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Barriers to ART delivery during complex emergencies

By Mona Haidar, MD, MPH Moderator | 06 Mar, 2009

Around 1.8 million people living with HIV were estimated to be living in conflict or natural/human made disaster areas in 2006 which constitutes around 5.4% of the global epidemic. Also, 7 of 15 countries with the largest number of PLWH suffered from major conflicts during 2002-2006.

Conflict situations can destroy countries infrastructure, disrupt health systems and social services and cause people's displacement. Consequently, ART programs are destabilized which put patients at increased risk of ART interruption and drug resistance development.

Providing ART in conflict settings involves additional obstacles to those generally encountered under politically stable conditions like instability in security and population’s mobility. Conflicts also amplify many of the already existing barriers like human resources shortage, food insecurity, poor infrastructure and others.

Understanding barriers and concerns around this issue can be helpful to avoid unnecessary delays in action that can be harmful for individuals, national health systems, public health and global health in general.

we would like to invite you to share with the community your relevant experiences in the field or other general opinions on this topic.

Thank you!

Attached resource:
  • HIV Treatment in a Conflict Setting:Outcomes and Experiences from Bukavu,Democratic Republic of the Congo (external URL)

    Link leads to:

    Summary: This paper describes lessons from MSF three years’ experience of providing HIV care, including antiretroviral therapy (ART), to a conflict-affected population in the Democratic Republic of the Congo (DRC). Program design and outcomes are discussed in this paper.

    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

    Source: PLoS Medicine

    Publication Date: May 1, 2007

    Language: English

    Keywords: ART, conflict, DRC, Monitoring & Measurement, Publications & Research



Ziad Khatib Replied at 5:31 PM, 6 Mar 2009

Hi Mona,
Very good point!
My experience in south Sudan, people would come back from high HIV
prevalence countries with possibility have been infected there. They
would keep moving/traveling inside Sudan to go back to their home town
ARV programs are taking off in Sudan but I don't think they are widely spread.

Also in Zimbabwe, patients are fleeing to neighboring countries,
mainly South Africa, and access to HIV care (or other services as
well) is an issue for them, although the department of health in SA
changed the policy of access to care to make it to all people, but
there are gaps in translating policy into practice.It ends up
Zimbabweans prefer to stay underground instead of seeking care and
this can put them at risk to be sent back home.

Best regards

Anat Rosenthal, PhD Replied at 11:51 AM, 10 Mar 2009

Hi all,
Thank you Mona for starting this discussion.

Ziad - your experiences with patients from Zimbabwe in SA resonate with my experiences with asylum seekers and undocumented migrants in Israel who are afraid of disclosing their health status even to NGO workers in fear of deportation or loss of asylum seeker status.

Do you have any experience with successful "invitation" of such patients into care programs?


Ziad Khatib Replied at 5:08 PM, 10 Mar 2009

Hi Anat,
I would recommend looking into the Mexico-AIDS conference website for
presentation on Zimbabweans seeking HIV care in Johannesburg,
(Authors: Francois Venter, Kerrigan McCarthy, Matthew Cherich). They
presented interesting results showing Zimbabweans (and other
undocumented immigrants) tend to have better adherence than South

I am afraid have not seen report about the underground population, I
presume it is hard to reach and might not be ethical to research them
without providing care.

Do you have any report from Il to share?

Best regards

Anat Rosenthal, PhD Replied at 11:36 AM, 12 Mar 2009

Hi Ziad,

Thank you for the reference.

I agree that there are ethical problems in conducting research without providing care but even under circumstances where care is provided underground populations remain hard to reach.

In a project I was involved with we faced difficulties when inviting potential patients to receive services in NGO settings. After many struggles it was understood that an effective strategy to contact undocumented migrants and asylum seekers would have to involve a more diverse type of health services. Consequently a network of NGO was initiated in order to provide a workshop that trained members of migrant communities as health promoters and to serve as mediators between members of their communities and health services providers in various arenas. The integration of various subjects of health and prevention and the creation of an environment of health activities allowed for a more open discussion about AIDS and yet our experience still pointed to the fact that although such projects can increase trust and build a strong working relationship between NGOs and the communities it was still very hard for individuals to approach services.



Prosper Lutala Replied at 4:28 PM, 12 Mar 2009

Hi Anat;
Thank for this input regarding  issues surrounding practices/researches in complex emergencies situation.
P. Lutala

Mona Haidar, MD, MPH Moderator Replied at 9:15 PM, 14 Mar 2009

Great discussion!

Thank you all for your valuable inputs. I would like to share with you a UNHCR document that is relevant to our discussion.

UNHCR released the following policy document in 2007 :
"Clinical guidelines on antiretroviral therapy management for displaced populations-Southern Africa".
you can access the PDF file on this link:

The policy is intended to offer guidance to clinicians, non-governmental organisations (NGOs) and governments on the provision of ART among displaced populations, including prevention of mother to child transmission (PMTCT), post-exposure prophylaxis (PEP) and long term ART.
The guidance set forth in this document applies to all displaced populations, including refugees, asylum seekers, internally displaced persons and migrants.

Ziad Khatib Replied at 2:20 AM, 15 Mar 2009

Thanks Mona.
How would it be defined Zimbabweans immigrants, as complex emergencies or..?

Best regards

Edward Mills Replied at 7:18 PM, 27 Mar 2009

Hello Folks
yes, Zimbabwe can reasonably be defined as a complex emergency. Its a very loose term, to the point of not really having a meaning.

Kelli O'Laughlin Replied at 11:15 AM, 1 Apr 2009

Hello Colleagues,

Regarding our discussion of the definition of complex emergencies and if
Zimbabwe fits into that category. I agree with Ed Mills that it is a complex
emergency; the term is defined by OCHA (UN Office for the Coordination of
Humanitarian Affairs) in their handbook from August of 1999:

It reads:

What is a complex emergency?
The official definition of a complex emergency is "a humanitarian crisis in a
country, region or society where there is total or considerable breakdown of
authority resulting from internal or external conflict and which requires an
international response that goes beyond the mandate or capacity of any single
agency and/ or the ongoing United Nations country program." (IASC, December

Such "complex emergencies" are typically characterized by:
-extensive violence and loss of life; massive displacements of people;
widespread damage to societies and economies
-the need for large-scale, multi-faceted humanitarian assistance
-the hindrance or prevention of humanitarian assistance by political and
military constraints
-significant security risks for humanitarian relief workers in some areas

Kelli O'Laughlin

Attending Physician
Department of Emergency Medicine
Brigham & Women's Hospital
Instructor of Medicine
Harvard Medical School
Associated Faculty
Harvard Humanitarian Initiative

Ziad Khatib Replied at 11:54 AM, 1 Apr 2009

Dear Kelli,
Thank you for your kind and informative follow-up.
Best regards from the SA AIDS conference-Durban.

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.