War and forced displacement have reduced the transmission of HIV in sub-Saharan Africa

Conflict, forced displacement, and wide-scale rape have not increased the prevalence of HIV in sub-Saharan Africa, conclude the authors of an Article in this week's issue of 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.

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, new prevalence data of HIV infection have become available and allow for a more thorough and scientific assessment within and between populations affected by conflict and displacement. A notion is emerging that the dynamics of conflict and forced displacement could alter the pattern of sexual behaviour and might reduce the transmission of HIV.

Paul Spiegel (UN High Commissioner for Refugees, Geneva, Switzerland) and colleagues combined original data with a systematic review of published work to compare prevalence of HIV infection in seven countries in sub-Saharan Africa directly affected by conflict with that in populations not directly affected, and in refugees versus in the nearest surrounding host communities.

The authors found no data in the seven countries to show that conflict increased the prevalence of HIV infection irrespective of the magnitude of prevalence at the start of the conflict. Prevalence in urban areas affected by conflict decreased in Burundi, Rwanda, and Uganda at similar rates to urban areas unaffected by conflict in their respective countries. Of the 12 sets of refugee camps: nine had a lower prevalence of HIV infection, two had a similar prevalence, and one a higher prevalence than their respective host countries. 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 (Medical Research Council, Pretoria, South Africa) 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. She goes on to emphasise that these findings: “Provide a further reminder of the need for rape services to be situated within comprehensive sexual and reproductive health-care services, rather than overly emphasising prevention of HIV infection.”