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World Bank Group
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Washington, DC 20433
Tel: +1 202 458 4946
Fax: +1 202 522 1252
[email protected]
Great Lakes Initiative on HIV/AIDS (GLIA)
P.O. Box 4320
Kigali – Rwanda
Tel: + 250 587344/5
Fax:+ 250 587343
www.greatlakesinitiative.org
[email protected]
www.greatlakesinitiative.org
[email protected]
Global HIV/AIDS Program, World Bank
Rapid analysis of HIV epidemiological and
response data on vulnerable populations
in the Great Lakes Region of Africa
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For more information, please contact:
Great Lakes Initiative on AIDS (GLIA)
and
Global HIV/AIDS Monitoring and Evaluation Team (GAMET)
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WWW.G REATLAKESI NITI ATI VE . O RG
43014
January 2008
Titles in this publication series
available at: www.worldbank/aids > publications
1.
Lessons from World Bank-Supported Initiatives to Fight HIV/AIDS in Countries
with IBRD Loans and IDA Credits in Nonaccrual. May 2005.
2.
Lessons Learned to date from HIV/AIDS Transport Corridor Projects. August 2005.
3.
Accelerating the Education Sector Response to HIV/AIDS in Africa: A Review of
World Bank Assistance. August 2005
4.
Australia’s Successful Response to AIDS and the Role of Law Reform. June 2006.
5.
Reducing HIV/AIDS Vulnerability in Central America. December 2006. (English,
Spanish)
6.
Reducing HIV/AIDS Vulnerability in Central America: Costa Rica: HIV/AIDS
Situation and Response to the Epidemic. December 2006. (English, Spanish)
7.
Reducing HIV/AIDS Vulnerability in Central America: El Salvador: HIV/AIDS
Situation and Response to the Epidemic. December 2006. (English, Spanish)
8.
Reducing HIV/AIDS Vulnerability in Central America: Guatemala: HIV/AIDS
Situation and Response to the Epidemic. December 2006. (English, Spanish)
9.
Reducing HIV/AIDS Vulnerability in Central America: Honduras: HIV/AIDS
Situation and Response to the Epidemic. December 2006. (English, Spanish)
10. Reducing HIV/AIDS Vulnerability in Central America: Nicaragua: HIV/AIDS
Situation and Response to the Epidemic. December 2006. (English, Spanish)
11. Reducing HIV/AIDS Vulnerability in Central America: Panama: HIV/AIDS
Situation and Response to the Epidemic. December 2006. (English, Spanish)
12. Planning and Managing for HIV/AIDS Results – A Handbook September 2007
(English, Spanish, French, Russian)
13. Rapid analysis of HIV epidemiological and HIV response data about vulnerable
populations in the Great Lakes Region of Africa. January 2008. (English, French)
Published with the Great Lakes Initiative on AIDS.
RAPID ANALYSIS OF HIV EPIDEMIOLOGICAL AND
RESPONSE DATA ON VULNERABLE POPULATIONS
IN THE GREAT LAKES REGION OF AFRICA
Great Lakes Initiative on AIDS (GLIA)
and
Global AIDS Monitoring & Evaluation Team (GAMET)
World Bank Global HIV/AIDS Program
January 2008
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
World Bank Global HIV/AIDS Program
This series of reports is produced by the Global HIV/AIDS Program of the World Bank's Human
Development Network, to publish interesting new work on HIV/AIDS quickly, and make it widely
available.
The findings, interpretations, and conclusions expressed in this report are entirely those of the
author(s) and should not be attributed in any manner to the World Bank, to its affiliated
organizations or to members of its Board of Executive Directors or the countries they represent.
Citation and the use of material presented in this series should take into account that it may be
provisional.
Reports are posted at www.worldbank.org/AIDS (go to “publications”).
For free print copies of reports in this series please contact the corresponding author whose name
appears the bottom of page iii of the paper. Enquiries about the series and submissions should be
made directly to Joy de Beyer (jdebeyer@worldbank).
Cover photographs:
1. (center) Women march behind armed soldiers at an HIV/AIDS demonstration in Kenya. © 2006
Felix Masi/Voiceless Children, Courtesy of Photoshare
2. (top left) “Breaktime at Amuru Rekiceke school”, Uganda – girls walk past a sign saying
“VIOLENCE IS WRONG”. By kind permission of WRENmedia, www.wrenmedia.co.uk
3. (top right) Fishermen prepare nets on the shore of Lake Victoria, Tanzania. © World Bank.
Photographer: Scott Wallace.
4. (bottom left) Violence in Rwanda and Burundi have caused thousands of refugees to flee to
neighboring countries. © 2008 Pittsburgh Post-Gazette, all rights reserved. Reprinted with
permission.
5. (bottom right) A group of ex-combatants who have been trained and employed by local NGOs
to construct roads in the region of Ituri, Democratic Republic of the Congo. © 2006 Wendy
MacNaughton, Courtesy of Photoshare
© 2008 The International Bank for Reconstruction and Development / The World Bank
1818 H Street, NW
Washington, DC 20433
All rights reserved.
i
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ii
Rapid analysis of HIV epidemiological and response data
on vulnerable populations in the Great Lakes Region of Africa
Nicole Fraser,a Marelize Görgens-Albino,b and John Nkongoloc
a
Team Leader, Epidemiologist, Consultant to the World Bank
Monitoring and Evaluation Expert, World Bank
c
Research Assistant, Consultant to the World Bank
b
This analysis of HIV epidemiological and response data on vulnerable populations residing in or
moving through the Great Lakes Region was commissioned by the Great Lakes AIDS Initiative
(GLIA) to improve the evidence base underpinning development of the new GLIA Strategic Plan
for the period 2008-2012. The work was a collaborative effort led and guided by the GLIA
Secretariat, and jointly funded by the Global AIDS Monitoring and Evaluation Team (GAMET) of
the World Bank Global HIV/AIDS Program (GHAP), and the GLIA Secretariat.
Abstract:
Background: The Great Lakes Initiative on HIV/AIDS (GLIA), a new regional institution created
by the governments of Burundi, Democratic Republic of Congo (DRC), Kenya, Rwanda, Tanzania
and Uganda, aims to support the HIV responses of these countries by focusing on mobile
populations not covered by national HIV programs and on improving capacity for and regional
collaboration. In developing a new 5-year HIV Strategic Plan, the GLIA undertook this analysis to
decide: “On which populations should the GLIA focus, why and with what type of HIV
interventions?”
Design: A literature search and analysis of 387 documents identified eight highly vulnerable
populations whose lives are touched by mobility, conflict and violence; whose vulnerability, HIV
risk factors, size and HIV prevalence are known and make significant contributions to ongoing HIV
transmission. The extent to which the 8 sub-populations are targeted in the National HIV Strategic
Plans of the 6 countries was assessed, and recommendations made on how the GLIA could add
value and complement national programs.
Results: Epidemiological data for the Great Lakes Region suggest that higher risk populations are
important in driving the epidemic and that unprotected higher risk sex and paid sex remain key
contributors. Long-distance truck drivers, Fishermen & fisherwomen, Uniformed services,
Refugees, Internally displaced persons, Prisoners, and Females affected by sexual violence are
populations of significant size (14 million persons), with HIV prevalence significantly higher than
other sub-populations, and constitute a significant proportion of total PLHIVs in the six countries
(from 8% in Kenya, to 20% in Uganda). They are not comprehensively targeted or well covered by
national programs, but there is some evidence of success through promising interventions for these
vulnerable populations.
Conclusions: The 8 populations are important intervention targets because of their size, intensity of
higher-risk sexual behaviors, level and trends of HIV prevalence, potential to act as an HIV
“bridging population” into the general population, mobility or interaction with mobile persons, and
exposure to conflict and violence. The study recommends: (a) evidence-informed interventions for
each population; (b) strategic objectives for GLIA to consider; (c) four value-adding roles for GLIA
- communications & advocacy; monitoring, evaluation & research; technical support; and
networking.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Keywords: HIV, AIDS, Epidemic, Response, Policy Analysis, GAMET, Great Lakes AIDS Initiative
(GLIA), World Bank, Burundi, Democratic Republic of Congo, Kenya, Rwanda, Tanzania, Uganda.
Correspondence Details: Marelize Görgens-Albino, email: [email protected], Mobile
phone: +27.82.774.5523. Fax: (202) 522-1252
iii
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Acronyms and Abbreviations
AIDS
AIS
AMREF
ANC
ART
ARV
ATGWU
AU
AVEGA
BCC
BSS
CBO
CEPGL
CMA
CNLS
COMESA
CSO
CSW
DFID
DHS
DRC
EAC
FHI
FSW
GBV
GLIA
HBC
HEARD
HIV
IDP
IEC
IGAD
ILO
IOM
ITF
MAP
MC
MISP
MOH
MOU
MSF
NAC
NACC
NACP
NAS
Acquired Immuno-deficiency Syndrome
AIDS Indicator Survey
African Medical and Research Foundation
Ante-natal care
Antiretroviral therapy
Antiretroviral (drugs)
Amalgamated Transport and General Workers’ Union
African Union
Association des Veuves du Génocide
Behavioral Change Communication
Behavioral Surveillance Survey
Community-based Organization
Communauté Economique des Pays des Grands Lacs
Civil-Military Alliance to Combat HIV and AIDS
Commission / Conseil National de Lutte contre le SIDA
Common Market for Eastern and Southern Africa
Civil Society Organization
Commercial Sex Worker
U.K. Department for International Development
Demographic and Health Survey
Democratic Republic of Congo
East African Community
Family Health International,
Female Sex Worker
Gender-based Violence
Great Lakes Initiative on HIV/AIDS
Home Based Care
Health Economics and HIV/AIDS Research Division
Human Immunodeficiency Virus
Internally Displaced Person
Information, Education and Communication
Inter-Governmental Agency for Development
International Labour Organisation
International Organization for Migration
International Transport Workers’ Federation
Multi-Country HIV/AIDS Program for the Africa Region
Male circumcision
Minimal Initial Services Package
Ministry of Health
Memorandum of Understanding
Medecins sans Frontières
National HIV/AIDS Council/Commission/Committee
National AIDS Control Council
National HIV/AIDS Control Program
National AIDS Secretariat
iv
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
NEPAD
NGO
NSP
OCHA
OI
OVC
PEP
PLHIV
PMTCT
PNLS
PSI
REDSO
SADEC
SFLP
SRH
SSA
STD
STI
SWAA
TB
TRAC
UAC
UNAIDS
UNECA
UNHCR
UNODC
USAID
VCT
WHO
ZAC
New Partnership for Africa’s Development
Non-Governmental Organization
National Strategic Plan
United Nations Office for the Coordination of Humanitarian Affairs
Opportunistic Infection
Orphans and Vulnerable Children
Post exposure prophylaxis
People Living with HIV
Prevention of Mother-To-Child Transmission
Program National de Lutte contre le SIDA
Population Services International
USAID Regional Economic Development Services Office
Southern African Development and Economic Community’
Sustainable Fisheries Livelihoods Programme
Sexual and Reproductive Health
Sub-Saharan Africa
Sexually Transmitted Disease
Sexually Transmitted Infections
Society for Women against AIDS in Africa
Tuberculosis
Treatment Research and AIDS Center
Uganda AIDS Commission
United Nations Joint HIV/AIDS Programme
UN Economic Commission for Africa
UN High Commissioner for Refugees
United Nations Office on Drugs and Crime
U.S. Agency for International Development
Voluntary Counseling and Testing
World Health Organization
Zanzibar AIDS Commission
v
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
vi
Table of Contents
ACKNOWLEDGEMENTS ........................................................................................................ X
EXECUTIVE SUMMARY ...................................................................................................... XII
1. INTRODUCTION..................................................................................................................... 1
1.1 Overview of the Great Lakes Region ................................................................................ 1
1.2 Background to the Great Lakes Initiative on HIV/AIDS................................................ 2
1.3 Purpose of the Study ........................................................................................................... 3
1.4 Structure of the Report....................................................................................................... 3
2. METHODOLOGY .................................................................................................................. 4
2,1 Literature Search ................................................................................................................ 5
2.2 Cataloguing & Classifying Documents.............................................................................. 5
2.3 Data Analysis ....................................................................................................................... 6
2.4 Limitations of the Study ..................................................................................................... 6
3. RESULTS: DESCRIPTION OF THE COUNTRIES’ HIV EPIDEMICS ........................ 8
3.1 Transmission Pathways ...................................................................................................... 8
3.2 Epidemic State ................................................................................................................... 10
3.3 Epidemic Phase (Trends in the HIV Epidemics)............................................................ 11
3.4 Age Patterns of Infection .................................................................................................. 13
3.5 Urban-Rural Differentials ................................................................................................ 14
3.6 Incidence of Infection........................................................................................................ 15
3.7 Sexual Behavior Data....................................................................................................... 17
3.8 Male Circumcision ............................................................................................................ 19
3.9 Transactional Sex .............................................................................................................. 20
3.10 In Summary ..................................................................................................................... 21
4. RESULTS: VULNERABLE POPULATIONS IN THE GLR........................................... 22
4.1 Who are the Vulnerable Populations in the GLR? ........................................................ 22
4.2 Long-Distance Truck Drivers .......................................................................................... 24
4.3 Fishermen & Fisherwomen .............................................................................................. 29
4.4 Military & Other Uniformed Forces ............................................................................... 32
4.5 Female Sex Workers ......................................................................................................... 36
4.6 Refugees, Internally Displaced Persons, Host Populations & Returnees .................... 41
4.7 Refugees.............................................................................................................................. 42
4.8 Internally Displaced Persons............................................................................................ 46
4.9 Returnees............................................................................................................................ 49
4.10 Prisoners........................................................................................................................... 49
4.11 Females Affected by Sexual Violence ............................................................................ 53
4.12 Summary: Population Sizes, HIV Prevalence and Number of PLHIV...................... 58
5. RESULTS: VULNERABLE POPULATIONS AND COUNTRY NSPS.......................... 63
6. RESULTS: PROMISING INTERVENTIONS ................................................................... 65
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
vii
6.1 Targeting Truckers and Other Vulnerable Populations in Transport Corridors ...... 66
6.2 Targeting Fishermen and Fishing Communities............................................................ 69
6.3 Targeting Military and Other Uniformed Services ....................................................... 71
6.4 Targeting Refugees, Internally Displaced Persons and Returnees............................... 74
6.5 Targeting Prisoners........................................................................................................... 76
6.6 Targeting Sexual Violence and Affected Females .......................................................... 78
6.7 Targeting FSWs and Their Clients.................................................................................. 79
7. CONCLUSIONS .................................................................................................................... 81
8. POLICY IMPLICATIONS OF THIS STUDY ................................................................... 86
ANNEXES
I
Selected Maps ......................................................................................................................90
II Description of the Countries in the Great Lakes Region ..............................................101
III Mobility and Migration of People in the Great Lakes Region .....................................104
IV Components of the GLIA Support Project.....................................................................111
V
Terms of Reference for the Study ..................................................................................112
VI Study Calendar..................................................................................................................123
VII Literature Catalogue ........................................................................................................125
VIII Analysis of the national strategic plans of the GLIA countries....................................176
IX Selected statistics...............................................................................................................186
List of Tables
Table 1. Summary of population sizes and PLHIV numbers of selected populations ...... xviii
Table 2. Methods to estimate population size, median HIV prevalence and PLHIV numbers
for the selected vulnerable populations .............................................................................. 7
Table 3. HIV prevalence and PLHIV numbers in GLIA countries ....................................... 10
Table 4. Sex-specific HIV prevalence and sex ratio................................................................. 11
Table 5. HIV prevalence by residence, disaggregated by sex ................................................. 15
Table 6. Population-based data on sexual behavior in GLIA countries .............................. 17
Table 7. Prevalence of transactional sex in GLIA countries................................................... 21
Table 8. Vulnerable populations identified and frequency of mention, by country............. 22
Table 9. Truck driver population data for GLIA countries .................................................. 25
Table 10. HIV prevalence in truck driver population and median prevalence .................... 25
Table 11. Truck drivers – Population size, vulnerability and HIV risk factors .................. 28
Table 12. Fishing population data for GLIA countries........................................................... 29
Table 13. HIV prevalence in fishermen and median prevalence........................................... 30
Table 14. Fishermen & fisherwomen – Population size, vulnerability and HIV risk factors
............................................................................................................................................... 32
Table 15. Military population data for GLIA countries ........................................................ 33
Table 16. Comparison of sexual behavioral data for Burundi and the DRC........................ 35
Table 17. Military population – Population size, vulnerability and HIV risk factors.......... 36
Table 18. Sexual behavior data of female sex workers in GLIA countries ........................... 39
Table 19. Female sex workers - Population size, vulnerability and HIV risk factors .......... 41
Table 20. Refugee population data for GLIA countries.......................................................... 43
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
viii
Table 21. HIV prevalence in refugees (2003-2007) and median prevalence......................... 44
Table 22. IDP population data for GLIA countries................................................................. 47
Table 23. Refugees & IDPs – Group size, vulnerability and HIV risk factors...................... 49
Table 24. Prison population data for GLIA countries ............................................................ 50
Table 25. HIV prevalence in prison populations and median prevalence............................. 50
Table 26. Prisoners – Population size, vulnerability and HIV risk factors ........................... 52
Table 27. Prevalence of sexual violence against women and median prevalence ................ 55
Table 28. Population of females affected by sexual violence................................................... 57
Table 29. Females affected by sexual/GB violence – Population size, vulnerability and HIV
risk factors ........................................................................................................................... 57
Table 30. Summary of population sizes and PLHIV numbers of selected populations ...... 61
Table 31. Targeting of vulnerable populations in current National Strategic Plans............ 63
Table 32. Vulnerable populations to target and promising interventions............................. 83
Table 33. Migration data from GLIA countries (mid-year 2000)……………….……………… 105
List of Figures
Figure 1. (a) Surface area of the GLR countries, and (b) Population density of the GLR
countries................................................................................................................................. 1
Figure 2. Trends in median HIV prevalence in ANC clients 1990-2007 in (a) major urban
areas and (b) outside major urban areas in the GLR .................................................... 12
Figure 3. ANC sites in Uganda with increased HIV prevalence between 2002 and 2005 .... 13
Figure 4. Age specific HIV prevalence in GLIA countries ..................................................... 14
Figure 5. Distribution of the percent incident cases by mode of exposure: Example of
Kenya ................................................................................................................................... 16
Figure 6. Provincial/regional data on HIV prevalence versus male circumcision rates .... 19
Figure 7. Mean number of overnight trucks: Mombasa-Nairobi (a), Nairobi-Uganda
border (b)............................................................................................................................. 26
Figure 8: Trends of HIV prevalence in the Ugandan military 1991-2003............................. 35
Figure 9. HIV prevalence in female sex workers in GLIA countries, 1990-2006 ............... 38
Figure 10. Refugee, IDP and Returnee Displacement cycle.................................................... 42
Figure 11: Relative level of the HIV burden in the selected vulnerable populations in the
GLIA countries ................................................................................................................... 58
Figure 12. Proportions of PLHIV in all eight vulnerable populations combined compared
to total PLHIV, per country............................................................................................... 59
Figure 13. Urbanisation trends in GLIA countries................................................................107
List of Maps
The countries of the Great Lakes Region………………………………………………… ......91
Population density and HIV prevalence level by antenatal sentinel site
Burundi, and Democratic Republic of Congo………………………................................92
Kenya, and Rwanda………………………………………………………..........................93
Tanzania, and Uganda……………......................................................................................94
HIV Prevalence of the Adult Male and Female Population by Province ...............................95
HIV Prevalence of the Adult Male Population by Province……………………………….. ..96
HIV Prevalence of the Adult Female Population by Province……………………… ............97
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ix
Major road axes, truck stops and truck volume……………………………………… ...........98
Change in IDP and Refugee Numbers (December 2006 to mid-Year 2007)… ……. ............99
Vulnerable populations in the GLIA countries: estimated group size and estimated
numbers of PLHIV…………………… ............................................................................100
Burundi .......................................................................................................................................101
Democratic Republic of Congo .................................................................................................101
Kenya ..........................................................................................................................................102
Rwanda .......................................................................................................................................102
Tanzania......................................................................................................................................103
Uganda ........................................................................................................................................103
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
x
ACKNOWLEDGEMENTS
Producing this report was a collaborative effort under the leadership and guidance of the GLIA
Secretariat. The analysis was jointly funded by the World Bank’s Global AIDS Monitoring and
Evaluation Team (GAMET) at the Global HIV/AIDS Program (GHAP) and GLIA Secretariat.
The authors thank the GLIA Council of Ministers, GLIA Executive Committee, GLIA Executive
Secretary and the staff of the GLIA Secretariat for their vision and support in conducting this
analysis. The work could not have been carried out without the support of the National AIDS
Commissions and Ministries of Health of the six GLIA countries – Burundi, Democratic
Republic of Congo (DRC), Kenya, Rwanda, Tanzania, and Uganda.
The GLIA Secretariat extends a special thanks to the people who gave their time and energy to
review the analysis and provide constructive inputs that improved the final product. We
gratefully acknowledge contributions and additional data received from (listed in alphabetical
order): Joy de Beyer (World Bank), Watchiba Dede (DRC), Pamphile Kantabaze (World Bank),
Susan Kasedde (UNAIDS), Jody Zall Kusek (World Bank), Sophia Luhindi (GLIA Secretariat),
Emmanuel Malangalila (World Bank), Masauso Nzima (UNAIDS ESA RST), Elisabetta Pegurri
(UNAIDS Rwanda), Marian Schilperoord (UNHCR), Richard Seifman (World Bank), Paul
Spiegel (UNHCR), Peter Tukei (Kenya Medical Research Institute), Joseph Wakana (GLIA
Secretariat), Brian Wall (UNAIDS Uganda), David Wilson (World Bank), Dieudonne Yiweza
(UNHCR), as well as the individual participants in the Bujumbura GLIA epidemiological and
HIV response analysis technical review workshop (11 and 12 December 2007, Burundi).
Our grateful appreciation to the World Bank Task Team Leaders for the World Bank Multicountry AIDS Program (MAP) funding for the GLIA, in Burundi, Kenya, Uganda, Tanzania,
Rwanda, and the DRC for their support of this study. We thank these Task Team Leaders (and
their representatives) for their leadership and inputs – specifically Pamphile Kantabaze, Frode
Davanger, Alex Kamurase, Montserrat Meiro-Lorenzo, Michael Mills, Peter Okwero, Miriam
Schneidman and and Jean-Pierre Manshande.
Thank you also to the GAMET team members who shared their experience in conducting
syntheses in other parts of the world – Rosalia Rodriguez-Garcia, and Julie Victor-Ahuchogu
and to the UNAIDS country offices, Geneva, and the Regional Support Teams for East and
Southern Africa for their support of this work.
The report was greatly improved by using spatial analysis. We thank Bruno Bonansea and
Jeffrey Lecksell at the World Bank Map Design Unit for producing new maps, and World Health
Organisation, OCHA/Relief Web and Professor Alan Ferguson for providing us with copyright
permission to reproduce maps that they created as part of their research in this report.
We acknowledge the valuable contributions of Pascale Kraus and Catherine Gibeault who
translated key materials for the Bujumbura technical review workshop, enabling participants to
read the research results in French (translations for workshop funded by GHAP at the World
Bank), and, then translated the full report once it was finalized (funded by the GLIA).
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
xi
Finally, we thank every researcher and every research subject of the 285 pieces of research that
were reviewed as part of the analysis, for their hard work and effort in publishing their research
results – without their work, this meta-analysis would not have been possible.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
xii
EXECUTIVE SUMMARY
1. Introduction
The Great Lakes Initiative on HIV/AIDS (GLIA) was created in 1998 by the Governments of
Burundi, Democratic Republic of Congo (DRC), Kenya, Rwanda, Tanzania and Uganda to address
the HIV epidemic more effectively within the Great Lakes Region, a region significantly affected
by mobility, conflict and displacement. The mission of the GLIA is to support, supplement and
complement the HIV response efforts of the six National AIDS Commissions, without duplicating
services: “the GLIA’s mission [is] to contribute to the reduction of HIV infections and to mitigate
the socio-economic impact of the epidemic in the Great Lakes Region by developing regional
collaboration and implementing interventions that can add value to the efforts of each individual
country”.
This analysis of HIV epidemiological and HIV response data relating to vulnerable populations
residing in or moving through the Great Lakes Region was commissioned by the GLIA to improve
the evidence base for the development of the GLIA Strategic Plan for the period 2008-2012. The
main question guiding this analysis was: “On which populations should the GLIA focus, why and
with what type of HIV interventions?” to help the GLIA determine – as per its mission statement –
how it can add value to the HIV response efforts of the six GLIA member countries.
The objectives of the study were to (a) describe the HIV epidemic state and phase in each GLIA
country (section 2); (b) identify populations with high vulnerability to, at high risk of HIV infection
or at higher risk of HIV transmission (section 3); (c) describe these populations’ HIV prevalence,
risk factors, mobility and sexual behavior (section 3); (d) assess the coverage of these populations
by the HIV strategic plans of the six countries (section 4); (e) identify, based on evidence (if
available) promising HIV interventions for these populations (discussed in the main study, but not
in this summary); (f) define, based on available evidence, which vulnerable populations the GLIA
should focus on (section 5), and (g) recommend the type of interventions the GLIA should support,
given its mission and the framework of its Strategic Plan (section 6).
The literature search yielded 285 published and unpublished documents from GLIA countries; a
literature catalogue was developed as an output of this study. Estimations of population sizes,
median HIV prevalence and numbers of people living with HIV (PLHIV) were calculated for the
military, long-distance truck drivers, fishermen and fisherwomen, refugees, internally displaced
persons (IDPs), prisoners, and females affected by sexual violence, but not for female sex workers
(FSW) due to lack of clear risk group membership. Some limitations of the study are that data on
the size of vulnerable populations are scarce or incomplete, and HIV prevalence data are often out
of date or from small samples.
2. Results - The HIV Epidemics in the GLIA Countries
The HIV epidemics in the six countries are highly diverse, with provincial HIV prevalence ranging
from 15.1% (Nyanza Province, Kenya) and 13.5% (Mbeya Region, Tanzania) to 0.6% (Zanzibar)
and 0% (North-Eastern Province, Kenya). National HIV prevalence in Kenya, Tanzania and Uganda
are 6-7%, about twice as high as prevalence in Burundi, DRC and Rwanda (approx. 3%). HIV
prevalence is higher in women than men in all countries. Young women in Burundi, Kenya,
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
xiii
Rwanda and Uganda are 3-4 times more likely to be HIV positive than their male peers, but in
Tanzania infection rates are more similar between the sexes (no population based data are available
for DRC).
Overall, the HIV epidemics are stabilizing or contracting – most clearly in Uganda, Kenya, Rwanda
and rural Tanzania. However, some sentinel surveillance sites show an upward trend in prevalence.
There is less evidence that the epidemics in DRC and Burundi are contracting or stabilizing. HIV
prevalence levels are significantly higher in urban areas than in rural areas, suggesting that higher
risk populations in urban areas are important drivers of the epidemics. In all six countries, the HIV
epidemic has been dominated by sexual transmission. Intravenous drug use (IDU) has been
identified as an important driver in some concentrated urban and coastal areas of Kenya and
Tanzania.
Data on HIV incidence, providing information about where new infections happen, are scarce for
the GLIA countries. Kenya’s modeled data suggest that the bulk of new infections are in the general
population (30%), in partners of those involved in casual sex (28%), and in individuals involved in
casual heterosexual sex with non-regular partners (18%). Clients of sex workers accounted for 11%
and sex workers for 1.3% of all new infections, and there were considerable numbers of new
infections in IDUs (4.8%) and men having sex with men (4.5%).
Male circumcision (MC), an important modulator of population prevalence, was found to vary
widely in the GLIA countries, ranging from 84% in Kenya, to 70% in Tanzania, 25% in Uganda and
11% in Rwanda. The epidemiological data for the general populations of the GLIA countries
suggest that higher risk populations play an important role in driving the epidemic and that
unprotected higher risk sex, and to some extent paid sex, remain key contributors to the continuing
transmission of HIV.
3. Results - Vulnerable Populations in the GLIA Countries
The literature review identified more than 20 different vulnerable populations that differ vastly in
characteristics and sometimes overlap. Good data were available on some populations, little data
were found on others (such as mobile traders, domestic servants, police force, miners, men having
sex with men, workers on marine and inland waterways, abducted children and trafficked people).
From the list of all vulnerable populations, the study team produced a short-list of eight vulnerable
populations for detailed analysis, focusing on populations: whose life is touched by mobility,
conflict and violence; who, according to the epidemiological evidence, make significant
contributions to the ongoing transmission of HIV; or whose population size, HIV prevalence,
vulnerability profile and HIV risk factors are known or could be estimated from the literature.
xiv
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
SUB-POPULATIONS WHO ARE IN MOBILE OCCUPATIONS, OR INTERACT WITH PERSONS IN
MOBILE OCCUPATIONS
3a. Long-distance truck drivers:
Estimated population size in GLR = 298,458; Estimated median HIV prevalence: 18%
Vulnerability factors
Risk Factors for HIV
• Long separation from spouses and family
• Serial and concomitant partners
• Unrealistic work schedules, monotonous work
• Regular sex workers are treated as wives, with
low condom use
• Loneliness & isolation, mitigated by providing transport to people
• Road risks (accidents, theft)
• Work in remote, poor environments with inadequate facilities
• Easy access to alcohol, stress leading to abuse of alcohol/drugs
• Inconsistent levels of condom use
• Low level of condom use with regular partners
and spouses
• Availability of disposable funds
• Limited access to regular HIV prevention
services, including VCT
• Long, frustrating delays at borders and custom checkpoints
• Casual sex readily available
• Harassment /stigmatisation by police, border officials, etc.
• Lack of health infrastructure where transport workers need it,
large trucks cannot get to facilities off the main road
• Milieu around border posts caters for the
sexual needs of transport workers, with
brothels, taverns and bars
• Stigma and discrimination by employers, low legal protection
• Context of sexual violence and harassment
• Macho culture
• Women asking for rides pay with sex
3b. Fishermen & fisherwomen:
Estimated population size in GLR = 447,656; Estimated median HIV prevalence: 24.7%
Vulnerability factors
• Time fishermen spend away from home, high mobility
• Alcohol use to help cope with dangers/stress of occupation
• Demographic profile (mostly young age)
• Fishing is a high-risk occupation which can contribute to culture
of risk denial or risk confrontation
• Access to daily cash income, high income in fishing season
• Ready availability of commercial sex in fishing ports
• Social marginalisation and low status
• Subordinate position of women in many fishing communities
• Difficult to reach with disease prevention efforts
Risk factors for HIV
• Culture of hypermasculinity which may include
expectation of multiple sexual partners
• Poor access to facilities and medicine and low
uptake of available health services
• Difficult to reach with adequate AIDS treatment
and mitigation measures
• Fishing camps and ports may lack social
structures that constrain sexual behavior as in
home communities
xv
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
3c. Military:
Estimated population size in GLR = 401,020. Estimated median HIV prevalence: The only recent data identified came
from the Uganda Defence Force (20%). Due to claims that HIV prevalence may be lower than suspected, a prevalence
range of 10-20% was used to estimate PLHIV numbers in the military.
Determining vulnerability and HIV risk factors are not always straightforward for the military and sometimes there are
plausible counter-factors that would reduce vulnerability or HIV risk.
Vulnerability factors (counter factors in brackets)
Risk factors for HIV (counter factors in brackets)
• Generally young men, at the age of seeking partners (but: young
males in lowest HIV prevalence group)
• Trained to regard risk-taking and aggressive
behavior as the norm
• Trained not to be deterred by risk and danger
• Access to CSW and settlements with ‘soldiers
wives’ (but: these sexual networks are often
restricted)
• Separated for long periods from spouses and partners, or denied
marriage during enlistment periods
• When away, removed from the social discipline (but: disciplined
army environment, not all soldiers away from base)
• Living in same-sex quarters
• Some ranks well paid
• Susceptible to peer pressures
• May seek to relieve themselves from combat stress through sex
• At risk of physical injury involving loss of blood
and need for blood transfusion under possibly
non-sterile conditions
• Sharing of razors and skin-piercing instruments in
tattooing and scarification
• (Testing and selection of HIV negative individuals
at recruitment, and motivation to stay negative)
• Abstinence on duty may be followed by breaks of sex and alcohol
3d. Female sex workers:
The study did not attempt to estimate population size and median HIV prevalence, due to challenges in defining this sub
population.
Vulnerability factors
Risk factors for HIV
• Illegal metier, hidden occupation
• Early onset of sexual activity
• Other work may pay less
• High intensity of sexual intercourse with multiple
concurrent partners
• Alcohol and drug consumption
• Occupation in places where transactional sex is frequent
• Compromised power relations
• These multiple concurrent partners often have
multiple partners themselves (sexual network)
• Low level of empowerment and education
• Low risk perception towards regular clients (trust
leads to non-use of condoms)
• Lack of protection by law or society
• Regular clients with other sexual contacts
• Stigmatised by community
• Lack negotiating power on safer sex practices
• Can be illegal migrant
• Anal sex (client demand, menstruation, STIs)
xvi
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
SUB-POPULATIONS WHO ARE MOBILE OR AT INCREASED RISK DUE TO VIOLENCE
3e. Refugees & IDPs:
Refugees: Estimated population size in GLR = 1.2 million; Estimated median HIV prevalence: 1.65%
IDPs: Estimated population size in GLR = 2.9 million; Estimated national HIV prevalences for each country used for
calculations (range 3.1% - 6.7%).
Vulnerability factors
• Dispossessed of land, productive resources, home
• Illegal settlement and resulting expulsion
• War destroys infrastructure (health, education, etc)
• Poor access to comprehensive health services
• Multiple threats to health other than HIV
Risk factors for HIV
• Minimum standards in humanitarian interventions
may not include HIV prevention
• Barriers to HIV prevention: disruption of health
services; testing for HIV may be difficult
• Disruption of sexual partnerships and networks
• Economic situation of women and children
• Outside habitual norms and social control,
persons may adopt new behaviors
• Migration from rural areas where HIV prevalence and knowledge
of HIV low
• Sexual interaction with military or paramilitary
• Unaccompanied minors lack parental protection
• Psychological trauma
• Potentially, disruption of family and social structures
• IDPs: Lack of official status & protection framework
• Transactional sex, also as “survival strategy”
• Sexual violence, multiple perpetrators
• New sexual relationships with power differentials
• Potentially, increased use of alcohol and illicit
drugs, and unsafe blood transfusion practices
3f. Prisoners:
Estimated population size in GLR = 222,042; Estimated median HIV prevalence: 5.6%
Vulnerability factors
Risk factors for HIV
• Weakness of the criminal justice and judicial systems
• IDU with contaminated equipment
• Mixing of un-sentenced and convicted persons
• New norms of dominance and power
• Stigmatization of prisoners by society
• High-risk sexual activities (anal sex, gang
rape, etc)
• Appalling living conditions, overcrowding
• Substandard or nonexistent health care
• Gender exclusive environment, lack of conjugal visits
• Restriction on drug use & harm reduction measures
• Criminalization & denial of sexual activity/rape
• High turnover and mobility among prisoners
• Little autonomy in own protection
• Prostitution as a coping mechanism
• Tattooing and other forms of skin piercing
• Blood brotherhood rituals
• Untreated STIs
• Prevention commodities (condoms, lubricants,
needles/ syringes, bleach) often not available
• Lack of access to IEC services
xvii
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
3g. Females affected by sexual violence:
Estimated excess female PLHIV due to sexual violence in GLR = 157,777, based on the estimate that approximately 7.8
million females in the GLR have a history of sexual violence, and that females with a history of sexual violence are
about 1.4 times more likely to be HIV positive.
Vulnerability factors
Risk factors for HIV
• Low literacy, subordinate status of females
• Multiple perpetrators from higher risk groups
• Violence widely tolerated as a form of social control
• Young age of female
• Rape survivors stigmatised by partners, community
• Abusive partner imposing sexual practices
• High levels of male dominance in relationship
• HIV positive male partner
• Physical violence in partnership
• Physical trauma in genital/anal area
• Alcohol use
• Condom use rare in violent sex
• Frequent partner change, casual partners
• Lack of counseling and PEP
4. Results - Vulnerable Populations and National Strategic Plans
The following observations were made in analyzing the coverage of vulnerable groups in the
seven National Strategic Plans (NSPs) of the six GLIA countries (the United Republic of Tanzania
has NSPs for the mainland (managed by the Tanzania Commission for AIDS) and for Zanzibar
(managed by the Zanzibar AIDS Commission):
•
FSW, military, fishermen, refugees, prisoners, PLHIV, youth, and orphans and vulnerable
children (OVC) are mentioned by all NSPs.
•
Truckers, IDPs, host communities, returnees, females affected by sexual/gender-based violence,
migrant workers, IDUs, men having sex with men (MSM), female petty traders, married
couples, and young women are mentioned by most NSPs.
•
Transport operators are mentioned by one NSP.
•
Other groups mentioned are: discordant couples, people with disabilities, health service
personnel, the general population, pregnant women, and unaccompanied minors.
•
Some NSPs define a tailored strategy for each group very precisely, but others propose virtually
identical strategies ‘across the board’, which suggests that these strategies may not be based on
specific identified needs of each vulnerable population.
•
It appears that there is scope to add value to the targeted interventions in all GLIA countries, if
critical additions to current and planned actions can be identified.
5. Conclusions – Estimated population sizes and numbers of PLHIVs, and targeting
vulnerable populations by the GLIA
HIV is in all six countries in the GLR. Although some common trends are emerging, the HIV
epidemics differ across the countries and across sub-populations in each country. This means that
not all sub-populations have similar HIV epidemiological trends or are at equal risk of HIV
infection. The results presented in this study clearly show that some sub-populations display higher-
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
xviii
risk sexual behavior, are in mobile occupations, are in contact with persons in mobile populations,
or are exposed to violence and conflict, and as a result, have higher median HIV prevalence than the
general population in the GLR.
Eight such vulnerable and mobile sub-populations were identified in the analysis: long-distance
truck drivers and other transport workers; fishermen and fisherwomen; female sex workers; military
and other uniformed forces; refugees; internally displaced persons; prisoners; and females affected
by sexual- and gender-based violence.
These eight sub-populations are important targets (to a greater or lesser extent) in the GLR because
of a combination of reasons: their numbers (7% of the overall GLR population, and 12% of all
PLHIVs), the intensity of their higher-risk sexual behaviors, their potential as bridging populations,
their level and trends of HIV prevalence, their mobility, the extent to which they interact with
mobile persons, and the extent to which they are touched by conflict and violence over which they
have no control.
Interventions for some of the eight identified sub-populations have been defined in the National
HIV Strategic Plans of the 6 GLIA countries. The GLIA could implement specific interventions that
would complement the efforts of the seven NACs in implementing the seven NSPs. Table 1
summarizes the reasons why the GLIA should focus on each sub-population, as well as the types of
interventions recommended.
Table 1. Summary of population sizes and PLHIV numbers of selected populations
POPULATION
Population size,
PLHIV numbers
LONG-DISTANCE
TRUCK DRIVERS
Size: 298,458
PLHIV: 53,722
FISHERMEN &
FISHERWOMEN
Size: 447,656
PLHIV: 110,571
Should the GLIA strategic
plan focus on this
population?
What are promising interventions that should be considered for
the GLIA strategic plan?
YES. GLIA should fund HIV
service delivery to this group
in the short to medium term,
so that countries can learn
best about ‘what works’
before implementing a
minimum package of services
for this group themselves
• Advocacy by the GLIA for the identification of hotspots along all
corridors and for inclusive programming ensuring that needs of
truckers and of the communities in truck stops are addressed
YES. GLIA should provide
HIV prevention, treatment
and support services through
appropriate sub contractors.
Despite consistently high HIV
prevalences among
fishermen and fisherwomen
in the GLR, there has been
little concerted action
targeting fishing communities.
• Provision of HIV prevention, treatment & support services through
appropriate sub contractors, including the training of fisheries
officers on BCC for HIV, and the development of communication
material that ‘speaks the language of the ports’
• Sharing of information by the GLIA for interventions that have
worked
• Epidemiological and formative research to inform the design of
programs, commissioned by the GLIA
• Advocacy for the integration of HIV services for fishermen and
fisherwomen, mobile VCT and GBV counseling, and for custommade programs for these communities in each GLIA country
• Sharing of experiences of ‘what works’ in dealing with this
population
• Epidemiological and ethnographic research in different
occupational groups in fishing sector commissioned by the GLIA
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
POPULATION
Population size,
PLHIV numbers
REFUGEES
Size: 1,229,069
PLHIV: 20,280
IDPs
Should the GLIA strategic
plan focus on this
population?
YES. GLIA should fund
service delivery by subcontractors in the short to
medium term. National
governments are relatively
inexperienced in providing
HIV services in refugee sites.
FEMALES
AFFECTED BY
SEX. VIOLENCE
Size: 7,772,897
Attribut. PLHIV:
132,500
PRISONERS
Size: 222,042
PLHIV: 12,434
MILITARY
Size: 401,020
PLHIV: 40,102 –
80,204
• Advocacy for the integration of HIV services for refugees and host
populations, inclusive VCT and GBV counseling
• Advocacy for IEC/BCC interventions before, during and after
repatriation, and for uniform treatment, care and support policies in
the GLIA countries
• Operational research on the continuum of care inclusive ART in the
displacement cycle, funded by the GLIA
PLHIV: 151,761
No size data
available
• Provision of HIV prevention, treatment & support services
• Fostering collaboration between refugees organizations and hosts
Size: 2,929,479
FEMALE SEX
WORKERS
What are promising interventions that should be considered for
the GLIA strategic plan?
YES, but direct service
delivery to the diverse
population of FSW should be
left with the national
programs providing tailored
interventions.
YES, but GLIA should not
fund direct service delivery.
This population is dispersed
and hidden so hard to reach
by specific interventions.
Sexual violence should be
addressed through existing
services provided by the
national governments.
YES, but direct service
provision should remain with
other actors and the national
governments. The population
is relatively small and isolated
so interventions may have
limited effectiveness.
YES, but direct service
provision to the military (and
other uniformed personnel)
should be left as the
responsibility of national HIV
programs.
• Advocacy for appropriate legislation, adequate and accessible
services for FSWs, and a reduction in stigma and discrimination
displayed towards FSWs
• Epidemiological, socio-cultural and socio-economic research and
size estimation studies in GLIA countries to gain a better understanding of women involved in sex work and transactional sex
• Advocacy by the GLIA for interventions to change perceptions and
opinions about sexual and GBV, and for the integration of GBV
screening & counseling in service delivery (VCT, ANC, SRH,
abortion care, adolescent programs)
• Sharing of training materials and experiences in terms of the
integration of services into all aspects of service provision; for
example: the training of health care personnel which includes
medical, psychological and forensic elements and post-rape care
• Advocacy by the GLIA to support development of national HIV
policies in prisons and for interventions supporting general
improvement of prison living conditions
• Epidemiological research in prison communities, and operational
research on the HIV and TB epidemics in prison communities and
‘what works’, commissioned by the GLIA
• Advocacy by the GLIA for better condom distribution programs,
IEC/BCC programs, release of HIV prevalence data
• Sharing of information by the GLIA on types of interventions that
have worked in other countries
• Qualitative research commissioned by the GLIA to understand
better the sub-culture in the military
xix
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
xx
6. Policy implications of the study
For the GLIA to achieve its mission of adding value to the HIV efforts of the six GLIA member
countries, the understanding of the GLIA’s complementarity and ‘value-added’ should be deepened
and broadened. In the medium to long term, the study results suggest that the GLIA’s broad
strategic objectives should be to:
•
Support the development of HIV strategies in the GLR that are informed by evidence on the
modes of HIV transmission;
•
Act as a catalyst for providing HIV services to populations in need of them and so help ensure
universal access for all populations in the GLIA;
•
Share information about ‘what works’ in providing HIV services to different populations; and
•
Foster harmonization of HIV/AIDS action frameworks and policies within the GLR, in order to
take into account the needs of mobile and migrant populations, and the general trend towards a
common regional market.
The GLIA should assume the following roles (within the next 2 years, giving 24 months to gear up
for anticipated changes), to meet the objectives:
a) The GLIA should play a strong communications and advocacy role to ensure that specific,
evidence-informed strategies for all eight vulnerable populations are included in the national
HIV strategic plans of the six GLIA countries. This advocacy must be pitched at the systems
level and may include advocacy for legislative changes, and specific regional policy directives
(specific areas of advocacy and policy dialogue are defined in the report)
b) The GLIA can only play a strong communication and advocacy role in the region if it has data,
and can use the data to strengthen the case for certain initiatives. For this reason, the GLIA
should strengthen its monitoring, evaluation and research role in the region: it should become
a knowledge hub of all available HIV information in the region, share experiences, and help
develop the evidence base for all decision-making concerning HIV in the region (the report
proposes specific areas of monitoring, evaluation and research)
c) Although the GLIA does not play a coordination role in the region (and should not do so, as this
is not its mandate and would not complement the efforts of the seven NACs), the GLIA should
in future play a technical HIV support role in the region, and should staff accordingly. The
GLIA is in an excellent position to learn and share information on strategies that ‘work’ in
different countries within the GLR, and to build capacity in the areas of research, M&E and
learning. This learning can be applied and regional technical support made available to benefit
the GLIA countries (specific technical support activities are described in the report).
d) GLIA is ideally placed to foster harmonization and networking within the GLR. Unless
HIV/AIDS action frameworks and policies are harmonized, migrant and vulnerable populations
will continue to be disadvantaged in HIV prevention, treatment, care and support. Practical
implementation of the common regional market and free movement of people has not yet
happened and may benefit from GLIA leveraging support in selected areas. Networking and
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
xxi
promoting institutional linkages by GLIA will contribute to information exchange and
alignment of strategies and action plans.
Despite these longer-term strategic objectives proposed for the GLIA, it is not recommended that
the GLIA immediately cease all HIV service delivery. In the short to medium term, the GLIA
remains an important partner in HIV service delivery to four specific vulnerable populations
(truckers, fishermen & fisherwomen, refugees and IDPs) through sub-contractors. Whenever
feasible, a formal capacity building component should be part of these sub-contracts. The GLIA
should retain this role in the next 24 months, as it gears up for broader service delivery to NACs, as
defined above. In its Strategic Plan 2008-2012, the GLIA must define exit strategies for service
provision to the four vulnerable populations in order to ensure uninterrupted service delivery to
these priority populations.
Finally, for the GLIA to fulfil these strategic objectives and its anticipated roles, the GLIA
Secretariat’s skills mix and organizational structure need to be harmonized with these strategic
objectives and roles. Planning for this and embarking on the needed processes should take place
over the next 24 months.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
1
1. INTRODUCTION
1.1 OVERVIEW OF THE GREAT LAKES REGION
Although different definitions exist, the term ‘Great Lakes Region’ (GLR) is used in this report to
refer to the geographic area encompassing the national borders of Burundi, the Democratic
Republic of Congo (DRC), Kenya, Rwanda, the United Republic of Tanzania, and Uganda
(see map in Annex I). The six countries have a combined total population of about 190 million.
The six GLR countries have vastly different geographic area and population density: DRC is more
than twice as large as any of the other countries, and Burundi and Rwanda are substantially smaller
than the rest (figure 1a). Burundi and Rwanda have high population densities of above 300 people
per km2, Uganda has about 130 people per km2 and Kenya, Tanzania and DRC have low population
densities (figure 1b). Population distribution is shown in the maps in Annex I.
Figure 1. (a) Surface area of the GLR countries, and (b) Population density of the GLR countries
(a)
(b)
Area (km2)
Population /km2
2,500,000
400
350
2,000,000
300
250
1,500,000
200
1,000,000
150
100
500,000
50
0
0
Burundi
DRC
Kenya
Rwanda
Tanzania
Uganda
Burundi
DRC
Kenya
Rwanda
Tanzania
Uganda
Source: data from CIA fact book
All six countries face generalized HIV epidemics that have been exacerbated by conflict, population
displacement, and social and political upheaval in the region (see Annex II for some countryspecific information). Their current estimated adult prevalence rates range from 3.1 - 6.7%, with an
estimated total of 5 million people living with HIV (PLHIVs). 1 In the 1980s, the countries
established National AIDS Control Programs (NACPs) within their respective Ministries of
Health, to combat the spread of the epidemic. With the advent of multi-sectoral responses to HIV
and AIDS in the 1990s, the Governments created high-level National HIV and AIDS
Coordinating Authorities (NACAs): in 1987 the DRC’s “Conseil National de Lutte contre le
SIDA”, in 1992 the Uganda AIDS Commission, in 1999 the Kenya National AIDS Control Council,
in 2000 the Rwanda ”Commission Nationale de Lutte contre le SIDA”, and in 2001 the Burundi
“Conseil National de Lutte contre le SIDA” and the Tanzania Commission for AIDS. 2 These
1
http://www.unaids.org/en/Regions_Countries/Countries/default.asp, accessed 14 Sept 2007
DRC: http://www.kff.org/hivaids/7354.cfm; Uganda: http://www.kff.org/hivaids/7368.cfm; Kenya:
http://www.kff.org/hivaids/7356.cfm; Rwanda: http://www.cnls.gov.rw/cnls.php;
Burundi : http://data.unaids.org/pub/Report/2006/2006_country_progress_report_burundi_en.pdf; Tanzania:
http://www.kff.org/hivaids/7367.cfm
2
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
2
institutions broadly have the mandate to provide strategic leadership and coordination, monitoring
and evaluation of the national response, and to ensure a concerted and focused response by all
sectors of society.
There is strong evidence that mobility and migration are important factors contributing to the AIDS
epidemic 3,4,5 (for definitions of different types of migration, see Annex III). Several studies have
shown that people who travel or who have recently migrated tend to be at higher risk for HIV and
other STDs (e.g. Tanzania, 6 Uganda, 7 Senegal 8). The role of migration in spreading HIV has been
described primarily as the result of men who become infected while they are away from home, and
infect their wives or regular partners when they return. More recently, evidence from Tanzania
suggests that people are not only vulnerable to HIV infection through the risk behavior of their
mobile partners, but also through their own risk behavior when left behind. 9 Female migrants
experience specific risks in transit. Overall, there is a dearth of knowledge and research about
female migrants, their vulnerability to HIV, and the mechanics and socioeconomic context of
female mobility. For male migrants, migration often means long periods of time away from home,
working long hours, living in bleak conditions and performing dangerous jobs. Isolation, loneliness,
access to alcohol and sex workers set the stage for sexual risk behaviors which may endanger the
worker himself, his partner and his family.
Migration and mobility are increasing in the GLR, because of more readily available transport;
economic imbalances; urbanisation trends; media images of places of opportunity and safety;
borders becoming more open (common market areas); displacement due to conflict; and people
trafficking. Tanzania is the leading country in both absolute numbers of international migrants, and
proportion of international migrants compared to the total population. Net migration in 2000 was
almost 2 million for Rwanda (net arrivals), and DRC recorded a loss of almost 1.5 million people
(net departures). Overall in 2000, the GLIA countries had more international migrants departing
than arriving in the GLR (net departures of 203,000 people). 10 More detailed information about
mobility and migration in the GLR is in Annex III.
1.2 BACKGROUND TO THE GREAT LAKES INITIATIVE ON HIV/AIDS
With growing recognition of the seriousness of the epidemic and the need for multisectoral
responses within the region as well as at country level, the countries in the GLR sought more
comprehensive ways to address their national problems through increased regional collaboration.
The Ministers for Health, riding on the success of the regional polio vaccination initiative, created
the “Great Lakes Initiative on HIV/AIDS" (GLIA) project in 1998. In the same year, an Executive
3
Decosas J & Adrien A (1997). Migration and HIV. AIDS, 11(Suppl. A):S77–S84.
Mabey D & Mayaud P (1997). Sexually transmitted diseases in mobile populations. Genitourin Med, 73:18–22.
5
Quinn TC (1994). Population migration and the spread of types 1 and 2 HIV. Proc Natl Acad Sci USA, 91:2407–
2414.
6
Barongo LR et al. (1992). The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural villages
in Mwanza region, Tanzania. AIDS, 6:1521–1528.
7
Nunn AJ et al. (1995). Migration and HIV-1 seroprevalence in a rural Ugandan population. AIDS , 9:503–506.
8
Pison G et al. (1993). Seasonal migration: a risk factor for HIV infection in rural Senegal. J Acquir Immune Defic
Syndr, 6:196–200.
9
Kishamawe C et al. (2006). Mobility and HIV in Tanzanian couples: both mobile persons and their partners show
increased risk. AIDS, 20:601-608.
10
Data hub, Migration Policy Institute (http://www.migrationinformation.org/datahub/comparative.cfm)
4
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
3
Secretariat for GLIA was established in Rwanda, and pilot programs were implemented – supported
principally by UNAIDS.
A high-level GLIA Consultative Meeting on HIV/AIDS held in Nairobi in May 2003 resulted in a
GLIA Joint Declaration and Draft Institutional Framework that led to an agreement that the GLIA
would operate through the National AIDS Commissions of the six countries in the GLR. On July
27, 2004, the Convention establishing the GLIA was signed by ministers from the six countries, and
the Council of Ministers held its inaugural session. The Convention defined the mission of the
GLIA as follows:
The mission of the GLIA is “to contribute to the reduction of HIV infections and to mitigate the socioeconomic impact of the epidemic in the Great Lakes Region by developing regional collaboration and
implementing interventions that can add value to the efforts of each individual country.”
(GLIA Convention, 2004)
Different development partners have supported the GLIA, and the GLIA is actively mobilizing
additional funds. The decision at the 2003 GLIA Consultative Meeting was to apply for a grant
from the World Bank to finance a specific inter-regional program managed by the GLIA. The $20
million grant was approved in March 2005, under the World Bank Multi-country AIDS Program
(MAP). This MAP project, known as the ‘GLIA Support Project’, was designed to support intercountry collaboration to respond to the epidemic, pool resources within the framework of a subregional cooperation plan, and add value to national efforts by supporting specific interventions –
Annex IV provides details on the project components.
1.3 PURPOSE OF THE STUDY
In 2007, the GLIA began developing its strategic plan for the period 2008 – 2012. To ensure that the
strategic plan is based on available evidence and is complementary to the efforts of the six NACAs
(i.e. fulfils the GLIA’s mission), the GLIA secretariat requested the World Bank for technical
support to conduct an epidemiological and HIV response study in the GLR, focusing on vulnerable,
cross-border and mobile populations (see Annex V for the study terms of reference). The study aims
to answer the question:
“On which populations should the GLIA focus, why, and with what type of HIV
interventions?”
1.4 STRUCTURE OF THE REPORT
•
Chapter 1 describes the Great Lakes Region, the GLIA’s background, the purpose of the study,
and structure of the report.
•
Chapter 2 describes the study methodology and limitations.
•
Chapter 3 provides a general description of the epidemic state in each GLIA country, looking at
the following aspects: transmission pathways, epidemic state, trend data, age patterns of
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
4
infection, urban-rural differentials, incidence of infection, sexual behavior data, male
circumcision, and transactional sex.
•
Chapter 4 identifies all the vulnerable populations in the Great Lakes Region (based on the
available literature), and summarises relevant HIV-related evidence about selected vulnerable
populations (their population size, epidemiological data, sexual behavior data, and vulnerability
and risk factors).
•
Chapter 5 provides a summary of the vulnerable populations covered in each country’s
National HIV Strategic Plan.
•
Chapter 6 describes intervention options targeting the vulnerable populations.
•
Chapter 7 provides conclusions based on the results, defining the populations on which the
GLIA strategic plan should focus (based on evidence presented in Chapters 3 to 6), the reasons
why it should focus on these populations, and promising types of interventions that the GLIA
could support in future.
•
Finally, Chapter 8 summarises the policy implications of the study’s findings, describes a
three-fold future role for the GLIA and gives recommendations on what should be included in
the GLIA strategic plan.
2. METHODOLOGY
This was a desk study of all existing published and unpublished documentation from the GLIA
countries, and from other countries implementing activities or with experiences relevant to the study
questions or that provided evidence currently not available in the GLR. Results from other countries
were included if they strengthened an argument or gave additional credibility to an estimate. The
study team’s task entailed analyzing all existing HIV epidemiological data on vulnerable
populations in the GLR, and systematically compiling vulnerability and HIV risk factors for
selected populations.
•
•
“Vulnerability factors” were defined as social and contextual factors describing the individual’s
condition in society (e.g. living in a gender exclusive environment, low level of empowerment)
“Risk factors” are directly linked – or on the causal pathway – to HIV infection (e.g. frequent
partner change, concurrent partners, sharing contaminated instruments, low condom use).
The study team did an extensive literature search, catalogued and classified all documents found in
the literature search, analysed the data based on certain parameters, and developed conclusions and
policy implications. A report was drafted and submitted to the GLIA secretariat and other peer
reviewers for initial internal review. Subsequently, the report was presented to a wide range of
stakeholders – the six GLIA countries and interested development partners – for peer review (11-12
December 2007 in Bujumbura, Burundi), after which the report was finalized and translated into
French. The study calendar is presented in Annex VI.
Specific information about each of the process steps is described below.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
5
2,1 LITERATURE SEARCH
The research team used several approaches to identify the maximum published and unpublished
data and literature relevant to this research. Four strategies were used:
1. Searches on websites of the following organizations: African Union, AMREF, Association des
Veuves du Genocide, Care International, Centre for Defence Studies UK, Civil-Military Alliance to
Combat HIV and AIDS, CNLS Burundi, CNLS Rwanda, COMESA, Danish Institute for
International Studies, East African Community, FHI, HEARD, Internal Displacement Monitoring
Centre, International AIDS Society, International Centre for Prison Studies, International Institute
for Strategic Studies, ILO, International Organization for Migration, International Rescue
Committee, International Transport Workers’ Federation, Kaiser Family Foundation, Measure DHS,
MSF, Migration Policy Institute, NACC Kenya, NEPAD, PNLS Ministère de Santé DRC,
Population Services International, Relief Web, Rwanda Census Bureau, Sustainable Fisheries
Livelihoods Programme, SWAA Burundi, Tanzania Bureau of Statistics, TACAIDS, The Sphere
Project, TRAC Rwanda, Uganda AIDS Commission, Uganda Bureau of Statistics, UN
Disarmament Demobilization and Reintegration Resource Centre, UN Economic Commission for
Africa, UNAIDS, UNHCR, UN Office on Drugs and Crime, US Institute for Peace, World Bank,
Zanzibar AIDS Commission.
2. Searches of large online databases and through search engines: Journal storage, PubMed,
Medline, Google Scholar, and Google. The searches included publications from 1986 onward
without language restrictions, using Medical Subject Heading terms to identify relevant papers.
3. Search based on citation lists in publications: The team searched all references of the identified
publications to find further relevant documents and web sites.
4. Solicitation of documents from contacts: The research team contacted the GLIA countries in
writing, asking for specific documents which were not available in the public domain.
The following terms were used to search websites, online databases and search engines:
Burundi/ DRC/ Kenya/ Rwanda/ Uganda/ Tanzania/ SSA, Eastern Africa/ Southern Africa/ Central
Africa/ Great Lakes, HIV prevention, HIV infection/ prevalence/ epidemic/pandemic, HIV/AIDS,
Refugee, IDP, Mobility/ migration/cross border, Displacement of population, Social disruption,
Socio-economic context HIV/AIDS, Conflict/war, Vulnerability/ vulnerable group, HIV risk,
Sexual behavior/ practice, Reproductive health, STD/STI, Customs union/movement of
people/goods, Waterways/ boatmen/ fishermen, Sexual violence/ survivor / gender based violence,
Border/transport/ corridor/truck/worker, Sex worker/prostitute
2.2 CATALOGUING & CLASSIFYING DOCUMENTS
A total of 376 documents considered relevant to the study were classified, 289 of which referred to
one or more of the GLIA countries. There were 20 documents on Burundi, 19 on DRC, 45 on
Kenya, 19 on Rwanda, 53 on Tanzania, 41 on Uganda, and 92 on more than one GLIA country.
All documents were checked to remove duplicates, and listed in a document catalogue that records:
Country, Document title, File size, File name, Institutions, Authors, Year, Language, Target groups
& sizes (see Annex VII for literature catalogue). All catalogued documents were read and
technically reviewed to feed into the evidence base of the study.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
6
2.3 DATA ANALYSIS
After reading all identified documentation, the research team extracted relevant data and performed
some standard analyses:
1. Extracted data about the population size of each vulnerable population
2. Determined the median HIV prevalence of each vulnerable population
3. Estimated the size of each of population. The number of people living with HIV (PLHIV) in
each sub-population was calculated by multiplying the estimated number of people in the group
by the median HIV prevalence estimate based on the best data available (except for the
population group ‘females affected by sexual violence’ – see below for more information).
4. Compared the list of identified vulnerable populations in the GLIA to the seven national HIV
strategic plans (including NSPs for mainland Tanzania and for Zanzibar), in order to analyse
which vulnerable populations are not covered by current national HIV strategic plans
5. Defined which vulnerable populations the GLIA should focus on, taking account of HIV
prevalence, risk factor data, size estimates and comparisons with national HIV strategic plans.
Given the paucity of data, inclusion criteria of HIV prevalence studies could not be limited to
studies of recent date, random sampling and high response rates, so all published or reported
surveys were included. No confidence intervals on estimates of group size, median HIV prevalence
and PLHIV numbers were used, so all the values are taken as point estimates. Specific aspects of
the calculations for each of the main vulnerable populations are summarized in Table 2.
2.4 LIMITATIONS OF THE STUDY
This study had several limitations. Some data were not accessible, which limited in particular the
assessment of the armed forces as a vulnerable population group. In general, the analysis was
restricted by the nature and quality of information on vulnerable populations in the GLIA countries.
In some studies, the year of measurement was unclear. HIV prevalence data in some publications
were not used because data from the same cohort reported in a different publication were already
included. Calculations sometimes included: data older than 10 years due to paucity of more recent
evidence; data on slightly different samples due to different inclusion criteria; data from studies
using biased or small samples; or data with restricted geographic coverage that over-represented
certain sub-groups. No raw data were used for calculations, so data could not be adjusted for
confounding to improve comparability. Smaller studies were given the same weight as larger, more
representative studies.
The study team did not attempt to rank the vulnerable populations in order of importance to the
GLIA, due to the many variables which would need to be taken into account (such as estimated
population size, current coverage and access to preventive and curative health services, HIV
transmission potential, burden of disease, etc.).
The study did not include any modelling to compute current levels and trends in patterns of
prevalence and incidence of HIV in the GLIA countries. The methodology therefore did not allow a
comprehensive estimation of the percentage of new infections coming from the various vulnerable
populations.
11
World Prison Population List providing
most recent figures of 2004, 2005,
2006
Estimated based on six studies
presenting the proportion of females
in the adult female population who
have a history of sexual or genderbased violence.
