Conflict not leading to HIV rises, systematic review finds

The belief that war, forced migration, and large-scale rape have increased rates of HIV infection in Africa is probably a myth, according to a systematic review of all the available evidence carried out by the United Nations High Commissioner for Refugees and published this week in The Lancet.

Furthermore, there are no data to show that refugees fleeing conflict spread HIV infection in host communities; the reverse may be the case, conclude the authors.

It is a common belief that violence and rape fuel the HIV epidemic in countries affected by conflict, and consequently refugees fleeing humanitarian emergencies have a high prevalence of HIV infection.

However, when prevalence data from the past five years for seven African countries affected by internal conflicts were analysed, Dr Paul Spiegel and colleagues could find no clear evidence to support the view. Either studies showed no change in prevalence, or the methodology was not sufficiently sound.

In the Democratic Republic of the Congo, the African nation most severely affected by wars and internal displacement of refugees in the past ten years, no studies identified by the authors showed an increase in HIV prevalence in areas affected by conflict. For example, a national antenatal seroprevalence survey carried out in 2003-4 found no difference in prevalence between eastern Congo (the conflict-affected area) and western Congo, and lower prevalence in eastern Congo than at antenatal sentinel sites over the border in Rwanda.

Congolese refugees in Rwanda were found to have lower HIV prevalence than Rwandans in 2002, and Congolese refugees in camps in Tanzania and Zambia were also found to have lower HIV prevalence than the surrounding population in 2003 and 2005 respectively.

In Sudan a similar pattern was observed. In Rwanda the authors found that previous data used to support the view that civil war had led to an upsurge in HIV prevalence were equivocal and difficult to interpret. Among Rwandan refugees in Tanzania studies found no difference in HIV prevalence between refugees and the surrounding population (around 10%), despite previous antenatal surveillance estimates of 26% HIV prevalence in pregnant women in Kigali, the capital of Rwanda.

Despite wide-spread rape in many countries, there were no data to show that rape increased prevalence of HIV at the population level.

The authors suggest that previous poor survey methods and biased interpretation of data might have led to the high rates of HIV infection previously reported during conflict. They point out that because data collection during conflict is fraught with difficulties and interpretation should be cautious, such estimates need to be supplemented with reliable data from after conflict. They conclude: “This study shows the need for mechanisms to provide time sensitive information on the effect of conflict on disease incidence.”

In an accompanying Comment, Rachel Jewkes of the South African Medical Research Council says that despite some unanswered questions that accompany any review of secondary data, the large number of countries from which data are available, and the fact that other countries—including Angola and Mozambique—have much the same patterns as those in the review, affirms the validity of Spiegel and colleagues’ argument.

"[The authors'] conclusions are a salient reminder of the value of interrogating assumptions about the HIV epidemic that are often taken as common knowledge," she comments.

She goes on to point out: "Many areas of conflict have night-time curfews or other restrictions on movement, which greatly reduce exposure of the civilian population to the contexts in which they could encounter new sexual partners and engage in risky sex after an evening's drinking. Conflict and displacement often splits families, and refugee settings may have disproportionate numbers of women and girls, which could have a net effect of reducing sexual activity."

She suggests that countries may be more vulnerable to an increase in HIV prevalence after conflict is ended, during the reconstruction period, due to increased social mobility and infrastructure development.