Public Disclosure Authorized 43014 Great Lakes Initiative on AIDS (GLIA) and Global HIV/AIDS Monitoring and Evaluation Team (GAMET) Global HIV/AIDS Program, World Bank Public Disclosure Authorized Rapid analysis of HIV epidemiological and response data on vulnerable populations in the Great Lakes Region of Africa Public Disclosure Authorized Public Disclosure Authorized 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 co-authors: Nicole Fraser, Marelize Görgens, and John Nkongoloc World Bank Global HIV/AIDS Program January 2008 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region i 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. 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 b Monitoring and Evaluation Expert, World Bank c Research Assistant, Consultant to the World Bank 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 iii 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: mgorgens@worldbank.org, Mobile phone: +27.82.774.5523. Fax: (202) 522-1252 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region iv Acronyms and Abbreviations AIDS Acquired Immuno-deficiency Syndrome AIS AIDS Indicator Survey AMREF African Medical and Research Foundation ANC Ante-natal care ART Antiretroviral therapy ARV Antiretroviral (drugs) ATGWU Amalgamated Transport and General Workers’ Union AU African Union AVEGA Association des Veuves du Génocide BCC Behavioral Change Communication BSS Behavioral Surveillance Survey CBO Community-based Organization CEPGL Communauté Economique des Pays des Grands Lacs CMA Civil-Military Alliance to Combat HIV and AIDS CNLS Commission / Conseil National de Lutte contre le SIDA COMESA Common Market for Eastern and Southern Africa CSO Civil Society Organization CSW Commercial Sex Worker DFID U.K. Department for International Development DHS Demographic and Health Survey DRC Democratic Republic of Congo EAC East African Community FHI Family Health International, FSW Female Sex Worker GBV Gender-based Violence GLIA Great Lakes Initiative on HIV/AIDS HBC Home Based Care HEARD Health Economics and HIV/AIDS Research Division HIV Human Immunodeficiency Virus IDP Internally Displaced Person IEC Information, Education and Communication IGAD Inter-Governmental Agency for Development ILO International Labour Organisation IOM International Organization for Migration ITF International Transport Workers’ Federation MAP Multi-Country HIV/AIDS Program for the Africa Region MC Male circumcision MISP Minimal Initial Services Package MOH Ministry of Health MOU Memorandum of Understanding MSF Medecins sans Frontières NAC National HIV/AIDS Council/Commission/Committee NACC National AIDS Control Council NACP National HIV/AIDS Control Program NAS National AIDS Secretariat ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region v NEPAD New Partnership for Africa’s Development NGO Non-Governmental Organization NSP National Strategic Plan OCHA United Nations Office for the Coordination of Humanitarian Affairs OI Opportunistic Infection OVC Orphans and Vulnerable Children PEP Post exposure prophylaxis PLHIV People Living with HIV PMTCT Prevention of Mother-To-Child Transmission PNLS Program National de Lutte contre le SIDA PSI Population Services International REDSO USAID Regional Economic Development Services Office SADEC Southern African Development and Economic Community’ SFLP Sustainable Fisheries Livelihoods Programme SRH Sexual and Reproductive Health SSA Sub-Saharan Africa STD Sexually Transmitted Disease STI Sexually Transmitted Infections SWAA Society for Women against AIDS in Africa TB Tuberculosis TRAC Treatment Research and AIDS Center UAC Uganda AIDS Commission UNAIDS United Nations Joint HIV/AIDS Programme UNECA UN Economic Commission for Africa UNHCR UN High Commissioner for Refugees UNODC United Nations Office on Drugs and Crime USAID U.S. Agency for International Development VCT Voluntary Counseling and Testing WHO World Health Organization ZAC Zanzibar AIDS Commission 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 Multi- country 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region xiv 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 • Loneliness & isolation, mitigated by providing transport to people low condom use • Road risks (accidents, theft) • Inconsistent levels of condom use • Work in remote, poor environments with inadequate facilities • Low level of condom use with regular partners and spouses • Easy access to alcohol, stress leading to abuse of alcohol/drugs • Limited access to regular HIV prevention • Availability of disposable funds services, including VCT • Long, frustrating delays at borders and custom checkpoints • Casual sex readily available • Harassment /stigmatisation by police, border officials, etc. • Milieu around border posts caters for the • Lack of health infrastructure where transport workers need it, sexual needs of transport workers, with large trucks cannot get to facilities off the main road 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 Risk factors for HIV • Time fishermen spend away from home, high mobility • Culture of hypermasculinity which may include • Alcohol use to help cope with dangers/stress of occupation expectation of multiple sexual partners • Demographic profile (mostly young age) • Poor access to facilities and medicine and low uptake of available health services • Fishing is a high-risk occupation which can contribute to culture of risk denial or risk confrontation • Difficult to reach with adequate AIDS treatment and mitigation measures • Access to daily cash income, high income in fishing season • Fishing camps and ports may lack social • Ready availability of commercial sex in fishing ports structures that constrain sexual behavior as in • Social marginalisation and low status home communities • Subordinate position of women in many fishing communities • Difficult to reach with disease prevention efforts ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region xv 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 • Trained to regard risk-taking and aggressive males in lowest HIV prevalence group) behavior as the norm • Trained not to be deterred by risk and danger • Access to CSW and settlements with ‘soldiers • Separated for long periods from spouses and partners, or denied wives’ (but: these sexual networks are often marriage during enlistment periods restricted) • When away, removed from the social discipline (but: disciplined • At risk of physical injury involving loss of blood army environment, not all soldiers away from base) and need for blood transfusion under possibly non-sterile conditions • Living in same-sex quarters • Sharing of razors and skin-piercing instruments in • Some ranks well paid tattooing and scarification • Susceptible to peer pressures • (Testing and selection of HIV negative individuals • May seek to relieve themselves from combat stress through sex 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 • Alcohol and drug consumption concurrent partners • Occupation in places where transactional sex is frequent • These multiple concurrent partners often have multiple partners themselves (sexual network) • Compromised power relations • Low risk perception towards regular clients (trust • Low level of empowerment and education 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) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region xvi 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 Risk factors for HIV • Dispossessed of land, productive resources, home • Minimum standards in humanitarian interventions • Illegal settlement and resulting expulsion may not include HIV prevention • War destroys infrastructure (health, education, etc) • Barriers to HIV prevention: disruption of health services; testing for HIV may be difficult • Poor access to comprehensive health services • Disruption of sexual partnerships and networks • Multiple threats to health other than HIV • Outside habitual norms and social control, • Economic situation of women and children persons may adopt new behaviors • Migration from rural areas where HIV prevalence and knowledge • Sexual interaction with military or paramilitary of HIV low • Transactional sex, also as “survival strategy” • Unaccompanied minors lack parental protection • Sexual violence, multiple perpetrators • Psychological trauma • New sexual relationships with power differentials • Potentially, disruption of family and social structures • Potentially, increased use of alcohol and illicit • IDPs: Lack of official status & protection framework 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 • Appalling living conditions, overcrowding rape, etc) • Substandard or nonexistent health care • Prostitution as a coping mechanism • Gender exclusive environment, lack of conjugal visits • Tattooing and other forms of skin piercing • Restriction on drug use & harm reduction measures • Blood brotherhood rituals • Criminalization & denial of sexual activity/rape • Untreated STIs • High turnover and mobility among prisoners • Prevention commodities (condoms, lubricants, needles/ syringes, bleach) often not available • Little autonomy in own protection • Lack of access to IEC services ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region xvii 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 Should the GLIA strategic What are promising interventions that should be considered for Population size, plan focus on this the GLIA strategic plan? PLHIV numbers population? LONG-DISTANCE YES. GLIA should fund HIV • Advocacy by the GLIA for the identification of hotspots along all TRUCK DRIVERS service delivery to this group corridors and for inclusive programming ensuring that needs of in the short to medium term, truckers and of the communities in truck stops are addressed Size: 298,458 so that countries can learn • Sharing of information by the GLIA for interventions that have PLHIV: 53,722 best about ‘what works’ worked before implementing a minimum package of services • Epidemiological and formative research to inform the design of for this group themselves programs, commissioned by the GLIA FISHERMEN & YES. GLIA should provide • Provision of HIV prevention, treatment & support services through FISHERWOMEN HIV prevention, treatment appropriate sub contractors, including the training of fisheries and support services through officers on BCC for HIV, and the development of communication Size: 447,656 appropriate sub contractors. material that ‘speaks the language of the ports’ PLHIV: 110,571 Despite consistently high HIV • Advocacy for the integration of HIV services for fishermen and prevalences among fisherwomen, mobile VCT and GBV counseling, and for custom- fishermen and fisherwomen made programs for these communities in each GLIA country in the GLR, there has been little concerted action • Sharing of experiences of ‘what works’ in dealing with this targeting fishing communities. 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 xix POPULATION Should the GLIA strategic What are promising interventions that should be considered for Population size, plan focus on this the GLIA strategic plan? PLHIV numbers population? REFUGEES YES. GLIA should fund • Provision of HIV prevention, treatment & support services service delivery by sub- Size: 1,229,069 • Advocacy for the integration of HIV services for refugees and host contractors in the short to populations, inclusive VCT and GBV counseling PLHIV: 20,280 medium term. National governments are relatively • Advocacy for IEC/BCC interventions before, during and after inexperienced in providing repatriation, and for uniform treatment, care and support policies in HIV services in refugee sites. the GLIA countries IDPs • Fostering collaboration between refugees organizations and hosts Size: 2,929,479 • Operational research on the continuum of care inclusive ART in the PLHIV: 151,761 displacement cycle, funded by the GLIA FEMALE SEX YES, but direct service • Advocacy for appropriate legislation, adequate and accessible WORKERS delivery to the diverse services for FSWs, and a reduction in stigma and discrimination population of FSW should be displayed towards FSWs No size data left with the national available • Epidemiological, socio-cultural and socio-economic research and programs providing tailored size estimation studies in GLIA countries to gain a better under- interventions. standing of women involved in sex work and transactional sex FEMALES YES, but GLIA should not • Advocacy by the GLIA for interventions to change perceptions and AFFECTED BY fund direct service delivery. opinions about sexual and GBV, and for the integration of GBV SEX. VIOLENCE This population is dispersed screening & counseling in service delivery (VCT, ANC, SRH, and hidden so hard to reach abortion care, adolescent programs) Size: 7,772,897 by specific interventions. • Sharing of training materials and experiences in terms of the Attribut. PLHIV: Sexual violence should be integration of services into all aspects of service provision; for addressed through existing example: the training of health care personnel which includes 132,500 services provided by the medical, psychological and forensic elements and post-rape care national governments. PRISONERS YES, but direct service • Advocacy by the GLIA to support development of national HIV provision should remain with policies in prisons and for interventions supporting general Size: 222,042 other actors and the national improvement of prison living conditions PLHIV: 12,434 governments. The population • Epidemiological research in prison communities, and operational is relatively small and isolated research on the HIV and TB epidemics in prison communities and so interventions may have ‘what works’, commissioned by the GLIA limited effectiveness. MILITARY YES, but direct service • Advocacy by the GLIA for better condom distribution programs, provision to the military (and IEC/BCC programs, release of HIV prevalence data Size: 401,020 other uniformed personnel) • Sharing of information by the GLIA on types of interventions that PLHIV: 40,102 – should be left as the have worked in other countries 80,204 responsibility of national HIV programs. • Qualitative research commissioned by the GLIA to understand better the sub-culture in the military 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 country- specific 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 2 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 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. 4 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) 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 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 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 inter- country collaboration to respond to the epidemic, pool resources within the framework of a sub- regional 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 7 Table 2. Methods to estimate population size, median HIV prevalence and PLHIV numbers for the selected vulnerable populations Population Estimation of population sizes Estimation of median HIV prevalence and PLHIV numbers Challenges with estimations Military www.nationsencyclopedia.com and Due to recent claims that HIV prevalence in military may be lower than suspected, a Statistics of HIV prevalence in military were virtually unavailable. The only data www.mongabay.com prevalence range of 10-20% was used to estimate PLHIV numbers. for this decade identified came from Uganda Defence Force (20%). Truck drivers Kenya: size estimations were Median HIV prevalence was calculated based on six different studies. Almost all HIV prevalence data came from studies of Kenyan truckers. Size available. Other countries: Population estimates for truckers are highly uncertain, mainly because few truckers are sizes were extrapolated from the total organized, so union statistics are incomplete. Occupational statistics from population, using the proportion of population censuses did not use relevant employment categories. The only size Kenyan truck drivers to the total estimate identified concerned Kenyan truck drivers. Kenyan population Fishermen & Size estimates for Rwanda, Tanzania Median HIV prevalence was calculated based on four reasonably recent studies from Available statistics on persons occupied in the fishing sector in the GLR fisherwomen & Uganda used 2002 population several GLIA countries. present several weaknesses due to irregular reporting by countries, different census data. FAO provided estimates concepts used to enumerate employment, and the informal nature of the fishing for Burundi (2000), DRC (2000) , occupation. Kenya (2005) Female sex Did not estimate population size, due Presentation of HIV prevalence data from various studies, but no calculation of For non-brothel based sex work, it is problematic to define boundaries between workers to the problem of defining the median HIV prevalence and PLHIV numbers. full-time, part-time or occasional sex work, and transactional sex for money or boundaries of ‘risk group’ gifts. Different forms of sex work may have highly variable levels of exposure membership (see explanation of to HIV, which may lead to large within-group differences in HIV prevalence (this challenges) topic is not well researched). 11 Refugees OCHA (June 2007 figures) Median HIV prevalence was based on eight recent surveys in different camps No major challenges. Internally OCHA (June 2007 figures) The calculation of PLHIV numbers was based on the estimated national HIV No IDP-specific HIV prevalence data were available displaced prevalences from UNAIDS for 2007. persons Prisoners World Prison Population List providing Median HIV prevalence was based on seven studies from different GLIA countries Total prison populations are uncertain in DRC and Rwanda. Four assessments most recent figures of 2004, 2005, presenting data collected between 1995 and 2007. of HIV prevalence were done > 5 years ago. Some HIV data come from small 2006 studies. Females Estimated based on six studies The relative risk (RR) of sexual violence for HIV infection was estimated using RR This group is not a specific occupational risk group or segregated in a specific affected by presenting the proportion of females data from two SSA studies with identical RR data (1.4 – females with a history of place like camps, prisons, but an integral part of the general population. sexual in the adult female population who sexual violence are 1.4 times more likely to be HIV positive than females without Calculations therefore used a different methodology. PLHIV numbers could not violence have a history of sexual or gender- such a history). The RR estimate was used to calculate the number of PLHIV be based on median HIV prevalence in this group, since population prevalence based violence. attributable to sexual violence, using UNAIDS total numbers of adult female PLHIV varies considerably across the GLIA countries. Several powerful data sources for each GLIA country. The number of excess female PLHIV attributable to sexual had to be excluded from the estimation of population size because they used a violence was based on the excess risk of HIV sero-positivity in violence-affected narrow definition of sexual violence (i.e. rape). females. 11 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. 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 A recent study on 191 IDUs (of whom 96% male) in Zanzibar found 26% HIV sero- positivity (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. ƒ 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 ƒ 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 ƒ 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 ƒ 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 ƒ 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. ƒ 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. ƒ Application of the UNAIDS incidence model estimated for Kenya for 2005 that about 5% of incident cases stem from IDU. 23 16 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 Estimated Number of people living with HIV Adults aged 15-49 All 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 • 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 30 DRC Ur Ke Ur Rw Ur 25 Tz Ur Ug Ur 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 Bu Nur 30 DRC Nur Ke Nur Rw Nur 25 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 Burundi (Nat. Seroprevalence Survey 2002) DRC [data only available in broad age groups] HIV prevalence Refer to 2007 DHS, publication early in 2008 14.0 Women 12.0 Men 10.0 8.0 6.0 4.0 2.0 0.0 15-24 25-34 35-44 45-54 55+ Kenya (DHS 2003) Rwanda (DHS 2005) HIV HIV prevalence prevalence 14.0 14.0 Women Women 12.0 12.0 Men Men 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 Tanzania (AIS 2003/4) Uganda (AIS 2004/5) HIV HIV prevalence prevalence 14.0 14.0 Women Women 12.0 12.0 Men Men 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 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 Women Men All Source Urban Rural P* Urban Rural p Urban Rural P Burundi 13.3% 2.9% <0.0001 6.2% 2.1% <0.0001 10.0% 2.5% <0.0001 Nat. Seroprevalence & Survey 2002 DRC - - - - - - - Kenya 12.3% 7.5% <0.001 7.5% 3.6% <0.001 10.0% 5.6% <0.001 DHS 2003 Rwanda 8.6% 2.6% <0.0001 5.8% 1.6% <0.0001 7.3% 2.2% <0.0001 DHS 2005 Tanzania 12.0% 5.8% <0.0001 9.6% 4.8% <0.0001 10.9% 5.3% <0.0001 AIS2003/4 Uganda 12.8% 6.5% <0.0001 6.7% 4.7% n.s. 10.1% 5.7% <0.001 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 HIV- 1-seronegative CSW in Nairobi between 1985 and 1994. 30 Forty-three CSW remained sero- negative 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 Burundi DRC Kenya Rwanda Tanzania Uganda Sexual debut: Age at first sexual intercourse Women 25-49 yrs n.d. n.d. 17.6 yrs 20.3 yrs 17.0 yrs 16.4 yrs Men 25-54/59 yrs 17.2 yrs 20.8 yrs 18.5 yrs 18.1 yrs Sexual debut: Had sex by age 15 Women 15-24 yrs n.d. n.d. 13.7% 2.6% 12.4% 15.5% Men 15-24 yrs 28.8% 10.8% 9.4% 12.2% Multiple partners: Had more than one sex partner in the last 12 months Women n.d. n.d. 1.7% 0.6% 4.3% 2.4% Men 11.7% 5.1% 30.1% 28.4% Higher-risk sex*: Engaging in higher risk sex in past 12 months Women 15-49 yrs n.d. n.d. 17.6% 8.1% 23.7% 15.9% Men 15-49 yrs 39.6% 13.6% 45.2% 34.9% Women 15-24 yrs 30.0% 15.3% 34.0% 27.1% Men 15-24 yrs 84.4% 48.0% 82.8% 65.3% Condom use: Using condom at last higher risk sex Women n.d. n.d. 23.9% 19.7% 27.5% 34.9% Men 46.5% 40.9% 51.0% 57.0% Age-mixing: Higher-risk sex in the past 12 months with a man who was ≥10 yrs older Women 15-19 yrs n.d. n.d. 4.0% 4.6% 6.2% 7.0% Self-reported STIs: STI/discharge/genital sore/ulcer in past 12 months Women n.d. n.d. 4.4% 5.0% 5.1% 22.1% Men 3.1% 2.7% 5.6% 12.5% Knowledge of HIV status: Ever tested and received result Women n.d. n.d. 13.1% 21.2% 12.1% 24.8% Men 14.3% 20.1% 12.3% 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 ethno- demographic 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 HIV % 25 Ke -Men Tz Men 20 Ug - Men 2 R = 0.8073 Linear (Ke -Men) 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 Uganda Men reporting paid sex, past 12 months n.d. n.d. 2.9% n.d. 10.6% 2.8% Men using condom, last paid sex 64.5% 59.0% - Women receiving money, gifts/favours for sex 5.5% n.d. 6.6%* Sources: Kenya DHS 2003, Rwanda DHS 2005, Tanzania DHS 2004, Uganda DHS 2006 * Women giving or receiving money, gifts, favours for sex 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. Sub- populations 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 Total Bar attendants/ Brew sellers 0 0 3 0 3 0 6 Fishermen/Fishing communities 0 0 4 0 0 3 7 General population / men 7 5 8 10 11 12 53 Health care providers 0 0 2 2 1 0 5 IDPs/ host communities/ returnees 1 2 0 0 0 6 9 (Injection) Drug users 0 0 4 0 2 2 8 Migrants 0 0 0 1 1 1 3 Military/Combatants/Peace keepers 0 3 0 0 0 3 6 Men having Sex with Men 0 0 1 0 0 1 2 Patients 0 2 0 0 2 2 6 People living with HIV (PLHIV) 5 4 3 4 4 6 26 Police/Gendarmerie/Customs officers 0 0 0 0 0 1 1 Prisoners 2 0 4 2 2 2 12 Refugees/host communities/ returnees 0 0 2 2 7 6 17 Rural communities 0 0 1 0 8 3 12 Sex workers and their clients 2 5 12 1 2 1 23 Truckers/Truck assistants 0 2 9 0 4 0 15 Victims of gender based violence 0 1 1 0 6 3 11 Women 3 6 5 0 6 5 25 Workers incl. miners 1 2 3 0 3 1 10 Youth/Adolescents/Children/OVC 3 6 7 1 4 6 27 NOTE: not shown here are documents covering several population groups in several GLIA countries 49 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: Long distance truck drivers Fishermen and fisherwomen Military and other uniformed services • Interaction with persons in mobile occupations: Female sex workers • Populations with specific experiences Refugees, IDPs, host populations and returnees* of conflict, crime and violence: 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 all- weather 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 Site Sample %HIV+ Year prevalence DRC Truck drivers and assistants 4.9% 2006 n.d. DRC- West Truck drivers 3.3% 2006 n.d. Kenya: Athi River Truck drivers 27% 1994 6.7% (2003) Kenya: Mariakani Truck drivers and assistants 26% 1995 6.7% (2003) Kenya Trucking company employees 18% 1999 6.7% (2003) Kenya: Mombasa-Nairobi highway Truck drivers 27% 1992 6.7% (2003) Kenya: Mombasa Trucking company workers 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) 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 trans- 52 Africa highway: the continuing role for prevention in high risk groups. Sex Transm Infect, 82:368-71. