Elsevier

The Lancet

Volume 369, Issue 9580, 30 June–6 July 2007, Pages 2187-2195
The Lancet

Articles
Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review

https://doi.org/10.1016/S0140-6736(07)61015-0Get rights and content

Summary

Background

Violence and rape are believed to fuel the HIV epidemic in countries affected by conflict. We compared HIV prevalence in populations directly affected by conflict with that in those not directly affected and in refugees versus the nearest surrounding host communities in sub-Saharan African countries.

Methods

Seven countries affected by conflict (Democratic Republic of Congo, southern Sudan, Rwanda, Uganda, Sierra Leone, Somalia, and Burundi) were chosen since HIV prevalence surveys within the past 5 years had been done and data, including original antenatal-care sentinel surveillance data, were available. We did a systematic and comprehensive literature search using Medline and Embase. Only articles and reports that contained original data for prevalence of HIV infection were included. All survey reports were independently evaluated by two epidemiologists to assess internationally accepted guidelines for HIV sentinel surveillance and population-based surveys. Whenever possible, data from the nearest antenatal care and host country sentinel site of the neighbouring countries were presented. 95% CIs were provided when available.

Findings

Of the 295 articles that met our search criteria, 88 had original prevalence data and 65 had data from the seven selected countries. Data from these countries did not show an increase in prevalence of HIV infection during periods of conflict, irrespective of prevalence when conflict began. Prevalence in urban areas affected by conflict decreased in Burundi, Rwanda, and Uganda at similar rates to urban areas unaffected by conflict in their respective countries. Prevalence in conflict-affected rural areas remained low and fairly stable in these countries. Of the 12 sets of refugee camps, nine had a lower prevalence of HIV infection, two a similar prevalence, and one a higher prevalence than their respective host communities. Despite wide-scale rape in many countries, there are no data to show that rape increased prevalence of HIV infection at the population level.

Interpretation

We have shown that there is a need for mechanisms to provide time-sensitive information on the effect of conflict on incidence of HIV infection, since we found insufficient data to support the assertions that conflict, forced displacement, and wide-scale rape increase prevalence or that refugees spread HIV infection in host communities.

Introduction

There is a common belief that conflict fuels the HIV/AIDS epidemic, and consequently, refugees and internally displaced people fleeing humanitarian emergencies have a high prevalence of HIV infection.1, 2, 3, 4, 5, 6 However, this assumption has been questioned.7, 8, 9 Much of the research behind these claims has not been rigorously assessed and seems to have ignored elements during conflict that might reduce transmission. A notion is emerging about how the HIV epidemic is affected by conflict and forced displacement that depends on the interaction of several complex and commonly countervailing factors.

Sub-Saharan Africa is disproportionately affected by both conflict and the HIV pandemic. Only during the past few years have reports with sufficient data for prevalence of HIV infection become available to make comparisons within and between populations affected by conflict and displacement. These new data allow for a more thorough and scientific assessment of the subject. We asked whether there is evidence to show that conflict increases HIV transmission and whether refugees fleeing conflict have a higher prevalence of infection than do surrounding host populations. We compared prevalence of HIV infection in populations directly affected by conflict with that in populations not directly affected by conflict but located nearest to the conflict, and compared prevalence in refugees and in the nearest surrounding host communities.

Section snippets

Search strategy and selection criteria

From May, 2005, to September, 2006, we searched PubMed, Medline, and Embase from January, 1981, onwards without language restrictions, using Medical Subject Heading terms to identify papers that dealt with the topic of HIV and armed conflict or HIV epidemic. Database searches were done with one or more combinations of the following terms: “HIV”, “AIDS”, “conflict”, “war”, “insurgency”, and “refugee”. Once countries were selected, searches were then done by combination of country names and one

Results

The figure shows the selection of studies meeting inclusion criteria. Nine articles and reports included original data from at least one of the authors. The findings are summarised by country. Although some data for prevalence of HIV infection are available in the DRC since the late 1980s,10, 16, 18, 19 until recently there have been no reliable data from the east, which has been affected by conflict. A 1997 study20 in western DRC (Kinshasa, Mbuji-Mayi, and Bwamanda) showed prevalence to have

Discussion

From original data combined with a systematic review of published work, we conclude that there is insufficient evidence that HIV transmission increases in populations affected by conflict. Furthermore, there are insufficient data to conclude that refugees fleeing conflict have a higher prevalence of HIV infection than do their surrounding host communities. In many circumstances, comparisons of HIV prevalence in both situations show the opposite result.

Data collection during conflict, although

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