Estimation of population sizes
www.nationsencyclopedia.com and
www.mongabay.com
Kenya: size estimations were
available. Other countries: Population
sizes were extrapolated from the total
population, using the proportion of
Kenyan truck drivers to the total
Kenyan population
Size estimates for Rwanda, Tanzania
& Uganda used 2002 population
census data. FAO provided estimates
for Burundi (2000), DRC (2000) ,
Kenya (2005)
Did not estimate population size, due
to the problem of defining the
boundaries of ‘risk group’
membership (see explanation of
challenges)
OCHA (June 2007 figures)
OCHA (June 2007 figures)
The relative risk (RR) of sexual violence for HIV infection was estimated using RR
data from two SSA studies with identical RR data (1.4 – females with a history of
sexual violence are 1.4 times more likely to be HIV positive than females without
such a history). The RR estimate was used to calculate the number of PLHIV
attributable to sexual violence, using UNAIDS total numbers of adult female PLHIV
for each GLIA country. The number of excess female PLHIV attributable to sexual
violence was based on the excess risk of HIV sero-positivity in violence-affected
females.
Median HIV prevalence was based on seven studies from different GLIA countries
presenting data collected between 1995 and 2007.
Median HIV prevalence was based on eight recent surveys in different camps
The calculation of PLHIV numbers was based on the estimated national HIV
prevalences from UNAIDS for 2007.
Presentation of HIV prevalence data from various studies, but no calculation of
median HIV prevalence and PLHIV numbers.
Median HIV prevalence was calculated based on four reasonably recent studies from
several GLIA countries.
Estimation of median HIV prevalence and PLHIV numbers
Due to recent claims that HIV prevalence in military may be lower than suspected, a
prevalence range of 10-20% was used to estimate PLHIV numbers.
Median HIV prevalence was calculated based on six different studies.
Total prison populations are uncertain in DRC and Rwanda. Four assessments
of HIV prevalence were done > 5 years ago. Some HIV data come from small
studies.
This group is not a specific occupational risk group or segregated in a specific
place like camps, prisons, but an integral part of the general population.
Calculations therefore used a different methodology. PLHIV numbers could not
be based on median HIV prevalence in this group, since population prevalence
varies considerably across the GLIA countries. Several powerful data sources
had to be excluded from the estimation of population size because they used a
narrow definition of sexual violence (i.e. rape).
For non-brothel based sex work, it is problematic to define boundaries between
full-time, part-time or occasional sex work, and transactional sex for money or
gifts. Different forms of sex work may have highly variable levels of exposure
to HIV, which may lead to large within-group differences in HIV prevalence (this
topic is not well researched). 11
No major challenges.
No IDP-specific HIV prevalence data were available
Available statistics on persons occupied in the fishing sector in the GLR
present several weaknesses due to irregular reporting by countries, different
concepts used to enumerate employment, and the informal nature of the fishing
occupation.
Challenges with estimations
Statistics of HIV prevalence in military were virtually unavailable. The only data
for this decade identified came from Uganda Defence Force (20%).
Almost all HIV prevalence data came from studies of Kenyan truckers. Size
estimates for truckers are highly uncertain, mainly because few truckers are
organized, so union statistics are incomplete. Occupational statistics from
population censuses did not use relevant employment categories. The only size
estimate identified concerned Kenyan truck drivers.
Nagot N et al. (2002). Spectrum of commercial sex activity in Burkina Faso: classification model and risk of exposure to HIV. J Acquired Immune Defic Syndr, 29:517-521.
Females
affected by
sexual
violence
Refugees
Internally
displaced
persons
Prisoners
Female sex
workers
Fishermen &
fisherwomen
Truck drivers
Population
Military
Table 2. Methods to estimate population size, median HIV prevalence and PLHIV numbers for the selected vulnerable populations
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
7
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
8
3. RESULTS: DESCRIPTION OF THE COUNTRIES’ HIV EPIDEMICS
3.1 TRANSMISSION PATHWAYS
In all six countries, the first AIDS case was reported in the 1980s, and has been largely
dominated by sexual transmission of HIV infection. HIV transmission through transfusion of
infected blood or blood products undoubtedly has occurred (and still may to a very limited
degree), but in most countries, blood safety has been a priority since the early days of the
epidemic. Some data on screening of blood units for transfusion are available. 12 In Kenya, in
1999, Moore et al. 13 found a prevalence of 6.4% among Kenyan blood donors. These included
family replacement donors; blood screening was done using 3rd generation HIV kits. At the time,
HIV prevalence in the general population was 8 to 10%. It was then estimated that 2.1% of
transfusions in Kenya led to HIV infection. However, now, HIV prevalence amongst blood
donors (based on a strict voluntary system) is below 1%. The National Blood Transfusion
Service now uses 4th generation test kits.
Transmission through unsafe medical injections may have contributed to the epidemic, but it is
difficult to quantify HIV transmission from inadequately sterilized equipment because cases
tend to occur in locations where diagnostic and surveillance systems are poor. According to
WHO 14, administration of unsafe injections in health care settings is responsible for
approximately 250 000 HIV cases every year (worldwide). Practices such as re-use of syringes
without proper sterilization, and improper disposal of used injection equipment, add to these
cases. Programs on universal precautions are not well reported.14 DHS data from GLIA
countries on medical injections suggest that needles and syringes come almost exclusively from
newly opened packages. The consensus is that transmission through infected blood or blood
products and through unsafe medical injections is probably low.
In contrast, transmission through injection drug use (IDU) is documented by some studies. Many
IDU share needles and syringes as well as having unprotected sex, and have been identified as a
'bridging population', speeding the spread of HIV to the general population. Median
transmission probability for intravenous drug injection is estimated at 0.08 (UNAIDS incidence
model). A report on female IDUs in mainland Tanzania 15 and a report on male IDUs in
12
In Burundi, reducing risk of blood-borne transmission is among the priority programs of the National Action Plan
2002-2006 (Burundi UNGASS Report 2006). This analysis did not see data from Burundi on blood screening for
transfusion or universal precautions. The DRC national policy and strategies for health care and support include
HIV screening of blood destined for transfusions and systematic precautions in health care facilities (DRC
UNGASS Report 2006). All the provincial capitals in DRC are reported to be supplied with screened blood units.
No data were available from DRC on the proportion of transfused blood units screened for HIV, or on activities
regarding universal precautions. In Kenya, 100% of transfused blood units were screened for HIV in 2005 (Kenya
UNGASS Report 2006). HIV screening of blood transfusion and universal precautions in health care settings are
components of the care and treatment program in Kenya, but no further documentation was available. Rwanda has
taken measures to safeguard blood supplies for transfusion. The Blood Transfusion Centre reports 100% HIV
screening of transfused blood (Rwanda UNGASS Report 2006). In Tanzania mainland, data collected on the mode
of transmission in AIDS case surveillance suggest that transfusion of infected blood may have been responsible for
0.5% of all AIDS cases (Tanzania UNGASS Report 2006). Zanzibar reports that transmission through body fluids
and blood products and skin piercing (including injection drug use) and other surgical instruments accounts for
about 6% of HIV infections (Zanzibar UNGASS Report 2006). Uganda reports for 2005 that 100% of all transfused
blood unites were screened for HIV (Uganda UNGASS Report 2006).
13
Moore et al. Lancet 2001: 358: 651-660
14
WHO bulletin 2003 81 :491
15
McCurdy S et al (2005). ‘Flashblood’ and HIV risk among IDUs in Tanzania, August 2005. Accessed from
http://www.bmj.com/cgi/eletters/330/7493/684, 27 Oct 2007.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
9
Zanzibar 16 both discuss an observed blood sharing practice (‘flashblood’) in which an IDU with
no access to drugs gets an aliquot of blood from a friend who has just injected himself with a
drug. This practice undoubtedly increases the risk of transmission of HIV (and other pathogens)
substantially towards the estimated probability for contaminated blood transfusion (0.89-0.96,
UNAIDS incidence model).
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
16
A recent study on 191 IDUs (of whom 96% male) in Zanzibar found 26% HIV seropositivity (Dahoma et al. 2006). The study also assessed sexual risk behaviors: 71% of study
participants reported multiple sexual partners; almost all female IDUs (6 of 7) reported
exchanging sex for drugs; 34% of male participants indicated a preference for anal sex, and
23% reported participation in group sex.
A rapid situation assessment carried out in 2001 in five Tanzanian towns found heroin to be
a major concern in Arusha, Dar es Salaam and Zanzibar, and emerging as problem in
Mwanza, but not in Mbeya. 17
A study of 624 young multi-drug (alcohol, cannabis, tobacco, heroin, valium, khat) users in
Dar es Salaam found that 75% of the sample were using heroin, and that 18.3% of the
sample reported injecting drugs. 18
A study investigating drug use and sexual behaviors among 237 male and 123 female heroin
users in Dar es Salaam found that men were significantly older, more likely to inject only
white heroin, share needles, and give or lend used needles to other injectors. Women were
more likely to be living on the streets, have injected brown heroin, have had a higher number
of sex partners, and have used a condom with the most recent sex partner. 19
Pockets of IDUs have been reported in Nairobi and the Coast Province towns of Mombasa,
Malindi, and Lamu. Odek-Ogunde et al. (2004) found in heroin users in Nairobi (of whom
90% male) with HIV prevalence of 36%. 20
Beckerleg et al. (2005) argue that heroin injection now appears to be occurring in most large
towns of Kenya and Tanzania. 21 They estimated that there were 600 heroin users in Malindi
in 2000, of which 50% injectors.
A survey of 120 drug users, including IDUs, in Mombasa, indicated a high prevalence of
Hepatitis C infection and HIV. 22 UNODC has stated that IDU is increasing in Kenya, and
that there is an urgent need to address HIV transmission by IDU.
Application of the UNAIDS incidence model estimated for Kenya for 2005 that about 5% of
incident cases stem from IDU. 23
Dahoma MJU et al. (2006). HIV and substance abuse: the dual epidemics challenging Zanzibar. African J Drug
& Alcohol Studies, 5(2):130-139.
17
Kilonzo GP et al. (2001). Rapid Situational Assessment for Drug Demand Reduction in Tanzania. UNDCP 2001
18
Muhondwa E et al. (2002). An assessment of the treatment needs of drug users un Dar es Salaam. Report by
Christ Compassion in Action prepared for Save the Children UK, Tanzania Programme 2002.
19
Williams M et al. (2007). Differences in HIV risk behaviors by gender in a sample of Tanzanian injection drug
users. AIDS and Behavior, 11(1) 137-144.
20
Odek-Ogunde M et al. (2004). Seroprevalence of HIV, HBC and HCV in injecting drug users in Nairobi, Kenya:
World Health Organization Drug Injecting Study Phase II findings. Int Conf AIDS. 2004 Jul 11-16; 15: abstract no.
WePeC6001.
21
Beckerleg S et al. (2005). The rise of injecting drug use in east Africa: a case study from Kenya. Harm Reduction
Journal 2005, 2:12
22
UNODC report sheds new light on the relationship between drug abuse, injecting drug use and HIV/AIDS in
Kenya. vol 2004. United Nations Office on Drugs and Crime (UNODC), Regional Office for Eastern Africa
(ROEA). Nairobi, Kenya: United Nations Office on Drugs and Crime, 2004.
http://www.unodc.org/kenya/press_release_2004-07-01_1.html
23
Gouws E et al. (2006). Short term estimates of adult HIV incidence by mode of transmission: Kenya and
Thailand as examples. Sex Transm Infect, 82(suppl III):iii51-55.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
10
Injecting drug use (IDU) has been identified as an important driver of the HIV epidemic in some
urban and coastal centers of Kenya and Tanzania. The review did not identify IDU-related
information from Burundi, DRC, Rwanda and Uganda. IDU and other non-sexual transmission
is overall not a major driving factor of the epidemics in the GLIA countries. Countries which
have identified the problem have defined IDUs as an important target group for intervention (see
Annex VIII on NSP analysis). One regional issue is the large scale trafficking in heroin between
South Asia and East Africa and the supply routes within the GLR.
3.2 EPIDEMIC STATE
The epidemic state of all six GLIA countries is classified as “generalised”, meaning that the HIV
infection is firmly established in the general population. 24 This study reviewed the spatial
pattern of HIV prevalence levels using provincial (or regional) prevalence data from population
based surveys. Four countries (Kenya, Rwanda, Tanzania and Uganda) had such data available,
collected over the last five years. Two countries currently do not have provincial prevalence data
(Burundi and DRC). The maps depicting the spatial patterns are presented in Annex I.
While HIV transmission began in local high-risk networks, it subsequently spread beyond these
into the wider community. With transmission now occurring outside the high-risk groups, it will
continue despite interventions within high-risk groups. Nevertheless, interventions targeting
high-risk groups maintain their importance because high-risk groups continue to contribute
disproportionately to the epidemic. A summary of current estimated HIV prevalence and
numbers of people living with HIV (PLHIV) in the GLIA countries is given in Table 3.
Table 3. HIV prevalence and PLHIV numbers in GLIA countries
Estimated HIV prevalence
Adults aged 15-49
Estimated Number of people living with HIV
Women 15+ yrs
Men
Children 0-14 yrs
15+ yrs
Burundi
3.3 [2.7 – 3.8]%
150 000
79 000
51 000
20 000
DRC
3.2 [1.8 – 4.9]%
1 000 000
520 000
360 000
120 000
Kenya
6.1 [5.2 – 7.0]%
1 300 000
740 000
410 000
150 000
Rwanda
3.1 [2.9 – 3.2]%
190 000
91 000
72 000
27 000
Tanzania
6.5 [5.8 – 7.2]%
1 400 000
710 000
580 000
110 000
Uganda
6.7 [5.7 – 7.6]%
1 000 000
520 000
370 000
110 000
Source: http://www.unaids.org/en/Regions_Countries/Countries/default.asp, accessed 14 Sept 2007
All
•
HIV prevalences in Kenya, Tanzania and Uganda are almost twice as high as in Burundi,
DRC and Rwanda (there is uncertainty about the estimate for DRC, illustrated by the wide
confidence interval)
•
The estimated total number of PLHIV is around one million or above in the four larger
countries, and below 200,000 in Burundi and Rwanda
•
The female : male ratio among PLHIVs is between 1.22 (Tanzania) and 1.80 (Kenya) which
indicates that the epidemic spreads particularly among women, leading to feminization of the
epidemic.
More country specific data on the feminization of the epidemic are presented in Table 4.
24
UNAIDS/WHO. Guidelines for second generation surveillance, 2000
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
11
Table 4. Sex-specific HIV prevalence and sex ratio
HIV prevalence HIV prevalence HIV prevalence
Sex ratio
Source
All
Women
Men
(Women/Men)
Burundi
3.2
3.8
2.6
1.5 / 1
Nat. Sero-survey 2002
DRC
Kenya
6.7
8.7
4.6
1.9 / 1
DHS 2003
Rwanda
3.0
3.6
2.3
1.6 / 1
DHS 2005
Tanzania mainland
7.0
7.7
6.3
1.2 / 1
AIS 2003/4
Tanzania Zanzibar
0.6
0.9
0.2
4.5 / 1
Population survey 2002
Uganda
6.4
7.5
5.0
1.5 / 1
AIS 2004/5
NOTE: HIV prevalence data in Tables 3 and 4 differ because Table 3 data are UNAIDS estimates based on a
mathematical model, whilst Table 4 prevalence values are actual results from surveys undertaken in the countries
•
Very high sex ratios are found in Zanzibar (4.5) and to a lesser extent in Kenya (1.9),
suggesting that significant numbers of females are infected through sexual transmission. The
finding from the survey in Zanzibar may be explained partly by limited sample size and
large confidence intervals of the estimates.
•
The smallest differential between women and men is found in Tanzania Mainland (1.2), and
this is supported by sexual behavior data from Tanzanian men (high prevalence of paid sex,
multiple partners and higher risk sex)
3.3 EPIDEMIC PHASE (TRENDS IN THE HIV EPIDEMICS)
In order to follow the trends of the HIV epidemic, the GLIA countries have been conducting
sentinel surveillance in different populations. Figure 2 presents data from antenatal care (ANC)
clients for sites located in major urban areas (a) and outside major urban areas (b). Annex I
illustrates the locations and HIV prevalence recorded at antenatal sentinel sites. Figure 3
compares ANC surveillance data from Uganda for 2002 and 2005.
The graphs in Figures 2 and 3 show that:
•
Epidemic curves are not always smooth, possibly due to changes in selection of sentinel sites
and large variations across sites, leading to large confidence intervals
•
HIV prevalence is generally higher in major urban areas than in other areas, but the
differential is getting smaller
•
The HIV epidemics are at least stabilizing in four of the six GLIA countries (Kenya,
Tanzania, Rwanda and Uganda). However, there are upward trends in certain sites, e.g. in
Burundi at the Centre de Médecine Communautaire de Buyenzi (HIV prevalence of 18% in
2005 up from 12.6% in 2004) and at some ANC sites in Uganda (see Figure 3).
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
12
Figure 2. Trends in median HIV prevalence in ANC clients 1990-2007 in (a) major urban areas and (b)
outside major urban areas in the GLR
(a) Major urban areas
HIV (%)
35
Bu Ur
DRC Ur
Ke Ur
Rw Ur
Tz Ur
Ug Ur
30
25
20
15
10
5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
(b) Outside major urban areas
HIV (%)
35
30
25
Bu Nur
DRC Nur
Ke Nur
Rw Nur
Tz NUr
Ug Nur
20
15
10
5
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Sources: Epidemiological fact sheets UNAIDS, Epidemiological Bulletins 2004 and 2005 Burundi, ANC Sentinel
Surveillance Report DRC 2005, Surveillance of HIV and syphilis among ANC attendees 2005/6 Tanzania, DRC
draft rapport national sur l'epidémie à VIH 2006.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
13
Figure 3. ANC sites in Uganda with increased HIV prevalence between 2002 and 2005
2002
2005
14
12
10
8
6
4
2
0
Lacor
Arua
Kilembe
Masindi
Mbale
Mbarara
Mutolere
Nebbi
Soroti
Jinja
2002
11.9
4.6
4.2
4.7
5.9
10.8
1.5
1.3
4.6
5
2005
12.5
9.3
4.9
7.9
7.3
11.9
4.7
3.3
7.1
8.4
Source: Shafer et al. NACPU/MRC/UVRI (2005)
3.4 AGE PATTERNS OF INFECTION
Five countries have recent national population-based data on HIV prevalence and associated
factors from Demographic and Health Surveys (DHS), AIDS Indicator Surveys (AIS) and
National Seroprevalence Surveys (NSS): Kenya DHS 2003, Rwanda DHS 2005, Tanzania AIS
2003/4, Uganda AIS 2004/5, and Burundi NSS 2002. The Burundi Behavioral and Serological
Survey of 2007, the DRC DHS 2007 and the Tanzania AIS 2007 were ongoing at the time of this
study. Figure 4 presents data on HIV prevalence in different age groups for women and men.
•
In certain age groups in Burundi, Kenya, Tanzania and Uganda, one person out of eight is
HIV positive
•
HIV prevalence peaks in women in different age groups: At 25-29 years (Kenya), 25-34
years (Burundi), 30-34 years (Tanzania, Uganda), and 35-39 years (Rwanda). In men, most
prevalence peaks are in the 40-44 year age group, suggesting that transmission takes place
between younger women and older men (age mixing, cross generational sex, and the “sugar
daddy syndrome” have been documented). However, there are nearly identical levels of HIV
in young males and young females up to the age of 19 years in both Rwanda and Tanzania.
•
Women in Burundi, Kenya, Rwanda and Uganda aged 15-24 years are 3-4 times more likely
to be HIV positive than men in the same age group [relative risks: Burundi 2.9, Kenya 4.3,
Rwanda 3.4, Uganda 3.3], but not in Tanzania where infection rates are much more similar
between young women and young men.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
14
Figure 4. Age specific HIV prevalence in GLIA countries
DRC
Burundi (Nat. Seroprevalence Survey 2002)
[data only available in broad age groups]
Refer to 2007 DHS, publication early in 2008
HIV
prevalence
14.0
Women
Men
12.0
10.0
8.0
6.0
4.0
2.0
0.0
15-24 25-34 35-44 45-54 55+
Rwanda (DHS 2005)
Kenya (DHS 2003)
HIV
prevalence
HIV
prevalence
14.0
14.0
Women
Men
12.0
Women
Men
12.0
10.0
10.0
8.0
8.0
6.0
6.0
4.0
4.0
2.0
2.0
0.0
0.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
Uganda (AIS 2004/5)
Tanzania (AIS 2003/4)
HIV
prevalence
HIV
prevalence
14.0
14.0
Women
Men
12.0
12.0
10.0
10.0
8.0
8.0
6.0
6.0
4.0
4.0
2.0
2.0
0.0
Women
Men
0.0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59
3.5 URBAN-RURAL DIFFERENTIALS
Early statistics of the HIV epidemic in East Africa found large differences in HIV prevalence
between urban areas and transport hubs compared to rural areas away from major transport
routes. 25, 26 This differential is still maintained as demonstrated by recent DHS and AIS data
(Table 5).
25
Asamoah-Odei E et al. (2004). HIV prevalence and trends in Sub-Saharan Africa: no decline and large
subregional differences. Lancet 2004; 364: 35–40.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
15
Table 5. HIV prevalence by residence, disaggregated by sex
Burundi
Urban
13.3%
Women
Rural
P*
2.9% <0.0001
Urban
6.2%
Men
Rural
2.1%
p
<0.0001
Urban
10.0%
All
Rural
2.5%
P
<0.0001
12.3%
8.6%
12.0%
12.8%
7.5%
2.6%
5.8%
6.5%
7.5%
5.8%
9.6%
6.7%
3.6%
1.6%
4.8%
4.7%
<0.001
<0.0001
<0.0001
n.s.
10.0%
7.3%
10.9%
10.1%
5.6%
2.2%
5.3%
5.7%
<0.001
<0.0001
<0.0001
<0.001
Source
&
DRC
Kenya
Rwanda
Tanzania
Uganda
<0.001
<0.0001
<0.0001
<0.0001
Nat. Seroprevalence
Survey 2002
DHS 2003
DHS 2005
AIS2003/4
AIS 2004/5
* probability value from Mantel-Haenszel chi2 test, n.s.=not significant (p≥0.05)
&
urban and semi-urban figures are combined
•
In the five countries where data on the urban – rural differential in HIV prevalence are
available, urban prevalence is significantly higher than rural prevalence (in women, men,
and the total population surveyed), with the exception of urban vs. rural men in Uganda, for
whom the difference is not significant
•
The urban-rural differential exists in small and densely populated countries (like Burundi
and Rwanda), as well as in large, more sparsely populated countries (like Kenya and
Tanzania)
•
The differential suggests that higher risk groups in urban areas are key drivers of the
epidemic (CSW, migrants, wage earners, etc.).
3.6 INCIDENCE OF INFECTION
Most GLIA countries have a good amount of population-level HIV prevalence data (reflecting
both recent and historical infections), but very limited HIV incidence 27 data, which would
provide vital information about new infections. The review found some HIV incidence data from
trials and a long-term surveillance study, but the samples are small and unrepresentative (and
incidence was estimated in different ways):
•
Rakai trial, Uganda (2007): 1·33 cases per 100 person-years in the control group 28
•
Kisumu trial, Kenya (2007): 2-year HIV incidence of 4·2% in the control group 29
•
Kisesa cohort, Mwanza Region, Tanzania (1997-2000): Overall annual incidence rate
1.35% (males 1.4%, females 1.3%; remote rural areas 1.1%, roadside settlements 1.9%,
market town part 2.4%)
Incident HIV-1 infection was determined in an observational cohort study of 424 initially HIV1-seronegative CSW in Nairobi between 1985 and 1994. 30 Forty-three CSW remained seronegative after three or more years of follow-up despite high exposure to HIV. The understanding
of correlates of protection from HIV infection remains limited, but it seems that the combined
26
Ghys et al. 2006). Measuring trends in prevalence and incidence of HIV infection in countries with generalised
epidemics. Sex Transm Infect 2006; 82 (suppl 1): 52–56.
27
'HIV incidence' is the number of new HIV infections in a population during a certain time period. People who
were infected before that time period are not included in the total, even if they are still alive.
28
Gray RH et al. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial 1.
Lancet, 369(9562):657-66
29
Bailey RC et al. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised
controlled trial 2. Lancet, 369(9562):643-56.
30
Fowke KR et al. (1996). Resistance to HIV-1 infection among persistently sero-negative prostitutes in Nairobi,
Kenya. Lancet, 348:1347-51.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
16
contribution of innate and adaptive immunity as well as genetic factors is most likely of great
importance. 31
In the absence of measured population-level incidence data, the sources of incident infection can
be modeled, for instance using the UNAIDS incidence model. Gouws et al. (2006) report
modeling results based on Kenyan data (figure 5). 32 These results confirm the previous
interpretations of population data from Kenya, and are further supported by data on sexual
behavior from Kenya
Figure 5. Distribution of the percent incident cases by mode of exposure: Example of Kenya
A total of 82 369 new infections (out of a
total 15–49 year adult population of about
16.4 million) were estimated to have
occurred in Kenya in 2005, most of which
were among:
ƒ the general population (30.1%)
ƒ individuals involved in casual
heterosexual sex with non-regular
partners (18.3%)
ƒ partners of those involved in casual
sex (27.7%)
ƒ clients of sex workers accounted for
10.5% and sex workers for 1.3% of all
new infections
ƒ a considerable number of new
infections occurred in IDUs (4.8%)
and MSM (4.5%)
Small numbers of infections occurred as
a result of medical injections (0.6%) and
blood transfusions (0.2%)
Source: Gouws E et al. (2006). Short term estimates of adult HIV incidence by mode of transmission: Kenya and
Thailand as examples. Sex Transm Infect, 82(suppl III):iii51-55.
The contribution to new infections from the MSM population (4.5%, figure 4) highlights the
need for targeted interventions. Further evidence of high HIV prevalence among Kenyan MSM
comes from an ongoing cohort study among MSM in Kilifi: 38% (23/60) of men were HIV
positive at baseline. 33 VCT data from sites throughout the country show that among 780 MSM
tested between 2002 and 2005, 10.6% were HIV-infected. 34 There is a continuing lack of
epidemiological, behavioral and social data which could inform intervention strategies based on
knowledge of MSM’s circumstances, situations and needs (in many parts of the world, MSM are
married; they are less a group set apart than a key constituent of the general population; sex
between men is not associated with a particular individual or social identity; and may not be
openly talked about 35). This analysis did not find data on MSM from the other GLIA countries
besides Kenya.
31
Hirbod T & Broliden K (2007). Mucosal immune responses in the genital tract of HIV-1-exposed uninfected
women. Journal of Internal Medicine 262 (1), 44–58.
32
Gouws E et al. (2006). Short term estimates of adult HIV incidence by mode of transmission: Kenya and
Thailand as examples. Sex Transm Infect, 82(suppl III):iii51-55.
33
Sanders EJ et al. (2006). Establishing a high risk HIV-bnegative cohort in Kilifi, Kenya. AIDS Vaccine 2006
Conference. Amsterdam, August 2006 [abstract 470.00].
34
Angala P et al. (2006). Men who have sex with men (MSM) as presented in VCT data in Kenya. XVI
International AIDS Conference, Toronto, August 2006 [abstract MOPE0581].
35
UNAIDS (2005). Men who have sex with men, HIV prevention and care. Report of a stakeholder consultation.
Geneva, 10-11 November 2005.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
17
3.7 SEXUAL BEHAVIOR DATA
The sexual behavior data presented in Table 6 all come from recent DHS (Kenya 2003, Rwanda
2005, Tanzania 2004, Uganda 2006). No comparable data could be identified for Burundi and
DRC.
Table 6. Population-based data on sexual behavior in GLIA countries
Sexual debut: Age at first sexual intercourse
Women 25-49 yrs
Men 25-54/59 yrs
Sexual debut: Had sex by age 15
Women 15-24 yrs
Men 15-24 yrs
Multiple partners: Had more than one sex
partner in the last 12 months
Women
Men
Higher-risk sex*: Engaging in higher risk sex
in past 12 months
Women 15-49 yrs
Men 15-49 yrs
Women 15-24 yrs
Men 15-24 yrs
Condom use: Using condom at last higher
risk sex
Women
Men
Age-mixing: Higher-risk sex in the past 12
months with a man who was ≥10 yrs older
Women 15-19 yrs
Self-reported STIs: STI/discharge/genital
sore/ulcer in past 12 months
Women
Men
Knowledge of HIV status: Ever tested and
received result
Women
Men
Burundi
DRC
Kenya
Rwanda
Tanzania
Uganda
n.d.
n.d.
17.6 yrs
17.2 yrs
20.3 yrs
20.8 yrs
17.0 yrs
18.5 yrs
16.4 yrs
18.1 yrs
n.d.
n.d.
13.7%
28.8%
2.6%
10.8%
12.4%
9.4%
15.5%
12.2%
n.d.
n.d.
1.7%
11.7%
0.6%
5.1%
4.3%
30.1%
2.4%
28.4%
n.d.
n.d.
17.6%
39.6%
30.0%
84.4%
8.1%
13.6%
15.3%
48.0%
23.7%
45.2%
34.0%
82.8%
15.9%
34.9%
27.1%
65.3%
n.d.
n.d.
23.9%
46.5%
19.7%
40.9%
27.5%
51.0%
34.9%
57.0%
n.d.
n.d.
4.0%
4.6%
6.2%
7.0%
n.d.
n.d.
4.4%
3.1%
5.0%
2.7%
5.1%
5.6%
22.1%
12.5%
n.d.
n.d.
13.1%
14.3%
21.2%
20.1%
12.1%
12.3%
24.8%
20.6%
Sources: Kenya DHS 2003, Rwanda DHS 2005, Tanzania DHS 2004, Uganda DHS 2006
* Sexual intercourse with a partner who neither was a spouse nor who lived with the respondent
•
There are significant differences in sexual behavior across the four GLIA countries for
which data were available
•
Knowledge of HIV status was less than 20% in all GLIA countries
•
Percentage of men and women engaging in higher-risk sex varied dramatically from 83%
amongst Tanzanian men aged 15 to 24, to 8% amongst women aged 15 to 49 in Rwanda.
•
Condom use during last higher-risk sex was universally higher amongst men than women
•
Self-reported STIs were dramatically different in Uganda (22%F, 13% M) than in other
countries (less than 6% for men and women)
Sexual behaviors and practices happen against a background of traditional and modern sexual
and reproductive customs and norms. Some customs are confined to one ethnic group, or to a
place or socio-economic strata of the population. The analysis identified illustrative examples of
such customs in the GLR and their presumed impact on HIV transmission:
•
Wife inheritance (levirat) is a practice among Luo traditions and customs. When a husband
dies, his wife is expected to be inherited for continuity of the family, particularly if she is of
child bearing age. In the olden days, the inheritor was strictly expected to come from within
the clan and next of kin of the dead husband i.e. his brothers or cousins, but this is no longer
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
18
the case – the inheritor can be outside the clan. If the late husband died of an AIDS related
cause and the surviving wife is HIV positive, the inheritor is at high risk for HIV infection. 36
•
Female genital cutting varies widely across ethnic groups in the Great Lakes Region, and
national prevalence is equally diverse: 32% for Kenya (DHS 2003), 15% for Tanzania (DHS
2004/5) and <1% for Uganda (DHS 2006). It is practiced for a variety of reasons, including
marriageability, curbing sexual desire, protecting virginity, religious rite, initiation into
womanhood, improved hygiene, and beautification. A recent article 37 revealed transmission
of HIV to girls with a non-perforated hymen (virgins) and that 97% of the time, the same
instrument could be used on 15-20 girls. 38 Other factors that may increase risk are the
increased need for blood transfusions due to haemorrhage when the procedure is performed,
or at childbirth, or as a result of vaginal tearing. Many women with type III mutilation
experience dyspareunia, as well as repeated tissue damage and bleeding, experience difficult
and painful vaginal intercourse leading to some of them practising anal intercourse with
heterosexual partners, further increasing the risk of HIV transmission. It is therefore
plausible that HIV transmission may be enhanced by the widespread practice of female
genital cutting. 39
•
Cross-generational sexual relationships are frequent and contribute to HIV transmission
between higher-prevalence populations (older men) and low-prevalence populations
(younger females). A study conducted in Kenyan towns found that women's primary
incentive for engaging in such relationships is financial, and that there is peer pressure from
women to find older partners. 40 Such couples rarely use condoms. Material gain, sexual
gratification, emotional factors, and recognition from peers override concern for STI/HIV
risk. Women's ability to negotiate condom use is compromised by age and economic
disparities.
•
Opinions and beliefs connected to condoms and their use have important implications for
condom provision and uptake. The socio-cultural context of condom use among the Maasai,
an east African agro-pastoralist population, for example, has been studied, 41 and the ethnodemographic literature describes the socio-cultural significance of semen in a range of
settings. Opinions and beliefs connected to condoms include their contraceptive effects,
negative impact on quality of sex, the wasting of semen and the 'otherness' of condoms.
•
'Chira' is a curse which is said to befall people who are seen to have gone against the
customs and traditions of the society. The affected persons develop similar signs and
symptoms of full blown AIDS. Conflict therefore does exist between 'Chira' and AIDS
among the Luo community. According to Luo traditions and customs, HIV and AIDS do not
exist, it is 'Chira' and 'Chira' is not transmitted through heterosexual relationships but
through going against the social customs and traditions.41
36
Owino JP (1998). Wife inheritance and 'Chira' cultural impediments in HIV and AIDS control, prevention and
management: a case study of Luo community in Kenya. Int Conf AIDS. 1998; 12: 474 (abstract no. 24168).
37
Etokidem AJ (2004). HIV/AIDS transmission through female genital cutting: a case report. Int Conf AIDS 2004
Jul 11-16; 15 (abstract no. D 10677)
38
Mutenbei IB & Mwesiga MK (1998). The impact of obsolete traditions on HIV/AIDS rapid transmission
inAfrica: The case of compulsory circumcision on young girls in Tanzania. Int Conf on AIDS 1998; 12:
436(abstract 23473)
39
Monjok E (2007). Female Genital Mutilation: Potential for HIV Transmission in sub-Saharan Africa and
Prospect for Epidemiologic Investigation and Intervention. African Journal of Reproductive Health, 11(1), 33-42.
http://www.bioline.org.br/request?rh07004
40
Longfield K et al. (2004). Relationships between older men and younger women: Implications for STIs/HIV in
Kenya. Studies in Family Planning, 35(2), 125-134.
41
Coast E (2007). Wasting semen: Context and condom use among the Maasai. Culture, Health & Sexuality, 9(4),
387-401.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
•
19
‘Matalisi’ is a phenomenon uncovered during a study of youth sexual behavior in Uganda.
The ‘Matalisi’, a go-between, plays a central role in early sexual initiation and sexual
relationships of most youth in Mpigi, Uganda. Matalisis were used in most courtships and
initial sexual liaisons. Participating as someone’s Matalisi preceded most first coitus. 42
3.8 MALE CIRCUMCISION
Male circumcision (MC) is a socio-cultural factor increasingly recognized as a chief determinant
of population-level HIV prevalence (WHO, 2006). MC is practiced in many areas in the GLR
and often serves as a rite of passage to adulthood. However, MC rates vary widely: Kenya
(83.7%), Rwanda (10.7%), Tanzania (69.7%), and Uganda (24.9%). Rates are higher in urban
areas than in rural areas in Rwanda, Tanzania and Uganda, but not in Kenya, and generally
higher in more educated/wealthier population strata. A chief determinant of MC is religion;
usually more than 90% of Muslim men are circumcised (figure lower for Rwanda). The Kenya
DHS 2003 found signs that there has been a decline in the practice of MC in Kenya. Figure 6
presents data from three GLIA countries from which disaggregated provincial/regional
prevalence figures of both male HIV infection and MC are available. Please note that the scatter
graph compares pairs of values for each province/region of Kenya, Tanzania and Uganda. The
paired values (diamonds, circles and triangles in Figure 6) are the percentage of men
circumcised and the HIV prevalence in men in each of these locations.
Figure 6. Provincial/regional data on HIV prevalence versus male circumcision rates
25
HIV %
Ke -Men
Tz Men
Ug - Men
20
Linear (Ke -Men)
2
R = 0.8073
Linear (Tz Men)
Linear (Ug - Men)
15
10
2
R = 0.1149
5
2
R = 0.0241
0
0
10
20
30
40
50
60
70
80
90
100
110
% male circumcision
Sources: Kenya DHS 2003, Tanzania AIS 2003/4, Uganda AIS 2004/5
•
There is a linear relationship between HIV prevalence and MC rates in men in Kenya, but
not in Tanzania and Uganda
•
Circumcision rates can partly but not fully explain current HIV prevalence levels – other
important factors play a role, such as age at sexual debut, multi-partnering, maturity of the
epidemic and prevention efforts
42
Morrow O et al. (2004). The Matalisi: Pathway to Early Sexual Initiation Among the Youth of Mpigi, Uganda.
AIDS and Behavior, 8(4), 365-378.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
20
In two randomized trials in the GLR, MC significantly reduced the risk of HIV acquisition in
young men, supporting the recommendation that “where appropriate, voluntary, safe, and
affordable, circumcision services should be integrated with other HIV preventive interventions
and provided as expeditiously as possible”:
•
In the trial in Rakai 43, Uganda, HIV incidence over 24 months was 0·66 cases per 100
person-years in the intervention group (circumcision at trial start) and 1·33 cases per 100
person-years in the control group (delayed circumcision). The estimated efficacy of the
intervention was 51% (95% CI 16–72; p=0·006).
•
The trial in Kisumu 44, Kenya, found a 2-year HIV incidence of 2.1% in the circumcision
group and 4.2% in the control group (p=0.0065). The protective effect of MC was 60%
(95% CI 32–77).
Although preliminary data from the Kenya trial indicate that men in their first year after being
circumcised did not engage in higher levels of risk behavior than uncircumcised men, 45 little is
known about the long-term behavioral impact, if any, of introducing MC (more information on
MC is presented in the chapter on promising interventions).
3.9 TRANSACTIONAL SEX
Transactional sex involves exchange of sex for money, favours, or gifts. The practice is
associated with high risk of contracting HIV and other STIs due to compromised power relations
and the tendency to have concurrent, multiple partnerships. Transactional sex has been shown to
be the driving force in the dynamics of HIV in many different sites. The estimated population
attributable fraction (PAF) of transactional sex was 84% in Accra 46 and 76% in Cotonou. 47
A recent meta-analysis confirmed the importance of ‘paid sex’ as a risk factor for heterosexual
HIV transmission in SSA for both women and men. 48 In all the studies combined, about 9% of
HIV positive women reported ever having been paid for sex, versus 4% of HIV negative women,
and the Odds Ratio was 2.29 (95%CI [1.45-3.62]). This analysis was based on 9 studies, of
which 6 came from GLIA countries (dated 1990-1993). About 31% of HIV positive men
reported ever paying for sex versus 18% of HIV negative men, with an Odds Ratio of 1.75
(95%CI [1.30-2.36]). Five of the 10 studies with data on men came from GLIA countries (dated
1987-1991).
Data from the countries in the Great Lakes Region have been summarised in Table 7.
43
Gray RH et al. (2007). Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial 1.
Lancet, 369(9562):657-66.
44
Bailey RC et al. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised
controlled trial 2. Lancet, 369(9562):643-56.
45
Agot KE et al. (2007). Male circumcision in Siaya and Bondo Districts, Kenya: Prospective cohort study to
assess behavioral disinhibition following circumcision. JAIDS, 44:66-70.
46
Coté et al. (2004). Transactional sex is the driving force in the dynamics of HIV in Accra, Ghana. AIDS,
18(6):917-925.
47
Lowndes CM et al. (2003). Male clients of female sex workers in Cotonou, Benin (West Africa): contributions to
the HIV epidemic and effect of targeted interventions. 15th Biennial Congress of the International Society for
Sexually Transmitted Diseases Research, Ottawa, July 2003 [abstract 0729]
48
Chen et al. (2007). Sexual risk factors for HIV infection in early and advanced HIV epidemics in Sub-Saharan
Africa: systematic overview of 68 epidemiological studies. PLoS ONE (www.plosone.org), October 2007, issue 10.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
21
Table 7. Prevalence of transactional sex in GLIA countries
Transactional sex:
Burundi DRC
Kenya
Rwanda Tanzania
Men reporting paid sex, past 12 months
n.d.
n.d.
2.9%
n.d.
10.6%
Men using condom, last paid sex
64.5%
59.0%
Women receiving money, gifts/favours for sex
5.5%
n.d.
Sources: Kenya DHS 2003, Rwanda DHS 2005, Tanzania DHS 2004, Uganda DHS 2006
* Women giving or receiving money, gifts, favours for sex
Uganda
2.8%
6.6%*
These data show that:
•
Not all countries systematically collect population-based data on transactional sex
•
Prevalence of reported paid sex varies widely and is high in Tanzania
•
Condom use in paid sexual intercourse is still not ‘the rule’
3.10 IN SUMMARY
What do we know about the HIV epidemics in the six GLIA countries?
•
The HIV epidemics in the GLIA countries are highly diverse, with HIV population
prevalence ranging from as high as 15.1% (Nyanza Province, Kenya) and 13.5% (Mbeya
Region, Tanzania) to as low as 0.6% (Zanzibar) and 0% (North-Eastern Province, Kenya)
•
The epidemics are stabilising or even contracting, most clearly in Uganda, Kenya,
Rwanda, and non-urban Tanzania. There is less evidence on epidemic trends and phase in
the DRC and Burundi, due to a lack of data (although the 2007 bio-behavioral surveys in
these two countries should provide good data).
•
Some epidemics are relatively well understood due to availability of recent prevalence and
behavioral data in the general population and ongoing epidemiological analysis (e.g. Kenya).
•
Other epidemics are less well understood due to lack of recent population-based HIV
prevalence data (e.g. DRC).
•
The data suggest that higher risk populations play an important role in driving the
epidemic and that unprotected higher risk sex, and to some extent paid sex, remain key
contributors to the continuing transmission of HIV.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
22
4. RESULTS: VULNERABLE POPULATIONS IN THE GLR
4.1 WHO ARE THE VULNERABLE POPULATIONS IN THE GLR?
It is important to recognize the difference between HIV vulnerability and risk factors. Subpopulations that already have high HIV prevalence are often referred to as high-risk
populations. In contrast, vulnerable populations may or may not have high HIV prevalence,
but are considered to be vulnerable because of their condition in society. Sub-populations such
as FSW are both vulnerable to HIV (due to stigma and discrimination) and suffer from a high
prevalence of HIV (for reasons of high HIV exposure). Sub-populations such as housewives, for
example, may be vulnerable to HIV because they lack the power to influence the behaviors of
their husbands, but they do not currently have disproportionately high prevalence of HIV.
There are various reasons why an individual may be vulnerable to HIV. Some may not have
information about HIV prevention and/or treatment of AIDS. Others may lack the power to
implement the needed behaviors (e.g., FSW may not be sufficiently empowered to insist that
their clients use condoms), or lack access to prevention or treatment services (e.g., an individual
may not live in an area where ART is readily available). Vulnerability may therefore not only
influence HIV risk but also the disease pathogenesis and course by determining who has access
to VCT, who receives timely ART, and who will be stigmatized and further marginalized.
Early in the epidemic, Zwi and Cabral (1991) identified five ways in which populations may
become high risk during low-intensity conflict: displacement, military activity, economic
disruption, psychological stresses, and increased migration. 49 This analysis takes a fresh look at
this proposition and presents the current best evidence on the leading factors of vulnerability and
HIV risk in the Great Lakes Region.
Table 8. Vulnerable populations identified and frequency of mention, by country
Population
Burundi
DRC
Kenya
Rwanda
Tanzania Uganda
Bar attendants/ Brew sellers
0
0
3
0
3
0
Fishermen/Fishing communities
0
0
4
0
0
3
General population / men
7
5
8
10
11
12
Health care providers
0
0
2
2
1
0
IDPs/ host communities/ returnees
1
2
0
0
0
6
(Injection) Drug users
0
0
4
0
2
2
Migrants
0
0
0
1
1
1
Military/Combatants/Peace keepers
0
3
0
0
0
3
Men having Sex with Men
0
0
1
0
0
1
Patients
0
2
0
0
2
2
People living with HIV (PLHIV)
5
4
3
4
4
6
Police/Gendarmerie/Customs officers
0
0
0
0
0
1
Prisoners
2
0
4
2
2
2
Refugees/host communities/ returnees
0
0
2
2
7
6
Rural communities
0
0
1
0
8
3
Sex workers and their clients
2
5
12
1
2
1
Truckers/Truck assistants
0
2
9
0
4
0
Victims of gender based violence
0
1
1
0
6
3
Women
3
6
5
0
6
5
Workers incl. miners
1
2
3
0
3
1
Youth/Adolescents/Children/OVC
3
6
7
1
4
6
NOTE: not shown here are documents covering several population groups in several GLIA countries
49
Total
6
7
53
5
9
8
3
6
2
6
26
1
12
17
12
23
15
11
25
10
27
Zwi AB & Cabral AJ (1991). Identifying ‘high risk situations’ for preventing AIDS. BMJ, 303(6816):1527-9.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
23
Table 8 summarizes the vulnerable populations that were identified through the literature
review. It can be noted that:
•
For some vulnerable population groups, it is difficult to identify relevant data and
information. This includes mobile traders, domestic servants, police, miners, and abducted
children. No HIV-specific information was found about the highly vulnerable population of
trafficked people - men, women, and children trafficked for forced labour and sexual
exploitation.
•
There is great overlap between vulnerable populations, i.e. a person can belong to more
than one constituency. A brew seller can also be an IDP and a sex worker, a long-distance
truck driver can also be a migrant, and a victim of gender based violence can also be an
adolescent girl. People move in and out of specific age groups, occupational groups,
geographic groups - they are mobile between countries, change their ways of earning a
living, and may have acquired HIV infection while belonging to a specific population group,
but not still be part of that population group at the time of enumeration and testing
•
Some population groups share key characteristics. For instance, living away from the
family due to mobility (truckers, military, fishermen), occupational risk (miners, truckers,
FSW), a history of violence (females affected by sexual violence, refugees, combatants), or
being more likely to be clients of FSW (truckers, police, traders)
•
Size estimations of vulnerable populations are not systematically done by any agency in
the countries and data are scarce or incomplete. For instance, occupational groups like
fishermen and drivers mostly work in the informal sector and are rarely enumerated nor
represented by a union. Typologies of female sex workers (FSW) suggest that there are
several different types of FSW, ranging from brothel-based women to low-income women
who do occasional sex work for cash or kind – which makes size estimations basically
impossible
•
Mapping techniques are not sufficiently used in order to present spatially related data.
One positive exception is the detailed mapping of the Africa Highway Northern Corridor,
which is a good practice example of formative research
•
The six countries have shared border areas but also large areas which are at the fringe
of the GLR. These are for instance the Indian Ocean Islands Zanzibar and Pemba, the arid
North of Kenya, and parts of the DRC with inaccessible areas and more navigable rivers than
any other country in Africa.
The study team developed a short-list of vulnerable populations for detailed analysis by applying
the following selection criteria to the list of populations in Table 8:
1. Populations whose lives are touched by specific issues characteristic to the GLR – mobility
(voluntary or forced), conflict and violence.
2. Populations who, according to the epidemiological evidence, make significant contributions
to the ongoing transmission of HIV.
3. Populations whose population size, HIV prevalence, vulnerability profile and HIV risk
factors are known or can be estimated from the literature.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
24
4. Universal importance of populations with high rates of sexual partner change, based on
recent work done by Chen et al. 50 which showed that people with this behavior – e.g. female
sex workers and their clients – are important drivers of epidemics, irrespective of the
epidemic phase.
5. General knowledge about the proportionally higher rates of females than males infected
(thus needing to focus strongly on females as a vulnerable population).
Taking these factors into account, the study team retained the following population groups for
detailed discussion:
• Populations in mobile occupations:
• Interaction with persons in mobile
occupations:
• Populations with specific experiences
of conflict, crime and violence:
Long distance truck drivers
Fishermen and fisherwomen
Military and other uniformed services
Female sex workers
Refugees, IDPs, host populations and returnees*
Prisoners
Females affected by sexual and gender-based violence
* these populations are also mobile/displaced
The rest of this chapter presents, for each of these populations, the data on population size, HIV
epidemiology and sexual behavior; and then summarizes the population size, vulnerability and
HIV risk factors for all these populations.
4.2 LONG-DISTANCE TRUCK DRIVERS
In East Africa, early surveillance showed a strong correlation between HIV prevalence and
locations along transport axes. As the epidemic grew, HIV diffused outwards from the original
focus along the main roads into the main towns, then to more rural areas.
Two survey-type activities focusing on transport workers have been conducted by the GLIA:
key stopover sites along the main regional road axes of the region have been identified (1999),
and a situation assessment on health services at selected truck stops along the two regional road
axes was carried out in 2006 by IOM and UNAIDS. 51 Some of the data provided by that
assessment were mapped within this data analysis (see Annex I).
Population size
There is substantial uncertainty in the estimation of trucker numbers, particularly so for the
DRC: the country is more urbanized than the other GLIA countries (one would therefore expect
a higher number of truckers), but the road network is very poor, only about 2,250 km are allweather paved highway (Table 9).
50
Chen et al. (2007). Sexual risk factors for HIV infection in early and advanced HIV epidemics in Sub-Saharan
Africa: systematic overview of 68 epidemiological studies. PLoS ONE (www.plosone.org), October 2007, issue 10
51
IOM.UNAIDS/GLIA (2006). Long-distance Truck Drivers’ Perceptions and Behaviors Towards STI/HIV/TB
and Existing Health Services in Selected Truck Stops of the Great Lakes Region: a Situation Assessment
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
25
Table 9. Truck driver population data for GLIA countries
Total population (2007)
Estimated number of truck drivers
Burundi
8,390,505
13,138
DRC
65,751,512
102,954
Kenya
36,913,721
57,800
Rwanda
9,907,509
15,513
Tanzania
39,384,223
61,668
Uganda
30,262,610
47,385
Total
190,610,080
298,458
Sources: Number of Kenyan truck drivers from Kissling et al (2005). All other trucker population sizes were
extrapolated from the total population, using the same proportion of Kenyan truck drivers to the total Kenyan
population (methodology according to Kissling et al. 2005).
HIV epidemiology and mobility
Truck drivers, often stigmatized as a “core transmitter group”, were studied early in the
epidemic, particularly in Kenya and Uganda, where surveys carried out along highways found
consistently high rates of HIV infection in the long-distance truck driving population. Morris
and Ferguson (2006) recently used, for modeling purposes, a value of 20% to estimate HIV
prevalence in transport workers.
Table 10. HIV prevalence in truck driver population and median prevalence
National HIV
%HIV+
Year
prevalence
DRC
4.9%
2006
n.d.
DRC- West
3.3%
2006
n.d.
Kenya: Athi River
27%
1994
6.7% (2003)
Kenya: Mariakani
26%
1995
6.7% (2003)
Kenya
18%
1999
6.7% (2003)
Kenya: Mombasa-Nairobi highway
27%
1992
6.7% (2003)
Kenya: Mombasa
18%
1997
6.7% (2003)
Median HIV Prevalence
18%
Sources: PNMLS (2006) Enquête de surveillance comportementale en DRC, volume 2; Bwayo J et al. (1994)
Human immunodeficiency virus infection in long-distance truck drivers in east Africa.. Arch Intern Med, 154:1391–
1396; Mbugua GG et al. (1995). Epidemiology of HIV infection among long distance truck drivers in Kenya. East
Afr Med J, 72:515–518; Rakwar J et al. (1999). Cofactors for the acquisition of HIV-1 among heterosexual men:
prospective cohort study of trucking company workers in Kenya. AIDS, 13:607–614; Job B et al. (1992). HIV
infection in long distance truck drivers in Kenya: seroprevalence, seroincidence, and risk factors. International
Conference on AIDS 1992, abstract no. ThC1514; Jackson DJ et al. (1997). Decreased incidence of sexually
transmitted diseases among trucking company workers in Kenya: results of a behavioral risk-reduction
programme. AIDS, 11(7):903-9. (HIV prevalence of truckers in Kampala reported by Carswell JW et al. in 1989 is
not used in the calculation); Kenya DHS (2003)
Site
Sample
Truck drivers and assistants
Truck drivers
Truck drivers
Truck drivers and assistants
Trucking company employees
Truck drivers
Trucking company workers
A recent study on the transport corridor between the port of Mombasa and Kampala showed the
large number of FSW available at truck stops, and the high number of new HIV infections
projected to occur among sex workers and their clients. 52 Maps produced by the project are
shown in figure 7.
Morris CN & Ferguson AG (2006). Estimation of the sexual transmission of HIV in Kenya and Uganda on the transAfrica highway: the continuing role for prevention in high risk groups. Sex Transm Infect, 82:368-71.
52
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Figure 7. Mean number of overnight trucks: Mombasa-Nairobi (a), Nairobi-Uganda border (b)
(a)
(b)
Source : Ferguson AG & Morris CN (2007). Mapping transactional sex on the Northern Corridor highway in
Kenya. Health & Place, 13:504-519.
Rakwar et al. (1999) found an annual HIV incidence of 3.1% in a prospective cohort study of
trucking company workers in Kenya. Two interrelated occupational factors, employment as a
driver/driver’s assistant and duration of time on the road, were both risk factors for HIV
seroconversion. Baeten et al. (2005) found that per-contact HIV infectivity of truckers was
highest in those who travel ≥14 days/month. 53
Sexual behavior data
53
Baeten JM et a. (2005). Female-to-male infectivity of HIV-1 among circumcised and uncircumcised Kenyan
men. JID, 191:546-553.
26
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
27
The only recent BSS data on truckers identified come from DRC (PNMLS, 2006). Overall, 48%
of truckers and truck assistants reported having paid for sex in the past 12 months. Only 30% of
all sexually active truckers had ever used a condom, 28% had ever had a HIV test, and 17% had
been exposed to peer education. A study on adolescent high risk sexual behavior at truck stops
(Malaba, Mashinari, and Sachangwan) found alarmingly high levels of risk behavior. 54 Girls
aged 15-17 years reported a median of 15 lifetime sexual partners, including truck drivers, and
boys reported a median of 12 lifetime partners, including FSW in truck stops. Only 54% of girls
and 35% of boys reported having ever used a condom.
Qualitative data are available that show the extent of interaction between truck drivers and FSW:
• Mbugua (2000) gives an example of a popular truck stop known as Mdaula situated along
Morogoro highway towards southern Tanzania. 55 During evenings, Mdaula truck stop
becomes a lively centre and the chain of bars, lodges, FSWs and bar attendants do brisk
business when the hundreds of truck drivers and their assistants arrive. The centre attracts
young women from rural areas, often school dropouts, who provide commercial sex to the
relatively well-paid transport professional, drivers, their assistants and other traders.
•
Haour-Knipe et al. (1999) point out that a truck driver may provide transportation for people
(women in particular) to relieve the monotony of a long trip, and rides usually may be paid
for by sex. 56
•
“It takes me 3 months to pick goods from Mombasa to deliver in Burundi. I cannot sincerely
survive all this time without having a woman along the routes, so I have a sex worker in
Mombasa, one in Kisumu, and one in Kampala. These are the points where I stop for one or
sometimes even several weeks, while waiting for customs clearance.” Kenyan truck driver 57
•
A recent study of the transport corridor between the port of Mombasa and Kampala showed
that there were approximately 8,000 sex workers on this highway and that, annually, 3,000–
4,000 new HIV infections were projected to occur along this transport corridor among sex
workers and their clients. 58
•
“8,000 drivers work on East Africa’s Northern Corridor, with monthly earnings on average
equivalent to US$150. 7,000 sex workers ply the route, charging around US$2 per
customer. There are 300 established sex workers at the Malaba border crossing post
between Kenya and Uganda”. David Browne, Highway of Hope 59
•
ITF research on HIV/AIDS and transport workers in Uganda in 1999 reported finding that
sex workers operating at truck stop points in Uganda had an HIV sero-positivity rate as high
as 76%. 60 A study in Tanzania among truck-drivers also found that condom use with
regular or steady FSWs is very low, because sex workers are treated as trusted partners or
54
Nzyuko S et al. (1996). Adolescents high risk sexual behavior along the trans-Africa highway in Kenya. Int Conf
AIDS 1996, 11:140, abstract no. MoC1487.
55
Mbugua I (2000). Keeping on Truckin’ – but Playing it Safe. Daily Nation Newspaper - Special report.
56
Haour-Knipe M et al (1999). Interventions For Workers Away From their Families” in Preventing HIV in
Developing Countries: Biomedical and Behavioral Approaches, edited by Gibney et al. Press, New York 1999
57
Voeten H et al. (2002). Clients of female sex workers in Nyanza Province, Kenya. Sex Trans Dis 2002, 29:8,
444-452.
58
Morris CN & Ferguson AG (2006). Estimation of the sexual transmission of HIV in Kenya and Uganda on the
trans-Africa highway: the continuing role for prevention in high risk groups. Sex Transm Infect, 82:368-71.
59
http://www.itfglobal.org/HIV-Aids/agenda1-hwy.cfm
60
Ouma NM et al. (2002). HIV/AIDS prevention and care for transport workers in Uganda. Int Conf AIDS. 2002
Jul 7-12; no.ThPeF8071.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
28
‘wives’, with whom using a condom is unacceptable because it tends to signal a lack of
trust. 61
•
Transport unions emphasize that one of the main factors resulting in the spread of HIV is the
amount of time it sometimes takes to cross a border post: “All of the bureaucratic hold ups
which are required by various authorities – and, in many countries, all the bribes that have
to be paid – result in drivers wasting days at border posts. They are then more likely to visit
CSWs or engage in other unhealthy behavior. Whole communities spring up around major
border posts to cater for the needs of transport workers.” 62
Other transport sector workers
No HIV data were available on other road transport workers (i.e. other than long-distance truck
drivers), despite the large numbers of some of these workers, e.g. informal taxi industry; 63
informal truck operators; workers employed without formal contracts by informal truck
operators, self-employed workers eking out a living by carting rubbish, carrying luggage,
repairing tyres, selling petrol and so on; and female workers who clean, prepare and sell food to
passengers, or sell petrol.
Summary of Findings: Truck Drivers
Table 11. Truck drivers – Population size, vulnerability and HIV risk factors
Truck drivers – Estimated Population Size in GLR = 298,458
Truck drivers: Factors of Vulnerability
Truck drivers: Risk Factors for HIV
• Long separation from spouses and family
• Serial and concomitant partners
• Unrealistic work schedules
• Regular sex workers are treated as wives
• Loneliness and isolation, mitigated by providing transportation for people
(women in particular)
• Inconsistent levels of condom use with
commercial and occasional sexual
partners
• Monotonous work
• Road risks (accidents, theft)
• Work in remote and poor environments with inadequate rest and
recreational facilities
• Easy access to alcohol
• Stress leading to abuse of alcohol and drugs
• Availability of disposable funds
• Long and frustrating delays at border crossovers and custom checkpoints
• Low level of condom use with regular
partners and spouses
• Limited access to regular HIV prevention
services, including VCT
• Casual sex readily available
• Milieu around border posts caters for the
sexual needs of transport workers, with
brothels, taverns and bars
• Harassment and stigmatisation by police, border officials and communities
• Context of sexual violence and
• Lack of health infrastructure where transport workers need it, large trucks
cannot get to facilities off the main road
• Women joining truck may pay for ride by
• Stigma and discrimination by employers
harassment
sex
• Absence of legal protection
• Macho culture
61
Laukamm-Josten U et al. (2000). Preventing HIV infection through peer education and condom promotion
among truck drivers and their sexual partners in Tanzania, 1990–1993. AIDS Care 2000; 12:27–40
62
ITF. HIV/AIDS: Transport workers take action. http://www.itfglobal.org/files/seealsodocs/324/hiv%2Daids.pdf
63
“Reaching out to informal workers“ http://www.itfglobal.org/transport-international/ti24-informal.cfm (accessed
16 oct 2007)
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
29
4.3 FISHERMEN & FISHERWOMEN
Fishing in marine and inland water is an important contributor to the development of coastal,
lakeshore and riverside communities and to national economies in the GLR. Fisheries frequently
act as localized ‘engines of growth’ by bringing the market economy to remote rural areas. This
analysis distinguishes between fishermen and fisherwomen (men and women involved in fish
catching operations), ‘fisherfolk’ (any persons involved in fishing and fish trading and
processing) and people living in fishing communities (any person resident in a port, village or
fish landing station where fishing is a prominent occupation).
Fishermen/women have different work patterns. Some go to sea for a few days at a time, others
for a few weeks or months. Some work from their home ports, others travel from home to find
work in large fishing ports. Those who are at sea from many months sometimes stop at other
ports in their own country or in other countries in the region. Some work full-time in industrial
fisheries and may be organized in units (for instance, Burundian fishermen on Lake Tanganyika
are in groups of 25-35 in an industrial fishing unit). Others fish part-time as a secondary
occupation for 10-12 days per month, often to supplement their income from farming. And
others are purely occasional fishermen. A fishing team on an inland lake usually has 4-5
members. The fishing units are fairly autonomous, and the fishermen’s mentality is often one of
accentuated individualism.
Population size
Available data on the number of fisherfolk in the GLR have several weaknesses due to irregular
reporting by countries, different concepts used to enumerate employment, and the informal
nature of many fishing occupations. Country specific data are given in Annex IXa from FAO
and population censuses – summary data are shown in Table 12 below.
Table 12. Fishing population data for GLIA countries
Total population (2007)
Estimated number of Fishermen & Fisherwomen
Burundi
8,390,505
10,969
DRC
65,751,512
108,400
Kenya
36,913,721
55,176
Rwanda
9,907,509
3,460
Tanzania
39,384,223
150,865
Uganda
30,262,610
118,786
Total
190,610,080
447,656
Sources: FISHSTAT (FAO), Population Census 2002 (Tanzania), Population Census 2002 (Rwanda), and
Population Census 2002 (Uganda)
HIV epidemiology and mobility
HIV prevalence in some fishing communities in low and middle-income countries is known to
be high relative to national average seroprevalence rates – see Table 13. 64 Most of the studies
supporting this claim refer to fishermen, but acknowledge that the men and women who work in
associated occupations such as fish trading and processing are also vulnerable, in part because
they are often part of the fishermen’s sexual networks.
64
Allison EH, Seeley JA. Another group at high risk for HIV. Science 2004; 305:1104.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
30
•
HIV prevalence in fishermen is elevated: Studies found prevalence rates in DRC of 20.3%
(4.2% in general population) 65, on Lake Albert in Uganda 24.0% (4.1% in nearby
agricultural villages) 66, and in Kenya 30.5% (general population 6.7%) 67 and 25.3% (at
39.2% in individuals in their 30s). 68
•
STI prevalence among fishermen in Kisumu, Kenya (Bukusi et al 2006) was 74.3% for
HSV-2 and 9.6% for syphilis. Reported condom use was 28.1% with a girlfriend, 12.5%
with a casual partner and 3.9% with a wife.