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 26 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. 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 • Inconsistent levels of condom use with (women in particular) commercial and occasional sexual • Monotonous work partners • Road risks (accidents, theft) • Low level of condom use with regular partners and spouses • Work in remote and poor environments with inadequate rest and • Limited access to regular HIV prevention recreational facilities services, including VCT • Easy access to alcohol • Casual sex readily available • Stress leading to abuse of alcohol and drugs • Milieu around border posts caters for the • Availability of disposable funds sexual needs of transport workers, with • Long and frustrating delays at border crossovers and custom checkpoints brothels, taverns and bars • Harassment and stigmatisation by police, border officials and communities • Context of sexual violence and harassment • 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 sex • Stigma and discrimination by employers • 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 Site %HIV+ Year (see Table 3) DRC Kalemie (partners of fishermen) 20.3 2001 3.2% Kenya Lake Victoria 25.3 2006 6.1% Kenya Fishing villages 30.5 2002 6.1% Uganda Ntoroko 24.0 1992 6.7% 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 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 HIV- positive 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 Fishermen: Risk Factors for HIV • Time fishermen spend away from home • Culture of hyper-masculinity which may • Mobility of many fisherfolk include expectation of multiple sexual partners • Alcohol use to help cope with the dangers or stress of their occupation • Poor access to facilities and medicine • Demographic profile (mostly young age) and low uptake of available health • Fishing is a high-risk occupation which can contribute to culture of risk services denial or risk confrontation • Difficult to reach with adequate AIDS • Access to daily cash income, high income during main fishing season treatment and mitigation measures • Ready availability of commercial sex in fishing ports • Fishing camps and ports may lack social structures that constrain sexual behavior • Social marginalisation and low status as in home communities • Subordinate economic and social position of women in many fishing communities • Difficult to reach with disease prevention efforts 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 Total population (2007) Active troops Reserve force Paramilitary Total Burundi 75 8,390,505 40,000 0 5,500 45,500 DRC 76 65,751,512 83,800 0 1,400 85,200 Kenya 77 36,913,721 24,120 0 5,000 29,120 Rwanda 78 9,907,509 61,000 0 10,000 71,000 Tanzania 79 39,384,223 27,000 80,000 1,400 108,400 Uganda 80 30,262,610 60,000 0 1,800 61,800 Total 190,610,080 295,920 80,000 25,100 401,020 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 context- specific 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 76 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 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 90 trends at VCT clinics for 80 UDF soldiers. These data 70 may overestimate the true 60 HIV prevalence, as they come from a subset of 50 soldiers who were possibly 40 motivated by a concern that 30 they might be positive. No 20 sample size data were available. 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 Burundi DRC Had a sexual relationship in the past 12 months. 45% (soldiers), 53% (police), 78% (gendarmes) 90% Had more than one partner in the last 12 months 7% (all uniformed services) 41% Paid for sex in the last 12 months 7% (all uniformed services) 28% Condom use with occasional, non-commercial 15% (soldiers), 45% (police) and 6% 34% partners (gendarmes) Ever had a HIV test 70% (soldiers and police), 50% (gendarmes) 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 • Trained to regard risk-taking and in lowest HIV prevalence group) aggressive behavior as the norm • Perceiving themselves invulnerable and trained not to be deterred by • Access to CSW and settlements with risk and danger ‘soldier wives’ (but: these sexual networks • Separated for long periods from spouses and partners, or denied are often restricted] marriage during enlistment periods • At risk to physical injury involving loss of • When away, removed from the social discipline (but: disciplined army blood and need for blood transfusion environment, not all soldiers away from base) under possibly non-sterile conditions • Living in same-sex quarters • Sharing of razors and skin-piercing • Some ranks well paid instruments in tattooing and scarification • Susceptible to peer pressures • (Testing and selection of HIV negative • May seek to relieve themselves from the stress of combat through individuals at recruitment, and motivation sexual activity to stay negative) • Sexual abstinence while on duty may be followed by short breaks of sex and alcohol 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 sero- positivity 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 Burundi DRC Ur 60 DRC Nur 50 Ke Ur Ke Nur 40 Rw 30 Tz Ur Tz NUr 20 Ug 10 0 02 98 99 00 01 03 04 05 06 90 91 97 92 95 96 93 94 20 20 20 20 20 20 20 19 19 19 19 19 19 19 19 19 19 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 Burundi DRC Kenya, Western (2004) 104 (2006) 105 Province (2000) 106 Drug consumption 16% 12% n.d. Doing other work than sex work 34% 48% 83% Sexual intercourse with client in past 7 days 69% 79% 82% Sexual intercourse with other partner in past 7 days 18% 38% 76% Median number of sex partners, last 7 days 4.0 3.1 1.5 Condom use last act with client 74% 46% 61% with other partner 46% 43% n.d. Consistent condom use, past month with client 49% 25% 49% with other partner 27% 20% 14% Barriers to condom use with client Trust 23% 37% 25% Refusal 22% 26% 92% Dislike of condoms 4% 21% 5% Non-availability of condom 32% 12% 6% Regular client / “no risk” 8% 11% 41% Barriers to condom use with other partner Trust 62% 39% 64% Refusal 12% 27% 40% Dislike of condoms 0% 20% - Non-availability of condom 21% 11% 1% “No risk” 3% 12% 13% Has done HIV test 41% 37% n.d. Has been exposed to peer education, last 6 months 12% 23% n.d. 101 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 Trans- Africa 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 • These multiple concurrent partners often have multiple • Occupation in places where transactional sex is partners themselves (sexual network) frequent (bars, etc) • Risk perception towards regular clients (trust leads to non- • Compromised power relations use 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 • Can be illegal migrant STIs) 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 Trans- Africa 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 sub- Saharan 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 200,000- 300,000 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 Total population (2007) Refugees (June 2007) General trends Burundi 8,390,505 23,215 Slow increase due to influx from DRC in early 2007 DRC 65,751,512 197,232 Decrease due to repatriation of Sudanese, Congolese and Angolan refugees Kenya 36,913,721 269,196 Decrease due to repatriations- voluntary and assisted - to Southern Sudan, but operations hampered by heavy rains hindering transfer and access to places of origin Rwanda 9,907,509 46,600 Decrease due to UNHCR-assisted repatriations Tanzania 39,384,223 471,912 Decrease due to UNHCR-promoted returns at the beginning of June 2006 Uganda 30,262,610 220,914 Decrease due to gradual return process especially for Sudanese Total 190,610,080 1,229,069 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 National HIV prevalence estimate from Camps %HIV+ Year of host country (see Table 3) Kenya Somalia Dadaab 0.60 2003 6.1% Uganda Sudan Palorinya settlement 1.00 2004 6.7% Kenya Somalia Dadaab 1.40 2005 6.1% Tanzania Burundi Lukole 1.60 2003 6.5% Tanzania Burundi Nduta and Mtendeli 1.70 2003 6.5% Tanzania DRC Lugufu and Nyaragusu 1.80 2003 6.5% Uganda Sudan Kyangwali 2.70 2004 6.7% Tanzania Burundi Mtabila and Muyovosi 4.50 2003 6.5% Median HIV prevalence 1.65% Source: Spiegel et al. (2007), retaining refugee camps in GLIA countries • Immediately following the massive movement of refugees from Rwanda to Tanzania in mid- 1994, 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 sub- Saharan 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 sub- optimal. 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 No official IDPs a Uganda 1,400,000 128 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. Total 2,871,979 - 2,986,979 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 sub- Saharan 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 • Minimum standards in humanitarian interventions • Dispossessed of land, productive resources and may not include prevention of STIs/HIV home • Barriers to HIV prevention: disruption of health • Illegal settlement and resulting expulsion services; testing for HIV may be difficult (lack of confidentiality in confined camps, lack of counseling • War alters gender roles service) • War destroys infrastructure (health, education, • Disruption of sexual partnerships and networks communication, transport) • Outside habitual norms and social control, persons • Poor access to comprehensive health services may adopt behaviors which are incompatible with • Multiple threats to health other than HIV, such as their status measles, diarrhoeal diseases, acute respiratory • Sexual interaction of emergency-affected people with diseases, malaria, and protein energy malnutrition military or paramilitary personnel • Heightened economic vulnerability of women and • Transactional sex, also as “survival strategy” children • Sexual violence and coercive sex, multiple • Migration from rural areas where HIV prevalence and perpetrators knowledge of HIV low • New sexual relationships may have power • Unaccompanied minors lack parental guidance and differentials which impair negotiation of safer sex protection • Potentially, increased use of alcohol and illicit drugs • Psychological trauma, may precipitate erosion of traditional values • Potentially, unsafe blood transfusion practices at a time of increased blood transfusion and unsafe • Potentially, disruption of family and social structures 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 Total Total prison Female prison Female prisoners, % of Prison population population population (year) population total prison population rate (per 100,000 (2007) (year) inhabitants) Burundi 8,390,505 7,969 (2005) 216 (2002) 2.7% 106 DRC 65,751,512 c. 30,000 (2004) c. 83 (2004)& - 57 Kenya 36,913,721 47,036 (2006) 1,254 (2002) 2.7% 130 Rwanda 9,907,509 c. 67,000 (2005)* 2,925 (2002)* 4.4% 152* Tanzani 39,384,223 43,911 (2006) 1,515 (2005) 3.5% 113 a Uganda 30,262,610 26,126 (2005) 901 (2005) 3.4% 95 Total 190,610,080 222,042 6,894 3.1% * 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 2000- 2003 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 Prisoners: Risk Factors for HIV • Weakness of the criminal justice and judicial systems • New norms of dominance and power, • Mixing of un-sentenced and convicted persons altering traditional gender identities and roles that become highly sexualized • Stigmatization of prisoners by society • High-risk sexual activities (anal sex in • Appalling physical conditions in prisons, due to lack of resources for homosexual acts, rape, gang rape, maintenance of penal institutions sexual abuse) • Substandard or nonexistent health care, poor safety of medical and • Prostitution as a coping mechanism dental equipment • Tattooing and other forms of skin • Gender exclusive environment piercing • Inadequate food and nutrition • Blood brotherhood rituals • Overcrowding • Untreated STIs • Lack of conjugal visits • Prevention commodities (condoms, • Some sentenced for drug-related crimes, IDU habit continues in prison lubricants, needles/ syringes, bleach) often not available • Legal restriction on drug use, lack of harm reduction measures like drug substitution • Lack of access to IEC services • Criminalization and denial of sexual activity in prisons • Bisexual and homosexual relations including ‘marriages’ among male • High turnover and mobility among prisoners prisoners • Underreporting of rape • If IDU, high likelihood of contaminated • Little autonomy in own protection, minimal control over living conditions injection equipment 141 Kudat A (2006). Males for Sale. Dogan Yayinlari. Istanbul. 142 IRIN (2007) Kenya: Slow response to high HIV rates in prisons http://irinnews.org/Report.aspx?ReportId=74055 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 multi- sectoral 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 multi- country 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) 152 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 post- conflict 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. 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 % history of sexual/ Site Sample GB violence Year Source Kenya National Women 15-49 yrs 15.7% 2003 DHS Kenya 2003 Rwanda National Women 15-49 yrs 12.9% 2005 DHS Rwanda 2005 Tanzani Women 15-49 yrs a Dar es Salaam 23% 2002 WHO, 2005 Tanzani Women 15-49 yrs a Mbeya 31% 2002 WHO, 2005 Tanzani Women 20-44 yrs a Moshi 3.4% ? McCloskey et al. 2005 Uganda Rakai Women 15-24 yrs 13.4% 2003 Zablotska et al. 2006 Uganda Mbale District Women w. infants 37.0% Karamagi et al. 2006 Median 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). 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 Est. number of women Est. total women 15+ yrs Est. excess female PLHIV population 15-64 with history of living with HIV (PLHIVs) attributable to sexual/ years (2007) sexual/GB violence* [UNAIDS] GB violence& Burundi 2,162,093 339,449 79,000 4,668 DRC 16,571,549 2,601,733 520,000 30,726 Kenya 10,174,922 1,597,463 740,000 43,726 Rwanda 2,765,767 434,225 91,000 5,377 Tanzani 10,649,507 1,671,973 710,000 41,953 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 Females affected by GBV: Risk Factors for HIV • Low literacy • Multiple perpetrators belonging to higher risk groups • Subordinate status of females themselves • Lack of empowerment • Young age of female – higher susceptibility to trauma due to under-development of reproductive tract • Violence widely tolerated as a form of social control • Relationship with abusive man imposing risky sexual • Rape survivors stigmatized and shunned by partners and community practices on partner • High levels of male dominance/control in relationship • High frequency of abuse • Physical violence in partnership • HIV positive male partner • Frequent partner change, casual partners • Physical trauma – genital trauma (tears and • Alcohol use before sex abrasions to the vaginal wall due to violence or • Sexual decision making by male partner vaginal dryness), and anal trauma 166 New Vision (2001). Genocide widows die of AIDS. December 11, 2001, Kampala. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 58 • Female attempts to negotiate safer sex may trigger violence • Condom use rare in violent sexual acts • Use of VCT may trigger violence • 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) 100,000 Est. number of PLHIV 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 383 3,254 4,442 769 7,787 3,645 IDP, PLHIV 3,300 35,903 18,758 - - 93,800 Prisoners, PLHIV 446 1,680 2,634 3,752 2,459 1,463 Female/sex.violence attributable PLHIV 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 Burundi DRC 17% 15% 84% 85% Kenya Rwanda 8% 17% 92% 83% Tanzania Uganda 9% 20% 91% 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 60 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 61 Table 30. Summary of population sizes and PLHIV numbers of selected populations Vulnerable Population Characteristics Burundi DRC Kenya Rwanda Tanzania Uganda Total Long distance truck drivers Population Size 13,138 102,954 57800 15,513 61,668 47,385 298,458 (a) PLHIV (est HIV prev 18%) 2,365 18,532 10,404 2,792 11,100 8,529 53,722 Population Size 10,969 108,400 55,176 3,460 150,865 118,786 447,656 Fishermen / fisherwomen (b) PLHIV (est HIV prev 24.7%) 2,709 26,775 13,628 855 37,264 29,340 110,571 Population Size 45,500 85,200 29,120 71,000 108,400 61,800 401,020 Military (c) PLHIV (est 20% HIV prev) 9,100 17,040 5,824 14,200 21,680 12,360 80,204 PLHIV (est 10% HIV prev 4,550 8,520 2,912 7,100 10,840 6,180 40,102 Population Size n.d. n.d. n.d. n.d. n.d. n.d. n.d. FSWs (d) PLHIV n.d. n.d. n.d. n.d. n.d. n.d. n.d. Population Size 23,215 197,232 269,196 46,600 471,912 220,914 1,229,069 Refugees (e) PLHIV (est HIV prev 1.65%) 383 3,254 4,442 769 7,787 3,645 20,280 Population Size 100,000 1,121,979 307,500 - - 1,400,000 2,929,479 IDPs (f) PLHIV (est nat. HIV prev used) 3,300 35,903 18,758 - - 93,800 151,761 Population Size 7,969 30,000 47,036 67,000 43,911 26,126 222,042 Prisoners (g) PLHIV (est HIV prev 5.6%) 446 1,680 2,634 3,752 2,459 1,463 12,434 Females affected by sex Population Size 339,449 2,601,733 1,597,463 434,225 1,671,973 1,128,054 7,772,897 violence (h) PLHIV* (RR= 1.4) 3,935 25,902 36,861 4,533 35,367 25,902 132,500 13,300,621 Vulnerable Populations (i) 540,240 4,247,498 2,363,291 637,798 2,508,729 3,003,065 (7 % of total adult population in GLR) TOTALS 561,472 Vulnerable PLHIV (j) 22,238 129,086 92,551 26,901 115,656 175,040 ( 12% of total adult PLHIV population in GLR) * Excess PLHIV attributable to sexual violence Annotations for Table 30 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 62 (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. (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. (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. (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. (e) Refugees: Group size came from OCHA (June 2007 figures). Median HIV prevalence was based on eight recent surveys in different camps. (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). (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. (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. (i) Total estimated number of the 7 types of vulnerable populations analysed in this report (j) Estimated number of adult PLHIV in these vulnerable populations: Total PLHIVs in these vulnerable populations 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 Tanzania Uganda mainland Zanzibar 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 cost- effectiveness 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 sub- Saharan 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 Trans- Africa 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 small- scale, 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. 196 MoLFD (2004). Study on the impact of HIV/AIDS on fishing in Kenya and how the MoLFD can respond. Final report. 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 pre- test, 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 73 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 percent- age 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 non- civilian health programs can be fruitful. Interventions: 202 PSI (2004). A new kind of war. PSI arms African militaries against AIDS. PSI Profile, February 2004. 203 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 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-to- door 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 HIV- prevention 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-of- school 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 sub- standard 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 77 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 78 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: • 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 211 WHO Global Atlas, 2005 data. http://www.who.int/globalatlas/dataQuery/default.asp 212 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 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 violence- related 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: • Communication and advocacy programs have not effectively mainstreamed the rights of vulnerable populations, including commercial sex workers (Kenya) 214 http://raisingvoices.org 215 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 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 higher- 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. 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 sub- population, as well as the types of interventions that would be recommended for each vulnerable population. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 83 Table 32. Vulnerable populations to target and promising interventions POPULATION Should the GLIA strategic plan focus on Should the GLIA fund HIV service delivery for this What are promising interventions that should be considered for the this population (YES/NO)? vulnerable population (YES/NO)? GLIA strategic plan? If YES, why? If NO, why not? If YES, why? If NO, why not? TRUCK DRIVERS YES. YES, in the short to medium term (next 24 months). • Sub contracting of HIV service delivery to these populations in fixed Size: 298,458 Long-distance truck drivers have been The GLIA cannot oversee programs for mobile populations in hot spots targeted with interventions over many six countries indefinitely, given that each country is meant to • Advocacy by the GLIA for identification of hotspots along all corridors HIV+: 18% years, but they remain among the high risk include all populations in their national HIV strategic plans. and for inclusive programming that ensures that the needs of truckers PLHIV: 53,722 groups. There is evidence that adolescents However, given the little attention that this vulnerable group has and of the communities at truck stops are addressed Number of NSPs focusing living in communities along major transport received in the past from national AIDS commissions (some on this population: 6 axes are at high risk of contracting HIV, and • Sharing of information by the GLIA on interventions that have worked, regional programs have been implemented, but frequently that truck drivers are a possible bridging e.g. efforts are not driven by NACs) and the need for uniform population. o Training private pharmacists to provide quality HIV and STI interventions, the GLIA should fund HIV service delivery to this services and referral group in the short to medium term (up to the next 24 months), Truckers may have long periods of so that countries can learn ‘what works’ best before o Roadside wellness centers with VCT service separation from family, stress & implementing a minimum package of services for this group o Interventions to speed up border crossing procedures boredom/waiting time, frustrations & road themselves. risks, easy access to alcohol & commercial o Interventions addressing the link between HIV and alcohol sex, disposable funds, macho culture, may consumption; peer educators in drinking places have ‘road wives’ and limited access to • Epidemiological and formative research to inform the design of health services. programs for truck drivers, commissioned by the GLIA FISHERMEN & YES. YES, in the short to medium term (next 24 months). High HIV • Provision of HIV prevention, treatment and support services through FISHERWOMEN Despite consistently high HIV prevalence prevalence has been recorded in fishing communities for a appropriate sub contractors, including training fisheries officers on Size: 447,656 among fishermen and fisherwomen in the number of years, Yet, there is little evidence that IEC and BCC BCC for HIV, and developing communication materials that ‘speak the HIV+: 24.7% GLR, there has been relatively little activities have been tailored to their specific living context and language of the ports’ PLHIV: 110,571 concerted action targeting fishing experiences, or that they have received specific attention. Number of NSPs communities. Due to the number of Given that this is a relatively small population for each NAC • Advocacy for the integration of HIV services for fishermen and focusing on this fishermen and fisherwomen, their mobility individually, NACs are less likely to spend time and effort on this fisherwomen, mobile VCT and GBV counseling, and for custom-made population: 7 and accompanying behavior, they are an sub population. However, at a regional level this is a significant programs for these communities in each GLIA country important sub-population. population. This fact, combined with the fact that this analysis • Sharing experiences of ‘what works’ in dealing with these populations has shown that the issues affecting these populations and their Fishermen/women are highly mobile, HIV risk and vulnerability are similar across the 6 GLIA • Epidemiological and ethnographic research in different occupational experience occupational dangers, alcohol countries, the GLIA could support the efforts of the 7 NACs by groups in fishing sector commissioned by the GLIA use, daily or seasonal cash income, culture implementing a series of evidence-informed pilot strategies, so of hyper-masculinity, availability of as to determine the most successful strategies for dealing with commercial sex in ports, system of ‘sex for these populations. All GLIA countries can then learn from these fish’, poor access to health care. experiences without having to reinvent the wheel. