Tanzania: AN HIV Case Study

In recent decades a major health concern facing refugees and internally displaced populations has been the identification and treatment of individuals who are HIV positive.  Refugee settings have many characteristics that can provide a setting for increased prevalence.  One large contributor is the difference in prevalence rates between milit
ary groups and the civilian population, as well as the differential in infection rates that exist among refugees from various countries and geographic areas1.  However, there exists convincing evidence that the perceived increase in risk for HIV infection in refugee settings is exaggerated by media or mitigated by other factors2.  Such mitigating factors include geographic isolation of some camps, decreased sexual behaviors in traumatized populations, and increased mortality in high-risk populations3.  Despite these competing views, the argument can be made that HIV/AIDS prevention and treatment programs must be implemented in refugee camps, especially when the displaced population involves refugees from countries or geographic regions that have been shown to have high HIV prevalence prior to the start of conflict.  A vital aspect of prevention and treatment programs involves targeting women due to their increased risk for acquiring HIV in refugee settings.  Women often engage in sexual behaviors with soldiers in control of the camp, have less access to health care compared to men, and are more likely to engage in commercial sex due to poverty4.  To highlight the importance of HIV programs a specific case study of the Benaco refugee camp in Tanzania will be examined in regards to pilot programs used to determine HIV treatment and their consequences for use in other refugee situations. 
 

Benaco Refugee Camp, Tanzania:  1994-1996

The Benaco refugee camp was created in 1994 as a result of the ethnic conflict in Rwanda.  Following the Hutus rise to power a few weeks into the conflict, a mass exodus of Tutsis began into neighboring Tanzania and Zaire. The Benaco refugee camp was located only a few miles from the Rwandan border in the Ngara district and within a month had swelled from 250,000 people to roughly 500,000 making the camp the second largest city in Tanzania5.  Prior to the start of the conflict, Rwanda had a fairly high prevalence rate of HIV compared to other African nations, leading many, including the United Nations to investigate the need for HIV prevention programs. 

The United Nations High Commissioner for Refugees paired with organizations such as the AIDS Control and Prevention Project (AIDSCAP), CARE, and Population Services International (PSI) to carry out surveys and health studies to determine the proper management of this health crisis6.  At the time the Benaco camp was established there was a large differential in the HIV infection rates among urban Rwandan refugees (35%), rural Rwandan refugees (5%), and local Tanzanian residents (7%)7.  Studies within the displaced Rwandan population and the local Tanzania population began immediately due to the fear that the mixture of such a large number of people from diverse backgrounds could lead to a rapid increase in HIV and STI transmission. 

Benaco Refugee Camp, 1996

 

        A program was proposed by the African Medical Research and Education Foundation (AMREF) which consisted of five goals:  to confirm the need for an HIV and STI program, to formulate a training program for prevention and care, to conduct a multi-agency control activity, to outline a means of evaluating the program’s effectiveness, and to properly document the findings for future research and use in other refugee situations8.  Funding for the program came from AIDSCAP, which shifted its resources from its work in Rwanda to the refugee camp. 

The program was initiated in three stages, the first of which involved a rapid situation analysis.  This analysis was carried out by CARE using STI surveys in different populations, one of which consisted of 100 patients in an antenatal clinic.  Additionally, an analysis was done involving the agencies participating in the program to determine the specific policies regarding HIV that already existed.  Surprisingly, not a single NGO studied had a well-defined policy or plan of action for AIDS and STI treatment in refugee settings9.  The second stage of intervention implementation involved peer education, information dissemination, and condom distribution.  Prior to the Rwandan conflict, PSI had been leading an AIDS prevention program throughout Rwanda which demonstrated the need for further programs in a refugee setting.  Initial data showed that HIV awareness was high, but that condom use was low among refugees due to stigma10.  In order to properly address this discrepancy, PSI implemented a social marketing campaign which aimed to increase the demand for condoms as well as condom availability through the use of promoters at special camp social events as well as the formation of information/distribution centers.  The third and final stage of the program assessed the effectiveness of the program in terms of HIV and STI knowledge, condom use, treatment of HIV infected individuals, and the number of new HIV infections. 