•
A longitudinal study based on diary information in south-west Uganda, where significant
differences in HIV prevalence have been found between urban and rural areas, showed that
higher-risk women living in the fishing village and rural area had around 90% of their
contacts with local men. 69
•
A participatory rural appraisal exercise for a community fisheries project in Kagera region
on the western side of Lake Victoria, Tanzania allowed fisherfolk to describe the ways in
which AIDS was changing livelihoods in poor fishing and farming communities. “On the
lakeshore and islands, adults were falling ill and dying. This loss of men and women in their
prime was causing major economic and social stresses for the single parents, grandparents,
and orphans”. 70
Table 13. HIV prevalence in fishermen and median prevalence
National HIV prevalence estimate
%HIV+
Year
(see Table 3)
3.2%
Kalemie (partners of fishermen)
DRC
20.3
2001
6.1%
Kenya
Lake Victoria
25.3
2006
6.1%
Kenya
Fishing villages
30.5
2002
6.7%
Uganda
Ntoroko
24.0
1992
Median HIV prevalence
24.7%
Sources : Kambale L (2001). Etude de la séroprévalence de l’infection par VIH dans la zone de santé de Kalemie
au Nord Katanga. Kivu : Save the Children/PNLS. http://www.kongo-kinshasa.de/dokumente/ngo/index.php
(accessed October 7, 2007); Bukusi EA et al. (2006). HIV/STI prevalence & risk among fishermen in Kisumu,
Kenya. XVI International AIDS Conference, abstract no. CDC0248; UNAIDS (2002), Epidemiological fact sheet
Kenya; Kipp W et al. (1995) Prevalence and risk factors of HIV-1 infection in three parishes in western Uganda.
Trop Med Parasitol 46:141-146; Kenya DHS (2003), Uganda AIS 2004/5
Site
Many fishing populations are highly mobile. Men move between landing sites and local markets
on a daily and seasonal basis. Fish processors, traders and transporters – men and women –
move between landing sites, regional and national markets and processing factories. Other
service providers – including FSW – move with them. These movements and networks are likely
to play a part in transmission of infection between higher and lower prevalence areas. A study
65
Kambale L (2001). Etude de la séroprévalence de l’infection par VIH dans la zone de santé de Kalemie au Nord
Katanga. Kivu : Save the Children/PNLS. http://www.kongo-kinshasa.de/dokumente/ngo/index.php (accessed
October 7, 2007)
66
Kipp W et al. (1995). Prevalence and risk factors of HIV-1 infection in three parishes in western Uganda. Trop
Med Parasitol 46:141-146
67
Reviewed in Kissling E et al. (2005). Fisherfolk are among groups most at risk of HIV: cross-country analysis of
prevalence and numbers infected
68
Bukusi EA et al. (2006). HIV/STI prevalence & risk among fishermen in Kisumu, Kenya. XVI International
AIDS Conference, abstract no. CDC0248.
69
Pickering H et al. (1997). Sexual networks in Uganda: mixing patterns between a trading town, its rural
hinterland and a nearby fishing village. Int J STD AIDS 1997; 8:495–500.
70
Appleton J. ‘At my age I should be sitting under that tree’: the impact of AIDS on Tanzanian lakeshore
communities. Gender
Dev 2000; 8:19–27.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
31
on the impact of HIV/AIDS on fishing in Kenya 71 found that mobility within the fisherfolk was
high and migration to new sites happened every time fishing became less lucrative in a certain
site.
The Kenyan impact study established four categories of people who are most susceptible as a
result of their livelihood strategies, namely (a) fishing crew, (b) boat owners, (c) those engaged
in selling and processing fish, and (d) those involved in selling alcohol.
The fishing schedules leave the fishing crew with a lot of idle time on their hands:
“We put the nets at night and collect the catch very early in the morning. By the time you leave the
lake you are freezing and to warm you a woman or a drink are needed.” Fisherman in Kenyan study
Only in very traditional small scale settings do the fishing crew market and sell the fish. Boat
owners earn a relatively high income, and may have free time to fill. The women who sell and
process the fish depend on the fishing crew for the fish which is their main source of income.
Bar owners and beer sellers, the majority of who are women, are relatively immobile. They
spend most of their time at their premises which, in many cases, double as living quarters. It is
not uncommon for them to consume alcohol and get sexually involved with their male
customers. This practice was reported also to apply, to a limited extent, to those employed in
restaurant and lodging businesses. There are daily migrants coming into fishing communities
who secure their livelihoods from the lake shore but do not reside in the community. Fish
mongers, fish processors, auctioneers and agents for the private export-oriented firms reside
sometimes as far away as 30 km. With their daily incomes, these daily migrants contribute to the
vibrant business around the shores.
Sexual behavior data
No behavioral surveillance data on fisherfolk could be found. There was, however, some
qualitative data that described the practice of ‘sex for fish’, described in the case study below.
Sex, fish and stigma in Kenyan beach communities (DFID case study) 72
Nyanza Province borders Uganda and Tanzania and they shares the waters of Lake Victoria. Its many beaches,
some of the worst flashpoints of HIV and AIDS, present health experts with a unique problem — the jaboya
system of sex for fish. Bondo Town has a vibrant beach community. Almost everybody here is in the fish
business. The fish are weighed at the beach and transported in big trucks. Ruth Anyango, a 50-year-old
fishmonger at Uhanya Beach near Bondo, explains how the jaboya system came about. “There’s a lot of poverty
here on these beaches and this exposes the women to HIV and AIDS. The jaboya system is commonly
practised. First the fishermen come with their catch. But we are so many sellers that there’s not enough for all of
us. If you don’t get fish, your business will come to a standstill, so you’re forced to befriend the fishermen for
them to give you fish. I got into the fish business when I was young and I had to befriend some of them. Now that
I’m grown up I can say no. In 1994, I went for a HIV test and I learnt I was infected. Since then I’ve lived
positively. My husband died of AIDS, I have children who have died as well. The surviving children are HIVpositive so I have to help them live positively.”
71
MoLFD (2004). Study on the impact of HIV/AIDS on fishing in Kenya and how the MoLFD can respond. Final
report July 2004.
72
http://www.dfid.gov.uk/casestudies/files/africa/kenya-sex-fish.asp
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
32
Other occupational populations on marine and inland waterways
A population of migrant workers with similarities to fishermen is those who work on marine and
inland waterways such as boatmen and sailors. This analysis found no data from the GLR on
these populations, although, based on their expected vulnerability level and sexual behaviors,
they are likely to be an important bridging group between sex workers and the general
population. Considerable evidence and reports on interventions are available from South-East
Asia, where migrant workers on waterways are targeted as a high-risk group. A report from
Vietnam explains that “seafaring is not just an occupation but a lifestyle”. 73 In the Indian States
of Jammu and Kashmir, the State AIDS Prevention and Control Society considers boatmen to be
a high-risk group like female sex workers, intravenous drug users and truckers. 74
Summary of Findings: Fishermen and fisherwomen
Table 14. Fishermen & fisherwomen – Population size, vulnerability and HIV risk factors
Fishermen & fisherwomen - Estimated Population Size in GLR = 447,656 (92% men and 8% women)
Fishermen: Factors of Vulnerability
•
Time fishermen spend away from home
•
Mobility of many fisherfolk
•
Alcohol use to help cope with the dangers or stress of their occupation
•
Demographic profile (mostly young age)
•
Fishing is a high-risk occupation which can contribute to culture of risk
denial or risk confrontation
•
Access to daily cash income, high income during main fishing season
•
Ready availability of commercial sex in fishing ports
•
Social marginalisation and low status
•
Subordinate economic and social position of women in many fishing
communities
•
Difficult to reach with disease prevention efforts
Fishermen: Risk Factors for HIV
•
Culture of hyper-masculinity which may
include expectation of multiple sexual
partners
•
Poor access to facilities and medicine
and low uptake of available health
services
•
Difficult to reach with adequate AIDS
treatment and mitigation measures
•
Fishing camps and ports may lack social
structures that constrain sexual behavior
as in home communities
4.4 MILITARY & OTHER UNIFORMED FORCES
Military populations consist of members of national armed forces, including regular army, navy,
and air force contingents, militia and reserve units, and paramilitary/ guerrilla groups. The term
‘uniformed forces’ sums up different professions – soldiers, police officers, immigration
workers, customs agents and prison guards all belong to the group. These groups are placed
under different ministries and exhibit highly different patterns of mobility. This section will
mainly focus on the armed forces due to the scarcity of HIV related information about other
uniformed services (the Government of Kenya has commissioned a study on size estimation of
uniformed services, and the results will allow size estimations of uniformed services other than
the military).
Population size
73
Care Vietnam (2002). Seafarers, their sex partners and HIV/AIDS/STDs.
http://www.un.org.vn/undp/projects/vie98006/Sex%5cMobile%20SeafarersKienGiang.doc
74
Bhat BA ().Knowledge and beliefs about HIV/AIDS among youth in Jammu and Kashmir.
http://www.iipsindia.in/abstractfiles/2006831122236_01_B.A_Bhat_paper.doc
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
33
Table 15. Military population data for GLIA countries
Country
Burundi 75
DRC 76
Kenya 77
Rwanda 78
Tanzania 79
Uganda 80
Total
Total population (2007)
8,390,505
65,751,512
36,913,721
9,907,509
39,384,223
30,262,610
190,610,080
Active troops
40,000
83,800
24,120
61,000
27,000
60,000
295,920
Reserve force
0
0
0
0
80,000
0
80,000
Paramilitary
5,500
1,400
5,000
10,000
1,400
1,800
25,100
Total
45,500
85,200
29,120
71,000
108,400
61,800
401,020
Conventional wisdom has been that HIV levels are higher in the military and possibly other
uniformed services. Recently, new evidence has led to a rethinking of this conventional
wisdom; and a recommendation that more fine-tuned, empirically-informed and contextspecific analyses are needed for the military. 81
HIV epidemiology and mobility
Statistics on HIV prevalence in the uniformed services are hard to find; there are very few
published studies. Reasons include: some militaries cannot afford or do not want to test soldiers,
many soldiers do not want to be tested, national security issues are involved (there is great
reluctance to release data perceived as confidential or sensitive 82). There is strong anecdotal
evidence that, in the very early stage of the east African epidemic, some militaries were hard-hit
by the loss of officers to AIDS. 83 The first documented statistical link between soldiers and the
spread of HIV was in Uganda, where the geographical pattern of AIDS was correlated with the
placement of the Ugandan National Liberation Army in the six years after the Amin civil war. 84
Historically, HIV prevalence amongst the military early in the epidemic seems to have been
higher than in the general population. HIV prevalence estimates for the late 1990s for Africa
include 40-60% of Angolan soldiers (2.8% of adult population), 10-25% in Congo (Brazzaville)
(6.4% of adult population), 4.6% in Eritrea (2.8% of adult population), 15-30% in Tanzania
(8.1% of adult population) and 50% in Zimbabwe (25% of adult population). The Bureau of
Census (1999) compiled HIV data for males in the military and police from 1994-1999 and
reported for Tanzania (military & police, 4 studies) a median prevalence of 13.3% and for
Uganda (military, 3 studies) a median prevalence of 27.0%. A South African defence
intelligence assessment estimated HIV prevalence among the armed forces of the DRC in 1999
at 50%. 85 A voluntary survey of 3,000 soldiers in the Ugandan Defence Force (UDF) completed
75
http://www.nationsencyclopedia.com/Africa/Burundi-ARMED-FORCES.html, accessed 16 oct 2007
http://www.nationsencyclopedia.com/Africa/Congo-Democratic-Republic-of-the-DROC-ARMED-FORCES.html
77
http://www.mongabay.com/reference/new_profiles/331.html
78
http://www.nationsencyclopedia.com/Africa/Rwanda-ARMED-FORCES.html
79
http://www.nationsencyclopedia.com/Africa/Tanzania-ARMED-FORCES.html
80
http://www.nationsencyclopedia.com/Africa/Uganda-ARMED-FORCES.html
81
De Waal A (2005). HIV/AIDS and the military (issue paper 1), AIDS, security and democracy: Expert seminar
and policy conference, Clingendael Institute, The Hague, 2-4 May 2005.
82
Whiteside A et al. (2006). AIDS, security and the military in Africa: a sober appraisal. African Affairs,
105/419,201-18.
83
De Waal A (2005). HIV/AIDS and the military (issue paper 1), AIDS, security and democracy: Expert seminar
and policy conference, Clingendael Institute, The Hague, 2-4 may 2005.
84 Smallman-Raynor, MR & AD Cliff (1991) Civil War and the Spread of AIDS in Central Africa. Epidemiology
and Infection 107: 69–80.
85
Heinecken L (2001). Living in terror: The looming security threat to Southern Africa. African Security Review,
10, 4
76
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
34
in 2001 showed a prevalence rate of 23%, a figure that has now dropped to around 20% and is
generally accepted by most outside observers, including the U.S. Department of Defence. 86 All
new applicants for the UDF are now screened for HIV; in 2003, the infection rate for all
applicants was 4.7%, below the estimated HIV prevalence in the Ugandan general population
(6.7% in 2005, see Table 3).
However, the jury is not yet out on HIV prevalence in the military. De Waal (2005) and
Whiteside et al. (2006) have questioned the conventional wisdom that rates of HIV prevalence
today amongst the military are typically two-to-five times greater than in civilian populations. In
sub-Saharan Africa, De Waal stated that this may have been true only early in the epidemic. He
proposed three reasons why in a generalized heterosexual epidemic, armies would be expected
to have HIV levels comparable to or even lower than the general population:
•
In armies that rely heavily on national service or conscription, or which are primarily
composed of infantry, the majority of soldiers will be young men aged 18-25 years, mostly
from rural backgrounds. HIV rates among this sub-population are lower than in the general
adult population including young women of the same age. This demographic factor is the
single most important reason to expect lower HIV prevalence in the military.
•
Many military units are poorly paid, immobile and stationed in remote areas for long periods
of time. The stereotype of an over-sexed, aggressive, mobile and well-paid soldier is often
inaccurate. There are suggestions that garrisons attract groups of FSW who cater exclusively
to soldiers, and that the FSW follow a hierarchy that matches the ranks of the army, so that
the lower ranks mingle with one group while officers prefer another. This would imply a
relatively closed sexual network of lower-ranking soldiers (with presumably low HIV
prevalence) and sex workers. These conditions do not facilitate accelerated spread of HIV.
•
Many armies screen recruits and reject those they consider physically unfit. Increasingly,
HIV testing is part of medical screening, and HIV positive status is considered a reason for
rejecting a potential recruit. In a number of armies, HIV testing is also required for contract
renewal, promotion or further training. These procedures of testing and selection of
uninfected individuals suggests that new recruits and young soldiers may have a lower
level of HIV than their civilian counterparts.
The line taken by De Waal and Whiteside is in stark contrast to the earlier literature, which
considered soldiers at increased risk of HIV and other STIs because they: may be away from
their regular partners; under peer pressure and outside of behavioral control of family and
community; may have values that encourage risky behavior; may be ‘wealthy’ in poor
surroundings; combat injuries may expose them to unscreened blood through direct
contamination or transfusion. 87
Trends in prevalence in the military seem to be falling. One report suggests various reasons that
rates of HIV infection in the military remain low or have begun to fall in some countries. 88 The
prevalence data from the UDF are the only data the study team could identify for this decade
from any of the six GLIA countries. Trends at VCT clinics for UDF soldiers are illustrated in
figure 8.
86
International Crisis Group (2004). HIV/AIDS as a security issue in Africa: Lessons from Uganda. ICG Issues
Report N°3, Kampala/Brussels
87
UNAIDS (1998). ‘AIDS and the military’, UNAIDS Best Practice Collection, May 1998.
88
Healthlink Worldwide (2002). Combat AIDS: HIV and the World’s Armed Forces.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
35
Figure 8: Trends of HIV prevalence in the Ugandan military 1991-2003
percent
100
NOTE: The graph presents
trends at VCT clinics for
UDF soldiers. These data
may overestimate the true
HIV prevalence, as they
come from a subset of
soldiers who were possibly
motivated by a concern that
they might be positive. No
sample size data were
available.
90
80
70
60
50
40
30
20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Source: Bwire GS & Musingunzi (2004), XV International AIDS Conference, abstract no. MoPeC3457
Sexual behavior data
BSS data about sexual behavior were available for Burundi and the DRC: The behavioral data
from Burundi and DRC show that sexual behavior and risk profiles vary greatly between
uniformed services in a country and between countries – as shown in Table 16.
Table 16. Comparison of sexual behavioral data for Burundi and the DRC
Sexual behavior
Had a sexual relationship in the past 12 months.
Had more than one partner in the last 12 months
Paid for sex in the last 12 months
Condom use with occasional, non-commercial
partners
Ever had a HIV test
Burundi
45% (soldiers), 53% (police), 78% (gendarmes)
7% (all uniformed services)
7% (all uniformed services)
15% (soldiers), 45% (police) and 6%
(gendarmes)
70% (soldiers and police), 50% (gendarmes)
DRC
90%
41%
28%
34%
22%
Sources: Burundi BSS (2003/4), DRC BSS
Some other data about sexual behavior within the military were found: Generally, circumstantial
evidence suggests that military and paramilitary personnel have frequently and systematically
used rape to terrorise and drive a population from an area. In the case of Rwanda, there is
evidence that soldier rapists considered infection with HIV to be a deliberate component of their
sexual violence. 89, 90 The topic of sexual violence is further discussed in the sections on females
affected by sexual violence and violence towards prisoners.
Other Uniformed Forces and Persons in Contact with the Military
Peacekeepers: ‘Peacekeepers’ are soldiers or civilian personnel deployed in another country
under a United Nations mandate to assist in the transition from war to peace. In the GLR, the
MONUC mission in the DRC comprised 18,275 uniformed personnel, as of 30 August 2007. 91
89
African Rights, Rwanda (2004). Broken bodies, torn spirits; living with genocide, rape and HIV/AIDS (African
Rights, Kigali.
90
Randell V (2002). Sexual violence and genocide against Tutsi women. Propaganda and sexual violence in the
Rwandan genocide: an argument for intersectionality in international law, Columbia Human Rights Law Review,
33(3):733-755.
91
http://www.un.org/Depts/dpko/dpko/contributors/Yearly06.pdf accessed 16 oct 2007.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
36
Bazergan (2002) reported that some host countries have requested that UN personnel be
screened for HIV, while some contributing nations are reluctant to send their troops to areas
with high levels of HIV. 92 However, very little is published about the sexual behavior and HIV
prevalence of peacekeepers. They are perceived to be at increased risk, since they are usually
older (and so come from population age cohorts typically with higher HIV prevalence (De Waal,
2005)), better paid and mobile.
Irregular Forces: There are anecdotes that suggest that HIV prevalence is high among irregular
forces, but data are lacking and the significance of this group for the epidemiology of HIV
within the GLR is unknown.
Civilians living near military institutions: Higher HIV prevalence rates may be found in civilian
populations living near military installations or are associated with the movements of soldiers
(Healthlink 2002). In northern Uganda, women known locally as ‘Jua Kali’ live in small
settlements next to the rural billets, selling alcohol and sex. When the soldiers are re-deployed,
the women wait for the next group. 93
Summary of Findings: Military
Table 17. Military population – Population size, vulnerability and HIV risk factors
(in brackets: counter factors which are expected to reduce vulnerability and HIV risk)
Military - Estimated Population Size in GLR = 401,020
Military: Factors of Vulnerability
Military: Risk Factors for HIV
• Generally young men, at the age of seeking partners (but: young males
in lowest HIV prevalence group)
• Perceiving themselves invulnerable and trained not to be deterred by
risk and danger
• Separated for long periods from spouses and partners, or denied
marriage during enlistment periods
• When away, removed from the social discipline (but: disciplined army
environment, not all soldiers away from base)
• Living in same-sex quarters
• Some ranks well paid
• Susceptible to peer pressures
• May seek to relieve themselves from the stress of combat through
sexual activity
• Sexual abstinence while on duty may be followed by short breaks of sex
and alcohol
• Trained to regard risk-taking and
aggressive behavior as the norm
• Access to CSW and settlements with
‘soldier wives’ (but: these sexual networks
are often restricted]
• At risk to physical injury involving loss of
blood and need for blood transfusion
under possibly non-sterile conditions
• Sharing of razors and skin-piercing
instruments in tattooing and scarification
• (Testing and selection of HIV negative
individuals at recruitment, and motivation
to stay negative)
4.5 FEMALE SEX WORKERS
The data for the military, fisherfolk, and transport sector workers all indicate that transactional
sex occurs between these mobile populations and local women. This analysis found that there
are many different forms of transactional sex with women – resulting in different types of FSW.
92
Bazergan RY (2002). HIV/AIDS, the military and human security. Oral abstract, the XIV Int. AIDS Conference,
abstract no. ThOrG1509.
93
Abwola S & Dolan C (1999). HIV & Conflict in Gulu District: findings from an ACORD study. In: Background
papers presented to the conference on 'Peace research and the reconciliation agenda', Gulu, Northern Uganda, Sept
1999, COPE Working Paper no. 32, ACORD, 2000.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
37
In a study in Kisesa, Tanzania, four groups of FSW were distinguished 94: bar workers (42% of
the total), women who solicit sex in bars (30%), women who provide sex in their home (“guesti
bubu” - 20%), and women who sell sex when they badly need money (8%). None of these
women were labelled or self-identified as ‘CSW’. As was shown in a study of female bar
workers elsewhere in the district—and supported by intervention work with women working in
bars in nearby Mwanza town— the line between commercial and non-commercial sex is not
clear. Some women have a regular partner and occasional casual partners, while others had
larger numbers of casual contacts. In Kisesa, the number of women listed as available for sex for
money was around 1 per 14 men aged 15 and over.
Commercial sex is most active in trading and commercial centers, where cash incomes increase
the likelihood for both the client and the sex worker of engaging in paid sex. Workplace-related
factors, especially in agro-industrial estates, help development of a commercial sex sector:
seasonal work, poor housing and a young male workforce all favour an unstable community and
family life. Voeten et al. (2002) found that a large proportion of FSW clients are men who work
in these places as bartenders, cashiers and musicians. 95 Sex workers in truck stops may work as
bar maids, brothel girls, lodge attendants, local brew sellers and ‘street workers’ who socialise
with transport workers and workers in the road construction industry. Commercial sex work and
other economic activities become intricately interwoven.
Population size
The great variety in types and classifications of sex work prevents a sound estimation of the
population size of FSW due to the following reasons:
•
The difficulty of defining membership: Transactional sex is the exchange of sex for money,
favours or gifts - not every woman who has an experience of transactional sex is a sex
worker, but there is no cut-off defined to allow clear delineation of group membership.
•
The continuum between commercial and non-commercial sex: Women may have several
different types of non-paying and paying sexual partners, ranging from a husband/steady
boyfriend, to regular and casual partners, regular and non-regular clients. Many sex acts
outside the steady partnership will not be perceived as commercial and the position and
perception of the different partners may change over time.
•
The informal character of sex work: Sex work in the GLR is mostly subsistence driven
and characterized by informality. Most FSW are not full-time sex workers, and receive a
relatively small number of paying clients.
•
Different areas of operation, mobility: Some FSWs work from bars (including hotels or
nightclubs), others work at home, in the streets or as “escort service” prostitutes (who are
the least accessible group). FSW may have considerable mobility.
•
The hidden nature of sex work: The occupation is mostly illegal, hidden and clandestine.
The uncertainty of FSW population size is accompanied by presumed highly different levels of
exposure to HIV in different categories of sex work due to varying volumes of clients,
differential condom use rates and sexual practices (see also section of sexual behavior).
94
Boerma JT et al. (2002). Sociodemographic context of the AIDS epidemic in a rural area in Tanzania with a
focus on people’s mobility and marriage. Sex Transm Infect, 78(Suppl I):i97–i105.
95
Voeten et al. (2002). Clients of Female Sex Workers in Nyanza Province, Kenya: A core Group in STD/HIV
Transmission. Sex Transm Dis, 29(8):444-452.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
38
HIV epidemiology and mobility
In every SSA country, studies of FSWs have consistently reported the highest HIV seropositivity rates of any group in the country. Studies of FSW in the GLIA countries have
recorded high sero-positivity:
•
In Kenya, HIV prevalence in FSWs as high as 50–80% have been reported. 96,97 A study of
part-time sex workers in Mombasa revealed HIV prevalence of 31%. 98 The Kenya BSS on
FSW did not assess HIV prevalence but 12% of FSW had a laboratory-confirmed STI.
•
In DRC, HIV prevalence of FSW in Kinshasa in 1988 was 34%. 99 The 2002 BSS of FSW
showed average HIV prevalence of 12.2% (lowest in Kikwit at 1.4%, highest in Kananga at
17.5%).
Modeling by UNAIDS 100 estimated that of all 82,369 new infections estimated to occur in 2005
in Kenya, sex workers accounted for 1.3% of all new infections and clients of sex workers
for 10.5% (incidence per 100 population per year of 1.9 for sex workers, 3.6 for clients of sex
workers and 0.8 for partners of clients of sex workers). These results from Kenya are consistent
with Chen et al. (2007) who found in a meta-analysis of epi. data in SSA that 9% of HIV
positive females have engaged in paid sex (as opposed to 3% of HIV negative women), and that
31% of HIV positive men have paid for sex (as opposed to 18% of HIV negative men).
Figure 9. HIV prevalence in female sex workers in GLIA countries, 1990-2006
HIV prevalence
90
80
70
60
50
40
30
20
Burundi
DRC Ur
DRC Nur
Ke Ur
Ke Nur
Rw
Tz Ur
Tz NUr
Ug
10
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
0
Sources: Epidemiological Fact Sheets UNAIDS, PNMLS (2006) on BSS DRC, DRC draft rapport national sur
l'epidémie à VIH 2006
96
Plummer FA et al. (1991). Importance of core groups in the epidemiology and control of HIV-1 infection. AIDS,
5:S169-176.
97
Morison L et al. (2001). Commercial sex and the spread of HIV in four cities in sub-Saharan Africa. AIDS,
15:S61-69.
98
Hawken M et al. (2002). Part time female sex workers in a suburban community in Kenya: a vulnerable hidden
population. Sex Transm Infect, 78:271-273.
99
Laurent C et al. (2001). Seroepidemiological survey of hepatitis C virus among commercial sex workers and
pregnant women in Kinshasa, DRS. Int J Epidem, 30:872-877.
100
Gouws E et al. (2006). Short term estimates of adult HIV incidence by mode of transmission : Kenya and
Thailand as examples. Sex Transm Infect, 82 (suppl III) :iii51-55.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
39
It appears that prevalence data on FSW are collected only sporadically by GLIA countries, or, if
they are collected, they are not well publicized (see figure 9). Only Kenya has trend data from
1990 to 2000 that show a remarkable downward trend. None of the six UNGASS reports of 2005
discusses HIV trends among FSWs. Hawken et al. (2002) found prevalence of gonorrhoea,
chlamydia, and syphilis of 1.8%, 4.2%, and 2.0% respectively. The overall HIV-1
seroprevalence was 30.6%.
Mobility of FSWs varies by site and by personal circumstances. O’Connor et al. (1992), and
Mwizarubi et al. (1997) said that sex workers move between stops, towns and their villages. 101,
102
The BSS in DRC showed high mobility of FSW with up to 57% of FSW having done sex
work in other sites. 103 Ferguson et al. (2006) found that the majority of sex workers spend at
least one night per month away from their base, but that only a minority were highly mobile,
with one quarter of the overnights being recorded in places over 20km from the home hot spot.
Sexual behavior, economic and other data relating to FSWs
BSS data: Three GLIA countries have recent behavioral data about FSW, as summarised in
Table 18 below.
Table 18. Sexual behavior data of female sex workers in GLIA countries
Drug consumption
Doing other work than sex work
Sexual intercourse with client in past 7 days
Sexual intercourse with other partner in past 7 days
Median number of sex partners, last 7 days
Condom use last act
with client
with other partner
Consistent condom use, past month
with client
with other partner
Barriers to condom use with client
Trust
Refusal
Dislike of condoms
Non-availability of condom
Regular client / “no risk”
Barriers to condom use with other partner
Trust
Refusal
Dislike of condoms
Non-availability of condom
“No risk”
Has done HIV test
Has been exposed to peer education, last 6 months
Burundi
(2004) 104
16%
34%
69%
18%
4.0
74%
46%
49%
27%
23%
22%
4%
32%
8%
62%
12%
0%
21%
3%
41%
12%
DRC
(2006) 105
12%
48%
79%
38%
3.1
46%
43%
25%
20%
37%
26%
21%
12%
11%
39%
27%
20%
11%
12%
37%
23%
101
Kenya, Western
Province (2000) 106
n.d.
83%
82%
76%
1.5
61%
n.d.
49%
14%
25%
92%
5%
6%
41%
64%
40%
1%
13%
n.d.
n.d.
O’Connor P et al (1992), Ethnographic study of the truck stop Environment in Tanzania. Dar es Salaam
Tanzania.
102
Mwizarubi, B. et al (1997). Working in high-transmission areas: Truck routes” in Ng’weshemi J. et al (editors),
1997 “HIV Prevention and AIDS Care in Africa: A District level approach”. Royal Tropical Institute – The
Netherlands
103
PNMLS (2006). Enquete de surveillance comportementale en DRC, volume 2.
104
CEFORMI/FHI (2004). Enquête de surveillance de comportements face au VIH/SIDA auprès des
professionnelles du sexe, Burundi.
105
PNMLS (2006). Enquete de surveillance comportementale en DRC, volume 2.
106 University of Nairobi (2000). Behavioral Surveillance & STD Seroprevalence Survey Western Province, Kenya. Female Sex Workers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
40
Notes to Table 18:
Drug consumption: Reported drugs used are mainly glue and cannabis (non injectable drugs)
Alternative work: The Kenyan BSS found that many FSW do alternative work. Income generating activities in the
formal sector seemed to enhance income from sex work (formal employment might provide FSW with access to
clients who are capable of paying a higher fee, and an association with the formal sector may increase esteem for
the woman, translating into a higher fee a client is willing to pay)
Sexual practices with clients: The client volume varied widely, with FSW in Western Province, Kenya reporting
less than half the volume of FSW in Burundi. The Kenya BSS also recorded anal sex practiced by 10% of FSW.
O’Connor et al. (1992) found that anal sex is common particularly with long term partners, and that some FSW
practice anal sex if they have had vaginal sex earlier in the day and during their menstrual periods.
Differential condom use rates: Consistent condom use with clients is alarmingly low (25% in DRC), despite a
high level of awareness that any person could be HIV infected. Many of the adolescent FSW lack knowledge of
how to protect themselves from infection and consequently use condoms only sporadically. Consistent condom use
with other partners is very low considering that these are high risk sexual acts. Non-use is motivated by concepts of
regularity and trust between partners, condom refusal, and perceptions of low risk.
“Know your status”: Less than half of FSW are aware of their HIV status
Other data on FSWs’ number of partners, empowerment, and payment for services provided:
The study by Hawken et al. (2002) is important because it focused on self identified, part-time
FSWs, a type of sex work that is hidden and un-quantified. These FSW, who live in a suburb
in Mombasa, reported a mean number of sexual partners of 2.8 in the previous week. The mean
number of non-regular clients and regular clients in the previous week was 1.5 and 1.0,
respectively. Many reported never using a condom with a client (29%) and non-paying partner
(45%). The median weekly income from sex work was $US15; 67% women had an alternative
income in the informal sector.
The differences among FSW have repercussions for FSWs’ empowerment, visibility to
programs and protection. Sex workers’ level of empowerment is usually low. Economic need
reduces their basis for negotiating less risky behavior, including condom use. The study by
O’Connor et al. (1992) found that clients who “pay well” (e.g. drivers from the DRC) make
FSW powerless in negotiating the type of sex to be practiced. The Kenyan BSS found that the
level of education of the surveyed FSW was below the national average (Univ. Nairobi, 2000).
Research involving FSW in 39 “hot spots” between Mombasa and the border towns Malaba and
Busia showed great variation in frequency of sexual partnering among FSW. 107 The number of
different partners per month ranged from 1-79 (mean 14) and the number of sexual acts ranged
from 3-192 (mean 54). Condoms were used in 69% of liaisons with regular clients and in 90% of
liaisons with casual clients. The author comments: “The condom use rates recorded are overall
very high, suggesting that safer sex is practiced. This is tempered by the contrast in use rates
between regular and casual partners. The trust-intimacy continuum, serving to lower consistent
condom use with regular partners, is a commonly-noted phenomenon. A simulation study on sex
worker-client contacts suggests that the number of different sex worker contacts is more
important than the number of liaisons in maintaining STI infection among clients. The
importance of high levels of condom use with casual clients is underlined by this finding”.
According to the literature, many sexual contacts are paid for in kind, and many FSW have
sexual partners who do not pay, often more than their number of paying clients. 108 Ferguson et
al. (2006) summarize their observation saying that casual clients outnumbered regular clients by
107
Ferguson AG et al. (2006). Using diaries to measure parameters of transactional sex: an example from the TransAfrica highway in Kenya. Culture, Health & Sexuality, 8(2):175-185.
108
University of Nairobi (2000). Behavioral Surveillance & STD Seroprevalence Survey Western Province, Kenya.
Female Sex Workers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
41
over 4:1, but over half of sexual acts recorded were with regular clients. It will be important to
target behavior change in the clients as well, and there is much need to facilitate
translation of knowledge into appropriate action in the personal relationships of sex
workers.
Clients of FSWs
FSW clients are a main bridging population (sub-population that interacts with both a high-risk
sub-population (i.e. FSWs) and low-risk sectors of the population (marital partners of FSW
clients)) and play a key role in spreading the epidemic into the general population. Ferguson et
al. (2006) analysed occupations of FSW clients in Kenya and found a wide range, suggesting a
varied bridge population. 109 Truckers were the main class of clients, but the clientele
transcended socio-economic divisions (“a truck driver may be followed chronologically by a
senior government administrator, a lawyer or a shoe-shiner”). Clientele were also a mix of
people “on the road” (e.g. truckers, salesmen) and the resident population (e.g. policemen,
catering staff).
Summary of Findings: Female sex workers
Table 19. Female sex workers - Population size, vulnerability and HIV risk factors
FSWs: Factors of Vulnerability
FSWs: Risk Factors for HIV
• Illegal metier, hidden occupation
• Early onset of sexual activity
• Other work may pay less
• High intensity of sexual intercourse with multiple concurrent
partners
• Alcohol and drug consumption
• Occupation in places where transactional sex is
frequent (bars, etc)
• These multiple concurrent partners often have multiple
partners themselves (sexual network)
• Compromised power relations
• Risk perception towards regular clients (trust leads to nonuse of condoms)
• Low level of empowerment and education
• Regular clients with other sexual contacts
• Lack of protection by law or society
• Lack negotiating power on safer sex practices
• Stigmatised by community
• Anal sex (as a result of client demand, menstruation, or
STIs)
• Can be illegal migrant
4.6 REFUGEES, INTERNALLY DISPLACED PERSONS, HOST POPULATIONS & RETURNEES
The GLR is disproportionately affected by armed conflict, violence, forced population mixing
and displacement. By mid-2007, the GLIA countries had a total of 1.2 million refugees (12% of
the estimated global refugee number) and approximately 2.9 million IDPs (23% of the estimated
IDPs globally receiving UNHCR protection and assistance). All GLIA countries have a track
record of hosting refugees and of IDPs fleeing humanitarian emergencies. The complex
situations are often divided into phases for guidance in determining program needs and
priorities: The exodus or emergency phase, which may last up to six months, is followed by the
post-emergency and stabilization phases, which often last for years. Some refugees eventually
return home, others are resettled in another country, and still others remain displaced for
extended periods.
109
Ferguson AG et al. (2006). Using diaries to measure parameters of transactional sex: an example from the TransAfrica highway in Kenya. Culture, Health & Sexuality, 8(2):175-185
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
42
Figure 10. Refugee, IDP and Returnee Displacement cycle
A conflict-affected population may either
become IDPs or cross an international border
to become refugees. Having been displaced,
these populations are surrounded by, and
interact with, a host community. They also
interact with armed forces, peacekeepers, aid
workers and sex workers. When possible,
displaced populations return to their original
homes or to other locations. Both when
displaced populations are amongst host
communities and when they return home or
relocate, they are at particular risk. 110
The HIV risk faced by refugees and IDPs depends on the interactions of several complex factors,
including the maturity of the HIV epidemic, relative HIV prevalence in the host and refugee
populations, prevalence of other STIs that may facilitate transmission, level of sexual interaction
between the two populations, presence of context-specific risk factors such as commercial sex
and systematic rape by military or paramilitary groups, and the level and quality of HIV
prevention services.
Most of the literature concentrates on how conflict increases HIV risk (behavioral change, GBV,
transactional sex, reductions in resources and services). Sometimes overlooked is decreased risk
from reductions in mobility, in accessibility, in urbanisation, and other countervailing factors.
A recent systematic review addressed the question whether there is evidence that conflict
increases HIV transmission and whether refugees fleeing conflict have a higher HIV prevalence
than the surrounding host population. 111 The review concludes that “there is insufficient
evidence that HIV transmission increases in populations affected by conflict, and 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”.
4.7 REFUGEES
A refugee is defined as a person who has fled his or her country and is unable or unwilling to
return because of persecution based on race, religion, nationality, membership in a particular
social group, or political opinion. The term also includes those fleeing war, civil strife, famine,
and environmental disasters. 112
110
Spiegel PB (2004). HIV/AIDS among conflict-affected and displaced populations: Dispelling myths and taking
action. Disasters, 28(3):322-339.
111
Spiegel PB et al. (2007). Prevalence of HIV infection in conflict-affected and displaced people in seven subSaharan African countries: a systematic review. Lancet, 369:2187-95.
112
Definition from: US Committee for Refugees. World Refugee Survey 2000. Washington, D.C., Dec 1999
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
43
Refugees may live in camps for a long time. In Rwandan refugee camps, 81% of refugees are
reported to have lived in the locality for 5-10 years. 113 Typically, women and children make up
the majority in refugees (and IDP) populations. 114 Men often abandon or are separated from
their families for military reasons or to search for employment, or they may be targeted by
opposing forces, killed or taken prisoner. The percentage of female-headed households therefore
may be high, and these households may have higher economic vulnerability. In addition, women
may be forced to find a new partner outside the social group they belong to, due to the
unfavorable ratio of men to women in the group (ref UNHCR/GLIA-Rw, 2004). However,
refugees often move as whole villages, and social structures may be maintained, and the notion
that refugees generally need to form new partnerships due to displacement is not the case (P.
Njogu, pers. comm.). Table 20 summarizes refugee numbers and trends for each GLIA country.
Population size
Tanzania hosts over 471, 912 refugees, of whom 273,678 are UNHCR-assisted while another
200,000 Burundian refugees from the 1972-influx live in self-sufficient settlements in the
Tabora and Rukwa Regions. The Government estimates that over the years another 200,000300,000 Burundians and Congolese have settled spontaneously in villages in north western
Tanzania. Kenya is home to a number of diverse refugee groups from the region; the largest
population of over 187, 565 UNHCR-registered refugees came from Somalia. DRC was host to
an estimated 156,690 refugees, all under UNHCR assistance, despite on-going armed conflict in
Eastern DRC (May 2007). In Burundi, Congolese and Rwandan refugees are in camps in the
north and central areas (Kirundo, Kayanza, Gitega, Karuzi), while IDP populations are largely in
the southern parts of the country. The many Sudanese in Uganda represent a mixture of old and
new cases as a result of on-going fighting in Southern Sudan. Population size estimates are in
Table 20, and recent changes in refugee and IDP populations are shown on an UNHCR map in
Annex I.
Table 20. Refugee population data for GLIA countries
Country
Burundi
DRC
Total population (2007)
8,390,505
65,751,512
Refugees (June 2007)
23,215
197,232
Kenya
36,913,721
269,196
Rwanda
Tanzania
9,907,509
39,384,223
46,600
471,912
Uganda
30,262,610
220,914
Total
190,610,080
1,229,069
General trends
Slow increase due to influx from DRC in early 2007
Decrease due to repatriation of Sudanese, Congolese
and Angolan refugees
Decrease due to repatriations- voluntary and assisted - to
Southern Sudan, but operations hampered by heavy
rains hindering transfer and access to places of origin
Decrease due to UNHCR-assisted repatriations
Decrease due to UNHCR-promoted returns at the
beginning of June 2006
Decrease due to gradual return process especially for
Sudanese
Overall decrease from December 2006 of 78,556
Source: OCHA Regional Office for Central and East Africa (2007). Displaced populations report, January-June
2007
113
UNHCR/GLIA-Rw (2004). Enquete de surveillance comportementale chez les refugiés et la population. Camp
de Kiziba et Secteurs de Rubazo et Kagabiro
114
UNHCR (1992) Sub-Committee of the Whole on International Protection: Progress Report on Implementation
of the UNHCR Guidelines on the Protection of Refugee Women, Executive Committee of the High Commissioner's
Programme, 43rd Session. EC/SCP/67.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
44
HIV epidemiology and circumcision data
Reports with sufficient data on HIV prevalence have only recently become available to make
comparisons within and between populations affected by conflict and displacement. Data quality
can limit interpretation, since work in displaced populations and conflict situations can be
difficult. Comparisons with host population data are often problematic due to differences in
methodology of data collection, year of measurement, geographic coverage, etc.
The review by Spiegel et al. was based on data from seven countries (DRC, southern Sudan,
Rwanda, Uganda, Sierra Leone, Somalia, and Burundi). 115 Of the 12 sets of refugee camps, 9
had a lower prevalence of HIV infection, 2 a similar prevalence, and one a higher prevalence
than the respective host communities. The main reason was that refugees came from lower
prevalence countries (such as Somalia, Sudan). Despite wide-scale rape in many countries, there
were no data to show that rape increased prevalence of HIV infection at the population level.
Camp-specific data on HIV prevalence in refugees and host populations from this publication
are shown in Annex IXb. The review also showed that in Burundi, Rwanda and Uganda,
prevalence in urban areas affected by conflict decreased at similar rates to urban areas
unaffected by conflict in each country. Prevalence in conflict-affected rural areas remained low
and fairly stable in these countries. The review did not find increases in HIV prevalence during
periods of conflict, irrespective of the prevalence level when conflict began.
Table 21. HIV prevalence in refugees (2003-2007) and median prevalence
Refugees
from
Camps
%HIV+
Year
Kenya
Somalia
Dadaab
0.60
2003
Uganda
Sudan
Palorinya settlement
1.00
2004
Kenya
Somalia
Dadaab
1.40
2005
Tanzania
Burundi
Lukole
1.60
2003
Tanzania
Burundi
Nduta and Mtendeli
1.70
2003
Tanzania
DRC
Lugufu and Nyaragusu
1.80
2003
Uganda
Sudan
Kyangwali
2.70
2004
Tanzania
Burundi
Mtabila and Muyovosi
4.50
2003
Median HIV prevalence
1.65%
Source: Spiegel et al. (2007), retaining refugee camps in GLIA countries
National HIV prevalence estimate
of host country (see Table 3)
6.1%
6.7%
6.1%
6.5%
6.5%
6.5%
6.7%
6.5%
•
Immediately following the massive movement of refugees from Rwanda to Tanzania in mid1994, a rapid assessment of STI prevalence in refugee camps was conducted. 116 Over 60%
of the women had some form of reproductive tract infection (candidiasis, bacterial vaginosis,
trichomoniasis), 3% had gonorrhea and 2% syphilis. Among men, 1-2% had gonorrhea, 3%
urethritis and 6% syphilis. The authors note that the RTI and STI levels found within the
refugee population were consistent with those found in an earlier study among residents in
Mwanza Region.
•
Two studies by Rey and colleagues in refugee camps for Rwandans in Goma in 1994 found
HIV prevalence at 6% among 48 adult controls and 19% among 48 adult patients presenting
115
Spiegel PB et al. (2007). Prevalence of HIV infection in conflict-affected and displaced people in seven subSaharan African countries: a systematic review. Lancet, 369:2187-95.
116
Mayaud P et al. (1997). STD rapid assessment in Rwandan refugee camps in Tanzania. Genitourin Med,
73(1):33-38.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
45
with ‘fever of unknown origin’, 117 and 5% among 143 orphans, suggesting a problem of
substantial magnitude. 118
When interpreting HIV prevalence data of refugee and host populations, the level of MC in the
populations may play an important role. In Kakuma, 51% of refugee men were circumcised
(Sudanese, Somali and Ethiopian origin), but only 6% of local men (Kenyans of Turkana
ethnicity) [UNHCR/GLIA-Ke]. Higher risk of HIV infection for refugees may be particularly
important for those from rural areas, where HIV prevalence and knowledge of HIV are typically
low, who settle near cities or large villages. 119 Rural Sudanese refugees in Uganda have
demonstrated a marked lack of awareness about HIV.
Sexual behavior data
There is a whole body of recent data on sexual behavior of refugees and host populations
collected through Behavioral Surveillance Surveys (BSS) in Kiziba camp and surrounding
villages in Rwanda, 120 in Kakuma camp and town in Kenya, 121 Lukole and Lugufu camps and
villages in Tanzania 122 and Nakivale/Oruchinga and Kyangwali refugee settlements and
surrounding villages in Uganda. 123 The GLIA, in conjunction with UNHCR, has led the
conceptualisation, standardisation and implementation of the BSS methodology in these refugee
settings.
The pattern of displacement, mobility and interactions between refugee and host populations
varied between sites. In the camps, the vast majority had been resident for 12 months or more.
The surrounding villages had variable degrees of in-migration. In some cases, there was more
movement of nationals to camps than vice-versa. The following observations can be made
concerning sexual behavior and service utilization (see Annex IXc for detailed data and graphs):
•
Abstinence in unmarried youth was highest overall in Uganda, but there was otherwise no
clear population-specific pattern – the greatest differential was between male refugees and
male villagers in Lugufu. There was no convincing evidence that the Kenyan abstinence
campaign “Tume chill” (Swahili slang for “We are cool”) had had an effect.
•
In five of the six sites, a higher proportion of refugees than the host population had recently
used VCT services, suggesting that VCT service provision or access might be better for
refugees.
•
The prevalence of high risk sexual intercourse varied greatly between camps, host
populations and gender. The behavior was almost an exception in the two Ugandan sites, and
very frequent in Kakuma (40% of males) and Lugufu (53% of male refugees). Although
much more common in males, a substantial percentage of females in several sites also
reported higher-risk sex (20-30%).
117
Ray JL et al. (1996). Fever of unknown origin in the camps of Rwandan refugees in the Goma region of Zaire.
Bull Soc Pathol Exot, 89(3):204-8.
118
Rey JL et al. (1995). HIV seropositivity and cholera in refugee children from Rwanda. AIDS, 9(10):1203-4.
119
Jurugo, E.C. (1996) Rural Refugees in Uganda: Their Vulnerability to HIV/AIDS. 11th International Conference
on AIDS. Vancouver, 7–12 July: abstr Tu.D.2917.
120
UNHCR/GLIA-Rw (2004). Enquete de surveillance comportementale chez les refugiés et la population. Camp
de Kiziba et Secteurs de Rubazo et Kagabiro.
121
UNHCR/GLIA-Ke (2004). Behavioral surveillance surveys among refugees and host populations, Kakuma.
122
UNHCR/GLIA-Tz (2005). Behavioral surveillance surveys among refugees and surrounding host populations:
Lukole and Lugufu, Tanzania.
123
UNHCR/GLIA-Ug (2006). Behavioral surveillance surveys refugees and host populations, Uganda.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
46
•
Reported condom use in higher-risk encounters was equally variable. Encouraging data came
from Lukole, where the majority of male refugees reported condom use. The opposite was
found for male refugees in Lugufu (a high percentage of whom reported higher-risk sex), but
only 36% reported condom use in high-risk sex acts.
•
Reported forced sex was higher among refugees than villagers in the Tanzanian sites, but
lower in the Kenyan and Rwandan sites. In Tanzania, most respondents highlight that forced
sex occurred after displacement (for refugees) or after the arrival of refugees (for nationals).
•
The BSS data show that each site has a very specific population in terms of ethnicity,
circumcision, education, sexual knowledge, attitude and practices. Intervention needs may
therefore vary.
•
The BSS also found that the health care-seeking behavior of persons who have STIs is suboptimal. Only a part of the affected population had sought treatment at a recognized health
facility the last time they had an STI. A relatively large proportion, both refugees and host
nationals, sought treatment from the pharmacy.
While the BSS data support the notion that refugees often consume less alcohol than host
populations, two recent studies conducted within a joint UNHCR/WHO project on substance use
in conflict-affected and displaced populations highlighted that the opposite may be the case in
some camps. 124, 125 An assessment in Kakuma, Kenya, suggested that since arriving at the camp,
refugees (particularly from the Sudanese communities) had been increasingly involved in
brewing and consuming traditional alcohols. Many women had begun brewing alcohol as their
main source of livelihood, using cereals distributed to refugees as food rations.
•
The epidemiological and behavioral data provide evidence that commonly held beliefs about
refugees’ vulnerability and HIV risks may be wrong. The view that refugees inevitably have
higher HIV prevalence needs to be corrected.
•
GLIA BSS data suggest that some refugee characteristics potentially lessen the HIV risk of
refugees: camp populations are sometimes far better informed about HIV and AIDS, may be
more likely to use condoms, may have lower consumption of alcohol and ‘khat’ than their
hosts, may have lower prevalence of forced sex and fewer reports of needle sharing, and may
enjoy better HIV services than nationals (vulnerability factors and HIV risk factors of
refugees are summarized in the next section on IDPs).
4.8 INTERNALLY DISPLACED PERSONS
Internal displacement is the forced removal of a person from his/her home within the person’s
country. 126 IDPs are persons or groups of persons who have been forced or obliged to flee or to
leave their homes or places of habitual residence, in particular as a result of or in order to avoid
the effects of armed conflict, situations of generalized violence, violations of human rights or
natural or human-made disasters, and who have not crossed an internationally recognized State
border. IDP figures tend to be rough estimates obtained through UN agencies, and some
represent agency specific populations of concern. Table 22 presents data on estimated numbers
124
UNHCR/WHO (2006). Rapid assessment of substance use and HIV vulnerability in Kakuma refugee camp and
surrounding community, Kakuma, Kenya.
125
Macdonald D (2007). Rapid assessment of substance use in conflict-affected and displaced populations: IDP
camps in Gulu, Kitgum and Pader Districts of northern Uganda.
126
IOM (2004). Glossary on migration.
http://www.egypt.iom.int/eLib/UploadedFolder%5CGlossary_on_Migration_En.pdf
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
47
of IDPs as of mid-2007. Challenges to accurate IDP tracking in the region include increased
levels of insecurity hence poor or no access to affected populations, lack of acknowledgement
by governments of the presence of IDPs in their territory hence poor or no monitoring, in
addition to the complications created by the temporary nature of some of the displacements.
Table 22. IDP population data for GLIA countries
IDPs (mid-year 2007)
General trends
Burundi
100,000
Decrease: Slow IDP return due to lack of sufficient land to settle the returnees.
DRC
1,121,979
Increase due to the conflict and insecurity in the Kivus
Kenya
250,000-365,000 127
No official assessment to confirm current IDP population.
Rwanda
No official IDPs
Tanzani
a
No official IDPs
Uganda
1,400,000 128
Total
2,871,979 - 2,986,979
Decrease due to IDP returns after peace talks between Government and LRA. Lack
of basic services has hindered effective resettlement at new transit sites. Continued
incidents of insecurity adversely affect IDP’s opportunity and motivation to return.
Overall decrease from December 2006 of 123,021-188,021
Source: OCHA Regional Office for Central and East Africa (2007). Displaced populations report, January-June
2007
•
In mid-2007, the displacement situations in DRC and Uganda were among those of serious
humanitarian concern globally (OCHA, 2007).
•
Tanzania and Rwanda officially have no IDPs, save for temporary displacements as result
of climatic conditions like flooding (OCHA, 2007).
•
In Kenya there are no official published reports on the status or statistics of IDPs hence the
estimated range of figures. New displacements as a result of ethnic conflicts were noted
during the first half of 2007: an additional 70,000 new displacements were recorded in Mt.
Elgon District in 2007 (OCHA, 2007). 129
•
Lack of access to land remains a key obstacle to efforts to resettle displaced populations in
Rwanda, Burundi and Tanzania. High population density in Rwanda and Burundi hinder
effective resettlement of both IDPs and returning refugee populations (OCHA, 2007).
•
The on-going expulsions of illegal immigrants from Tanzania has further aggravated the
situation in both Burundi and Rwanda, where most of the returnees are currently living in
transit centers due to lack of addresses or land to repatriate back to. Assistance in cases of
expulsion continues to be hampered by logistical challenges and insufficient financial
resources. An estimated 20,000 Burundians and over 60,000 Rwandans who have been
living illegally in Tanzania have been targeted for expulsion by the end of 2007 (OCHA,
2007).
127
OCHA Kenya, August 2007 - This range includes more recent but also un-assessed displacement in Mt. Elgon,
Molo and Tana River Districts in early 2007.
128
OCHA Kampala: 1,000,000 in IDP camps and 400,000 in new transit sites closer to their homesteads.
129
This does not include displacements associated with the disputed election results late 2007/early 2008.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
48
Sexual behavior data
BSS data were collected in 30 IDP sites in Burundi in 2004. 130 Overall, 3% of IDPs (5% of male
IDPs) reported a sexual relationship with somebody other than a spouse or cohabiting partner
during the past 12 months. One percent reported paid sex. Reported condom use was very low,
both for ‘ever used’ (10%) and for use during the last sexual act (3%). Condom use was higher
with casual partners (25%) and for paid sex (28%). Concerning VCT service utilisation, 16%
reported having undergone a HIV test and received the result.
Unlike refugees who enjoy international recognition within a well defined refugee protection
framework, IDP protection is solely a government domain with international humanitarian actors
only coming in at the invitation of host governments. In camps for IDPs in Uganda, serious
problem of sexual violence and exploitation have been reported. 131 IDP communities in the
north are plagued by an array of GBV-related problems, including domestic violence,
abductions, rape, abortion complications and transactional sex. “The perpetrators of sexual
exploitation and abuse are not only LRA members but men in the communities, spouses, and
members of the Ugandan military. Challenges to implementing plans and policies to confront
sexual violence include inadequate human resources, weak referral pathways and insufficient
international pressure on the Ugandan government. There are not enough civilian police, and
physicians must sign documents before victims of sexual violence can take their cases to court.”
Factors of vulnerability and HIV risk differ from context to context. The groups most frequently
at risk in emergencies are women, children, older people, disabled people and PLHIV. 132 In
certain contexts, people may also become vulnerable by reason of ethnic origin, religious or
political affiliation. Some coping strategies employed by women and girls tend to expose them
to higher risk of HIV infection, e.g. prostitution and illicit relationships, or sexual violence as
they travel to unsafe areas. PLHIV may face greater risk of malnutrition, because of a number of
factors, including reduced food intake due to appetite loss or difficulties in eating; poor
absorption of nutrients due to diarrhea, parasites or damage to intestinal cells; changes in
metabolism; and chronic infections and illness. Women’s risk of contracting HIV as a result of
sexual violence increases when there are multiple perpetrators, or when women are held by
military personnel for prolonged periods for sexual purposes, as has been reported in emergency
situations. 133
Factors potentially lessening HIV risk have been identified for refugees and may also be
important for IDPs, but there are insufficient data to determine this. Other countervailing factors
must equally be borne in mind: mass killing, forced displacement and being in hiding can reduce
individuals’ exposure to HIV. 134
130
CEFORMI/FHI (2005). Enquête de surveillance de comportements face au VIH/SIDA auprès les personnes
déplacées.
131
http://www.unfpa.org/emergencies/symposium06/docs/daytwosessionfivebnamirimbe.ppt
132
The Sphere Project (2004). Humanitarian Charter and Minimum Standards in Disaster Response
http://www.sphereproject.org/component/option,com_docman/task,cat_view/gid,17/Itemid,26/lang,English/
133
Salama P et al (1999). Health and human rights in contemporary human crises: Is Kosovo more important than
Sierra Leone? BMJ,319:1569-71
134
Spiegel PB et al. (2007). Prevalence of HIV infection in conflict-affected and displaced people in seven subSaharan African countries: a systematic review. Lancet, 369:2187-95.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
49
Summary of Findings: Refugees and IDPs
Table 23. Refugees & IDPs – Group size, vulnerability and HIV risk factors
Refugees –- Estimated Population Size in GLR = 1.2 million (June 2007)
IDPs - Estimated Population Size in GLR = 2.9 million (mid-year 2007)
Refugees and IDPs: Factors of Vulnerability
Refugees and IDPs: Risk Factors for HIV
•
IDPs: Lack of official status & protection framework
•
•
Dispossessed of land, productive resources and
home
Minimum standards in humanitarian interventions
may not include prevention of STIs/HIV
•
•
Illegal settlement and resulting expulsion
•
War alters gender roles
Barriers to HIV prevention: disruption of health
services; testing for HIV may be difficult (lack of
confidentiality in confined camps, lack of counseling
service)
•
War destroys infrastructure (health, education,
communication, transport)
•
Disruption of sexual partnerships and networks
•
Poor access to comprehensive health services
•
•
Multiple threats to health other than HIV, such as
measles, diarrhoeal diseases, acute respiratory
diseases, malaria, and protein energy malnutrition
Outside habitual norms and social control, persons
may adopt behaviors which are incompatible with
their status
•
Sexual interaction of emergency-affected people with
military or paramilitary personnel
•
Heightened economic vulnerability of women and
children
•
Transactional sex, also as “survival strategy”
•
Migration from rural areas where HIV prevalence and
knowledge of HIV low
•
Sexual violence and coercive sex, multiple
perpetrators
•
Unaccompanied minors lack parental guidance and
protection
•
New sexual relationships may have power
differentials which impair negotiation of safer sex
•
Psychological trauma, may precipitate erosion of
traditional values
•
Potentially, increased use of alcohol and illicit drugs
•
•
Potentially, disruption of family and social structures
Potentially, unsafe blood transfusion practices at a
time of increased blood transfusion and unsafe
injections
4.9 RETURNEES
Repatriation is problematic when returning refugees have interacted with host communities with
high prevalence, and so may have a higher prevalence than those who have never left. But it
should also be acknowledged that their knowledge and behavior might be better than that of
people who have remained in-country. Returning refugees should be used as a resource and not
thought of just as a population that might spread HIV.
4.10 PRISONERS
A ‘prisoner’ is used broadly to refer to adult and juvenile males and females detained in criminal
justice and correctional facilities during the investigation of a crime; while awaiting trial; after
conviction and before sentencing; or after sentencing. 135 Although the term does not formally
cover persons detained for reasons relating to immigration or refugee status, and those detained
without charge, nonetheless many of the considerations discussed here may apply to them also.
HIV has been identified as a major health problem in prisons around the world. Prison grounds
offer ideal conditions for transmission of many infectious diseases, including TB, hepatitis, STIs
and HIV. Prison populations are predominantly male and most prisons are male-only
institutions, including the prison staff. In these gender exclusive environments, male-to-male
135
UNODC (2006). HIV/AIDS prevention, care, treatment and support in prison settings. A framework for an
effective national response.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
50
sexual activity (prisoner-to-prisoner and guard-to-prisoner) is frequent. 136 The actual number of
instances is likely to be much higher than reported mainly due to denial, fear of being exposed or
the criminalization of sodomy and homosexuality.
There is high turnover and mobility among prisoners. The average stay is short and return rates
are high. International evidence suggests that most prisoners are eventually released and return
to their communities. If they have contracted HIV, whether outside or inside the prison, they
become potential links for transmitting HIV from and into the general population. The risk of
HIV infection is also increased for those in contact with members of prison populations such as
prison staff and spouses or partners, and by extension, the broader population.
Population size
Table 24. Prison population data for GLIA countries
Burundi
DRC
Kenya
Rwanda
Tanzani
a
Uganda
Total
Total
population
(2007)
8,390,505
65,751,512
36,913,721
9,907,509
39,384,223
Total prison
population (year)
Female prisoners, % of
total prison population
7,969 (2005)
c. 30,000 (2004)
47,036 (2006)
c. 67,000 (2005)*
43,911 (2006)
Female prison
population
(year)
216 (2002)
c. 83 (2004)&
1,254 (2002)
2,925 (2002)*
1,515 (2005)
30,262,610
190,610,080
26,126 (2005)
222,042
901 (2005)
6,894
3.4%
3.1%
2.7%
2.7%
4.4%
3.5%
Prison population
rate (per 100,000
inhabitants)
106
57
130
152*
113
95
* It is understood that the majority are held on suspicion of participating in the 1994 genocide & Only main prison in Kinshasa
Sources: The World Prison Population List – 7th ed, Jan 2007. International Centre for Prison Studies, King’s College,
London.; The World Female Imprisonment List, April 2006. International Centre for Prison Studies, King’s College, London.
HIV epidemiology
Data from sub-Saharan African countries suggest higher prevalence among African prisoners
than in the general adult population, but data are available only for a limited number of countries
and there is no provision of systematic data on the magnitude of the problem (Table 25).
Table 25. HIV prevalence in prison populations and median prevalence
National HIV prevalence
Site
%HIV+
Year
estimate (see Tables 3 and 4)
Burundi
Ngozi Prison
3.5
2001
3.3%
Kenya
13 prisons
10.0
2007
6.1%
Rwanda
Karubanda/ Butare
5.3
1999
3.1%
Rwanda
Ex-prisoners
9.0
2004
3.1%
Tanzania Zanzibar
Pemba
1.3
1995
0.6%
Tanzania Zanzibar
Zanzibar
5.6
1995
0.6%
Uganda
7.5
2002
6.7%
Median
5.6
Sources: Mpinganzima D et al. (2002), An AIDS programme in a prison of Burundi. Proceedings of the XIV Int.
AIDS Conference Abstract no. TuPeF5356; IRIN (2007) Kenya: Slow response to high HIV rates in prisons
http://irinnews.org/Report.aspx?ReportId=74055; Wane J & Sinayobye F (2001), Etude CAP et séroprévalence de
l’inféction à VIH en milieu carceral: cas de la prison de Karubanda à Butare. Proceedings of the XII Int.
Conference on AIDS and STDs in Africa. Poster 11PT2-96; TRAC (2004), Annual report; Haji SH (1995),
Prevalence of HIV infection in inmate prisoners Pemba Island, Zanzibar, Tanzania. Proceedings of the IX Int.
Conference on AIDS and STD in Africa. Abstract TuD128; Zanzibar AIDS Control Programme (1995), Program
Manager - HIV/AIDS Case Report Update for Zanzibar; Foster G (2002), A captive audience for AIDS education.
Mail and Guardian (South Africa), Mar 15, 2002.
136
Human Rights Watch (2002).World Report; & (1999) World Report. Special Programs and Campaigns-Prisons.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
51
•
The data in Table 25 have severe limitations; sometimes they come from statistically
insignificant samples and some data sets are more than 10 years old. There is a considerable
knowledge gap in understanding the magnitude of the epidemic in prison communities and
its multiplier effect on the non-prison population in the region.
•
In Rwanda, prisoners are tested for HIV after release from prison during the time in the
“Solidarity Camps”. In 2004, 9% of 2,721 ex-prisoners tested were found to be HIV
positive. In 2004, a KAP study in several prisons by MININTER, PSI and PEPFAR
identified an urgent need for comprehensive VCT services in the prisons (report not
available).