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 84 POPULATION Should the GLIA strategic plan focus on this Should the GLIA fund HIV service What are promising interventions that should be considered for the GLIA population (YES/NO)? delivery for this vulnerable population strategic plan? If YES, why? If NO, why not? (YES/NO)? If YES, why? If NO, why not? REFUGEES YES. YES, in the short to medium term (next • Provision of HIV prevention, treatment and support services through Size: 1,229,069 When displaced populations (refugees, IDPs) are amongst 24 months). The sheer size of the appropriate sub contractors HIV+: 1.65% host communities and when they return home (returnees), populations involved, and the PLHIV: 20,280 they are particularly vulnerable, but the view that they inexperience of national governments in • Advocacy for integration of HIV services for refugees and host populations, Number of NSPs inevitably have higher HIV prevalence needs to be dealing with HIV prevention in refugee including VCT and GBV counseling focusing on this corrected. There is insufficient evidence that HIV sites mean that the GLIA has to play a • Advocacy for IEC/BCC interventions before, during and after repatriation, and population: 7 transmission increases in populations affected by conflict. leading role, at least for the next 24 for uniform treatment, care and support policies in the GLIA countries Due to their displacement cycle, sub-regional planning months as countries learn how to • Fostering collaboration between organizations of refugees and host processes are crucial. implement programs for refugee sites communities Refugees have increased economic vulnerability themselves (particularly the young, elderly and sick), disrupted • Operational research on the continuum of care - including ART - in the social/sexual partnerships, may suffer from psychological displacement cycle, funded by the GLIA trauma, may have moved into a higher prevalence area, may have poor access to health care. IDPs YES. YES, in the short to medium term (next • Provision of HIV prevention, treatment and support services through Size: 2,929,479 IDPs lack a protection framework, have increased 24 months). The sheer size of the appropriate sub contractors HIV+: 3.1%-6.7%, economic vulnerability, disrupted social/ sexual populations involved, and the • Advocacy for integrating HIV services for IDPs and host populations, depending on partnerships, may suffer from psychological trauma, may inexperience of national governments in including VCT and GBV counseling country have moved to a higher prevalence area, may have poor dealing with HIV prevention at IDP sites • Advocacy for IEC/BCC interventions before, during and after repatriation, and PLHIV: 151,761 access to health care. mean that the GLIA has to play a leading for uniform treatment, care and support policies in the GLIA countries Number of NSPs role, at least for the next 24 months as • Fostering collaboration between organizations of IDPs and host communities focusing on this countries learn how to implement • Operational research on the continuum of care - including ART - in the population: 5 programs at IDP sites themselves displacement cycle, funded by the GLIA FEMALE SEX YES. NO. Although female sex workers and • Advocacy and policy dialogue for appropriate legislation, adequate and WORKERS Paid sex is an important driver of the epidemic during early their clients remain important drivers of accessible services for FSWs, and reduction in stigma and discrimination Number of NSPs and advanced epidemics, and data show various types of the epidemic, the population is very towards FSWs focusing on this paid and transactional sex. diverse in frequency of sexual partnering population: 7 and behaviors, places of operation, • Epidemiological, socio-cultural and socio-economic research and size socio-economic circum-stances, and HIV estimation studies in GLIA countries to gain a better understanding of women exposure. Therefore, each country involved in sex work and transactional sex should focus on this population themselves with their own tailor-made programs ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 85 POPULATION Should the GLIA strategic plan focus on this population (YES/NO)? Should the GLIA fund HIV service What are promising interventions that should be considered If YES, why? If NO, why not? delivery for this vulnerable for the GLIA strategic plan? population (YES/NO)? If YES, why? If NO, why not? FEMALES AFFECTED YES. GBV is a significant contributor to women’s risk of HIV acquisition. NO. Although this is a large and • Advocacy by the GLIA for interventions to change perceptions BY SEX. VIOLENCE Intimate partner violence is prevalent and mostly tolerated by society. significant population, it is also a and opinions about sexual and gender-based violence, and for Size: 7,772,897 Some groups of men suffer considerable sexual violence, such as population that is dispersed and integration of GBV screening & counseling in service delivery RR=1.4 prisoners. Evidence on the link between sexual violence and HIV is weak hidden, so difficult for service delivery. (VCT, ANC, SRH, abortion care, adolescent programs) Attribut. PLHIV: in SSA. Progress in reducing GBV is unlikely to be achieved without Therefore, separate programs for 132,500 significant changes in individual & community attitudes towards GBV. these females should not be offered, • Sharing of training materials and experiences in integrating Number of NSPs focusing Affected females may be stigmatised by partners/community, may lack but rather integrated into existing services into all aspects of service provision; for example: the on this population: 5 empowerment, be in abusive partnerships, experience physical violence services so as to respond to the needs training of health care personnel which includes medical, & trauma, tolerate violence as ‘normal’, may be subjected to violence of these women and minimise further psychological and forensic elements and post-rape care because of wanting to protect herself or because of HIV sero-positivity. trauma, stigma or discrimination. PRISONERS YES. NO. There are already other regional • Advocacy by the GLIA for interventions supporting the Size: 222,042 Very few data were available, but it is clear that prisoners have little initiatives to support these populations, development of national HIV policies in prisons and for HIV+: 5.6% mobility/ power to leave a high-risk setting. Prisoners lack protection, and there are signification legal interventions supporting general improvement of prison living PLHIV: 12,434 have tough living conditions, overcrowding, sexual violence, denial & challenges to overcome. The conditions Number of NSPs focusing criminalisation of sex, high risk sex, IDU, prostitution, lack of conjugal population is relatively small. Isolated on this population: 7 visits, poor access to quality preventive & curative services and HIV service delivery interventions • Epidemiological research in prison communities, and commodities. Prison environments are generally not conducive to HIV (which the GLIA may be able to operational research on HIV and TB in prison communities interventions and broad efforts to improve health and living conditions for provide through sub contracting) may and ‘what works’, commissioned by the GLIA prisoners are urgently needed. Knowledge gaps include the magnitude of have limited effectiveness in prisons the HIV and TB epidemics in prisons, their effect on populations working which have an urgent need for broad or living around prisons and successful intervention strategies. strengthening of health services. MILITARY YES. NO. • Advocacy by the GLIA for better condom distribution and Size: 401,020 Although the true burden of HIV in the armed forces of the GLIA countries IEC/BCC programs, release of HIV prevalence data Due to the history of the region, each could not be assessed due to data confidentiality, the vulnerability profile • Sharing of information by the GLIA on types of interventions in HIV+: 10%-20% country should be responsible for of the military predicts high HIV risk, but this may be modulated by other countries that have worked, e.g.: BCC/ peer education programs for its own military and PLHIV: 40,102 – 80,204 effective interventions and place-specific characteristics. ‘speaking the language of the barracks’; Addition of condom uniformed service personnel. Number of NSPs focusing Military personnel may be posted away from home, under pressure, pouch to equipment belt; Strong STI and VCT services in on this population: 7 trained to regard risk-taking as the norm, exposed to contaminated or bases; Mobile video unit presentations; Condom wholesale & unscreened blood, may have disposable income. Middle ranking officers retail marketing in and around camps/ bases fit demographic and occupational profile of high risk group. • 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 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 cross- border 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 90 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 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 91 Source: World Bank 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 93 KENYA RWANDA Source: UNAIDS Epidemiological fact sheets (http://www.who.int/globalatlas/default.asp) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 94 TANZANIA UGANDA Source: UNAIDS Epidemiological fact sheets (http://www.who.int/globalatlas/default.asp) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 95 HIV Prevalence of the Adult Male and Female Population by Province Source: World Bank ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 96 HIV Prevalence of the Adult Male Population by Province HIV Prevalence of the Adult Female Population by Province Source: World Bank ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 97 Major road axes, truck stops and truck volume Source: World Bank ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 98 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 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 99 Vulnerable populations in the GLIA countries: estimated group size and estimated number of PLHIV 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. 2 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 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 multi- sectoral 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) Estimated number of International migrants as Net number of international international migrants % of the total population migrants4 Burundi 77,000 1.23% - 400,000 DRC 739,000 1.52% - 1,487,000 Kenya 327,000 1.07% - 21,000 Rwanda 89,000 1.15% 1,977,000 Tanzania 893,000 2.56% -206,000 Uganda 529,000 2.25% - 66,000 Total / Average 2.65 million 1.63% -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. 4 Balance resulting from the difference between arrivals and departures 5 IOM (2005). World migration report – Costs and benefits of migration. 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 one- stop 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 35 30 percent urban 25 20 15 10 5 0 1980 1985 1990 1995 2000 2005 2010 2015 2020 Burundi DRC Kenya Rwanda Tanzania 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 5 6 7 8 rural annual growth rate 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 under- researched 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 socio- economic 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 non- migrant 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-Kigali- Bujumbura-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 THE GREAT LAKES REGION IN AFRICA ............................................................................................112 1.2 HIV TRENDS IN THE GENERAL POPULATIONS IN THE GREAT LAKES REGION IN AFRICA ................112 1.3 HETEROGENEITY OF THE HIV EPIDEMIC IN THE GREAT LAKES REGION IN AFRICA ........................113 1.4 TYPES OF HIV INTERVENTIONS FOR SUB-POPULATIONS WITH HIGHER HIV PREVALENCE .............115 1.5 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 112 1 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 Type of HIV epidemic Estimated HIV Estimated number Estimated number Know HIV status Lakes Region prevalence in of adults and of AIDS orphans general children living population with HIV 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 17 to 18 % (2005) Rwanda Low intensity 3.1% 190 000 210 000 21% generalised Tanzania Severe generalized 6.5% 1 400 000 1 100 000 18% mainland Zanzibar Concentrated 0.8% 7 000 Not known (20 000 19% orphans in total) Uganda Concentrated in older 6.7% 1 000 000 1 000 000 12% men age groups 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 26 Country Analysis Briefs. Feb 2004. Accessed online at http://www.eia.doe.gov/emeu/cabs/eafrica.html on 12 August 2007 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 113 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 (Mulanga- Kabeya 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. • 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. c) 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 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 114 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 sub- populations 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 small- scale 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 115 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 116 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 sub- populations 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 sub- epidemics 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 117 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 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 118 • 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 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 Deliverables/outputs a) Inception report in English: including a table of contents, draft report outline and summary of major written and oral sources to be consulted 29 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 119 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) Recommended changes to the Terms of Reference for the finalization of the GLIA Strategic Plan 7 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 face- to-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 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 120 • 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) 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 mgorgens@worldbank.org. 11 References Arroyo, M.A, Hoelscher, M., Sateren, W., Samky, E., Maboko, L., Hoffmann, O., Kijak, G., Robb, M., Birx, D.L., McCutchan, F.E. 2005. 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American Society for Microbiology ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 122 ANNEX VI Study Calendar GAMET Lead GA Specialist LR Researcher RA Research Assistant GP GLIA peer review panel GLIA GLIA M&E Sec Secretariate FP FPs WR WB peer review WB GIS team at World Bank Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 18 Date 10 - 17 - 24 - 01 - 08 - 15 - 22 - 29 5-9 12 - 19 - 26 - 3-7 10 - 17 - 7- 10 - 17 - 24 - 14 21 28 05 12 19 26 Oct- Nov 16 23 30 Dec 14 21 11 14 21 28 Sept Sept Sept Oct Oct Oct Oct 2Nov Nov Nov Nov Dec Dec Jan Jan Jan Jan Lead the study, manage contracts, oversee RA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA Liaise w. countries, M&E FPs on study & dissemination GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA GA Introduce study to GLIA governance structures Sec Literature search & cataloguing, reading & technical review RA RA RA RA Source documents for the study 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 Sec Sec Data review & analysis LR LR LR LR Support data review & analysis RA RA Mapping & production of graphs/tables LR LR LR LR LR Supporting mapping & production of graphs/tables RA RA RA RA Production of GIS maps WB 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 Sec Sec Sec Sec Sec Sec Sec Sec Sec Sec Support organization of dissemination meetings RA Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 18 ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 123 Date 10 - 17 - 24 - 01 - 08 - 15 - 22 - 29 5-9 12 - 19 - 26 - 3-7 10 - 17 - 7- 10 - 17 - 24 - 14 21 28 05 12 19 26 Oct- Nov 16 23 30 Dec 14 21 11 14 21 28 Sept Sept Sept Oct Oct Oct Oct 2Nov Nov Nov Nov Dec Dec Jan Jan Jan Jan Send zero draft report for WB internal peer review GA WB peer review (ends 8/11) WR WR Production of revised report (due 12/11) LR Send first draft report to GLIA (by 15/11) GA GLIA sends first draft report to GLIA peer review panel Sec GLIA technical review, secretariat & own panel (ends 30/11) GP GP GP GLIA technical review, secretariat & own panel (ends 30/11) Sec Sec Sec Production of final draft report & exec summ (due 7/12) LR Prepare PowerPoint presentation Eng LR Translation of presentation and exec summary transl Technical review workshop (11&12/12) Final report from GLIA researcher (21/12/07) LR Translation of final report transl transl transl Submission of final report in Eng & Fr to GLIA (20 Jan 08) GA GLIA Strategic Plan Validation workshop ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 124 ANNEX VII Literature Catalogue ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 1 Burundi An AIDS programme in a prison Mpinganzima prison Society for women and AIDS in Africa, Burundi. D Mpinganzima et E Prisoners of Burundi Burundi The XIV International AIDS Conference al. 2 Burundi Analyse de la situation du CSLP SIDA Version5 SP/REFES, CSLP 2005 F PLHIV, OVC, women, VIH/SIDA au Burundi youth 3 Burundi BULLETIN BULLETIN2005definitif MINISTERE DE LA SANTE PUBLIQUE UNITE 2005 F Women EPIDEMIOLOGIQUE SECTORIELLE DE LUTTE CONTRE LE SIDA. ANNNUEL DE SURVEILLANCE SERVICE SERO-EPIDEMIOLOGIE DU DU VIH/SIDA/IST EN 2005 VIH/SIDA/IST, Bujumbura, Burundi 4 Burundi BULLETIN BULLETIN EPID. MINISTERE DE LA SANTE PUBLIQUE UNITE 2004 F Women EPIDEMIOLOGIQUE 2004FINAL SECTORIELLE DE LUTTE CONTRE LE SIDA. ANNNUEL DE SURVEILLANCE SERVICE SERO-EPIDEMIOLOGIE DU DU VIH/SIDA/IST POUR VIH/SIDA/IST, Bujumbura, Burundi L’ANNEE 2004 5 Burundi BURUNDI: Prisoners form HIV- BURUNDI prisons IRIN IRIN News 2007 E Prisoners positive association behind bars 2007 6 Burundi Country-specific information: 2006_country_progress_r 2006 E General population,HIV- BURUNDI eport_burundi_en Positive people 7 Burundi ENQUÊTE DE SURVEILLANCE BSSrapportdeplaces-final- MINISTERE DE LA SANTE PUBLIQUE UNITE Theodore 2005 F IDPs DE COMPORTEMENTS Jan05 SECTORIELLE DE LUTTE CONTRE LE SIDA. Niyongabo RELATIFS AUX IST/SIDA AU SERVICE SERO-EPIDEMIOLOGIE DU BURUNDI VIH/SIDA/IST, Bujumbura, Burundi 8 Burundi ENQUÊTE DE SURVEILLANCE BSSrapportcorpsunif-final1 MINISTERE DE LA SANTE PUBLIQUE UNITE Théodore 2005 F General population DE COMPORTEMENTS SECTORIELLE DE LUTTE CONTRE LE SIDA. NIYONGABO RELATIFS AUX IST/SIDA AU SERVICE SERO-EPIDEMIOLOGIE DU BURUNDI VIH/SIDA/IST, Bujumbura, Burundi 9 Burundi ENQUÊTE DE SURVEILLANCE BSSrapportjeunes-final1- MINISTERE DE LA SANTE PUBLIQUE UNITE Théodore 2005 F Young people DE COMPORTEMENTS 012705 SECTORIELLE DE LUTTE CONTRE LE SIDA. NIYONGABO RELATIFS AUX IST/SIDA AU SERVICE SERO-EPIDEMIOLOGIE DU BURUNDI. Raport jeunes_ Final VIH/SIDA/IST, Bujumbura, Burundi 10 Burundi ENQUÊTE DE SURVEILLANCE BSSrapportProstituéesfina MINISTERE DE LA SANTE PUBLIQUE UNITE Théodore 2005 F Prostitutes(Sex workres) DE COMPORTEMENTS l SECTORIELLE DE LUTTE CONTRE LE SIDA. NIYONGABO RELATIFS AUX IST/SIDA AU SERVICE SERO-EPIDEMIOLOGIE DU BURUNDI. Rapport Final VIH/SIDA/IST, Bujumbura, Burundi prostituees ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 125 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 11 Burundi Enquête Démographique et de Burundi DHS 1987 Ministère de l'Intérieur Département de la L Segamba, V 1988 F Santé au Burundi 1987 (ONLY contents Fr.pdf Population Gitega Burundi, Institute for Resource Ndikumasabo, C CONTENTS CHAPTER) Development/Westinghouse Columbia Maryland Makinson, M Ayad USA 12 Burundi ENQUETE NATIONALE DE RAPPORT Ministère de la Santé Publique / Ministère à la 2002 F General population SEROPREVALENCE DE SEROPREVALENCE Présidence Chargée de la Lutte contre le L’INFECTION PAR LE VIH AU 2002 Sida,Bujumbura, Burundi. World Bank BURUNDI 13 Burundi ENQUETE SOCIO Etude 2001 Burundi Ministère de la Santé Publique Theodore 2001 F 1204subjects age 15-59 COMPORTEMENTALE SUR Projet Santé Publique II Niyongabo L’INFECTION PAR LE Programme National de Lutte contre le Sida Au VIH/SIDA AU BURUNDI Burundi 14 Burundi PLAN D’ACTION NATIONAL PLAN D'ACTION 2002- 2002 F General population DE LUTTE CONTRE LE 2006 VIH/SIDA 2002-2006 15 Burundi Plan StrategicNational de Lutte burundi psnls 2007 2011 Présidence de la République, Ministère à la 2006 F General Population contre le Sida 2007-2011 - Présidence chargé de la Lutte contre le SIDA. Republique du Burundi. 16 Burundi Rapport d'avancement: omd2004 Gouvernement du Burundi 2004 F PLHIV Objectifs du millenaire pour le developpement 17 Burundi RAPPORT NATIONAL SUR LE RNDH Burundi_2003 Ministère de la Planification pour le Développement 2003 F General population DEVELOPPEMENT HUMAIN (PNUD) du Développement et de la Reconstruction AU BURUNDI: Le VIH/SIDA et (MPDR), UNDP le Développement humain au Burundi 18 Burundi Summary country profile for june2005_bdi WHO 2005 E PLHIV HIV/AIDS treatment scale-up 19 Burundi The prevalence of HIV and risk The prev_HIV_risk Faculté de médecine, Département de médecine Buzingo T et al. E sex workers behavior of prostitutes living in 2 beh_prostitutes_Bu sociale et préventive, Université Laval, Québec, populous regions of Bujumbura Canada. (Burundi 20 Burundi Validation of a Method to Burundi1.pdf AIDSCAP Project Family Health International T Saidel, D Sokal, 1996 E Male workers Estimate Age-specific Human Arlington VA, Family Health International Durham J Rice, T Buzingo, Immunodeficiency Virus (HIV) NC, Department of Biostatistics and Epidemiology S Hassig Incidence Rates in Developing Tulane University, School of Public Health and Countries Using Population- Tropical Medicine New Orleans LA, Projet National based Seroprevalence Data de Lutte Contre ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 126 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 21 DRC Access to healthcare, mortality DRC_healthcare_11- MSF Alain Kassa et al. 2005 E 5171people(Kilwa), 8792 and violence in Democratic 2005.pdf (Basankusu), 8635 Republic of the Congo (Inongo), 9286 (Lubutu), 5035 (Bunkeya ) 22 DRC ADDRESSING HIV NEEDS OF d3-hounsokou- UNHCR E. Hounsokou, 2006 E Refugees and IDPs DISPLACED POPULATIONS IN hiv_lusaka_presentation_u THE DEMOCRATIC REPUBLIC nhcr_en OF CONGO. PCB, UNAIDS, Lusaka, Zambia. 