Humanitarian crises and HIV

Humanitarian crises stop things working as they should. Social and economic structures can break down. Whole communities can be destroyed and families split up. People can lose their homes and their incomes, and young people can lose access to education. People can lack even the most basic shelter, and face food and water shortages. All this can increase some of the factors that make people vulnerable to HIV, such as:

• Gender-based violence and sexual violence: this is common in humanitarian crises: seven out of 10 women are estimated to experience gender-based violence in some crisis situations.
• Transactional sex and sex work: women are more likely to trade sex for basics like food, water and shelter. This is especially the case if women come from male-dominated cultures and get separated from male relatives and partners. Many people who take up sex work during emergencies might not have done it before. So they might find it harder to negotiate safer sex.
• Alcohol and drug use: this can cause people to take sexual risks. Alcohol or drug dependence can lead to transactional sex and sexual exploitation.
• Mental health issues: this can cause people to take risks with their health or make them vulnerable to exploitation and abuse.

Some humanitarian crises cause large numbers of people to leave their homes (called mass displacement). Many refugees and displaced people find it difficult to access healthcare, including HIV treatment. Policies in host countries might mean they are not entitled to healthcare. Or they might have an uncertain legal status and be scared to use services in case authorities spot them. Displaced people and refugees also experience social exclusion, discrimination, violence, exploitation and abuse. All these things increase HIV risk.

Services might be suspended or limited, including HIV prevention, testing, treatment and care. Healthcare staff and patients might struggle to access facilities, even if they are open. Emergencies can also cause problems with the supply of antiretroviral drugs, condoms and HIV testing kits.

People with HIV and people most at risk of HIV (such as adolescent girls, sex workers and men who have sex with men) become even more vulnerable during humanitarian crises. In a crisis, these groups get pushed even further to the back of the queue for services and resources, especially if they are displaced. At the same time, the rights violations they already experience, such as social exclusion and gender-based violence, can get even worse.

When plans are being made to respond to humanitarian crises it is important to include services and support for people with HIV, people most affected by HIV, refugees and displaced people. It is essential to agree how people with HIV will continue to access treatment and care should a crisis hit, and how people most at risk of HIV will be able to access HIV prevention and testing services. Advocating for refugees to be included in national HIV strategic plans is also important.

It is vital to involve community-led groups in emergency planning and preparation, and in delivering emergency responses. These organisations are trusted by marginalised communities and have direct links into them. They know what marginalised communities need and what will work.

During a crisis, it can be a useful to provide the following at public gatherings, health centres, water points, food distribution points and temporary shelters:

• information on how to prevent HIV and STIs
• information on where and how to access HIV testing and treatment
• free HIV self-testing kits or community-based testing
• free internal and external condoms and lubricants
• PrEP and PEP if available
• services for reporting and responding to sexual violence.

Health travel cards provide details of the kind of antiretroviral treatment (ART) someone is on. Providing these cards in advance can help people with HIV continue their treatment and get the right medication if they need to move. Providing multi-month ART prescriptions allows people to keep taking their medication, even if it is hard to reach a clinic. This can also work for PrEP.

During a crisis, it can be useful to establish a system for people to report sexual violence and other rights violations, then provide them with the services and support they need in relation to these experiences. Involve trusted community members so people feel comfortable reporting incidents and accepting support.

This makes people, especially women and children, less vulnerable to HIV as it can reduce the need to engage in transactional sex. People with HIV should be a key focus for food assistance because not having food makes it harder to take HIV treatment.

The end of crises can increase the risk of HIV and STI infections as areas reopen, and people return. Increased focus on HIV prevention may be particularly important at this time.