•
In Kenya, increasing TB morbidity and mortality among Kenya prisoners has raised concern;
HIV infection and poor living conditions are reported to be the key risk factors for TB
transmission and reactivation in such congregate settings. 137 Death register records of 20002003 from 13 major prisons across the country showed that TB and AIDS were responsible
for at least 40% of preventable prison deaths. Designed for 7,328 prisoners, the 13
facilities hosted some 17,000 people during the survey.
Sexual behavior and related data
This analysis did not find surveys of sexual behavior in prisons, but it is possible to summarize
from the literature some aspects of sexual behavior and the context in which this behavior takes
place. In the closed environment of prisons, women are especially vulnerable to sexual abuse,
including rape, by staff and other prisoners. In many countries, women prisoners are held in
small facilities immediately adjacent to or located in male prisons. In rarer instances, women and
young girls are not separated from the male prison population at all. Female prisoners may be
supervised exclusively or mainly by male staff. Women in prison are also susceptible to sexual
exploitation and may trade or be forced to trade sex for food, goods or drugs with other prisoners
or staff. Data on juveniles (people under 17 years of age) held in African prisons are limited. In
most countries, juvenile prisoners represent between 0.5 and 5% of the total prison population.
They are often detained with adults and thus are at great risk of sexual abuse by prison staff and
older prisoners. 138
According to UNAIDS, even when people enter prisons, they retain the majority of their human
rights including the right to freedom from cruel and inhuman punishment and the right to the
highest attainable standard of health and security of person. 139 They lose only the rights that are
necessarily and explicitly limited because of their imprisonment. Protecting prisoners’ health is
also pragmatic public health policy, because prisoners are eventually released and infection
acquired inside prison can be transmitted readily to the population outside the prison.
The existing body of literature points to a number of factors contributing to HIV transmission in
African prisons. Violence in prison - most of which goes unrecorded - is ritualized and is
fundamental in establishing inmate identities and hierarchies. 140 Prisons offer new norms of
dominance and power, particularly between male prisoners. Male rape, perhaps the most
137
Odhiambo J. et al. TB and AIDS: The leading preventable causes of prison deaths in Kenya. Poster Exhibition:
The XV International AIDS Conference: Abstract no. ThPeC7519
138
International Center for Prison Studies (2006). Children in Prison, Guidance Note 14. London, King’s College
http://www.kcl.ac.uk/depsta/rel/icps/gn-14-children-in-prison.pdf.
139
UNAIDS policy guidance on prisons. http://www.unaids.org/en/Policies/Affected_communities/prisons.asp
140
Gear S (2007). Behind the bars of masculinity: male rape and homophobia in and about South African men’s
prisons. Sexualities, 10(2):209-227.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
52
severely under-reported, is one of many forms of assault that occurs (predominantly) between
prisoners. Rape and other forms of sexual violence happen between prisoners of the same or
different sex, and between staff and prisoners. Gang rape and exchange of men for favours
among gangs and individual prisoners take place frequently. Victims of continual rape and
sexual abuse often resort to prostitution as a survival or coping mechanism. 141 Poor food and
nutrition, including low quality and scarcity of food, motivate prisoners to exchange sex for
food.
In Kenyan law, male-to-male sex is a criminal offence that carries a jail sentence of five to 14 years.
Although it is rarely used, the legislation excludes MSM from government HIV programs. 142 Kenyan law
prohibits sex in prison, so conjugal visits are banned. "The inmates resort to sodomy and lesbianism, a
situation that aggravates the spread of HIV, and since none of them wants to admit that they practise the
same openly it is hard to ask them to use condoms, as this will again encourage the practice considered
a norm," the Oscar Foundation Free Legal Aid Clinic Kenya commented. The slow response to high
HIV/AIDS levels in prison is mainly due to weak and outdated legislation, as well as religious and cultural
inhibitions. In 2007, Government of Kenya commissioned a study on prison rape.
Summary of findings: Prisoners
Table 26. Prisoners – Population size, vulnerability and HIV risk factors
Prison population - Estimated Population Size in GLR = 222,042 (97% men and 3% women)
Prisoners: Factors of Vulnerability
• Weakness of the criminal justice and judicial systems
• Mixing of un-sentenced and convicted persons
• Stigmatization of prisoners by society
Prisoners: Risk Factors for HIV
• New norms of dominance and power,
altering traditional gender identities and
roles that become highly sexualized
• Appalling physical conditions in prisons, due to lack of resources for
maintenance of penal institutions
• High-risk sexual activities (anal sex in
homosexual acts, rape, gang rape,
sexual abuse)
• Substandard or nonexistent health care, poor safety of medical and
dental equipment
• Prostitution as a coping mechanism
• Gender exclusive environment
• Tattooing and other forms of skin
piercing
• Inadequate food and nutrition
• Blood brotherhood rituals
• Overcrowding
• Untreated STIs
• Lack of conjugal visits
• Prevention commodities (condoms,
lubricants, needles/ syringes, bleach)
often not available
• Some sentenced for drug-related crimes, IDU habit continues in prison
• Legal restriction on drug use, lack of harm reduction measures like drug
substitution
• Criminalization and denial of sexual activity in prisons
• High turnover and mobility among prisoners
• Underreporting of rape
• Little autonomy in own protection, minimal control over living conditions
141
Kudat A (2006). Males for Sale. Dogan Yayinlari. Istanbul.
IRIN (2007) Kenya: Slow response to high HIV rates in prisons
http://irinnews.org/Report.aspx?ReportId=74055
142
• Lack of access to IEC services
• Bisexual and homosexual relations
including ‘marriages’ among male
prisoners
• If IDU, high likelihood of contaminated
injection equipment
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
53
4.11 FEMALES AFFECTED BY SEXUAL VIOLENCE
Sexual violence against females 143 and gender based violence (GBV) 144 are serious human rights
and public health issues, which disproportionately affect women and girls of all ages, from all
cultures, countries and socio-economic backgrounds. These types of violence take many forms,
including rape, domestic violence, forced marriage, exploitation and harassment, sexual slavery,
forced prostitution, human trafficking, and genital cutting. 145 These impact women and girls’
physical, emotional, psychological and social well-being. Sexual violence against females
occurs across all socioeconomic and cultural backgrounds, and in many societies, women are
socialised to accept, tolerate, and even rationalise such experiences and to remain silent about
them.
Sexual violence related to conflict and war
Sexual violence against females is a major problem in the GLR, particularly in areas affected by
past or current conflict. In the Rwandan conflict, observers have suggested that between 200,000
and 500,000 women were raped. 146,147,148 The low social status of women leaves them
vulnerable to sexual violence, while cultural taboos prevent them from seeking help. Although
estimation of the probability of HIV transmission from rape is difficult, it is probably higher
than from consensual sex because of genital or rectal trauma and because there may be several
assailants. 149 Associations to help victims of sexual violence are often led by survivors, and care
for thousands of widows, rape survivors, and orphans, some specifically caring for those
infected with HIV.
Burundi has a well publicized national program for clinical management of rape and a multisectoral emergency response plan is in place. 150 Nevertheless, violence against women and girls
continues. A particular problem affects secondary school female students who have to leave
their homes and board with host families near schools. The girls are expected to “pay” for this
hospitality, and this, combined with being away from their own families, makes them targets for
sexual exploitation. The International Rescue Committee seeks to compel school systems to
provide for the protection of students. A partnership approach among students, school systems
and ministries has been adopted, and students are getting involved in school management.
A survey by Ligue ITEKA in Burundi in 2004 found that of the 2,173 people interviewed, 40%
believed that "sexual violence with teenagers [children, especially infants], protects against
143
Female has been physically forced to have sexual intercourse; had sexual intercourse because she was afraid of
what her partner might do; been forced to do something sexual she found degrading or humiliating (WHO multicountry study on women’s health and domestic violence against women, 2005)
144
Any type of violence directed at groups or individuals on the basis of their gender (HIV/AIDS and gender-based
violence literature review, Harvard School of Public Health, 2006)
145
In Kenya, the government has enacted the National Commission on Gender and Development Act of 2003 to
help in the coordination and mainstreaming of gender concerns in national development. The Children Act of 2001
also classifies children exposed to domestic violence and female circumcision as children in need of care and
protection.
146
Carballo M et al. (2000) Demobilization and Its Implications for HIV/AIDS, Linking Complex Emergency
Response and Transition Initiative (CERTI) Crisis and Transition Tool Kit, October 2000, p16.
147
Sharlach L (2000). Rape as Genocide: Bangladesh, the Former Yugoslavia, and Rwanda. New Pol Sci, 22(1),
p9.
148
Human Rights Watch (1996). Shattered Lives: Sexual Violence During the Rwandan Genocide and Its
Aftermath. New York, NY.
149
Gostin L et al.(1994). HIV testing, counseling and prophylaxis after sexual assault. JAMA 1994; 271: 1436–44.
150
http://www.unfpa.org/emergencies/symposium06/docs/burundidaytwosessionfiveb.ppt
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
54
HIV/AIDS, while 35% believe that teens are not infected". 151 Minister Ntirampemba comments:
"Many victims seem reluctant to start a legal procedure, as they know that in the long run the
crime will not be taken seriously".
In DRC, both during and after the conflict, violence against women has been widespread, and
often used as a deliberate weapon of war. 152 A dysfunctional justice system and inadequate
social and health infrastructures have left women disenfranchised and highly vulnerable to
sexual violence and exploitation. MSF concluded from surveys in DRC in 2005 that “poverty,
the high number of young people with nothing to do or former militiamen or aides-de-camp with
no money or education, the appeal of easy money, the judicial system’s incapacity, the
starvation wages paid to soldiers and the brutality of some of those supposed to be upholding
law and order all contribute to proliferating violent behavior. [..] The number of rapes reported
was also very high in 2004. It reflects the situation of women and young girls at the mercy of
armed men who systematically rape those they encounter during combat or kidnap their victims
and keep them as sex slaves in their camp or in the quarry mines. [..] This high incidence of
sexual violence in early 2005 is in sharp contrast with the total lack of medical care or any
other support for these women”. 153
Tanzania is the GLIA country that has suffered least armed conflict in recent history. However,
rape and other physically forced or violent sex are common, often remain undisclosed, and are
considered to contribute to high rates of HIV infection. 154
International legal and humanitarian constructs now define gender-based violence (GBV) during
conflict as a way to demoralize communities, as an instrument of genocide, and as a crime against
humanity when it is systematically directed against civilian populations. 155 In 1998, for the first time, an
international tribunal convicted a Hutu rapist of a crime against humanity for his actions. 156
Partner violence
Physical and sexual violence affect women’s ability to protect themselves from infection.
Refusing sex, inquiring about other partners, or suggesting condom use have all been described
as triggers for intimate partner violence; yet all are intimately connected to the behavioral
cornerstones of HIV prevention. The ‘WHO Multi-country study on women’s health and
domestic violence against women’ showed that most acts of sexual violence are perpetrated by
intimate partners. 157
Data collected in Tanzania within the framework of this multi-country study underlines the
magnitude of partner inflicted violence: one in ten Tanzanian girls under 15 years of age had
been sexually abused. 158 About 15% of Tanzanian women reported that their first experience of
151
http://www.plusnews.org/report.aspx?ReportID=74086 (accessed on 20 sept 2007)
http://www.unfpa.org/emergencies/symposium06/docs/final_report.pdf
153
MSF (2005). Access to health care, mortality and violence in DRC
154
Plummer M et al. (2002). Sexual violence, pressure and HIV in rural Tanzania.
http://196.207.17.140/pubs/presentations/PRS000079.ppt
155
Ward J. (2002) If Not Now, When? Addressing gender-based violence in refugee, internally displaced, and postconflict settings: A global overview. New York, NY: The Reproductive Health for Refugees Consortium c/o The
Women’s Commission for Refugee Women and Children and the International Rescue Committee.
156
Jefferson LR. (2004) In War as in Peace: Sexual Violence and Women’s Status. New York,Human Rights
Watch.
157
Garcia-Moreno C (2006). Prevalence of intimate partner violence: findings from the WHO multi-country study
on women’s health and domestic violence Lancet; 368: 1260–69
158
WHO (2005). WHO Multi-country study on women’s health and domestic violence against women: Tanzania.
152
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
55
sex was forced, and the younger a woman at first sex, the more likely that this was forced. 29%
of women who had experienced partner violence had told no one about it, 60% of all women
who experienced partner violence had never gone for help to any formal service or person in a
position of authority. 56% of women in Dar es Salaam and 48% in Mbeya did not seek help
because they thought the violence was “normal” or not serious enough. The most common
reasons for seeking help were not being able to endure more violence or being badly injured.
Population size
Table 27. Prevalence of sexual violence against women and median prevalence
Kenya
Rwanda
Tanzani
a
Tanzani
a
Tanzani
a
Uganda
Uganda
Site
National
National
Dar es Salaam
Mbeya
Moshi
Rakai
Mbale District
Sample
Women 15-49 yrs
Women 15-49 yrs
Women 15-49 yrs
Women 15-49 yrs
% history of sexual/
GB violence
15.7%
12.9%
Year
2003
2005
Source
DHS Kenya 2003
DHS Rwanda 2005
23%
2002
WHO, 2005
31%
2002
WHO, 2005
Women 20-44 yrs
3.4%
?
McCloskey et al. 2005
13.4%
2003
Zablotska et al. 2006
37.0%
Karamagi et al. 2006
15.7%
Not included: Tanzanian AIS 2003-2004 (only forced sex/rape was assessed and there was some evidence that
respondents may not have included marital rape when answering the question); Ugandan AIS 2005 and the four
GLIA BSS (only determined occurrence of rape but not other experiences of sexual violence).
Women 15-24 yrs
Women w. infants
Median
There is a specific concern about partner violence affecting young women. A study in Dar es
Salaam, Tanzania of men and women aged 16-24 years found complex interactions among
violence, forced sex and infidelity in young people’s sexual relationships. 159 Men who were
violent toward female partners also frequently described forced sex and sexual infidelity in these
partnerships. Men with multiple concurrent sexual partners reported becoming violent when
their female partners questioned their fidelity, and reported forcing regular partners to have sex
when these partners resisted their sexual advances. In a study in Rakai, Uganda of sexually
experienced 15-19 year old women, 14% reported that their first sexual intercourse had been
coerced. 160 The women who reported coerced first intercourse were significantly less likely than
those who did not to be currently using modern contraceptives, to have used condoms at last
intercourse and to have used them consistently; they were more likely to report their current or
most recent pregnancy as unintended and to report one or more genital tract symptoms.
HIV epidemiology
Gender inequality and GBV are increasingly cited as important determinants of women’s HIV
risk; yet empirical research on possible connections remains limited. Although most women
affected by HIV are in SSA, almost all existing research on violence and women’s HIV risk
comes from the USA. Comparisons across studies are often difficult because different forms of
violence (intimate partner violence, domestic violence, GBV, sexual violence, sexual and
physical violence combined, coerced sex, etc) are being assessed over different time frames
(lifetime violence, violence in current relationship, etc). Only very few SSA projects have made
159
Maman S et al. (2004). Exploring the Association Between HIV and Violence: Young People's Experiences with
Infidelity, Violence and Forced Sex in Dar es Salaam, Tanzania. Int Fam Plan Perspect, 30(4):200-206.
160
Koenig MA et al. (2004). Coerced first intercourse and reproductive health among adolescent women in Rakai,
Uganda.Int Fam Plan Perspect,30(4):156-64.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
56
quantitative assessments of violence and women’s HIV risk (the Rwandan and the Kenyan DHS
did not present the relationship between sexual violence and HIV status):
•
A study by Dunkle et al. 161 of ANC clients in Soweto, South Africa identified violence as
an independent risk factor for HIV infection. Intimate partner violence (physical, sexual)
was significantly associated with HIV sero-positivity (HIV prevalence 1.4 times elevated,
from 28.6% to 40.2%). Child sexual assault, forced first intercourse, and adult sexual assault
by non-partners were not associated with HIV sero-status.
•
In a large community cohort of women aged 15-24 years in Rakai, Uganda, HIV prevalence
was significantly increased when women reported both sexual coercion and alcohol use
before sex, with alcohol having a stronger effect on HIV prevalence than sexual coercion. 162
•
A study of female patients at a STI clinic in Nairobi, Kenya found that HIV positive women
had an almost two-fold increase in lifetime partner violence; HIV prevalence was 39% in
women with a history of partner violence and 27% in women without such a history
(prevalence 1.4 times elevated). 163
•
A study in Kigali, Rwanda of women in stable relationships found that HIV-positive
women were more likely to report a history of physical violence or sexual coercion by their
partners than HIV-negative women. 164
•
A study of 245 women attending a VCT centre in Dar es Salaam, Tanzania noted that in
women younger than 30 years, HIV-positive women were more likely to report at least one
event of physical or sexual violence from their current partner than were HIV-negative
women, while in women older than 30 years, HIV status was not associated with violence. 165
•
The Kenya BSS (2000) found that FSW reporting violence from a sexual partner were 3
times more likely to have a history of STDs.
HIV prevalence data by history of violence were available from two studies, and both found that
women with such a history had a 1.4 times higher HIV prevalence than women without such a
history.
The studies from Kigali and Dar es Salaam provide valuable evidence of a connection between
intimate partner violence and women’s HIV risk, but the studies had important limitations: the
investigators in both studies assessed whether women were subject to partner violence only after
the women were aware of their sero status, and the research was limited by a narrow breadth of
experiences that were defined as violent and controlling. Neither study controlled for effects of
women’s risk behaviors although these behaviors might be associated with violence. Overall,
there is insufficient evidence on the relationship between sexual/GB violence and HIV risk, from
GLIA countries and elsewhere in SSA. Existing data are either not analysed with respect to the
link between violence and HIV (e.g. DHS), or studies are not designed to assess reliably
women’s experiences and the HIV link (e.g., definitions of rape, coercion, forced sex are not
161
Dunkle KL et al. (2004). Gender-based violence, relationship power, and risk of HV infection in women
attending antenatal clinics in South Africa. Lancet, 363(May1), 1415-21.
162
Zablotska I et al. (2006). Alcohol use, intimate partner violence, sexual coercion and HIV among women aged
15-24 in Rakai, Uganda. XVI Int. AIDS Conference, abstract no. CDD0175.
163
Fonck K et al. (2005). Increased risk of HIV in women experiencing physical partner violence in Nairobi,
Kenya. AIDS and Behavior, 9(3):335-339.
164
van der Straten A et al. (1995) Couple communication, sexual coercion and HIV risk reduction in Kigali,
Rwanda. AIDS, 9(8):935-944
165
Maman S et al. (2002). HIV-positive women report more lifetime partner violence: findings from a voluntary
counseling and testing clinic in Dar es Salaam, Tanzania. Am J Public Health, 92: 1331–37.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
57
always well explained to participants). In several studies, there is considerable overlap between
rape-associated factors and known HIV risk factors, suggesting a need for further research on
the interface of rape and HIV. Cross-sectional study designs limit ability to establish relative
timing of violence, risk behavior and acquisition of HIV infection. Underestimation of sexual
violence may be considerable, due to underreporting and sampling strategies involving health
facility users. It is also worth mentioning that no agreed standard yet exists for measuring the
severity of intimate partner violence.
Table 28. Population of females affected by sexual violence
Total female
population 15-64
years (2007)
2,162,093
16,571,549
10,174,922
2,765,767
10,649,507
Est. number of women
with history of
sexual/GB violence*
339,449
2,601,733
1,597,463
434,225
1,671,973
Est. total women 15+ yrs
living with HIV (PLHIVs)
[UNAIDS]
79,000
520,000
740,000
91,000
710,000
Est. excess female PLHIV
attributable to sexual/
GB violence&
4,668
30,726
43,726
5,377
41,953
Burundi
DRC
Kenya
Rwanda
Tanzani
a
Uganda
7,185,058
1,128,054
520,000
30,726
Total
49,508,896
7,772,897
2,660,000
157,177
Estimates based on the following assumptions:
* An estimated 15.7% of female population has a history of sexual or GB violence in the GLR
&
Women with sexual/GBV history (GBV∼women) are 1.4 times more likely to be HIV infected than
women without a history (NoGBV∼women)
Attributable fraction: Formula (GBV∼women x 0.4 x PHIVs∼UNAIDS) / (NoGBV∼women + (1.4 x GBV∼women))
Women affected by sexual violence can experience severe emotional crisis, anger, and
humiliation as they share their testimonies. Preliminary evidence suggests that the HIV
prevalence rate among rape survivors is high. Two-thirds of a recent sample of 1,200 Rwandan
genocide widows tested positive for HIV. 166 Affected women are at risk of isolating themselves
from the judicial process and their communities. Physical and psychological illnesses continue
to plague them, and include AIDS, STIs, fistulas, scars, chronic pain, depression, posttraumatic
stress and flashbacks. Young women and girls are at high risk of HIV infection due to their
profound vulnerability to gender-based violence and poverty.
Summary of findings: Females affected by sexual and gender-based violence
Table 29. Females affected by sexual/GB violence – Population size, vulnerability and HIV risk factors
Population - Estimated Population Size in GLR = 7.78 million have a history of sexual violence,
leading to an estimated 157,777 excess female PLHIV
Females affected by GBV: Factors of Vulnerability
•
•
•
•
•
•
•
•
•
•
166
Low literacy
Subordinate status of females
Lack of empowerment
Violence widely tolerated as a form of social control
Rape survivors stigmatized and shunned by partners and community
High levels of male dominance/control in relationship
Physical violence in partnership
Frequent partner change, casual partners
Alcohol use before sex
Sexual decision making by male partner
Females affected by GBV: Risk Factors for HIV
•
•
•
•
•
•
Multiple perpetrators belonging to higher risk groups
themselves
Young age of female – higher susceptibility to trauma
due to under-development of reproductive tract
Relationship with abusive man imposing risky sexual
practices on partner
High frequency of abuse
HIV positive male partner
Physical trauma – genital trauma (tears and
abrasions to the vaginal wall due to violence or
vaginal dryness), and anal trauma
New Vision (2001). Genocide widows die of AIDS. December 11, 2001, Kampala.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
•
Female attempts to negotiate safer sex may trigger violence
•
Use of VCT may trigger violence
•
•
58
Condom use rare in violent sexual acts
Lack of post-exposure prophylaxis
4.12 SUMMARY: POPULATION SIZES, HIV PREVALENCE AND NUMBER OF PLHIV
This section provides summary overviews of the study observations on population sizes and
PLHIV numbers. Figure 11 shows estimated PLHIV numbers for each GLIA country for seven
of the vulnerable populations, illustrating their relative level of HIV burden. Figure 12 shows the
share of total estimated PLHIV in each GLIA country that the populations are estimated to
comprise. Table 30 summarizes the estimates for the eight vulnerable populations of size,
median HIV prevalence and estimated number of PLHIV, as a basis for assessing the case for
including them among the population groups meriting targeted interventions.
Figure 11: Relative level of the HIV burden in the selected vulnerable populations in the GLIA countries
(Note: FSW are excluded from this figure because of lack of data on population size and HIV prevalence)
Est. number of
PLHIV
100,000
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
-
Burundi
DRC
Kenya
Rwanda
Tanzania
Uganda
Military, PLHIV
9,100
17,040
5,824
14,200
21,680
12,360
Truckers, PLHIV
2,365
18,532
10,404
2,792
11,100
8,529
Fisherfolk, PLHIV
2,709
26,775
13,628
855
37,264
29,340
Refugees, PLHIV
IDP, PLHIV
Prisoners, PLHIV
Female/sex.violence attributable PLHIV
383
3,254
4,442
769
7,787
3,645
3,300
35,903
18,758
-
-
93,800
446
1,680
2,634
3,752
2,459
1,463
3,935
25,902
36,861
4,533
35,367
25,902
Sources: As described in the methodology section and in the annotation in Table 30.
Note: This graph presents the higher estimate of PLHIV numbers among the military, using 20% as the median
HIV prevalence. The Tanzanian estimate for the military includes the reserve force.
•
The graph shows that the relative magnitude of PLHIV numbers varies widely between
vulnerable populations and countries.
•
In two countries (DRC, Uganda), the highest number of estimated PLHIV is contributed by
IDPs.
•
The estimated number of PLHIV among fishermen and fisherwomen is comparatively high
in Tanzania, Uganda and DRC.
•
In Rwanda and Burundi, it is estimated that the military contributes most PLHIV.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
•
59
In Kenya, the females affected by sexual violence is by far the most important population in
terms of contributing PLHIV, and a similar number of PLHIV among such females is
estimated for Tanzania.
Figure 12. Proportions of PLHIV in all eight vulnerable populations combined compared to total PLHIV,
per country
DRC
Burundi
15%
17%
85%
84%
Kenya
8%
Rwanda
83%
92%
Tanzania
9%
91%
17%
Uganda
20%
80%
Sources: As described in the methodology section and in the annotation in Table 30.
Note: The pie charts presents, for each country, all eight vulnerable populations combined as a percentage of the
total estimated PLHIV in the country. For the military, the higher estimate of PLHIV numbers was used, based on
the estimated median HIV prevalence of 20%. The Tanzanian estimate for the military includes the reserve force.
•
The proportion of PLHIV in the selected vulnerable populations compared to the total
number of PLHIV in the GLIA countries ranges from 8% (Kenya) to 20% (Uganda).
•
In the three countries with lower HIV population prevalence of around 3% (Burundi, DRC,
Rwanda), this proportion is 17%, 15% and 17%, respectively. In contrast, in the three
countries with higher HIV population prevalence of 6-7% (Kenya, Tanzania, Uganda), the
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
proportion is 8%, 9% and 20%, respectively. The main reason for the high proportion in
Uganda (20%) is the fact that there is an estimated 93,800 PLHIV among IDPs.
60
Vulnerable PLHIV (j)
Vulnerable Populations (i)
129,086
4,247,498
25,902
2,601,733
1,680
30,000
35,903
1,121,979
3,254
197,232
n.d.
n.d.
8,520
17,040
85,200
26,775
108,400
18,532
102,954
DRC
92,551
2,363,291
36,861
1,597,463
2,634
47,036
18,758
307,500
4,442
269,196
n.d.
n.d.
2,912
5,824
29,120
13,628
55,176
10,404
57800
Kenya
26,901
637,798
4,533
434,225
3,752
67,000
-
-
769
46,600
n.d.
n.d.
7,100
14,200
71,000
855
3,460
2,792
15,513
Rwanda
Annotations for Table 30
22,238
540,240
3,935
446
PLHIV (est HIV prev 5.6%)
PLHIV* (RR= 1.4)
7,969
Population Size
339,449
3,300
PLHIV (est nat. HIV prev used)
Population Size
100,000
383
Population Size
PLHIV (est HIV prev 1.65%)
23,215
n.d.
PLHIV
Population Size
n.d.
* Excess PLHIV attributable to sexual violence
TOTALS
Females affected by sex
violence (h)
Prisoners (g)
IDPs (f)
Refugees (e)
FSWs (d)
Military (c)
Population Size
45,500
Population Size
4,550
2,709
PLHIV (est HIV prev 24.7%)
PLHIV (est 10% HIV prev
10,969
Population Size
9,100
2,365
PLHIV (est HIV prev 18%)
PLHIV (est 20% HIV prev)
13,138
Population Size
Long distance truck drivers
(a)
Fishermen / fisherwomen (b)
Burundi
Characteristics
Vulnerable Population
115,656
2,508,729
35,367
1,671,973
2,459
43,911
-
-
7,787
471,912
n.d.
n.d.
10,840
21,680
108,400
37,264
150,865
11,100
61,668
Tanzania
175,040
3,003,065
25,902
1,128,054
1,463
26,126
93,800
1,400,000
3,645
220,914
n.d.
n.d.
6,180
12,360
61,800
29,340
118,786
8,529
47,385
Uganda
Table 30. Summary of population sizes and PLHIV numbers of selected populations
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
( 12% of total adult PLHIV population in GLR)
561,472
(7 % of total adult population in GLR)
13,300,621
132,500
7,772,897
12,434
222,042
151,761
2,929,479
20,280
1,229,069
n.d.
n.d.
40,102
80,204
401,020
110,571
447,656
53,722
298,458
Total
61
62
(j) Estimated number of adult PLHIV in these vulnerable populations: Total PLHIVs in these vulnerable populations
(i) Total estimated number of the 7 types of vulnerable populations analysed in this report
(h) Females affected by sexual violence: Group size was estimated based on six studies presenting the proportion of females in the adult female
population who have a history of sexual or gender-based violence. Calculation of PLHIV numbers used data on the relative risk (RR=1.4) of HIV
sero-positivity in women with a history of sexual violence compared to women without such a history. The RR estimate was used to calculate the
number of PLHIV attributable to sexual violence, using UNAIDS figures of the total number of adult female PLHIV for each GLIA country. The
number of excess female PLHIV attributable to sexual violence was based on the excess risk of HIV sero-positivity in violence affected females.
(g) Prisoners: Population size was taken from the World Prison Population List most recent figures for 2004, 2005 and 2006. Median HIV
prevalence was based on seven studies from different GLIA countries presenting data collected between 1995 and 2007.
(f) Internally displaced persons: Group size came from OCHA (June 2007 figures). No IDP-specific HIV prevalence data were available; the
calculation of PLHIV numbers was therefore based on the UNAIDS estimated national HIV prevalence for 2007 (presented in Table 3).
(e) Refugees: Group size came from OCHA (June 2007 figures). Median HIV prevalence was based on eight recent surveys in different camps.
(d) Female sex workers: Analysis of FSW was limited to HIV prevalence, and did not include estimates of sizes or PLHIV, due to the difficulty of
delineating membership of this risk group.
(c) Military: Size estimates came from www.nationsencyclopedia.com. The only newer prevalence data came from the Uganda Defence Force
(20%). Due to recent claims that HIV prevalence in military forces may be lower than previously thought, a prevalence range of 10-20% was used to
estimate PLHIV numbers.
(b) Fishermen & fisherwomen: Size estimates for Rwanda, Tanzania and Uganda came from the 2002 population censuses. FAO provided
estimates for Burundi (2001 data), DRC (2000) and Kenya (2005). Median HIV prevalence was calculated based on four reasonably recent studies
from several GLIA countries.
(a) Truck drivers: The only size estimate identified was for Kenyan truck drivers. All other trucker population sizes were extrapolated from the
total population, using the same proportion of Kenyan truck drivers to the total Kenyan population. Median HIV prevalence was calculated based on
six studies, mainly involving Kenyan truckers.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
63
5. RESULTS: VULNERABLE POPULATIONS AND COUNTRY NSPS
The current National Strategic Plans (NSPs) for HIV/AIDS of the six GLIA countries were
analyzed to determine which vulnerable population groups are specifically mentioned as target
groups, and which groups are not mentioned (please note that a mention in the NSP of a specific
population does not mean that interventions are actually implemented for the benefit of this
population). The following plans were included in the assessment:
•
•
•
•
•
•
•
Burundi ‘Plan Stratégique de Lutte Contre le VIH/SIDA. 2007-2011’
DRC ‘Plan Stratégique National de Lutte contre le VIH/ SIDA/ MST 1999–2008’
Kenya ‘National Strategic Plan 2005/6-2009/10’
Rwanda ‘Plan Stratégique Nationale de Lutte contre le VIH/SIDA’
Tanzania-Mainland ‘National Multi-Sectoral Strategic Framework on HIV and AIDS 2008 –
2012’
Tanzania-Zanzibar ‘National HIV/AIDS Strategic Plan 2003-2007’
Uganda ‘National HIV and AIDS Strategic Plan. 2007/8 – 2011/12’
Details of the analysis are in Annex VIII; Table 31 gives an overview. The tables present results
for the population groups discussed in this report, and other important vulnerable populations.
Table 31. Targeting of vulnerable populations in current National Strategic Plans
Burundi
DRC
Kenya
Rwanda
Tanzania
mainland
Tanzania
Zanzibar
Uganda
Selected vulnerable populations (discussed in this report)
Truckers
√
√
√
√
√
√
Fishermen / fisherwomen
√
√
√
√
√
√
√
Military
√
√
√
√
√
√
√
Female sex workers
√
√
√
√
√
√
√
Refugees
√
√
√
√
√
√
√
IDPs
√
√
√*
√*
*
√
Host communities
√
√
√
Returnees
√
√
Prisoners
√
√
Females/GBV
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
Other vulnerable populations
Migrant workers
√
√
√
√
√
Transportation operators
Injecting drug users
√
√
√
√
Men having sex with men
√
√
√
√
Female petty traders
√
Married couples
√
PLHIV
√
√
√
Youth
√
√
OVC
√
√
Young women
* currently no official IDPs
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
64
Table 31 shows that:
•
FSW, military, fishermen, refugees, prisoners, PLHIV, youth and OVC are mentioned by all
NSPs
•
Truckers, IDPs, host communities, returnees, females affected by sexual/GB violence,
migrant workers, IDUs, MSM, female petty traders, married couples and young women are
mentioned by the majority of NSPs
•
Transportation operators are mentioned by one NSP
•
Other groups mentioned are discordant couples, people with disabilities, health service
personnel, the general population, pregnant women and unaccompanied minors (see Annex
VIII)
•
While some NSPs define the strategy to be adopted for each group very precisely (e.g. NSP
Zanzibar), others propose virtually identical strategies ‘across the board’ (e.g. the NSP
Burundi and Rwanda include similar strategies for all types of vulnerable populations),
which suggests that these strategies may not be based on specific identified needs of these
vulnerable populations.
•
It appears that there is scope to add value to the targeted interventions in all GLIA countries,
if critical additions to current and planned actions can be identified.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
65
6. RESULTS: PROMISING INTERVENTIONS
This section gives illustrative examples of promising interventions which are being or have been
implemented and which try to address the specific needs of selected vulnerable populations
identified in the literature review. An important reminder: the various vulnerable populations are
not homogeneous themselves; they include younger, older, and more or less educated
individuals, and those in specific occupational groups like fishermen and FSW exert their métier
at variable intensity, which impacts their level of vulnerability. It is therefore essential that
countries tailoring interventions to vulnerable groups conduct the necessary research, so that any
implemented interventions effectively address the varied needs of the members within the
vulnerable populations. Countries must know the size of these populations, the spectrum of
heterogeneity within a population, the members’ whereabouts, motivations and context of their
experiences.
The examples of promising intervention primarily come from GLIA countries, but some are
taken from other countries due to their innovative character or specific merit. Please note that
the examples may not have been formally assessed, and the adoption or scaling–up of the
presented interventions may therefore require a formal evaluation.
Male circumcision has already been mentioned as a promising intervention in the chapter on the
epidemiology of HIV in GLIA countries. Three large randomized controlled trials of MC were
halted when interim analyses showed very significant reductions in HIV infection among men
who received the intervention. 167 168 169 Using the trial results, and modeling the population
impact under plausible assumptions suggests that MC could have a population-level impact
equivalent to an intervention that reduces transmission by 37% in both directions (male to
female and female to male) – for example, equivalent to a one-shot vaccine with life-long
protection and efficacy of 37%. 170 This modeling suggests that increased coverage of MC in
SSA could prevent as many as 2 million HIV infections over ten years. 171 Moreover, the costeffectiveness analysis by Kahn et al. indicates that MC could be so cost-effective as to be
actually cost-saving. 172 The protection of MC may be partially offset by increased HIV risk
behavior, or “risk compensation,” especially reduced condom use or increased numbers of sex
partners (risk compensation occurs when individuals adjust their behavior in response to
perceived changes in their vulnerability to a disease 173). Risk compensation may be especially
important for MC because avoiding the sexual dissatisfactions of condom use and the desire to
have more sex partners may be significant motivations for men to seek circumcision. 174 Recent
data from Kenya suggest that MC does not increase risky behavior, and may lead to a transient
167
Auvert B et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV
infection risk: The ANRS 1265 Trial. PLoS Med 2: e298. doi:10.1371/journal.pmed.0020298
168
Bailey RC et al. (2007) Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized
controlled trial. Lancet 369: 643–656.
169
Gray RH et al. (2007) Male circumcision for HIV prevention in Rakai, Uganda: A randomized trial. Lancet 369:
657–666.
170
Williams BG et al (2006). The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS
Medicine, 2006: 3. e262. doi:10.1371/journal.pmed.0030262
171
Ibid.
172
Kahn JG et al. (2006) Cost-effectiveness of male circumcision for HIV prevention in a South African setting.
PLoS Med 3: e517. doi:10.1371/journal. pmed.0030517
173
Pinkerton SD (2001) Sexual risk compensation and HIV/STD transmission: Empirical evidence and theoretical
considerations. Risk Analysis 21: 727–736.
174
Westercamp N, Bailey RC (2006) Acceptability of male circumcision for prevention of HIV/AIDS in subSaharan Africa: A review. AIDS Behav. Epub 20 October 2006. doi: 10.1007/s10461-006-9169-4
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
66
decrease, 175 and modeled outcomes suggest that “risk compensation would have to be at
extremely high levels to counteract the protective effect of male circumcision at community
level”. 176 Several researchers working on MC emphasize that any scaling-up of MC will need to
incorporate effective risk reduction counseling and that monitoring risk behaviors in
communities where MC is scaled up is essential. Williams et al (2006) conclude that the greatest
benefit can be expected where HIV prevalence is high, MC is low and populations large; that
MC should start with young men, then middle aged men then children; and that we must find
ways to target high risk men with MC.
6.1 TARGETING TRUCKERS AND OTHER VULNERABLE POPULATIONS IN TRANSPORT
CORRIDORS
Truck drivers are eminently visible and relatively easy to reach during their occupational and
leisure activities. Targeting HIV prevention and care programs to truck drivers thus does not
pose the same challenges as other groups.
Inclusive programming has been found to be a critical success factor – addressing the needs of
truckers and the needs of the communities in the high transmission area, partners at home,
adolescent girls and boys from surrounding areas and itinerant traders. 177 For example, Morris &
Ferguson estimated there to be approximately 8,000 FSWs at 47 truck stops between Mombasa
and Kampala sites, and that 3,200-4,148 new primary infections would occur on the highway in
one year among FSW and transport workers (demonstrating the continued role of core
transmitter groups in fuelling the epidemic). 178 The authors point out that 2,056-2,713 new
infections could be averted if condom use increased from the current level of 78% to 90% in
these high risk contacts.
Pilot projects targeting truckers were implemented in Burundi, Rwanda, Tanzania and Uganda
by the GLIA between 1999 and 2001. A review of these projects in 2001 recommended a
harmonized approach in HIV prevention and care for transport workers, consistency in IEC
messages, continuity of services, and availability of condoms along road axes.
The Northern Corridor is now the focal point of joint efforts to improve working conditions for
the drivers who use it. An initiative has been agreed by the International Transport Workers’
Federation (ITF) and organizations including the Kenya Long Distance Truck Drivers’
Association (KLDTDA), Uganda’s Amalgamated Transport and General Workers’ Union
(ATGWU), Uganda Long Distance and Heavy Truck Drivers’ Association and the
Communications and Transport Workers’ Union of Tanzania. Their objectives include the
removal of tedious clearance procedures at border posts, which foster excessive delays and
corruption, and collaboration to ensure terms and conditions of service are improved upon and
that members’ human and working rights are respected. Interventions to speed up the time it
takes to cross border posts can include increasing capacity, having combined customs duties
(rather than a separate exit and entry procedure), and streamlining the paperwork necessary to
bring people and goods across borders, especially within economic development zones. Malaba
recently became Africa’s first one-stop border post for rail cargo.
175
Agot KE et al. (2007). Male circumcision in Siaya and Bondo Districts, Kenya: Prospective cohort study to
assess behavioral disinhibition following circumcision. J Acquir Immune Defi c Syndr 44: 66–70.
176
Nagelkerke N et al. Modelling the Effect of Male Circumcision on the HIV epidemic in Africa.
177
IOM (2005). HIV and mobile workers: a review of risks and programs among truckers in West Africa.
IOM/UNAIDS.
178
Morris CN & Ferguson AG (2006). Estimation of the sexual transmission of HIV in Kenya and Uganda on the
trans-African highway: the continuing role for prevention in high risk groups. Sex Transm Infect, 82:368-371.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
67
The Safe-T-Stop programme launched in transport corridors in Kenya and Tanzania is designed
to reduce HIV transmission, improve care for PLHIV, and mitigate the impact of AIDS in
communities frequented by truckers and other mobile populations. The cluster model pioneered
by the ROADS 179 program promotes collective action by small, sustainable, community-based
organizations with similar focus and interests. The program has trained private pharmacists and
drug shop operators in the sites to provide quality HIV services, including referral and
counseling for ART, as well as peer educators, theatre performers and home-based care
volunteers. It has also promoted and distributed insecticide treated nets to households of PLHIV,
as part of the initiative’s drive to integrate essential non-HIV services into programming,
including malaria prevention, family planning and alcohol treatment. 180 ROADS continues to
take a regional leadership role in linking alcohol and HIV programming. In Busia, Kenya, the
PLHIV cluster has established an Alcoholics Anonymous chapter that meets weekly to discuss
substance abuse and other issues, including adherence to ART. In Mariakani, women who brew
mnazi are participating in primary prevention and discussions addressing the link between HIV
transmission and alcohol abuse. Their enthusiastic response has surprised community members,
who previously thought brewers would be reluctant to participate. The brewers are being
trained as peer leaders, promoting condoms in their informal establishments, and referring
customers and peers for HIV counseling and testing, care and treatment.
In Uganda, ATGWU and Uganda Railway Workers Union have been implementing a joint
UNAIDS-funded HIV/AIDS project for truckers. 181 They also target the crews of trains and
ships, other transport workers, and sex workers at truck stopovers. Activities carried out by the
project include workplace policy development and sensitisation seminars; community awareness
campaigns; counselor training; peer education; negotiations for better work conditions; and
social marketing of condoms. The project involves trade unions, employers and the government
in the interventions. Lessons learned: (a) to reach FSW, it is helpful to involve local authorities;
(b) truckers can be reached more easily at their workplaces than at stopovers; (c) using peer
educators helps to reach the target groups more easily; (d) establishing counseling centers,
liaison offices and facilities at truck stopovers is effective.
The Kenyan Railway Workers’ Union has successfully implemented employer-supported peer
counseling in the work place. There is strong evidence from GLIA countries and elsewhere, that
peer education programs among truck drivers are successful. 182
179
ROADS (Regional Outreach addressing AIDS through Development Strategies) is a regional 5-year program
funded by USAID.
180
In July 2006, the East, Central and Southern Africa Health Community Secretariat in partnership with the
ROADS project conduct a rapid three-country assessment (Kenya, Rwanda, Zambia) of legal and regulatory issues
related to alcohol, the impact of alcohol abuse on HIV prevention and treatment, and country-specific strategies to
mitigate the impact. Findings underscored the severe impact of alcohol abuse on all aspects of HIV programming as
well as the disconnection between AIDS and alcohol treatment efforts. In March 2007, the ECSA Technical Experts
Group—mandated to make policy recommendations to regional governments—reviewed the findings in Arusha,
Tanzania and developed key resolutions. These were presented to and adopted by the health ministers. The
resolutions instruct countries to establish working groups on alcohol and HIV within their multisectoral AIDS
programs. ECSA is establishing a Task Force to support countries in this effort. Source: ROADS Signs - Recent
highlights from the ROADS project, May 2007.
181
Ouma NM et al. (2002). HIV/AIDS prevention and care for transport workers in Uganda. Int. Conf AIDS. 2002
Jul 7-12; 14: abstract no. ThPeF8071.
182
Jackson DJ et al. (1997). Decreased incidence of sexually transmitted diseases among trucking company workers
in Kenya: results of a behavioral risk-reduction program. AIDS, 11:903–909. Laukamm-Josten U et al. (2000).
Preventing HIV infection through peer education and condom promotion among truck drivers and their sexual
partners in Tanzania, 1990–1993. AIDS Care, 12:27–40. Walden VM et al. (1999). Measuring the impact of a
behavior change intervention for commercial sex workers and their potential clients in Malawi. Health Educ Res,
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
68
Kenyan truckers passing through Malaba on the border with Uganda can now take advantage of
a recreation office set up by ATGWU in 2006. 183 Initially funded by the American Solidarity
Center, it has provided a desperately needed facility for relaxation, and community relations
have been boosted by drivers and uniformed service personnel jointly making use of this facility.
Also in Malaba, the ATGWU is supporting four peer counseling community associations. 184
The South African road-freight industry initiative ‘Trucking Against AIDS’, launched in 1999,
has established 10 roadside wellness centers and also runs two mobile roadside centers. 185 They
provide awareness education, condoms, and treat or refer patients. The intervention is financed
jointly by the employees (in the form of a levy) and employers contributing an equal percentage,
based on the number of employees employed in each company. The agreement between the
Road Freight Employers’ Association and the Transport Ministry is enforceable by law.
Wellness centers are one of the most effective ways of dealing with HIV/AIDS in the transport
sector. 186 Many transport unionists feel they have the potential to be the cornerstone of efforts to
fight HIV/AIDS amongst transport workers. Some wellness centers are currently part of
tripartite agreements, others are donor initiatives but implementation is done in cooperation with
the unions. Because of limited funding they usually consist of little more than a shipping
container or a room set aside in a union office with a nurse. Condoms and literature are
distributed, and confidential testing and counseling for HIV is offered, as well as treatment for
STIs, OIs and minor injuries. There is great potential to scale up this intervention, and to situate
more such wellness centers strategically where transport workers congregate, such as at border
posts, ports, railway compounds, ferry terminals, seafarers' centers and other transit hubs.
The Ugandan ATGWU has successfully developed a HIV/AIDS workplace policy. 187 The union
has been able to include the HIV/AIDS policy in different collective bargaining agreements, and
insists that the HIV/AIDS workplace policy is included in all collective bargaining agreements
wherever they are organized. Collective agreements can also be very useful regarding the
adoption of HIV/AIDS policies by smaller transport companies. If a small company is part of an
employer’s association, it is bound by industry decisions. 188
In Uganda, the ATGWU and Uganda Railway Workers Union (URWU) are implementing a
UNAIDS-sponsored project to take accessible information to transport workers all over the
country. 189 Eight ‘traveling AIDS counselors’ run awareness-raising seminars, visiting different
sites such as railway stations, union offices, and truck stops, and women and children living in
nearby communities. Following the seminars, the counselors talk in confidence to workers who
come forward, and arrange tests for workers who decide they would like to know their status.
They leave boxes of condoms for workers to take away. The project also runs four community
based drama groups which take awareness-raising drama shows into workplaces and
communities.
14:545–554. Leonard L et al. (2000). HIV prevention among male clients of female sex workers in Kaolack,
Senegal: results of a peer education program. AIDS Educ Prev, 12:21–37.
183
http://www.itfglobal.org/transport-international/ti25-kenya.cfm, accessed 22 oct 2007.
184
http://www.itfglobal.org/HIV-Aids/agenda1-hwy.cfm
185
http://www.itfglobal.org/transport-international/ti22struggle.cfm, accessed 24 oct 2007.
186
ITF: HIV/AIDS – Transport workers take action.
187
http://www.itfglobal.org/transport-international/ti22struggle.cfm, accessed 24 oct 2007
188
http://www.itfglobal.org/files/seealsodocs/324/hiv%2Daids.pdf
189
http://www.itfglobal.org/transport-international/counselors.cfm
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
69
The Zimbabwean Council of Trade Unions (ZCTU) recognized the problems facing drivers, and
campaigned for truck drivers to be allowed to take their wives, other family members or
companions along with them when they traveled. This was legislated in Zimbabwe, and is highly
beneficial, apart from preventing the usual long separation of drivers from their families, having
a companion helps a driver concentrate on long trips.
A promising intervention for high transmission areas, where STI treatment services are often
sub-optimal, is the promotion of pre-packaged therapy for syndromic STI treatment. 190 A team
in Uganda developed the “Clear Seven” kit for management of urethral discharge in men. The
kit contains ciprofloxacin, doxycycline, condoms, partner referral cards and an instruction
leaflet, and is socially marketed at clinics, pharmacies, and retail drug shops. The study found
that “Clear Seven” users had significantly higher self reported cure rates than controls (84% v
47%), greater compliance (93% v 87%), and increased condom use during treatment (36% v
18%).
The research methodology used in the Northern corridor merits mention as a powerful approach
to inform the design of a project targeting transport workers and other population groups in high
transmission areas. A suite of techniques was used, including FSW diaries for measuring the
volumes and characteristics of transactional sex, 191 GIS mapping of the elements of each ‘hot
spot’ on the highway, 192 a census of overnight trucks and bar patrons to establish the dimensions
and character of the client population at each spot, focus group discussions among sex workers
and truckers to bring out local and contextual issues, and a survey of each bar and lodging
mapped to gather information on clientele, volumes of alcohol sold and availability and costs of
condoms. Such a comprehensive study can yield high-quality information on sensitive behavior
that provides important evidence to inform HIV intervention design.
6.2 TARGETING FISHERMEN AND FISHING COMMUNITIES
The impact of AIDS in fishing communities goes beyond that of ill-health and mortality.
Premature death robs fishing communities of the knowledge gained by experience and reduces
incentives for longer-term and inter-generational stewardship of resources. 193 Seeley & Allison
(2005) 194 review the situation of fishing communities in the era of AIDS and conclude from the
available evidence that “fisherfolk will be among those untouched by planned initiatives to
increase access to anti-retroviral therapies in the coming years; a conclusion that might apply
to other groups with similar socio-economic and sub-cultural attributes, such as other seafarers,
and migrant-workers including small-scale miners, and construction workers”. Interventions are
needed to address these factors.
190
Jacobs B et al. (2003). Social marketing of pre-packaged treatment for men with urethral discharge (Clear
Seven) in Uganda. Int J STD AIDS, 14:216–21.
191
Ferguson AG et al. (2006). Using diaries to measure parameters of transactional sex: an example from the TransAfrica highway in Kenya. Culture, Health & Sexuality, 8(2):175-185.
192
Ferguson AG et al. (2007). Mapping transactional sex on the Northern Corridor highway in Kenya. Health &
Place, 13, 504-519.
193
Allison EH & Seeley JA (2004). HIV and AIDS among fisherfolk: a threat to 'responsible fisheries'? Fish and
Fisheries 5 (3), 215–234.
194
Seeley JA & Allison EH (2005). HIV/AIDS in fishing communities: Challenges to delivering antiretroviral
therapy to vulnerable groups. AIDS Care, 17(6):688 – 697.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
70
Despite growing evidence that AIDS has a serious impact on fishing communities in the GLR,
research and interventions have lagged. Where some action is being taken, it is usually smallscale, and addresses different aspects of the impact of the epidemic: 195
•
Junior farmer field and life schools for orphans and vulnerable children in
fishing/farming communities in western Kenya
•
Community initiated safety nets – local fishing crew associations and Beach
Management Units donating a proportion of their daily catch to support orphans’
education (Lakes George and Edward, Uganda)
•
Provision of primary health care services to mobile fishermen (Tanzania, DRC)
•
Provision of nutritional and positive living support for orphans and PLHIV (Lake
Victoria, Uganda).
Other countries have implemented workplace-based prevention in seafood companies
(Namibia), BCC activities with peer educators in fishing communities (Republic of Congo,
Benin, Ghana), saving schemes for vulnerable women and girls in fishing communities
(Republic of Congo), and small-scale aquaculture for PLHIV (Malawi). A few government
ministries are beginning to develop interventions aiming at impact-reduction for their fisheries
sector.
The literature review revealed that Kenya addressed important information gaps in the fishing
sector. A study designed by the Ministry of Livestock and Fisheries Development (MoLFD)
analyzed the impact of HIV/AIDS in the fishing sector and assessed how the government could
respond. 196 The MoLFD had established an AIDS Coordinating Unit (ACU) in 2003, which had
developed a draft Strategic Plan, but its operation had been seriously constrained by dearth of
funds, weak technical expertise in strategic planning and monitoring & evaluation, and lack of
information on potential partners.
Some of the interventions recommended by the MoLFD study:
• Set up a technical working group of Ministerial ACU and stakeholders from the public,
private and NGO sector
• Develop fisheries sector-specific HIV/AIDS workplace policy and strategic plan of
action
• Mobilize funds in all concerned sectors (shipping companies, fish processing plants, etc)
for implementing interventions
• Mainstream HIV/AIDS into the policy agenda of the fisheries sector
• Do epidemiological and ethnographic research in the different occupational groups
involved in fisheries (boat owners, fishermen, fish processors, fish sellers) to provide
data disaggregated by HIV status, socio-demographic and behavioral characteristics
• Train fisheries officers on HIV vulnerability and risks of men and women living in
fishing communities
• Undertake broad mobilization of stakeholders working with fisherfolk and operating in
fishing zones in order to use them as entry points for interventions – e.g. beach
management units, local government, NGOs, CBOs
195
FAO. Impact of HIV/AIDS on fishing communities. Policy brief.
MoLFD (2004). Study on the impact of HIV/AIDS on fishing in Kenya and how the MoLFD can respond. Final
report.
196
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
•
71
Increase IEC and BCC activities in fishing communities.
HIV Prevention among mobile populations in the Greater Mekong Sub-region found that any
intervention targeting fishermen needs to carry out formative research to determine the type of
fishermen and their travel patterns, in order to design appropriate activities. 197 Research should
cover the major ports they visit and their home ports, and include the extended community. In
some larger ports, integrated program should be considered to address HIV prevention and
mobile groups.
6.3 TARGETING MILITARY AND OTHER UNIFORMED SERVICES
In cases where the military has higher HIV prevalence levels, several aspects of operational
efficiency will be influenced: additional resources are needed for recruiting and training soldiers
to replace those who have fallen ill or died, and for providing health care for sick soldiers. There
may be increased absenteeism, reduced morale and heavier workloads. Risks in caring for
injured soldiers and securing blood supplies during military operations become concerns. In
addition, AIDS is generating political and legal challenges for civil-military relations over how
to deal with HIV and AIDS in the ranks and how to treat PLHIV. 198
HIV levels in armies depend on many factors including the demographics of the army, its pattern
of deployment, the nature and stage of the epidemic in the country, and the measures taken to
control the disease by the military authorities. Several authors have suggested that the greatest
risk may occur in a post-conflict phase, demanding special attention to minimizing HIV risks
during post-conflict rehabilitation, but this analysis has not found evidence to support this
suggestion.
Because of their command and control structures, uniformed services are uniquely placed to
integrate HIV prevention, care and treatment services into their system. Studies of military
personnel have found that only 17% had been exposed to interpersonal communication. Radio
was the most frequently used mass media (76%) in Burundi, whilst in the DRC only 16% had
participated in HIV educational/sensitization session at the work place in the last six months.
Radio use was almost universal (98%).
As the impact of HIV infection has become more evident, increasing numbers of military
hierarchies have developed prevention and care programs. Between March 1995 and December
1996 a first-ever global survey was conducted by the Civil-Military Alliance (CMA) and
UNAIDS in order to document military HIV/AIDS policy and programs on prevention and care.
The survey found that some armies offered comprehensive programs, but others only conducted
a minimum of prevention activities (see box on following page). The published survey report
disaggregated data by region but not by country.
Ghana, Eritrea, Ethiopia and Indonesia have made the condom pouch a required part of their
equipment belt of every serving soldier. Condom provision has been accompanied by HIV/AIDS
awareness and sensitization programs.
197
Asian Development Bank & UNDP (2002). Toolkit for HIV prevention among mobile populations in the greater
Mekong Sub-region. http://www2.unescobkk.org/hivaids/FullTextDB/aspUploadFiles/toolkit1_eng.pdf
198
Elbe S (2003). The Strategic Dimensions of HIV/AIDS, Adelphi Paper for the International Institute of Strategic
Studies, Oxford: Oxford University Press.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
72
International Survey of HIV/AIDS prevention and control programs in regular armed forces (CMA/UNAIDS)
In this survey, responses of 17 of 35 contacted countries of the AFRO Region were available. All of the responding
militaries reported efforts to provide prevention education and 71% had formal policies for prevention
education/information. Group briefings (94%, mandatory in 53%) and pre-deployment IEC (94%) were the most
commonly employed educational methods. Only 59% provided briefings in the immediate post-deployment period,
when troops may be at greater risk of acquiring or transmitting HIV. The survey also found that 94% of the 17
militaries distributed condoms for free, 73% had a written plan for condom provision, and 71% had a written plan
for condom promotion. Concerning HIV testing and counseling, 38% of the 17 militaries had a HIV testing policy
and 94% had some type of military HIV testing (81% mandatory testing – mostly during recruitment, some prior to
deployment; and 88% VCT). In 14% of the militaries, recruitment was denied to HIV positive people, and in 82%
foreign deployment was excluded if positive.
Based on the survey results, it was concluded that “many military prevention programs can be improved through
post-deployment briefings and proactive interventions involving education, condom distribution, and counseling
combined with testing. Mandatory testing is often inconsistent with stated goals, and AIDS care policies may strain
military budgets. Testing based on benefit-cost assessments may increase efficiency in military HIV control.
Military budgets may benefit from greater civil /military cost sharing in AIDS care.” 199
UNAIDS considers peer education to be a highly effective approach to achieve behavior change
by uniformed services personnel. In collaboration with FHI, UNAIDS published in 2003 a peer
education kit for uniformed services that can be used in training peer educators and by the peer
educators themselves. 200
The Uganda People’s Defence Force (UPDF) has been running HIV/AIDS awareness programs
since 1989 based on three objectives, 201 which follow the national guidelines:
• Prevention of further transmission, through health education, raising awareness,
sensitisation seminars, film shows, lectures and discussions
• Mitigation of the impact of HIV/AIDS on those who have contracted HIV, through pretest, post-test and on-going counseling and home care
• Capacity building in program management, with central planning directed from defence
headquarters at Bombo and programs implemented at division level by army doctors and
health educators
• Attachment of a health educator to each battalion to oversee the HIV/AIDS awareness
program in the field. Film shows were considered to be especially effective.
USAID funds a project for soldiers’ wives in Mubende. The UPDF is expected to benefit from a
Community – Resilience - Dialogue Project operated in sixteen districts by a consortium of
donors led by the AIDS Information Centre. An HIV/AIDS Working Group has been established
with the UPDF, funded and supported by USAID, to look at the special needs of the Ugandan
military.
The global ‘Uniformed Services Task Force’ spearheaded by FHI, comprises the U.S.
Department of Defence, the Futures Group, the Naval Health Research Center, PSI, UNAIDS
and USAID. This task force develops tools to assist national and civil defences, identifies and
199
Yeager RD et al. (2000). International military HIV/AIDS policies and programs : strengths and limitations in
current practice. Int. J. AMSUS, 165(2):87-92.
200
http://data.unaids.org/Publications/IRC-pub05/JC928-EngagingUniServices-PeerEd_en.pdf
201
International Crisis Group (2004). HIV/AIDS as a security issue in Africa: Lessons from Uganda. ICG Issues
Report no 3, Kampala/Brussels.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
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shares best practices and has defined the following elements of comprehensive uniformed
services programs:
• Advocacy to garner support for HIV/AIDS programming amongst the highest ranks
• Qualitative research to develop a clear picture of the unique sub culture in the military
• Basic and in-service HIV/AIDS training for all recruits and personnel; peer education
and other communication activities that speak the language of the barracks; condom
demonstration, distribution and promotion; quality VCT; strong STI diagnosis and
treatment services; care and support for HIV-affected personnel and dependents
• Monitoring and evaluation of these activities.
In Cambodia’s Kompong Chhnang Province, a drop in HIV prevalence from 4% to 0.65% is
attributed to overlapping interventions:
• Peer education and condom distribution for the uniformed services
• National 100% condom policy which seeks to enforce condom use in all commercial sex
establishments.
PSI’s interventions for preventing HIV/AIDS in the military emphasize the following: 202
• BCC promoting partner reduction, correct and consistent condom use, knowing one’s
HIV status through VCT, increased self-risk perception and reduction of stigma towards
PLHIV
• Research activities to refine and appropriately target communication messages (e.g.
focus group discussions collecting information on how soldiers think and act)
• Hosting video and mobile video unit presentations
• Training peer educator on communication techniques, prevention methods, clinic
referrals, and creating peer education clubs to support the educators
• Condom supply to bases, bars and retail outlets convenient to military bases
• Establishing VCT centers for the military and their families
• Building the military’s capacity to implement HIV/AIDS interventions by working with
ministries of defence, the leadership of the uniformed services and local NGOs
PSI/DRC increased condom use and reduced multi-partnering among the military in Camp
Kokolo, the nation’s largest military base. It established condom wholesalers in five additional
military and police camps, making the product readily available throughout the large camps.
PSI/Togo’s ‘Operation Haute Protection’ targets the soldiers living on the four largest military
bases and their dependents. After one year of implementation, a BSS revealed that the percentage of married soldiers reporting condom use with their regular, non-spouse partner increased
from 8% to 60%.
In Kenya, concern about low support of male partners of the PMTCT intervention led to the
introduction of PMTCT services in the Kenya Armed Forces Medical Service. 203 This example
shows that a national agenda for HIV prevention in the civilian, general population can harness
the military sector to pursue its program aims, and that collaboration between civilian and noncivilian health programs can be fruitful.
Interventions:
202
PSI (2004). A new kind of war. PSI arms African militaries against AIDS. PSI Profile, February 2004.
Ekesa OI et al. (2004). Increasing access to PMTCT services through workplace facilities – experiences from the
Kenyan Armed Forces medical Services. XV Int. AIDS Conference, abstract no. ThPeB7052.
203
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
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•
•
74
Training civilian and non-civilian nurses on PMTCT package (counseling, testing, infant
feeding counseling, provision of NVP)
Providing required consumables for PMTCT service delivery at each duty station
Community mobilization that includes IEC on PMTCT at soldiers meetings and door-todoor visits in barracks.
6.4 TARGETING REFUGEES, INTERNALLY DISPLACED PERSONS AND RETURNEES
Between 1993 and 2003, the average duration of refugee situations has significantly increased,
from nine years to 17 years. 204 Refugees are dependent on the host country government and
surrounding population, and where necessary, humanitarian agencies for essential needs
including health care. In many situations, the majority of refugees never live in camps but seek
assistance and shelter directly from host populations. Until now, however, most of the HIVprevention activities have been directed to camp populations. Innovative interventions are
needed to give refugees and IDPs outside camps access to minimal services.
When conflict and forced displacements occur, it is more effective and efficient from a public
health and program perspective to deal with the HIV-related needs of the populations affected by
the displacement (refugees, IDP and host populations) in an integrated fashion, preferably under
the umbrella of the national aid strategy. 205 This approach ensures that the refugees receive the
HIV-related assistance they need. It also ensures that local populations do not suffer from the
displacement around them. Due to the displacement cycle of refugees, sub-regional planning
processes are crucial to ensure coordination among countries, as well as the continuity of
prevention and care for local populations, refugees and returnees. Integrating humanitarian and
development funding for HIV-related services for refugees and surrounding populations benefits
both populations because it provides improved and more efficient service delivery and makes
programs more sustainable.