6 –8 December 2006 23 DRC Democratic Republic of Congo map DRC. Pdf UN 2004 E&F 24 DRC ENQUÊTE DE SURVEILLANCE bss - vol 2 final as of Comite National de Lutte contre le SIDA, Le Fond Patrick Kayembe 2006 F Sex workers, military, long COMPORTEMENTALE (ESC) august 29 Mondial De Lutte Contre Le SIDA, la Tuberculose Kalambayi distance truck drivers, ET DE SEROPREVALENCE et le Paludisme, informal mines workers EN REPUBLIQUE (diamond&gold), street DEMOCRATIQUE DUCONGO. children, unmarried RAPPORT D’ENQUÊTES: adolescents & young Volume 2, Août 2006 adults 25 DRC ENQUETES DE BSS vol 1 family Health International, Impact, CTB. Patrick Kayembe 2005 F Sex workers, military, long SURVEILLANCE DES Rapport_de_synthese___f Kalambayi distance truck drivers, COMPORTEMENTS (ESC) ET inal informal mines DE SEROPREVALENCE EN workers(diamond&gold), REPUBLIQUE street children, unmaried DEMOCRATIQUE DU adolescents and young CONGO.Rapport de synthèse. adults 30 AOUT 2005 26 DRC Etude de la séroprévalence de sc_hih.pdf Save the Children Laurent kambale 2002 Fr 596 Pregnant women age l'infection par le VIIH dans laa kapund 15-49 Zone de Santé de Kalemie au Nord Katanga 27 DRC Etude Pilote de Risques et de la etude de risque DRC Anne Mossige et 2003 F General population Vulnérabilité en République al. Démocratique du Congo 28 DRC Global reach: how trade unions getadata International Alert Charlotte Vaillant 2006 E General population are responding to AIDS 29 DRC HIV/AIDS and the Uniformed FHISnapshotsUniformedS FHI, ImPACT & USAID Robert 2005 E uniformed Servivices ervicesenhv Ritzenthaler services(Military, peacekepres) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 127 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 30 DRC PLAN STRATEGIQUE PLAN STRATEGIQUE Cmite natioanl de Lutte contre le SIDA 1999 F General Populations NATIONAL DE LUTTE NATIONAL. Republique CONTRE LE VIH/SIDA/MST Democratique du Congo. PSN (1999 - 2008) 31 DRC Political and socioeconomic Congo1.pdf Institut de Recherche pour le Developpement C Mulanga, SE E IDPs, sex workers, STI instability: how does it affect Montpellier and Department of International Health Bazepeo, JK patients, pregnant women HIV? A case study in the University of Montpellier France, Laboratoire du Mwamba, C Butel, Democratic Republic of Congo PNLS Kinshasa/Lubumbashi/Kisangani, J-W Tshimpaka, Laboratoire de l’Hopital Dipumba Mbuyi-Mayi, M Kashi, F Lepira, PNLS Ministere de la Sante DRC M Carael, M Peeters, E Delaporte 32 DRC Rapport annuel 2004 PNLS RAPPORT ANNUEL PNLS of DRC 2005 F PLHIV, OVC, women, PNLS 2004 youth, STI patients, FSW 33 DRC Report on the implementation of 2006_country_progress_r 2006 E General population, HIV- the Declaration of Commitment eport_congo_republic_en Positive people of Heads of State and of Government for the response to HIV/AIDS in the DRC. UNGASS, 2005 34 DRC Seroepidemiological survey of sex workers Congo.pdf Laboratoire des Retrovirus, Institut de Recherche C Laurent, D 2001 E 1233 CSWs age 14-55 hepatitis C virus among pour le Develoment (IRD), Montpellier, France Henzel, C commercial sex workers and Mulanga-Kabeya, pregnant women in Kinshasa, G Maertens, B Democratic Republic of Congo Larouze, E Delaporte 35 DRC Summary country profile for june2005_cod WHO 2005 E PLHIV HIV/AIDS treatment scale-up 36 DRC Surveillance sentinelle du VIH Serosurveillance 2005 PNLS of DRC J Okende 2005 F ANC clients chez les femmes enceintes, RDC 2005 37 DRC Tendances de la prevalence du Tendance prevalence du University of Kinshasa P Kayembe 2005 F ANC clients VIH entre 1985 et 2005 en RDC VIH en RDC 38 DRC The HIV epidemic in Kinshasa, DRC.pdf AIDS Reference Laboratory NACP Kinshasa, GTZ D Denolf, JP 2001 E Pregnant women Democratic Republic of Congo Kinshasa, Institute of Tropical Medicine Antwerp Musongela, N Belgium Nzila, M Tahiri, R Colebunders 39 DRC Violences sexuelles contre les Violence DRC Editions Concordia Collete 2004 F Women victim of sexual femmes, crimes sans châtiment Braeckman et al. violence ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 128 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 40 Kenya A cow dies with grass in it’s Fishermen Kisumu 2006 AIDS 2006 - XVI International AIDS Conference A. Sharma et al. 2003 E Fishermen mouth” – Fishermen’s response to “zero grazing” in Kisumu, Kenya 41 Kenya A Theoretically Based highway_ke1 AMREF Kim Witte et al 1998 E Commercial sex workers, Evaluation of HIV / AIDS truck drivers, truck drivers Prevention Campaigns Along assistants and young men the Trans-Africa Highway in Kenya 42 Kenya Adolescent sexual behavior Highway_ke4 African Medical and Research Foundation, Nairobi, Nzyuko S et al. 1996 E 200 adolescents aged 15- along the Trans-Africa Highway Kenya 19 at truck stops in Kenya. 43 Kenya Back to basics in HIV 1384.pdf Family Health International, Imperial College E Pisani, GP 2003 E Persons involved in prevention: focus on exposure London, East West Center/Thai Red Cross Society Garnett, T Brown, heterosexual sex with a Collaboration, Futures Group, UNAIDS J Stover, NC partner at high risk, Grassly, C casual heterosexual sex Hankins, N Walker, PD Ghys 44 Kenya Behavioral Surveillance & STD Kenya BSS 1999 Universities of Nairobi and Manitoba, Impact U Schwartz et al. 1999 E 1000 employees(sugar & Seroprevalence Survey, CompanyWorkers.pdf paper processing Western Province Kenya, 1999, companies) Company Workers 45 Kenya Behavioral Surveillance & STD Kenya BSS 1999 Universities of Nairobi and Manitoba, Impact U Schwartz et al. 1999 E 368Female workers in Seroprevalence Survey, FSWs.pdf Western province, 124 Western Province Kenya, 1999, Busia, 120 Mumias, 98 Female Sex Workers Webuye, 27 Nzoia, 211 bars&lodgings, 150 home, 6 streets,1 factors 46 Kenya Clients of Female Sex Workers Kenya truck drivers1 Department of Public Health, Erasmus University, M. VOETEN et al. 2002 E 64 clients of female sex in Nyanza Province, Kenya Rotterdam, The Netherlands; Nyanza Provincial workers Acore Group in STD/HIV Medical Office, Kisumu, Kenya; Department of Transmission Anthropology, Moi University, Eldoret, Kenya; and Medical Anthropology Unit, University of Amsterdam, The Netherlands 47 Kenya Cofactors for the acquisition of Kenya truck driver From the Department of Medical Microbiology, Joel Rakwar et al. 1999 E Truck drivers, Brew HIV-1 among heterosexual cofactors.pdf University of Nairobi, Nairobi, Kenya; Departments sellers, bar/ guest house men: prospective cohort study of Epidemiology, University of Washington, attendants, female petty of trucking company workers in Seattle, WA, USA; Coast Provincial General traders, sex workers Kenya Hospital, Mombasa, Kenya ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 129 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 48 Kenya DEVELOPMENT OF AFRICAN pop_Development_of_Afri DANISH INSTITUTE FOR INTERNATIONAL Patrick O. Alila et 2005 E Transport workers FREIGHT TRANSPORT – THE can_Freight_transport STUDIES al. CASE OF KENYA 49 Kenya Education and Nutritional Status Kenya OVC HIV ORC Macro, Central Bureau of Statistics Nairobi V Mishra et al. 2005 E 2756(0-4yrs) and 4172(6- of Orphans and Children of HIV- parents.pdf Kenya 14)orphans& children of Infected Parents in Kenya HIV_infected parents 50 Kenya Effect of Circumcision on Kenya truck dirvers.doc Departments of Epidemiology, Medicine, and L. Ludo et al. 1999 E Truck drivers, sex workers, Incidence of Human Biostatistics, University of Washington, Seattle; guest house and bars Immunodeficiency Virus Type 1 Departments of Medical Microbiology and attendants, petty traders, and Other Sexually Transmitted Community Health, University of Nairobi, and Coast and area residents Diseases: A Prospective Cohort Provincial General Hospital, Mombasa, Kenya; Study of Trucking Company Department of Medical Micr Employees in Kenya 51 Kenya Female-to-Male Infectivity of Female-to-male University of Washington, 325 Ninth Ave., Box Jared M. Baeten 2005 E 745Kenyan truck drivers HIV-1 among Circumcised and _inefectivity_hiv_Circ&Unc 359909, Seattle,WA 98104-2499. of Medical et al. Uncircumcised Kenyan Men irc_men.Kenya Microbiology, University of Nairobi, Nairobi, and 6Coast Provincial General Hospital, Mombasa, Kenya 52 Kenya Female-to-Male Infectivity of Female-to-male The Infectious Diseases Society of America Jared M. Baeten 2005 E 745 Kenyan Truck Drivers HIV-1 among Circumcised and _inefectivity_hiv_Circ&Unc et al. Uncircumcised Kenyan Men irc_men.Kenya 53 Kenya From Behavior Change Kenya BCC 2006.pdf FHI P Mwarogo 2007 E Men at worksites, female Communication to Strategic sex workers, women, and Behavioral Communication on youth HIV in Kenya, 1999–2006 54 Kenya HIV/STI prevalence & risk Bukusi fishermen prev AIDS 2006 - XVI International AIDS Conference E.A. Bukusi et al. 2006 E 249 men working in the among fishermen in Kisumu, behavior 2006 fishing industry, Kenya 55 Kenya Increased Risk of HIV in Fonck et al Aids and International Centre for Reproductive Health, Ghent Karoline Fonck et 2005 E Women ictims of violence Women Experiencing Physical Behavior September 2005 University, De Pintelaan 185 P3, 9000 Ghent, al. Partner Violence in Nairobi, Belgium. University of Nairobi, Deptment of Medical Kenya Microbiology, P.O. Box 19676, Nairobi, Kenya. 56 Kenya Integrating Family Planning Kenya VCT 2006.pdf FHI, Kenya Ministry of Health (National AIDS and 2006 E male and female clients Services into Voluntary STD Control Programme & Division of age 15, and health care Counseling and Testing Centers Reproductive Health), JHPIEGO, AMKENI Project providers in Kenya: Operations Research Results ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 130 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 57 Kenya Kenya DHS 2003 Kenya DHS 2003.pdf Central Bureau of Statistics Nairobi, Ministry of 2004 E General population 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 58 Kenya Kenya HIV/AIDS Service Kenya HIV MCH SPA National Coordinating Agency for Population and R Muga et al. 2005 E Health facilities Provision Assessment Survey 2004.pdf Development Nairobi Kenya, MOH Kenya, ORC 2004 Macro 59 Kenya Kenya Natioanal AIDS Strategic NSP_Ke.2005 National AIDS Control Council (NACC). 2005 E General Population Plan/KNASP 2005/6-2009/10 60 Kenya Kenya Prisons Health Kenya Prisons ACU doc Kenya Prison Service 2007 E Prisoners Services/Aids control uniy 61 Kenya KENYA: Slow response to high Kenya prisons IRIN 2007 IRIN News 2007 E Prisoners HIV rates in prisons 62 Kenya Long distance truck-drivers: 1. truck drivers.doc Department of Medical Microbiology, College of Bwayo JJ et al. 1991 E 331 men truck drivers Prevalence of sexually Health Sciences, University of Nairobi. Kenya transmitted diseases (STDs) 63 Kenya Male circumcision for HIV Bailey circumcision 2007 Division of Epidemiology and Biostatistics, School Robert C Bailey et 2007 E 2784 men aged18-24 prevention in young men in of Public Health, University of Illinois at Chicago, al. Kisumu, Kenya: a randomised controlled trial 64 Kenya Mapping transactional sex on Highway_ke2 Department of Medical Microbiology, University of Alan G. 2006 E 381 truck drivers and 403 the Northern Corridor highway Manitoba, Canada Fergusona and sex workers in Kenya Chester N. Morris 65 Kenya Migration, Sexual Behavior and Migration_SB_Risk_Kenya Center for Migration Srudies of New York Martin Brockerhoff 1999 E 7540 women, 2336 men the Risk of HIV in Kenya .pdf & Ann E. Biddlecom 66 Kenya Rapid assessment of substance Kenya final report UNHCR, WHO Adelekan ML 2006 E refugees, women brewers, use and HIV vulnerability in CSW, drug users Kakuma refugee camp and surrounding community, Kakuma, Kenya 67 Kenya Seroprevalence of HIV, HBC HIV_IDUs_kenya International Conference AIDS 2004 Jul 11-16 Odek-Ogunde M, 2004 E IDUs and HCV in injecting drug users Okoth FA, Lore W, in Nairobi, Kenya: World Health Owiti FR Organization Drug Injecting Study Phase II findings ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 131 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 68 Kenya Sex for fish - transactional Buffardi Sex for fish 2006 AIDS 2006 - XVI International AIDS Conference A. Buffardi et al. 2006 E Fishermen, sex workers, relationships between fishermen female fishmongers and widows in Kisumu, Kenya 69 Kenya Short term estimates of adult Gouws_MoT2005_STI200 Department of Policy, Evidence and Partnership, E Gouw et al. 2006 E IDUs, Partners IDU, SW, HIV incidence by mode of 6 Joint United Nations Programme on HIV/AIDS SW clients, partners of transmission: Kenya and (UNAIDS), clients, MSM, partners of Thailand as examples Geneva, Switzerlan MSM 70 Kenya Spatial modeling of HIV Kenya spatial modeling Measure DHS L Montana, M 2007 E 4303 women age 15-49 prevalence in Kenya HIV prevalence Neuman, V Mishra and 4183 men age 15-54 (Interviews and HIV tests) 71 Kenya STUDY ON THE IMPACT OF Fisheries Final MINISTRY OF LIVESTOCK AND FISHERIES 2004 E Fishermen HIV/AIDS ON FISHING IN DEVELOPMENT, Kenya KENYA AND HOW THE MOLFD CAN RESPOND 72 Kenya Summary country profile for june2005_ken WHO 2005 E PLHIV HIV/AIDS treatment scale-up 73 Kenya TB and AIDS: The leading TB and Centers for Disease Control & Prevention, Nairobi, Odhiambo J et al. 2004 E Prisoners preventable causes of prison AIDS_prisons_kenya-doc Kenya deaths in Kenya 74 Kenya TB and AIDS: The leading Odhiambo Kenya Prison The XV International AIDS Conference J Odhiambo et al. E Prisoners preventable causes of prison deaths in Kenya 75 Kenya The HIV/AIDS Epidemic in Kenya aids profile.pdf Government of Kenya, Ministry of Health; 2005 E General population, HIV- Kenya National AIDS Control Council of Kenya; WHO Positive people 76 Kenya The impact of HIV/AIDS on rural FAO migration Human Sciences Research Council Pretoria RSA S Drimie 2002 E Rural communities, Truck households and land issues in drivers, sex workers Southern and Eastern Africa 77 Kenya The rise of injecting drug use in HIV_IDUs_kenya1 Public and Environmental Health Research Unit, Susan Beckerleg 2005 E IDUs east Africa: a case study from London School of Hygiene & Tropical Medicine, et al. Kenya London, UK 78 Kenya The Stall in the Fertility Kenya fertility Office of Population Research Princeton University, CF Westoff, AR 2006 E Women Transition in Kenya transition.pdf ORC Macro Cross 79 Kenya The Sugar Daddy Syndrome: cross-gen Population Services International, Washington, 2005 E older men, young women African Campaigns Battle DC ,USA Ingrained Phenomenon 80 Kenya TOTAL WAR AGAINST HIV TOWA PAD MAY 10 - World Bank 2007 E General population AND AIDS PROJECT FINAL ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 132 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 81 Kenya UNGASS 2006 Country Report 2006_country_progress_r 2006 E General population, HIV- Kenya Reporting period: eport_kenya_en Positive people January 2003 – December 2005 82 Kenya Using diaries to measure highway_ke5 Futures Group, Nairobi, Kenya; Strengthening Alan G. Ferguson 2006 E 403 female sex workers parameters of transactional sex: STD/HIV Control Project, Nairobi, Kenya; University et al. an example from the Trans- of Manitoba, Canada; and Africa highway in Kenya University of Nairobi, Kenya 83 Kenya Behavioural Surveillance kakuma BSS.pdf UNHCR 2004 E Refugees, Host population Surveys Among Refugees and Surrounding Host Population 84 Kenya Sex and survival, the sexual Urban poor Nairobi UNDP South East Asia HIV and Development F. Nii-Amoo 2004 E Urban poor population behavior of the poor in African Programme Workshop Dodoo 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 85 Rwanda 3rd GENERAL CENSUS OF Census Rwanda 2002 MINISTRY OF FINANCE AND 2003 E Generale Populaton POPULATION AND HOUSING ECONOMIC PLANNING OF RWANDA – AUGUST 2002 86 Rwanda Advocacy for HIV/AIDS Advocacy for HIV- ARBEF, Kigali, Rwanda Nyabienda L. 2002 E Prisoners prevention in / from Rwanda's RwPrisons prisons 87 Rwanda ANNUAL REPORT ON Annualreport_HIV Kampala, Uganda 2007 E General population IMPLEMENTATION OF HIV AIDS_Rwanda2006 AND AIDS ACTIVITIES IN RWANDA, 2006 88 Rwanda Current trends in Rwanda’s Current_trendsRwanda20 US Centers for Disease Control and Prevention, E Kayirangwa et 2006 E General population HIV/AIDS epidemic 06 Global AIDS Program, 2210 Kigali Pl, Washington, al. DC 20521, USA 89 Rwanda Enquete de surveillance BSS RWANDA FINAL 21- UNHCR Cheikh Tidiane 2004 F Refugees, IDPs, host comportementale chez les 11-05.pdf Touré, Paul community refugies et la population (Camp Spiegel de Kiziba et secteurs de Rubazo et Kagabiro) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 133 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 90 Rwanda FOLLOW-UP TO UNGASS2006_23Feb 2 UNAIDS 2006 E General population THEDECLARATION OF COMMITMENT ON HIV/AIDS (UNGASS) 91 Rwanda Good practices in HIV Rwanda good practices in HIV Dr.Agnès E General population, local Rwanda Binagwaho et al. communities, Civil Society 92 Rwanda Health Sector Policy. 041027 Final Health Policy Government of Rwanda 2004 E General population, HIV- Government of Rwanda Paper Positive people 93 Rwanda HIV/AIDS and STI prevention Prevention and care in UNAIDS/UNHCR 2003 E Refugees and care in Rwandan refugee camps in Tz camps in the United Repiblic of Tanzania 94 Rwanda PLACE Rwanda: Resume des Etude PLACE F FSW and clients, youth indicateurs 95 Rwanda PLAN STRATEGIQUE RwandaNSF2005FR PRESIDENCE DE LA REPUBLIQUE DU 2005 F General Population NATIONALE DE LUTTE RWANDA. COMMISSION NATIONALE DE LUTTE CONTRE LE VIH/SIDA. Version CONTRE LE SIDA finale 96 Rwanda Population Mobility and JC513-PopMob-Tu-en UNAIDS 2001 E Migrants, mobile HIV/AIDS in Indonesia populations, and locale populations 97 Rwanda Rwanda Demographic and Rwanda DHS 2005 Institut National de la Statistique Ministère des 2006 E Male and female age 15- Health Survey 2005 Eng.pdf Finances et de la Planification Économique 59 Rwanda, ORC Macro 98 Rwanda Rwanda Enquête Rwanda DHS 2005 Fr.pdf Institut National de la Statistique Ministère des 2006 F Male and female age 15- Démographique et de Santé Finances et de la Planification Économique 59 2005 Rwanda, ORC Macro 99 Rwanda Rwanda Enquête sur la RW01SPAFr.zip Ministry of Health Rwanda, National Population 2003 F Health care providers and prestation des services de soins Office Rwanda, ORC Macro clients de santé 2001 100 Rwanda Rwanda Service Provision RW01SPAEng.zip Ministry of Health Rwanda, National Population 2003 E Health care providers and Assessment Survey 2001 Office Rwanda, ORC Macro clients 101 Rwanda RWANDA: FOLLOW-UP TO 2006_country_progress_r 2006 E General population, HIV- THE DECLARATION OF eport_rwanda_en Positive people COMMITMENT ON HIV/AIDS (UNGASS) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 134 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 102 Rwanda Summary country profile for june2005_rwa WHO 2005 E PLHIV HIV/AIDS treatment scale-up 103 Rwanda VIH/SIDA au Rwanda: Bulletin TRAC (2005), Estimations Treatment & Research AIDS Center 2005 F PLHIV, prisoners epidémiologique et projections epidemiologiques 104 Tanzania A typology of groups at risk of AMREF2 AMRF; Medical Research Council Social and Nicola Desmond 2002 E Male mineworkrs & HIV/STI in a gold mining town in Public Health Sciences Unit, University of Glasgow, et al. women north-western Tanzania UK 105 Tanzania Antibody to Herpes Simplex Tanzania migration 2.doc London School of Hygiene and Tropical Medicine Angela Obasi et 1999 E 259 women and 231 men Virus Type 2 as a Marker of al. in 12 rural communities Sexual Risk Behavior in Rural Tanzania 106 Tanzania Behavioural Surveillance Tanzania BSS Ref-Host UNHCR 2005 E 3200 persons: 50% Surveys Among Refugees and Pop FINAL 2005.pdf refugees & 50 % host pop, Surrounding Host Populations: 15-49yrs Lukole and Lugufu, Tanzania 107 Tanzania Census Tanzania 2002 Census Tanzania 2002 2002 E General Population 108 Tanzania Community effects on the risk of tanzania7.pdf Carolina Population Center, University of North SS Bloom et al. 2002 E 2271 men &2752 women HIV infection in rural Tanzania Carolina,USA. 15-44yrs 109 Tanzania Country AIDS policy analysis Country policy analysis AIDS Policy Research Center L Garbus 2004 E Miners, women, OVCs, project: HIV/AIDS in Tanzania 2004 HIV in Tz refugees, trafficked people, prisoners, FSW, GBV victims 110 Tanzania Evaluation of the introduction of PEP FIELD UNHCR Altaras R, 2005 E Refugees, GBV women, post-exposure prophylaxis in EXPERIENCE. doc Schilperoord M health professionals the clinical management of rape survivors in Kibondo refugee camps Tanzania 111 Tanzania Exploring the Association Association-hiv-violence- School of Nursing, Department of lnternational Heidi Lary et al. 2005 E 40 young men and 20 between HIV and Violence: Dar es Salaam_Tz Health, Bloomberg School of Public Health,Johns young women aged 16-24 Young People's Experiences Hopkins University,Baltimore, MD, USA. with Infidelity, Violence and Forced Sex in Dar es Salaam, Tanzania 112 Tanzania Gender Inequality and Intimate GenderInequality_violence School of Social Policy and Practice, Universio of Laura Ann 2005 E 1444 Women aged 20-44 Partner Violence among Pennsylvania, Philadelphia, PA, USA. Department McCloskey et al. Women in Moshi, Tanzania of Society, Human Development and Health. Haward School of Public Health, Cambridge, MA, USA. Department of Sociology, University of Maryland, College Park ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 135 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 113 Tanzania High potential of escalating HIV Tanzania2a.pdf Centre for International Health, University of Khadija I Yahya- 2007 E 1698 adults age 15-49 transmission in a low Bergen, Bergen, Norway; School of Nursing, Malima et al. prevalence setting in rural Muhimbili University College of Health Sciences, Tanzania Dar es Salaam, Tanzania; Department of Training, Ministry of Health, Dar es Salaam, Tanzania; Haydom Lutheran Hospit 114 Tanzania HIV Impact on Mother and Child tanzania4.pdf TANESA Project and National Institute for Medical Japheth 2003 E 26000 inhabitants Mortality in Rural Tanzania Research, Mwanza Tanzania; Measure Evaluation Ng’weshemi et al. Project, University of North Carolina, Chapel Hill; and Centre for Population Studies, London School of Hygiene and Tropical Medicine, UK 115 Tanzania HIV Prevention among Injecting Ball_HIVPrevention World Health Organization, 20 Avenue Appia, 1211 Andrew L. Ball et 1998 E IDUs Drug Users: Responses in Geneva 27, Switzerland al. Developing and Transitional Countries 116 Tanzania HIV/AIDS /STI Surveillance HIV_AIDS_STI Ministry of Health, Tanzania Mainland 2005 E General Population Report Surveillance Report 19 117 Tanzania HIV-1 Epidemic Among Female bar staff Tanzania Department of Population and International Health, Saidi H. Kapiga et 2002 E Female bar and Bar And Hotel Workers in Harvard School of Public Health, 665 Huntington al. hotelworkers Northern Tanzania: Risk Avenue, Bldg. 1, Room 1106A, Boston, MA 02115, Factors and Opportunitiesfor U.S.A Prevention 118 Tanzania HIV-Positive Women Report HIV- American Public Health Association Suzanne Maman 2002 E HIV-Positive Women More Lifetime Partner Violence: positivewomen_partnerviol et al. victim of violence Findings From a Voluntary ence Counseling and Testing Clinic in Dar es Salaam, Tanzania 119 Tanzania Hope for Tanzania: Lessons Hope_for_Tz_Mbeya Ministry of Health, United Republik of Tanzania & B. Jordan-Harde 2000 E General population Learned from a Decade of GTZ et al. Comprehensive AIDS Control in Mbeya Region. Part I: Experiences and Achievements 120 Tanzania Introduction of a pilot project for PEP Tanz camps MS 18- UNHCR, IRC, UNFPA Schilperoord M, 2004 E Refugees, GBV women post-exposure prophylaxis for 1-04 Okumu G, rape survivors in refugee camps Doedens W in Tanzania 121 Tanzania Methodological lessons from a tanzania8.pdf Centre for Population Studies, London School of O Hoffman et al. 2004 E 770 barmaids, 91 cohort study of high risk women Hygiene and Tropical Medicine, London, UK questhouse attendants, in Tanzania 123 restaurant attendants, and 535 sellers of local brew( All female) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 136 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 122 Tanzania Mobility and HIV in Tanzanian Kishamawe mobility Department of Public Health, Erasmus MC, Coleman 2006 E 2800 Mobile couples couples: both mobile persons Tanzania 2006 University Medical Center Rotterdam. PO Box Kishamawe et al. and their partners show 1738, 3000 DR Rotterdam, The Netherlands increased risk 123 Tanzania National Multi - Sectoral NSF 2008 - 2012_Tz 2007 E General Population Strategic Framework on HIV and AIDS 2008 – 2012 Tanzania. 