and sore             many disguises. The high turnover
     None of these historical processes –        muscles, which further weakened                 of those who work in this industry
     economic reform in the agricultural         them. These common side-effects                 and their extreme mobility are both
     sector, the economic reform of health       were experienced as life threatening            significant. Freed to sell sex, for a
     care, and the emergence of a plasma         by these agricultural producers,                period of time, with anonymity and
     fractionation industry – created            exactly because they seemed to                  perhaps impunity, away from the
     the necessary conditions for the            assault the most essential dimensions           social world to which they hope to
     outbreak of the HIV epidemic. But           of their lives: food and labour.                return very much as they would after
     the pathological confluence of these                                                        working in factories, the population
     historical processes determined             The lack of comprehensive treatment             of ‘commercial sex workers’ is
     the geography and demography of             delivery is only part of the reason for         difficult to identify and track. Risk
     the HIV epidemic among plasma               the failure of the programme. The               taking, often despite knowledge,
     donors in rural central China.              villages that saw the greatest decline          motivation and skills, is then not
                                                 in participation and adherence                  simply a behaviour but integral to the
     In the current atmosphere of                were all well-known ‘AIDS villages’,            temporary nature of the work itself.
     overwhelming attention to curbing           favoured by pharmaceutical
     the spread of HIV in the general            manufacturers and traditional                   How do we, then, effectively
     population, it is easy to forget that the   medicine practitioners chasing                  block the pathways of pathology?
     same social and political conditions        lucrative dreams of finding a cure for          The answer can come from quite
     and cultural logic that have led            ‘the plague of the millennium’. Major           unexpected quarters. In 2006, the
     to the epidemic in central China            research hospitals recruited clinical           Chinese government abolished all
     continue to shape the experience of         trial subjects from these villages for          agricultural taxes, which for decades
     the disease of those already infected.      pharmaceutical developers. In these             had been an indispensable source
     Among the earliest symptoms of              villages, government-supplied ARV               of revenue. A little more than a year
     the progression of HIV disease, and         drugs, which promised only the                  later, many hospitals were suffering
     the one most keenly felt by these           suppression but not the eradication             shortages of albumin. This time,
     hardworking villagers, is fatigue. The      of the disease, competed poorly                 the shortfall was directly caused
     irreversible loss of their labour power     with the plethora of free samples               by the modest amount of money
     due to HIV infection was a shocking         of hope represented by remedies                 the government now gives to rural
     price to pay for money they had             of uncertain efficacy but without               residents, which has made selling
     made selling plasma years before.           the pain of the feared side-effects.            plasma less attractive and less
                                                 This epidemiological pattern makes              necessary. An unintended but happy
     In the midst of intensifying media          a mockery of the compassion and                 outcome of this shift in economic
     attention on the AIDS-related deaths        hope that highly active antiretroviral          policy is the reduction of the risk
     in a few villages in Henan, the             therapy (HAART) is meant to inspire.            of HIV infection among plasma
     government hastily rolled out a free                                                        donors and blood product users.
     antiretroviral (ARV) treatment early        The parallels to be drawn between
     in 2003. This limited programme             the out-migration of rural labour,              Shao Jing (
     distributed ARV drugs but without           source plasma collection and clinical           teaches anthropology at Nanjing
     adequate medical services to                trials are stunning. Construction               University, Nanjing, China.
     deal with side effects and ensure           companies relied on ‘labour
                                               HIV/AIDS, SECURITY AND CONFLICT                                                  29

      Education: critical to HIV
      prevention and mitigation
      Marian Hodgkin and Marian Schilperoord