Integrating refugee issues into National Strategic Plans and other national HIV and AIDS
policies and plans helps achieve the following benefits (UNAIDS/UNHCR):
• Helps gain access to additional resources
• Avoids creation of parallel services and systems, while reducing costs of health services
for local populations and refugees
• Improves local health-care services
• Removes barriers to providing services, including antiretroviral therapy
• Reduces discrimination and stigma
Collaboration between civil society organizations: In Kibondo refugee camp in Tanzania,
Stop AIDS, a local organization formed by refugees, linked up with the Tanzanian Service
Health and Development for People Living with HIV/AIDS—a group within the local host
population—to provide HIV awareness and education to both refugees and the surrounding
community. The groups’ efforts included providing education prevention activities and
programs to secondary schools, as well as to youth and adolescent groups as part of out-ofschool activities. The two groups also worked together to organise joint concerts and mass
204
UNHCR (2004). Protracted refugee situations, standing committee 30th meeting. EC/54/SC/CRP.14. Geneva, 10
June 2004.
205
UNAIDS/UNHCR. Strategies to support the HIV related needs of refugees and host populations. UNAIDS Best
Practice Collection.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
75
campaigns in schools and public places, where members spoke publicly and helped to educate
audiences on issues involved in living with HIV.
Collaboration between UNHCR and Government Programs: In Uganda, UNHCR designed
its HIV services to work in conjunction with Uganda’s National Strategic Plan. In Kyangwali
and Palorinya settlements, the programs developed were aimed at expanding and strengthening
VCT services and PMTCT for refugees and host nationals. Eight static sites provide confidential
VCT throughout the settlements, supported jointly by the government and UNHCR. Several
post-test clubs have been established and equipped to sensitize both refugee and surrounding
host populations on HIV prevention and care through the use of music, dance and drama. In
addition to HIV programs, treatment of OIs and STIs and other related health services have been
provided by the Government of Uganda and UNHCR to refugees and host country nationals.
The World Food Programme has provided nutritional assistance to host country nationals and
refugees living with HIV.
Integration of refugee issues into the MAP: In 2003, as the DRC was discussing a MAP
project with the World Bank, UNHCR raised the possibility of including refugee issues in the
DRC proposal. It was decided that UNHCR would become a partner, and refugee issues would
be included in the MAP proposal. UNHCR started implementing additional HIV activities in
selected refugee, IDP and returnee settings in 2005. Specific activities are BCC, condom
distribution and education, universal precautions and blood safety, VCT, PMTCT, treatment of
STIs and OIs, and the possible introduction of ART.
From 1996 to 2000, CARE Rwanda implemented an HIV/STI prevention project with peer
educators and health animators, targeted at Rwandan returnees. The project resulted in
significant increases in knowledge and use of STI services, including condom use. A major
conclusion was that more funding was required to support the volunteer health animators, for
whom the dropout rate was 20%. 206
In Angola, UNHCR found that HIV discrimination against returnees was high and consequently
embarked on advocacy activities to dispel misperceptions that returnees necessarily have high
HIV infection rates. 207 This led to an agreement with the government that the right of return
would not be influenced by HIV status. Comprehensive plans to strengthen HIV/AIDS programs
in camps and in Angola were developed and funded. In Angolan returnee reception centers,
basic HIV/AIDS education, condom promotion and peer education were reinforced. UNHCR
concluded that advocacy must occur during early stages of voluntary repatriation to ensure that
refugee/returnee HIV status does not influence right of return. Angolan returnees included
trained personnel who could benefit Angola if their credentials are recognized and linkages with
local programs are made. UNHCR also found that targeted HIV/AIDS interventions should be
integrated into voluntary repatriation programs at the onset of planning among partners in host
countries and the country of origin; that cross-border communication and coordination are
imperative; that HIV programs in areas of return must be integrated and provided to all persons
(e.g. non-displaced, displaced, and returnees) to be effective and to minimize discrimination.
Cross-border coordination is of specific relevance for ART continuation.
206
CARE Rwanda (2000). HIV/STD prevention among the returnee and resettles population of Gitarama, Rwanda,
1996-2000. In: Proceedings of conference 2000: Findings on reproductive health of refugees and displaced
populations. Washington D.C.: Reproductive Health for Refugees Consortium. December 2000.
207
Bruns LC et al. (2004). Strengthening HIV/AIDS interventions during voluntary repatriation: the Angolan
experience. Int Conf AIDS, abstract no. D12646.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
76
Humanitarian Charter and Minimum Standards in Disaster Response (the Sphere Project, 2004) 208
Current humanitarian standards include a minimum package of services to prevent transmission of HIV. People
should have access to the following essential package of services during the disaster phase:
ƒ free male condoms and promotion of proper condom use
ƒ universal precautions to prevent iatrogenic/nosocomial transmission in emergency and health-care
settings
ƒ safe blood supply; relevant information and education
ƒ syndromic case management of STIs
ƒ prevention and management of the consequences of sexual violence
ƒ basic health care for PLHIV.
Other priorities are: to broaden the range of HIV services during the post-emergency and rehabilitation phase; to
better involve the community, especially PLHIV and their carers, in the design, implementation, and M&E of the
program; to establish more comprehensive surveillance, prevention, treatment, care and support services including
ART; and to implement protection and education programs to reduce stigma and discrimination.
6.5 TARGETING PRISONERS
In the enclosed environment of prisons, it should be highly feasible to target HIV/AIDS
interventions at the incarcerated population. However, in practice, interventions face substandard or antiquated prison conditions where overcrowding, violence, inadequate natural
lighting and ventilation, and lack of room for confidential exchanges are the rule. When these
conditions are combined with inadequate means for personal hygiene, inadequate nutrition, lack
of access to clean drinking water, and inadequate medical services, it is clear that prison
environments generally do not provide conducive environments for HIV interventions.
Action to prevent the spread of HIV in prisons and to provide health services to PLHIV in
prisons is therefore integral to – and enhanced by – broader efforts to improve prison conditions.
There is a considerable knowledge gap in understanding the magnitude of the epidemic in
prison communities and its multiplier effect on the non-prison population in the region. Equally
scarce is information about interventions carried out by the correctional institutions to address
HIV/AIDS, and any ‘lessons learned’.
The report presented earlier about “the slow response to high HIV rates in Kenyan prisons”
attributes the deplorable situation in Kenyan prisons primarily to weak and outdated legislation.
In different countries, the power to change prison legislation, policy, and programs rests with
different authorities – in some cases the government, in other cases senior prison officials, and in
others, local prison management. 209
The following general principles for HIV/AIDS prevention and care in prisons promoted by
UNODC (2006) reflect the international consensus on effective prison management and the
ethical treatment of prisoners as defined in various international health, HIV/AIDS, and human
rights instruments.
208
http://www.sphereproject.org/component/option,com_docman/task,cat_view/gid,17/Itemid,26/lang,English/,
accessed 20 sept 2007
209
UNODC (2006). HIV/AIDS prevention, care, treatment and support in prison settings.
UNODC/WHO/UNAIDS.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
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General Principles for HIV/AIDS Prevention and Care in Prisons
1. Good prison health is good public health - The vast majority of prisoners eventually return to the wider
society, therefore reducing transmission of HIV in prisons is an important element in reducing the spread of
infection in society outside of prisons.
2. Good prisoner health is good custodial management - Protecting and promoting the health of prisoners
benefits the prisoners, and also increases workplace health and safety for prison staff.
3. Respect for human rights and international law - States have an obligation to develop and implement prison
legislation, policies, and programs consistent with international human rights norms.
4. Adherence to international standards and health guidelines - The standards and norms outlined in
established international human rights instruments and public health guidelines should guide the development
of responses to HIV/AIDS in prisons.
5. Equivalence in prison health care - Prisoners are entitled, without discrimination, to a standard of health care
equivalent to that available in the outside community, including preventive measures.
6. Evidence-based interventions - The development of prison policy, legislation, and programs should be based
upon empirical evidence of their effectiveness in reducing the risks of HIV transmission, and improving the
health of prisoners.
7. Holistic approach to health - HIV/AIDS is only one of many health care challenges facing prison officials and
prisoners. Efforts to reduce HIV transmission in prisons, and to care for PLHIVs, must be holistic and integrated
with broader measures to tackle inadequacies in general prison conditions and health care.
8. Addressing vulnerability, stigma, and discrimination - HIV/AIDS programs and services must be
responsive to the unique needs of vulnerable or minority populations within the prison system, and combat
HIV/AIDS-related stigma and discrimination.
9. Collaborative, inclusive, and intersectoral cooperation and action - While prison authorities have a central
role in implementing effective measures and strategies to address HIV/AIDS, this task also requires cooperation
and collaborative action that integrates the mandates and responsibilities of various local, national, and
international stakeholders.
10. Monitoring and quality control - Regular reviews and quality control assessments – including independent
monitoring – of prison conditions and prison health services should be encouraged as an integral component of
efforts to prevent transmission of HIV in prisons and to provide care for prisoners living with HIV/AIDS.
11. Reducing prison populations - Overcrowded prison conditions are detrimental to efforts to improve prison
living standards and prison health care services, and to preventing the spread of HIV infection among prisoners.
Therefore, action to reduce prison populations and prison overcrowding should accompany – and be seen as
an integral component of – a comprehensive prison HIV/AIDS strategy.
Countries are at different stages of development in implementing responses to HIV/AIDS in
prisons. This review found very few reports describing interventions against HIV/AIDS
conducted by penal institutions. A report from the Uganda Prisons Service gives a short account
of the Uganda Prisons AIDS Control Programme (UPACP) established in 1993. 210 The main
activities were IEC, drama and film shows, community campaigns, formation of AIDS concern
clubs, distribution of condoms, training of 2,000 inmates and staff in skills of care, support and
basic counseling, and training on ARV for health staff. VCT and laboratory capacity were built.
The UPACP noted in particular the challenges of providing a continuum of care on release, and
of reviewing the implemented interventions.
Active transmission of TB in overcrowded prisons, and high TB-related morbidity and
mortality in prisons, have repeatedly been mentioned as a concern. The GLIA countries have
some of the highest TB rates in SSA, with Kenya at 936/100,000 and Rwanda at 673/100,000
210
Kaddu M & Nabatanzi F (2004). HIV/AIDS management and control in the Uganda prison service. Int Conf
AIDS, abstract no. B10672.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
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being most affected. 211 A prison-based TB project in Malawi found that it is urgent to improve
tuberculosis control, including collection of health data, education of prisoners and clinical staff
about tuberculosis, active screening of prisoners for pulmonary tuberculosis by sputum-smear
microscopy, and active case-finding in the prisons.
6.6 TARGETING SEXUAL VIOLENCE AND AFFECTED FEMALES
Interventions addressing sexual violence against females face the challenge of dealing with a
hidden target population, and are confronted with a culture of silence around this human rights
violation.
Rwanda has the legal arsenal needed to combat many aspects of violence against women
effectively, and the country has put in place interventions to address GBV at community
level. 212 Resources come from UNIFEM, UNFPA, UNDP and others.
Interventions:
•
Community gender-based violence prevention clubs help raise awareness about the
problem of GBV
•
A free phone number has been instituted for households to call the police when someone
has been subjected to sexual violence. The police send the survivor to the hospital and
open a file. Accompanying measures are trauma counseling and other types of care for
rape survivors.
With the support of international partners like ECHO and UNICEF, Burundi is trying to deal
with the problem of GBV, effectively a human rights violation.
Interventions:
•
Special centers for victims of sexual violence aim to provide tailored support and
increase legal action against the perpetrators in order to fight the culture of impunity
surrounding sexual violence. So far, only very few survivors have requested support to
initiate legal action.
•
As part of a nationwide campaign against sexual violence, police and court officials are
receiving extra training, and one thousand social workers have been mobilised to raise
public awareness in grassroots sessions across the country.
In DRC, a program supported by UNICEF on sexual violence and exploitation has been
initiated. 213
Interventions:
211
•
Prevention of sexual violence through advocacy with warring factions responsible for
abuses
•
Development of community networks to protect women and children from violence, a
critical success factor, and provision of appropriate support to women
WHO Global Atlas, 2005 data. http://www.who.int/globalatlas/dataQuery/default.asp
http://www.unfpa.org/emergencies/symposium06/docs/daytwosessionfivebmukabalisa.ppt
213
Hiddleston T et al. (2004). Protecting women and children from sexual violence and exploitation in conflict. XV
Int. AIDS Conference, oral abstract.
212
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
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79
Training of health care workers which includes medical, psychosocial and forensic
elements, and on how to interview and provide post rape care for survivors (STI
treatment, PEP, etc.)
Kampala-based Raising Voices has formed the Gender-Based Violence Prevention Network,
now covering 17 countries. 214 The aim is to bridge the gap between the agendas of violencerelated organizations (who virtually ignore HIV) and HIV organizations (who often see violence
as ‘too feminist’ and complex), in order to arrive at a gendered response to common HIV
prevention interventions.
Interventions:
•
Campaign on the intersection of sexual violence and HIV to educate NGOs,
policymakers and decision makers
•
“Action and Advocacy kits” containing potential seminar and scheduling guidelines,
flyers and newspaper articles that people could submit for publication to local
newspapers
•
Community dialogues managed by regional organizations.
WE-ACTx is an international community-based initiative with the primary goal to increase
women’s and children’s access to HIV testing, care, treatment, support, education and training in
resource-limited settings at the grassroots level. WE-ACTx began working in Rwanda in early
2004 to provide HIV care to genocide rape survivors, in active partnership with the Rwandan
government and five local NGO partners. The project has demonstrated that providing HIV care
to survivors of genocidal rape requires integrating medical care with psychosocial support and
addressing barriers to care for these women, including poverty.
In Tanzania, the introduction of PEP for rape survivors in refugee camps has been piloted in
Kibondo camp. 215 PEP guidelines, policies and procedures were created and training provided to
health and community service officers together with community sensitisation. PEP was accepted
by all rape survivors, and 80% undertook HIV VCT. The introduction of PEP as a component of
post-rape care in refugee camps was subsequently tested and evaluated in five Tanzanian
sites. 216 The studies demonstrated that once PEP is available there is increased reporting by rape
survivors and that PEP encourages health care seeking after rape.
6.7 TARGETING FSWS AND THEIR CLIENTS
The data presented in sections 4.2 to 4.5 showed the clear linkage between FSWs and their
clients (who may include fisherfolk, truck drivers and the military). Yet, interventions for these
populations are scarce: the UNGASS reports of 2005 of Kenya and Tanzania comment, for
example, that:
•
214
Communication and advocacy programs have not effectively mainstreamed the rights of
vulnerable populations, including commercial sex workers (Kenya)
http://raisingvoices.org
Schilperoord M et al. (2004). Introduction of a pilot project for post-exposure prophylaxis for rape survivors in
refugee camps in Tanzania. Abstract XV International AIDS Conference, Bangkok [abstract no. D12533].
216
UNHCR (2005). Evaluation of the introduction of post-exposure prophylaxis in the clinical management of rape
survivors in Kibondo refugee camps Tanzania. Division of Operational Support, October 2005.
215
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
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80
Currently there are very few initiatives to prevent HIV among the risk groups (incl. FSW)
apart from very small scale NGO/CSO-driven interventions. The effectiveness of these
interventions is not well documented. A specific challenge is the marginalization of sex
workers, drug user and men having sex with men - these practices are against government
policies (Tanzania).
Integrated interventions could work well for these populations, as in the case study described
here:
“Taking It to the Streets”: Reaching truckers, sex workers, rural populations with mobile VCT
PSI programs are increasingly delivering VCT services through mobile and community-based means in order to
reach more people, especially high-risk populations. PSI and its partners implement mobile VCT interventions to
increase access to and demand for VCT among specific targets groups. For example, corporate VCT reaches men
at their workplaces in Mozambique, Zimbabwe and South Africa; branded vans in India target sex workers and
truckers; and tents serve rural populations in Lesotho, Swaziland and Zimbabwe. Mobile VCT is also used to
target mobile populations, including IDPs in Uganda and the military in Rwanda, Côte d’Ivoire and Zimbabwe.
Military personnel have been trained to perform the counseling and testing. South Africa and Swaziland work with
churches and faith-based organizations to provide mobile VCT. Côte d’Ivoire and Rwanda provide VCT in military
barracks and in health facilities. Mozambique and Swaziland partner with the Ministry of Health and deliver
satellite VCT services to rural health facilities. In Zimbabwe and Rwanda, VCT is provided at prisons, benefiting
both prisoners and prison officers. Counseling of sex workers takes place in locations such as brothels and
nightclubs instead of traditional health clinics, where risk of lifestyle-related stigmatization is higher.
PSI/Zimbabwe uses mapping technology in all provinces to identify high transmission areas (mines, commercial
farms, barracks, and prisons) and uses intensified interpersonal communication to create demand for VCT among
these populations.
PSI has found that demand for VCT is high and often exceeds delivery capacity. Referral systems must be in place
before implementing mobile services. Community-based partners can be trained to link clients to services through
post-test clubs and community-based clinics when the mobile team leaves the site. Mobile VCT helps target
underserved, high-risk target populations. The two main barriers to VCT use, geographic access and fear of
stigma, can be overcome by this intervention.
Source: PSI (2006). Taking it to the streets. Profile December 2006.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
81
7. CONCLUSIONS
This analysis set out to determine: On which populations should the GLIA focus, why and with
what type of HIV interventions? To answer this question, the HIV epidemics of the six GLIA
countries have been characterised; eight key vulnerable populations identified; their HIV
prevalence, risk, vulnerability, sexual behavior, mobility and exposure to violence documented
and quantified; and promising interventions for these populations found and described. What
remains, is to make firm recommendations on the sub-populations on which the GLIA should
focus, and with which type of HIV interventions.
The HIV epidemic is present in all countries in the GLR and some trends are emerging:
a) The HIV epidemics in the GLIA countries are all generalised. Transmission is mainly
sexual, there are distinct age patterns in infection (older males and younger females), and
prevalence is higher in urban than rural areas (in all 6 countries, urban prevalence is almost
double rural prevalence, except in Burundi, where urban prevalence is four times as high as
the rural prevalence).
b) There is also evidence that the epidemics are at least stabilising in Uganda, Kenya, Rwanda
and Tanzania (i.e. advanced epidemics); this is less clear for the epidemics of Burundi and
DRC (i.e. possibly early stage epidemics).
However, the HIV epidemics are heterogeneous between countries and within countries:
c) Despite all six GLIA countries having generalized epidemics, the epidemics are
heterogeneous across the countries, with estimated national prevalence ranging from 0.6%
(Zanzibar) to 7 % (Tanzania mainland).
d) IDU has been identified as an important driver of the HIV epidemic in some urban and
coastal centers of Kenya and Tanzania. However, IDU and other non-sexual transmission is
overall not a major driving factor of the epidemics in the GLIA countries.
e) Sexual behavior patterns of the general populations vary dramatically across the GLR (e.g.
the percent of people who report high risk sex varies from 8% to 82% – see Table 6), rates of
male circumcision also vary very widely (from 11% in Rwanda to 84% in Kenya).
f) The epidemic is also heterogeneous within countries in geographic distribution (sub-national
HIV prevalence ranging from 0% to 15%); and proportion of females infected (up to four
times higher than males in some sub-groups of the general population in the GLR).
The heterogeneity of the HIV epidemic in the GLR means that not all sub-populations
have similar HIV epidemiological trends or are at equal risk of HIV infection:
g) The results presented in the report clearly show that some sub-populations display higherrisk sexual behavior, are in mobile occupations, are in contact with persons in mobile
populations, or are exposed to violence and conflict, and as a result, have higher median HIV
prevalence than the general population in the GLR.
h) Eight such vulnerable and most-at-risk sub-populations were identified in this analysis:
military and other uniformed forces; long-distance truck drivers and other transport workers;
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
82
fishermen and fisherwomen; female sex workers; refugees and internally displaced persons;
prisoners; and females affected by sexual and gender-based violence.
i) The burden and relative size of these eight sub-populations, are not necessarily the same for
each GLIA country, for example: HIV burden attributable to sexual violence is highest in
Kenya, whilst there is a high burden of HIV among fishermen in Tanzania. The highest
number of people living with HIV in any of the eight populations in any country was
estimated among IDPs in Uganda.
These mobile populations are relevant and important for the countries of the GLR for a
number of reasons:
j) These eight sub-populations are relevant (to a greater or lesser extent) in the GLR for a
combination of reasons: the relative size of the sub-population size (7% of the overall GLR
population, and 12% of the total number of PLHIVs), the intensity of their higher-risk sexual
behaviors, their potential as a bridging population, their level and trends of HIV prevalence,
their mobility, the extent to which they interact with mobile persons, or the frequency with
which they are in contact with conflict and violence over which they have no control.
Interventions for some of the eight identified sub-populations have been defined in the
National HIV Strategic Plans of the 6 GLIA countries:
k) The 7 NSPs of the 6 GLIA countries (Tanzania has 2 national strategic plans: one for the
mainland and one for Zanzibar) present strategies targeted at many of the vulnerable
populations, as follows: military and other uniformed forces (in all 7 NSPs); long-distance
truck drivers and other transport workers (in 6 of the 7 NSPs); fishermen and fisherwomen
(in all 7 NSPs); female sex workers (in all 7 NSPs); refugees (in all 7 NSPs); internally
displaced persons (in 5 of the 7 NSPs); prisoners (in all 7 NSPs); and females affected by
sexual and gender-based violence (in 5 of the 7 NSPs).
l) Despite the fact that the NSPs present strategies for many of the eight vulnerable populations
in the 6 GLIA countries, data show that these strategies are sometimes too general, not
always based on evidence of ‘what works’ and that not all strategies are being implemented.
Therefore, there are specific interventions that the GLIA can implement in relation to
these vulnerable populations that will complement the efforts of the 7 NACs through the
implementation of the 7 NSPs.
m) Table 32 overleaf summarizes the reasons why the GLIA should focus on each subpopulation, as well as the types of interventions that would be recommended for each
vulnerable population.
FISHERMEN &
FISHERWOMEN
Size: 447,656
HIV+: 24.7%
PLHIV: 110,571
Number of NSPs
focusing on this
population: 7
Number of NSPs focusing
on this population: 6
PLHIV: 53,722
HIV+: 18%
Size: 298,458
TRUCK DRIVERS
POPULATION
Fishermen/women are highly mobile,
experience occupational dangers, alcohol
use, daily or seasonal cash income, culture
of hyper-masculinity, availability of
commercial sex in ports, system of ‘sex for
fish’, poor access to health care.
YES.
Despite consistently high HIV prevalence
among fishermen and fisherwomen in the
GLR, there has been relatively little
concerted action targeting fishing
communities. Due to the number of
fishermen and fisherwomen, their mobility
and accompanying behavior, they are an
important sub-population.
Truckers may have long periods of
separation from family, stress &
boredom/waiting time, frustrations & road
risks, easy access to alcohol & commercial
sex, disposable funds, macho culture, may
have ‘road wives’ and limited access to
health services.
Should the GLIA strategic plan focus on
this population (YES/NO)?
If YES, why? If NO, why not?
YES.
Long-distance truck drivers have been
targeted with interventions over many
years, but they remain among the high risk
groups. There is evidence that adolescents
living in communities along major transport
axes are at high risk of contracting HIV, and
that truck drivers are a possible bridging
population.
YES, in the short to medium term (next 24 months). High HIV
prevalence has been recorded in fishing communities for a
number of years, Yet, there is little evidence that IEC and BCC
activities have been tailored to their specific living context and
experiences, or that they have received specific attention.
Given that this is a relatively small population for each NAC
individually, NACs are less likely to spend time and effort on this
sub population. However, at a regional level this is a significant
population. This fact, combined with the fact that this analysis
has shown that the issues affecting these populations and their
HIV risk and vulnerability are similar across the 6 GLIA
countries, the GLIA could support the efforts of the 7 NACs by
implementing a series of evidence-informed pilot strategies, so
as to determine the most successful strategies for dealing with
these populations. All GLIA countries can then learn from these
experiences without having to reinvent the wheel.
The GLIA cannot oversee programs for mobile populations in
six countries indefinitely, given that each country is meant to
include all populations in their national HIV strategic plans.
However, given the little attention that this vulnerable group has
received in the past from national AIDS commissions (some
regional programs have been implemented, but frequently
efforts are not driven by NACs) and the need for uniform
interventions, the GLIA should fund HIV service delivery to this
group in the short to medium term (up to the next 24 months),
so that countries can learn ‘what works’ best before
implementing a minimum package of services for this group
themselves.
Should the GLIA fund HIV service delivery for this
vulnerable population (YES/NO)?
If YES, why? If NO, why not?
YES, in the short to medium term (next 24 months).
83
• Epidemiological and ethnographic research in different occupational
groups in fishing sector commissioned by the GLIA
• Sharing experiences of ‘what works’ in dealing with these populations
• Advocacy for the integration of HIV services for fishermen and
fisherwomen, mobile VCT and GBV counseling, and for custom-made
programs for these communities in each GLIA country
• Provision of HIV prevention, treatment and support services through
appropriate sub contractors, including training fisheries officers on
BCC for HIV, and developing communication materials that ‘speak the
language of the ports’
• Epidemiological and formative research to inform the design of
programs for truck drivers, commissioned by the GLIA
Interventions addressing the link between HIV and alcohol
consumption; peer educators in drinking places
Interventions to speed up border crossing procedures
o
o
Roadside wellness centers with VCT service
o
• Sharing of information by the GLIA on interventions that have worked,
e.g.
o Training private pharmacists to provide quality HIV and STI
services and referral
• Advocacy by the GLIA for identification of hotspots along all corridors
and for inclusive programming that ensures that the needs of truckers
and of the communities at truck stops are addressed
• Sub contracting of HIV service delivery to these populations in fixed
hot spots
What are promising interventions that should be considered for the
GLIA strategic plan?
Table 32. Vulnerable populations to target and promising interventions
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Number of NSPs
focusing on this
population: 7
FEMALE SEX
WORKERS
YES.
Paid sex is an important driver of the epidemic during early
and advanced epidemics, and data show various types of
paid and transactional sex.
YES.
When displaced populations (refugees, IDPs) are amongst
host communities and when they return home (returnees),
they are particularly vulnerable, but the view that they
inevitably have higher HIV prevalence needs to be
corrected. There is insufficient evidence that HIV
transmission increases in populations affected by conflict.
Due to their displacement cycle, sub-regional planning
processes are crucial.
Refugees have increased economic vulnerability
(particularly the young, elderly and sick), disrupted
social/sexual partnerships, may suffer from psychological
trauma, may have moved into a higher prevalence area,
may have poor access to health care.
YES.
IDPs lack a protection framework, have increased
economic vulnerability, disrupted social/ sexual
partnerships, may suffer from psychological trauma, may
have moved to a higher prevalence area, may have poor
access to health care.
REFUGEES
Size: 1,229,069
HIV+: 1.65%
PLHIV: 20,280
Number of NSPs
focusing on this
population: 7
IDPs
Size: 2,929,479
HIV+: 3.1%-6.7%,
depending on
country
PLHIV: 151,761
Number of NSPs
focusing on this
population: 5
Should the GLIA strategic plan focus on this
population (YES/NO)?
If YES, why? If NO, why not?
POPULATION
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
NO. Although female sex workers and
their clients remain important drivers of
the epidemic, the population is very
diverse in frequency of sexual partnering
and behaviors, places of operation,
socio-economic circum-stances, and HIV
exposure. Therefore, each country
should focus on this population
themselves with their own tailor-made
programs
YES, in the short to medium term (next
24 months). The sheer size of the
populations involved, and the
inexperience of national governments in
dealing with HIV prevention at IDP sites
mean that the GLIA has to play a leading
role, at least for the next 24 months as
countries learn how to implement
programs at IDP sites themselves
Should the GLIA fund HIV service
delivery for this vulnerable population
(YES/NO)?
If YES, why? If NO, why not?
YES, in the short to medium term (next
24 months). The sheer size of the
populations involved, and the
inexperience of national governments in
dealing with HIV prevention in refugee
sites mean that the GLIA has to play a
leading role, at least for the next 24
months as countries learn how to
implement programs for refugee sites
themselves
• Epidemiological, socio-cultural and socio-economic research and size
estimation studies in GLIA countries to gain a better understanding of women
involved in sex work and transactional sex
• Advocacy and policy dialogue for appropriate legislation, adequate and
accessible services for FSWs, and reduction in stigma and discrimination
towards FSWs
• Provision of HIV prevention, treatment and support services through
appropriate sub contractors
• Advocacy for integrating HIV services for IDPs and host populations,
including VCT and GBV counseling
• Advocacy for IEC/BCC interventions before, during and after repatriation, and
for uniform treatment, care and support policies in the GLIA countries
• Fostering collaboration between organizations of IDPs and host communities
• Operational research on the continuum of care - including ART - in the
displacement cycle, funded by the GLIA
• Operational research on the continuum of care - including ART - in the
displacement cycle, funded by the GLIA
• Fostering collaboration between organizations of refugees and host
communities
• Advocacy for IEC/BCC interventions before, during and after repatriation, and
for uniform treatment, care and support policies in the GLIA countries
• Advocacy for integration of HIV services for refugees and host populations,
including VCT and GBV counseling
• Provision of HIV prevention, treatment and support services through
appropriate sub contractors
What are promising interventions that should be considered for the GLIA
strategic plan?
84
YES. GBV is a significant contributor to women’s risk of HIV acquisition.
Intimate partner violence is prevalent and mostly tolerated by society.
Some groups of men suffer considerable sexual violence, such as
prisoners. Evidence on the link between sexual violence and HIV is weak
in SSA. Progress in reducing GBV is unlikely to be achieved without
significant changes in individual & community attitudes towards GBV.
Affected females may be stigmatised by partners/community, may lack
empowerment, be in abusive partnerships, experience physical violence
& trauma, tolerate violence as ‘normal’, may be subjected to violence
because of wanting to protect herself or because of HIV sero-positivity.
YES.
Very few data were available, but it is clear that prisoners have little
mobility/ power to leave a high-risk setting. Prisoners lack protection,
have tough living conditions, overcrowding, sexual violence, denial &
criminalisation of sex, high risk sex, IDU, prostitution, lack of conjugal
visits, poor access to quality preventive & curative services and
commodities. Prison environments are generally not conducive to HIV
interventions and broad efforts to improve health and living conditions for
prisoners are urgently needed. Knowledge gaps include the magnitude of
the HIV and TB epidemics in prisons, their effect on populations working
or living around prisons and successful intervention strategies.
YES.
Although the true burden of HIV in the armed forces of the GLIA countries
could not be assessed due to data confidentiality, the vulnerability profile
of the military predicts high HIV risk, but this may be modulated by
effective interventions and place-specific characteristics.
Military personnel may be posted away from home, under pressure,
trained to regard risk-taking as the norm, exposed to contaminated or
unscreened blood, may have disposable income. Middle ranking officers
fit demographic and occupational profile of high risk group.
FEMALES AFFECTED
BY SEX. VIOLENCE
Size: 7,772,897
RR=1.4
Attribut. PLHIV:
132,500
Number of NSPs focusing
on this population: 7
PLHIV: 40,102 – 80,204
HIV+: 10%-20%
Size: 401,020
MILITARY
Number of NSPs focusing
on this population: 7
PRISONERS
Size: 222,042
HIV+: 5.6%
PLHIV: 12,434
Number of NSPs focusing
on this population: 5
Should the GLIA strategic plan focus on this population (YES/NO)?
If YES, why? If NO, why not?
POPULATION
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Due to the history of the region, each
country should be responsible for
programs for its own military and
uniformed service personnel.
Should the GLIA fund HIV service
delivery for this vulnerable
population (YES/NO)?
If YES, why? If NO, why not?
NO. Although this is a large and
significant population, it is also a
population that is dispersed and
hidden, so difficult for service delivery.
Therefore, separate programs for
these females should not be offered,
but rather integrated into existing
services so as to respond to the needs
of these women and minimise further
trauma, stigma or discrimination.
NO. There are already other regional
initiatives to support these populations,
and there are signification legal
challenges to overcome. The
population is relatively small. Isolated
HIV service delivery interventions
(which the GLIA may be able to
provide through sub contracting) may
have limited effectiveness in prisons
which have an urgent need for broad
strengthening of health services.
NO.
• Advocacy by the GLIA for better condom distribution and
IEC/BCC programs, release of HIV prevalence data
• Sharing of information by the GLIA on types of interventions in
other countries that have worked, e.g.: BCC/ peer education
‘speaking the language of the barracks’; Addition of condom
pouch to equipment belt; Strong STI and VCT services in
bases; Mobile video unit presentations; Condom wholesale &
retail marketing in and around camps/ bases
• Qualitative research and surveys commissioned by the GLIA
to understand better the sub-culture in the military, including
cross sectional studies to focus on sexual behavior of persons
in this sub-population
• Epidemiological research in prison communities, and
operational research on HIV and TB in prison communities
and ‘what works’, commissioned by the GLIA
• Advocacy by the GLIA for interventions supporting the
development of national HIV policies in prisons and for
interventions supporting general improvement of prison living
conditions
• Sharing of training materials and experiences in integrating
services into all aspects of service provision; for example: the
training of health care personnel which includes medical,
psychological and forensic elements and post-rape care
• Advocacy by the GLIA for interventions to change perceptions
and opinions about sexual and gender-based violence, and for
integration of GBV screening & counseling in service delivery
(VCT, ANC, SRH, abortion care, adolescent programs)
What are promising interventions that should be considered
for the GLIA strategic plan?
85
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
86
8. POLICY IMPLICATIONS OF THIS STUDY
NOTE: The policy implications have been developed taking into account the objectives, principles
and strategic orientations stated in the ‘Convention Establishing the Great Lakes Initiative on
AIDS’.
The GLIA was created to complement the efforts of the national governments’ HIV responses and
to add value to HIV efforts in the region. What does it mean to complement and add value to the
efforts of the NACs? This has been a central question at the heart of the GLIA since its existence.
The GLIA’s complementarity and its ‘value-adding’ role has, to date, been interpreted as being (a)
the provision of HIV services to selected sub-populations that have not been targeted with HIV
interventions by the six national governments, and (b) to support regional collaboration (mostly in
the form of capacity building, opportunities for dialogue, and workshops).
The results of this study may suggest a broadened interpretation of the GLIA’s ‘value-addedness’
and implications of its complementary role. Whilst there are clearly vulnerable populations in the
GLR at increased risk of HIV transmission that have not yet been targeted by the six governments’
National HIV Strategic Plans, these populations remain the responsibility of the seven NACs, as
affirmed in the countries’ own policy documents, and the countries’ commitments to universal
access to HIV services to ALL persons in their countries who need it. Therefore, in the long run, the
GLIA’s main role should not be HIV service delivery to any population. Instead, the study suggests
(see Table 32 column 4 for a summary) that the GLIA’s complementarity, in the long run, lies in
seeing the seven NACs as its main clients, with the following strategic objectives:
a) To support the development of HIV strategies in the GLR that are informed by evidence on the
modes of HIV transmission; and
b) To act as a catalyst for providing HIV services to populations in need of them and so help
ensure universal access for all populations in the GLIA; and
c) To support cross-pollination of information about ‘what works’ in providing HIV services to
different populations.
d) To foster harmonization of HIV/AIDS action frameworks and policies within the GLR, in order
to take into account the needs of mobile and migrant populations, and the general trend towards
a common regional market.
The GLIA should, in the long run, assume the following roles to meet its objectives:
First, the GLIA should play a strong communications and advocacy role to ensure that specific,
evidence-informed strategies for all eight vulnerable populations are included in the national HIV
strategic plans of the six GLIA countries. For the communication to be structured, GLIA requires a
communication strategy and an understanding of ‘what works’. The advocacy must be pitched at the
systems level and may include advocacy for legislative changes, and specific regional policy
directives. Specific areas of advocacy and policy dialogue may include:
•
Advocate for and support the integration of GBV screening and services into VCT programs,
ANC services, child well-being centers, and during post-abortion care in all GLIA countries.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
87
This should be extended beyond the health sector to include other sectors of society and
government, and include interventions concerning adolescent women's reproductive health (to
directly address sexual coercion of young women) and interventions targeted at men.
•
Support the expansion of mobile VCT services targeting many different vulnerable population
groups in all GLIA countries. Select the implementing agency through a tender process and
stipulate that the provision of mobile VCT services must be based on mapping of high
transmission areas and lack of quality services through stationary VCT centers, and must
simultaneously provide GBV screening and services.
•
Promote use of the UNAIDS peer education kit for uniformed services by making it available to
government departments and private sector entities in the required languages and quantities.
Support peer education initiatives among uniformed personnel (immigration and police officers,
customs agents, security guards, etc) at major cross-border posts through a special fund,
stipulating that prevention services must be linked on both sides of the border for synergy, and
that communities on opposite sides of the border are considered as a single extended town with
heavy interaction between border populations.
•
Advocate for and support the development of national policies on HIV/AIDS in prisons in the
GLIA countries (Kenya has already drafted a policy).
•
Bring in regional dialogue groups which are regionally under-represented or under-utilized,
such as MSM and labor federations.
The GLIA can only play a strong advocacy role in the region if it has data available, and can use the
data to strengthen the case for embarking on certain initiatives. For this reason, the GLIA should,
secondly, strengthen its monitoring, evaluation and research role in the region: it should become
a knowledge hub of all available HIV information in the region, share experiences, and help to
support the evidence base for all decision-making concerning HIV in the region. Some specific
aspects of monitoring, evaluation and research may include:
•
Create an online database containing all research and publications on HIV/AIDS/STIs from the
GLIA countries, including annual HIV M&E reports and survey data, as well as an inventory of
technical resource persons within the GLR, in order to create a ‘knowledge hub’. 217
•
Create and manage a regional HIV monitoring and evaluation journal
•
Support the implementation of operational research/action-research on integration and crossborder coordination of HIV activities during repatriation of refugees and return of displaced
persons, with specific emphasis on communication/advocacy and the continuum of care and
ART for PLHIV.
•
Support research studies on workers on marine and inland waterways in selected areas (such as
Zanzibar, river basin of the DRC), in order to understand their burden of HIV, as well as the
needs and opportunities for intervention by the NACs.
217
Alternately, expand the already existing ‘Réseau documentaire international sur la Région des Grands Lacs
Africains’ (www.grandslacs.net).
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
88
•
Advocate for and fund an expert consultation in all GLIA countries to model HIV incidence, in
order to create a better understanding of how new infections occur.
•
Support the supplementary analysis of the DHS data from Kenya and Rwanda to strengthen the
evidence base of the relationship between sexual violence and HIV, and the AIS data from
Tanzania and Uganda (and potentially the GLIA BSS data) regarding the relationship between
rape and HIV status. Advocate that any future studies on sexual violence and HIV also explore
HIV as a risk factor for GBV, GBV as a barrier to HIV care and treatment, and the vicious cycle
that GBV and HIV can create.
•
Support the implementation of standardized situation analyses of HIV/AIDS in fishing
communities in DRC, Kenya, Tanzania and Uganda (HIV/AIDS burden, mapping of fishing
zones, ongoing interventions, inventory of services, potential partners) to provide a basis for
evidence-based interventions.
•
Assess in detail, the current and planned coverage of the ROADS and Safe-T-Stop Initiatives and
provide support in evaluation and accelerated scaling up of the intervention to cover all primary
transport corridors of the GLR.
•
Establish strategic collaborations with stakeholders in the fields of research, M&E and
translation into policy and action. For instance, with the REACH Policy Initiative, 218 which is
located within the East African Health Research Council with a mission “to access, synthesize,
package and communicate evidence required for policy and practice and for influencing policy
relevant research agendas for improved population health and health equity.”
Thirdly, although the GLIA does not play (and should not play, as it is not its mandate and would
not be complementary to the efforts of the seven NACs) a coordination role in the region, the GLIA
should in future play a technical HIV support role in the region, and should staff accordingly. The
GLIA is in an excellent position to cross-pollinate and learn strategies around ‘what works’ in
different countries within the GLR, and to build capacity in the areas of research, M&E and
learning. This learning can be applied and regional technical support made available for the benefit
of the GLIA countries. Such support may include, for example, production of IEC/BCC materials
for specific ‘specialized’ and marginalized vulnerable populations present in all GLIA countries
(e.g. fishing communities), sharing of action plans and practical experience regarding large scale
implementation of male circumcision, or exchange of costing and procurement knowledge.
And finally, GLIA is ideally placed to foster harmonization and networking within the GLR. The
analysis has highlighted the increasing level of migration within the region. Unless HIV/AIDS
action frameworks and policies are harmonized, migrant and vulnerable populations will continue to
be disadvantaged in HIV prevention, treatment, care and support. One area of action could be
promotion of the good practice of FSW registration (as a first step to managing and eventually
legalizing prostitution). The analysis has also discussed the intention to develop a common market
with free movement of people and goods. Practical implementation has not yet followed and would
benefit from GLIA leveraging support (for instance, for eased border procedures for truckers).
Networking and promotion of institutional linkages by GLIA would contribute to information
218
http://www.idrc.ca/uploads/user-S/11551301781REACH_Prospectus.pdf
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
89
exchange and alignment of strategies and action plans (for instance, between GLIA and IGAD,
EAC and SADC).
Despite these longer-term strategic objectives proposed for the GLIA, it is not recommended that
the GLIA immediately cease all HIV service delivery. In the short to medium term, the GLIA
remains an important partner in HIV service delivery to four specific vulnerable populations
(truckers, fishermen & fisherwomen, refugees and IDPs) through sub-contractors. Whenever
feasible, a formal capacity building component should form part of these sub-contracts. The GLIA
should retain this role in the next 24 months, as it gears up for broader service delivery to NACs, as
defined above. In its Strategic Plan 2008-2012, the GLIA must define exit strategies for service
provision to the four vulnerable populations in order to ensure uninterrupted service delivery to
these priority populations.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ANNEX I Selected Maps
Page
The countries of the Great Lakes Region……………………………………………………91
Population density and HIV prevalence level by antenatal sentinel site
Burundi, and Democratic Republic of Congo………………………………………..92
Kenya, and Rwanda…………………………………………………………………. 93
Tanzania, and Uganda………………………………………………………………. 94
HIV Prevalence of the Adult Male and Female Population by Province…………………… 95
HIV Prevalence of the Adult Male Population by Province……………………………….. 96
HIV Prevalence of the Adult Female Population by Province……………………………… 96
Major road axes, truck stops and truck volume…………………………………………….. 97
Change in IDP and Refugee Numbers (December 2006 to mid-Year 2007)………………. 98
Vulnerable populations in the GLIA countries: estimated group size and estimated number of
PLHIV………………………………………………………………………… 199
90
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Source: World Bank
91
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
92
Population density and HIV prevalence level by antenatal sentinel site
Source: UNAIDS Epidemiological fact sheets (http://www.who.int/globalatlas/default.asp)
The UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, in collaboration with the WHO Public Health
Mapping and GIS Team, Communicable Diseases, is producing maps showing the location and HIV prevalence in relation to
population density, major urban areas and communication routes. For generalized epidemics, these maps show the location of
prevalence of antenatal surveillance sites.
BURUNDI
DRC
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
KENYA
RWANDA
Source: UNAIDS Epidemiological fact sheets (http://www.who.int/globalatlas/default.asp)
93
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
TANZANIA
UGANDA
Source: UNAIDS Epidemiological fact sheets (http://www.who.int/globalatlas/default.asp)
94
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
HIV Prevalence of the Adult Male and Female Population by Province
Source: World Bank
95
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
HIV Prevalence of the Adult Male Population by Province
HIV Prevalence of the Adult Female Population by Province
Source: World Bank
96
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Major road axes, truck stops and truck volume
Source: World Bank
97
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Change in IDP and Refugee Numbers (December 2006 to mid-Year 2007)
Source: OCHA Regional Office for Central and East Africa (2007). Displaced populations report, January-June 2007
98
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Vulnerable populations in the GLIA countries: estimated group size and estimated number of PLHIV
99
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
100
ANNEX II Description of the Countries in the Great Lakes Region
BURUNDI
A country with a long history of ethnic conflict, Burundi in 2005
continued along a road of relative peace, seeing the democratic
election of a new, power-sharing government headed by Pierre
Nkurunziza. The new government signed a South African
brokered ceasefire with the country's last rebel group in
September 2006 but still faces many challenges. The country’s
war-shattered economy and infrastructure are high on the
government’s development agenda, but a cost recovery system
of healthcare means that many Burundians still lack access to
basic medical services, despite a May 2006 announcement of
free medical care for pregnant women and children under 5.
Towards the end of 2006 the media and some independent
human rights NGOs became increasingly critical of the
government’s activities, and faced official obstruction and
harassment. The UN Operation in Burundi completed its
mandate at the end of 2006 after a 3-year peace-keeping
mission.
Population: 8,390,505 (mid 2007)
Human Development Index (2006): Rank 169
DEMOCRATIC REPUBLIC OF CONGO
Millions of people continue to live in crisis throughout DRC.
Militias and soldiers exert enormous pressure on civilians, who
are subject to looting, extortion, rape and other violence.
Fighting in the eastern provinces of North Kivu, South Kivu and
Katanga have been causing the displacement of tens of
thousands of people. Many live in the bush under the continuous
threat of insecurity. Others have fled to villages and are hosted
by local populations or live in camps. Malnutrition is one result of
ongoing violence, which prevents people from farming their
lands for fear of being attacked. Against this backdrop, 2006
witnessed the first and relatively peaceful presidential and
parliamentary elections in the DRC in 40 years. Joseph Kabila
was inaugurated as President in December 2006. Provincial
assemblies were constituted, and elected governors and
national senators in January 2007. Overall progress in DRC
continues to be affected by violence and insecurity, especially in
the East. The humanitarian needs remain immense. In 2006, the
UN Mission in the DRC maintained over 18,000 peacekeepers.
Population: 65,751,512 (mid 2007)
Human Development Index (2006): Rank 167
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
101
KENYA
Across the north of Kenya, years of drought had a
devastating impact on the mainly pastoral population and
their livelihood. The scattered population was also
displaced by ongoing inter-clan conflicts. In 2002, Mwai
Kibaki was elected president, running as the candidate of
the multiethnic, united opposition group, the National
Rainbow Coalition. The coalition splintered in 2005 over
the constitutional review process. The government's draft
constitution was defeated in a popular referendum in
November 2005.
The regional hub for trade and finance in East Africa,
Kenya has been hampered by corruption and by reliance
upon several primary goods whose prices have remained
low. Kenya provides shelter to almost a quarter of a
million refugees, including Ugandans who flee across the
border periodically to seek protection from Lord's
Resistance Army rebels.
Population: 36,913,721 (mid 2007)
Human Development Index (2006): Rank 152
RWANDA
The 1994 genocide is having a lasting impact on many
aspects of people’s lives. There is now a gender
imbalance in Rwanda, a large number of widows heading
households and a lack of trained professionals. Despite
substantial international assistance and political reforms including the first post-genocide presidential and
legislative elections in 2003 - the country continues to
struggle to boost investment and agricultural output, and
ethnic reconciliation is complicated. Kigali's increasing
centralization and intolerance of dissent, the nagging
Hutu extremist insurgency across the border, and
Rwandan involvement in two wars in recent years in DRC
continue to hinder Rwanda's efforts to escape its bloody
legacy. Approximately 57,000 Rwandan refugees still
reside in 21 African states, including Zambia, Gabon, and
20,000 who fled to Burundi in 2005 and 2006 to escape
drought and recriminations from traditional courts
investigating the 1994 massacres.
Population: 9,907,509 (mid 2007)
Human Development Index (2006): Rank 158
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
102
TANZANIA
Despite the large number of different ethnic groups who comprise the
population, mainland Tanzania is peaceful and stable with few tribal or
regional divisions. CCM remains the overwhelmingly dominant force in
mainland politics. In December 2005 Jakaya Kikwete comfortably won the
presidential election. Tanzania is affected by the prolonged crisis in the
Great Lakes region. Large flows of refugees have had a significant negative
impact. UNHCR announced in January 2007 that, for the first time in more
than a decade, the population of refugee camps in Tanzania had dropped
below 300,000. More than 250,000 refugees have returned to their homes
from Tanzania since 2002. Voluntary returns to northern Burundi began in
2002, under a tripartite commission (UNHCR, Burundi, Tanzania). So far
180,000 people have returned.
Population: 39,384,223 (mid 2007)
Human Development Index (2006): Rank 162
UGANDA
For nearly 20 years, people in northern Uganda have suffered from brutal
conflict between government forces and rebel groups including the Lord’s
Resistance Army (LRA). This has involved atrocities against the local Acholi
and Langi population. Some 1.7 million of the population of Gulu, Kitgum
and Pader Districts in northern Uganda still live in IDPs camps, though there
has been a small increase in security in the last few months. A cessation of
hostilities agreement was signed in August 2006, and a second agreement
signed in May 2007. Large-scale displacements mandated by the
government have added to the misery. By mid-2006, almost two million
people — nearly 90 per cent of the population of the north — had been
uprooted to 200 camps. Unable to work or farm, these people are
completely reliant on external assistance. Ugandan refugees as well as
members of the LRA seek shelter in southern Sudan and the DRC's
Garamba National Park; LRA forces have also attacked Kenyan villages
across the border.
Population: 30,262,610 (mid 2007)
Human Development Index (2006): Rank 145
Sources: The World Bank 2007, CIA fact book, Médecins sans Frontières, Foreign Commonwealth Office, Human
Development Report 2006
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
103
ANNEX III Mobility and Migration of People in the Great Lakes Region
Migration is a process of moving, either across an international border, or within a state.1 The following types of
migration have been defined2:
Assisted migration: The movement of migrants accomplished with the assistance of a government, governments or
an international organization.
Clandestine migration: Secret or concealed migration in breach of immigration requirements.
Economic migration: A movement of persons leaving their habitual place of residence to settle outside their country of
origin in order to improve their quality of life. This term also applies to persons settling outside their country of origin for
the duration of an agricultural season (‘seasonal workers’).
Facilitated migration: Fostering or encouraging of legitimate migration by making travel easier and more convenient.
Facilitation can include any number of measures, such as a streamlined visa application process, or efficient and well
staffed passenger inspection procedures.
Forced migration: A migratory movement in which an element of coercion exists, including threats to life and
livelihood, whether arising from natural or man-made causes (e.g. movements of refugees, IDPs).
Internal migration: A movement of people from one area of a country to another for the purpose or with the effect of
establishing a new residence. This migration may be temporary or permanent. Internal migrants move but remain within
their country of origin (e.g. rural to urban migration).
International migration: Movement of persons who leave their country of origin, or the country of habitual residence,
to establish themselves either permanently or temporarily in another country.
Irregular migration (illegal migration): Movement that takes place outside the regulatory norms of the sending, transit
and receiving countries. There is no clear or universally accepted definition of irregular migration. There is, however, a
tendency to restrict the use of the term “illegal migration” to cases of smuggling of migrants and trafficking in persons.
Labour migration: Movement of persons from their home State to another State for the purpose of employment.
Labour migration is addressed by most States in their migration laws. In addition, some States take an active role in
regulating outward labour migration and seeking opportunities for their nationals abroad.
Orderly migration: The movement of a person from his/her usual place of residence to a new place of residence, in
keeping with the laws and regulations governing exit of the country of origin and travel, transit and entry into the host
country.
Regular migration: Migration that occurs through recognized, legal channels.
Return migration: The movement of a person returning to his/her country of origin or habitual residence usually after
spending at least one year in another country. Return migration includes voluntary repatriation.
Spontaneous migration: An individual or group who initiate and proceed with their migration plans without any outside
assistance. Spontaneous migration is usually caused by push-pull factors and is characterized by the lack of State
assistance or any other type of international or national assistance.
Mobility is variously defined in terms of short and/or long distance travel, seasonal and/or permanent migration, or
high risk occupations requiring travel such as mobile traders and truck drivers. The process of migration and
mobility has the following stages:
source – where people come from, why they leave, what relationships they maintain at home while away
transit – places people pass through, how they travel and maintain themselves
destination – where people go, their living and working conditions in the new place
return – the communities to which people return
Migration among African countries is perhaps the least well documented in the developing world. The rapidity with
which some movements start or reverse themselves implies that they are seldom reflected properly in censuses.
Although movements of refugees have been an important aspect of international migration in Africa, other types of
migration have accounted for the bulk of international migrants.
1
IOM (2005). World migration report – Costs and benefits of migration, Migration terminology.
IOM (2004). Glossary on migration.
http://www.egypt.iom.int/eLib/UploadedFolder%5CGlossary_on_Migration_En.pdf
2
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
104
The new Constitution of the African Union recognizes the role of migrants, who are considered to be an integral part
of national human resources, regardless of their place of residence. The African Union Commission is currently
developing a Strategic Framework for the management of migration, and engaging in many consultations among
member states. Apart from the technical capacities of migrants to compensate shortcomings in the home country,
repatriation of migrant funds can significantly contribute to the country’s economy. For instance, the total value of
remittances to Uganda in 2002 was 365 million US$ or 6.3% of the GDP.3 Nevertheless, migration as a multisectoral issue barely features in national development strategies, and has not been adequately addressed in any of the
development frameworks prescribed for SSA (MDGs, PRSPs, NEPAD, Tokyo International Conference on Africa's
Development).
GLIA countries - International migration
Table 32 gives an overview of international migration of the six countries as per mid-year 2000. Tanzania is the
leading country in both absolute numbers of international migrants, and proportion of international migrants
compared to the total population. The net migration was in 2000 at almost 2 million for Rwanda (excess arrivals),
and DRC recorded a loss of almost 1.5 million people (excess departures). Overall, the GLIA countries had more
international migrants departing from the GLR than arriving in the GLR (excess departures of 203,000 people).
Table 33. Migration data from GLIA countries (mid-year 2000)
Burundi
DRC
Kenya
Rwanda
Tanzania
Uganda
Total / Average
Estimated number of
international migrants
77,000
739,000
327,000
89,000
893,000
529,000
2.65 million
International migrants as
% of the total population
1.23%
1.52%
1.07%
1.15%
2.56%
2.25%
1.63%
Net number of international
migrants4
- 400,000
- 1,487,000
- 21,000
1,977,000
-206,000
- 66,000
-203,000
Source: Data hub, Migration Policy Institute (http://www.migrationinformation.org/datahub/comparative.cfm)
The proportion of females among international migrants in Africa has increased steadily and faster than at the world
level (no GLR specific data available).5 The IOM refers to this phenomenon as the feminisation of migration, i.e.
the growing participation of women in migration. More and more women are moving independently, not simply
accompanying husbands or other family members, but to meet their own economic needs. They are becoming
primary wage earners and taking jobs in domestic work, cleaning restaurants and hotels, child rearing, care of the
elderly, but also as more specialized nurses and hospital aides. Informal cross-border trading has expanded
dramatically, with women playing a major role in the buying and selling of goods across borders. Female migrants
are more vulnerable to human rights abuses, since they frequently work in gender-segregated and unregulated
sectors of the economy, such as domestic work, the entertainment and the sex industry, unprotected by labour
legislation or social policy.
3
IOM (2005). World migration – Costs and benefits of migration, annex page 492.
Balance resulting from the difference between arrivals and departures
5
IOM (2005). World migration report – Costs and benefits of migration.
4
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
105
Cross-border movement
Cross-border people movement occurs by land, air and sea routes. Cross-border movement by land is accounted for
at official land border posts but also happens in other borders areas as irregular or unaccounted migration. Some
inhabitants of border areas are engaged in a perpetual cycle of migration due to cross-border economic activities and
pastoralist traditions. These people often move within their ethnic areas, which frequently involves the crossing of
international borders as the endemic cycles of drought and water shortages cause population displacements (e.g.
pastoralists in north-eastern Kenya). Cross-border movement by air is accounted for at departure and arrival at
international airports. Cross-border movement by sea is accounted for at immigration in ports and harbours.
Border statistics, derived from the collection of information at ports of entry into and departure from a country, can
be considered the most appropriate for the direct measurement of international migration flows. However, in
practice, countries often apply different degrees of control depending upon citizenship of passengers and mode of
transport. In general, greater control is exercised upon arrivals than upon departures. This analysis did not find
border statistics of the GLIA countries.
Among the regional economic communities, regional cooperation on migration is today considered an important
factor to support economic development and to contribute to peace and stability in the GLR. Various organisations
have been supporting and agenda of free movement of people and goods in order to facilitate trade and migration.
The East African Community (EAC) has made considerable progress in establishing regional migration regimes. On
18 June 2007, Rwanda and Burundi signed the Treaties of Accession into the EAC, formally joining Kenya, Uganda
and Tanzania.6 With the move of these countries towards the Common Market, where all factors of production will
be free to move across boarders, labour will correspondingly move (target date for signing of the Protocol on
Common Market end of December 2008).
Already in the 1980s, Kenya, Uganda and Tanzania had initiated the Northern Corridor Transit Traffic
Agreement aimed at the eradication of barriers to the unimpeded flow of goods and passengers in the region. The
corridor, covering 7,000km, now extends to Kisangani in the DRC. Important border posts are Malaba and Busia on
the Kenya-Uganda border, Namanga on the Kenya-Tanzania border, Gatina on the Rwanda-Uganda border and
Kasese, which is the exit-entry point between Uganda and DRC.
Mombasa is the major gateway to seagoing business in Eastern Africa and the Northern Transit Transport Corridor.
The railway and road network linking the port and some of the Eastern African Region countries commences here.
This route hosts drivers transporting goods as far as Uganda, Rwanda, Burundi, the DRC, Northern Tanzania and
Southern Sudan. Soon Ethiopia will be in the loop.
An interesting development has happened in Malaba, the busiest border post between Uganda and Kenya: A onestop border post for rail cargo has been created in 2006. This should cut waiting time at the border from days to
hours, lessening the burden for truck drivers and other transport workers, and helps to transform the Northern
Corridor into an economic development corridor.
Internal migration
Significant internal population movements are generated by the increasing urbanization in the GLIA countries
(figure 12a). The percentage of people living in urban areas is growing rapidly, and the urban annual growth rates
are often twice as high as the rural growth rates (figure 12b). High urbanization rates result in the rapid growth of
urban agglomerations, compounded by high rates of natural internal population growth. While urbanization is an
integral part of economic and social development, if rapid and unregulated, it can have adverse consequences for
migrating and urban populations by straining the existing urban infrastructure and services and resulting in higher
rates of urban poverty
6
http://www.eac.int/news_2007_06_rwanda_and_burundi_join_EAC.htm, accessed 20 oct 2007.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
106
Figure 13. Urbanisation trends in GLIA countries: (a) Proportion of urban population 1980-2020
45
40
percent urban
35
30
25
20
15
10
5
0
1980
1985
Burundi
1990
DRC
1995
2000
Kenya
2005
Rwanda
2010
2015
Tanzania
2020
Uganda
Source: UN Dept. of Economic and Social Affairs, Population Division.
(b) Population growth rates in urban and rural areas 2005-2010
Uganda
Tanzania
Rwanda
Kenya
DRC
Burundi
%
0
1
2
3
4
rural annual growth rate
5
6
7
8
urban annual growth rate
Source: UN Dept. of Economic and Social Affairs, Population Division.
Nairobi is the largest city in the GLR. More than 60% of the population is now estimated to live in slums where
access to basic amenities such as water, electricity, and sanitation facilities in these settlements is practically
nonexistent. In a report on how poverty-sexual behaviour interactions affect women and children living in the slums
of Nairobi, Nii-Amoo (2004) stresses the particular vulnerability of the urban poor relative to their rural
counterparts.7 Much of the risky behaviour described can be considered part of a survival strategy whereby women
7
Nii-Amoo FD (2004). Sex and survival, the sexual behaviour of the poor in African cities. Paper presented at the
UNDP South East Asia HIV and Development Programme Workshop on Inter-relations between Development,
Spatial Mobility, and HIV/AIDS. Paris, France, September 1-3, 2004.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
107
in difficult economic circumstances have to fall back on sex as currency for obtaining the basic needs for themselves
and their families.
Internal (and cross-border) labour migration can be seasonal, short-term or permanent. Traditionally, labour
migration in SSA has been directed towards a limited number of countries, but in recent years, these configurations
have changed, and it is difficult to classify countries strictly as either origin or destination countries. Some serve as
transit routes, while others are both origin and destination countries for migrant workers. Regional economic
communities are key to facilitating cooperation on labour mobility at the intra-regional level.
In recent years, the incidence of people trafficking, especially women and children, has increased dramatically in
SSA. Many African countries have become points of origin, transit and destination at the same time for the
traffickers and trafficked. As in other regions, trafficking within Africa takes various forms, including large
movements of children and young women from rural to urban areas for domestic work and forced prostitution. A
study conducted in the south–western part of Tanzania found considerable local trafficking from rural areas, which
increased during the months of October to December during which primary schools closed. The study also notes the
existence of cross-border trafficking, where young girls from Malawi and Zambia are recruited by long-distance
truck drivers or business people. 8 Regional economic communities have responded in different ways to the
challenges of trafficking. Tanzania is one of the few countries to criminalize trafficking in persons for sexual
exploitation.
A study in East Africa illustrates the impact of armed conflict on trafficking. In Uganda, large numbers of children
in conflict areas are abducted by the Lord’s Resistance Army (LRA), and are forced to work as child soldiers or
slaves/wives to the LRA commanders.9 From June 2002 to July 2003, approximately 8,400 children were abducted
in this way, bringing the total to well over 20,000 since the start of the 17-year conflict. Thousands of children
remain missing. In the GLR, conflict related forced migration, both international and internal, remains an
important aspect of migration. This topic is further discussed in the report section on refugees and IDPs.
Mobility, Migration and HIV
“The failure to address HIV and AIDS in relation to migration, and migration in relation to HIV and AIDS
potentially entails enormous social, economic and political costs; yet the field continues to be seriously underresearched and either not addressed, or only inappropriately addressed by policymakers”10
“Migration is the strongest single predictor of HIV prevalence in sub-Saharan Africa; other potential socioeconomic confounders cannot account for this effect”11
There is strong evidence that mobility and migration per se are important factors contributing to the AIDS epidemic.
12 13 14
, , Several studies have shown that people who travel or who have recently migrated tend to be at higher risk for
HIV and other STDs (e.g. Tanzania15, Uganda16, Senegal17). The role of migration in the spread of HIV has been
described primarily as the result of men who become infected while they are away from home, and infect their wives
or regular partners when they return. Married men often travel without their spouses. Being away from their families
and communities, and thus from social and sexual control, may cause mobile men to change their sexual behaviour.
8
GTZ (2003). Study on trafficking in women in East Africa. A situation analysis by Elaine Pearson. Eschborn,
December 2003.
9
IOM (2005). World migration report – Costs and benefits of migration.
10
IOM (2005). World migration – Costs and benefits of migration.
11
Helene Voeten (Mobility Project3) www.healthdev.org/eforums/af-aids
12
Decosas J & Adrien A (1997). Migration and HIV. AIDS, 11(Suppl. A):S77–S84.
13
Mabey D & Mayaud P (1997). Sexually transmitted diseases in mobile populations. Genitourin Med, 73:18–22.
14
Quinn TC (1994). Population migration and the spread of types 1+2 human immunodeficiency viruses. Proc Natl
Acad Sci USA, 91:2407–14.
15
Barongo LR et al. (1992). The epidemiology of HIV-1 infection in urban areas, roadside settlements and rural
villages in Mwanza region, Tanzania. AIDS, 6:1521–1528.