5th and Final Draft 124 Tanzania Prevalence and risk factors for tanzania3.pdf Department of General Practice and Community Elia J Mmbaga et 2007 E 2093 Individuals 25-44 yrs HIV-1 infection in rural Medicine, University of Oslo, Oslo, Norway; al. Kilimanjaro region of Tanzania: Department of Epidemiology and Biostatistics, Implications for prevention and Muhimbili University College, Dar es Salaam, treatment Tanzania; Department of Nutrition, University of Oslo, Oslo, Norway and Dep 125 Tanzania Prevention of HIV Infection and AMREF1 African Medical & Research Foundation (AMREF) E Young refugees 10-20yrs Enhancement of reproductive Health among Young People in Refugees camps of North- western Tanzania 126 Tanzania REPORT ON AMREF6 AMREF, UNHCR Tz. 2003 E Refugees and host IMPLEMENTATION OF THE populations EXPANSION OF STD/HIV/AIDS SERVICES FOR REFUGEES AND REFUGEE AFFECTED POPULATIONS OF KIGOMA AND KAGERA REGIONS 127 Tanzania Risk factors for active syphilis tanzania and syphilis - National Institute for Medical Research, Mwanza, James Todd et al. 2001 E 5956 men & 6630 women and TPHA seroconversion in a mobility.pdf Tanzania; London School of Hygiene and Tropical 15-54 yrs rural African population Medicine, London, UK; AMREF, Mwanza, Tanzania; Regional Medical Office, Mwanza, Tanzania 128 Tanzania Risk Factors Influencing HIV tanzania6.pdf London School of Hygiene and Tropical Medicine, James Todd et al. 2005 E 92 case patients & 903 Infection Incidence in a Rural London, United Kingdom; National Institute for control subjects African Population: A Nested Medical Research; African Medical and Research Case-Control Study Foundation; Regional Medical Office, Mwanza, Tanzania; and WHO 129 Tanzania Seroepidemiology for HIV, HBV, Zanzibar epidemiology for XVI International AIDS Conference P Fedeli et al. 2006 E 2729 public health clinics' HCV and HTLV among patients HIV 2002 patiants attending public health clinics in Zanzibar-Tanzania ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 137 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 130 Tanzania Sexual and Reproductive Health AMREF5 AMREF & UNFPA 1998 E Refugees Project for Refugee Impacted District in West and North West Tanzania Ngara and Kigoma Region 131 Tanzania SEXUAL VIOLENCE, AMREF3 AMREF M. Plummer et al. E 6077 primary school PRESSURE AND HIV IN adolescents RURAL MWANZA, TANZANIA 132 Tanzania Sociodemographic context of tanzania5.pdf Department of Epidemiology, School of Public J T Boerma et al. 2002 E 20000 People 14-44yrs the AIDS epidemic in a rural Health, and Carolina Population Center, University area in Tanzania with a focus of North on people's mobility and Carolina, Chapel Hill, USA marriage 133 Tanzania Summary country profile for june2005_tza WHO 2005 E PLHIV HIV/AIDS treatment scale-up 134 Tanzania SUMMARY REPORT OF SummaryReport BSS MINISTRY OF HEALTH 2004 E Young people BEHAVIOURAL Youths 2002 Issued 2004 SURVEILLANCE SURVEYS AMONG YOUTHS, 2002 135 Tanzania Surveillance of HIV and Syphilis ANC 3 report 02-1-2007 MINISTRY OF HEALTH AND SOCIAL WELFARE Rowland Swai et 2006 E 31224 women antenatal Infections Among Antenatal TANZANIA MAINLAND al. clinic attendees Clinic Attendees 2005/06 136 Tanzania Syndromic treatment of sexually incident diseases Infectious Disease Epidemiology Unit, London Kate K. Orrotha et 2000 E 12537 adults aged 15-54 transmitted diseases reduces Tanzania School of Hygiene and Tropical Medicine, Keppel al. the proportion of incident HIV Street, London WC1E 7HT, UK infections attributable to these diseases in rural Tanzania 137 Tanzania Tanzania Atlas of HIV/AIDS Tanzania atlas HIV National Bureau of Statistics Tanzania, National 2006 E Men awomen age 15-49 Indicators 2003-04 indicators 2004.pdf AIDS Control Programme Tanzania, ORC Macro from 6499 households 138 Tanzania Tanzania Demographic and Tanzania DHS 2004.pdf National Bureau of Statistics Tanzania, ORC Macro 2005 E 9735 households: men & Health Survey 2004 women age 15-49 139 Tanzania Tanzania HIV/AIDS Indicator Tanzania AIS 2003.pdf Tanzania Commission for AIDS, National Bureau of 2005 E General population, HIV- Survey 2003-04 Statistics Tanzania, ORC Macro Positive people 140 Tanzania TANZANIA: FOLLOW-UP TO 2006_country_progress_r 2006 E General population,HIV- THE DECLARATION OF eport_tanzania_en Positive people COMMITMENT ON HIV/AIDS (UNGASS) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 138 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 141 Tanzania The Development Potential of ROADS FHI & USAID 2007 E Long-transport drivers and Regional Programs: An SignMay2007_A4_2 community members Evaluation of World Bank Support of Multicountry Operations 142 Tanzania The NACP: Historical NACP_Tz Profile 2006 NACP Tanzania 2006 E background of HIV/AIDS epidemic in Tanzania 143 Tanzania The role of behavioral data in behav data - mobility.pdf Centre for Population Studies, London School of B Zaba, E 2005 E Pregnant women HIV surveillance Hygiene and Tropical Medicine, National Institute Slaymaker, M for Medical Research Mwanza Tanzania, Urassa, JT Department of Measurement and Health Boerma Information Systems WHO 144 Tanzania The silent HIV epidemic among Tanzania.pdf Centre for International Health, University of Khadija I Yahya- 2006 E 1377 Rural pregnant pregnant women within rural Bergen, Bergen, Norway; School of Nursing, Malima et al. women Northern Tanzania Muhimbili University College of Health Sciences, Dar es Salaam, Tanzania; Department of Training, Ministry of Health, Dar es Salaam, Tanzania; Haydom Lutheran Hospit 145 Tanzania Towards Borderless Strategies Tanzania_Phase1_Tpt_HI Transportek 2004 E Truck drivers, SWs,bar Against HIV/AIDS V-AIDS_Final-Microsoft maids, brothel girls, lodge Word attendants, local brew sellers, free lance ‘street workers, truck driver assistants and workers in the road construction industry. 146 Tanzania Towards universal access to jc1291-mbeya_en Dr Ulrich F. Vogel 2007 E General population prevention, treatment and care: experiences and challenges from the Mbeya region in Tanzania—a case study 147 Tanzania TRANSPORT SECTOR TranspSectorZb_Tz_Resp E Transport workers RESPONSE TO HIV/AIDS: onse_HIVAIDS.pdf TAMING HIV/AIDS ON OUR ROADS 148 Tanzania Trends in HIV and sexual Tanzania migration.pdf TANESA Project and National Institute for Medical Gabriel Mwaluko 2003 E 5783 men and women in behaviour in a longitudinal study Research, Mwanza Tanzania; Department of et al. 1994-1995 (round1), 6392 in a rural population in Epidemiology, University of North Carolina, Chapel in 1996-1997 (round2) and Tanzania, 1994–2000 Hill; and Centre for Population Studies, London 7438 in 1999-2000 School of Hygiene and Tropical Medicine, UK (round3), 15 yrs and over ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 139 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 149 Tanzania WHO Multi-country study on Tanzania2 WHO Jessie Mbwambo 2005 E 1820 women women's Health and Domestic aged between 15 and 49 Violence Against Women 150 Tanzania/ Prevalence of HIV infection in Hiv_male prison inmates- Ali AK et al. 1993 E Male prisoners Zanzibar male prison inmates in Zanzibar.doc Zanzibar: a voluntary programme 151 Tanzania/Z HIV AND SUBSTANCE Zanzibar IDU study Zanzibar AIDS Control Programme, Ministry of Mohammed. J. U. 2006 E 26 female and 482 male anzibar ABUSE:THE DUAL EPIDEMICS Health and Social Welfare, Zanzibar, Tanzania Dahoma et al. DUs CHALLENGING ZANZIBAR 152 Tanzania/Z SPECIFICATIONS FOR ZAC Supervision Zanzibar AIDS Commission 2006 E 1. ZAC National M&E anzibar PARTICIPATORY Guidelines Type 1 Office 2. District HIV/Aids SUPERVISION AND DATA Focal Persons 3. AUDITING DACCOMs, SHACCOMs 4. Umbrella Organisations 5. HIV and AIDS implementers 6. Funders of HIV and AIDS interventions 153 Tanzania/Z Zanzibar National HIV/AIDS ZNSP after PSs Mtg Zanzibar AIDS Commission(ZAC) F.S Chizimbi et al. 2003 E General Populations anzibar Strategic Plan 2003-2007 154 Tanzania/Z Zanzibar National Multisectoral Zanzibar National HIV Zanzibar AIDS Commission 2006 E 1. ZAC National M&E anzibar HIV Monitoring andEvaluation M&E Framework 2006 Office 2. District HIV/Aids System Volume2 volume 2 - final Focal Persons 3. DACCOMs, SHACCOMs 4. Umbrella Organisations 5. HIV and AIDS implementers 6. Funders of HIV and AIDS interventions 155 Tanzania/Z Zanzibar National Multisectoral ZHAPMoS%20guidelines Zanzibar AIDS Commission 2006 E 1. ZAC National M&E anzibar HIV Monitoring andEvaluation %20rev%207 Office 2. District HIV/Aids System: Guidelines for Focal Persons 3. Zanzibar’s HIV and AIDS DACCOMs. SHACCOMs Programme Monitoring System 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 140 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 156 Tanzania/Z ZanzibarZanzibar National Zanzibar National HIV Zanzibar AIDS Commission 2006 E 1. ZAC National M&E anzibar Multisectoral HIV Monitoring M&E Framework 2006 Office 2. District HIV/Aids andEvaluation System volume 1 - final Focal Persons 3. Volume1 DACCOMs, SHACCOMs 4. Umbrella Organisations 5. HIV and AIDS implementers 6. Funders of HIV and AIDS interventions 157 Uganda Age Differences in Sexual age difference Uganda School of Hygiene and Public Health, Johns Robert J. Kelly et 2003 E 6177 women aged 15-29 Partners and Risk of HIV-1 Hopkins University, 615 North Wolfe Street, al. Infection in Rural Uganda Baltimore, MD 21205, U.S.A 158 Uganda Behavioral Surveillance Surveys Final Uganda BSS.pdf UNHCR, World Bank, GTZ, OPM, MOH, UAC, AAH K McDavid 2006 E Refugees & host Uganda 2006 communities 159 Uganda Bringing HIV Prevention to pwg- Global HIV Prevention Working Group 2007 E Uncircumcised male Scale: An Urgent Global Priority hiv_prevention_report_fina adults, IDUs, MSM, SWs, l_en.pdf prisoners, students 160 Uganda Coerced First Intercourse and Coerced-first- Department of Population and Health Sciences, Michael A. Koenig 2004 E 575 sexually experienced Reproductive Health among intercouse_reprodhealth_ Bloomberg School of Public Health,Johns Hopkins et al. adolescent women Adolescent Women in Rakai, women.Rakai.Ug University,Baltimore M.D, USA; Rakai Health Uganda Sciences Program, Uganda Virus Research Institute, Entebbe, Uganda 161 Uganda Condom acceptance is higher mobilitiy and risk Departments of Sociology and Statistics, The Martina Morris et 2000 E 1627 adults (15-49 among travelers in Uganda reduction.pdf Pennsylvania State University, University al. yrs)Mobile Park,Pennsylvania; The Center for Population and Population/Travelers and Family Health, Columbia University, New York, non-travelers New York, USA; The Department of Medicine and Clinical Epidemiology Unit, 162 Uganda Country AIDS policy analysis Garbus (2003) Country AIDS Policy Research Center L Garbus, E 2003 E PLHIV, women, OEV, project: HIV/AIDS in Uganda AIDS policy analysis Marseille military, trafficked people, project Uganda IDPs, refugees 163 Uganda Education of refugees in Dryden (2003) Education Refugee Law Project S Dryden- 2003 E Refugees Uganda: Relationships between of refugees in Uganda Peterson setting and access 164 Uganda Going Beyond "ABC" to Include ABC_GEM_HIV.AIDS.wor HIV Center for Clinical and Behavioral Studies, Shari L. Dworkin 2007 E General Population "GEM": Critical Reflections on d.doc New York State Psychiatric Institute and Columbia and Anke A. Progress in the HIV/AIDS University, 1051 Riverside Drive Unit 15, New York, Ehrhardt Epidemic NY 10032 165 Uganda Great Lakes Initiative on behavioral_surveillance_re GLIA & UNHCR 2006 E Refugees HIV/AIDS Behavioral port 2006 GLIA Surveillance Surveys ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 141 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 166 Uganda Health and mortality survey Ugandamortsurvey IDP WHO, Unicef, WFP, UNFPA, IRC & MINISTRY OF 2005 E IDPs among internally displaced HEALTH, THE REPUBLIC OF UGANDA persons in Gulu, Kitgum and Pader districts, northern Uganda 167 Uganda HEALTH EDUCATION IN AMREF4 AMREF Kalimi Mworia 2003 E 67762 Adolescents and REFUGEE CAMPS HIV/AIDS and Josephat youth refugees(Ug) PEER EDUCATION Nyagero PROGRAMME FOR ADOLESCENTS AND YOUTH IN REFUGEE CAMPS OF EAST AND HORN OF AFRICA 168 Uganda HIV Epidemic Trends in Uganda HIV National AIDS Control Programme, Ministry of LA Shafer et al. 2005 E General population, Uganda: 1989 - 2005 Trends_Toronto_ Health, Uganda. MRC/UVRI Uganda Research Unit pregnant women on AIDS, Uganda Virus Research Institute 169 Uganda HIV/AIDS AS A SECURITY IssuesReport_233 International Crisis Group 2004 E Militaries, uniformed ISSUE IN AFRICA: LESSONS forces, War & Conflict FROM UGANDA.16 April 2004 affected populations 170 Uganda HIV/AIDS management and Kaddu Uganda Prison Uganda Prisons Service, Kampala, Uganda & The M Kaddu and F 2004 E Prisoners control in the Uganda Prison XV International AIDS Conference Nabatanzi Service (UPS) 171 Uganda HIV/AIDS RELATED SCHOOL BASELINE UGANDA HIV/AIDS CONTROLPROJECT 2006 E SECONDARY SCHOOL KNOWLEDGE AND SURVEY SEXUALITY STUDENTS PRACTICES AMONG SECONDARY SCHOOL STUDENTS 172 Uganda Home-Based HIV Testing and Uganda home based HIV ORC Macro, Child Health and Development Centre PS Yoder et al. 2006 E 902 women and 784 men Counselling in a Survey Context testing.pdf Makerere University Uganda, MOH Uganda, CDC age 15-49 in Uganda Uganda 173 Uganda Intimate partner violence Women_intimate- Department of Paediatrics and Child Health, Charles AS 2006 E Rural and urban women against women in eastern violence_Ug Makerere University and the Centre for Karamagi et al. with infants. Uganda: implications for HIV International Health, Bergen University prevention 174 Uganda JUST DIE QUIETLY: uganda0803full Human Right Watch 2003 E Women Victim of domestic DOMESTIC VIOLENCE AND violence WOMEN’S VULNERABILITY TO HIV IN UGANDA 175 Uganda Male circumcision for HIV Gray circumcision 2007 Johns Hopkins University, Bloomberg School of Ronald H Gray et 2007 E 4996 Uncircumcised men prevention in men in Rakai, Public Health, Suite 4132, 615 N Wolfe Street, al. Uganda: a randomised trial Baltimore, MD 21215, USA ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 142 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 176 Uganda Mortality associated with HIV uganda migration.pdf Department of Medicine and Clinical Epidemiology Nelson K. 2000 E 11571 persons in round1, infection in rural Rakai District, Unit, Faculty of Medicine, Makerere University, Sewankambo et 4171 in round2 and 4241 Uganda Kampala, Uganda; Department of Population and al. in round 3=19983 subjects Family Health Sciences, Johns Hopkins University, 15-59yrs School of Hygiene and Public Health, Baltimore, Maryland, USA; 177 Uganda National HIV and AIDS NSP - FINAL DRAFT 28 Uganda AIDS Commission 2007 E General Population Strategic Plan 2007/8 – 2011/12 august 2007 DG Final Draft comments 178 Uganda Prevalence and risk factors for 36385523 GTZ; Ministry of Health, Uganda and Bernhard W. Kipp et al. 1995 E 6373 in kigoyera and 1420 Hiv-1 infection in three parishes Nocht Institute for tropical Medecine, Hamburg, persons in Kyamukoka in westrn Uganda Germany parish 179 Uganda Rapid assessment of substance Uganda Final August 2007 UNHCR Macdonald D 2007 E Drug users, IDPs, GBV use in conflict-affected and women displaced populations: IDP camps in Gulu, Kitgum and Pader Districts of northern Uganda 180 Uganda Relative risks and population uganda migration3 - rakai Department of Population and Family Health Ronald H. Gray et 1999 E Men and women 15-59 yrs attributable fraction of incident trial.pdf Sciences, School of Hygiene and public Health, al. from 56 villages. HIV associated with symptoms John Hopkins University, USA. of sexually transmitted diseases and treatable symptomatic sexually transmitted diseases in Rakai District, Uganda 181 Uganda Relief efforts hampered in one IDMC (2006), Uganda - IDMC 2006 E IDPs of the world's worst internal Relief efforts hampered displacement crises 182 Uganda Reproductive Health of Young Uganda RH youth ORC Macro 2002 E Youg men and women Adults in Uganda 2001.pdf age 15-24 183 Uganda Risk factors for Kaposi’s uganda migration2 - International Agency for Research on Cancer, John L. Ziegler et 1997 E 458 HIV-seropositive KS sarcoma in HIV-positive KS.pdf World Health Organization, Lyon, France; Cancer al. cases and 568 HIV- subjects in Uganda Epidemiology Unit, Imperial Cancer Research seropositive controls. Fund, University of Oxford, Oxford, UK; Uganda Cancer Institute, Makerere University Medical School, Kampala, Uganda; 184 Uganda Sexual networks in Uganda: Uganda migration Medical Research Council/Uganda Virus Research H Pickering et al. 1997 E 143 men(75 town mixing patterns between a patterns.pdf Institute, Entebbe, Uganda residents, 40 fishing trading town, its rural hinterland villages, and 28 rural and a nearby fishing village areas); 81 women ( 47 town residents, 25 fishing ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 143 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country villages, and 9 rural ereas) 185 Uganda Social Dynamics of VCT and Uganda VCT social UPHOLD Project Kampala Uganda, ORC Macro X Nsabagasani, 2006 E 48 men and 57 women Disclosure in Uganda dynamics.pdf PS Yoder 186 Uganda Strengthening resistance. strengthening Center for Women’s Global Leadership Rutgers, Cynthia 2007 E Women victim of violence Confronting violence against The State University of New Jersey 160 Ryders Rothschild, Mary women and HIV/AIDS Lane New Brunswick, NJ 08901-8555 USA Anne Reilly and Sara A. Nordstrom 187 Uganda Summary country profile for june2005_uga WHO 2005 E PLHIV HIV/AIDS treatment scale-up 188 Uganda Susceptibility and Vulnerability nahamyaWP Department of Economics Kyambogo University Nahamya Wilfred 2005 E Fishing communities to HIV/AIDS among the Fishing P.O Box 1, Kyambogo Uganda Karukuza and Communities in Uganda: A Elwange Case of Lake Kioga Charlestine Bob 189 Uganda The HIV/AIDS Epidemic: UAC (2003), The HIV- UAC Uganda UAC 2003 E PLHIV, women, children Prevalence and impact AIDS epidemic 190 Uganda Transmission in Lang Highway_ug1.pdf International Conference AIDS. 2002 Jul 7-12 Ouma NM, Anayo 2002 E Transport workers B and Ojiambo- Ochieng R. 191 Uganda Trends in HIV-1 prevalence may migration uganda.pdf Center for Population and Family Health, Columbia Maria J. Wawer et 1997 E 2591 Adults (15-59 yrs) not reflect trends in incidence in University School of Public Health, New York, USA; al. mature epidemics: data from the The Institute of Public Health, Makerere University, Rakai population-based cohort, Kampala, Uganda; The Department of Population Uganda Dynamics, Johns Hopkins University School of Hygiene and Health 192 Uganda Trends of HIV in the Ugandan Bwire Ugandan Military The XV International AIDS Conference G S Bwire, A 2003 E 7320 soldiers Military 1991-2003 2003 Musingunzi 193 Uganda Uganda Demographic and Uganda DHS 2006.pdf Uganda Bureau of Statistics, ORC Macro 2007 E 8531 women and 2503 Health Survey 2006 men age 15-49 194 Uganda UGANDA: FOLLOW-UP TO 2006_country_progress_r 2006 E General population, HIV- THE DECLARATION OF eport_uganda_en Positive people COMMITMENT ON HIV/AIDS (UNGASS) 195 Uganda Uganda HIV/AIDS Sero- Uganda AIS 2005.pdf Ministry of Health Uganda, ORC Macro 2006 E 10437 households: men Behavioural Survey 2004-2005 and women age 15-49 196 Uganda Uganda: Renewed international IDMC (2006), Uganda IDMC 2006 E IDPs and national attention yields displaced persons only limited improvements for the displaced ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 144 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 197 Uganda Where There Are No ARVs, uganda-basic-care.pdf Population Services International, Washington, 2006 E Pop in low inconme Basic Care and Prevention Kit DC ,USA settings Can Maintain Health of HIV- Positive 198 Various PROMOTING HEALTH 08 Ranson.pdf London School of Hygiene and Tropical Medicine Kent Ranson, Tim 2007 E Iternal Displaced People, (Bu, DRC, EQUITY IN CONFLICT- Poletti, Olga refugees, Women Ke) AFFECTED FRAGILE STATES Bornemisza and Egbert Sondorp 199 Various A SOCIAL AND GENDER SMEC report GLIA-SA- GLIA, SMEC International Pty. Ltd. (Australia) 2006 E Refugees, IDPs and host (Bu, DRC, ASSESSMENT OF HIV/AIDS Sept2006 populations Ke, Rw, Tz, AMONG REFUGEE, IDP AND Ug) HOST POPULATIONS IN THE GREAT LAKES REGION OF AFRICA 200 Various AIDS epidemic update 2006_EpiUpdate_en.pdf UNAIDS, WHO UNAIDS, WHO 2006 E General population (Bu, DRC, Ke, Rw, Tz, Ug) 201 Various Antiretroviral Medication Policy UNHCR ART Policy FINAL UNHCR 2007 E Refugees (Bu, DRC, for Refugees 10-1-07.pdf Ke, Rw, Tz, Ug) 202 Various APPENDIX I: Health Needs and greatlakes.pdf WHO 2005 E General population (Bu, DRC, WHO activities in the Great Ke, Rw, Tz, Lakes Region Ug) 203 Various Conflict and HIV: A framework HIV and conflict Tulane University Center for International Resource NB Mock, S 2004 E Refugees, IDPs, host (Bu, DRC, for risk assessment to prevent assessment frameowrk.pdf Development New Orleans, Department of Duale, LF Brown, community Ke, Rw, Tz, HIV in conflict-affected settings International Health and Development Tulane E Mathys, HC Ug) in Africa University School of Public Health and Tropical O'Maonaigh, NKL Medicine New Orleans USA Abul-Husn, S Elliott 204 Various Displaced Populations Report Displaced_Populations_R OCHA 2007 E IDPs (Bu, DRC, eport_OCHA_2007 Ke, Rw, Tz, Ug) 205 Various GREAT LAKES - BURUNDI, great-lakes.pdf WHO 2005 E (Bu, DRC, DRC, RWANDA, TANZANIA, Ke, Rw, Tz, UGANDA: HEALTH SECTOR Ug) NEEDS ASSESSMENT ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 145 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 206 Various GREAT LAKES INITIATIVE ON GLIA_highway_project GLIA Gaspard Bikwemu 2004 E Refugees, IDPS, (Bu, DRC, HIV/AIDS: ENVIRONMENTAL returnees, ares Ke, Rw, Tz, AND SOCIAL MANAGEMENT surounding the refugee Ug) FRAMEWORK communities. 