In the north-eastern city of Malakal in South Sudan, an HIV support network with around 150 members met on a regular basis to talk about the challenges they faced in accessing antiretroviral medicines and the food they needed to stay healthy. But in 2013, when the civil war broke out and fighting reached Malakal, everything changed.

Hundreds of people were killed and thousands more fled their homes, many to the camp run by the United Nations Mission in South Sudan (UNMISS) in the outskirts of Malakal. Only six of the members of the network found their way to the camp. Joseph Leggi Pio, who works at the HIV Unit in UNMISS and was one of the founding members of the group, doesn’t know what happened to the rest.

Life isn’t easy for anyone in the camp, but it can be especially difficult for people living with HIV. Medical facilities inside the overcrowded camp are facing logistical problems, including shortages of antiretroviral medicines and food and long waiting times to see health workers. Mr Pio said one of the patients living with HIV at the camp had recently died. Another person managed to move to Juba, where there is better access to HIV treatment services. Many more people living with HIV regularly visit Mr Pio’s office to find out when the medicine will arrive.

More than 100 000 internally displaced people are crammed into 10 UNMISS protection sites throughout the country, none of which were built to shelter anywhere near that number of people.

“Everything is a priority,” said Leku Dominic Samson, Senior Medical Assistant with the International Organization for Migration. “The HIV needs are only starting to be addressed.” Health workers have focused on emergency first aid, while also dealing with widespread diarrhoea and an increasing number of malaria cases.

The Government of South Sudan and health workers are committed to finding ways of providing HIV prevention and treatment services to internally displaced people in the UNMISS sites. Humanitarian organizations and United Nations agencies, including UNMISS, UNAIDS and the Office for the Coordination of Humanitarian Affairs, provided technical and financial support to open an additional primary health-care centre, where HIV testing and counselling services are available.

These organizations are also advocating to install a CD4 machine at the United Nations Hospital in the Malakal camp to help health workers monitor the viral load of people living with HIV. In the meantime, HIV prevention and treatment messages are being disseminated to more than 20 000 people living in the camp.

“Awareness is always an issue in the camp as people continue to arrive from all over the country, including rural areas where access to health information is limited,” said Mr Pio. He added that people’s behaviour in the camps, where they tend to take more risks, is worrisome. He is especially concerned that young people, many of whom were separated from their families during the fighting, are having unprotected sex, at times due to lack of access  to condoms.

Mr Pio and other health activists are training groups of HIV counsellors to mobilize people around the camp to talk about HIV and encourage them to protect themselves. The counsellors also take this opportunity to distribute up to eight boxes of condoms a day.

The counsellor trainings and community dialogues are beginning to show positive impact. For example, Tungwar Wuor—a resident at the Malakal camp—said he had little knowledge about HIV before he went through the training session to become a counsellor in March. Now he has red ribbons on all his clothes and talks easily about how people can protect themselves and others from HIV infection. “I wanted to help other people know their HIV status and how to prevent HIV,” said Mr Wuor. “HIV infection is something that can be stopped.”

He added that many people are initially wary when he starts talking to them about the virus, because of the stigma associated with HIV. He said some of them associate HIV with immorality. He has also been working with religious leaders to include HIV prevention messaging in their services.

“I explain to them that it is possible for anyone to contract the virus if they do not protect themselves and that people living with HIV can access treatment to lead positive lives,” said Mr Wuor. 

More than 540 people living with HIV in the capital of the Central African Republic, Bangui, have been able to resume taking antiretroviral therapy owing to a joint project run by UNAIDS and the government of the Republic of Korea.

The recent instability in the country forced many people away from their homes and into camps for internally displaced people, where health services are limited. In addition, many health facilities were destroyed, inaccessible or unstaffed during the crisis. Around a third of people on antiretroviral therapy across the country were unable to continue their treatment.

Social services and community volunteers have located 544 of 1500 people who left treatment programmes in Bangui, enabling them to resume access to the life-saving medication. UNAIDS and the government of the Republic of Korea aim to extend the project to other provinces and to start rebuilding some of the country’s shattered health infrastructure.

A total of 120 000 people were living with HIV in the Central African Republic in 2013, with about 16 500 on antiretroviral therapy.

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Addressing the needs of the millions of people around the world affected by humanitarian emergencies will be critical to ending the AIDS epidemic by 2030, top experts agreed at a meeting held in Geneva, Switzerland, on 3 March.

Calling for a new way of addressing HIV in humanitarian emergencies, the experts examined ways to ensure that the specific needs of people affected by humanitarian emergencies are taken in to account as the response to HIV is fast-tracked over the next five years.

At the end of 2013, there were more than 51 million people worldwide who had been forcibly displaced, the highest number since the end of the Second World War. Many others facing humanitarian disasters remain at home but suddenly find themselves in fragile environments.

The links between HIV and humanitarian emergencies are complex. Vulnerability to the virus can be heightened because of, for example, greater exposure to sexual violence and more reliance on transactional sex to meet basic needs. In addition, health services and HIV intervention programmes may become much harder to access or even nonexistent.

The experts at the meeting, which was co-hosted by UNAIDS, the Office of the United Nations High Commissioner for Refugees and the World Food Programme, shared the latest evidence-informed insights, knowledge, experiences and data that support the inclusion of people affected by humanitarian emergencies in HIV programmes. These will be key elements for the upcoming 36th meeting of the UNAIDS Programme Coordinating Board in July 2015 which will have a special focus on HIV in emergency contexts.

Specific areas discussed included: obstacles to HIV programming in emergencies; identifying gaps and how to address them; coordination arrangements between different agencies; improving adherence to treatment; and tailoring HIV-related programmes to address a range of differing types of emergency.

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