      Good-quality protective formal and non-formal education can                      behaviour and enhance protection.
      provide the knowledge and skills for the prevention of HIV and                   Education practitioners should also
                                                                                       work with health and protection
      protection from the impact of AIDS.                                              colleagues to establish referral
      Information about HIV prevention         HIV education is an imperative life-    systems for learners affected by
      and mitigation must be integrated        saving intervention but education       HIV who require health, social
      into education responses to              practitioners should not rush into      or psychosocial services.
      emergencies to help ensure that          programming without keeping in
      learners and their teachers remain       mind the context-specific dimensions    Teaching	and	learning	for	
      supported and safe. Education can        of an emergency response. Working       prevention	and	mitigation: While
      offer one of the points of entry for     with communities, teachers, school      HIV and sexual and repro-ductive
      health, protection and other sectors     councils, parent-teacher associations   health education might not be
      working on HIV prevention and            and learners themselves to assess,      included in formal curricula in
      response and facilitating referral to    plan, implement, monitor and            normal circumstances, a crisis
      essential services for those affected    evaluate education interventions will   can provide the opportunity to
      by HIV. It is also a fundamental right   help improve programme quality          address these issues in schools
      enshrined in the UN Convention           and ensure cultural sensitivity.        and kick-start curriculum reform.
      on the Rights of the Child and an                                                International actors should work
      accompanying General Comment             Analysis of the context and             with communities and national
      which emphasises governments’            coordination within the education       education authorities to define age-
      obligations to ensure that children      sector and with other humanitarian      appropriate and gender-sensitive
      “have the ability to acquire the         response actors in health, protection   content. Curricula should address
      knowledge and skills to protect          and nutrition are critical. Education   context-specific knowledge, attitudes,
      themselves and others as they            actors will not necessarily have        behaviours and practices with
      begin to express their sexuality”.1      the capacity to undertake a full        scientifically accurate information.
                                               analysis of the nature and type         Participatory learning processes
      Unfortunately, access to information     of HIV epidemic in a particular         such as brainstorming, small-
      and services related to HIV and          context but can work with others        group work, role play, debates
      sexual and reproductive health as        to determine the level of HIV           or storytelling are particularly
      part of education during emergency       prevalence and gather information       important for developing life-skills.
      interventions is generally haphazard     about the most vulnerable and at-       Trained teachers using carefully
      – mostly through non-formal              risk populations. This will help        developed curricula can also help
      youth programmes or as part of           education practitioners plan relevant   learners develop understanding and
      work done with young people in           educational content and begin to        tolerance, thereby contributing to
      community centres. Inclusion in          map possible referral mechanisms.       reducing stigma and discrimination
      formal education curricula is less                                               against those living with HIV.
      common. Often key messages are not       It is critically important – when
      consistently accurate, and teaching      considering how to enhance HIV          Working	with	education	personnel:
      methods are usually lecture-based        prevention and mitigation during        Teachers and other educators should
      or involve a brief visit from a health   crises – to heed the principles         be supported by institutions and
      centre nurse. There is generally no      of participation, analysis and          communities so that they can address
      active engagement with students,         coordination and to recognise           HIV and AIDS in their own lives
      development of critical life skills      that good-quality education can         and in the lives of those they teach.
      or discussion and active learning.       reduce the vulnerability of learners    In some emergencies the teaching
                                               to HIV and AIDS. Education              force itself may be severely affected
      The Inter-Agency Network                 programming must mainstream             by HIV and it will be necessary to
      for Education in Emergencies             HIV issues and consider targeted        recruit replacement teachers, support
      (INEE) has recently updated its          responses such as the following:        staff or volunteers. It should also
      Minimum Standards for Education:                                                 be recognised that education is not
      Preparedness, Response, Recovery2        Access	to	protection	and	provision	     necessarily protective. Working with
      to help practitioners and                of	services	through	education:          teachers, learners and communities
      policymakers consider how every          During emergencies, children and        to develop a code of conduct can help
      aspect of an education response          young people are often at greater       to ensure that sexual exploitation
      is not only affected by HIV but          risk of HIV infection or of being       and abuse and other forms of
      also provides an opportunity             affected by HIV. Education can          gender-based violence are not
      to prevent new infections and            provide support as well as routines     tolerated and that, where necessary,
      mitigate the impact of HIV.              and structures that reduce risky        disciplinary action is taken.
30                                              HIV/AIDS, SECURITY AND CONFLICT

     The role of policy development in            Sex- and age-disaggregated             Settings3 and complementary guidance
     ensuring that the education sector           data and analysis are vital.           developed by the INEE HIV/AIDS Task
     is prepared and committed to                                                        Team to strengthen educationalists’
     addressing HIV must be appreciated.        ■■Donor practices and emergency          response to HIV. A holistic sector-
     The inclusion of education for               funding mechanisms should              wide approach must address
     crisis-affected populations in               require systematic action to address   primary, secondary and tertiary
     national HIV/AIDS strategies                 HIV in emergencies, in the same        education and formal, non-formal and
     and education sector plans and               way that gender awareness and          informal programmes in emergency
     emergency preparedness plans creates         mainstreaming are now expected         preparedness, response and recovery.
     synergies between education and              by humanitarian funders.
     HIV actors. More needs to be done,                                                  Marian Hodgkin (
     however, to ensure that responses          ■■Better coordination is needed          is Coordinator for Partnerships and
     to emergencies fully address                 between national and international     Knowledge Management for the
     opportunities for positive change:           HIV actors and those within the        Inter-Agency Network for Education in
                                                  education sector so that ad hoc        Emergencies (INEE http://www.ineesite.
     ■■ is critical to analyse pre-crisis
       It                                         and small-scale HIV education          org). Marian Schilperoord (schilpem@
       HIV data and information                   interventions can be scaled up. is a member
       collected by other sectors and,                                                   of INEE’s HIV/AIDS Task Team and
       where appropriate, to include            Practitioners can draw on the INEE       a Public Health and HIV Specialist
       HIV-related questions as part of         Minimum Standards, the Inter-Agency      at UNHCR.
       participatory education needs            Standing Committee’s Guidelines for      1.
       assessments and evaluations.             Addressing HIV in Humanitarian           2.