207 Various Helping Micro and Small GRL conference UN, AU, IG/GLR 2006 E General population (Bu, DRC, Entreprises cope with HIV/AIDS Ke, Rw, Tz, Ug) 208 Various HIV and Prisons in Prison Paper-PreFinal-NE UNAIDS, World Bank, United Nations Office on Nilufar Egamberdi 2007 E Prisoners (Bu, DRC, Sub_Saharan Africa: Drugs and Crime Ke, Rw, Tz, Opportunities for Africa Ug) 209 Various HIV prevalence and trends in SSA HIV trends.pdf WHO Emil Asamoah- 2004 E 140000 pregnat women (Bu, DRC, sub-Saharan Africa: no decline Odei, Jesus M from 22 SSA countries Ke, Rw, Tz, and large subregional Garcia Calleja, J Ug) differences Ties Boerma 210 Various HIV Risk and Prevention in HIV and disasters - Centers for Disease Control and Prevention AJ Khaw, P 2000 E Refugees,IDPs, host (Bu, DRC, Emergency-affected review.pdf Salama, B community, Women, Ke, Rw, Tz, Populations: A Review Burkholder, TJ children, armed forces, Ug) Dondero peacekeepers, sex workers 211 Various HIV surveillance in complex HIV in complex Epidemic Intelligence Service and International P Salama, TJ 2001 E Refugees, IDPs, (Bu, DRC, emergencies emergencies.doc Emergency and Refugee Health Branch National Dondero Returnees, Migrants Ke, Rw, Tz, Center for Environmental Health, Division of Ug) HIV/AIDS Prevention National Center for HIV, STD, and TB Prevention CDC Atlanta USA 212 Various HIV/AIDs epidemiological AFRO2005.pdf WHO 2005 E General population (Bu, DRC, Surveillance report for the WHO Ke, Rw, Tz, African Region 2005 Update Ug) 213 Various HIV/AIDS and Internally HIV and UNHCR analysis UNHCR P Spiegel, H 2006 E IDPs (Bu, DRC, Displaced Persons in 8 Priority of NSPs Harroff-Tavel Ke, Rw, Tz, Countries Ug) 214 Various HIV/AIDS: Waking up to the waking_up_challenges Conflict Research Unit, Clingendael Institute, The S. Verstegen 2005 E Conflict affected (Bu, DRC, Challenges Netherlands Ministry of Foreign Affairs populations Ke, Rw, Tz, Ug) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 146 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 215 Various Integration of HIV/AIDS UNHCR Food Nutirtion UNHCR & WFP 2004 E Refugees,returnees & (Bu, DRC, activities with food and nutrition support.pdf IDPs Ke, Rw, Tz, support in refugee settings: Ug) specific programme strategies 216 Various Monitoring the AIDS epidemic burundi HIV Centre for Population Studies London School of B Zaba, T 2000 E Young women (Bu, DRC, using HIV prevalence data prevalence.pdf Hygiene & Tropical Medicine, Carolina Population Boerma, R White Ke, Rw, Tz, among young women attending Centre School of Public Health University of North Ug) antenatal clinics: prospects and Carolina at Chapel Hill USA problems 217 Various Note on HIV/AIDS and the HIV and UNHCR.pdf UNHCR 2006 E Refugees, IDPs, returnees (Bu, DRC, Protection of Refugees, IDPs and stateless Ke, Rw, Tz, and Other Persons of Concern Ug) 218 Various Number of fishers and fish data fishers FIEs E Fishermen (Bu, DRC, farmers Ke, Rw, Tz, Ug) 219 Various Partnership: An Operations UNHCR complete- UNHCR 2003 E UNHCR staff and (Bu, DRC, Management Handbook for handbook partners; Refugees, Ke, Rw, Tz, UNHCR’s Partners returnees & IDPs Ug) 220 Various Prevention and control of WHO stis_strategy.pdf WHO 2006 E Refugees, and other (Bu, DRC, sexually transmitted infections: people of concern Ke, Rw, Tz, draft global strategy Ug) 221 Various Prisons and AIDS Prisons-PoV_en UNAIDS 1997 E Prisoners (Bu, DRC, Ke, Rw, Tz, Ug) 222 Various PROJECT APPRAISAL GLIA PAD vol1.pdf World Bank 2005 E GLIA & WB staff (Bu, DRC, DOCUMENT ON A Ke, Rw, Tz, PROPOSED GRANT IN THE Ug) AMOUNT OF SDR 13.7 MILLION (USD 20 MILLION EQUIVALENT) TO THE GREAT LAKES INITIATIVE ON HIV/AIDS (GLIA) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 147 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 223 Various Refugees and HIV/AIDS HIV and UNHCR 2001.pdf UNHCR 2001 E Refugees (Bu, DRC, Ke, Rw, Tz, Ug) 224 Various Refugees, HIV and AIDS: HIV and UNHCR policy up UNHCR 2004 E Refugees (Bu, DRC, UNHCR's strategic plan 2005- to 2007 Ke, Rw, Tz, 2007 Ug) 225 Various SECTION 1. REGIONAL Int_migration_regions_200 IOM Ndioro Ndiaye and 2005 E Migrant populations, (Bu, DRC, OVERVIEW SELECTED 5 Philippe Boncour Refugees & IDPS Ke, Rw, Tz, GEOGRAPHIC REGIONS Ug) 226 Various SECTION 3. INTERNATIONAL Int_migration_data_2005 IOM Ndioro Ndiaye and 2005 E Migrant populations, (Bu, DRC, MIGRATION DATA AND Philippe Boncour refugees & IDPs Ke, Rw, Tz, STATISTICS Ug) 227 Various Strategic Conflict Analysis: Lake SIDA_ConfAna_Lake_Vict SIDA 2004 E Conflict affected (Bu, DRC, Victoria Region oria.pdf populations Ke, Rw, Tz, Ug) 228 Various Stratégies pour la prise en UNHCR refugees and UNAIDS & UNHCR 2006 F Refugees and host (Bu, DRC, charge des besoins relatifs au AIDS_BP_En FINAL3- populations Ke, Rw, Tz, VIH des réfugiés et populations 06.pdf Ug) hôtes 229 Various Strategies to support the HIV- UNHCR Refugees and UNAIDS & UNHCR 2006 E Refugees and host (Bu, DRC, related needs of refugees and AIDS_BP_En FINAL10- populations Ke, Rw, Tz, host populations 05.pdf Ug) 230 Various Strategies to support the HIV- Highway_ke&ug1 UNAIDS, UNHCR Paul Spiegel, 2005 E Refugees and host (Bu, DRC, related needs of refugees and Andrea Miller and populations Ke, Rw, Tz, host populations. A joint Marian Ug) publication of the Joint United Schilperoord Nations Programme on HIV/AIDS (UNAIDS) and the United Nations High Commissioner for Refugees (UNHCR) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 148 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 231 Various The global coaltition on Women jc1308_gcwa_progressrep UNAIDS 2006 E Women (Bu, DRC, and AIDS ort2006_en Ke, Rw, Tz, Ug) 232 Various The Great Lakes Region MAP of GLR. Pdf UN 2004 E (Bu, DRC, Ke, Rw, Tz, Ug) 233 Various WHO guidelines on HIV JC277-WHO-Guidel- WHO, UNAIDS 1993 E Prisoners (Bu, DRC, infection and AIDS in prisons Prisons_en Ke, Rw, Tz, Ug) 234 Various WHO Multi-country Study on WHO domestic violence WHO Claudia García- 2005 E Women Victim of domestic (Bu, DRC, Women’s Health and Domestic summary Moreno et al. violence Ke, Rw, Tz, Violence against Women Ug) 235 Various World Female Imprisonment women-prison-list-2006 KING'S COLLEGE LONDON, International Centre Roy Walmsley 2006 E Female Prisoners (Bu, DRC, List (Women and girls in penal for Prison Studies Ke, Rw, Tz, institutions, including pre-trial Ug) detainees/remand prisoners) 236 Various World Prison Population List world-prison-pop-seventh KING'S COLLEGE LONDON, International Centre Roy Walmsley 2006 E Prisoners (Bu, DRC, (seventh edition) for Prison Studies Ke, Rw, Tz, Ug) 237 Various HIV/AIDS among conflict- HIV and Conflict- UNHCR PB Spiegel 2004 E Refugees, IDPs, host (Bu, DRC, affected and displaced Disasters 9-04.pdf community, Women, Ke, Rw, populations: Dispelling myths children, Armed forces, Ug, Tz) and taking action peacekeepers, sex workers 238 Various Communicable diseases in CDs in CEs - Lancet 11- WHO, UNICEF, UNHCR MA Connolly, M 2004 E Refugees, IDPs, host (Bu, DRC, complex emergencies: impact 04.pdf Gayer, MJ Ryan, community Rw, Tz) and challenges P Salama, P Spiegel, DL Heymann 239 Various AIDS and Violent Conflict in Docking et al 2001 United States Institute of Pe a c e Doking et al. 2001 E Conflict affected (Bu, DRC, Africa populations Rw, Ug) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 149 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 240 Various Prevalence of HIV infection in Lancet HIV and Conflict UNHCR and The University of Copenhagen, Paul B Spiegel et 2007 E Refugees, IDPs, armed (Bu, DRC, confl ict-aff ected and displaced FINAL 30-6-07.pdf Copenhagen, Denmark al. forces, paramilitary Rw, Ug) people in seven sub-Saharan personnel, SWs, African countries: a systematic unaccompanied minors, review sexual violence victims, economic vulnerable women 241 Various THE RIGHT TO SURVIVE the_right_to_survive Rights & Democracy 1001, de Maisonneuve Blvd. Françoise 2004 E Women victim of sexual (Bu, DRC, SEXUAL VIOLENCE, WOMEN East, Suite 1100 Montreal (Quebec) H2L 4P9 Nduwimana violence Rw, Ug) AND HIV/AIDS Canada 242 Various HIV/AIDS and the Changing Changing landscape of University of Warwick S Elbe 2002 E Armed forces combatants, (Bu, Ke, Landscape of War in Africa war in Africa.pdf Girls& women victims of Rw, Tz, sexual violence, sex Ug) workers, refugees, IDPs 243 Various The impact of the African AIDS Caldwell6.pdf Health Transition Centre Australian National JC Caldwell 1997 E General population (Bu, Ke, epidemic University Rw, Tz, Ug) 244 Various HIV in prison in low-income and HIV_prisoners_low&middl Program of International Research and Training, Kate Dolan et al 2007 E Prisoners (Bu, Rw, middle-income countries e_income countries National Drug and Alcohol Research Centre, Ug, Tz) University of New South Wales, Sydney 2052, Australia 245 Various UNHCR Good Practiceon Good_Pract_Empowerme UNHCR 2001 E Refugee young girls & (Bu, Tz) Gender Equality Mainstreaming. nt_0106.pdf women Practical Guide to Empoewrment 246 Various Informal Cross Border Trade Country_presentation_Ug 2004 E (DRC, Ke, (ICBT) SurveyTrade Survey-- andaICBTReport Rw, Tz, Phase I. Phase I October 2003 Ug) –January 2004 247 Various RURAL-URBAN Gould mobility AIDS 2004 CICRED and UNDP South East Asia HIV and W.T.S. Gould 2004 E Rural & Urban Mobile (DRC, Ke, INTERACTIONS AND HIV/AIDS Development Programme Populations Rw, Tz, IN EASTERN AFRICA. (SEAHIV) Ug) 248 Various The State of Business state_businesscoalitions_ World Bank 2006 E private sector, General (DRC, Ke, Coalitions in Sub-Saharan SSA population Rw, Tz, Africa Ug) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 150 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 249 Various ROADS Signs. Recent ROADS Signs May 2007 FHI, USAID 2007 E Gneral population , Truck (DRC, Ke, highlights from the ROADS _A4_2 drivers Tz) Project 250 Various Impact of HIV/AIDS ON Policy_Brief-Final_En FAO 2002 E Fishing communities (DRC, Ke, FISHING COMMUNITIES Tz, Ug) 251 Various Fisherfolk are among groups fishing prevalence Seeley 1.The AIDS and Development Group, University of Esther Kissling et 2005 E Fisherflok (DRC, Ke, most at risk of HIV: cross- East Anglia, Norwich, UK. 2. WorldFish Center, al. Ug) country analysis of prevalence Regional Research Center for Africa and West and numbers infected Asia, Cairo, Egypt. 3 School of Development Studies, University of East Anglia, Norwich, NR4 7TJ, U 252 Various LIVING IN TERROR. The LIVING IN TERROR Centre for Military Studies (Military Academy), Lindy Heinecken 2001 E Militaries, uniformed (DRC, Ke, looming security threat to University of Stellenbosch forces, War & Conflict Ug) Southern Africa affected populations 253 Various Structural barriers and migration international.pdf Columbia University, New york, Usa; State Richard G. Parker, 2000 E Heterosexual women, (DRC, Ke, facilitators in HIV prevention: a University of Rio de Janeiro, Brazil; Center for delia Easton and female commercial sex Ug) review of international research Disease Controle and Prevention, Atlanta, Georgia, Charles H. Klein workers, male truck drivers USA and The Department of Public health , san and men who have sex Francisco, California, USA. with men 254 Various Forced Migration and AMREF8 Columbia University; Women's Commission for Therese McGinn 2001 E Refugees and IDPs (DRC, Rw, Transmission of HIV and Other Refugee Women and Childen et al. Tz) Sexually Transmitted Infections: Policy and Programmatic Responses 255 Various Background and context of background_kapiri Mposhi E long distance truck (DRC, Tz) Kapiri Mposhi, Zambia drivers/assistants, second hand clothes traders, maize and livestock traders, fishermen, SWs 256 Various The spread and effect of HIV-1 HIV spread in Africa.pdf Institute of Tropical Medicine Antwerp Belgium, A Buve, K 2002 E General population (DRC, Tz, infection in sub-Saharan Africa Country and Regional Support Department Bishikwabo- Ug) UNAIDS Geneva Switzerland, University of North Nsarhaza, G Carolina Chapel Hill NC USA Mutangadura 257 Various Gap between Preferred and birth intervals DHS.pdf ORC Macro H Rafalimanana, 2001 E 3568(Ke), 4752(Rw), (Ke, Rw, Actual Birth Intervals in Sub- CF Westoff 6851(Tz), 6117(ug) Tz, Ug) Saharan Africa: Implications for Women 15-49yrs Fertility and Child Health ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 151 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 258 Various HIV and Islam: is HIV Truck drivers.pdf Department of Anthropology, Peabody Museum, Peter B. Gray 2003 E Muslim Truck drivers (Ke, Rw, prevalence lower among Harvard University, Cambridge, MA, USA Tz, Ug) Muslims? 259 Various HIV behavioural surveillance BSS Gl Public Health 6- UNHCR PB Spiegel, PV Le 2006 E (Ke, Rw, surveys in conflict and post- 06.pdf Tz, Ug) conflict situations: A call for improvement 260 Various Male circumcision and risk of male circ.pdf Medical Research Council Tropical Epidemiology Helen A. et al 2000 E Male population (Ke, Rw, HIV infection in sub-Saharan Group, London School of Hygiene and Tropical Tz, Ug) Africa: a systematic review and Medicine, London meta-analysis 261 Various National population based HIV Calleja_PopSurveys_STI2 WHO, UNAIDS J M Garcı´a- 2006 E Pregnant women (Ke, Rw, prevalence surveys in sub- 006.pdf Calleja, E Gouws, Tz, Ug) Saharan Africa: results and P D Ghys implications for HIV and AIDS estimates 262 Various Sexual risk factors for HIV Sexual Risk factors for HIV Centre for Global Health L Chen et al. 2007 E Sex partners, FSW clients, (Ke, Rw, infection in early and advanced in SSA people with STIs /HSV-2 Tz, Ug) HIV epidemics in Sub-Saharan Africa: systematic overview of 68 epidemiological studies 263 Various The Solidarity Center’s puds_hiv_eastafricafacts Solidarity Center 2007 E truck drivers (Ke, Rw, HIV/AIDS Work in East Africa Tz, Ug) 264 Various MAINSTREAMING AIDS IN mainstreaming_aids_28no UNAIDS, UNDP, World Bank Daphne 2005 E General population, HIV- (Ke, Rw, DEVELOPMENT v05 Topouzis et al. Positive people Ug) INSTRUMENTS AND PROCESSES AT THE NATIONAL LEVEL 265 Various Female Genital Cutting in the FGM DHS.pdf ORC Macro PS Yoder, N 2004 E women and Young girls (Ke, Tz) Demographic and Health Abderrahim, A Surveys: A Critical and Zhuzhini Comparative Analysis 266 Various HIV/AIDS INTERVENTIONS IN Truck_Drivers_Pop_South 2004 E truck drivers (Ke, Tz) TRUCK DRIVER POPULATION .pdf IN SOUTHERN AFRICA: A REVIEW OF LITERATURE AND BCC MATERIALS 267 Various L’excision dans les Enquêtes excision EDS Fr.pdf ORC Macro PS Yoder, N 2005 F women and Young girls (Ke, Tz) Démographiques et de Santé : Abderrahim, A Une Analyse Comparative Zhuzhini ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 152 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 268 Various Trends and Differentials in Adolescents SSA.pdf ORC Macro M Mahy, N Gupta 2002 E Men and women 15-19yrs (Ke, Tz) Adolescent Reproductive Behavior in Sub-Saharan Africa 269 Various A study of the association of HIV wealth DHS.pdf Macro International Inc., University of Montreal, V Mishra et al. 2007 E Male Interviewed: (Ke, Tz, HIV infection with wealth in sub- UNAIDS, WHO, HEC Montreal Ke=3578,Tz=5659, Ug) Saharan Africa 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 270 Various Community Responses to Corridors_Hope_Southern Family Health International (FHI) 2004 E Transport workers, sex (Ke, Tz, HIV/AIDS Along Transit _Africa workers Ug) Corridors & Areas of Intense Transport Operations in Eastern & Southern Africa 271 Various Concurrent sexual partnerships Concurrent sexual Office of HIV-AIDS USAID Washington, Center for DT Halperin, H 2004 E Men and women, sex (Ke, Tz, help to explain Africa’s high HIV partners Lancet 7-04.pdf Health and Wellbeing Princeton University Epstein workers Ug) prevalence: implications for Princeton New Jersey USA prevention 272 Various Study on Trafficking in Women trafficking GTZ GTZ Elaine Pearson 2003 E Women and Girls (Ke, Tz, in East Africa Ug) 273 Various continuing role for prevention in highway_ke&ug.pdf UNAIDS & UNHCR C N Morris and A 2006 E Trukck drivers/assistants (Ke, Ug) high risk groups Kenya and G Ferguson Uganda on the trans-Africa highway: 274 Various Estimation of the sexual Highway _ke_ug University of Manitoba, C N Morris, A G 2006 E 857sex workers, 202 truck (Ke, Ug) transmission of HIV in Kenya Ferguson drivers and Uganda on the trans-Africa highway: the continuing role for prevention in high risk groups 275 Various Estimation of the sexual Highway_ke_ug.pdf University of Manitoba, Canada C N Morris and A 2006 E 202 truck drivers, 578 (Ke, Ug) transmission of HIV in Kenya G Ferguson female sex workers and Uganda on the trans-Africa highway: the continuing role for prevention in high risk groups ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 153 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 276 Various HOT SPOT MAPPING OF Northern Corridor and Strengthening STD/HIV Control In Kenya Project, Dr. Chester N. 2004 E long distance truck (Ke, Ug) TRANSACTIONAL SEX ON transactional sex Ministry of transport, Futures group Europe Morris and Dr. drivers/assistants, female THE NORTHERN CORRIDOR: Alan Ferguson sex workers Mombasa-Kampala 277 Various Sexual and treatment-seeking Highway_behav_eastafric Department of Medical Microbiology, University of Chester N Morris 2007 E 162 Truck Drivers and 219 (Ke, Ug) behaviour for sexually a Manitoba and Alan G Their Assistants transmitted infection in long- Ferguson distance transport workers of East Africa 278 Various Sexual and treatment-seeking highway_behav_eastafrica Department of Medical Microbiology,University of Chester N Morris 2007 E 162 Truck drivers, 219 (Ke, Ug) behaviour for sexually Manitoba & Institute for Human Virology- and Alan G drivers assistants transmitted infection in long- Nigeria Ferguson distance transport workers of East Africa 279 Various Sexually transmitted infections STIs fishermen lake AIDS 2006 - XVI International AIDS Conference M. Ng'ayo et al. 2006 E 250 fishermen aged 18-68 (Ke, Ug) and HIV among fishermen along Victoria Lake Victoria shore: do they qualify for a microbicide trial? 280 Various Child Vulnerability and gillespieOVCsynth.pdf International Food Policy Research Institute, S Gillespie et al. 2005 E Vulnerable Children (Ke, Ug, HIV/AIDS in sub-Saharan University of Calgary Canada, Tulane University Tz) Africa: What We Know and USA What Can Be Done 281 Various Gender-based violence, Dunkle GBV KIV link Gender and Health Group, Medical Research Kristin L Dunkle et 2004 E 1366 women (Rw, Tz) relationship power, and risk of lancet 2004 Council, Private Bag X385, Pretoria 0001, South al. HIV infection in women Africa attending antenatal clinics in South Africa 282 Various Sexually transmitted diseases in SCAN0987_000.pdf Department of Clinical Sciences, London School of David Mabey & 1997 E International travellers (Rw, Tz) mobile populations Hygiene & Tropical Medicine, London, UK Philippe Mayaud from Europe, migrant workers in southern Africa, and Rwandan refugees in Camp in Tanzania. 283 Various Taking It to the mobile-VCT Population Services International, Washington, 2006 E mobile populations, IDPs (Rw, Ug) Streets :Reaching Truckers, DC ,USA Sex Workers, Rural Populations with Mobile VCT 284 Various Approaches to the control of 174.pdf London School of Hygiene and Tropical Medicine P Mayaud, D 2004 E Sexually active young (Tz, Ug) sexually transmitted infections Mabey population, Urban in developing countries: old migrants, IDPs, sex problems and modern workers challenges ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 154 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 285 Various HIV/AIDS Surveillance in GTZ_surveillance_Mbeya GTZ 1999 E General population (Tz, Ug) Developing Countries. Experiences and Issues 286 Various Interactions between HIV mobilitiy and risk Department of infectious & tropical Diseases, David Mabey 2000 E 293 subjects (Tz, Ug) infection and other sexually reduction2 London School pf Hygiene & Tropical Medicine, transmitted diseases London, UK 287 Various The empirical evidence for the aids mortality.pdf MRC Clinical Trials Unit London, London School of K Porter, B Zaba 2004 E Young adult pop, women (Tz, Ug) impact of HIV on adult mortality Hygiene and Tropical Medicine in the developing world: data from serological studies 288 Variuos Determinants of the Impact of mobility in Tanzania and Department of Public Health, Erasmus Medical E.L. Korenromp et 2005 E 293 Men and women (Tz, Ug) Sexually Transmitted Infection Uganda.pdf Center, University Medical Center Rotterdam, al. Treatment on Prevention of HIV Rotterdam, The Netherlands; London School of Infection: A Synthesis of Hygiene and Tropical Medicine, London, United Evidence from the Mwanza, Kingdom; Medical Research Council Programme Rakai, and Masaka Intervention on AIDS in Uganda, Uganda Viru Trials 289 Various Higher risk behaviour and rates Uganda and TAnzania London School of Hygiene and Tropical Medicine, Kate K. Orroth et 2003 E 1. Migration-definition (Tz, Ug) of sexually transmitted diseases STD study.pdf Keppel Street, London, UK. al. pop:(645 participants in in Mwanza compared to Rakai Ug), (2072 in Uganda may help explain HIV Masaka Ug) abd (1500 in prevention trial outcomes Mwanza Tz) 2.Sexual behaviour:(11600 in Rakai), (5900 in Masaka) and (1100 in Mwanza) 290 Issue Paper 1: HIV/AIDS and military hiv 2005 Clingendael Institute, Expert Seminar and Policy 2005 E Military, peacekeepers the Military Conference: AIDS, Security and Democracy , The Hague, 2-4 May 2005 291 19th Meeting of the UNAIDS 20061101_pcb_security_a UNAIDS 2006 E Refugees, IDPs, Host Programme Coordinating Board nd_humanitarian_respons Communities Lusaka, Zambia, 6–8 December e_en 2006. AIDS, Security and Humanitarian Response 292 AIDE-MÉMOIRES Policy Commanders_Guidelines Civil-Military alliance & UN Department of 2000 E Military/ Uniformed Guidelines on HIV/AIDS Peacekeeping operations Services personnel Prevention and Control for UN Military Planners and Commanders 293 AIDS and the military militarypv_en UNAIDS 1998 E Military 294 AIDS BRIEF: MILITARY AIDS-Brief- USAID, WHO Rodger Yeager 2000 E Military and Unniformed POPULATIONS Military%20Sector Forces ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 155 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 295 AIDS, Security and Conflict military hiv de Waal SSRC and Harvard University Alex de Waal 2005 E Military Initiative. Speaking Notes on Themes and Evidence 296 AIDS, SECURITY AND THE Whiteside et al military Royal African Society, Oxford University ALAN 2006 E Military and other MILITARY IN AFRICA: A 2006 WHITESIDE, uniformed forces SOBER APPRAISAL ALEX DE WAAL AND TSADKAN GEBRE-TENSAE 297 Behind the Bars of Masculinity: Abstract Gear 2007 Centre for the Study of Violence and Reconciliation, Sasha Gear 2007 E Male Prisoners Male Rape and Homophobia in South Africa and about South African Men's Prisons 298 Building Regional HIV Corridors_Hope_Southern FHI 2005 E Truck drivers, sex workers, Resilience along the ASEAN -Africa-Microsoft Word guest house and bars Highway Network attendants, petty traders, and area residents 299 By virtue of their occupation, Military_Risk_SpecialRepo Miller N and 1995 E Military, sailors soldiers and sailors are at rt.doc Yeager R greater risk. Special report: the military 300 Children in prison gn-14-children-in-prison KING'S COLLEGE LONDON, International Centre 2004 E Children in Prison for Prison Studies 301 Circular migration and sexual south africa migration.pdf South African Medical Research Council, Centre Mark Lurie et al. 1997 E Men age 20-50 networking in rural For Epidemiological Studies in Southern Africa KwaZulu/Natal: implications for (CERSA), Hlabisa, KwaZulu/Natal, South Africa; the spread of HIV and other Johns Hopkins University School of Hygiene and sexually transmitted diseases Public Health, Baltimore MD, USA 302 Combat AIDS. HIV AND THE Healthlink armed forces Healthlink Worldwide, Cityside 40 Adler Street. Martin Foreman 2002 E Uniformed services WORLD’S ARMED FORCES 2002 London E1 1EE UK (Military, peacekeepers) 303 Community Responses to Corridor_eastern_southern IFRTD,CSIR 2004 E Tramsport workers, sex HIV/AIDS Along Transit .doc workers, East African Corridors & Areas of Intense community Transport Operations in Eastern & Southern Africa 304 Conflict and Disease: An AMREF7 AMREF Daraus Bukenya 2002 E Women and children overview in the African conflicts. Paper presented at the Mwalimu Nyerere Foundation Conference ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 156 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 305 Corridors of Hope in Southern cross-border-2003 Edmond de Rothschild Foundation Chemical T.M. Hammett et 2003 E drug users Africa: HIV Prevention Needs Dependency Institute, Beth Israel Medical Center, al. and Opportunities in Four 1st Ave at 16th Street, New York, NY 10003, USA; Border Towns Guangxi Center for HIV/AIDS Prevention and Control, 80 Taoyuan Road, Nanning 530021, China; International Cooperati 306 Development and FHIFINAL sz Lo RSA FHI, IMPACT & USAID David Wilson 2001 E Truck drivers, bus drivers, implementation of a cross- taxi drivers, sex workers, border HIV prevention miners, informal traders intervention for injection drug users in Ning Ming County (Guangxi Province), China and Lang Son Province, Vietnam 307 Effect of a structural intervention Partner violence RSA Development Action Research Programme Paul M Pronyk et 2006 E Poor rural women for the prevention of intimate- (RADAR) School of Public Health, University of the al. partner violence and HIV in rural Witwatersrand, PO Box 2, Acornhoek, South Africa South Africa: a cluster 136 randomised trial 308 Evidence of Declining STD Mobile populations.doc . S. Richard et al 2000 E Miners, women Prevalence in a South African Mining Community Following a Core-Group Intervention. 