16
Nunn AJ et al. (1995). Migration and HIV-1 seroprevalence in a rural Ugandan population. AIDS , 9:503–506.
17
Pison G et al. (1993). Seasonal migration: a risk factor for HIV infection in rural Senegal. J Acquir Immune Defic
Syndr, 6:196–200.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
108
Some women who stay behind may be compelled to engage in transactional sex for food and other living expenses Lurie et al. (2003) found in South Africa that only half of the migrant men did send money back home.18
A South African study investigated HIV infection among migrants and their partners staying behind and among nonmigrant couples in which both partners stayed at home.19 The results showed that HIV discordance in migrant
couples was 2.5 times more likely than in non-migrant couples. Men and women in a migrant couple were both
more likely to be infected from outside the relationship than by their spouse. This study also found that in one-third
of the couples with only one HIV positive partner, the wife who stayed at home was infected. Another South African
study showed that migrant women were significantly more likely than non-migrant women to have had two or more
partners in the last year and to have had sexual contact with a partner other than the regular partner.20 This was
accompanied by a higher HIV prevalence in migrant women.
A study in Kisesa Ward in Mwanza, Tanzania aimed to establish whether men and women who are part of couples
in which one of the partners is mobile show more sexual risk behaviour and a higher HIV prevalence than
continuously co-resident men and women, and whether absence of the mobile partner increased the risk behaviour of
the partner staying behind.21 The results obtained showed that whereas long-term mobile men did not report more
risk behaviour than resident men, short-term mobile men reported having multiple sex partners in the last year
significantly more often. In contrast, long-term mobile women reported having multiple sex partners
significantly more often than resident women, and also had a higher HIV prevalence (7.7% versus 2.7%). In couples,
men and women who were resident and had a long-term mobile partner both reported more sexual risk behaviour
and also showed higher HIV prevalence than people with resident/short-term mobile partners. Remarkably, risk
behaviour of men increased more when their wives moved than when they were mobile themselves. More
sexual risk behaviour and an increased risk of HIV infection were seen not only in mobile persons, but also in
partners staying behind. Since moving rates of women in Kisesa are high (70% lived elsewhere at least once in their
life), these results indicate that long-term mobile women play an important role in the spread of HIV.
People are not only vulnerable to HIV infection by the risk behaviour of their partners, but also by their own risk
behaviour when left behind.
A study in Rakai District, Uganda, found that the local population was highly mobile, with over 70% reporting
travel to a potentially higher risk destination in the past year. Travellers were more likely to have higher levels of
sexual risk behaviour, but the risk appeared to be offset by significantly greater knowledge, acceptance, and use of
condoms. The mobile population in this rural area hence appears willing to adopt risk reduction measures
appropriate to their exposure.
It is important to note that female migrants who engage in transactional sex often do not identify themselves as sex
workers. Many of the risks faced by sex workers apply to them as well. Women are particularly vulnerable in these
circumstances, and even programmes targeting either migrants or sex workers may not reach them. 22 Female
migrants experience a heightened risk of HIV infection in transit; female informal traders meet sexual harassment
and rape by officials when crossing borders, and by truckers or taxi drivers while travelling to and from markets and
other sales sites. Sex is regularly used as a tool of exchange for food, transport, or leniency in the workplace. All
sources of information indicate that while migrant women are quite heterogeneous in nature, poverty and gender
inequalities heighten their risks for HIV and AIDS. There is a dearth of knowledge and research about women
migrants in particular, and their vulnerability to HIV. Although women have composed part of the migrant labour
force in Southern Africa since the turn of the century, there is little research that highlights the mechanics and
socioeconomic context of female mobility.
18
Lurie M et al. (2003). The impact of migration on HIV-1 transmission in South-Africa: a study of migrant men
and non-migrant men and their partners. Sex Trans Dis 2003; 30:149–156.
19
Lurie M et al. (2003). Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant
couples in South Africa. AIDS 2003; 17:2245–2252.
20
Zuma K et al. (2003). Risk factors for HIV infection among women in Carletonville, South Africa: migration,
demography and sexually transmitted diseases. Int J STD AIDS, 14:814–817.
21
Kishamawe C et al. (2006). Mobility and HIV in Tanzanian couples: both mobile persons and their partners show
increased risk. AIDS, 20:601-608.
22
Health and Development Networks (2006). HIV and people on the move
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
109
In the same way that gender inequality increases migrant women’s vulnerability to HIV, gender also impacts on the
vulnerability of male migrants. For men, migration often means long periods of time away from partners and
families, working long hours, living in bleak conditions and performing dangerous jobs. Isolation, loneliness, access
to alcohol and sex workers set the stage for sexual risk behaviours which ultimately may endanger the worker
himself, his partner and his family.
Undocumented migrant workers (also called migrant workers in an irregular situation) are migrant workers not
authorized to enter, to stay or to engage in employment in a state. They display heightened vulnerability due to their
illegal status and are prone to exploitation and discrimination. Because of their fear of deportation they avoid contact
with official government agencies and have little access to health and welfare information and services. The lack of
rights has been repeatedly recorded as one of the key factors increasing HIV vulnerability for migrants and mobile
populations. Migrants’ rights, including the right to work, to move within the country, to education or to access
health care, are often directly related to the legal status of individuals. Foreign workers are generally not represented
by unions, and often have weak negotiating and bargaining powers vis-à-vis their employers.
HIV-related migration
HIV changes migration and mobility patterns in a variety of ways.23 Stigma is still an important issue in Africa, and
people diagnosed with HIV or displaying physical evidence of disease may migrate, to avoid discrimination or
stigmatisation by their community, in search of more tolerant surroundings. Also, PLHIVs commonly return to live
with their families to receive care. This might entail moving from an urban area back to a rural area or from one
country to another. Others migrate in order to provide care to family members living elsewhere. When a household
loses its primary breadwinner due to HIV, the remaining family members may migrate to seek income-earning
opportunities. People with AIDS-related opportunistic infections may migrate to obtain ARV treatment and quality
health care elsewhere if it is not available in their own communities. This could involve cross-border movements to
a country perceived to have better health care facilities. An often neglected issue is child migration associated with
HIV. Children engage in migration for many reasons, as orphans and even before they become orphans, if their
parents or other members of their extended families are affected by AIDS. However, policy rarely considers children
as migrants and instead seeks to support children affected by AIDS as static members of their communities.
23
Health and Development Networks (2006). HIV and people on the move.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
110
ANNEX IV Components of the GLIA Support Project
The GLIA Support Project has the following components:24
•
Component 1 - Support to refugees, and displaced persons will provide services to a limited
number of such populations, and could include the full range of prevention, care, treatment
and mitigation, namely through provision of services and goods.
•
Component 2 - Support to HIV/AIDS related networks concerns transport networking, and
will focus on a) long-haul workers and those communities and groups associated with them,
and, b) on two principal transmission corridors, namely Mombasa-Nairobi-Kampala-KigaliBujumbura-Bukavu-Goma, and Dar es Salaam-Dodoma-Kigali-Bujumbura-Bukavu-Goma.
This component will provide important reinforcement of national, and under-funded regional
advocacy efforts to reduce the stigma of those infected and affected; and, engage in the
sharing and testing of people living with HIV/AIDS, through support practices by
nongovernmental organizations (NGOs), and the private sector for this vulnerable population.
•
Component 3 - Support to Regional health-sector collaboration will be provided for a) an
inventory of effective interventions and information sharing, b) review of protocols,
materials and training opportunities for prevention and treatment, c) information exchange on
refugee, displaced, or returnee concerning HIV/AIDS health-related programs, d) transport
sector HIV/AIDS strategy coordination and piloting of targeted transport packages along two
main regional roads, and. e) information exchange on drug policies and procurement.
•
Component 4 - Management, capacity strengthening, monitoring and evaluation, and
reporting, covers three activities: 1) administration and management; 2) capacity
strengthening and Policy discussion/ technical support; and, 3) monitoring and evaluation,
and reporting activities.
24
Project Appraisal Document GLIA Report 30267-AFR
(http://web.worldbank.org/external/projects/main?pagePK=104231&piPK=73230&theSitePK=40941&menuPK=22
8424&Projectid=P080413)
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
111
ANNEX V Terms of Reference for the Study
Global HIV/AIDS Program (GHAP) and the Global AIDS Monitoring and
Evaluation Team (GAMET)
Terms of Reference
For a consultant to conduct an epidemiological analysis of existing HIV-related
data in the Great Lakes Region in Africa
Table of Contents
1
BACKGROUND.............................................................................................................................112
1.1
1.2
1.3
1.4
1.5
THE GREAT LAKES REGION IN AFRICA ............................................................................................112
HIV TRENDS IN THE GENERAL POPULATIONS IN THE GREAT LAKES REGION IN AFRICA ................112
HETEROGENEITY OF THE HIV EPIDEMIC IN THE GREAT LAKES REGION IN AFRICA ........................113
TYPES OF HIV INTERVENTIONS FOR SUB-POPULATIONS WITH HIGHER HIV PREVALENCE .............115
PROVIDING HIV INTERVENTIONS FOR MOST AT RISK SUB-POPULATIONS THROUGH THE NATIONAL HIV
RESPONSES OF THE COUNTRIES IN THE GLR..................................................................................115
2
RATIONALE FOR THE STUDY..................................................................................................116
3
STUDY QUESTION FOR AND OBJECTIVES OF THE SECONDARY ANALYSIS ..........116
4
RATIONALE FOR THE WORLD BANK’S INVOLVEMENT IN THE STUDY .....................117
5
STUDY TEAM’S SCOPE OF WORK .........................................................................................117
6
DELIVERABLES/OUTPUTS .......................................................................................................118
7
DISSEMINATION OF STUDY FINDINGS .................................................................................119
8
REPORTS AND SCHEDULE OF DELIVERY...........................................................................119
9
QUALIFICATIONS AND PROFESSIONAL EXPERIENCE OF LEAD RESEARCHER ....119
10
APPLICATION PROCEDURES FOR LEAD RESEARCHER................................................120
11
REFERENCES...............................................................................................................................120
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
1
112
Background
1.1
The Great Lakes Region in Africa
The term “Great Lakes Region” is somewhat loosely defined – it is used to refer to either a geographic area
in the Rift Valley (the area between northern Lake Tanganyika, western Lake Victoria, and lakes Kivu,
Edward and Albert); or to the countries that surround these lakes. For the purpose of this Terms of
Reference and this study, the Great Lakes Region comprises of the six governments and countries of
Burundi, the Democratic Republic of Congo, Kenya, Rwanda, Tanzania and Uganda1.
An estimated 107 million people live in the Great Lakes Region – one of the most densely populated areas
of Africa. Because of past volcanic activity this area also contains some of Africa's best farmland. Its
altitude gives it a sub-tropical climate despite being right on the equator, becoming temperate in the
mountains25.
The economies of the Great Lakes Region states have different structures, and are at various stages of
development. All of the states in the Great Lakes region are dependent on foreign aid, with Rwanda,
Tanzania and Uganda classified as Heavily Indebted Poor Countries (HIPCs) by the World Bank. The six
countries in the Great Lakes Region had an estimated combined gross domestic product (GDP) in 2003 of
about $29.4 billion26.
In the past 20 years, many countries in the region has been marred by conflict, genocide, natural disasters
and difficult socio-economic conditions that have caused mass displacements of people (internal and
external) and growing levels of poverty. The conflict in the region has also negatively affected countries in
the region that did not experience internal conflict, e.g. Tanzania.
1.2
HIV trends in the general populations in the Great Lakes Region in Africa
The Great Lakes Region (GLR) countries are particularly affected by the HIV/AIDS epidemic with more
than 6 million people living with HIV out of a total of some 26.6 million in Sub-Saharan Africa. Table 1
below details the estimated number of people living with HIV, the HIV prevalence (in the general
population), and the estimated number of children affected by HIV.
Table 1: HIV situation in the general populations in the six countries in the Great Lakes Region of Africa in 2005
Country in Great
Lakes Region
Type of HIV epidemic
Estimated HIV
prevalence in
general
population
Estimated number
of adults and
children living
with HIV
Estimated number
of AIDS orphans
Know HIV status
Burundi
Endemic
3.3%
150 000
120 000
Not available
DRC
Generalised
3.2%
1 000 000
680 000
Not available
Kenya
Severe generalized
6.1%
1 200 000
650 000
(2005)
17 to 18 %
Rwanda
Low intensity
generalised
3.1%
190 000
210 000
21%
Tanzania
mainland
Severe generalized
6.5%
1 400 000
1 100 000
18%
Zanzibar
Concentrated
0.8%
7 000
Not known (20 000
orphans in total)
19%
Uganda
Concentrated in older
age groups
6.7%
1 000 000
1 000 000
12% men
10% women
Sources: Asamoah-Odei et al. 2004; UNAIDS 2006 Report on the Global AIDS epidemic; CDC Global
AIDS Program website: www.cdc.gov; Tanzania Demographic and Health Survey, 2004/5; Zanzibar
Joint HIV Response Midterm Review Report, 2007
25
Wikipedia. 2007. Accessed online at http://en.wikipedia.org/wiki/African_Great_Lakes on 12 August 2007
Country Analysis Briefs. Feb 2004. Accessed online at http://www.eia.doe.gov/emeu/cabs/eafrica.html on 12
August 2007
26
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
1.3
Heterogeneity of the HIV epidemic in the Great Lakes Region in Africa
Table 1 contains the latest data about the HIV epidemics in the six countries in the GLR. The HIV
epidemics in these countries are not, however, homogeneous: either over time in a specific country, at any
given point within a country, or at a given point in different countries in the GLR. Researchers have
pointed out four main types of variances in the HIV epidemics that point to the heterogeneity of the HIV
epidemics not only from country-to-country, but even within a country:
a)
Heterogeneity over time: The HIV epidemics in these countries have not remained constant over time.
Asamoah-Odei, Garcia Calleja and Boerma (2004) concluded, after reviewing HIV prevalence data
from 300 antenatal clinics in 22 countries in SSA from 140 000 pregnant women that there is no
decline in HIV prevalence except in East Africa (median prevalence decreased from 12.9 to 8.5%), and
that there are great sub regional differences between West Africa and SSA in terms of prevalence
(median HIV prevalence in 2002 of 3.2% compared with 21.3% for southern Africa ). There is not
necessarily consensus over the reasons for the reductions in HIV prevalence. Buve (2002) in a
multicenter study of four African cities in West, East and Southern Africa, concluded that changes in
HIV prevalence could not be attributed to differences in sexual behaviour, but rather to differences in
male circumcision rates (much higher in West Africa than East or Southern Africa) and HSV-2
infection (higher in East and Southern Africa).
•
•
•
•
There is sufficient evidence to prove that, compared to the 1990s, there are fewer new HIV
infections amongst the general populations in at least Uganda (reductions of up to 50% since the
late 1990s) and urban Kenya, and that these reductions are as a result of changes in sexual
behaviour (Cross et al., 2004; Stoneburner and Low-Beer, 2004; Hallett et al., 2006; Kirungi et al.,
2006). Not all evidence corroborate these observations. In Uganda, there is also new evidence that
points to increasing new HIV infections. While incidence may not have changed, absolute
numbers have significantly increased. In 2005, about 130,000 new infections were reported
compared to 60,000 in 2001.
In other countries in the region (e.g. the DRC), conflict has prevented HIV surveillance from
being carried out routinely and changes are therefore difficult to interpret, but there was some
evidence at least in the late 1990s that HIV prevalence has stabilized in the DRC (MulangaKabeya et al., 1998).
In Rwanda, Kayirangwa et al. (2006) suggested that Rwanda may have experienced declines over
time in urban areas.
Sokal et al. pointed out as early as 1993 that the HIV epidemic in Burundi was stable (it was in an
endemic state) but that there were not enough ANC sites to understand variances in the epidemic.
b) Heterogeneity in the modes of HIV transmission: In Africa, there is mostly consensus that HIV is
transmitted primarily through heterosexual contact (up to 90% of HIV infections), although some have
disputed this (Gisselguist et al. 2003). There are different estimates of how HIV is transmitted in the
GLR, for example.
•
•
c)
In Uganda: Transmission is mainly through heterosexual sex (75 to 80 percent), whilst it is
estimated that mother-to-child-transmission accounts for 15-25 percent of new infections
(UNAIDS, 2006).
In Rwanda, Kayirangwa et al., 2006 showed that there is a high age of sexual debut (over 20
years for men and women (Rwanda DHS, 2006)) and low numbers of concurrent partners –
pointing to other mechanisms and possible lower infection rates in the future.
Heterogeneity in the HIV prevalence in urban and rural areas: Various studies have shown that
the HIV prevalence is higher in the urban areas in the countries in the GLR than in the rural areas of
the same countries [Arroyo et al, (2005) for Tanzania; Kayirangwa et al., (2006) for Rwanda;
Mulanga-Kabeya et al., (1998) for DRC; Sokal et al., (1993) for Burundi. UNAIDS (2006) for
Uganda; Cross et al. (2003) for Kenya].
d) Heterogeneity in HIV prevalence in different sub-populations: Finally, research has also pointed to
the heterogeneity of HIV within some sub-populations27 within the general population; the trends in
27
For the purpose of this TOR, a sub-population is defined as a specific group of individuals that can be
identified because they share a common characteristic or behaviour (this does not mean that all persons in a
given sub population share all of the same characteristics – there can, for example, be both male and female sex
113
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
HIV prevalence might even be the opposite in some of these sub-populations than in the general
population (e.g. in Uganda, where rural prevalence in some areas increased as the general population
prevalence was decreasing (Nunn et al., 1997)). For example, Kapiga et al. (2006), Mmabaga et al.
(2006) and Sateren et al. (2006)’s research corroborated that:
•
•
•
HIV prevalence is distinctively higher in women who have a male partner 10 or more years older
than them,
Females are much more likely to be HIV positive (a phenomenon found throughout the region in
countries with generalized epidemics: [Cross et al, (2004), Zanzibar AIDS Commission (2007)]
HIV prevalence increase with an increase in the number of sexual partners
Sateren et al. (2006) further pointed out that persons in an isolated community in Kenya who engaged in
transactional sex and persons who traveled also had higher HIV prevalence than the general population.
Other research has crystallized some other sub-populations who may either already have higher HIV
prevalence than the general population, or who may still have low HIV prevalence but who are at increased
risk of HIV infection in the future due to their ‘membership’ of a certain sub-population. These subpopulations are more vulnerable than the rest of the population28.These are summarized below, as well as
the research that substantiate these vulnerable populations:
Fishing Communities in the Great Lakes Region and those that interact with them: Seeley and Allison
(2006) summarized the situation regarding fishing communities, in general, well: “Fishing communities
have been identified as among the highest-risk groups for HIV infection in countries with high overall rates
of HIV/AIDS prevalence. Vulnerability to HIV/AIDS stems from, the time fishers and fish traders spend
away from home, their access to cash income, their demographic profile, the ready availability of
commercial sex in fishing ports and the sub-cultures of risk taking and hyper-masculinity in fishermen. The
subordinate economic and social position of women in many fishing communities makes them even more
vulnerable to infection. In this paper we review the available literature to assess the social, economic and
cultural factors that shape many fisher folks' life-styles and that make them both vulnerable to infection and
difficult to reach with anti-retroviral therapy and continued prevention efforts. We conclude from the
available evidence that fisher folk will be among those untouched by planned initiatives to increase access
to anti-retroviral therapies in the coming years; a conclusion that might apply to other groups with similar
socio-economic and sub-cultural attributes, such as other seafarers, and migrant-workers including smallscale miners, and construction workers.” There is also some evidence of transactional sex – sometimes, but
not always, referred to as commercial sex: for example, the women who get the catch-of-the-day for trading
in the nearest market would return favours to the fishermen.
Mobile Populations (truck drivers and other mobile populations): Many studies have shown the link
between higher risk sexual behaviour, higher prevalence and mobile populations, in particularly truck
drivers (Gysels, Pool, Bwanika,2001; Kishamawe et al., 2006). A study of truck drivers in South Africa, for
example, showed that 37% of them stopped for sex and that 29% of them never used a condom during sex
(Ramjee and Gouws, 2002). What is particularly interesting, is that Nunn et al. (1997) noted high
prevalence amongst truck drivers in Uganda in the late 1990s at a time when the HIV prevalence was
decreasing at ANC sites in Uganda, and Uganda’s HIV response was hailed internationally as best practice
– PEPFAR based their approach to HIV prevention in part, for example, on the Uganda model (Kamwi,
Kenyon and Newton, 2006). Ramjee and Gouws boldly stated in 2002 that “truck drivers may have
facilitated the spread of HIV infection throughout southern Africa”. This statement is corroborated by Lurie
et al. (2003) whose research showed that the HIV prevalence amongst migrant men were more than double
that of non-migrant men in South Africa (25.9% and 12.7%, respectively). However, they concluded that
migration was an independent risk factor for men and that the rural partners of migrant men were not as
affected by HIV.
workers). Sub-populations can therefore be, for example, all women, or all men, or commercial sex workers, or
injecting drug users, or persons in a specific age cohort, etc.
28
The link between HIV and vulnerability is reciprocal. On the one hand, HIV causes more people to be
vulnerable due to illness, grief, or the loss of a breadwinner in the family; on the other hand, persons who are
already vulnerable (due to risk factors such as poverty or domestic violence, or their own behaviour, or other
factors) are more susceptible to HIV infection. Within the context of this TOR, vulnerability does not refer to
persons who don’t have access to treatment, or to persons who are more likely to feel the impact of the
epidemic, such as orphans.
114
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Persons that mobile populations interact with: It is not only truck drivers who are at increased risk of
HIV infection. Nyamuryekung'e et al.’s research about STI approaches for women who serve truck drivers
showed that the person that truck drivers interact with, might include local brew sellers (47.2% of their
sample), bar/guest house attendants (27% of their sample), and petty traders (21.1% of their sample). When
they did the research in 1997, the overall HIV prevalence amongst these persons in Tanzania was 50%
(prevalence of the general population was 6% at the time).
Persons who have been in conflict: UNAIDS (2006) pointed out that HIV prevalence in the DRC varies
from 1.7 to 7.6% depending on the region, and may be as high as 20% among women who have suffered
sexual violence in areas of armed conflict. Khaw et al. (2000) also published research that identified the
factors why populations affected by complex emergencies may be more at risk of HIV transmission than
other populations. “While the potential for stigmatisation represents an important constraint, there is a need
to prioritise HIV/STI interventions in order to prevent HIV transmission in emergency-affected populations
themselves, as well as to contribute to regional control of the epidemic” Khaw et al. (2000).
Refugee populations: The relationship between HIV and conflict is multi dimensional and complex.
Persons in conflict sometimes relocate to escape the complex emergencies in which they may find
themselves (also called forced or involuntarily migration) – conflict is one of the main reasons for
populations migrating involuntarily to other areas in their own countries (as internally displaced persons) or
to other countries (as refugees). These persons are more vulnerable to shocks than the general population of
the areas they are migrating to (World Bank, 2004), but this does not necessarily translate into increased
levels of HIV infection, or in these populations fuelling the spread of HIV in the areas where they migrate
to (Spiegel, 2004). Massimo et al. (2001), for example, noted the increase in prevalence amongst women
attending between 1996 and 1999 in Uganda as directly linked to increased violence and mass
displacements of people in the area (by 1999, 67% of population lived in protected camps) – “The high
population density in these camps could have contributed to the creation of a sub-population that is
susceptible to new HIV-1 infections and which has less access to information and social services”
(Massimo et al., 2001). Northern Uganda is reported to have some of the highest HIV prevalence according
to the Uganda 2005 HIV Sero-Survey, which is associated with conflict and internal displacement. Higher
HIV prevalence may be associated with areas of higher conflict, but this is not universally true for all
persons who migrate involuntarily (Mulanga-Kabeya et al., 1998). One need to consider the different
categories of migrant populations – persons in long-term post-emergency camps may have, in fact, better
access to preventative and curative health services than those in the surrounding populations (Spiegel et al.,
2002).
1.4
Types of HIV interventions for sub-populations with higher HIV prevalence
The unique characteristics of some of the sub-populations (e.g. high mobility) pose challenges to
‘traditional’ models of HIV prevention, care and support interventions. As early as 1993, researchers
suggested that there was a need for more focused interventions and more data to understand and address the
sub-epidemics within different sub-populations well (Sokal et al., 1993). For example: (a) Nyamuryekung'e
et al. (1997) researched the acceptability and cost effectiveness of different types of alternative STI
approaches for women at truck stops; and (b) Gysels, Pool, Bwanika (2001) suggesting using ‘middlemen’
at truck stops as opinion leaders to influence safer sex behaviour [Middlemen mediate between the truck
drivers and CSWs at truck stops [“Middlemen buy goods from the drivers and introduce them to 'suitable'
women with whom they can have casual sex”].
Irrespective of the type of sub-population, a comprehensive approach to deal with sub-populations that are
at increased risk of HIV infection has been advocated for over the past 10 years (Nunn et al., 1997; Spiegel,
2004).
1.5
Providing HIV interventions for most at risk sub-populations through the
national HIV responses of the countries in the GLR
Given that there are sub-populations in the GLR with different HIV epidemics than in the general
population in the Great Lakes region, these populations need to be addressed in a comprehensive, but
different way that works for them and their situations. Given that each GLIA member country has a
national HIV strategic plan, one might ask: Can the NACs of the six GLIA countries address all of these
sub-populations as part of their national HIV responses? For some sub-populations, the answer is ‘yes’,
but NACs are only now learning how to customize their approaches for these sub populations. Any single
NAC would also not be able effectively respond to the needs of mobile populations.
115
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
The GLIA countries themselves confirmed this challenge: Four of the six GLIA countries noted in 2006
that one of their major challenges is how to deal with specific sub-populations.
2 Rationale for the Study
There is a plethora of research and information about the HIV epidemics in the general populations of the
countries in the Great Lakes Region – these epidemics are reducing in some areas, but are still significant
and also heterogeneous. One of the areas of heterogeneity is in terms of the HIV epidemics in subpopulations within the GLR. A brief literature review showed that the epidemics in the sub-populations do
not necessarily follow the same HIV trends as displayed in the general populations of the six GLIA
countries and that innovative HIV interventions are needed to address the needs of these sub-populations.
The available data about HIV trends, and factors that cause vulnerability (e.g. behavioural, knowledge,
attitude, socio-cultural, poverty, school enrollment and educational attainment, socio-economic
opportunities, etc.), in sub-populations have, however, not been compiled systematically, or analysed
across countries in the GLR. As a result, there is not a clear picture about the nature or size of all the subepidemics in the GLR. There is thus the possibility of the sub-epidemics being ‘lost’ within the context of
the generalized epidemic or within the success claimed in reducing prevalence in the general population.
Massimo et al. (2001) summarized it well: “In general, much attention should be paid to local contexts even
when a generalized decline in HIV-1 prevalence is observed on a large scale.”
The lack of systematically-documented evidence about HIV trends and risk factors in sub-populations in
the GLR might lead to available resources in the six GLR countries being directed primarily at the general
population instead of also focusing on these sub-populations. The GLIA was established by the six member
countries to “contribute to the reduction of HIV infections and to mitigate the socio-economic impact of the
epidemic in the Great Lakes Region by developing regional collaboration and implementing interventions
that can add value to the efforts of each individual country” (‘GLIA Mission Statement’). Due to the
mobile nature of at least some of the most at risk sub-populations in the GLR, the GLIA could be in a good
position to advocate for and address the needs of at least some of the sub-populations whose needs cannot
be addressed holistically, uniformly and effectively by any single NAC.
The overall aim of this secondary analysis is therefore to address the data gaps that will enable the GLIA to
make informed and strategic decisions about which sub-populations within the GLR it should target with
which kind of interventions.
3 Study Question for and Objectives of the Secondary Analysis
The main purpose of this secondary analysis is to answer the following question: “On which vulnerable
sub-populations should the GLIA’s regional HIV strategic plan focus with what type of HIV
interventions, and why?” To answer this study question, the study team will, during the secondary analysis
of data:
•
Identify who are vulnerable sub-populations to HIV infection in the countries in the Great Lakes
region;
•
Extract from existing documentation what is known about the HIV prevalence and risk factors (e.g.
behavioural, knowledge, attitude, socio-cultural, poverty, school enrollment and educational attainment,
socio-economic opportunities, etc.) of each of the identified vulnerable sub-populations, as well as the
sizes of these sub-populations and interventions to address the needs of the sub-populations;
•
Compare the list of vulnerable sub-populations in the GLIA to the six national HIV strategic plans to
see which vulnerable sub-populations are not covered by the national HIV strategic plans;
•
Define which vulnerable sub-populations on which the GLIA should focus, and what type of
interventions would be most likely to be successful for these sub-populations within the context of the
GLIA’s mission (based on eveidence of ‘what works’ when dealing with vulnerable populations); and
•
Locate, based on data extracted from existing documentation, geographic areas where the GLIA should
focus their HIV service delivery efforts.
116
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
4 Rationale for the World Bank’s involvement in the Study
As the GLIA satisfied the basic Multi-Country HIV/AIDS Program (MAP) criteria for eligibility, with
satisfactory evidence of a strategic approach to HIV/AIDS, a high level coordinating body, and willingness
to use exceptional implementation arrangements and multiple channels, the World Bank is currently
funding the GLIA through a USD 20 million GLIA Support Project. Being involved in this study will
enable the GLIA to develop a regional HIV strategic plan that is targeted, focused, and will have maximum
impact without duplicating the efforts of national governments, thereby maximizing the strategic value and
impact of the Bank’s investment in the GLR.
5 Scope of Work for Persons involved in the Study
A study team will be appointed to undertake the work. The study team will consist of an M&E specialist at
the World Bank’s Global AIDS Monitoring and Evaluation Team (GAMET), a seasoned researcher that
GAMET will contract for the purpose of the assignment, and a research assistant that GAMET will provide.
The roles of the team members will be:
STUDY TEAM
GAMET M&E Specialist (anticipated involvement of 15 days over a 9-week period):
•
Provide overall leadership for the study
•
Manage the contract of the Lead Researcher and oversee the work of the research assistant
•
Review and approve the inception report
•
Review the draft report and provide detailed technical comments
•
Submit the final report to the Peer Review Group for review and oversight
•
Liaise with the GLIA Secretariat in terms of the Terms of Reference, liaison with all GLIA countries
and M&E Focal Points, all research milestones and in terms of dissemination of research findings
Lead Researcher – contracted by The World Bank (anticipated involvement of 40 days over a 9-week
period):
•
Review the published, official, grey and draft documentation on HIV in the GLR countries, including
AIDS case reporting, HIV sentinel surveillance, other HIV prevalence data, national HIV strategic
plans, GLIA establishment documentation, the draft GLIA HIV strategic plan, VCT data and special
studies.
•
Collate and review the data on risk factors of sub-populations at most risk in the GLR countries (e.g.
behavioural, knowledge, attitude, socio-cultural, poverty, school enrollment and educational attainment,
socio-economic opportunities, etc.), including the prevalence and frequency of unprotected
transactional, commercial and high risk sex and unprotected anal sex, male circumcision practice, and
polygamy practices (where data permit) – so as to develop a list of vulnerable populations in the Great
Lakes Region.
•
Collate and review the data on the size of vulnerable sub-populations defined above
•
Using the above data – HIV prevalence data, risk factor data and size estimation data – and the list of
identified sub-populations, identify priority geographic areas and the links through which these areas
relate to lower prevalence areas using mapping techniques. The mapping should illustrate key trends in
HIV prevalence and risk in specific geographic areas over time.
•
Assess data adequacy and limitations and make realistic recommendations for affordable steps to
improve data availability and quality and decision making
•
Review national priorities to assess how they accord with local transmission priorities and vulnerable
populations, using mapping techniques to illustrate key points
117
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
•
Make practical, feasible recommendations to assist policymakers to improve prioritization and
resource allocation to reflect high priority geographic areas, populations and interventions for the
GLIA, within the context of the GLIA’s scope and mandate
•
Identify areas of potential future risk, that should be watched closely and make practical
recommendations to enhance vigilance in these areas
118
GAMET Research Assistant (anticipated involvement of 30 days over a 2-month period)
•
Collate, through internet studies and contacts with the GLIA secretariat in Kigali, the published,
official, grey and draft documentation29 on HIV in the 6 countries in the GLR, including AIDS case
reporting, HIV sentinel surveillance, other HIV prevalence data, VCT data and special research studies.
•
Support the Lead Researcher with data analysis and related tasks
•
Support the GAMET M&E specialist in organizing dissemination meetings and identifying avenues for
dissemination
INVOLVEMENT OF OTHER STAKEHOLDERS
GLIA Secretariat
•
Introduce the study to the GLIA governance structures, including the GLIA M&E Focal Points and to
the UNAIDS M&E advisers
•
Introduce the lead researcher to the GLIA M&E Focal Points and the UNAIDS M&E advisers
•
Provide input into the lead researcher’s inception report
•
Encourage GLIA M&E Focal Points to source documents that may be available – this is a critical
aspect of the study, as the quality of the secondary analysis will depend on the quality of data received
from the 6 GLIA countries
•
Coordinate logistics for the dissemination of research results
•
Reproduce the study report
GLIA M&E Focal Points
•
Comment on the Terms of Reference
•
Source documents for the study, and support the lead researcher in his/her efforts to source documents
•
Attend the regional dissemination seminar
•
Arrange in-country dissemination seminars, in conjunction with UNAIDS M&E advisers
6
a)
29
Deliverables/outputs
Inception report in English: including a table of contents, draft report outline and summary of major
written and oral sources to be consulted
An illustrative document guide appears in Appendix 2 as a possible checklist of the types of grey and published
documentation on which the secondary analysis will be based.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
b) Draft report in English: a succinct, highly readable 15 to 20 page secondary analysis report, including
graphs and pictorial exhibits, with further annexes as required (absolute maximum of 25 pages,
excluding annexes)
c)
Final report in English and French: an overall, equally succinct and highly accessible, 15 to 20 page
secondary analysis report, including graphs and pictorial exhibits, with further annexes as required
(absolute maximum of 25 pages, excluding annexes)
d) PowerPoint presentation of final report in English and French: a 30-50 slide PowerPoint presentation
containing a summary of the final report
e)
7
Recommended changes to the Terms of Reference for the finalization of the GLIA Strategic Plan
Dissemination of study findings
During and at the end of the task, the team will transfer knowledge through several channels, including
briefings with policymakers, researchers and development partners, presentations of methodology and
analytic approaches and publication of the approaches and findings.
The Lead Researcher will participate in one major regional dissemination workshop where he/she will
present and discuss the preliminary findings and draft report to key stakeholders at an appropriate regional
forum. In addition, the GLIA secretariat, with support from the World Bank, will organize a series of faceto-face and video-conferences to disseminate the findings within the six GLIA countries, to the GLIA
Executive Committee and to the GLIA Council of Ministers.
8
Reports and schedule of delivery
The following deliverables/outputs must be submitted to the World Bank according to the time frames
allocated below:
•
•
•
•
Inception report in English: 2 weeks after the commencement of the assignment
Draft report in English: 6 weeks after the commencement of the assignment
Final report and PowerPoint presentation in English and French: 1 week after receiving comments on
the draft report.
Comments on TOR of GLIA Strategic plan finalization – when final report is submitted
All reports (1 hard copy and 1 electronic file) should be submitted by the Lead Researcher to the World
Bank in English and/or French – as defined above. Together with the deliverables mentioned in section 6,
the Lead Researcher will also submit to the World Bank hard copies of all documents and papers
referenced in the final report. The World Bank, in turn, will submit this documentation to the GLIA
Secretariat, who will arrange dissemination as agreed.
9
Qualifications and Professional Experience of Lead Researcher
The researcher contracted through this Terms of Reference will need to have the following credentials:
•
The researcher should have experience managing a regional research program in Africa and should
have access to a comprehensive research database
•
The researcher should have extensive experience designing and delivering HIV interventions for
vulnerable populations
•
The researcher should be an internationally-reputed epidemiologist or public health specialist with
extensive HIV experience
•
The researcher should have an active research network in place and already active in the Great Lakes
Region
•
The researcher should have epidemiological, strategic planning and HIV intervention experience
•
The researcher should be able to demonstrate that he/she have undertaken similar analyses or research
studies previously
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ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
•
The researcher should possess the ability to communicate complex trends and concepts in simple, clear,
engaging language, with attractive graphic, pictorial and mapping images and exhibits
•
The researcher should preferably be bilingual, with strong French and English language skills (if a
bilingual researcher cannot be found, the World Bank will provide translation services of the inception
report, final report and final PowerPoint presentation)
120
10 Application Procedures for Lead Researcher
Persons interested in applying for the position of Lead Researcher for this study should send a cover letter
motivating how they meet the selection criteria and a CV demonstrating their experience in the areas listed
in Section 11 above to [email protected].
11 References
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M.L. and Birx, D.L. 2007. High prevalence of HIV infection among rural tea plantation residents in Kericho, Kenya, in
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Gysels, M., Pool, R., Bwanika, K. 2001. Truck drivers, middlemen and commercial sex workers, AIDS and the mediation of
sex in south west Uganda, in AIDS Care, Volume 13, Issue 3, June 2001 , pages 373 - 385
Hallett, T.B., Aberle-Grasse, J., Bello, G., Boulos, L.M., Cayemittes, M.P.A, Cheluget, B., Chipeta, J., Dorrington, R., Dube,
S., Ekra, A.K., Garcia-Calleja, J.M., Garnett, G.P., Greby, S., Gregson, S., Grove, J.T., Hader, S., Hanson, J., Hladik, W.,
Ismail, S., Kassim, S., Kirungi, W., Kouassi, L., Mahomva, A., Marum, L., Maurice, C., Nolan, M., Rehle, T., Stover, J.,
Walker, N. 2006. Declines in HIV prevalence can be associated with changing sexual behaviour in Uganda, urban Kenya,
Zimbabwe, and urban Haiti, in Sexually Transmitted Infections 2006;82(suppl_1):i1-i8; doi:10.1136/sti.2005.016014. BMJ
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Kamwi, P., Kenyon, T., Newton, G. 2006. PEPFAR and HIV prevention in Africa. The Lancet 2006; 367:1978-1979
Kapiga, S.H., Sam, N.E., Mlay, J., Aboud, S., Ballard, R.C., Shao, J.F., Larsen, U. 2006. The epidemiology of HIV-1
infection in northern Tanzania: Results from a community-based study, in AIDS Care, Volume 18, Issue 4, May 2006 ,
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Kayirangwa, E., Hanson, J., Munyakazi, L. and Kabeja. L. 2006. Current trends in Rwanda’s HIV/AIDS epidemic, in
Sexually Transmitted Infections 2006;82(suppl_1):i27-i31; doi:10.1136/sti.2006.019588. BMJ Publishing Group Ltd.
Khaw, A.J., Salama, P., Burkholder, B., Dondero, T.J. 2000. HIV Risk and Prevention in Emergency-affected Populations:
A Review, in Disasters 24 (3), 181–197. DOI: 10.1111/1467-7717.00141 \
Kirungi, W, L., Musinguzi, J., Madraa, E., Mulumba, N., Callejja, T., Ghys, P., and Bessinger, R. 2006. Trends in antenatal
HIV prevalence in urban Uganda associated with uptake of preventive sexual behaviour. Sexually Transmitted Infections
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Kishamawe, C., Vissers, D.C.J., Urassa, M., Isingo, R., Mwaluko, G., Borsboom, G.J.J.M, Voeten, H.A.C.M, Zaba, B.,
Habbema, J.D.F., de Vlas, S. J. 2006. Mobility and HIV in Tanzanian couples: both mobile persons and their partners show
increased risk, in AIDS. 20(4):601-608, February 28, 2006. Lippincott Williams & Wilkins, Inc.
Lurie, M.N., Williams, B.G., Zuma, K.M., Mkaya-Mwamburi, D., Garnett, G.P., Sturm, A.W., Sweat, M.D., Gittelsohn, J.,
Abdool Karim, S.S. 2003. The Impact Of Migration On HIV-1 Transmission in South Africa: A Study of Migrant and
Nonmigrant Men and Their Partners, in Sexually Transmitted Diseases. 30(2):149-156. February 2003. Lippincot Williams
& Wilkins.
Massimo, F., Ayella, E.O., Blè, C., Accorsi, S., Dente, M.G., Onek, P.A., Declich, S. 2001. Increasing HIV-1 prevalence
among pregnant women living in rural areas of the Gulu district (North Uganda), in AIDS Volume 15(17), 23 November
2001, pp 2330-2331
Mayaud P., Msuya, W., Todd, J., Kaatano, G., West. B., Begkoyian, G., Grosskurth, H., Mabey, D. 1997. STD rapid
assessment in Rwandan refugee camps in Tanzania. Genitourinary Medicine 1997 Feb;73(1):33-8
Mmbaga, E.J., Hussain, A., Leyna, G.H. 2006. Incidence of HIV-1 infection and changes in prevalence of reproductive tract
infections and sexual risk behaviours: a population-based longitudinal study in rural Tanzania, in African Journal of AIDS
Research. Vol. 5, No. 3 (2006)
Mulanga-Kabeya, C., Nzilambi, N., Edidi, B., Minlangu, M., Tshimpaka, T., Kambembo, L., Atibu, L., Mama, N., Ilunga,
W., Sema, H., Tshimanga, K., Bongo, B., Peeters, M., Delaporte, E. 1998. Evidence of stable HIV seroprevalences in
selected populations in the Democratic Republic of the Congo. AIDS. 12(8):905-910, May 28, 1998. Lippincott-Raven
Publishers. Accessed online at http://www.aidsonline.com/pt/re/aids/abstract.00002030-19980800000013.htm;jsessionid=G2RJ7T0dyrTvHSFh2vlfNxlQSWpCf7JY0S7C8vrcBG39gXSnzQNK!2112021004!181195629!8091
!-1
Nunn A J; Wagner H U; Okongo J M; Malamba S S; Kengeya-Kayondo J F; Mulder D W. 1996. HIV-1 infection in a
Ugandan town on the trans-African highway: prevalence and risk factors, in International Journal of STD & AIDS, Volume
7, Number 2, 1 April 1996 , pp. 123-130(8). Royal Society of Medicine Press
Nyamuryekung'e K, Laukamm-Josten U, Vuylsteke B, Mbuya C, Hamelmann C, Outwater A, Steen R, Ocheng D, Msauka
A, Dallabetta G. STD services for women at truck stop in Tanzania: evaluation of acceptable approaches. 1997. East Afr
Med J. 1997 Jun;74(6):343-7.
Ramjee, G., Gouws, E.E. 2002. Prevalence of HIV among truck drivers visiting sex workers in KwaZulu-Natal, South
Africa, in Sexually Transmitted Diseases, 2002 Jan;29(1):44-9. Lippincot Williams & Wilkins
Sateren, W.B., Foglia, G., Renzullo, P. O., Elson, L., Wasunna, M., Bautista, C.T. and Birx, D. L. 2006. Epidemiology of
HIV-1 Infection in Agricultural Plantation Residents in Kericho, Kenya: Preparation for Vaccine Feasibility Studies..
Journal of Acquired Immune Deficiency Syndromes. 43(1):102-106, September 2006. Lippincott Williams & Wilkins
Seeley, J.A., Allison, E.H., 2005. HIV/AIDS in fishing communities: Challenges to delivering antiretroviral therapy to
vulnerable groups, in AIDS Care, Volume 17, Issue August 2005 , pages 688 - 697
Stoneburner, R.L., Low-Beer. D. 2004. Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda. Science
30 April 2004: Vol. 304. no. 5671, pp. 714 – 718. DOI: 10.1126/science.1093166
Sokal, D.C., Buzingo, T., Nitunga, N., Kadende P., Standaert, B. 1993. Geographic and temporal stability of HIV
seroprevalence among pregnant women in Bujumbura, Burundi. AIDS. 1993 Nov;7(11):1481-4.
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UNAIDS and WHO. 2006. Source: 2006 Report on the global AIDS epidemic, UNAIDS/WHO, May 2006.
Vidal, N., Peeters, M., Mulanga-Kabeya, C., Nzilambi, N., Robertson, D., Ilunga, W., Sema, H., Tshimanga, K., Bongo, B.,
Delaporte, E. 2000. Unprecedented Degree of Human Immunodeficiency Virus Type 1 (HIV-1) Group M Genetic Diversity
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http://jvi.asm.org/cgi/content/abstract/74/22/10498 on 5 August 2007. American Society for Microbiology
121
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
122
ANNEX VI Study Calendar
Week
Date
Lead the study, manage contracts, oversee RA
Liaise w. countries, M&E FPs on study &
dissemination
Introduce study to GLIA governance structures
GA
GAMET
Specialist
LR
Lead
Researcher
RA
Research Assistant
GP
GLIA peer review panel
Sec
GLIA
Secretariate
FP
GLIA M&E
FPs
WR
WB peer review
WB
GIS team at World Bank
1
10 14
Sept
GA
2
17 21
Sept
GA
3
24 28
Sept
GA
4
01 05
Oct
GA
5
08 12
Oct
GA
6
15 19
Oct
GA
7
22 26
Oct
GA
8
29
Oct2Nov
GA
9
5-9
Nov
11
19 23
Nov
GA
12
26 30
Nov
GA
13
3-7
Dec
GA
10
12 16
Nov
GA
GA
GA
GA
GA
GA
GA
GA
GA
RA
GA
14
10 14
Dec
GA
15
17 21
Dec
GA
16
711
Jan
GA
17
10 14
Jan
GA
18
17 21
Jan
GA
18
24 28
Jan
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
15
16
17
18
18
Sec
Literature search & cataloguing, reading &
technical review
Source documents for the study
RA
RA
RA
FP
FP
FP
Reading & technical review of all documents
LR
LR
Production of inception report (due 23/9)
LR
LR
Support production of inception report
RA
RA
Review & approve inception report
GA
GA
Provide technical input and approve the
inception report
Data review & analysis
Sec
Sec
LR
LR
Support data review & analysis
LR
LR
RA
RA
Mapping & production of graphs/tables
LR
LR
LR
LR
Supporting mapping & production of
graphs/tables
Production of GIS maps
RA
RA
RA
RA
WB
WB
Production of draft report (due 30/10)
LR
LR
LR
LR
LR
LR
Organize dissemination meetings
GA
GA
GA
GA
GA
GA
GA
GA
GA
GA
Coordinate logistics for the dissemination of
study results
Support organization of dissemination meetings
Sec
Sec
Sec
Sec
Sec
Sec
Sec
Sec
Sec
Sec
5
6
8
9
10
11
12
13
14
Week
LR
WB
RA
1
2
3
4
7
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Date
Send zero draft report for WB internal peer
review
WB peer review (ends 8/11)
Production of revised report (due 12/11)
Send first draft report to GLIA (by 15/11)
GLIA sends first draft report to GLIA peer review
panel
GLIA technical review, secretariat & own panel
(ends 30/11)
GLIA technical review, secretariat & own panel
(ends 30/11)
Production of final draft report & exec summ
(due 7/12)
Prepare PowerPoint presentation Eng
Translation of presentation and exec summary
10 14
Sept
17 21
Sept
24 28
Sept
01 05
Oct
08 12
Oct
123
15 19
Oct
22 26
Oct
29
Oct2Nov
5-9
Nov
WR
WR
19 23
Nov
26 30
Nov
GP
GP
GP
Sec
Sec
Sec
12 16
Nov
3-7
Dec
10 14
Dec
17 21
Dec
711
Jan
10 14
Jan
17 21
Jan
transl
transl
transl
GA
LR
GA
Sec
LR
LR
transl
Technical review workshop (11&12/12)
Final report from GLIA researcher (21/12/07)
Translation of final report
Submission of final report in Eng & Fr to GLIA
(20 Jan 08)
GLIA Strategic Plan Validation workshop
LR
GA
24 28
Jan
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
124
ANNEX VII Literature Catalogue
ID
1
GLIA
Country
Burundi
Title
File name
Institutions
Authors
An AIDS programme in a prison
of Burundi
Analyse de la situation du
VIH/SIDA au Burundi
Mpinganzima prison
Burundi
CSLP SIDA Version5
Society for women and AIDS in Africa, Burundi.
The XIV International AIDS Conference
SP/REFES, CSLP
D Mpinganzima et
al.
2
Burundi
3
Burundi
BULLETIN
EPIDEMIOLOGIQUE
ANNNUEL DE SURVEILLANCE
DU VIH/SIDA/IST EN 2005
BULLETIN2005definitif
4
Burundi
5
Burundi
BULLETIN
EPIDEMIOLOGIQUE
ANNNUEL DE SURVEILLANCE
DU VIH/SIDA/IST POUR
L’ANNEE 2004
BURUNDI: Prisoners form HIVpositive association behind bars
6
Burundi
Country-specific information:
BURUNDI
2006_country_progress_r
eport_burundi_en
7
Burundi
ENQUÊTE DE SURVEILLANCE
DE COMPORTEMENTS
RELATIFS AUX IST/SIDA AU
BURUNDI
BSSrapportdeplaces-finalJan05
MINISTERE DE LA SANTE PUBLIQUE UNITE
SECTORIELLE DE LUTTE CONTRE LE SIDA.
SERVICE SERO-EPIDEMIOLOGIE DU
VIH/SIDA/IST, Bujumbura, Burundi
8
Burundi
ENQUÊTE DE SURVEILLANCE
DE COMPORTEMENTS
RELATIFS AUX IST/SIDA AU
BURUNDI
BSSrapportcorpsunif-final1
9
Burundi
ENQUÊTE DE SURVEILLANCE
DE COMPORTEMENTS
RELATIFS AUX IST/SIDA AU
BURUNDI. Raport jeunes_ Final
10
Burundi
ENQUÊTE DE SURVEILLANCE
DE COMPORTEMENTS
RELATIFS AUX IST/SIDA AU
BURUNDI. Rapport Final
prostituees
Year
Lang.
Target groups
E
Prisoners
2005
F
PLHIV, OVC, women,
youth
MINISTERE DE LA SANTE PUBLIQUE UNITE
SECTORIELLE DE LUTTE CONTRE LE SIDA.
SERVICE SERO-EPIDEMIOLOGIE DU
VIH/SIDA/IST, Bujumbura, Burundi
2005
F
Women
BULLETIN EPID.
2004FINAL
MINISTERE DE LA SANTE PUBLIQUE UNITE
SECTORIELLE DE LUTTE CONTRE LE SIDA.
SERVICE SERO-EPIDEMIOLOGIE DU
VIH/SIDA/IST, Bujumbura, Burundi
2004
F
Women
BURUNDI prisons IRIN
2007
IRIN News
2007
E
Prisoners
2006
E
General population,HIVPositive people
Theodore
Niyongabo
2005
F
IDPs
MINISTERE DE LA SANTE PUBLIQUE UNITE
SECTORIELLE DE LUTTE CONTRE LE SIDA.
SERVICE SERO-EPIDEMIOLOGIE DU
VIH/SIDA/IST, Bujumbura, Burundi
Théodore
NIYONGABO
2005
F
General population
BSSrapportjeunes-final1012705
MINISTERE DE LA SANTE PUBLIQUE UNITE
SECTORIELLE DE LUTTE CONTRE LE SIDA.
SERVICE SERO-EPIDEMIOLOGIE DU
VIH/SIDA/IST, Bujumbura, Burundi
Théodore
NIYONGABO
2005
F
Young people
BSSrapportProstituéesfina
l
MINISTERE DE LA SANTE PUBLIQUE UNITE
SECTORIELLE DE LUTTE CONTRE LE SIDA.
SERVICE SERO-EPIDEMIOLOGIE DU
VIH/SIDA/IST, Bujumbura, Burundi
Théodore
NIYONGABO
2005
F
Prostitutes(Sex workres)
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
125
Title
File name
Institutions
Authors
Year
Lang.
11
GLIA
Country
Burundi
Enquête Démographique et de
Santé au Burundi 1987 (ONLY
CONTENTS CHAPTER)
Burundi DHS 1987
contents Fr.pdf
Ministère de l'Intérieur Département de la
Population Gitega Burundi, Institute for Resource
Development/Westinghouse Columbia Maryland
USA
L Segamba, V
Ndikumasabo, C
Makinson, M Ayad
1988
F
12
Burundi
ENQUETE NATIONALE DE
SEROPREVALENCE DE
L’INFECTION PAR LE VIH AU
BURUNDI
RAPPORT
SEROPREVALENCE
2002
Ministère de la Santé Publique / Ministère à la
Présidence Chargée de la Lutte contre le
Sida,Bujumbura, Burundi. World Bank
2002
F
General population
13
Burundi
ENQUETE SOCIO
COMPORTEMENTALE SUR
L’INFECTION PAR LE
VIH/SIDA AU BURUNDI
Etude 2001 Burundi
Ministère de la Santé Publique
Projet Santé Publique II
Programme National de Lutte contre le Sida Au
Burundi
2001
F
1204subjects age 15-59
14
Burundi
PLAN D'ACTION 20022006
2002
F
General population
15
Burundi
PLAN D’ACTION NATIONAL
DE LUTTE CONTRE LE
VIH/SIDA 2002-2006
Plan StrategicNational de Lutte
contre le Sida 2007-2011 Republique du Burundi.
burundi psnls 2007 2011
Présidence de la République, Ministère à la
Présidence chargé de la Lutte contre le SIDA.
2006
F
General Population
16
Burundi
Rapport d'avancement:
Objectifs du millenaire pour le
developpement
omd2004
Gouvernement du Burundi
2004
F
PLHIV
17
Burundi
RNDH Burundi_2003
Ministère de la Planification pour le Développement
(PNUD) du Développement et de la Reconstruction
(MPDR), UNDP
2003
F
General population
18
Burundi
RAPPORT NATIONAL SUR LE
DEVELOPPEMENT HUMAIN
AU BURUNDI: Le VIH/SIDA et
le Développement humain au
Burundi
Summary country profile for
HIV/AIDS treatment scale-up
june2005_bdi
WHO
2005
E
PLHIV
19
Burundi
The prevalence of HIV and risk
behavior of prostitutes living in 2
populous regions of Bujumbura
(Burundi
The prev_HIV_risk
beh_prostitutes_Bu
Faculté de médecine, Département de médecine
sociale et préventive, Université Laval, Québec,
Canada.
Buzingo T et al.
E
sex workers
20
Burundi
Validation of a Method to
Estimate Age-specific Human
Immunodeficiency Virus (HIV)
Incidence Rates in Developing
Countries Using Populationbased Seroprevalence Data
Burundi1.pdf
AIDSCAP Project Family Health International
Arlington VA, Family Health International Durham
NC, Department of Biostatistics and Epidemiology
Tulane University, School of Public Health and
Tropical Medicine New Orleans LA, Projet National
de Lutte Contre
T Saidel, D Sokal,
J Rice, T Buzingo,
S Hassig
E
Male workers
Theodore
Niyongabo
1996
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
126
Title
File name
Institutions
Authors
Year
Lang.
21
GLIA
Country
DRC
Target groups
Access to healthcare, mortality
and violence in Democratic
Republic of the Congo
DRC_healthcare_112005.pdf
MSF
Alain Kassa et al.
2005
E
5171people(Kilwa), 8792
(Basankusu), 8635
(Inongo), 9286 (Lubutu),
5035 (Bunkeya )
22
DRC
d3-hounsokouhiv_lusaka_presentation_u
nhcr_en
UNHCR
E. Hounsokou,
2006
E
Refugees and IDPs
23
DRC
ADDRESSING HIV NEEDS OF
DISPLACED POPULATIONS IN
THE DEMOCRATIC REPUBLIC
OF CONGO. PCB, UNAIDS,
Lusaka, Zambia. 6 –8
December 2006
Democratic Republic of Congo
map DRC. Pdf
UN
2004
E&F
24
DRC
bss - vol 2 final as of
august 29
Comite National de Lutte contre le SIDA, Le Fond
Mondial De Lutte Contre Le SIDA, la Tuberculose
et le Paludisme,
Patrick Kayembe
Kalambayi
2006
F
25
DRC
BSS vol 1
Rapport_de_synthese___f
inal
family Health International, Impact, CTB.
Patrick Kayembe
Kalambayi
2005
F
26
DRC
ENQUÊTE DE SURVEILLANCE
COMPORTEMENTALE (ESC)
ET DE SEROPREVALENCE
EN REPUBLIQUE
DEMOCRATIQUE DUCONGO.
RAPPORT D’ENQUÊTES:
Volume 2, Août 2006
ENQUETES DE
SURVEILLANCE DES
COMPORTEMENTS (ESC) ET
DE SEROPREVALENCE EN
REPUBLIQUE
DEMOCRATIQUE DU
CONGO.Rapport de synthèse.
30 AOUT 2005
Etude de la séroprévalence de
l'infection par le VIIH dans laa
Zone de Santé de Kalemie au
Nord Katanga
sc_hih.pdf
Save the Children
Laurent kambale
kapund
2002
Fr
596 Pregnant women age
15-49
27
DRC
etude de risque DRC
Anne Mossige et
al.
2003
F
General population
28
DRC
Etude Pilote de Risques et de la
Vulnérabilité en République
Démocratique du Congo
Global reach: how trade unions
are responding to AIDS
getadata
International Alert
Charlotte Vaillant
2006
E
General population
29
DRC
HIV/AIDS and the Uniformed
Servivices
FHISnapshotsUniformedS
ervicesenhv
FHI, ImPACT & USAID
Robert
Ritzenthaler
2005
E
uniformed
services(Military,
peacekepres)
Sex workers, military, long
distance truck drivers,
informal mines workers
(diamond&gold), street
children, unmarried
adolescents & young
adults
Sex workers, military, long
distance truck drivers,
informal mines
workers(diamond&gold),
street children, unmaried
adolescents and young
adults
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
30
GLIA
Country
DRC
PLAN STRATEGIQUE
NATIONAL DE LUTTE
CONTRE LE VIH/SIDA/MST
PSN (1999 - 2008)
PLAN STRATEGIQUE
NATIONAL. Republique
Democratique du Congo.
Cmite natioanl de Lutte contre le SIDA
31
DRC
Political and socioeconomic
instability: how does it affect
HIV? A case study in the
Democratic Republic of Congo
Congo1.pdf
Institut de Recherche pour le Developpement
Montpellier and Department of International Health
University of Montpellier France, Laboratoire du
PNLS Kinshasa/Lubumbashi/Kisangani,
Laboratoire de l’Hopital Dipumba Mbuyi-Mayi,
PNLS Ministere de la Sante DRC
32
DRC
Rapport annuel 2004 PNLS
PNLS of DRC
33
DRC
34
DRC
Report on the implementation of
the Declaration of Commitment
of Heads of State and of
Government for the response to
HIV/AIDS in the DRC.
UNGASS, 2005
Seroepidemiological survey of
hepatitis C virus among
commercial sex workers and
pregnant women in Kinshasa,
Democratic Republic of Congo
RAPPORT ANNUEL
PNLS 2004
2006_country_progress_r
eport_congo_republic_en
sex workers Congo.pdf
Laboratoire des Retrovirus, Institut de Recherche
pour le Develoment (IRD), Montpellier, France
35
DRC
Summary country profile for
HIV/AIDS treatment scale-up
june2005_cod
WHO
36
DRC
Surveillance sentinelle du VIH
chez les femmes enceintes,
RDC 2005
Serosurveillance 2005
PNLS of DRC
37
DRC
Tendances de la prevalence du
VIH entre 1985 et 2005 en RDC
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F
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IDPs, sex workers, STI
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PLHIV, OVC, women,
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General population, HIVPositive people
2001
E
1233 CSWs age 14-55
2005
E
PLHIV
J Okende
2005
F
ANC clients
University of Kinshasa
P Kayembe
2005
F
ANC clients
DRC.pdf
AIDS Reference Laboratory NACP Kinshasa, GTZ
Kinshasa, Institute of Tropical Medicine Antwerp
Belgium
D Denolf, JP
Musongela, N
Nzila, M Tahiri, R
Colebunders
2001
E
Pregnant women
Violence DRC
Editions Concordia
Collete
Braeckman et al.
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F
Women victim of sexual
violence
C Mulanga, SE
Bazepeo, JK
Mwamba, C Butel,
J-W Tshimpaka,
M Kashi, F Lepira,
M Carael, M
Peeters, E
Delaporte
C Laurent, D
Henzel, C
Mulanga-Kabeya,
G Maertens, B
Larouze, E
Delaporte
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128
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File name
Institutions
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Year
Lang.
40
GLIA
Country
Kenya
Target groups
A cow dies with grass in it’s
mouth” – Fishermen’s response
to “zero grazing” in Kisumu,
Kenya
Fishermen Kisumu 2006
AIDS 2006 - XVI International AIDS Conference
A. Sharma et al.
2003
E
Fishermen
41
Kenya
highway_ke1
AMREF
Kim Witte et al
1998
E
Commercial sex workers,
truck drivers, truck drivers
assistants and young men
42
Kenya
A Theoretically Based
Evaluation of HIV / AIDS
Prevention Campaigns Along
the Trans-Africa Highway in
Kenya
Adolescent sexual behavior
along the Trans-Africa Highway
in Kenya.
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African Medical and Research Foundation, Nairobi,
Kenya
Nzyuko S et al.
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E
200 adolescents aged 1519 at truck stops
43
Kenya
Back to basics in HIV
prevention: focus on exposure
1384.pdf
Family Health International, Imperial College
London, East West Center/Thai Red Cross Society
Collaboration, Futures Group, UNAIDS
2003
E
Persons involved in
heterosexual sex with a
partner at high risk,
casual heterosexual sex
44
Kenya
Behavioral Surveillance & STD
Seroprevalence Survey,
Western Province Kenya, 1999,
Company Workers
Kenya BSS 1999
CompanyWorkers.pdf
Universities of Nairobi and Manitoba, Impact
E Pisani, GP
Garnett, T Brown,
J Stover, NC
Grassly, C
Hankins, N
Walker, PD Ghys
U Schwartz et al.
1999
E
1000 employees(sugar &
paper processing
companies)
45
Kenya
Behavioral Surveillance & STD
Seroprevalence Survey,
Western Province Kenya, 1999,
Female Sex Workers
Kenya BSS 1999
FSWs.pdf
Universities of Nairobi and Manitoba, Impact
U Schwartz et al.
1999
E
46
Kenya
Clients of Female Sex Workers
in Nyanza Province, Kenya
Acore Group in STD/HIV
Transmission
Kenya truck drivers1
M. VOETEN et al.
2002
E
47
Kenya
Cofactors for the acquisition of
HIV-1 among heterosexual
men: prospective cohort study
of trucking company workers in
Kenya
Kenya truck driver
cofactors.pdf
Department of Public Health, Erasmus University,
Rotterdam, The Netherlands; Nyanza Provincial
Medical Office, Kisumu, Kenya; Department of
Anthropology, Moi University, Eldoret, Kenya; and
Medical Anthropology Unit, University of
Amsterdam, The Netherlands
From the Department of Medical Microbiology,
University of Nairobi, Nairobi, Kenya; Departments
of Epidemiology, University of Washington,
Seattle, WA, USA; Coast Provincial General
Hospital, Mombasa, Kenya
368Female workers in
Western province, 124
Busia, 120 Mumias, 98
Webuye, 27 Nzoia, 211
bars&lodgings, 150 home,
6 streets,1 factors
64 clients of female sex
workers
Joel Rakwar et al.
