Do Complex Emergencies Fuel HIV/AIDS? Think Again. The Case of the Famine in the Horn of Africa
By Fiorenzo Conte
The famine in Somalia is causing thousands of refugees to flee their country and flock to the refugee camp of Dadaab, located in North Eastern province in Kenya. Part of the narratives that have surfaced in the media hold that the droughts and consequent displacement of people could jeopardize the health of people on HIV treatment and fuel the spread of the virus. IRIN Global presents the possible channels through which this might happen (read here for a very similar point made by International HIV/AIDS Alliance). First, refugees, and in particular women, who are walking long distance are more exposed to the risk of being sexually assaulted or raped. This appears to be the case for the Somali refugees, as a report from CARE states the number of rapes and sexual violence reported by refugees arriving in the Dadaab camp to have increased fourfold as compared to the same period last year. Furthermore, overcrowding in the camps is considered to somehow hamper protection mechanisms from sexual assaults. Second, during humanitarian emergencies women see their livelihood options reduce and therefore are more likely to engage in transactional sex, which when combined with low use of condoms, can increase the risk of HIV infections. IRIN quotes a study that ODI conducted in Turkana, a marginalized northwestern region in Kenya, where women were observed to resort to paid sex when a severe drought struck.
This description could be a possible scenario of the situation in Somalia and the Kenyan refugee camp. However, other evidence suggests that this could not be what is happening in the Horn of Africa.
When we consider the claim that the increase in sexual assaults could lead to higher infection rates, the evidence available appears at best weak and inconclusive. First of all one needs to read the number of rapes against the backdrop of the number of people arriving in the camp to appreciate the magnitude of the risk. CARE states that the number of reports of sexual violence increased from 75 in the period between January and June 2010 to 358 in the same period this year. During 2010 Dadaab received an average of 6,000 to 8,000 Somali refugees per month whereas now the number has increased to 10,000 per month. In other words sexual assaults are affecting a small group among the refugees. The fact that it is small does not mean it is insignificant, but it warns us from misreading and over-exaggerating the phenomenon. Furthermore, if an increase in sexual assaults and rapes is to result in higher HIV infection rates, the HIV population amongst the general population and among paramilitaries needs to be high. As the UN Commissioner for Refugees points out, perpetrators of sexual violence must be HIV positive to increase the risk of HIV transmission, and the likelihood of this is low in low prevalence countries. Data about HIV prevalence in Somalia are just not existent. If we are to assume that the Somali regions close to the Kenyan border have HIV prevalence rates similar to the Kenyan border regions where the refugee camp is located, the prevalence would be of 0.8%. In either cases one cannot talk of high prevalence. The current situation is somehow ( if we exclude the case of sexual violence) comparable to those of Sierra Leone, Sudan and Angola where:
“Although sexual violence was reportedly high throughout all three wars, especially in Sierra Leone, the relatively low prevalence among the pre-war population and possibly the paramilitaries may have not been sufficient to accelerate HIV infection in the population (4).”
Another statement often part of the complex emergency/AIDS narrative is that the living conditions in the refugees camps are likely to increase unprotected sexual activities and the risk of sexual violence. This could happen as much as it could not. As Tim Allen showed in his study “AIDS and evidence: Interrogating Some Ugandan Myths”, there is little evidence to conclude that IDP camps increase sexual activities and cases of sexual violence. In the case of the IDP camps in the war zones of Northern Uganda, social interactions were tightly regulated, there was little privacy, AIDS awareness was high and the movement of the inhabitants was restricted, in particular after dusk. This left little room for sexual activities to take place unhidden. As far as sexual violence is concerned, both armies involved in the conflict had a strict regulation about sexual assault and rape was in theory punishable. Soldiers were recruited locally hence their actions were accountable to local leaders even after the conflicts. Cases of rapes did happen but there is no clear evidence that this was a systematic and large-scale phenomenon. So how does the situation look like in the Dadaab camp? Very little is known. Overcrowding is reported to be a challenge in the camp which has reached more than 360,000 people and this might point to the lack of privacy and hence of opportunities for sexual activities. No data is available about AIDS awareness or condoms use. Hence, it is difficult to draw any definitive conclusions. As for the sexual violence, a study conducted in the refugee camp in Turkana (in the north west of Kenya) showed that forced sex was more common among national than refugees. This cautions us from drawing grim pictures before data are collected and collated to extract HIV trend.
The last factor which could increase the risk of HIV transmission is that women engage in transactional sex when faced with extreme circumstances. The ODI study quoted in the article puts forth some evidence that the number of young girls moving to urban centers where they exchange sex for money is perceived to increase in concomitance with the occurrence of the drought (such conclusion appears to be a possible scenario however it is not supported by any data about the magnitude of the phenomenon i.e. how many girls in Turkana are resorting to commercial sex as coping strategy and no information is available about the condom use with paying clients). What increases their likelihood of HIV infections is the fact that these urban centers are located on the northern trade corridor to Sudan which makes some of these towns HIV hotspots (some of the urban areas have 14% HIV prevalence rates). Therefore, engagement in unprotected transactional sex could result in an heightened risk of HIV infections when girls and women have the possibility to move to urban and semi-urban areas where HIV prevalence are considerably higher. It is not clear that this is the case for the people staying in Somalia, as no data is available. Similarly, one would assume that refugees in the camps are limited in their movements and therefore prevented from entering urban areas with higher prevalence.
In sum, the narrative of complex emergencies fuelling HIV/AIDS transmission is often presented as common sense. However, no definitive evidence exists and the interplay between the two forces appears to be determined by local factors. This warns us from taking as definitive, evidence produced by studies like this which look at the correlation between conflict and HIV/AIDS infections across countries thus using country level data. More generally, this prevents us from making any sensationalizing generalization before better data are collected locally.