309 From people to places: focusing south africa mobility.pdf Carolina Population Center, University of North Sharon S. Wier et 2003 E 3085 men and 1564 AIDS prevention efforts where it Carolina, USA. al. women matters most 310 GUIDELINES for HIV/AIDS iascguidelines_en.pdf IASC E HIV affected peeople, at interventions in emergency risk houdeholds, at risk settings communities 311 Health consequences of Campbell partner violence Johns Hopkins University School of Nursing, 525 Jacquelyn C 2002 E Women victim of violence intimate partner violence 2002 North Wolfe Street, Baltimore, MD 21205–2110, Campbell USA 312 HIV and Mobile Workers: A hiv_Mobileworkers_WestA IOM & UNAIDS Eleonore Caraël 2005 E Truckers REVIEW of RISKS AND frica.pdf PROGRAMMES AMONG TRUCKERS IN WEST AFRICA 313 Hiv and refugees jc1300-policybrief- UNAIDS & UNHCR 2007 E Refugees refugees_en ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 157 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 314 HIV in injecting drug users in HIV_IDUs_Asia Department of Health Policy, Management and Alex Wodak, 2004 E IDUs Asian countries Evaluation, Faculty of Medicine, University of Robert Ali and Toronto, 12 Queens Park Crescent West, Toronto, Michael Farrell Canada M5S 1A8 315 HIV Infection Among Sex sex workers and STD/AIDS Regional Coordination Unit, Greater Asamoah-Adu, 2001 E female sex workers Workers in Accra: Need to Ghana.doc Accra Region, Ministry of Health, Accra, Ghana; confort et al. Target New Recruits Entering Centre for International Health, University of the Trade Sherbrooke, Québec, Canada; West Africa Project to Combat AIDS, Accra, Ghana; Public Health Reference Laboratory, M 316 HIV Vulnerabilyty Mapping: Hiv2001 UN Transport workers Highway One, Viet Nam 317 HIV/AIDS and Gender-Based Final_Literature_Review.p Department of Population and International Health, 2006 E Victims of gender-based Violence (GBV):Literature df Harvard School of Public health violence Review 318 HIV/AIDS in the transport sector transpSector_hiv_souther ILO 2005 E Transport workers, sex of Southern African countries: A n.pdf workers rapid assessment of cross- border regulations and formalities 319 HIV/AIDS is a human rights Hiv%2Daids International Transport Workers’ Federation E Transport workers issue. Human rights are TRADE UNION issues 320 HIV/AIDS, Conflict and hiv_aids_conflict_displace Unicef & UNHCR 2006 E IDPs Displacement ment 321 HIV/AIDS, Population Mobility 2004_PopulationMobilityR IOM 2005 E Mobile Populations and Migration in Southern esearchAgendaReport Africa. Defining a Research and Policy Agenda 322 HIV/AIDS: Transport Workers Hivaids_globalunionsbroc Global Union E workers Take Action hure 323 HIV/AIDS+WORK: Using the HPP0000188 UNDP Jacques du 2002 E Mobile populations ILO Code of Practice on Guerny HIV/AIDS and the world of work 324 HIV-1 infection among injection IDU_brazil WHO Sylvia Lopes Maia 2004 E IDUs and ex-injection drug users from Teixeira et al. Rio de Janeiro, Brazil: prevalence, estimated incidence and genetic diversity ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 158 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 325 Human Immunodeficiency HIV_morbidity_mortality_I Department of Epidemiology, Universitv of North Rachel Royce 1996 E IDUs Virus-Related Morbidity and DU Carolina School of Public Health. Mortality in Injection Drug Users: Should the AIDS Definition Be Changed Yet Again 326 Humanitarian Charter and Sphere_hdbk_full The Sphere Project 2004 E General population, NGOs Minimum Standards in Disaster Response 327 IMPACT OF HIV/AIDS ON KM-Study report on THE AFRICAN CAPACITY BUILDING Wilfred Ndongko 2004 E Public sector workers PUBLIC SECTOR CAPACITY Capacity impact of HIV- FOUNDATION ACBF BOARD OF GOVERNORS et al. IN SUB-SAHARAN AIDS.doc AFRICA:TOWARDS A FRAMEWORK FOR THE PROTECTION OF PUBLIC SECTOR CAPACITY AND EFFECTIVE RESPONSE TO THE MOST AFFECTED COUNTRIES 328 Improving parameter estimation, 2006prague_report_en UNAIDS Dr Peter White 2007 E General population, HIV- projection methods, uncertainty Positive people estimation, and epidemic classification 329 Injecting Drug Use and AIDS in HIV_IDUs_Dev&Trans- World Bank Kara S. Riehman 1996 E IDUs Developing Countries: Countries Determinants and Issues for Policy Consideration 330 International Conference on HPP0000247 UNDP Lorna Guinness &. 2002 E Mobile populations Peace, Security, Democracy Lilani and Development in the Great Kumaranayake Lakes Region: DAR-ES- SALAAM DECLARATION ON PEACE, SECURITY, DEMOCRACY AND DEVELOPMENT IN THE GREAT LAKES REGION 331 International Conference on the HPP0000819 UNDP JAMIE UHRIG 2000 E Migrant and host Great Lakes Region: Regional communities Programme of Action: Economic Development and Regional Integration ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 159 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 332 International Military Human Yeager et al 2000 CMA Department of Political Science, West Virginia Rodger D. Yeager 2000 E Militaries, uniformed Immunodeficiency Virus / University, Morgantown, WV 26506 U.S.A, Division et al. forces, War & Conflict Acquired Immunodeficiency of Clinical Pharmacology, The Johns Hopkins affected populations Deficiency Syndrome Policies University School of Medicine, Baltimore, MD and Programs: Strengths and 21287 U.S.A, Civil-Military Alliance to Combat HIV Limitations in Current Practice and AIDS, 20 Route 333 Intimate partner Violence and Campbell partner violence School of Hygiene and Public Health, Johns Jacquelyn C 2002 E 2535 Women aged 21-55 Physical Health Consequences STIs 2002 Hopkins University, 615 North Wolfe Street, Campbell et al. Baltimore, MD 21205, U.S.A 334 Is there an HIV/AIDS Is there an HIV_AIDS Society in Trasitions Tessa Marcus 2001 E Truck drivers demonstration effects?- findings demonstration effect from a longitudinal study of long distance truck drivers 335 Issues in HIV prevention for Issues in HIV prevention Des Jarlais et al. 2004 E IDUs injecting drug users (IDUs) in for injecting drug users developing/transitional countries: Results from the WHO Phase II Drug injection study. 336 Lesotho and Swaziland: HPP0000936 UNDP & World Vision 2004 E Transport workers, HIV/AIDS Risk Assessments at construction workers, and Cross-Border and Migrant, Sites public works workers in Southern Africa 337 Mapping HIV Vulnerability along HPP0000943 UNDP Tia Phalla et al. 2004 E Construction workers, road Kampong Thom, Siem Reap, engineers, truckers, sex Odor Meanchey and Preah workers, hotel+guest Vihear, Cambodia house+restaurant attentants 338 Men who have sex with men, jc1233-msm- UNAIDS 2005 E Men who have sex with HIV prevention and care meetingreport_en men 339 Mitigating the Impact of HPP0000990 UNDP, World Vision, Macfarlaene Institute 2004 E Costruction workers, truck HIV/AIDS in Transport Sector drivers, fishermen, migrant Activities: A Synthesis of sex workers Literature 340 Mobile Populations and 2003_MobilepopulationsA IOM Barbara Rijks 2003 E Military personnel, HIV/AIDS in the Southern ndHIVAidsDocument.pdf Transport workers, Mine African Region. workers, workers in the Recommendations for Action construction sector and other major industries, agricultural farm workers, ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 160 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country informal traders, domestic workers, refugees, IDPs 341 Mobility and the spread of mobility_West Africa.pdf Institut National de la Santé et de la Recherche E.Lagarde et al. 2003 E 1200 Men and women age human immunodeficiency virus Médicale, U88-IFR69, Saint-Maurice, France; 15-59 into rural areas of West Africa Medical Research Council Laboratories, Fajara, The Gambia; Institut National d’Etude Démographique, Paris, France; Programme de recherche sur le SIDA de l’Institu 342 Model-Based Estimates of HIV Prison_rape_hiv. abstract. Medical College of Wisconsin, Milwaukee Steven D. 2007 E Prisoners Acquisition Due to Prison Rape Doc Pinkerton 343 Modelling the expected ModeOfTransmission_07_ WHO, UNAIDS 2007 E Sex workers& Clients, distribution of new HIV en Youth, military, truckers, infections by exposure group IDUs 344 Modelling the expected MoT_2007_example_MC_ WHO, UNAIDS 2007 E Sex workers& Clients, distribution of new HIV en Youth, military, truckers, infections by exposure group IDUs 345 Multisectoral Responses to icpsdd-gr-20nov UN, AU, IG/GLR 2004 E General population Mobile Populations’ HIV Vulnerability examples from People’s Republic of China, Thailand and Viet Nam 346 Multisectoral Responses to AsiaMultsectoriaResponse UNDP Jacques du 2003 E Migrants and host Mobile Populations’ HIV s2003.pdf Guerny et al. communities Vulnerability examples from People’s Republic of China, Thailand and Viet Nam 347 Needs Assessment Report on Indonesia mobility ILO, UNDP.UNAIDS, AusAID Graeme Hugo 2001 E Internal Mobile pop. & Mobility and Cross-Border international mobile HIV/AIDS Transmission in Lang population Son and Lao Cai, Vietnam 348 Needs Assessment. Report on CP_vietnam_HIV- Program for Appropriate Technology in Health 2005 E drug users, sex workers Mobility and Cross-Border AIDS_trans 2005.pdf (PATH) 2nd Floor, Hanoi Towers, 49 Hai Ba Trung, HIV/AIDS Transmission in Lang Hanoi, Vietnam Son and Lao Cai, Vietnam 349 Peacebuilding inThe Great jama_article_another_worl Rwanda Women's Network Mardge H. Cohen 2005 E Raped HIV+women Lakes: Challenges and d et al. Opportunities for the EU in the DRC ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 161 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 350 Peer Education Kit for JC928- UNAIDS Iain McLellan 2003 E Military, Uniformed Services: EngagingUniServices- peacekeepers,Police, Implementing HIV/AIDS/STI PeerEd_en other uniformed peer education for uniformed services(Men & Women) services. 351 Physical Health Consequences Coker violence STIs 2000 University of South Carolina, School of Public Ann L. Coker et al. 2000 E 1152 Women aged 18-65 of Physical and Psychological Health, Columbia, Intimate Partner Violence 352 Priorities for local AIDS control sr-04-30.pdf USAID 2004 E Border areas' communities efforts(PLACE): For use in border areas of Lesotho and South Africa 353 Provision of Syndromic Syndromatic American Sexually Transmitted Disease KIM WARD et al. 2003 E 90 Community Treatment of Sexually treatment_STI_Commu.Ph Association. pharmacists Transmitted Infections by armacists Community Pharmacists: A Potentially Underutilized HIV Prevention Strategy 354 Rapid assessment of substance Liberia final report UNHCR, WHO 2006 E drug users, IDPs use in conflict-affected and displaced populations : Liberia 355 Reducing vulnerability of Thailand fishermen Raks Thai Foundation, Bangkok, Thailand. The XV E Fishermen migrant fishermen and related programming International AIDS Conference populations in Thailand 356 Refugees and the Acquired HIV and UNHCR 1988 UNHCR 1988 E Refugees Immune Deficiency Syndrome analysis.pdf (AIDS) 357 Regional Guidelines on HIV and 2007- PHAMSA 2007 E AIDS for the Informal Cross 04_IOM_HIVGuidelinesIC Border Trade Sector in the BT SADC Region 358 Report of the THIRTEENTH y5919b00.pdf FAO 2004 E Fishermen SESSION OF THE COMMITTEE FOR INLAND FISHERIES OF AFRICA 359 Report on Mobility and prisonframework UN Office on Drug and Crime, UNAIDS, WHO Rick Lines and 2006 E Prisoners Heino Stöver 360 Report on the International JC1276-globalreach-en UNAIDS & ILO 2006 E Working people Symposium on Sexual Violence in Conflict and Beyond ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 162 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 361 Risk and vulnerabilities of 2007- Health and Development Networks (HDN) and the 2007 E Mobile Populations migrants and mobile 01_IOM_HIVandPeopleOn International Organization for Migration (IOM) populations in Southern Africa TheMove Partnership on HIV/AIDS and Mobile Populations in Southern Africa (PHAMSA 362 SEXUALLY TRANSMITTED PPSTLarge PSI/Washington 1120 19th Street, NW Suite 600 Florence Zake et E STIs patients INFECTIONS IN SUB- Washington, DC 20036 USA al. SAHARAN AFRICA: THE USE AND EFFECTIVENESS OF TREATMENT KITS 363 Solidarity Center: Our HIV/AIDS pubs-hivdonor Solidarity Center 2007 E Truck drivers and their mission families 364 The Contraception – Fertility contraception fertility ORC Macro CF Westoff, A 2001 E Link in Sub-Saharan Africa and SSA.pdf Bankole in Other Developing Countries 365 The Development Potential of reg_pgms_full World Bank Catherine Gwin et 2007 E General population Regional Programs: An al. Evaluation of World Bank Support of Multicountry Operations 366 The future of the HIV pandemic future of HIV response - Imperial College London, WHO NC Grassly, GP 2005 E Mobile Populations mobile populatins.pdf Garnett 367 The Global HIV/AIDS Program: Transport_lessons_hiV_co World Bank Stephen Brushett 2005 E Transport workers LESSONS LEARNED TO rridors.pdf and John Stephen DATE. FROM HIV/AIDS Osika TRANSPORT CORRIDOR PROJECTS 368 The Potential Costs and sexual violence conflict UNFAP 2006 E Women victim of sexual Benefits of Responding to the 2005 violence Mobility Aspect of the HIV Epidemic in South East Asia: A conceptual framework 369 The Solidarity Center’s sme ILO 2006 E SME workers HIV/AIDS Work in East Africa: RESULTS FROM SEPTEMBER 2005 TO MARCH 2007(Kenya&Uganda) 370 The structure of sexual Malawi sexual networks on Department of Sociology, Population Studies Stephane E 1800 households networks and the spread of HIV Likoma.pdf Center, University of Pennsylvania, USA helleringer and in Sub-Saharan Africa: evidence hans_Peter Kohler from Likoma island (Malawi) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 163 ID GLIA Title File name Institutions Authors Year Lang. Target groups Country 371 Toolkit for HIV Prevention SouthernAfrica_Corridors USAID Janean Martin 2004 E Truck drivers, sex workers, among mobile populations in Hope guest house and bars the Greater Mekong Subregion attendants, petty traders, and area residents 372 Unexpected low prevalence of StrandEtAl2007.pdf 2007 E HIV among fertile women in Luanda, Angola. Does war prevent the spread of HIV? 373 UNHCR, HIV/AIDS and FMR1909.pdf UNHCR Paul B Spiegel E Refugees and host refugees: lessons learned and Alia Nankoe populations 374 Violence against women: global Watts Zimmerman Health Policy Unit, Department of Public Health and Charlotte Watts 2002 E Women victim of violence scope and magnitude violence 2002 Policy, London School of Hygiene and Tropical and Cathy Medicine, London WC1E 7HT, UK Zimmerman 375 WINNING THE WAR AGAINST CMA_Planning_Handbook Civil-Military alliance,UNAIDS, Stuart J. Kingma 1999 E Military/ Uniformed HIV AND AIDS. A Handbook on et al. Services personnel Planning, Monitoring and Evaluation of HIV Prevention and Care. Programmes in the Uniformed Service 376 Women in Rwanda: Another transp-hivguidlines ILO 2005 E Transport workers, World Is Possible 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 DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA Plan Stratégique de Plan Stratégique National Strategic Plan Stratégique National Multi-Sectoral Zanzibar National National HIV and AIDS Lutte Contre le National de Lutte Plan 2005/6-2009/10 Nationale de Lutte Strategic Framework HIV/AIDS Strategic Strategic Plan. 2007/8 VIH/SIDA. 2007-2011 contre le VIH/ SIDA/ contre le VIH/SIDA, on HIV and AIDS 2008 Plan 2003-2007 – 2011/12, Aug 2007 MST 1999–2008 Nov 2005 –2012 Targeting of vulnerable populations Promotion of lower risk sexual Promotion of peer education Development of HIV/AIDS Sensitisation on abstinence, Increase access to HIV Strengthen capacity of SW in Promotion of abstinence, behaviours through IEC, BCC activities. Promotion of safer prevention, treatment and fidelity and condom use. prevention (IEC, condoms, areas of sex negotiations fidelity and use of male and and condom promotion. VCT. sex behaviours. care strategies for CSW and Strengthening of condom peer education, VCT & STIs skills, peer education and female condom. Female / commercial sex workers STI diagnosis and treatment their clients. social marketing and services). Acknowledge the condom use. Introduce Improvement of the economic specifically of female condom. vulnerability of CSW and alternative income generating situation of vulnerable groups. Prevention activities through MSM and advocate for their schemes for SW. IEC/BCC by using mass access to HIV services and Development of an integrated media channels, peer decriminalization of their VCT/STD services education, promotion activities. Make quality STI incorporating harm reduction materials (flyers, shirts, services available and based education. Strengthen posters, etc.), meetings, accessible to CSW and their existing laws and regulations cultural/sports activities, clients. that increase cultural/moral conferences. adherence and discourages sex work. Introduce BSS for sex workers and their clients. Establish an interventions database. Promotion of lower risk sexual Sensitisation activities and Development of innovative Sensitisation on abstinence, Increase access to HIV Review guidelines/ regulations Promotion of abstinence, Military, combatants, police, peace behaviours through IEC, BCC education through peers. HIV/AIDS prevention, fidelity and condom use. prevention information and relevant to STI transmission. fidelity and use of male and and condom promotion. VCT. Promotion of abstinence, treatment and care strategies Strengthening of condom services (IEC, condoms, peer Establish sound education female condom. Prevention STI diagnosis and treatment. fidelity and condom use. for targeting the uniformed social marketing and education, VCT and STI system on STD/HIV/AIDS. through IEC and VCT support. Strengthening of prevention services. Mainstream specifically of female condom. services). Integration of HIV Introduce peer education activities. HIV/AIDS in relevant sectors. Prevention activities through education in new staff schemes. Establish user- keepers IEC/BCC by using mass orientation/ seminars. friendly STI and VCT services media channels, peer Standardize HIV education and access to affordable education, promotion and peer education training preventive tools such as materials (flyers, shirts, across sectors and ensure condoms. posters, etc.), meetings, quality. Make information and cultural/sports activities, condoms available to all conferences. mobile and migrant workers in all sectors. BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 165 Promotion of lower risk sexual Prevention of sexual Develop innovative HIV/AIDS Sensitisation on abstinence, Increase access to HIV Create the necessary political behaviours through IEC, BCC transmission of HIV through prevention, treatment and fidelity and condom use. prevention (IEC, condoms, environment and systems to and condom promotion. VCT. sensitisation, condom care strategies. Mainstream Strengthening of condom peer education, VCT & STIs maximize the outputs of STI diagnosis and treatment. promotion and STI HIV/AIDS in the sectors social marketing and services). Implement regional initiatives that target management. Promotion of serving migrant workers. specifically of female condom. guidelines on workplace mobile populations (GLIA, peer education. Prevention activities through interventions. Integrate HIV IGAD IRAPP project, The IEC/BCC by using mass education in new staff EAC-AMREF Lake Victoria Long distance truck drivers /assistants media channels, peer orientation/ seminars. (EALP) HIV and AIDS education, promotion Standardize HIV education & programme. materials (flyers, shirts, peer education training and posters, etc.), meetings, ensure quality. Develop cultural/sports activities, outreach programmes to conferences. 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 Sensitisation activities and Develop innovative HIV/AIDS Sensitisation on abstinence, Increase access to HIV Organize peer education on Focus prevention on fishing behaviours through IEC, BCC education through peers. prevention, treatment and fidelity and condom use. prevention (IEC, condoms, training of trainers (ToT) on communities through HIV and condom promotion. VCT. Promotion of abstinence, care strategies for targeting Strengthening of condom peer education, VCT & STIs HIV transmission, prevention counselling & testing support. STI diagnosis and treatment. fidelity and condom use. migrant workers; and social marketing and services). Implement and household food and Fishermen – fishing communities Strengthening of prevention mainstream HIV/AIDS in the specifically of female condom. guidelines on workplace financial security of fishermen activities. sectors serving migrant Prevention activities through interventions. Develop dependants. Promote safer workers. IEC/BCC by using mass outreach programmes to sex practices among the media channels, peer include families and fishing communities. Conduct education, promotion communities of the workers. behavioural surveillance materials (flyers, shirts, Make information and among people engaged in posters, etc.), meetings, condoms available to all camping type of fishing. cultural/sports activities, mobile and migrant workers in conferences. all sectors. BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 166 Promotion of lower risk sexual Sensitisation activities and Promote more effective, Sensitisation on abstinence, Promote increased access to Education on appropriate and Promote good practices in behaviours through IEC, BCC education through peers. targeted BCC. Promote fidelity and condom use. HIV preventive information effective condom use. design and implementation of and condom promotion. VCT. Prevention of sexual abstinence, consistent safe Strengthening of condom and services (IEC, condoms, Establishment of system of income generation activities. STI diagnosis and treatment transmission of HIV through sex behaviour and delayed social marketing and peer education, VCT and STIs procurement and distribution Support income-generating Improvement of the economic sensitisation, condom sexual debut among young specifically of female condom. services). of male and female condoms. programmes. Strengthen situation of vulnerable groups. promotion and STI refugees. Prevention activities through Ensure availability, traditional coping mechanisms management. Strengthening IEC/BCC by using mass affordability and accessibility to enhance sustainable of prevention activities media channels, peer of vaginal microbicides and livelihoods. Integrate SRH Refugees oriented towards high risk education, promotion marketing of various assorted services in economic groups. materials (flyers, shirts, brands of condoms. empowerment activities. posters, etc.), meetings, Operationalise national food & cultural/sports activities, nutritional policies/guidelines conferences. to local governments, communities and PLHIV households. Facilitate the provision of essential materials. Promotion of lower risk sexual Prevention of sexual Sensitisation on abstinence, 1. To promote increased Facilitate increased access to behaviours through IEC, BCC transmission of HIV through fidelity and condom use. access to HIV preventive vocational education and and condom promotion. VCT. sensitisation, condom Strengthening of condom information and services (IEC, apprentice opportunities. Internally Displaced Persons STI diagnosis and treatment promotion and STI social marketing and condom access, peer Advocate for affirmative action Improvement of the economic management. Promotion of specifically of female condom. education, friendly testing and for OVC, girl child, people with situation of vulnerable groups. peer education. Strengthening Prevention activities through counseling and STIs services) disabilities and other of prevention activities IEC/BCC by using mass for the vulnerable populations. disadvantaged groups in oriented towards high risk media channels, peer access to informal education, groups. education, promotion vocational and life skills materials (flyers, shirts, development. Operationalise posters, etc.), meetings, national food and nutritional cultural/sports activities, policies/guidelines to local conferences. governments, communities and PLHIV households. Facilitate the provision of essential materials. Promotion of lower risk sexual Sensitisation on abstinence, Promote increased access to Promote good practices in behaviours through IEC, BCC fidelity and condom use. HIV preventive information design and implementation of Host community of refugees and condom promotion. VCT. Strengthening of condom and services (IEC, condom income generation activities. STI diagnosis and treatment social marketing and access, peer education, Support income-generating Improvement of the economic specifically of female condom. friendly testing and counseling programs. Strengthen situation of vulnerable groups. Prevention activities through and STIs services). traditional coping mechanisms IEC/BCC by using mass to enhance sustainable media channels, peer livelihoods of affected education, promotion households. Integrate SRH materials (flyers, shirts, services in economic posters, etc.), meetings, empowerment activities. cultural/sports activities, conferences. BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 167 Promotion of lower risk sexual Prevention of sexual Sensitisation on abstinence, Focus prevention on behaviours through IEC, BCC transmission of HIV through fidelity and condom use. vulnerable and high risk and condom promotion. VCT. sensitisation, condom Strengthening of condom groups by addressing socio- STI diagnosis and treatment promotion and STI social marketing and economic and cultural factors Improvement of the economic management. Promotion of specifically of female condom. and promote prevention Returnees situation of vulnerable groups. peer education. Strengthening Prevention activities through among PLHIV. of prevention activities IEC/BCC by using mass oriented towards high risk media channels, peer groups. education, promotion materials (flyers, etc.), meetings, cultural/sports activities, conferences. Promotion of lower risk sexual Promotion of peer education. Increase availability and Sensitisation on abstinence, To make condoms available Review guidelines/ regulations Develop and implement behaviours through IEC, BCC Prevention of sexual access to counseling and fidelity and condom use. to prisoners and address relevant to STI transmission. effective interventions for and condom promotion. VCT. transmission of HIV through testing and treatment of STIs. Strengthening of condom sexual abuse of male and Advocate for prisoners' HIV reduction of high-risk sex STI diagnosis and treatment. sensitisation, condom Accelerate condom social marketing and female prisoners. vulnerability towards decision including the most at risk promotion and STI distribution programme. specifically of female condom. makers & personnel. Establish groups; through IEC management. Prevention activities through education system on interventions. IEC/BCC by using mass STD/HIV/AIDS. Introduce Prisoners media channels, peer peer education schemes. education, promotion Establish user-friendly STI & materials (flyers, shirts, VCT services and access to posters, etc.), meetings, affordable preventive tools cultural/sports activities, (condoms etc). Introduce STI conferences. policy framework that includes access to care & support. Introduce dialogue sharing experience between prisons & HIV/AIDS institutions. Promotion of lower risk sexual Strengthening capacity of Promotion of PEP. Promote open discussion & Scale up HIV/AIDS behaviours through IEC, BCC police and health care system, awareness about gender interventions in trade unions Females affected bysexual/GB violence and condom promotion. VCT. including the private sector, to inequality, HIV, GBV & sexual involved in protecting house STI diagnosis and treatment. provide prompt services to abuse within families and at girls and hotel workers. victims of rape and sexual community level. Promote Enforce the legal act on violence. Strengthening respect for human rights of harassment and abuse. provision of PEP. Develop women and children. Promote strategies to fight stigma increased access to HIV associated with rape. 