1999
E
Truck drivers, Brew
sellers, bar/ guest house
attendants, female petty
traders, sex workers
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129
48
GLIA
Country
Kenya
Title
File name
Institutions
Authors
Year
Lang.
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DEVELOPMENT OF AFRICAN
FREIGHT TRANSPORT – THE
CASE OF KENYA
Education and Nutritional Status
of Orphans and Children of HIVInfected Parents in Kenya
pop_Development_of_Afri
can_Freight_transport
DANISH INSTITUTE FOR INTERNATIONAL
STUDIES
Patrick O. Alila et
al.
2005
E
Transport workers
49
Kenya
Kenya OVC HIV
parents.pdf
ORC Macro, Central Bureau of Statistics Nairobi
Kenya
V Mishra et al.
2005
E
2756(0-4yrs) and 4172(614)orphans& children of
HIV_infected parents
50
Kenya
Effect of Circumcision on
Incidence of Human
Immunodeficiency Virus Type 1
and Other Sexually Transmitted
Diseases: A Prospective Cohort
Study of Trucking Company
Employees in Kenya
Female-to-Male Infectivity of
HIV-1 among Circumcised and
Uncircumcised Kenyan Men
Kenya truck dirvers.doc
Departments of Epidemiology, Medicine, and
Biostatistics, University of Washington, Seattle;
Departments of Medical Microbiology and
Community Health, University of Nairobi, and Coast
Provincial General Hospital, Mombasa, Kenya;
Department of Medical Micr
L. Ludo et al.
1999
E
Truck drivers, sex workers,
guest house and bars
attendants, petty traders,
and area residents
51
Kenya
Female-to-male
_inefectivity_hiv_Circ&Unc
irc_men.Kenya
University of Washington, 325 Ninth Ave., Box
359909, Seattle,WA 98104-2499. of Medical
Microbiology, University of Nairobi, Nairobi, and
6Coast Provincial General Hospital,
Mombasa, Kenya
The Infectious Diseases Society of America
Jared M. Baeten
et al.
2005
E
745Kenyan truck drivers
52
Kenya
Female-to-Male Infectivity of
HIV-1 among Circumcised and
Uncircumcised Kenyan Men
Female-to-male
_inefectivity_hiv_Circ&Unc
irc_men.Kenya
Jared M. Baeten
et al.
2005
E
745 Kenyan Truck Drivers
53
Kenya
From Behavior Change
Communication to Strategic
Behavioral Communication on
HIV in Kenya, 1999–2006
Kenya BCC 2006.pdf
FHI
P Mwarogo
2007
E
Men at worksites, female
sex workers, women, and
youth
54
Kenya
Bukusi fishermen prev
behavior 2006
AIDS 2006 - XVI International AIDS Conference
E.A. Bukusi et al.
2006
E
249 men working in the
fishing industry,
55
Kenya
HIV/STI prevalence & risk
among fishermen in Kisumu,
Kenya
Increased Risk of HIV in
Women Experiencing Physical
Partner Violence in Nairobi,
Kenya
Fonck et al Aids and
Behavior September 2005
International Centre for Reproductive Health, Ghent
University, De Pintelaan 185 P3, 9000 Ghent,
Belgium. University of Nairobi, Deptment of Medical
Microbiology, P.O. Box 19676, Nairobi, Kenya.
Karoline Fonck et
al.
2005
E
Women ictims of violence
56
Kenya
Integrating Family Planning
Services into Voluntary
Counseling and Testing Centers
in Kenya: Operations Research
Results
Kenya VCT 2006.pdf
FHI, Kenya Ministry of Health (National AIDS and
STD Control Programme & Division of
Reproductive Health), JHPIEGO, AMKENI Project
2006
E
male and female clients
age 15, and health care
providers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
57
GLIA
Country
Kenya
Kenya DHS 2003
Kenya DHS 2003.pdf
58
Kenya
Kenya HIV/AIDS Service
Provision Assessment Survey
2004
Kenya HIV MCH SPA
2004.pdf
Central Bureau of Statistics Nairobi, Ministry of
Health Nairobi, Kenya Medical Research Institute,
National Council for Population and Development
Kenya, ORC Macro Maryland USA, Centers for
Disease Control and Prevention Nairobi Kenya
National Coordinating Agency for Population and
Development Nairobi Kenya, MOH Kenya, ORC
Macro
59
Kenya
NSP_Ke.2005
60
Kenya
Kenya Natioanal AIDS Strategic
Plan/KNASP 2005/6-2009/10
Kenya Prisons Health
Services/Aids control uniy
61
Kenya
62
130
Authors
Year
Lang.
2004
E
General population
2005
E
Health facilities
National AIDS Control Council (NACC).
2005
E
General Population
Kenya Prisons ACU doc
Kenya Prison Service
2007
E
Prisoners
KENYA: Slow response to high
HIV rates in prisons
Kenya prisons IRIN 2007
IRIN News
2007
E
Prisoners
Kenya
Long distance truck-drivers: 1.
Prevalence of sexually
transmitted diseases (STDs)
truck drivers.doc
Department of Medical Microbiology, College of
Health Sciences, University of Nairobi. Kenya
Bwayo JJ et al.
1991
E
331 men truck drivers
63
Kenya
Male circumcision for HIV
prevention in young men in
Kisumu, Kenya: a randomised
controlled trial
Bailey circumcision 2007
Division of Epidemiology and Biostatistics, School
of Public Health, University of Illinois at Chicago,
Robert C Bailey et
al.
2007
E
2784 men aged18-24
64
Kenya
Mapping transactional sex on
the Northern Corridor highway
in Kenya
Highway_ke2
Department of Medical Microbiology, University of
Manitoba, Canada
Alan G.
Fergusona and
Chester N. Morris
2006
E
381 truck drivers and 403
sex workers
65
Kenya
Migration, Sexual Behavior and
the Risk of HIV in Kenya
Migration_SB_Risk_Kenya
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Center for Migration Srudies of New York
Martin Brockerhoff
& Ann E.
Biddlecom
1999
E
7540 women, 2336 men
66
Kenya
Kenya final report
UNHCR, WHO
Adelekan ML
2006
E
refugees, women brewers,
CSW, drug users
67
Kenya
Rapid assessment of substance
use and HIV vulnerability in
Kakuma refugee camp and
surrounding community,
Kakuma, Kenya
Seroprevalence of HIV, HBC
and HCV in injecting drug users
in Nairobi, Kenya: World Health
Organization Drug Injecting
Study Phase II findings
HIV_IDUs_kenya
International Conference AIDS 2004 Jul 11-16
Odek-Ogunde M,
Okoth FA, Lore W,
Owiti FR
2004
E
IDUs
R Muga et al.
Target groups
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ID
131
68
GLIA
Country
Kenya
Title
File name
Institutions
Authors
Year
Lang.
Target groups
Sex for fish - transactional
relationships between fishermen
and widows in Kisumu, Kenya
Short term estimates of adult
HIV incidence by mode of
transmission: Kenya and
Thailand as examples
Buffardi Sex for fish 2006
AIDS 2006 - XVI International AIDS Conference
A. Buffardi et al.
2006
E
Fishermen, sex workers,
female fishmongers
69
Kenya
Gouws_MoT2005_STI200
6
Department of Policy, Evidence and Partnership,
Joint United Nations Programme on HIV/AIDS
(UNAIDS),
Geneva, Switzerlan
E Gouw et al.
2006
E
IDUs, Partners IDU, SW,
SW clients, partners of
clients, MSM, partners of
MSM
70
Kenya
Spatial modeling of HIV
prevalence in Kenya
Kenya spatial modeling
HIV prevalence
Measure DHS
L Montana, M
Neuman, V Mishra
2007
E
4303 women age 15-49
and 4183 men age 15-54
(Interviews and HIV tests)
71
Kenya
STUDY ON THE IMPACT OF
HIV/AIDS ON FISHING IN
KENYA AND HOW THE
MOLFD CAN RESPOND
Fisheries Final
MINISTRY OF LIVESTOCK AND FISHERIES
DEVELOPMENT, Kenya
2004
E
Fishermen
72
Kenya
Summary country profile for
HIV/AIDS treatment scale-up
june2005_ken
WHO
2005
E
PLHIV
73
Kenya
TB and
AIDS_prisons_kenya-doc
Centers for Disease Control & Prevention, Nairobi,
Kenya
Odhiambo J et al.
2004
E
Prisoners
74
Kenya
Odhiambo Kenya Prison
The XV International AIDS Conference
J Odhiambo et al.
E
Prisoners
75
Kenya
TB and AIDS: The leading
preventable causes of prison
deaths in Kenya
TB and AIDS: The leading
preventable causes of prison
deaths in Kenya
The HIV/AIDS Epidemic in
Kenya
Kenya aids profile.pdf
Government of Kenya, Ministry of Health;
National AIDS Control Council of Kenya; WHO
2005
E
General population, HIVPositive people
76
Kenya
The impact of HIV/AIDS on rural
households and land issues in
Southern and Eastern Africa
FAO migration
Human Sciences Research Council Pretoria RSA
S Drimie
2002
E
Rural communities, Truck
drivers, sex workers
77
Kenya
The rise of injecting drug use in
east Africa: a case study from
Kenya
HIV_IDUs_kenya1
Public and Environmental Health Research Unit,
London School of Hygiene & Tropical Medicine,
London, UK
Susan Beckerleg
et al.
2005
E
IDUs
78
Kenya
The Stall in the Fertility
Transition in Kenya
Kenya fertility
transition.pdf
Office of Population Research Princeton University,
ORC Macro
CF Westoff, AR
Cross
2006
E
Women
79
Kenya
The Sugar Daddy Syndrome:
African Campaigns Battle
Ingrained Phenomenon
cross-gen
Population Services International, Washington,
DC ,USA
2005
E
older men, young women
80
Kenya
TOTAL WAR AGAINST HIV
AND AIDS PROJECT
TOWA PAD MAY 10 FINAL
World Bank
2007
E
General population
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
UNGASS 2006 Country Report
Kenya Reporting period:
January 2003 – December 2005
Using diaries to measure
parameters of transactional sex:
an example from the TransAfrica highway in Kenya
2006_country_progress_r
eport_kenya_en
highway_ke5
Futures Group, Nairobi, Kenya; Strengthening
STD/HIV Control Project, Nairobi, Kenya; University
of Manitoba, Canada; and
University of Nairobi, Kenya
132
81
GLIA
Country
Kenya
Authors
82
Kenya
83
Kenya
Behavioural Surveillance
Surveys Among Refugees and
Surrounding Host Population
kakuma BSS.pdf
UNHCR
84
Kenya
Urban poor Nairobi
UNDP South East Asia HIV and Development
Programme Workshop
85
Rwanda
Census Rwanda 2002
MINISTRY OF FINANCE AND
ECONOMIC PLANNING
86
Rwanda
Sex and survival, the sexual
behavior of the poor in African
cities. ( Paper presented at the
UNDP South East Asia HIV and
Development Programme
Workshop on Inter-relations
between Development, Spatial
Mobility, and HIV/AIDS. Paris,
France, September 1-3 2004
3rd GENERAL CENSUS OF
POPULATION AND HOUSING
OF RWANDA – AUGUST 2002
Advocacy for HIV/AIDS
prevention in / from Rwanda's
prisons
Advocacy for HIVRwPrisons
ARBEF, Kigali, Rwanda
87
Rwanda
ANNUAL REPORT ON
IMPLEMENTATION OF HIV
AND AIDS ACTIVITIES IN
RWANDA, 2006
Annualreport_HIV
AIDS_Rwanda2006
Kampala, Uganda
88
Rwanda
Current trends in Rwanda’s
HIV/AIDS epidemic
Current_trendsRwanda20
06
US Centers for Disease Control and Prevention,
Global AIDS Program, 2210 Kigali Pl, Washington,
DC 20521, USA
E Kayirangwa et
al.
2006
E
General population
89
Rwanda
Enquete de surveillance
comportementale chez les
refugies et la population (Camp
de Kiziba et secteurs de
Rubazo et Kagabiro)
BSS RWANDA FINAL 2111-05.pdf
UNHCR
Cheikh Tidiane
Touré, Paul
Spiegel
2004
F
Refugees, IDPs, host
community
Alan G. Ferguson
et al.
F. Nii-Amoo
Dodoo
Nyabienda L.
Year
Lang.
Target groups
2006
E
General population, HIVPositive people
2006
E
403 female sex workers
2004
E
Refugees, Host population
2004
E
Urban poor population
2003
E
Generale Populaton
2002
E
Prisoners
2007
E
General population
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
90
GLIA
Country
Rwanda
FOLLOW-UP TO
THEDECLARATION OF
COMMITMENT ON HIV/AIDS
(UNGASS)
UNGASS2006_23Feb 2
UNAIDS
91
Rwanda
Good practices in HIV Rwanda
92
Rwanda
Health Sector Policy.
Government of Rwanda
good practices in HIV
Rwanda
041027 Final Health Policy
Paper
93
Rwanda
HIV/AIDS and STI prevention
and care in Rwandan refugee
camps in the United Repiblic of
Tanzania
Prevention and care in
camps in Tz
94
Rwanda
PLACE Rwanda: Resume des
indicateurs
Etude PLACE
95
Rwanda
PLAN STRATEGIQUE
NATIONALE DE LUTTE
CONTRE LE VIH/SIDA. Version
finale
RwandaNSF2005FR
PRESIDENCE DE LA REPUBLIQUE DU
RWANDA. COMMISSION NATIONALE DE LUTTE
CONTRE LE SIDA
96
Rwanda
Population Mobility and
HIV/AIDS in Indonesia
JC513-PopMob-Tu-en
97
Rwanda
Rwanda Demographic and
Health Survey 2005
98
Rwanda
99
133
Authors
Year
Lang.
2006
E
General population
E
General population, local
communities, Civil Society
General population, HIVPositive people
Dr.Agnès
Binagwaho et al.
Target groups
Government of Rwanda
2004
E
UNAIDS/UNHCR
2003
E
Refugees
F
FSW and clients, youth
2005
F
General Population
UNAIDS
2001
E
Migrants, mobile
populations, and locale
populations
Rwanda DHS 2005
Eng.pdf
Institut National de la Statistique Ministère des
Finances et de la Planification Économique
Rwanda, ORC Macro
2006
E
Male and female age 1559
Rwanda Enquête
Démographique et de Santé
2005
Rwanda DHS 2005 Fr.pdf
Institut National de la Statistique Ministère des
Finances et de la Planification Économique
Rwanda, ORC Macro
2006
F
Male and female age 1559
Rwanda
Rwanda Enquête sur la
prestation des services de soins
de santé 2001
RW01SPAFr.zip
Ministry of Health Rwanda, National Population
Office Rwanda, ORC Macro
2003
F
Health care providers and
clients
100
Rwanda
Rwanda Service Provision
Assessment Survey 2001
RW01SPAEng.zip
Ministry of Health Rwanda, National Population
Office Rwanda, ORC Macro
2003
E
Health care providers and
clients
101
Rwanda
RWANDA: FOLLOW-UP TO
THE DECLARATION OF
COMMITMENT ON HIV/AIDS
(UNGASS)
2006_country_progress_r
eport_rwanda_en
2006
E
General population, HIVPositive people
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
102
GLIA
Country
Rwanda
Summary country profile for
HIV/AIDS treatment scale-up
june2005_rwa
103
Rwanda
VIH/SIDA au Rwanda: Bulletin
epidémiologique
104
Tanzania
105
Tanzania
106
134
Year
Lang.
WHO
2005
E
PLHIV
TRAC (2005), Estimations
et projections
epidemiologiques
Treatment & Research AIDS Center
2005
F
PLHIV, prisoners
A typology of groups at risk of
HIV/STI in a gold mining town in
north-western Tanzania
Antibody to Herpes Simplex
Virus Type 2 as a Marker of
Sexual Risk Behavior in Rural
Tanzania
AMREF2
AMRF; Medical Research Council Social and
Public Health Sciences Unit, University of Glasgow,
UK
London School of Hygiene and Tropical Medicine
Nicola Desmond
et al.
2002
E
Male mineworkrs &
women
Angela Obasi et
al.
1999
E
259 women and 231 men
in 12 rural communities
Tanzania
Behavioural Surveillance
Surveys Among Refugees and
Surrounding Host Populations:
Lukole and Lugufu, Tanzania
Tanzania BSS Ref-Host
Pop FINAL 2005.pdf
2005
E
3200 persons: 50%
refugees & 50 % host pop,
15-49yrs
107
108
Tanzania
Tanzania
Census Tanzania 2002
Community effects on the risk of
HIV infection in rural Tanzania
Census Tanzania 2002
tanzania7.pdf
109
Tanzania
Country AIDS policy analysis
project: HIV/AIDS in Tanzania
110
Tanzania
111
Tanzania
112
Tanzania
Evaluation of the introduction of
post-exposure prophylaxis in
the clinical management of rape
survivors in Kibondo refugee
camps Tanzania
Exploring the Association
between HIV and Violence:
Young People's Experiences
with Infidelity, Violence and
Forced Sex in Dar es Salaam,
Tanzania
Gender Inequality and Intimate
Partner Violence among
Women in Moshi, Tanzania
Tanzania migration 2.doc
Authors
UNHCR
Target groups
Carolina Population Center, University of North
Carolina,USA.
SS Bloom et al.
2002
2002
E
E
General Population
2271 men &2752 women
15-44yrs
Country policy analysis
2004 HIV in Tz
AIDS Policy Research Center
L Garbus
2004
E
PEP FIELD
EXPERIENCE. doc
UNHCR
Altaras R,
Schilperoord M
2005
E
Miners, women, OVCs,
refugees, trafficked
people, prisoners, FSW,
GBV victims
Refugees, GBV women,
health professionals
Association-hiv-violenceDar es Salaam_Tz
School of Nursing, Department of lnternational
Health, Bloomberg School of Public Health,Johns
Hopkins University,Baltimore, MD, USA.
Heidi Lary et al.
2005
E
40 young men and 20
young women aged 16-24
GenderInequality_violence
School of Social Policy and Practice, Universio of
Pennsylvania, Philadelphia, PA, USA. Department
of Society, Human Development and Health.
Haward School of Public Health, Cambridge, MA,
USA. Department of Sociology, University of
Maryland, College Park
Laura Ann
McCloskey et al.
2005
E
1444 Women aged 20-44
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
135
Title
File name
Institutions
Authors
Year
Lang.
113
GLIA
Country
Tanzania
Target groups
High potential of escalating HIV
transmission in a low
prevalence setting in rural
Tanzania
Tanzania2a.pdf
Khadija I YahyaMalima et al.
2007
E
1698 adults age 15-49
114
Tanzania
HIV Impact on Mother and Child
Mortality in Rural Tanzania
tanzania4.pdf
Japheth
Ng’weshemi et al.
2003
E
26000 inhabitants
115
Tanzania
HIV Prevention among Injecting
Drug Users: Responses in
Developing and Transitional
Countries
Ball_HIVPrevention
Centre for International Health, University of
Bergen, Bergen, Norway; School of Nursing,
Muhimbili University College of Health Sciences,
Dar es Salaam, Tanzania; Department of Training,
Ministry of Health, Dar es Salaam, Tanzania;
Haydom Lutheran Hospit
TANESA Project and National Institute for Medical
Research, Mwanza Tanzania; Measure Evaluation
Project, University of North Carolina, Chapel Hill;
and Centre for Population Studies, London School
of Hygiene and Tropical Medicine, UK
World Health Organization, 20 Avenue Appia, 1211
Geneva 27, Switzerland
Andrew L. Ball et
al.
1998
E
IDUs
116
Tanzania
HIV/AIDS /STI Surveillance
Report
HIV_AIDS_STI
Surveillance Report 19
Ministry of Health, Tanzania Mainland
2005
E
General Population
117
Tanzania
bar staff Tanzania
Department of Population and International Health,
Harvard School of Public Health, 665 Huntington
Avenue, Bldg. 1, Room 1106A, Boston, MA 02115,
U.S.A
Saidi H. Kapiga et
al.
2002
E
Female bar and
hotelworkers
118
Tanzania
HIVpositivewomen_partnerviol
ence
American Public Health Association
Suzanne Maman
et al.
2002
E
HIV-Positive Women
victim of violence
119
Tanzania
Hope_for_Tz_Mbeya
Ministry of Health, United Republik of Tanzania &
GTZ
B. Jordan-Harde
et al.
2000
E
General population
120
Tanzania
HIV-1 Epidemic Among Female
Bar And Hotel Workers in
Northern Tanzania: Risk
Factors and Opportunitiesfor
Prevention
HIV-Positive Women Report
More Lifetime Partner Violence:
Findings From a Voluntary
Counseling and Testing Clinic in
Dar es Salaam, Tanzania
Hope for Tanzania: Lessons
Learned from a Decade of
Comprehensive AIDS Control in
Mbeya Region. Part I:
Experiences and Achievements
Introduction of a pilot project for
post-exposure prophylaxis for
rape survivors in refugee camps
in Tanzania
PEP Tanz camps MS 181-04
UNHCR, IRC, UNFPA
Schilperoord M,
Okumu G,
Doedens W
2004
E
Refugees, GBV women
121
Tanzania
Methodological lessons from a
cohort study of high risk women
in Tanzania
tanzania8.pdf
Centre for Population Studies, London School of
Hygiene and Tropical Medicine, London, UK
O Hoffman et al.
2004
E
770 barmaids, 91
questhouse attendants,
123 restaurant attendants,
and 535 sellers of local
brew( All female)
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
136
Title
File name
Institutions
Authors
Year
Lang.
122
GLIA
Country
Tanzania
Mobility and HIV in Tanzanian
couples: both mobile persons
and their partners show
increased risk
Kishamawe mobility
Tanzania 2006
Department of Public Health, Erasmus MC,
University Medical Center Rotterdam. PO Box
1738, 3000 DR Rotterdam, The Netherlands
Coleman
Kishamawe et al.
2006
E
2800 Mobile couples
123
Tanzania
National Multi - Sectoral
Strategic Framework on HIV
and AIDS 2008 – 2012
Tanzania. 5th and Final Draft
NSF 2008 - 2012_Tz
2007
E
General Population
124
Tanzania
Prevalence and risk factors for
HIV-1 infection in rural
Kilimanjaro region of Tanzania:
Implications for prevention and
treatment
tanzania3.pdf
2007
E
2093 Individuals 25-44 yrs
125
Tanzania
AMREF1
E
Young refugees 10-20yrs
126
Tanzania
AMREF6
AMREF, UNHCR Tz.
2003
E
Refugees and host
populations
127
Tanzania
Prevention of HIV Infection and
Enhancement of reproductive
Health among Young People in
Refugees camps of Northwestern Tanzania
REPORT ON
IMPLEMENTATION OF THE
EXPANSION OF STD/HIV/AIDS
SERVICES FOR REFUGEES
AND REFUGEE AFFECTED
POPULATIONS OF KIGOMA
AND KAGERA REGIONS
Risk factors for active syphilis
and TPHA seroconversion in a
rural African population
Department of General Practice and Community
Medicine, University of Oslo, Oslo, Norway;
Department of Epidemiology and Biostatistics,
Muhimbili University College, Dar es Salaam,
Tanzania; Department of Nutrition, University of
Oslo, Oslo, Norway and Dep
African Medical & Research Foundation (AMREF)
tanzania and syphilis mobility.pdf
James Todd et al.
2001
E
5956 men & 6630 women
15-54 yrs
128
Tanzania
Risk Factors Influencing HIV
Infection Incidence in a Rural
African Population: A Nested
Case-Control Study
tanzania6.pdf
James Todd et al.
2005
E
92 case patients & 903
control subjects
129
Tanzania
Seroepidemiology for HIV, HBV,
HCV and HTLV among patients
attending public health clinics in
Zanzibar-Tanzania
Zanzibar epidemiology for
HIV 2002
National Institute for Medical Research, Mwanza,
Tanzania; London School of Hygiene and Tropical
Medicine, London, UK; AMREF, Mwanza,
Tanzania; Regional Medical Office, Mwanza,
Tanzania
London School of Hygiene and Tropical Medicine,
London, United Kingdom; National Institute for
Medical Research; African Medical and Research
Foundation; Regional Medical Office, Mwanza,
Tanzania; and WHO
XVI International AIDS Conference
P Fedeli et al.
2006
E
2729 public health clinics'
patiants
Elia J Mmbaga et
al.
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
137
130
GLIA
Country
Tanzania
Title
File name
Institutions
Authors
Year
Lang.
Sexual and Reproductive Health
Project for Refugee Impacted
District in West and North West
Tanzania Ngara and Kigoma
Region
SEXUAL VIOLENCE,
PRESSURE AND HIV IN
RURAL MWANZA, TANZANIA
AMREF5
AMREF & UNFPA
AMREF3
AMREF
M. Plummer et al.
Sociodemographic context of
the AIDS epidemic in a rural
area in Tanzania with a focus
on people's mobility and
marriage
Summary country profile for
HIV/AIDS treatment scale-up
SUMMARY REPORT OF
BEHAVIOURAL
SURVEILLANCE SURVEYS
AMONG YOUTHS, 2002
tanzania5.pdf
Department of Epidemiology, School of Public
Health, and Carolina Population Center, University
of North
Carolina, Chapel Hill, USA
J T Boerma et al.
june2005_tza
Target groups
1998
E
Refugees
131
Tanzania
E
6077 primary school
adolescents
132
Tanzania
2002
E
20000 People 14-44yrs
133
Tanzania
WHO
2005
E
PLHIV
134
Tanzania
SummaryReport BSS
Youths 2002 Issued 2004
MINISTRY OF HEALTH
2004
E
Young people
135
Tanzania
Surveillance of HIV and Syphilis
Infections Among Antenatal
Clinic Attendees 2005/06
ANC 3 report 02-1-2007
MINISTRY OF HEALTH AND SOCIAL WELFARE
TANZANIA MAINLAND
Rowland Swai et
al.
2006
E
31224 women antenatal
clinic attendees
136
Tanzania
incident diseases
Tanzania
Infectious Disease Epidemiology Unit, London
School of Hygiene and Tropical Medicine, Keppel
Street, London WC1E 7HT, UK
Kate K. Orrotha et
al.
2000
E
12537 adults aged 15-54
137
Tanzania
National Bureau of Statistics Tanzania, National
AIDS Control Programme Tanzania, ORC Macro
National Bureau of Statistics Tanzania, ORC Macro
E
Tanzania
Tanzania atlas HIV
indicators 2004.pdf
Tanzania DHS 2004.pdf
2006
138
Syndromic treatment of sexually
transmitted diseases reduces
the proportion of incident HIV
infections
attributable to these diseases in
rural Tanzania
Tanzania Atlas of HIV/AIDS
Indicators 2003-04
Tanzania Demographic and
Health Survey 2004
2005
E
Men awomen age 15-49
from 6499 households
9735 households: men &
women age 15-49
139
Tanzania
Tanzania HIV/AIDS Indicator
Survey 2003-04
Tanzania AIS 2003.pdf
Tanzania Commission for AIDS, National Bureau of
Statistics Tanzania, ORC Macro
2005
E
General population, HIVPositive people
140
Tanzania
TANZANIA: FOLLOW-UP TO
THE DECLARATION OF
COMMITMENT ON HIV/AIDS
(UNGASS)
2006_country_progress_r
eport_tanzania_en
2006
E
General population,HIVPositive people
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
141
GLIA
Country
Tanzania
Title
File name
Institutions
The Development Potential of
Regional Programs: An
Evaluation of World Bank
Support of Multicountry
Operations
The NACP: Historical
background of HIV/AIDS
epidemic in Tanzania
ROADS
SignMay2007_A4_2
142
Tanzania
143
Tanzania
The role of behavioral data in
HIV surveillance
behav data - mobility.pdf
144
Tanzania
The silent HIV epidemic among
pregnant women within rural
Northern Tanzania
Tanzania.pdf
145
Tanzania
Towards Borderless Strategies
Against HIV/AIDS
Tanzania_Phase1_Tpt_HI
V-AIDS_Final-Microsoft
Word
146
Tanzania
jc1291-mbeya_en
147
Tanzania
Towards universal access to
prevention, treatment and care:
experiences and challenges
from the Mbeya region in
Tanzania—a case study
TRANSPORT SECTOR
RESPONSE TO HIV/AIDS:
TAMING HIV/AIDS ON OUR
ROADS
148
Tanzania
Trends in HIV and sexual
behaviour in a longitudinal study
in a rural population in
Tanzania, 1994–2000
Tanzania migration.pdf
138
Authors
Year
Lang.
FHI & USAID
2007
E
NACP_Tz Profile 2006
NACP Tanzania
2006
E
Centre for Population Studies, London School of
Hygiene and Tropical Medicine, National Institute
for Medical Research Mwanza Tanzania,
Department of Measurement and Health
Information Systems WHO
Centre for International Health, University of
Bergen, Bergen, Norway; School of Nursing,
Muhimbili University College of Health Sciences,
Dar es Salaam, Tanzania; Department of Training,
Ministry of Health, Dar es Salaam, Tanzania;
Haydom Lutheran Hospit
Transportek
B Zaba, E
Slaymaker, M
Urassa, JT
Boerma
2005
E
Pregnant women
Khadija I YahyaMalima et al.
2006
E
1377 Rural pregnant
women
2004
E
2007
E
Truck drivers, SWs,bar
maids, brothel girls, lodge
attendants, local brew
sellers, free lance ‘street
workers, truck driver
assistants and workers in
the road construction
industry.
General population
E
Transport workers
E
5783 men and women in
1994-1995 (round1), 6392
in 1996-1997 (round2) and
7438 in 1999-2000
(round3), 15 yrs and over
Dr Ulrich F. Vogel
TranspSectorZb_Tz_Resp
onse_HIVAIDS.pdf
TANESA Project and National Institute for Medical
Research, Mwanza Tanzania; Department of
Epidemiology, University of North Carolina, Chapel
Hill; and Centre for Population Studies, London
School of Hygiene and Tropical Medicine, UK
Gabriel Mwaluko
et al.
2003
Target groups
Long-transport drivers and
community members
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
149
GLIA
Country
Tanzania
139
Title
File name
Institutions
Authors
Year
Lang.
WHO Multi-country study on
women's Health and Domestic
Violence Against Women
Prevalence of HIV infection in
male prison inmates in
Zanzibar: a voluntary
programme
Tanzania2
WHO
Jessie Mbwambo
2005
E
1820 women
aged between 15 and 49
Ali AK et al.
1993
E
Male prisoners
Mohammed. J. U.
Dahoma et al.
2006
E
26 female and 482 male
DUs
2006
E
2003
E
1. ZAC National M&E
Office 2. District HIV/Aids
Focal Persons 3.
DACCOMs, SHACCOMs
4. Umbrella Organisations
5. HIV and AIDS
implementers 6. Funders
of HIV and AIDS
interventions
General Populations
150
Tanzania/
Zanzibar
Hiv_male prison inmatesZanzibar.doc
151
Tanzania/Z
anzibar
HIV AND SUBSTANCE
ABUSE:THE DUAL EPIDEMICS
CHALLENGING ZANZIBAR
Zanzibar IDU study
Zanzibar AIDS Control Programme, Ministry of
Health and Social Welfare, Zanzibar, Tanzania
152
Tanzania/Z
anzibar
SPECIFICATIONS FOR
PARTICIPATORY
SUPERVISION AND DATA
AUDITING
ZAC Supervision
Guidelines Type 1
Zanzibar AIDS Commission
153
Tanzania/Z
anzibar
Zanzibar National HIV/AIDS
Strategic Plan 2003-2007
ZNSP after PSs Mtg
Zanzibar AIDS Commission(ZAC)
154
Tanzania/Z
anzibar
Zanzibar National Multisectoral
HIV Monitoring andEvaluation
System Volume2
Zanzibar National HIV
M&E Framework 2006
volume 2 - final
Zanzibar AIDS Commission
2006
E
155
Tanzania/Z
anzibar
Zanzibar National Multisectoral
HIV Monitoring andEvaluation
System: Guidelines for
Zanzibar’s HIV and AIDS
Programme Monitoring System
ZHAPMoS%20guidelines
%20rev%207
Zanzibar AIDS Commission
2006
E
F.S Chizimbi et al.
Target groups
1. ZAC National M&E
Office 2. District HIV/Aids
Focal Persons 3.
DACCOMs, SHACCOMs
4. Umbrella Organisations
5. HIV and AIDS
implementers
6. Funders of HIV and
AIDS interventions
1. ZAC National M&E
Office 2. District HIV/Aids
Focal Persons 3.
DACCOMs. SHACCOMs
4. Umbrella Organisations
5. HIV and AIDS
implementers
6. Funders of HIV and
AIDS interventions
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Tanzania/Z
anzibar
Title
File name
Institutions
ZanzibarZanzibar National
Multisectoral HIV Monitoring
andEvaluation System
Volume1
Zanzibar National HIV
M&E Framework 2006
volume 1 - final
Zanzibar AIDS Commission
157
Uganda
age difference Uganda
158
Uganda
Age Differences in Sexual
Partners and Risk of HIV-1
Infection in Rural Uganda
Behavioral Surveillance Surveys
Uganda 2006
School of Hygiene and Public Health, Johns
Hopkins University, 615 North Wolfe Street,
Baltimore, MD 21205, U.S.A
UNHCR, World Bank, GTZ, OPM, MOH, UAC, AAH
159
Uganda
Bringing HIV Prevention to
Scale: An Urgent Global Priority
pwghiv_prevention_report_fina
l_en.pdf
Global HIV Prevention Working Group
160
Uganda
Coerced First Intercourse and
Reproductive Health among
Adolescent Women in Rakai,
Uganda
Coerced-firstintercouse_reprodhealth_
women.Rakai.Ug
161
Uganda
Condom acceptance is higher
among travelers in Uganda
mobilitiy and risk
reduction.pdf
162
Uganda
Country AIDS policy analysis
project: HIV/AIDS in Uganda
163
Uganda
164
Uganda
Education of refugees in
Uganda: Relationships between
setting and access
Going Beyond "ABC" to Include
"GEM": Critical Reflections on
Progress in the HIV/AIDS
Epidemic
Garbus (2003) Country
AIDS policy analysis
project Uganda
Dryden (2003) Education
of refugees in Uganda
Department of Population and Health Sciences,
Bloomberg School of Public Health,Johns Hopkins
University,Baltimore M.D, USA; Rakai Health
Sciences Program, Uganda Virus Research
Institute, Entebbe, Uganda
Departments of Sociology and Statistics, The
Pennsylvania State University, University
Park,Pennsylvania; The Center for Population and
Family Health, Columbia University, New York,
New York, USA; The Department of Medicine and
Clinical Epidemiology Unit,
AIDS Policy Research Center
165
Uganda
156
Great Lakes Initiative on
HIV/AIDS Behavioral
Surveillance Surveys
140
Year
Lang.
2006
E
Robert J. Kelly et
al.
2003
E
K McDavid
2006
E
Refugees & host
communities
2007
E
Uncircumcised male
adults, IDUs, MSM, SWs,
prisoners, students
Michael A. Koenig
et al.
2004
E
575 sexually experienced
adolescent women
Martina Morris et
al.
2000
E
1627 adults (15-49
yrs)Mobile
Population/Travelers and
non-travelers
L Garbus, E
Marseille
2003
E
Refugee Law Project
S DrydenPeterson
2003
E
PLHIV, women, OEV,
military, trafficked people,
IDPs, refugees
Refugees
ABC_GEM_HIV.AIDS.wor
d.doc
HIV Center for Clinical and Behavioral Studies,
New York State Psychiatric Institute and Columbia
University, 1051 Riverside Drive Unit 15, New York,
NY 10032
Shari L. Dworkin
and Anke A.
Ehrhardt
2007
E
General Population
behavioral_surveillance_re
port 2006 GLIA
GLIA & UNHCR
2006
E
Refugees
Final Uganda BSS.pdf
Authors
Target groups
1. ZAC National M&E
Office 2. District HIV/Aids
Focal Persons 3.
DACCOMs, SHACCOMs
4. Umbrella Organisations
5. HIV and AIDS
implementers
6. Funders of HIV and
AIDS interventions
6177 women aged 15-29
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
166
GLIA
Country
Uganda
Title
File name
Institutions
Health and mortality survey
among internally displaced
persons in Gulu, Kitgum and
Pader districts, northern
Uganda
HEALTH EDUCATION IN
REFUGEE CAMPS HIV/AIDS
PEER EDUCATION
PROGRAMME FOR
ADOLESCENTS AND YOUTH
IN REFUGEE CAMPS OF
EAST AND HORN OF AFRICA
HIV Epidemic Trends in
Uganda: 1989 - 2005
Ugandamortsurvey IDP
WHO, Unicef, WFP, UNFPA, IRC & MINISTRY OF
HEALTH, THE REPUBLIC OF UGANDA
167
Uganda
AMREF4
AMREF
168
Uganda
Uganda HIV
Trends_Toronto_
169
Uganda
HIV/AIDS AS A SECURITY
ISSUE IN AFRICA: LESSONS
FROM UGANDA.16 April 2004
HIV/AIDS management and
control in the Uganda Prison
Service (UPS)
HIV/AIDS RELATED
KNOWLEDGE AND
PRACTICES AMONG
SECONDARY SCHOOL
STUDENTS
Home-Based HIV Testing and
Counselling in a Survey Context
in Uganda
Intimate partner violence
against women in eastern
Uganda: implications for HIV
prevention
IssuesReport_233
170
Uganda
171
Uganda
172
Uganda
173
Uganda
174
Uganda
JUST DIE QUIETLY:
DOMESTIC VIOLENCE AND
WOMEN’S VULNERABILITY
TO HIV IN UGANDA
uganda0803full
Human Right Watch
175
Uganda
Male circumcision for HIV
prevention in men in Rakai,
Uganda: a randomised trial
Gray circumcision 2007
Johns Hopkins University, Bloomberg School of
Public Health, Suite 4132, 615 N Wolfe Street,
Baltimore, MD 21215, USA
141
Year
Lang.
2005
E
IDPs
Kalimi Mworia
and Josephat
Nyagero
2003
E
67762 Adolescents and
youth refugees(Ug)
National AIDS Control Programme, Ministry of
Health, Uganda. MRC/UVRI Uganda Research Unit
on AIDS, Uganda Virus Research Institute
International Crisis Group
LA Shafer et al.
2005
E
General population,
pregnant women
2004
E
Kaddu Uganda Prison
Uganda Prisons Service, Kampala, Uganda & The
XV International AIDS Conference
M Kaddu and F
Nabatanzi
2004
E
Militaries, uniformed
forces, War & Conflict
affected populations
Prisoners
SCHOOL BASELINE
SURVEY SEXUALITY
UGANDA HIV/AIDS CONTROLPROJECT
2006
E
SECONDARY SCHOOL
STUDENTS
Uganda home based HIV
testing.pdf
ORC Macro, Child Health and Development Centre
Makerere University Uganda, MOH Uganda, CDC
Uganda
Department of Paediatrics and Child Health,
Makerere University and the Centre for
International Health, Bergen University
PS Yoder et al.
2006
E
902 women and 784 men
age 15-49
Charles AS
Karamagi et al.
2006
E
Rural and urban women
with infants.
2003
E
Women Victim of domestic
violence
2007
E
4996 Uncircumcised men
Women_intimateviolence_Ug
Authors
Ronald H Gray et
al.
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
142
Title
File name
Institutions
Authors
Year
Lang.
176
GLIA
Country
Uganda
Mortality associated with HIV
infection in rural Rakai District,
Uganda
uganda migration.pdf
Nelson K.
Sewankambo et
al.
2000
E
11571 persons in round1,
4171 in round2 and 4241
in round 3=19983 subjects
15-59yrs
177
Uganda
E
General Population
Uganda
NSP - FINAL DRAFT 28
august 2007 DG
comments
36385523
2007
178
National HIV and AIDS
Strategic Plan 2007/8 – 2011/12
Final Draft
Prevalence and risk factors for
Hiv-1 infection in three parishes
in westrn Uganda
Department of Medicine and Clinical Epidemiology
Unit, Faculty of Medicine, Makerere University,
Kampala, Uganda; Department of Population and
Family Health Sciences, Johns Hopkins University,
School of Hygiene and Public Health, Baltimore,
Maryland, USA;
Uganda AIDS Commission
GTZ; Ministry of Health, Uganda and Bernhard
Nocht Institute for tropical Medecine, Hamburg,
Germany
W. Kipp et al.
1995
E
6373 in kigoyera and 1420
persons in Kyamukoka
parish
179
Uganda
Uganda Final August 2007
UNHCR
Macdonald D
2007
E
Drug users, IDPs, GBV
women
180
Uganda
uganda migration3 - rakai
trial.pdf
Department of Population and Family Health
Sciences, School of Hygiene and public Health,
John Hopkins University, USA.
Ronald H. Gray et
al.
1999
E
Men and women 15-59 yrs
from 56 villages.
181
Uganda
Rapid assessment of substance
use in conflict-affected and
displaced populations: IDP
camps in Gulu, Kitgum and
Pader Districts of northern
Uganda
Relative risks and population
attributable fraction of incident
HIV associated with symptoms
of sexually transmitted diseases
and treatable symptomatic
sexually transmitted diseases in
Rakai District, Uganda
Relief efforts hampered in one
of the world's worst internal
displacement crises
IDMC (2006), Uganda Relief efforts hampered
IDMC
2006
E
IDPs
182
Uganda
2002
E
Uganda
Uganda RH youth
2001.pdf
uganda migration2 KS.pdf
ORC Macro
183
Reproductive Health of Young
Adults in Uganda
Risk factors for Kaposi’s
sarcoma in HIV-positive
subjects in Uganda
John L. Ziegler et
al.
1997
E
Youg men and women
age 15-24
458 HIV-seropositive KS
cases and 568 HIVseropositive controls.
184
Uganda
Sexual networks in Uganda:
mixing patterns between a
trading town, its rural hinterland
and a nearby fishing village
Uganda migration
patterns.pdf
H Pickering et al.
1997
E
International Agency for Research on Cancer,
World Health Organization, Lyon, France; Cancer
Epidemiology Unit, Imperial Cancer Research
Fund, University of Oxford, Oxford, UK; Uganda
Cancer Institute, Makerere University Medical
School, Kampala, Uganda;
Medical Research Council/Uganda Virus Research
Institute, Entebbe, Uganda
Target groups
143 men(75 town
residents, 40 fishing
villages, and 28 rural
areas); 81 women ( 47
town residents, 25 fishing
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
143
ID
GLIA
Country
Title
File name
Institutions
Authors
Year
Lang.
Target groups
185
Uganda
X Nsabagasani,
PS Yoder
Cynthia
Rothschild, Mary
Anne Reilly and
Sara A. Nordstrom
2006
E
48 men and 57 women
Uganda
Uganda VCT social
dynamics.pdf
strengthening
UPHOLD Project Kampala Uganda, ORC Macro
186
Social Dynamics of VCT and
Disclosure in Uganda
Strengthening resistance.
Confronting violence against
women and HIV/AIDS
2007
E
Women victim of violence
187
Uganda
june2005_uga
WHO
2005
E
PLHIV
188
Uganda
Summary country profile for
HIV/AIDS treatment scale-up
Susceptibility and Vulnerability
to HIV/AIDS among the Fishing
Communities in Uganda: A
Case of Lake Kioga
nahamyaWP
Department of Economics Kyambogo University
P.O Box 1, Kyambogo Uganda
Nahamya Wilfred
Karukuza and
Elwange
Charlestine Bob
2005
E
Fishing communities
189
Uganda
The HIV/AIDS Epidemic:
Prevalence and impact
UAC (2003), The HIVAIDS epidemic
UAC Uganda
UAC
2003
E
PLHIV, women, children
190
Uganda
Transmission in Lang
Highway_ug1.pdf
International Conference AIDS. 2002 Jul 7-12
Ouma NM, Anayo
B and OjiamboOchieng R.
2002
E
Transport workers
191
Uganda
Trends in HIV-1 prevalence may
not reflect trends in incidence in
mature epidemics: data from the
Rakai population-based cohort,
Uganda
migration uganda.pdf
Maria J. Wawer et
al.
1997
E
2591 Adults (15-59 yrs)
192
Uganda
2003
E
7320 soldiers
Uganda
Bwire Ugandan Military
2003
Uganda DHS 2006.pdf
G S Bwire, A
Musingunzi
193
Trends of HIV in the Ugandan
Military 1991-2003
Uganda Demographic and
Health Survey 2006
Center for Population and Family Health, Columbia
University School of Public Health, New York, USA;
The Institute of Public Health, Makerere University,
Kampala, Uganda; The Department of Population
Dynamics, Johns Hopkins University School of
Hygiene and Health
The XV International AIDS Conference
2007
E
8531 women and 2503
men age 15-49
194
Uganda
UGANDA: FOLLOW-UP TO
THE DECLARATION OF
COMMITMENT ON HIV/AIDS
(UNGASS)
2006_country_progress_r
eport_uganda_en
2006
E
General population, HIVPositive people
195
Uganda
Uganda HIV/AIDS SeroBehavioural Survey 2004-2005
Uganda AIS 2005.pdf
Ministry of Health Uganda, ORC Macro
2006
E
10437 households: men
and women age 15-49
196
Uganda
Uganda: Renewed international
and national attention yields
only limited improvements for
the displaced
IDMC (2006), Uganda
displaced persons
IDMC
2006
E
IDPs
villages, and 9 rural ereas)
Center for Women’s Global Leadership Rutgers,
The State University of New Jersey 160 Ryders
Lane New Brunswick, NJ 08901-8555 USA
Uganda Bureau of Statistics, ORC Macro
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Uganda
Title
File name
Institutions
Where There Are No ARVs,
Basic Care and Prevention Kit
Can Maintain Health of HIVPositive
uganda-basic-care.pdf
Population Services International, Washington,
DC ,USA
198
Various
(Bu, DRC,
Ke)
PROMOTING HEALTH
EQUITY IN CONFLICTAFFECTED FRAGILE STATES
08 Ranson.pdf
London School of Hygiene and Tropical Medicine
199
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
SMEC report GLIA-SASept2006
GLIA, SMEC International Pty. Ltd. (Australia)
200
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
A SOCIAL AND GENDER
ASSESSMENT OF HIV/AIDS
AMONG REFUGEE, IDP AND
HOST POPULATIONS IN THE
GREAT LAKES REGION OF
AFRICA
AIDS epidemic update
2006_EpiUpdate_en.pdf
UNAIDS, WHO
201
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Antiretroviral Medication Policy
for Refugees
UNHCR ART Policy FINAL
10-1-07.pdf
202
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
APPENDIX I: Health Needs and
WHO activities in the Great
Lakes Region
203
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
204
205
197
144
Authors
Year
Lang.
2006
E
Pop in low inconme
settings
2007
E
Iternal Displaced People,
refugees, Women
2006
E
Refugees, IDPs and host
populations
2006
E
General population
UNHCR
2007
E
Refugees
greatlakes.pdf
WHO
2005
E
General population
Conflict and HIV: A framework
for risk assessment to prevent
HIV in conflict-affected settings
in Africa
HIV and conflict
assessment frameowrk.pdf
Tulane University Center for International Resource
Development New Orleans, Department of
International Health and Development Tulane
University School of Public Health and Tropical
Medicine New Orleans USA
2004
E
Refugees, IDPs, host
community
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Displaced Populations Report
Displaced_Populations_R
eport_OCHA_2007
OCHA
2007
E
IDPs
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
GREAT LAKES - BURUNDI,
DRC, RWANDA, TANZANIA,
UGANDA: HEALTH SECTOR
NEEDS ASSESSMENT
great-lakes.pdf
WHO
2005
E
Kent Ranson, Tim
Poletti, Olga
Bornemisza and
Egbert Sondorp
UNAIDS, WHO
NB Mock, S
Duale, LF Brown,
E Mathys, HC
O'Maonaigh, NKL
Abul-Husn, S
Elliott
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
145
GLIA
Country
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Title
File name
Institutions
Authors
Year
Lang.
GREAT LAKES INITIATIVE ON
HIV/AIDS: ENVIRONMENTAL
AND SOCIAL MANAGEMENT
FRAMEWORK
GLIA_highway_project
GLIA
Gaspard Bikwemu
2004
E
Refugees, IDPS,
returnees, ares
surounding the refugee
communities.
207
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Helping Micro and Small
Entreprises cope with HIV/AIDS
GRL conference
UN, AU, IG/GLR
2006
E
General population
208
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV and Prisons in
Sub_Saharan Africa:
Opportunities for Africa
Prison Paper-PreFinal-NE
UNAIDS, World Bank, United Nations Office on
Drugs and Crime
Nilufar Egamberdi
2007
E
Prisoners
209
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV prevalence and trends in
sub-Saharan Africa: no decline
and large subregional
differences
SSA HIV trends.pdf
WHO
Emil AsamoahOdei, Jesus M
Garcia Calleja, J
Ties Boerma
2004
E
140000 pregnat women
from 22 SSA countries
210
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV Risk and Prevention in
Emergency-affected
Populations: A Review
HIV and disasters review.pdf
Centers for Disease Control and Prevention
AJ Khaw, P
Salama, B
Burkholder, TJ
Dondero
2000
E
211
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV surveillance in complex
emergencies
HIV in complex
emergencies.doc
P Salama, TJ
Dondero
2001
E
212
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV/AIDs epidemiological
Surveillance report for the WHO
African Region 2005 Update
AFRO2005.pdf
Epidemic Intelligence Service and International
Emergency and Refugee Health Branch National
Center for Environmental Health, Division of
HIV/AIDS Prevention National Center for HIV, STD,
and TB Prevention CDC Atlanta USA
WHO
Refugees,IDPs, host
community, Women,
children, armed forces,
peacekeepers, sex
workers
Refugees, IDPs,
Returnees, Migrants
2005
E
General population
213
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV/AIDS and Internally
Displaced Persons in 8 Priority
Countries
HIV and UNHCR analysis
of NSPs
UNHCR
P Spiegel, H
Harroff-Tavel
2006
E
IDPs
214
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
HIV/AIDS: Waking up to the
Challenges
waking_up_challenges
Conflict Research Unit, Clingendael Institute, The
Netherlands Ministry of Foreign Affairs
S. Verstegen
2005
E
Conflict affected
populations
206
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Title
File name
Institutions
Integration of HIV/AIDS
activities with food and nutrition
support in refugee settings:
specific programme strategies
UNHCR Food Nutirtion
support.pdf
UNHCR & WFP
216
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
burundi HIV
prevalence.pdf
Centre for Population Studies London School of
Hygiene & Tropical Medicine, Carolina Population
Centre School of Public Health University of North
Carolina at Chapel Hill USA
217
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Monitoring the AIDS epidemic
using HIV prevalence data
among young women attending
antenatal clinics: prospects and
problems
Note on HIV/AIDS and the
Protection of Refugees, IDPs
and Other Persons of Concern
HIV and UNHCR.pdf
UNHCR
218
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Number of fishers and fish
farmers
data fishers FIEs
219
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Partnership: An Operations
Management Handbook for
UNHCR’s Partners
UNHCR completehandbook
UNHCR
220
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Prevention and control of
sexually transmitted infections:
draft global strategy
WHO stis_strategy.pdf
221
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Prisons and AIDS
222
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
PROJECT APPRAISAL
DOCUMENT ON A
PROPOSED GRANT IN THE
AMOUNT OF SDR 13.7
MILLION (USD 20 MILLION
EQUIVALENT) TO THE GREAT
LAKES INITIATIVE ON
HIV/AIDS (GLIA)
215
146
Authors
Year
Lang.
2004
E
Refugees,returnees &
IDPs
2000
E
Young women
2006
E
Refugees, IDPs, returnees
and stateless
E
Fishermen
2003
E
UNHCR staff and
partners; Refugees,
returnees & IDPs
WHO
2006
E
Refugees, and other
people of concern
Prisons-PoV_en
UNAIDS
1997
E
Prisoners
GLIA PAD vol1.pdf
World Bank
2005
E
GLIA & WB staff
B Zaba, T
Boerma, R White
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Title
File name
Institutions
Refugees and HIV/AIDS
HIV and UNHCR 2001.pdf
224
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Refugees, HIV and AIDS:
UNHCR's strategic plan 20052007
225
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
226
147
Year
Lang.
UNHCR
2001
E
Refugees
HIV and UNHCR policy up
to 2007
UNHCR
2004
E
Refugees
SECTION 1. REGIONAL
OVERVIEW SELECTED
GEOGRAPHIC REGIONS
Int_migration_regions_200
5
IOM
Ndioro Ndiaye and
Philippe Boncour
2005
E
Migrant populations,
Refugees & IDPS
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
SECTION 3. INTERNATIONAL
MIGRATION DATA AND
STATISTICS
Int_migration_data_2005
IOM
Ndioro Ndiaye and
Philippe Boncour
2005
E
Migrant populations,
refugees & IDPs
227
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Strategic Conflict Analysis: Lake
Victoria Region
SIDA_ConfAna_Lake_Vict
oria.pdf
SIDA
2004
E
Conflict affected
populations
228
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Stratégies pour la prise en
charge des besoins relatifs au
VIH des réfugiés et populations
hôtes
UNHCR refugees and
AIDS_BP_En FINAL306.pdf
UNAIDS & UNHCR
2006
F
Refugees and host
populations
229
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Strategies to support the HIVrelated needs of refugees and
host populations
UNHCR Refugees and
AIDS_BP_En FINAL1005.pdf
UNAIDS & UNHCR
2006
E
Refugees and host
populations
230
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Strategies to support the HIVrelated needs of refugees and
host populations. A joint
publication of the Joint United
Nations Programme on
HIV/AIDS (UNAIDS) and the
United Nations High
Commissioner for Refugees
(UNHCR)
Highway_ke&ug1
UNAIDS, UNHCR
2005
E
Refugees and host
populations
223
Authors
Paul Spiegel,
Andrea Miller and
Marian
Schilperoord
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
Title
File name
Institutions
The global coaltition on Women
and AIDS
jc1308_gcwa_progressrep
ort2006_en
232
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
The Great Lakes Region
233
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
234
148
Year
Lang.
UNAIDS
2006
E
MAP of GLR. Pdf
UN
2004
E
WHO guidelines on HIV
infection and AIDS in prisons
JC277-WHO-GuidelPrisons_en
WHO, UNAIDS
1993
E
Prisoners
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
WHO Multi-country Study on
Women’s Health and Domestic
Violence against Women
WHO domestic violence
summary
WHO
Claudia GarcíaMoreno et al.
2005
E
Women Victim of domestic
violence
235
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
World Female Imprisonment
List (Women and girls in penal
institutions, including pre-trial
detainees/remand prisoners)
women-prison-list-2006
KING'S COLLEGE LONDON, International Centre
for Prison Studies
Roy Walmsley
2006
E
Female Prisoners
236
Various
(Bu, DRC,
Ke, Rw, Tz,
Ug)
World Prison Population List
(seventh edition)
world-prison-pop-seventh
KING'S COLLEGE LONDON, International Centre
for Prison Studies
Roy Walmsley
2006
E
Prisoners
237
Various
(Bu, DRC,
Ke, Rw,
Ug, Tz)
HIV/AIDS among conflictaffected and displaced
populations: Dispelling myths
and taking action
HIV and ConflictDisasters 9-04.pdf
UNHCR
PB Spiegel
2004
E
238
Various
(Bu, DRC,
Rw, Tz)
Communicable diseases in
complex emergencies: impact
and challenges
CDs in CEs - Lancet 1104.pdf
WHO, UNICEF, UNHCR
2004
E
239
Various
(Bu, DRC,
Rw, Ug)
AIDS and Violent Conflict in
Africa
Docking et al 2001
United States Institute of Pe a c e
MA Connolly, M
Gayer, MJ Ryan,
P Salama, P
Spiegel, DL
Heymann
Doking et al.
Refugees, IDPs, host
community, Women,
children, Armed forces,
peacekeepers, sex
workers
Refugees, IDPs, host
community
2001
E
231
Authors
Target groups
Women
Conflict affected
populations
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
149
GLIA
Country
Various
(Bu, DRC,
Rw, Ug)
Title
File name
Institutions
Authors
Year
Lang.
Prevalence of HIV infection in
confl ict-aff ected and displaced
people in seven sub-Saharan
African countries: a systematic
review
Lancet HIV and Conflict
FINAL 30-6-07.pdf
UNHCR and The University of Copenhagen,
Copenhagen, Denmark
Paul B Spiegel et
al.
2007
E
Various
(Bu, DRC,
Rw, Ug)
Various
(Bu, Ke,
Rw, Tz,
Ug)
THE RIGHT TO SURVIVE
SEXUAL VIOLENCE, WOMEN
AND HIV/AIDS
HIV/AIDS and the Changing
Landscape of War in Africa
the_right_to_survive
Rights & Democracy 1001, de Maisonneuve Blvd.
East, Suite 1100 Montreal (Quebec) H2L 4P9
Canada
University of Warwick
Françoise
Nduwimana
2004
E
S Elbe
2002
E
Armed forces combatants,
Girls& women victims of
sexual violence, sex
workers, refugees, IDPs
243
Various
(Bu, Ke,
Rw, Tz,
Ug)
The impact of the African AIDS
epidemic
Caldwell6.pdf
Health Transition Centre Australian National
University
JC Caldwell
1997
E
General population
244
Various
(Bu, Rw,
Ug, Tz)
HIV in prison in low-income and
middle-income countries
HIV_prisoners_low&middl
e_income countries
Program of International Research and Training,
National Drug and Alcohol Research Centre,
University of New South Wales, Sydney 2052,
Australia
Kate Dolan et al
2007
E
Prisoners
245
Various
(Bu, Tz)
UNHCR Good Practiceon
Gender Equality Mainstreaming.
Practical Guide to
Empoewrment
Good_Pract_Empowerme
nt_0106.pdf
UNHCR
2001
E
Refugee young girls &
women
246
Various
(DRC, Ke,
Rw, Tz,
Ug)
Informal Cross Border Trade
(ICBT) SurveyTrade Survey-Phase I. Phase I October 2003
–January 2004
Country_presentation_Ug
andaICBTReport
2004
E
247
Various
(DRC, Ke,
Rw, Tz,
Ug)
RURAL-URBAN
INTERACTIONS AND HIV/AIDS
IN EASTERN AFRICA.
Gould mobility AIDS 2004
CICRED and UNDP South East Asia HIV and
Development Programme
(SEAHIV)
2004
E
Rural & Urban Mobile
Populations
248
Various
(DRC, Ke,
Rw, Tz,
Ug)
The State of Business
Coalitions in Sub-Saharan
Africa
state_businesscoalitions_
SSA
World Bank
2006
E
private sector, General
population
240
241
242
Changing landscape of
war in Africa.pdf
W.T.S. Gould
Target groups
Refugees, IDPs, armed
forces, paramilitary
personnel, SWs,
unaccompanied minors,
sexual violence victims,
economic vulnerable
women
Women victim of sexual
violence
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Various
(DRC, Ke,
Tz)
Various
(DRC, Ke,
Tz, Ug)
Title
File name
Institutions
ROADS Signs. Recent
highlights from the ROADS
Project
Impact of HIV/AIDS ON
FISHING COMMUNITIES
ROADS Signs May 2007
_A4_2
251
Various
(DRC, Ke,
Ug)
252
150
Year
Lang.
FHI, USAID
2007
E
Gneral population , Truck
drivers
Policy_Brief-Final_En
FAO
2002
E
Fishing communities
Fisherfolk are among groups
most at risk of HIV: crosscountry analysis of prevalence
and numbers infected
fishing prevalence Seeley
Esther Kissling et
al.
2005
E
Fisherflok
Various
(DRC, Ke,
Ug)
LIVING IN TERROR. The
looming security threat to
Southern Africa
LIVING IN TERROR
1.The AIDS and Development Group, University of
East Anglia, Norwich, UK. 2. WorldFish Center,
Regional Research Center for Africa and West
Asia, Cairo, Egypt. 3 School of Development
Studies, University of East Anglia, Norwich, NR4
7TJ, U
Centre for Military Studies (Military Academy),
University of Stellenbosch
Lindy Heinecken
2001
E
Militaries, uniformed
forces, War & Conflict
affected populations
253
Various
(DRC, Ke,
Ug)
Structural barriers and
facilitators in HIV prevention: a
review of international research
migration international.pdf
Richard G. Parker,
delia Easton and
Charles H. Klein
2000
E
254
Various
(DRC, Rw,
Tz)
AMREF8
Therese McGinn
et al.
2001
E
Heterosexual women,
female commercial sex
workers, male truck drivers
and men who have sex
with men
Refugees and IDPs
255
Various
(DRC, Tz)
Forced Migration and
Transmission of HIV and Other
Sexually Transmitted Infections:
Policy and Programmatic
Responses
Background and context of
Kapiri Mposhi, Zambia
Columbia University, New york, Usa; State
University of Rio de Janeiro, Brazil; Center for
Disease Controle and Prevention, Atlanta, Georgia,
USA and The Department of Public health , san
Francisco, California, USA.
Columbia University; Women's Commission for
Refugee Women and Childen
256
Various
(DRC, Tz,
Ug)
The spread and effect of HIV-1
infection in sub-Saharan Africa
HIV spread in Africa.pdf
Institute of Tropical Medicine Antwerp Belgium,
Country and Regional Support Department
UNAIDS Geneva Switzerland, University of North
Carolina Chapel Hill NC USA
A Buve, K
BishikwaboNsarhaza, G
Mutangadura
2002
E
257
Various
(Ke, Rw,
Tz, Ug)
Gap between Preferred and
Actual Birth Intervals in SubSaharan Africa: Implications for
Fertility and Child Health
birth intervals DHS.pdf
ORC Macro
H Rafalimanana,
CF Westoff
2001
E
249
250
Authors
background_kapiri Mposhi
E
Target groups
long distance truck
drivers/assistants, second
hand clothes traders,
maize and livestock
traders, fishermen, SWs
General population
3568(Ke), 4752(Rw),
6851(Tz), 6117(ug)
Women 15-49yrs
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
151
GLIA
Country
Various
(Ke, Rw,
Tz, Ug)
Various
(Ke, Rw,
Tz, Ug)
Title
File name
Institutions
Authors
Year
Lang.
HIV and Islam: is HIV
prevalence lower among
Muslims?
HIV behavioural surveillance
surveys in conflict and postconflict situations: A call for
improvement
Truck drivers.pdf
Department of Anthropology, Peabody Museum,
Harvard University, Cambridge, MA, USA
Peter B. Gray
2003
E
BSS Gl Public Health 606.pdf
UNHCR
PB Spiegel, PV Le
2006
E
260
Various
(Ke, Rw,
Tz, Ug)
Male circumcision and risk of
HIV infection in sub-Saharan
Africa: a systematic review and
meta-analysis
male circ.pdf
Medical Research Council Tropical Epidemiology
Group, London School of Hygiene and Tropical
Medicine, London
Helen A. et al
2000
E
Male population
261
Various
(Ke, Rw,
Tz, Ug)
Calleja_PopSurveys_STI2
006.pdf
WHO, UNAIDS
J M Garcı´aCalleja, E Gouws,
P D Ghys
2006
E
Pregnant women
262
Various
(Ke, Rw,
Tz, Ug)
Sexual Risk factors for HIV
in SSA
Centre for Global Health
L Chen et al.