     HIV/AIDS, security and conflict:
     What do we know? Where do we
     go from here?
     Pamela DeLargy and Jennifer F Klot

     In the ten years since the Security Council’s first resolution on HIV/              for women who head households,
     AIDS, much has been learned about the dynamics linking HIV and                      for women who serve in or are
                                                                                         associated with armed forces and
     AIDS, conflict and insecurity. Assessing progress made over the                     groups and, notably, among women
     past decade in responding to these dynamics enables us to identify                  without any means of support or
     new opportunities for prevention and response.                                      legal claims to marital property
                                                                                         and assets. With little in the way
     The articles in this collection together   border areas and in regions with         of alternative livelihoods, many
     with the findings from the AIDS,           higher and lower HIV prevalence.         women and girls are forced into
     Security and Conflict Initiative                                                    high-risk survival and transactional
     (ASCI) consolidate a growing body          Important new pathways for               sex and early marriage. Others fall
     of social science, public health,          HIV prevention and response              prey to illicit trafficking and sexual
     policy and operational research that       are identified in the context of         slavery. Responding to the range of
     challenges earlier assumptions about       humanitarian and recovery                social and physiological risk factors
     the interactive effects of HIV/AIDS        initiatives relating to disarmament,     associated with sexual violence and
     and insecurity. Contributing authors       demobilisation and reintegration,        exploitation in crises and fragile states
     draw attention to the social factors       with respect to uniformed services,      will require far greater investment
     associated with forced displacement        and sexual violence prevention and       in emergency reproductive health
     and migration and their central            response. New challenges have also       care and STI prevention. It will also
     role in shaping HIV exposure risks.        been identified. Despite dramatically    require gender-sensitive security
     Collectively, they reflect an important    increased access to HIV prevention,      risk assessments and response
     shift in emphasis from behaviourial        care and treatment, particularly in      among displaced communities,
     analyses of HIV transmission               refugee camps, demand continues to       along borders and in return areas
     risks to a focus on the structural         outpace access and availability among    and peacekeeping environments.
     factors that shape individual              those displaced by conflict as well
     behaviour. As demonstrated                 as in resettlement and return areas.     Some of the greatest gaps in conflict-
     throughout this collection,                                                         related HIV prevention and care
     risks vary across peacekeeping             The gendered nature of conflict-         relate to the uniformed services
     environments, camp settings,               related poverty exacerbates risks        including the police, military,
                                                HIV/AIDS, SECURITY AND CONFLICT                                                                         31

      navy and the correctional system.

                                                UNFPA/Pam Delargy
      Significant advances have been
      made in pre- and post-deployment
      prevention, counselling, testing, care
      and treatment for military personnel,
      their families and other dependents.
      But similar investments have yet
      to be made among police, a group
      at far greater risk of transmission
      and with far greater potential to
      serve as agents of change within
      the communities they serve.