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 168 ANNEX VIIIb. Targeting of OTHER vulnerable population groups BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA Plan Strategic de Lutte Contre Plan Strategique National de National Strategic Plan Plan Strategique Nationale de National Multi-Sectoral Zanzibar Natioanal HIV/AIDS National HIV and AIDS le VIH/SIDA. 2007-2011 Lutte contre le VIH/ SIDA/ 2005/6-2009/10 Lutte contre le VIH/SIDA, Nov Strategic Framework on HIV Strategic Plan 2003-2007 Strategic Plan. 2007/8 – MST 1999–2008 2005 and AIDS 2008 –12 2011/12, Aug 2007 Targeting of vulnerable populations Promotion of lower risk sexual Strengthening of prevention Develop innovative HIV/AIDS Sensitisation on abstinence, Increase access to HIV Introduce HIV/AIDS education behaviours through IEC, BCC activities oriented towards prevention, treatment and fidelity and condom use. prevention (IEC, condoms, for workers. Promote and condom promotion. VCT. high risk groups. care strategies for targeting Strengthening of condom peer education, VCT & STIs provision of employment STI diagnosis and treatment. migrant workers; and social marketing and services). Develop outreach contracts with health benefits. mainstream HIV/AIDS in the specifically of female condom. programmes to include Establish health care sectors serving migrant Prevention activities through families and communities of schemes providing medical workers. IEC/BCC by using mass the workers. Make information aid & hospital charges. Migrants workers media channels, peer and condoms available to all Ensure access to STD education, promotion mobile and migrant workers in clinics/VCT, condoms, vaginal materials (flyers, shirts, all sectors. Develop and microbicides. Create platforms posters, etc.), meetings, support special HIV for experience sharing cultural/sports activities, prevention and control between workers institutions & conferences. programmes designed to trade unions in private & reach the operators in the public set ups (local, informal sector, through international fora). Review collaboration with government policy/regulations that and the private sector. discriminate HIV/AIDS employee. Design special education programme on HIV/AIDS for Daladala owners/ operators. Ensure legal environment on protection of workers and their Transportation operators 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 169 BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA Promotion of lower risk sexual Develop specific strategies to Sensitisation on abstinence, Develop and implement a Introduce rehabilitation behaviours through IEC, BCC address the HIV prevention fidelity and condom use. comprehensive strategy to centres with vocational and condom promotion. VCT. and other HIV-related needs. Strengthening of condom reduce HIV transmission training. Strengthen existing STI diagnosis and treatment. social marketing and among IDUs, including laws & regulations /policy specifically of female condom. education, condom provision, framework for implementation Prevention activities through harm reduction measures & scaling up of harm IEC/BCC by using mass (disinfection and exchange of reduction, demand reduction media channels, peer needles and syringes) and and enforcing the laws against education, promotion rehabilitation services for illicit drug importation. Scale materials (flyers, shirts, persons who inject drugs. up peer-education training & posters, etc.), meetings, programming using ex-drug cultural/sports activities, addicts. Increase HIV/AIDS Injecting drug users conferences. 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 Develop specific strategies to Sensitisation on abstinence, Acknowledge the vulnerability behaviours through IEC, BCC address the HIV prevention fidelity and condom use. of MSM and advocate for their and condom promotion. VCT. and other HIV-related needs. Strengthening of condom access to HIV preventive STI diagnosis and treatment. social marketing and information and services and Men who have sex with men specifically of female condom. for decriminalization of their Prevention activities through activities. IEC/BCC by using mass media channels, peer education, promotion materials (flyers, shirts, posters, etc.), meetings, cultural/sports activities, conferences. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 170 BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA Improvement of the Sensitisation on abstinence, Introduce behavioural Prevention in the most at risk socioeconomic situation. fidelity and condom use. communication programme to groups of women through IEC Strengthening of condom mobile traders. Organize and VCT. social marketing and training of trainers/peer specifically of female condom. educator’s among the women Prevention activities through traders at their working IEC/BCC by using mass places. Conduct second- Female petty traders media channels, peer generation behavioural education, promotion surveillance. Strengthen materials (flyers, shirts, access to condom and posters, etc.), meetings, STD/VCT services. Promote cultural/sports activities, early STD treatment seeking conferences. behaviour. Promotion of lower risk sexual Encourage couple testing and Promote open discussion & Promote safe sexual norms Reduce HIV transmission behaviours through IEC, BCC counseling, and the provision awareness about gender and positive sexual behaviour among married people and and condom promotion. VCT. of information and education inequality, GBV and sexual among women and girls either discordant couples through STI diagnosis and treatment. on reproductive rights. abuse that increase through delayed sexual couple counselling, testing vulnerability of women, girls activities, or proper condom and disclosure. and boys to HIV within use. Empower women, families and at community especially girls, on decision- level and promote respect for making regarding their sexual human rights of women and behaviour. Educate employers children. Strengthen and husbands on protection of programmes with /by men to their spouses and house girls. Married couples 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. 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 VCT. Treatment of OIs. Involvement of PLHIV at the Sensitisation on abstinence, Enhance capacity at regional Assess attitudes of service Increase equitable access to behaviours through IEC, BCC Access to ARVs. highest levels in development fidelity and condom use. and district levels to plan, providers & sensitise them to ARV. Scale-up VCT. Increase and condom promotion. Psychosocial support of & coordination of the HIV/AID Strengthening of condom implement, coordinate, reduce stigma & access to prevention & Prophylaxis, diagnosis and PLHIV and affected persons. response. Strengthening social marketing and monitor and evaluate a quality discrimination. Review treatment of OIs including TB. treatment of OIs. Universal Economic support. support to capacity of PLHIV specifically of female condom. continuum of care, treatment policies & procedures, Integrate prevention into care access to ARVs. PLHIV and remaining family organisations to be involved Prevention activities through and support services. Scale overhaul those that stigmatise including nutrition counselling Psychological and nutritional members. STD care. effectively in prevention, IEC/BCC by using mass up the involvement of the /discriminate against PLHIV. & education. Support & support of PLHIV. Home Promotion of condom. Income treatment, care & mitigation. media channels, peer private sector in the provision Ensure confidentiality of all expand HBC, palliative care & based and palliative care generating activities. Supporting creation of education, promotion of the continuum of care, PLHIV. Train & involve PLHIV improve referral systems (continuum of care). representative & effective materials (flyers, shirts, treatment and support in outreach education. Use between HBC and health Improvement of PLHIV organisations at all posters, etc.), meetings, Expand availability & counselling services as facilities. Promote healthcare socioeconomic situation of levels. cultural/sports activities, accessibility of prophylaxis & starting point for empowering seeking behaviour among PLHIV and affected persons. conferences. Reduction of treatment for OIs. Ensure beneficiaries. Encourage males. Scale up access to health impact of HIV, STIs, TB PLHIV are actively involved in PLHIV to organise themselves and increase uptake for ART on PLHIV, their partners and (adherence) counselling and and/or join HIV/AIDS services for those in need, AIDS orphans. Availability and support of newly enrolled networks. Provide PLHIV & especially targeting women of affordability of essential drugs patients. Incorporate affected families with all age groups where the & ARVs. Counselling services, nutritional counselling, opportunity to meet other highest incidence of HIV and health insurance schemes, education & support in care PLHIV through peer AIDS is reflected. Promote & palliative care, assistance and treatment of PLHIV and counselling and support expand specialized paediatric (material, nutritional, care-givers, incl. changes of groups. Encourage PLHIV to and adolescent HIV care. psychological, legal). the diet according to food go public. Develop counselling Provide for increased locally available. Promote strategies to help PLHIV cope coverage ART treatment to PLHIV greater involvement of PLHIV with perceived & actual mothers receiving PMTCT. in planning & implementing experiences of stigma & Promote & support food and HBC & support. discrimination. Encourage nutrition security interventions public & private sector HIV among affected households testing services to offer and communities. 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. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 172 BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA Promotion of lower risk sexual Implement specific activities to Carefully targeted prevention Sensitisation on abstinence, Build capacity among parents Scale up vocational training, Promotion of abstinence behaviours through IEC, BCC make youth aware and take messages. Youth friendly fidelity and condom use. & guardians to communicate income generating among youths in and out of and condom promotion. VCT. responsibility over their access to HIV and Strengthening of condom with their children on SRH programmes and employment school. Ensure that all the STI diagnosis and treatment. behaviours and practices. reproductive health social marketing and issues & to support school opportunities for out of school youth access life skills that Promote delay of sexual information and other specifically of female condom. based RH & HIV education. youths. Promote safe sexual integrate HIV/AIDS inception. Promote condom services. Mobilising the Promotion of programmes Strengthen & expand norms & positive sexual prevention. Facilitate use. Prevention of sexual education system to provide provided by parents, teachers comprehensive life skills & behaviour among young increased access to transmission through comprehensive prevention and schools. VCT. HIV education/interventions people (incl. abstinence, vocational education and sensitisation activities on safer and care for youth in school. for schools, teacher training delayed inception, fidelity, apprentice opportunities. sex and treatment of STDs. Improving girls’ access to colleges & tertiary education condoms). Empower youths, Advocate for affirmative action education and skills training, institutions, through inclusion especially young women, on for OVC, girl child, people with and protecting their rights. of these issues in curriculum decision making regarding disabilities and other Building partnerships with and through school/institution their sexual reproductive lives disadvantaged groups in Youth youth-based organisations. based peer education & through life skills approaches. access to informal education, counseling. Encourage pupils Protect out of school youths vocational and life skills & students to develop own against substance abuse. development. HIV projects. Promote & Promote culturally sensitive expand peer-education and life skills education for youths, counsellor training for in and especially girls, so as to out of school youth. Increase enhance their confidence, provision & utilization of youth negotiation skills & decision- friendly & gender sensitive making. Promote youth SRH services and link to partnership in conceptualising, livelihood & income planning, implementing and generation. Promote & monitoring of Youth expand programmes against Programmes. drugs, alcohol. Promote access to HIV prevention. Promotion of lower risk sexual Care and support. Income Strengthening social Prevention activities through Build capacity among parents Develop community based Ensure that all the youth in behaviours through IEC, BCC generating activities to foster mechanisms for orphan care. IEC/BCC by using mass and guardians to recording system for and out of school access life and condom promotion. VCT. independence. Ensuring OVC access to media channels, peer communicate with their identification / registration of skills that integrate HIV/AIDS STI diagnosis and treatment. social services – education, promotion children about SRH and to OVC. Introduce sustainable prevention. Ensure provision OVC care and support. food/nutrition, education, materials (flyers, shirts, support school based RH and programmes to support OVC of the non tutional costs &d Ensure protection of rights of health, shelter & social posters, etc.), meetings, HIV education. Promote and in basic needs. Develop essential requirements to OVC and improve access to support. Strengthening legal cultural/sports activities, expand programmes against family-counselling programme OVC in formal basic services. and policy framework for conferences Promotion of drugs, alcohols. Promote during caring of a sick person education.Promote & support protecting the rights of OVC. specific programmes provided increased access to HIV & after death to properly take food & nutrition security Strengthening framework for by parents, teachers, schools. prevention services. care of AIDS orphans. interventions among HIV/AIDs OVC monitoring and coordinating VCT. Reduction of health Promote capacity building/skill affected households & interventions which support/ impact of HIV, STIs and TB. development for grown up communities. Operationalise protect rights of OVC. AIDS orphans to be capable national food & nutritional for self-employment, establish policies/guidelines to local basis for independent life. governments, communities & Introduce peer educator PLHIV households. Facilitate among OVC. Conduct provision of financial, and behavioural study. Increase essential materials. effective participation of NGOs in caring for OVC. ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 173 BURUNDI DR CONGO KENYA RWANDA TANZANIA-Mainland TANZANIA-Zanzibar UGANDA Promotion of lower risk sexual Promotion of abstinence, Sensitisation on abstinence, Promote open discussion and Promote safe sexual norms Promote abstinence, behaviours through IEC, BCC consistent safe sex and fidelity and condom use. awareness about gender and positive sexual behaviour fidelity and use of the male and condom promotion. VCT. delayed sexual debut among Strengthening of condom inequality, gender based among women and girls either and female condoms. STI diagnosis and treatment. young people. social marketing and violence & sexual abuse that through delayed sexual OVC care and support specifically of female condom. increase vulnerability of activities, or proper condom Prevention activities through women, girls and boys to HIV use. Empower women, IEC/BCC by using mass within families and at especially girls, on decision- media channels, peer community level and promote making regarding their sexual education, promotion respect for human rights of behaviour. Educate employers materials (flyers, shirts, women and children. and husbands on protection of posters, etc.), meetings, Empower girls and women to house girls.Scale up cultural/sports activities, negotiate safer sex through HIV/AIDS interventions in Young women conferences. enhancing knowledge about trade unions involved in sexuality, reproductive health protecting house girls and and HIV and imparting life hotel workers. Enforce the skills that increase their legal Act on harassment and effective control to protect abuse. 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. 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 DRC Kenya Rwanda Tanzania Uganda Total (2001) (2000) (2005) (2005) (2004) (2003) Men/Women Fishermen Inland - 107,000 45,967 6,325 100,115 64,391 Marine - 1,400 9,209 n/a 19,464 n/a Total 9,969 108,400 55,176 6,325 119,579 64,391 363840 Fisherwomen Inland - n.r. n.r. 1,125 n.r. n.r. Marine - n.r. n.r. n/a n.r. n.r. Total 1,000 - - 1,125 - - 2,125 Total Inland - 107,000 45,967 7,450 100,115 64,391 Total Marine - 1,400 9,209 - 19,464 - Grand Total 10,969 108,400 55,176 7,450 119,579 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 DRC Kenya Rwanda Tanzania Uganda (1990) (1984) (1999) (2002) (2002) (2002) Fisherwomen n.r. - report not 92 16,186 16,743 identified (13,428 Mainland) (2,759 Zanzibar) Fishermen n.r. - report not 3,368 134,679 102,043 identified (112,871 Mainland) (21,808 Zanzibar) Total - - - 3,460 150,865 118,786 ( 126,298 Mainland) (24,567 Zanzibar) 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 10,969 DRC 108,400 Kenya 55,176 Rwanda 3,460 Tanzania 150,865 Uganda 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 175 Annex IXb. Refugee Population in GLIA Countries, as of end June 2007 Refugees Country Nationality Number Total BURUNDI DRC 22,895 23,215 Rwandan 286 Others 34 DRC Angolan 128,160 197,232 Rwandan 34,017 Burundian 17,741 Ugandan 13,912 Others 3,402 KENYA Somali 187,565 269,195 Ethiopian 16,634 Eritrean 607 Sudanese 55,578 Ugandan 2,823 Congolese 2,441 Rwandan 2,343 Burundian 1,200 Tanzanian 4 RWANDA DRC and others 46,600 46,600 TANZANIA Burundian 153,841 273,678 (UNHCR assisted DRC 115,046 (UNHCR populations only) Somali 2,077 assisted) 471,912 (all) Others 2,714 UGANDA Sudanese 167,386 220,914 DRC 28,184 Rwandan 19,519 Somali 3,749 Ethiopian 107 Burundian 1,895 Others 74 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 176 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) ANALYSIS: HIV epidemiology and HIV response analysis – Great Lakes Region 177 Annex IXd. Summary of core indicators BSS GLIA in four countries Kenya Rwanda Tanzania Uganda Indicator Sex Camp Host Camp Host Camps Hosts Camp Host (Kak) (Ke1) (Kiz) (Rw1/2) (Luk/Lug) (Tz1/2) (N&O/Ho) (Ug1/2) Never married F 61% 69% 60% 48% 45%/52% 71%/48% 79%/80% 84%/74% who never had M 51% 43% 46% 47% 66%/21% 79%/65% 77%/78% 74%/57% sex (15-24 y) T 55% 55% 54% 48% 56%/32% 75%/56% 78%/79% 79%/63% Higher-risk sex in F 28% 14% 7% 12% 5%/28% 19%/20% 7%/1% 4%6% past 12 months M 40% 41% 32% 22% 3%/53% 19%/22% 6%/1% 2%/7% (15-24 y) T 35% 25% 17% 16% 4%/40% 19%/21% 6%/1% 3%/7% Condom use at F 42% 42% 25% 9% 9%/44% 31%/24% 11%/29% 33%/18% last higher-risk M 36% 29% 24% 23% 75%/36% 28%/32% 10%/57% 19%/32% sex (15-24 y) T 38% 33% 24% 17% 27%/39% 30%/27% 10%/48% 24%/27% >1 sex partner F n/a n/a n/a n/a 6%/26% 20%/27% 7%/4% 8%/11% last 12 months M 11%/50% 27%/36% 17%/13% 18%/27% (15-49) T 8%/37% 23%/30% 12%/9% 12%/19% HIV test in past F 17% 13% 9% 14% 34%/17% 14%/11% 8%/12% 5%/10% 12 months M 20% 5% 13% 12% 31%/19% 16%/10% 10%/9% 7%/7% (15-49 y) T 19% 10% 11% 13% 32%/18% 15%/10% 9%/11% 6%8% STI symptoms in F* 42% 65% n/a n/a 78%/63% 71%/86% 42%/52% 70%/55% last 12 mths and M* 48% 46% 100%/50% 50%/88% 57%/33% 58%25% sought treatment T* 90%/57% 63%/87% 49%/44% 65%/41% at h/ facility (15- 49) Women ever F 6% 11% 4% 8% 4%/10% 2%/4% 1%/2% 1%/2% 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 178 Refugees: Refugees: Sexual abstinence in unmarried youth (15-24 yrs) HIV test in past 12 months (15-49 yrs) percent percent 40 100 Refugees female Refugees male Refugees female 90 Villagers female Villagers male 35 Refugees male Villagers female 80 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 Kyangweli-U Kakuma-K Kiziba-R Lukole-T Lugufu-T Nakivale-U Kyangweli-U Refugees: Refugees: Prevalence of higher-risk sex (15-24 yrs) Condom use at last higher-risk sex (15-49 yrs) in the past 12 months percent percent 60 80 Refugees female Refugees female 70 Refugees male Refugees male 50 Villagers female Villagers female 60 Villagers male Villagers male 40 50 30 40 30 20 20 10 10 0 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 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 WWW.G REATLAKESI NITI ATI VE . O RG For more information, please contact: The Global HIV/AIDS Program Great Lakes Initiative on HIV/AIDS (GLIA) World Bank Group P.O. Box 4320 1818 H St. NW, Kigali – Rwanda Washington, DC 20433 Tel: + 250 587344/5 Tel:   +1 202 458 4946 Fax:+ 250 587343 Fax: +1 202 522 1252 www.greatlakesinitiative.org wbglobalHIVAIDS@worldbank.org info@greatlakesinitiative.org www.greatlakesinitiative.org jwakana@greatlakesinitiative.org