2007
E
Sex partners, FSW clients,
people with STIs /HSV-2
263
Various
(Ke, Rw,
Tz, Ug)
Various
(Ke, Rw,
Ug)
National population based HIV
prevalence surveys in subSaharan Africa: results and
implications for HIV and AIDS
estimates
Sexual risk factors for HIV
infection in early and advanced
HIV epidemics in Sub-Saharan
Africa: systematic overview of
68 epidemiological studies
The Solidarity Center’s
HIV/AIDS Work in East Africa
puds_hiv_eastafricafacts
Solidarity Center
2007
E
truck drivers
MAINSTREAMING AIDS IN
DEVELOPMENT
INSTRUMENTS AND
PROCESSES AT THE
NATIONAL LEVEL
Female Genital Cutting in the
Demographic and Health
Surveys: A Critical and
Comparative Analysis
mainstreaming_aids_28no
v05
UNAIDS, UNDP, World Bank
Daphne
Topouzis et al.
2005
E
General population, HIVPositive people
FGM DHS.pdf
ORC Macro
PS Yoder, N
Abderrahim, A
Zhuzhini
2004
E
women and Young girls
HIV/AIDS INTERVENTIONS IN
TRUCK DRIVER POPULATION
IN SOUTHERN AFRICA: A
REVIEW OF LITERATURE
AND BCC MATERIALS
L’excision dans les Enquêtes
Démographiques et de Santé :
Une Analyse Comparative
Truck_Drivers_Pop_South
.pdf
2004
E
truck drivers
2005
F
women and Young girls
258
259
264
265
Various
(Ke, Tz)
266
Various
(Ke, Tz)
267
Various
(Ke, Tz)
excision EDS Fr.pdf
ORC Macro
PS Yoder, N
Abderrahim, A
Zhuzhini
Target groups
Muslim Truck drivers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
268
GLIA
Country
Various
(Ke, Tz)
152
Title
File name
Institutions
Authors
Year
Lang.
Target groups
Trends and Differentials in
Adolescent Reproductive
Behavior in Sub-Saharan Africa
A study of the association of
HIV infection with wealth in subSaharan Africa
Adolescents SSA.pdf
ORC Macro
M Mahy, N Gupta
2002
E
Men and women 15-19yrs
HIV wealth DHS.pdf
Macro International Inc., University of Montreal,
UNAIDS, WHO, HEC Montreal
V Mishra et al.
2007
E
Community Responses to
HIV/AIDS Along Transit
Corridors & Areas of Intense
Transport Operations in Eastern
& Southern Africa
Concurrent sexual partnerships
help to explain Africa’s high HIV
prevalence: implications for
prevention
Corridors_Hope_Southern
_Africa
Family Health International (FHI)
2004
E
Male Interviewed:
Ke=3578,Tz=5659,
Ug=8830; Male Tested for
HIV: Ke=2941, Tz=4774,
Ug=8298; Female
Interviewed:Ke=8195,
Tz=6863, Ug=10826;
Female tested for HIV:
Ke=3285, Tz=5973,
Ug=10227
Transport workers, sex
workers
Concurrent sexual
partners Lancet 7-04.pdf
Office of HIV-AIDS USAID Washington, Center for
Health and Wellbeing Princeton University
Princeton New Jersey USA
DT Halperin, H
Epstein
2004
E
Men and women, sex
workers
269
Various
(Ke, Tz,
Ug)
270
Various
(Ke, Tz,
Ug)
271
Various
(Ke, Tz,
Ug)
272
Various
(Ke, Tz,
Ug)
Various
(Ke, Ug)
Study on Trafficking in Women
in East Africa
trafficking GTZ
GTZ
Elaine Pearson
2003
E
Women and Girls
continuing role for prevention in
high risk groups Kenya and
Uganda on the trans-Africa
highway:
highway_ke&ug.pdf
UNAIDS & UNHCR
C N Morris and A
G Ferguson
2006
E
Trukck drivers/assistants
274
Various
(Ke, Ug)
Highway _ke_ug
University of Manitoba,
C N Morris, A G
Ferguson
2006
E
857sex workers, 202 truck
drivers
275
Various
(Ke, Ug)
Estimation of the sexual
transmission of HIV in Kenya
and Uganda on the trans-Africa
highway: the continuing role for
prevention in high risk groups
Estimation of the sexual
transmission of HIV in Kenya
and Uganda on the trans-Africa
highway: the continuing role for
prevention in high risk groups
Highway_ke_ug.pdf
University of Manitoba, Canada
C N Morris and A
G Ferguson
2006
E
202 truck drivers, 578
female sex workers
273
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
153
GLIA
Country
Various
(Ke, Ug)
Title
File name
Institutions
Authors
Year
Lang.
HOT SPOT MAPPING OF
TRANSACTIONAL SEX ON
THE NORTHERN CORRIDOR:
Mombasa-Kampala
Northern Corridor and
transactional sex
Strengthening STD/HIV Control In Kenya Project,
Ministry of transport, Futures group Europe
Dr. Chester N.
Morris and Dr.
Alan Ferguson
2004
E
long distance truck
drivers/assistants, female
sex workers
277
Various
(Ke, Ug)
Highway_behav_eastafric
a
Department of Medical Microbiology, University of
Manitoba
Chester N Morris
and Alan G
Ferguson
2007
E
162 Truck Drivers and 219
Their Assistants
278
Various
(Ke, Ug)
highway_behav_eastafrica
Department of Medical Microbiology,University of
Manitoba & Institute for Human VirologyNigeria
Chester N Morris
and Alan G
Ferguson
2007
E
162 Truck drivers, 219
drivers assistants
279
Various
(Ke, Ug)
Sexual and treatment-seeking
behaviour for sexually
transmitted infection in longdistance transport workers of
East Africa
Sexual and treatment-seeking
behaviour for sexually
transmitted infection in longdistance transport workers of
East Africa
Sexually transmitted infections
and HIV among fishermen along
Lake Victoria shore: do they
qualify for a microbicide trial?
STIs fishermen lake
Victoria
AIDS 2006 - XVI International AIDS Conference
M. Ng'ayo et al.
2006
E
250 fishermen aged 18-68
280
Various
(Ke, Ug,
Tz)
Child Vulnerability and
HIV/AIDS in sub-Saharan
Africa: What We Know and
What Can Be Done
gillespieOVCsynth.pdf
International Food Policy Research Institute,
University of Calgary Canada, Tulane University
USA
S Gillespie et al.
2005
E
Vulnerable Children
281
Various
(Rw, Tz)
Dunkle GBV KIV link
lancet 2004
Gender and Health Group, Medical Research
Council, Private Bag X385, Pretoria 0001, South
Africa
Kristin L Dunkle et
al.
2004
E
1366 women
282
Various
(Rw, Tz)
Gender-based violence,
relationship power, and risk of
HIV infection in women
attending antenatal clinics in
South Africa
Sexually transmitted diseases in
mobile populations
SCAN0987_000.pdf
Department of Clinical Sciences, London School of
Hygiene & Tropical Medicine, London, UK
David Mabey &
Philippe Mayaud
1997
E
283
Various
(Rw, Ug)
Taking It to the
Streets :Reaching Truckers,
Sex Workers, Rural Populations
with Mobile VCT
mobile-VCT
Population Services International, Washington,
DC ,USA
2006
E
International travellers
from Europe, migrant
workers in southern Africa,
and Rwandan refugees in
Camp in Tanzania.
mobile populations, IDPs
284
Various
(Tz, Ug)
Approaches to the control of
sexually transmitted infections
in developing countries: old
problems and modern
challenges
174.pdf
London School of Hygiene and Tropical Medicine
2004
E
276
P Mayaud, D
Mabey
Target groups
Sexually active young
population, Urban
migrants, IDPs, sex
workers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
285
GLIA
Country
Various
(Tz, Ug)
Title
File name
Institutions
HIV/AIDS Surveillance in
Developing Countries.
Experiences and Issues
Interactions between HIV
infection and other sexually
transmitted diseases
GTZ_surveillance_Mbeya
GTZ
mobilitiy and risk
reduction2
Department of infectious & tropical Diseases,
London School pf Hygiene & Tropical Medicine,
London, UK
154
Authors
Year
Lang.
Target groups
1999
E
General population
David Mabey
2000
E
293 subjects
286
Various
(Tz, Ug)
287
Various
(Tz, Ug)
The empirical evidence for the
impact of HIV on adult mortality
in the developing world: data
from serological studies
aids mortality.pdf
MRC Clinical Trials Unit London, London School of
Hygiene and Tropical Medicine
K Porter, B Zaba
2004
E
Young adult pop, women
288
Variuos
(Tz, Ug)
mobility in Tanzania and
Uganda.pdf
Department of Public Health, Erasmus Medical
Center, University Medical Center Rotterdam,
Rotterdam, The Netherlands; London School of
Hygiene and Tropical Medicine, London, United
Kingdom; Medical Research Council Programme
on AIDS in Uganda, Uganda Viru
E.L. Korenromp et
al.
2005
E
293 Men and women
289
Various
(Tz, Ug)
Determinants of the Impact of
Sexually Transmitted Infection
Treatment on Prevention of HIV
Infection: A Synthesis of
Evidence from the Mwanza,
Rakai, and Masaka Intervention
Trials
Higher risk behaviour and rates
of sexually transmitted diseases
in Mwanza compared to
Uganda may help explain HIV
prevention trial outcomes
Uganda and TAnzania
STD study.pdf
London School of Hygiene and Tropical Medicine,
Keppel Street, London, UK.
Kate K. Orroth et
al.
2003
E
290
Issue Paper 1: HIV/AIDS and
the Military
military hiv 2005
2005
E
291
19th Meeting of the UNAIDS
Programme Coordinating Board
Lusaka, Zambia, 6–8 December
2006. AIDS, Security and
Humanitarian Response
AIDE-MÉMOIRES Policy
Guidelines on HIV/AIDS
Prevention and Control for UN
Military Planners and
Commanders
AIDS and the military
20061101_pcb_security_a
nd_humanitarian_respons
e_en
Clingendael Institute, Expert Seminar and Policy
Conference: AIDS, Security and Democracy
, The Hague, 2-4 May 2005
UNAIDS
1. Migration-definition
pop:(645 participants in
Rakai Ug), (2072 in
Masaka Ug) abd (1500 in
Mwanza Tz) 2.Sexual
behaviour:(11600 in
Rakai), (5900 in Masaka)
and (1100 in Mwanza)
Military, peacekeepers
2006
E
Refugees, IDPs, Host
Communities
Commanders_Guidelines
Civil-Military alliance & UN Department of
Peacekeeping operations
2000
E
Military/ Uniformed
Services personnel
militarypv_en
UNAIDS
1998
E
Military
AIDS BRIEF: MILITARY
POPULATIONS
AIDS-BriefMilitary%20Sector
USAID, WHO
2000
E
Military and Unniformed
Forces
292
293
294
Rodger Yeager
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
AIDS, Security and Conflict
Initiative. Speaking Notes on
Themes and Evidence
AIDS, SECURITY AND THE
MILITARY IN AFRICA: A
SOBER APPRAISAL
military hiv de Waal
SSRC and Harvard University
Alex de Waal
2005
E
Military
Whiteside et al military
2006
Royal African Society, Oxford University
2006
E
Military and other
uniformed forces
297
Behind the Bars of Masculinity:
Male Rape and Homophobia in
and about South African Men's
Prisons
Abstract Gear 2007
Centre for the Study of Violence and Reconciliation,
South Africa
ALAN
WHITESIDE,
ALEX DE WAAL
AND TSADKAN
GEBRE-TENSAE
Sasha Gear
2007
E
Male Prisoners
298
Building Regional HIV
Resilience along the ASEAN
Highway Network
Corridors_Hope_Southern
-Africa-Microsoft Word
FHI
2005
E
Truck drivers, sex workers,
guest house and bars
attendants, petty traders,
and area residents
299
By virtue of their occupation,
soldiers and sailors are at
greater risk. Special report: the
military
Military_Risk_SpecialRepo
rt.doc
1995
E
Military, sailors
300
Children in prison
gn-14-children-in-prison
KING'S COLLEGE LONDON, International Centre
for Prison Studies
2004
E
Children in Prison
301
Circular migration and sexual
networking in rural
KwaZulu/Natal: implications for
the spread of HIV and other
sexually transmitted diseases
Combat AIDS. HIV AND THE
WORLD’S ARMED FORCES
Community Responses to
HIV/AIDS Along Transit
Corridors & Areas of Intense
Transport Operations in Eastern
& Southern Africa
Conflict and Disease: An
overview in the African conflicts.
Paper presented at the
Mwalimu Nyerere Foundation
Conference
south africa migration.pdf
South African Medical Research Council, Centre
For Epidemiological Studies in Southern Africa
(CERSA), Hlabisa, KwaZulu/Natal, South Africa;
Johns Hopkins University School of Hygiene and
Public Health, Baltimore MD, USA
Healthlink Worldwide, Cityside 40 Adler Street.
London E1 1EE UK
IFRTD,CSIR
Mark Lurie et al.
1997
E
Men age 20-50
Martin Foreman
2002
E
2004
E
Uniformed services
(Military, peacekeepers)
Tramsport workers, sex
workers, East African
community
AMREF
Daraus Bukenya
2002
E
Women and children
295
296
302
303
304
GLIA
Country
155
Healthlink armed forces
2002
Corridor_eastern_southern
.doc
AMREF7
Miller N and
Yeager R
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
305
Corridors of Hope in Southern
Africa: HIV Prevention Needs
and Opportunities in Four
Border Towns
cross-border-2003
T.M. Hammett et
al.
2003
E
drug users
306
Development and
implementation of a crossborder HIV prevention
intervention for injection drug
users in Ning Ming County
(Guangxi Province), China and
Lang Son Province, Vietnam
Effect of a structural intervention
for the prevention of intimatepartner violence and HIV in rural
South Africa: a cluster
randomised trial
Evidence of Declining STD
Prevalence in a South African
Mining Community Following a
Core-Group Intervention.
FHIFINAL sz Lo RSA
Edmond de Rothschild Foundation Chemical
Dependency Institute, Beth Israel Medical Center,
1st Ave at 16th Street, New York, NY 10003, USA;
Guangxi Center for HIV/AIDS Prevention and
Control, 80 Taoyuan Road, Nanning 530021,
China; International Cooperati
FHI, IMPACT & USAID
David Wilson
2001
E
Truck drivers, bus drivers,
taxi drivers, sex workers,
miners, informal traders
Partner violence RSA
Development Action Research Programme
(RADAR) School of Public Health, University of the
Witwatersrand, PO Box 2, Acornhoek, South Africa
136
Paul M Pronyk et
al.
2006
E
Poor rural women
Mobile populations.doc
.
S. Richard et al
2000
E
Miners, women
From people to places: focusing
AIDS prevention efforts where it
matters most
GUIDELINES for HIV/AIDS
interventions in emergency
settings
south africa mobility.pdf
Carolina Population Center, University of North
Carolina, USA.
Sharon S. Wier et
al.
2003
E
3085 men and 1564
women
iascguidelines_en.pdf
IASC
E
HIV affected peeople, at
risk houdeholds, at risk
communities
311
Health consequences of
intimate partner violence
Campbell partner violence
2002
Johns Hopkins University School of Nursing, 525
North Wolfe Street, Baltimore, MD 21205–2110,
USA
Jacquelyn C
Campbell
2002
E
Women victim of violence
312
HIV and Mobile Workers: A
REVIEW of RISKS AND
PROGRAMMES AMONG
TRUCKERS IN WEST AFRICA
hiv_Mobileworkers_WestA
frica.pdf
IOM & UNAIDS
Eleonore Caraël
2005
E
Truckers
313
Hiv and refugees
jc1300-policybriefrefugees_en
UNAIDS & UNHCR
2007
E
Refugees
307
308
309
310
GLIA
Country
156
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
314
HIV in injecting drug users in
Asian countries
HIV_IDUs_Asia
Department of Health Policy, Management and
Evaluation, Faculty of Medicine, University of
Toronto, 12 Queens Park Crescent West, Toronto,
Canada M5S 1A8
Alex Wodak,
Robert Ali and
Michael Farrell
2004
E
IDUs
315
HIV Infection Among Sex
Workers in Accra: Need to
Target New Recruits Entering
the Trade
sex workers and
Ghana.doc
Asamoah-Adu,
confort et al.
2001
E
female sex workers
316
HIV Vulnerabilyty Mapping:
Highway One, Viet Nam
Hiv2001
STD/AIDS Regional Coordination Unit, Greater
Accra Region, Ministry of Health, Accra, Ghana;
Centre for International Health, University of
Sherbrooke, Québec, Canada; West Africa Project
to Combat AIDS, Accra, Ghana; Public Health
Reference Laboratory, M
UN
317
HIV/AIDS and Gender-Based
Violence (GBV):Literature
Review
Final_Literature_Review.p
df
Department of Population and International Health,
Harvard School of Public health
2006
E
Victims of gender-based
violence
318
HIV/AIDS in the transport sector
of Southern African countries: A
rapid assessment of crossborder regulations and
formalities
HIV/AIDS is a human rights
issue. Human rights are TRADE
UNION issues
HIV/AIDS, Conflict and
Displacement
transpSector_hiv_souther
n.pdf
ILO
2005
E
Transport workers, sex
workers
Hiv%2Daids
International Transport Workers’ Federation
E
Transport workers
hiv_aids_conflict_displace
ment
Unicef & UNHCR
2006
E
IDPs
321
HIV/AIDS, Population Mobility
and Migration in Southern
Africa. Defining a Research and
Policy Agenda
2004_PopulationMobilityR
esearchAgendaReport
IOM
2005
E
Mobile Populations
322
HIV/AIDS: Transport Workers
Take Action
HIV/AIDS+WORK: Using the
ILO Code of Practice on
HIV/AIDS and the world of work
HIV-1 infection among injection
and ex-injection drug users from
Rio de Janeiro, Brazil:
prevalence, estimated incidence
and genetic diversity
Hivaids_globalunionsbroc
hure
HPP0000188
Global Union
E
workers
UNDP
Jacques du
Guerny
2002
E
Mobile populations
IDU_brazil
WHO
Sylvia Lopes Maia
Teixeira et al.
2004
E
IDUs
319
320
323
324
GLIA
Country
157
Target groups
Transport workers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
Human Immunodeficiency
Virus-Related Morbidity and
Mortality in Injection Drug
Users: Should the AIDS
Definition Be Changed Yet
Again
Humanitarian Charter and
Minimum Standards in Disaster
Response
IMPACT OF HIV/AIDS ON
PUBLIC SECTOR CAPACITY
IN SUB-SAHARAN
AFRICA:TOWARDS A
FRAMEWORK FOR THE
PROTECTION OF PUBLIC
SECTOR CAPACITY AND
EFFECTIVE RESPONSE TO
THE MOST AFFECTED
COUNTRIES
Improving parameter estimation,
projection methods, uncertainty
estimation, and epidemic
classification
HIV_morbidity_mortality_I
DU
Department of Epidemiology, Universitv of North
Carolina School of Public Health.
Rachel Royce
1996
E
IDUs
Sphere_hdbk_full
The Sphere Project
2004
E
General population, NGOs
KM-Study report on
Capacity impact of HIVAIDS.doc
THE AFRICAN CAPACITY BUILDING
FOUNDATION ACBF BOARD OF GOVERNORS
Wilfred Ndongko
et al.
2004
E
Public sector workers
2006prague_report_en
UNAIDS
Dr Peter White
2007
E
General population, HIVPositive people
329
Injecting Drug Use and AIDS in
Developing Countries:
Determinants and Issues for
Policy Consideration
HIV_IDUs_Dev&TransCountries
World Bank
Kara S. Riehman
1996
E
IDUs
330
International Conference on
Peace, Security, Democracy
and Development in the Great
Lakes Region: DAR-ESSALAAM DECLARATION ON
PEACE, SECURITY,
DEMOCRACY AND
DEVELOPMENT IN THE
GREAT LAKES REGION
International Conference on the
Great Lakes Region: Regional
Programme of Action: Economic
Development and Regional
Integration
HPP0000247
UNDP
Lorna Guinness &.
Lilani
Kumaranayake
2002
E
Mobile populations
HPP0000819
UNDP
JAMIE UHRIG
2000
E
Migrant and host
communities
325
326
327
328
331
GLIA
Country
158
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
International Military Human
Immunodeficiency Virus /
Acquired Immunodeficiency
Deficiency Syndrome Policies
and Programs: Strengths and
Limitations in Current Practice
Intimate partner Violence and
Physical Health Consequences
Yeager et al 2000 CMA
Rodger D. Yeager
et al.
2000
E
Militaries, uniformed
forces, War & Conflict
affected populations
Jacquelyn C
Campbell et al.
2002
E
2535 Women aged 21-55
334
Is there an HIV/AIDS
demonstration effects?- findings
from a longitudinal study of long
distance truck drivers
Is there an HIV_AIDS
demonstration effect
Department of Political Science, West Virginia
University, Morgantown, WV 26506 U.S.A, Division
of Clinical Pharmacology, The Johns Hopkins
University School of Medicine, Baltimore, MD
21287 U.S.A, Civil-Military Alliance to Combat HIV
and AIDS, 20 Route
School of Hygiene and Public Health, Johns
Hopkins University, 615 North Wolfe Street,
Baltimore, MD 21205, U.S.A
Society in Trasitions
Tessa Marcus
2001
E
Truck drivers
335
Issues in HIV prevention for
injecting drug users (IDUs) in
developing/transitional
countries: Results from the
WHO Phase II Drug injection
study.
Lesotho and Swaziland:
HIV/AIDS Risk Assessments at
Cross-Border and Migrant, Sites
in Southern Africa
Issues in HIV prevention
for injecting drug users
Des Jarlais et al.
2004
E
IDUs
HPP0000936
UNDP & World Vision
2004
E
Transport workers,
construction workers, and
public works workers
337
Mapping HIV Vulnerability along
Kampong Thom, Siem Reap,
Odor Meanchey and Preah
Vihear, Cambodia
HPP0000943
UNDP
2004
E
338
Men who have sex with men,
HIV prevention and care
jc1233-msmmeetingreport_en
UNAIDS
2005
E
Construction workers, road
engineers, truckers, sex
workers, hotel+guest
house+restaurant
attentants
Men who have sex with
men
339
Mitigating the Impact of
HIV/AIDS in Transport Sector
Activities: A Synthesis of
Literature
HPP0000990
UNDP, World Vision, Macfarlaene Institute
2004
E
Costruction workers, truck
drivers, fishermen, migrant
sex workers
340
Mobile Populations and
HIV/AIDS in the Southern
African Region.
Recommendations for Action
2003_MobilepopulationsA
ndHIVAidsDocument.pdf
IOM
2003
E
Military personnel,
Transport workers, Mine
workers, workers in the
construction sector and
other major industries,
agricultural farm workers,
332
333
336
GLIA
Country
159
Campbell partner violence
STIs 2002
Tia Phalla et al.
Barbara Rijks
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
GLIA
Country
Title
File name
Institutions
160
Authors
Year
Lang.
Target groups
informal traders, domestic
workers, refugees, IDPs
341
Mobility and the spread of
human immunodeficiency virus
into rural areas of West Africa
mobility_West Africa.pdf
342
Model-Based Estimates of HIV
Acquisition Due to Prison Rape
Modelling the expected
distribution of new HIV
infections by exposure group
Modelling the expected
distribution of new HIV
infections by exposure group
Multisectoral Responses to
Mobile Populations’ HIV
Vulnerability examples from
People’s Republic of China,
Thailand and Viet Nam
Multisectoral Responses to
Mobile Populations’ HIV
Vulnerability examples from
People’s Republic of China,
Thailand and Viet Nam
Needs Assessment Report on
Mobility and Cross-Border
HIV/AIDS Transmission in Lang
Son and Lao Cai, Vietnam
Prison_rape_hiv. abstract.
Doc
ModeOfTransmission_07_
en
348
349
343
344
345
346
347
Institut National de la Santé et de la Recherche
Médicale, U88-IFR69, Saint-Maurice, France;
Medical Research Council Laboratories, Fajara,
The Gambia; Institut National d’Etude
Démographique, Paris, France; Programme de
recherche sur le SIDA de l’Institu
Medical College of Wisconsin, Milwaukee
E.Lagarde et al.
2003
E
1200 Men and women age
15-59
Steven D.
Pinkerton
2007
E
Prisoners
WHO, UNAIDS
2007
E
MoT_2007_example_MC_
en
WHO, UNAIDS
2007
E
icpsdd-gr-20nov
UN, AU, IG/GLR
2004
E
Sex workers& Clients,
Youth, military, truckers,
IDUs
Sex workers& Clients,
Youth, military, truckers,
IDUs
General population
AsiaMultsectoriaResponse
s2003.pdf
UNDP
Jacques du
Guerny et al.
2003
E
Migrants and host
communities
Indonesia mobility
ILO, UNDP.UNAIDS, AusAID
Graeme Hugo
2001
E
Internal Mobile pop. &
international mobile
population
Needs Assessment. Report on
Mobility and Cross-Border
HIV/AIDS Transmission in Lang
Son and Lao Cai, Vietnam
CP_vietnam_HIVAIDS_trans 2005.pdf
Program for Appropriate Technology in Health
(PATH) 2nd Floor, Hanoi Towers, 49 Hai Ba Trung,
Hanoi, Vietnam
2005
E
drug users, sex workers
Peacebuilding inThe Great
Lakes: Challenges and
Opportunities for the EU in the
DRC
jama_article_another_worl
d
Rwanda Women's Network
2005
E
Raped HIV+women
Mardge H. Cohen
et al.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
Peer Education Kit for
Uniformed Services:
Implementing HIV/AIDS/STI
peer education for uniformed
services.
Physical Health Consequences
of Physical and Psychological
Intimate Partner Violence
JC928EngagingUniServicesPeerEd_en
UNAIDS
Iain McLellan
2003
E
Military,
peacekeepers,Police,
other uniformed
services(Men & Women)
Coker violence STIs 2000
University of South Carolina, School of Public
Health, Columbia,
Ann L. Coker et al.
2000
E
1152 Women aged 18-65
352
Priorities for local AIDS control
efforts(PLACE): For use in
border areas of Lesotho and
South Africa
sr-04-30.pdf
USAID
2004
E
Border areas' communities
353
Provision of Syndromic
Treatment of Sexually
Transmitted Infections by
Community Pharmacists: A
Potentially Underutilized HIV
Prevention Strategy
Rapid assessment of substance
use in conflict-affected and
displaced populations : Liberia
Syndromatic
treatment_STI_Commu.Ph
armacists
American Sexually Transmitted Disease
Association.
2003
E
90 Community
pharmacists
Liberia final report
UNHCR, WHO
2006
E
drug users, IDPs
355
Reducing vulnerability of
migrant fishermen and related
populations in Thailand
Thailand fishermen
programming
Raks Thai Foundation, Bangkok, Thailand. The XV
International AIDS Conference
E
Fishermen
356
Refugees and the Acquired
Immune Deficiency Syndrome
(AIDS)
Regional Guidelines on HIV and
AIDS for the Informal Cross
Border Trade Sector in the
SADC Region
HIV and UNHCR 1988
analysis.pdf
UNHCR
1988
E
Refugees
200704_IOM_HIVGuidelinesIC
BT
PHAMSA
2007
E
358
Report of the THIRTEENTH
SESSION OF THE
COMMITTEE FOR INLAND
FISHERIES OF AFRICA
y5919b00.pdf
FAO
2004
E
Fishermen
359
Report on Mobility and
prisonframework
UN Office on Drug and Crime, UNAIDS, WHO
2006
E
Prisoners
360
Report on the International
Symposium on Sexual Violence
in Conflict and Beyond
JC1276-globalreach-en
UNAIDS & ILO
2006
E
Working people
350
351
354
357
GLIA
Country
161
KIM WARD et al.
Rick Lines and
Heino Stöver
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
361
Risk and vulnerabilities of
migrants and mobile
populations in Southern Africa
200701_IOM_HIVandPeopleOn
TheMove
Health and Development Networks (HDN) and the
International Organization for Migration (IOM)
Partnership on HIV/AIDS and Mobile Populations in
Southern Africa (PHAMSA
362
SEXUALLY TRANSMITTED
INFECTIONS IN SUBSAHARAN AFRICA: THE USE
AND EFFECTIVENESS OF
TREATMENT KITS
Solidarity Center: Our HIV/AIDS
mission
PPSTLarge
PSI/Washington 1120 19th Street, NW Suite 600
Washington, DC 20036 USA
pubs-hivdonor
Solidarity Center
The Contraception – Fertility
Link in Sub-Saharan Africa and
in Other Developing Countries
The Development Potential of
Regional Programs: An
Evaluation of World Bank
Support of Multicountry
Operations
The future of the HIV pandemic
contraception fertility
SSA.pdf
ORC Macro
reg_pgms_full
The Global HIV/AIDS Program:
LESSONS LEARNED TO
DATE. FROM HIV/AIDS
TRANSPORT CORRIDOR
PROJECTS
The Potential Costs and
Benefits of Responding to the
Mobility Aspect of the HIV
Epidemic in South East Asia: A
conceptual framework
The Solidarity Center’s
HIV/AIDS Work in East Africa:
RESULTS FROM SEPTEMBER
2005 TO MARCH
2007(Kenya&Uganda)
The structure of sexual
networks and the spread of HIV
in Sub-Saharan Africa: evidence
from Likoma island (Malawi)
363
364
365
366
367
368
369
370
GLIA
Country
162
Authors
Year
Lang.
2007
E
Mobile Populations
E
STIs patients
2007
E
Truck drivers and their
families
CF Westoff, A
Bankole
2001
E
World Bank
Catherine Gwin et
al.
2007
E
General population
future of HIV response mobile populatins.pdf
Imperial College London, WHO
NC Grassly, GP
Garnett
2005
E
Mobile Populations
Transport_lessons_hiV_co
rridors.pdf
World Bank
Stephen Brushett
and John Stephen
Osika
2005
E
Transport workers
sexual violence conflict
2005
UNFAP
2006
E
Women victim of sexual
violence
sme
ILO
2006
E
SME workers
Malawi sexual networks on
Likoma.pdf
Department of Sociology, Population Studies
Center, University of Pennsylvania, USA
E
1800 households
Florence Zake et
al.
Stephane
helleringer and
hans_Peter Kohler
Target groups
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
ID
Title
File name
Institutions
Authors
Year
Lang.
371
Toolkit for HIV Prevention
among mobile populations in
the Greater Mekong Subregion
SouthernAfrica_Corridors
Hope
USAID
Janean Martin
2004
E
372
Unexpected low prevalence of
HIV among fertile women in
Luanda, Angola. Does war
prevent the spread of HIV?
StrandEtAl2007.pdf
2007
E
373
UNHCR, HIV/AIDS and
refugees: lessons learned
Violence against women: global
scope and magnitude
FMR1909.pdf
UNHCR
Watts Zimmerman
violence 2002
Health Policy Unit, Department of Public Health and
Policy, London School of Hygiene and Tropical
Medicine, London WC1E 7HT, UK
WINNING THE WAR AGAINST
HIV AND AIDS. A Handbook on
Planning, Monitoring and
Evaluation of HIV Prevention
and Care. Programmes in the
Uniformed Service
Women in Rwanda: Another
World Is Possible
CMA_Planning_Handbook
Civil-Military alliance,UNAIDS,
transp-hivguidlines
ILO
374
375
376
GLIA
Country
163
Paul B Spiegel
and Alia Nankoe
Charlotte Watts
and Cathy
Zimmerman
Stuart J. Kingma
et al.
E
Target groups
Truck drivers, sex workers,
guest house and bars
attendants, petty traders,
and area residents
Refugees and host
populations
Women victim of violence
2002
E
1999
E
Military/ Uniformed
Services personnel
2005
E
Transport workers,
construction workers, and
public works workers,
transports policy makers
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
164
ANNEX VIII Analysis of the National Strategic Plans of the GLIA Countries
ANNEX VIIIa. Targeting of SELECTED vulnerable population groups
BURUNDI
Plan Stratégique de
Lutte Contre le
VIH/SIDA. 2007-2011
DR CONGO
Plan Stratégique
National de Lutte
contre le VIH/ SIDA/
MST 1999–2008
KENYA
National Strategic
Plan 2005/6-2009/10
RWANDA
Plan Stratégique
Nationale de Lutte
contre le VIH/SIDA,
Nov 2005
TANZANIA-Mainland
National Multi-Sectoral
Strategic Framework
on HIV and AIDS 2008
–2012
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment
Improvement of the economic
situation of vulnerable groups.
Promotion of peer education
activities. Promotion of safer
sex behaviours.
Development of HIV/AIDS
prevention, treatment and
care strategies for CSW and
their clients.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Increase access to HIV
prevention (IEC, condoms,
peer education, VCT & STIs
services). Acknowledge the
vulnerability of CSW and
MSM and advocate for their
access to HIV services and
decriminalization of their
activities. Make quality STI
services available and
accessible to CSW and their
clients.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Sensitisation activities and
education through peers.
Promotion of abstinence,
fidelity and condom use.
Strengthening of prevention
activities.
Development of innovative
HIV/AIDS prevention,
treatment and care strategies
for targeting the uniformed
services. Mainstream
HIV/AIDS in relevant sectors.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Increase access to HIV
prevention information and
services (IEC, condoms, peer
education, VCT and STI
services). Integration of HIV
education in new staff
orientation/ seminars.
Standardize HIV education
and peer education training
across sectors and ensure
quality. Make information and
condoms available to all
mobile and migrant workers in
all sectors.
KENYA
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
Zanzibar National
HIV/AIDS Strategic
Plan 2003-2007
UGANDA
National HIV and AIDS
Strategic Plan. 2007/8
– 2011/12, Aug 2007
Strengthen capacity of SW in
areas of sex negotiations
skills, peer education and
condom use. Introduce
alternative income generating
schemes for SW.
Development of an integrated
VCT/STD services
incorporating harm reduction
based education. Strengthen
existing laws and regulations
that increase cultural/moral
adherence and discourages
sex work. Introduce BSS for
sex workers and their clients.
Establish an interventions
database.
Review guidelines/ regulations
relevant to STI transmission.
Establish sound education
system on STD/HIV/AIDS.
Introduce peer education
schemes. Establish userfriendly STI and VCT services
and access to affordable
preventive tools such as
condoms.
Promotion of abstinence,
fidelity and use of male and
female condom.
Military, combatants, police, peace
keepers
Female / commercial sex workers
Targeting of vulnerable populations
BURUNDI
DR CONGO
TANZANIA-Zanzibar
Promotion of abstinence,
fidelity and use of male and
female condom. Prevention
through IEC and VCT support.
UGANDA
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Prevention of sexual
transmission of HIV through
sensitisation, condom
promotion and STI
management. Promotion of
peer education.
Develop innovative HIV/AIDS
prevention, treatment and
care strategies. Mainstream
HIV/AIDS in the sectors
serving migrant workers.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Increase access to HIV
prevention (IEC, condoms,
peer education, VCT & STIs
services). Implement
guidelines on workplace
interventions. Integrate HIV
education in new staff
orientation/ seminars.
Standardize HIV education &
peer education training and
ensure quality. Develop
outreach programmes to
include families and
communities of the workers.
Develop and support special
programmes reaching
operators in informal sector,
through collaboration with
government & private sector.
Make information and
condoms available to all
mobile and migrant workers in
all sectors.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Sensitisation activities and
education through peers.
Promotion of abstinence,
fidelity and condom use.
Strengthening of prevention
activities.
Develop innovative HIV/AIDS
prevention, treatment and
care strategies for targeting
migrant workers; and
mainstream HIV/AIDS in the
sectors serving migrant
workers.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Increase access to HIV
prevention (IEC, condoms,
peer education, VCT & STIs
services). Implement
guidelines on workplace
interventions. Develop
outreach programmes to
include families and
communities of the workers.
Make information and
condoms available to all
mobile and migrant workers in
all sectors.
Organize peer education on
training of trainers (ToT) on
HIV transmission, prevention
and household food and
financial security of fishermen
dependants. Promote safer
sex practices among the
fishing communities. Conduct
behavioural surveillance
among people engaged in
camping type of fishing.
Focus prevention on fishing
communities through HIV
counselling & testing support.
KENYA
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
UGANDA
Long distance truck drivers /assistants
Fishermen – fishing communities
165
BURUNDI
DR CONGO
Create the necessary political
environment and systems to
maximize the outputs of
regional initiatives that target
mobile populations (GLIA,
IGAD IRAPP project, The
EAC-AMREF Lake Victoria
(EALP) HIV and AIDS
programme.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Sensitisation activities and
education through peers.
Prevention of sexual
transmission of HIV through
sensitisation, condom
promotion and STI
management. Strengthening
of prevention activities
oriented towards high risk
groups.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment
Improvement of the economic
situation of vulnerable groups.
Prevention of sexual
transmission of HIV through
sensitisation, condom
promotion and STI
management. Promotion of
peer education. Strengthening
of prevention activities
oriented towards high risk
groups.
Host community of refugees
Internally Displaced Persons
Refugees
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment
Improvement of the economic
situation of vulnerable groups.
Promote more effective,
targeted BCC. Promote
abstinence, consistent safe
sex behaviour and delayed
sexual debut among young
refugees.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment
Improvement of the economic
situation of vulnerable groups.
BURUNDI
DR CONGO
KENYA
166
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Promote increased access to
HIV preventive information
and services (IEC, condoms,
peer education, VCT and STIs
services).
Education on appropriate and
effective condom use.
Establishment of system of
procurement and distribution
of male and female condoms.
Ensure availability,
affordability and accessibility
of vaginal microbicides and
marketing of various assorted
brands of condoms.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
1. To promote increased
access to HIV preventive
information and services (IEC,
condom access, peer
education, friendly testing and
counseling and STIs services)
for the vulnerable populations.
Facilitate increased access to
vocational education and
apprentice opportunities.
Advocate for affirmative action
for OVC, girl child, people with
disabilities and other
disadvantaged groups in
access to informal education,
vocational and life skills
development. Operationalise
national food and nutritional
policies/guidelines to local
governments, communities
and PLHIV households.
Facilitate the provision of
essential materials.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Promote increased access to
HIV preventive information
and services (IEC, condom
access, peer education,
friendly testing and counseling
and STIs services).
Promote good practices in
design and implementation of
income generation activities.
Support income-generating
programs. Strengthen
traditional coping mechanisms
to enhance sustainable
livelihoods of affected
households. Integrate SRH
services in economic
empowerment activities.
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
Promote good practices in
design and implementation of
income generation activities.
Support income-generating
programmes. Strengthen
traditional coping mechanisms
to enhance sustainable
livelihoods. Integrate SRH
services in economic
empowerment activities.
Operationalise national food &
nutritional policies/guidelines
to local governments,
communities and PLHIV
households. Facilitate the
provision of essential
materials.
UGANDA
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment
Improvement of the economic
situation of vulnerable groups.
Prevention of sexual
transmission of HIV through
sensitisation, condom
promotion and STI
management. Promotion of
peer education. Strengthening
of prevention activities
oriented towards high risk
groups.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Promotion of peer education.
Prevention of sexual
transmission of HIV through
sensitisation, condom
promotion and STI
management.
Females affected bysexual/GB violence
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
167
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, etc.),
meetings, cultural/sports
activities, conferences.
Focus prevention on
vulnerable and high risk
groups by addressing socioeconomic and cultural factors
and promote prevention
among PLHIV.
Increase availability and
access to counseling and
testing and treatment of STIs.
Accelerate condom
distribution programme.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
To make condoms available
to prisoners and address
sexual abuse of male and
female prisoners.
Review guidelines/ regulations
relevant to STI transmission.
Advocate for prisoners' HIV
vulnerability towards decision
makers & personnel. Establish
education system on
STD/HIV/AIDS. Introduce
peer education schemes.
Establish user-friendly STI &
VCT services and access to
affordable preventive tools
(condoms etc). Introduce STI
policy framework that includes
access to care & support.
Introduce dialogue sharing
experience between prisons &
HIV/AIDS institutions.
Strengthening capacity of
police and health care system,
including the private sector, to
provide prompt services to
victims of rape and sexual
violence. Strengthening
provision of PEP. Develop
strategies to fight stigma
associated with rape.
Promotion of PEP.
Promote open discussion &
awareness about gender
inequality, HIV, GBV & sexual
abuse within families and at
community level. Promote
respect for human rights of
women and children. Promote
increased access to HIV
preventive information and
services. Provide PEP,
emergency contraception,
presumptive treatment of STI,
counseling, legal support and
protection for rape victims,
including for sexually abused
children and for women in
abusive and forced marriages.
Scale up HIV/AIDS
interventions in trade unions
involved in protecting house
girls and hotel workers.
Enforce the legal act on
harassment and abuse.
Prisoners
Returnees
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Develop and implement
effective interventions for
reduction of high-risk sex
including the most at risk
groups; through IEC
interventions.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
168
ANNEX VIIIb. Targeting of OTHER vulnerable population groups
BURUNDI
Plan Strategic de Lutte Contre
le VIH/SIDA. 2007-2011
DR CONGO
Plan Strategique National de
Lutte contre le VIH/ SIDA/
MST 1999–2008
KENYA
RWANDA
National Strategic Plan
2005/6-2009/10
Plan Strategique Nationale de
Lutte contre le VIH/SIDA, Nov
2005
TANZANIA-Mainland
TANZANIA-Zanzibar
National Multi-Sectoral
Strategic Framework on HIV
and AIDS 2008 –12
Zanzibar Natioanal HIV/AIDS
Strategic Plan 2003-2007
Increase access to HIV
prevention (IEC, condoms,
peer education, VCT & STIs
services). Develop outreach
programmes to include
families and communities of
the workers. Make information
and condoms available to all
mobile and migrant workers in
all sectors. Develop and
support special HIV
prevention and control
programmes designed to
reach the operators in the
informal sector, through
collaboration with government
and the private sector.
Introduce HIV/AIDS education
for workers. Promote
provision of employment
contracts with health benefits.
Establish health care
schemes providing medical
aid & hospital charges.
Ensure access to STD
clinics/VCT, condoms, vaginal
microbicides. Create platforms
for experience sharing
between workers institutions &
trade unions in private &
public set ups (local,
international fora). Review
policy/regulations that
discriminate HIV/AIDS
employee.
Targeting of vulnerable populations
Transportation operators
Migrants workers
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Strengthening of prevention
activities oriented towards
high risk groups.
Develop innovative HIV/AIDS
prevention, treatment and
care strategies for targeting
migrant workers; and
mainstream HIV/AIDS in the
sectors serving migrant
workers.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Design special education
programme on HIV/AIDS for
Daladala owners/ operators.
Ensure legal environment on
protection of workers and their
rights based on ILO
recommendations. Promote
HIV/AIDS campaigns on
Daladala commuters by using
various IEC materials.
Conduct behavioural
surveillance for drivers and
their assistants/conductors.
Promote safer sex.
UGANDA
National HIV and AIDS
Strategic Plan. 2007/8 –
2011/12, Aug 2007
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
KENYA
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
DR CONGO
Develop specific strategies to
address the HIV prevention
and other HIV-related needs.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Develop and implement a
comprehensive strategy to
reduce HIV transmission
among IDUs, including
education, condom provision,
harm reduction measures
(disinfection and exchange of
needles and syringes) and
rehabilitation services for
persons who inject drugs.
Introduce rehabilitation
centres with vocational
training. Strengthen existing
laws & regulations /policy
framework for implementation
& scaling up of harm
reduction, demand reduction
and enforcing the laws against
illicit drug importation. Scale
up peer-education training &
programming using ex-drug
addicts. Increase HIV/AIDS
education message for
substance abusers. Produce
behavioural change packages
targeting substance abusers &
general public. Increase
capacity of CSOs that mitigate
harm & demand reduction.
Educate and promote
community [positive]
perceptions towards
substance abusers and
introduce community
supportive schemes that
discourage substance use.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Develop specific strategies to
address the HIV prevention
and other HIV-related needs.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Acknowledge the vulnerability
of MSM and advocate for their
access to HIV preventive
information and services and
for decriminalization of their
activities.
Men who have sex with men
Injecting drug users
BURUNDI
169
UGANDA
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
BURUNDI
DR CONGO
KENYA
Married couples
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
RWANDA
TANZANIA-Mainland
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Female petty traders
Improvement of the
socioeconomic situation.
170
Encourage couple testing and
counseling, and the provision
of information and education
on reproductive rights.
Promote open discussion &
awareness about gender
inequality, GBV and sexual
abuse that increase
vulnerability of women, girls
and boys to HIV within
families and at community
level and promote respect for
human rights of women and
children. Strengthen
programmes with /by men to
promote life skills and male
responsible behaviour in
sexual and family relations.
Promote access to HIV
prevention services. Provide
PEP, emergency
contraception, presumptive
STI treatment, counseling,
legal support & protection for
rape victims, incl. for sexually
abused children and women
in abusive /forced marriages.
TANZANIA-Zanzibar
UGANDA
Introduce behavioural
communication programme to
mobile traders. Organize
training of trainers/peer
educator’s among the women
traders at their working
places. Conduct secondgeneration behavioural
surveillance. Strengthen
access to condom and
STD/VCT services. Promote
early STD treatment seeking
behaviour.
Prevention in the most at risk
groups of women through IEC
and VCT.
Promote safe sexual norms
and positive sexual behaviour
among women and girls either
through delayed sexual
activities, or proper condom
use. Empower women,
especially girls, on decisionmaking regarding their sexual
behaviour. Educate employers
and husbands on protection of
their spouses and house girls.
Reduce HIV transmission
among married people and
discordant couples through
couple counselling, testing
and disclosure.
PLHIV
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
171
BURUNDI
DR CONGO
KENYA
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
UGANDA
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion.
Prophylaxis, diagnosis and
treatment of OIs. Universal
access to ARVs.
Psychological and nutritional
support of PLHIV. Home
based and palliative care
(continuum of care).
Improvement of
socioeconomic situation of
PLHIV and affected persons.
VCT. Treatment of OIs.
Access to ARVs.
Psychosocial support of
PLHIV and affected persons.
Economic support. support to
PLHIV and remaining family
members. STD care.
Promotion of condom. Income
generating activities.
Involvement of PLHIV at the
highest levels in development
& coordination of the HIV/AID
response. Strengthening
capacity of PLHIV
organisations to be involved
effectively in prevention,
treatment, care & mitigation.
Supporting creation of
representative & effective
PLHIV organisations at all
levels.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences. Reduction of
health impact of HIV, STIs, TB
on PLHIV, their partners and
AIDS orphans. Availability and
affordability of essential drugs
& ARVs. Counselling services,
health insurance schemes,
palliative care, assistance
(material, nutritional,
psychological, legal).
Enhance capacity at regional
and district levels to plan,
implement, coordinate,
monitor and evaluate a quality
continuum of care, treatment
and support services. Scale
up the involvement of the
private sector in the provision
of the continuum of care,
treatment and support
Expand availability &
accessibility of prophylaxis &
treatment for OIs. Ensure
PLHIV are actively involved in
(adherence) counselling and
support of newly enrolled
patients. Incorporate
nutritional counselling,
education & support in care
and treatment of PLHIV and
care-givers, incl. changes of
the diet according to food
locally available. Promote
greater involvement of PLHIV
in planning & implementing
HBC & support.
Assess attitudes of service
providers & sensitise them to
reduce stigma &
discrimination. Review
policies & procedures,
overhaul those that stigmatise
/discriminate against PLHIV.
Ensure confidentiality of all
PLHIV. Train & involve PLHIV
in outreach education. Use
counselling services as
starting point for empowering
beneficiaries. Encourage
PLHIV to organise themselves
and/or join HIV/AIDS
networks. Provide PLHIV &
affected families with
opportunity to meet other
PLHIV through peer
counselling and support
groups. Encourage PLHIV to
go public. Develop counselling
strategies to help PLHIV cope
with perceived & actual
experiences of stigma &
discrimination. Encourage
public & private sector HIV
testing services to offer
information to PLHIV about
NGO services and to refer
PLHIV to respective NGOs.
Work with stakeholders to
reduce stigma &
discrimination at community
level by promoting tolerance
and compassion, improving
community knowledge &
awareness about HIV/AIDS,
sensitising community &
religious leaders, and
advocating for legal and
human rights of PLHIV.
Ensure that PLHIV have free
or low cost access to
appropriate health care, incl.
treatment for OIs.
Increase equitable access to
ARV. Scale-up VCT. Increase
access to prevention &
treatment of OIs including TB.
Integrate prevention into care
including nutrition counselling
& education. Support &
expand HBC, palliative care &
improve referral systems
between HBC and health
facilities. Promote healthcare
seeking behaviour among
males. Scale up access to
and increase uptake for ART
services for those in need,
especially targeting women of
all age groups where the
highest incidence of HIV and
AIDS is reflected. Promote &
expand specialized paediatric
and adolescent HIV care.
Provide for increased
coverage ART treatment to
mothers receiving PMTCT.
Promote & support food and
nutrition security interventions
among affected households
and communities.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
BURUNDI
DR CONGO
KENYA
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
UGANDA
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
Implement specific activities to
make youth aware and take
responsibility over their
behaviours and practices.
Promote delay of sexual
inception. Promote condom
use. Prevention of sexual
transmission through
sensitisation activities on safer
sex and treatment of STDs.
Carefully targeted prevention
messages. Youth friendly
access to HIV and
reproductive health
information and other
services. Mobilising the
education system to provide
comprehensive prevention
and care for youth in school.
Improving girls’ access to
education and skills training,
and protecting their rights.
Building partnerships with
youth-based organisations.
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Promotion of programmes
provided by parents, teachers
and schools. VCT.
Scale up vocational training,
income generating
programmes and employment
opportunities for out of school
youths. Promote safe sexual
norms & positive sexual
behaviour among young
people (incl. abstinence,
delayed inception, fidelity,
condoms). Empower youths,
especially young women, on
decision making regarding
their sexual reproductive lives
through life skills approaches.
Protect out of school youths
against substance abuse.
Promote culturally sensitive
life skills education for youths,
especially girls, so as to
enhance their confidence,
negotiation skills & decisionmaking. Promote youth
partnership in conceptualising,
planning, implementing and
monitoring of Youth
Programmes.
Promotion of abstinence
among youths in and out of
school. Ensure that all the
youth access life skills that
integrate HIV/AIDS
prevention. Facilitate
increased access to
vocational education and
apprentice opportunities.
Advocate for affirmative action
for OVC, girl child, people with
disabilities and other
disadvantaged groups in
access to informal education,
vocational and life skills
development.
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
OVC care and support.
Ensure protection of rights of
OVC and improve access to
basic services.
Care and support. Income
generating activities to foster
independence.
Strengthening social
mechanisms for orphan care.
Ensuring OVC access to
social services –
food/nutrition, education,
health, shelter & social
support. Strengthening legal
and policy framework for
protecting the rights of OVC.
Strengthening framework for
monitoring and coordinating
interventions which support/
protect rights of OVC.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences Promotion of
specific programmes provided
by parents, teachers, schools.
VCT. Reduction of health
impact of HIV, STIs and TB.
Build capacity among parents
& guardians to communicate
with their children on SRH
issues & to support school
based RH & HIV education.
Strengthen & expand
comprehensive life skills &
HIV education/interventions
for schools, teacher training
colleges & tertiary education
institutions, through inclusion
of these issues in curriculum
and through school/institution
based peer education &
counseling. Encourage pupils
& students to develop own
HIV projects. Promote &
expand peer-education and
counsellor training for in and
out of school youth. Increase
provision & utilization of youth
friendly & gender sensitive
SRH services and link to
livelihood & income
generation. Promote &
expand programmes against
drugs, alcohol. Promote
access to HIV prevention.
Build capacity among parents
and guardians to
communicate with their
children about SRH and to
support school based RH and
HIV education. Promote and
expand programmes against
drugs, alcohols. Promote
increased access to HIV
prevention services.
Develop community based
recording system for
identification / registration of
OVC. Introduce sustainable
programmes to support OVC
in basic needs. Develop
family-counselling programme
during caring of a sick person
& after death to properly take
care of AIDS orphans.
Promote capacity building/skill
development for grown up
AIDS orphans to be capable
for self-employment, establish
basis for independent life.
Introduce peer educator
among OVC. Conduct
behavioural study. Increase
effective participation of
NGOs in caring for OVC.
Ensure that all the youth in
and out of school access life
skills that integrate HIV/AIDS
prevention. Ensure provision
of the non tutional costs &d
essential requirements to
OVC in formal
education.Promote & support
food & nutrition security
interventions among HIV/AIDs
affected households &
communities. Operationalise
national food & nutritional
policies/guidelines to local
governments, communities &
PLHIV households. Facilitate
provision of financial, and
essential materials.
Youth
OVC
172
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
BURUNDI
Young women
Promotion of lower risk sexual
behaviours through IEC, BCC
and condom promotion. VCT.
STI diagnosis and treatment.
OVC care and support
DR CONGO
KENYA
Promotion of abstinence,
consistent safe sex and
delayed sexual debut among
young people.
173
RWANDA
TANZANIA-Mainland
TANZANIA-Zanzibar
UGANDA
Sensitisation on abstinence,
fidelity and condom use.
Strengthening of condom
social marketing and
specifically of female condom.
Prevention activities through
IEC/BCC by using mass
media channels, peer
education, promotion
materials (flyers, shirts,
posters, etc.), meetings,
cultural/sports activities,
conferences.
Promote open discussion and
awareness about gender
inequality, gender based
violence & sexual abuse that
increase vulnerability of
women, girls and boys to HIV
within families and at
community level and promote
respect for human rights of
women and children.
Empower girls and women to
negotiate safer sex through
enhancing knowledge about
sexuality, reproductive health
and HIV and imparting life
skills that increase their
effective control to protect
themselves. Revise legislation
that condones early marriage
for girls (before age 18) and
does not recognize rape
within marriage. Provide PEP,
emergency contraception,
presumptive treatment of STI,
counseling, legal support and
protection for rape victims,
including for sexually abused
children and for women in
abusive and forced marriages.
Promote safe sexual norms
and positive sexual behaviour
among women and girls either
through delayed sexual
activities, or proper condom
use. Empower women,
especially girls, on decisionmaking regarding their sexual
behaviour. Educate employers
and husbands on protection of
house girls.Scale up
HIV/AIDS interventions in
trade unions involved in
protecting house girls and
hotel workers. Enforce the
legal Act on harassment and
abuse.
Promote abstinence,
fidelity and use of the male
and female condoms.
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
174
ANNEX IX Selected Statistics
Annex IXa. Size estimate fishermen and fisherwomen
FAO statistics on fishermen and fisherwomen in GLIA countries
Burundi
(2001)
DRC
(2000)
Kenya
(2005)
Rwanda
(2005)
Tanzania
(2004)
Uganda
(2003)
Total
Men/Women
Fishermen
Inland
Marine
Total
Fisherwomen
Inland
Marine
Total
9,969
107,000
1,400
108,400
45,967
9,209
55,176
6,325
n/a
6,325
100,115
19,464
119,579
64,391
n/a
64,391
363840
1,000
n.r.
n.r.
-
n.r.
n.r.
-
1,125
n/a
1,125
n.r.
n.r.
-
n.r.
n.r.
-
2,125
Total Inland
Total Marine
Grand Total
10,969
107,000
1,400
108,400
45,967
9,209
55,176
7,450
7,450
100,115
19,464
119,579
64,391
64,391
365,965
Source: FAO Fisheries and Aquaculture Information and Statistics Service (figures reported by countries to FIES in annual
FISHSTAT questionnaire). Figures in table exclude workers in aquatic-life cultivation
n.r.= not reported, n/a = not applicable
Population census data on fishermen and fisherwomen in GLIA countries
Burundi
(1990)
DRC
(1984)
Kenya
(1999)
Rwanda
(2002)
Tanzania
(2002)
Uganda
(2002)
Fisherwomen
n.r.
-
report not
identified
92
16,186
(13,428 Mainland)
(2,759 Zanzibar)
16,743
Fishermen
n.r.
-
report not
identified
3,368
134,679
(112,871 Mainland)
(21,808 Zanzibar)
102,043
Total
-
-
-
3,460
150,865
( 126,298 Mainland)
(24,567 Zanzibar)
118,786
Source: Tanzania Population CensusReports of Rwanda, Tanzania, Uganda
n.r.= not reported
Population Size Estimate:
Use of available census data and use of FAO country data where census data not available
Burundi
DRC
Kenya
Rwanda
Tanzania
Uganda
10,969
108,400
55,176
3,460
150,865
118,786
TOTAL
447,656 of which 413,635 men (92.4%) and 34,021 women (7.6%)
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Annex IXb.
175
Refugee Population in GLIA Countries, as of end June 2007
Country
Refugees
Nationality
Number
Total
BURUNDI
DRC
Rwandan
Others
22,895
286
34
23,215
DRC
Angolan
Rwandan
Burundian
Ugandan
Others
128,160
34,017
17,741
13,912
3,402
197,232
KENYA
Somali
Ethiopian
Eritrean
Sudanese
Ugandan
Congolese
Rwandan
Burundian
Tanzanian
187,565
16,634
607
55,578
2,823
2,441
2,343
1,200
4
269,195
RWANDA
DRC and others
46,600
46,600
TANZANIA
(UNHCR assisted
populations only)
Burundian
DRC
Somali
153,841
115,046
2,077
273,678
(UNHCR
assisted)
471,912
(all)
Others
UGANDA
Sudanese
DRC
Rwandan
Somali
Ethiopian
Burundian
Others
2,714
167,386
28,184
19,519
3,749
107
1,895
74
220,914
Source: OCHA Regional Office for Central and East Africa (2007). Displaced populations report, January-June
2007
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Annex IXc. HIV prevalence in refugees and host communities
Prevalence of HIV infection in refugees and host communities in selected sites, 1998-2005
(source: Spiegel et al., 2007)
Prevalence of HIV infection in eastern DRC (2004) and in nearest neighbouring-country sentinel sites
(source: Spiegel et al., 2007)
176
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
177
Annex IXd. Summary of core indicators BSS GLIA in four countries
Kenya
Indicator
Sex
Never married
who never had
sex (15-24 y)
Rwanda
Host
Camp
(Kiz)
(Rw1/2)
Tanzania
Hosts
Camps
(Luk/Lug)
(Tz1/2)
Uganda
Host
Camp
(N&O/Ho)
(Ug1/2)
Camp
(Kak)
Host
(Ke1)
F
M
T
61%
51%
55%
69%
43%
55%
60%
46%
54%
48%
47%
48%
45%/52%
66%/21%
56%/32%
71%/48%
79%/65%
75%/56%
79%/80%
77%/78%
78%/79%
84%/74%
74%/57%
79%/63%
Higher-risk sex in
past 12 months
(15-24 y)
F
M
T
28%
40%
35%
14%
41%
25%
7%
32%
17%
12%
22%
16%
5%/28%
3%/53%
4%/40%
19%/20%
19%/22%
19%/21%
7%/1%
6%/1%
6%/1%
4%6%
2%/7%
3%/7%
Condom use at
last higher-risk
sex (15-24 y)
F
M
T
42%
36%
38%
42%
29%
33%
25%
24%
24%
9%
23%
17%
9%/44%
75%/36%
27%/39%
31%/24%
28%/32%
30%/27%
11%/29%
10%/57%
10%/48%
33%/18%
19%/32%
24%/27%
>1 sex partner
last 12 months
(15-49)
F
M
T
n/a
n/a
n/a
n/a
6%/26%
11%/50%
8%/37%
20%/27%
27%/36%
23%/30%
7%/4%
17%/13%
12%/9%
8%/11%
18%/27%
12%/19%
HIV test in past
12 months
(15-49 y)
F
M
T
17%
20%
19%
13%
5%
10%
9%
13%
11%
14%
12%
13%
34%/17%
31%/19%
32%/18%
14%/11%
16%/10%
15%/10%
8%/12%
10%/9%
9%/11%
5%/10%
7%/7%
6%8%
STI symptoms in
last 12 mths and
sought treatment
at h/ facility (1549)
F*
M*
T*
42%
48%
65%
46%
n/a
n/a
78%/63%
100%/50%
90%/57%
71%/86%
50%/88%
63%/87%
42%/52%
57%/33%
49%/44%
70%/55%
58%25%
65%/41%
6%
11%
4%
8%
4%/10%
2%/4%
1%/2%
1%/2%
Women ever
F
forced to have
sex
* based on small numbers
Sources: BSS reports UNHCR/GLIA Kenya (2004), Rwanda (2004), Tanzania (2005), Uganda (2006).
ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region
Refugees:
Sexual abstinence in unmarried youth (15-24 yrs)
178
Refugees:
HIV test in past 12 months (15-49 yrs)
percent
percent
100
90
40
Refugees female
Refugees male
Villagers female
Villagers male
Refugees female
35
80
Refugees male
Villagers female
30
Villagers male
70
25
60
20
50
40
15
30
10
20
5
10
0
0
Kakuma-K
Kiziba-R
Lukole-T
Lugufu-T
Nakivale-U
Kakuma-K
Kyangweli-U
Refugees:
Prevalence of higher-risk sex (15-24 yrs)
in the past 12 months
Kiziba-R
Lukole-T
Lugufu-T
Nakivale-U
Kyangweli-U
Refugees:
Condom use at last higher-risk sex (15-49 yrs)
percent
percent
80
60
Refugees female
Refugees female
70
Refugees male
50
Villagers female
Refugees male
Villagers female
60
Villagers male
40
Villagers male
50
40
30
30
20
20
10
10
0
0
Kakuma-K
Kiziba-R
Lukole-T
Lugufu-T
Nakivale-U
Kyangweli-U
Refugee women ever forced to have sex
percent
12
Refugees female
10
Villagers female
8
6
4
2
0
Kakuma-K
Kiziba-R
Lukole-T
Lugufu-T
Nakivale-U
Kyangweli-U
Kakuma-K
Kiziba-R
Lukole-T
Lugufu-T
Nakivale-U
Kyangweli-U
Great Lakes Initiative on AIDS (GLIA)
and
Global HIV/AIDS Monitoring and Evaluation Team (GAMET)
Global HIV/AIDS Program, World Bank
Rapid analysis of HIV epidemiological and
response data on vulnerable populations
in the Great Lakes Region of Africa
WWW.G REATLAKESI NITI ATI VE . O RG
For more information, please contact:
The Global HIV/AIDS Program
World Bank Group
1818 H St. NW,
Washington, DC 20433
Tel: +1 202 458 4946
Fax: +1 202 522 1252
[email protected]
Great Lakes Initiative on HIV/AIDS (GLIA)
P.O. Box 4320
Kigali – Rwanda
Tel: + 250 587344/5
Fax:+ 250 587343
www.greatlakesinitiative.org
[email protected]
www.greatlakesinitiative.org
[email protected]
January 2008