By the time this stage of the program was to be conducted, most of the Rwandan refugees returned to their homes as part of a repatriation campaign in 1996.  Shortly thereafter the Benaco refugee camp was closed making data analysis nearly impossible to perform.  A serosurvey was conducted on a sample of Rwandan citizens which showed that levels of HIV prevalence were lower in externally displaced individuals when compared to internally displaced citizens (13.9% versus 10.5%).  Additionally, refugees displaced for a longer period of time, such as those in the Benaco camp for close to two years, showed an even lower prevalence rate of 9.7%11.  This data supports the hypothesis that the HIV prevention program was able to cancel out the additional risk factors present in the camp setting.  Due to this specific study, a Minimum Initial Services Package was created to help with prevention and treatment of STIs. 

In the past decade these NGOs have continued their work in Africa and regions of conflict.  The success of the program evaluated at the Benaco camp has led many agencies to start more clinics, educate about STIs, and initiate medical care for refugees already infected with HIV.  Women have been an important target of these initiatives as they make up a majority of many camps.  The distribution of condoms and education concerning STIs has helped women take control of one aspect in their life, their sexual health, in a setting where every day brings uncertainty and fear. 

Amanda Soto

Stanford University

Class of 2008

Sources:


1. Mock, Nancy B., et al.  “Conflict and HIV:  A framework for risk assessment to prevent

HIV in conflict-affected settings in Africa.”  Biomed Central Ltd. Oct. 2004.

2. Lowicki-Zucca, Massimo., et al.  “AIDS, conflict and the media in Africa:  risks in reporting bad data badly.”  BioMed   

    Central Ltd.  December 2005.

  1. 3.Mock et al.

4. Benjamin, JA.  “AIDS prevention for refugees.  The case of Rwandans in Tanzania.” Aidscaptions.  July 1996.  3(2):  4-9.

5. Benjamin JA

  1. 6.Benjamin JA

  2. 7.UNHCR.  “HIV/AIDS and STI prevention and care in Rwandan refugee camps in the United Republic of Tanzania.”  March 2003.   http://www.unhcr.org/protect/PROTECTION/4028afd34.pdf

8. UNHCR

9. UNHCR

10. “Preventing AIDS in the Rwandan Refugee Camps.”  PSI.  March 8, 2007.

     http://www.psi.org/resources/pubs/rwanda_ref.html

11. UNHCR


Components of AIDS and STI intervention in Rwandan refugee camps in

the United Republic of Tanzania, 1994–1996

Phase I: Rapid situation analysis

The initial situation analysis consisted of fi ve components:

A literature review of the epidemiological situation of STIs and HIV in Rwanda and

north-west Tanzania, with particular reference to Ngara District.

A stakeholder analysis, including interviews with key people, to obtain an overview of

policies and practices with regard to HIV/AIDS and STI prevention and care, and to

identify shortcomings in existing STI training and the provision of drugs for STIs.

Phase I

Rapid needs assessment

Review of policies, guidelines and health infrastructure

Rapid STI survey

Rapid 'knowledge, attitudes, beliefs and practices' (KABP) survey

Phase II

The intervention package

Information, education and communication (IEC) package, involving

materials, mass campaigns, health promoters and peer educators

Condom supply and promotion

STI services

HIV/AIDS care

Monitoring

STI clinic attendances and cure rates

Neisseria gonorrhoeae drug susceptibility monitoring

Quality control for rapid syphilis testing

Quality of STI services

Phase III

Impact evaluation

Repeat rapid STI and KABP surveys

Coordination, dissemination of results and advocacy

Regular reports to, and coordination with, partners

Planning on a participatory basis with other NGOs and local communities

Dissemination of research fi ndings through reports, scientifi c and other

publications, conferences and workshops

Long-term support to NGOs through training and development of case

studies, policies and guidelines