Date Published: May 29, 2007
Publisher: Public Library of Science
Author(s): Heather Culbert, David Tu, Daniel P O’Brien, Tom Ellman, Clair Mills, Nathan Ford, Tina Amisi, Keith Chan, Sarah Venis
Abstract: Providing HIV care in conflict settings involves additional obstacles to those generally encountered in other resource-limited settings, say Heather Culbert and colleagues.
Partial Text: Armed conflict and HIV infection have had a profound impact on the societies of sub-Saharan Africa. The number of countries engaged in armed conflict has fluctuated, totalling 24 African states in 2004 ; most of these conflicts are intrastate and chronic. The region also bears the world’s highest burden of HIV, with more than 25 million people reported to be infected .
Bukavu is a city of 600,000 inhabitants located on the southern shore of Lake Kivu in eastern DRC, bordering Rwanda (Figure 1). The region has experienced chronic conflict since 1996, involving the neighbouring states of Rwanda, Uganda, and Burundi, as well as numerous internal guerrilla armies. The conflict in DRC is estimated to have resulted in more than 3.9 million deaths between 1998 and 2004 . Despite a 2001 peace accord and elections held in July 2006, peace in the region remains elusive .
By the late 1990s, HIV prevalence in Bukavu was estimated at 4%–9% . The Médecins Sans Frontières (MSF) project was initiated in 2000 to provide treatment for those infected with HIV and to help reduce the rate of HIV transmission. Bukavu was chosen for this project because it had a high HIV prevalence, and was an area of relative calm in a region of conflict.
Between May 2002 and January 2006, 11,076 people had received VCT, of whom 19% were HIV positive. Of those who tested HIV positive, 94% (1,868 patients) received follow-up care in the HIV clinics (Figure 2).
Most armed conflicts in this region have occurred outside Bukavu. However, on May 26, 2004, rebel forces from within the Congolese military invaded the city, resulting in intense fighting for 13 days. During this period hundreds of civilians were killed, thousands fled across the border into Rwanda, and many women were raped .
Our experience has shown us that one of the keys to successful provision of ART in conflict settings is preparation for disruption. Programmes should establish contingency plans to enable staff and patients to react as efficiently as possible should the conflict worsen. Key areas to be considered as part of contingency planning are:
The HIV project in Bukavu shows that the provision of comprehensive HIV care, including ART, in chronic conflict settings can be feasible and effective, with early treatment outcomes similar to those in HIV projects in non-conflict settings. However, it should be noted that these results have been achieved with the support and resources of an international nongovernmental organisation (MSF), in an urban setting, with the episode of disruption occurring early in the programme, and thus similar results in conflict settings may not always be possible. Nevertheless, the key elements of contingency planning for care delivery in conflict settings are not resource-intense and we believe they can generally be applied to most care programmes.