      It is a bitter irony that the countries
      with the highest HIV prevalence in
      sub-Saharan Africa are not among
      those considered the most ‘fragile’ by
      current indices of good governance
      and economic development. This has
      obscured the urgency of need and
      related resource gaps, especially at
      local levels of governance. Even where
      well thought out, evidence-based
      programmes have been developed
      by governments, humanitarian or
                                                                                              Condom distribution in the Ethiopian military.
      development agencies, far too many
      donors simply do not understand
      the need for comprehensive HIV                                prevention, treatment and care           When the Security Council turns its
      programming in humanitarian and                               in regions most affected by              attention to HIV/AIDS in 2011, it is our
      recovery settings or are under the                            conflict and HIV, particularly           hope that serious consideration will
      false impression that it just cannot                          in sub-Saharan Africa                    be given to the fivefold challenges of:
      be done. The evidence does not bear
      this out. Much greater investment         ■■whether and how the gap between                            ■■aligning sexual violence
      in HIV prevention and response in           humanitarian funding and                                     prevention and response and
      situations of crisis, displacement          recovery mechanisms has resulted                             HIV prevention and response
      and fragility can facilitate recovery       in discontinuities in prevention
      and reduce the disproportionate             and care for affected populations                          ■■post-deployment HIV prevention,
      risks faced by women and girls.                                                                          treatment and care for uniformed
                                                ■■ dynamics of health system
                                                  the                                                          services personnel and their
      Growing recognition of these new            recovery in post-conflict                                    families and dependents
      challenges and better understanding         reconstruction and the degree
      of the dynamics linking HIV/AIDS,           to which this shapes the impact                            ■■ensuring continuity of access
      conflict and security suggest a             of displacement on HIV risk                                  to HIV prevention, care and
      new agenda for action. From our             transmission and on access                                   treatment during recovery
      perspective, this agenda calls for          to prevention and care                                       and post-conflict transitions
      a greatly accelerated and more
      nuanced response that takes                 the
                                                ■■ need for renewed attention to                             ■■strengthening regional
      into account the following:                 the care burdens disproportionately                          approaches to HIV prevention
                                                  assumed by women and girls,                                  and aligning policies across
      ■■ role of sexual violence and
        the                                       especially in situations with                                countries contributing
        exploitation in HIV transmission,         limited access to treatment and                              troops for peace keeping
        and therefore the need to align HIV       weak health care infrastructure
        and sexual violence prevention                                                                         the
                                                                                                             ■■ role of uniformed services
        policies and programmes                   the
                                                ■■ real and potential role                                     – and especially police – in HIV
                                                  of uniformed services – and                                  prevention and response.
      ■■ way in which gender shapes
        the                                       particularly the police – as agents
        migration and displacement                of change and, in some cases, as a                         Pamela DeLargy (
        patterns (forced by conflict or           ‘core group’ of HIV transmission                           is Senior Advisor in the Arab States
        climate change or economic                                                                           Regional Office at UNFPA (http://www.
        crisis), individual risk acquisition,     the
                                                ■■ dynamics of risk among non-                      Jennifer F Klot (klot@ssrc.
        care burdens and access to                state armed forces, including                              org) is Senior Advisor for HIV/AIDS,
        prevention, care and treatment            militias, rebel groups and those                           gender and security with the Social
                                                  associated with them, both                                 Science Research Council (http://
      ■■ mismatch between resources,
        the                                       during conflicts and afterwards                   Both authors were
        availability and access to HIV            in demobilisation processes.                               Guest Editors of this supplement.
AIDS, Security and Conflict Initiative (ASCI) resources
   ASCI	Research	Hub	                                                    ASCI	Full	Report	                                        ASCI	Executive	Summary                           

  The ASCI Research Reports listed below can be found at:
   1. The Police and HIV/AIDS: A Literature Review                                        16. HIV/AIDS Policies and Programming in DDR and SSR Activities in
      Hilary Pearce                                                                           Southern Sudan: A Post-Conflict Analysis
   2. Current Trends and Issues in Research on HIV/AIDS and                                   Anyieth D’Awol
      Police Forces in Africa                                                             17. How Should We Understand Sexual Violence and HIV/AIDS in
      Alastair Roderick                                                                       Conflict Contexts?
   3. HIV/AIDS and the Central American Uniformed Services                                    Judy El-Bushra
      Dirk Kruijt & Julio Balconi                                                         18. The Visual Economy of HIV/AIDS as a Security Issue
   4. The Impact of HIV/AIDS on the Operational Effectiveness                                 David Campbell
      of Military Forces                                                                  19. HIV, Sexual Violence and Exploitation during Post-Conflict
      Robert Kershaw                                                                          Transitions: The Case of Sierra Leone
   5. The Political Dimensions of Responses to HIV/AIDS in Southeast Asia                     Johannes John-Langba
      Dennis Altman                                                                       20. Comparative Study on Intervention Packages on HIV/AIDS in the
   6. Impact of HIV/AIDS on Governance in Manipur and Nagaland                                Uniformed Services in Africa
      Happymon Jacob                                                                          Center for Policy Research and Dialogue
   7. HIV and State Failure: Is HIV a Security Risk?                                      21. The Conflict-HIV/AIDS Nexus: An Empirical Assessment
      Tony Barnett & Indranil Dutta                                                           Christian Davenport & Cyanne Loyle
   8. Russian Demography, Health and the Military: Current and                            22. A Survey of HIV/AIDS Awareness and Risky Sexual Behaviour in a
      Future Issues                                                                           Vulnerable Population in Sri Lanka
      Murray Feschbach                                                                        International Centre for Ethnic Studies
   9. State Fragility and AIDS in the South Pacific                                       23. AIDS and Local Government in South Africa: Examining the Impact
      Michael O’Keefe                                                                         of an Epidemic on Ward Councillors
  10. Is HIV/AIDS a Threat to Security in Fragile States?                                     Kondwani Chirambo & Justin Steyn
      Azusa Sato                                                                          24. HIV/AIDS and Rape: Modelling Predictions of the Increase in
  11. States of HIV Fragility: Capacity, Vulnerabilities, and Epidemic                        Individual Risk of HIV Infection from Forced Sex in Conflict
      Evolution in Mozambique                                                                 and Post-Conflict
      Erling Høg                                                                              Anna Foss, Rachel von Simson, Cathy Zimmerman,
  12. Indigenous Welfare and HIV/AIDS Risks: The Impacts of Government                        Mazeda Hossain & Charlotte Watts
      Reform in the Papua Region, Indonesia                                               25. Remodelling the Core Group: Factoring Mobility and Power Into
      Claire Smith                                                                            Theories of HIV Transmission
  13. HIV/AIDS, Conflict and the Gendered Implications of Transition                          Charlotte Watts, Cathy Zimmerman, Anna Foss,
      in Burundi                                                                              Cathy Lowndes & Peter Vickerman
      Hakan Seckinelgin, Joseph Bigirumwami & Jill Morris                                 26. Revisiting New Variant Famine: The Case of Swaziland
  14. “First, What is Harm?” The Political Dilemmas of Humanitarian                           Scott Naysmith
      Aid to Burma (Myanmar)                                                              27. Post Conflict Transition and HIV Vulnerability
      Ohnmar Khin                                                                             Manuel Carballo
  15. Neither Will nor Capacity: A Review of the Challenges of Responding
      to AIDS in Fragile States
      Jon Weigel

Sources for further reading on HIV/AIDS, security and conflict
  Anema A et al. (2008), ‘Widespread rape does not directly appear to increase the        Iqbal Z, Zorn C (2010) ‘Violent conflict and the spread of HIV/AIDS in Africa’,
  overall HIV prevalence in conflict-affected countries: So now what?’, Emerging          Journal of Politics, 72.
  Themes in Epidemiology, 5(11).
                                                                                          Jewkes R (2007), ‘Comprehensive response to rape needed in conflict settings,
  Ba O et al. (2008), ‘HIV/AIDS in African militaries: An ecological analysis’,           Lancet’, 369(9580): 2140–141.
  Medicine, Conflict and Survival, 24(2):88–100.
                                                                                          Lowicki-Zucca M, Karmin S, Dehne K (2009), ‘HIV among peacekeepers and
  Barnett T (2006), ‘A long-wave event: HIV/AIDS, politics, governance and                its likely impact on prevalence on host countries’ HIV epidemics’, International
  ‘security’: sundering the intergenerational bond?’, International Affairs, 82(2):297–   Peacekeeping, 16(3):352–63.
                                                                                          Mock N B et al. (2004), ‘Conflict and HIV: A framework for risk assessment
  de Waal A (2006). AIDS and Power: Why There Is No Political Crisis – Yet. London,       to prevent HIV in conflict-affected settings in Africa’, Emerging Themes in
  Zed Books.                                                                              Epidemiology, 1(1).

  Elbe S (2002), ‘HIV/AIDS and the changing landscape of war in Africa’,                  Patel P, Tripodi P (2007), ‘Peacekeepers, HIV and the role of masculinity in
  International Security, 27(2):159–77.                                                   military behaviour’, International Peacekeeping, 14(5):584–98.                           

  Fourie P (2007), ‘The relationship between the AIDS pandemic and state fragility’,      Spiegel P B (2004), ‘HIV/AIDS among conflict-affected and displaced populations:
  Global Change, Peace & Security. 19(3):281-300.                                         Dispelling myths and taking action’, Disasters, 28(3):322–39.                                       

  Hankins C A et al. (2002), ‘Transmission and prevention of HIV and sexually             Whiteside A, de Waal A, Gebre-Tensae T (2006). ‘AIDS, security and the military
  transmitted infections in war settings: Implications for current and future armed       in Africa: A sober appraisal’, African Affairs, 105(419):201–18.
  conflicts’, AIDS, 16(17):2245–252.       

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