STD & HIV/AIDS Programmes
described in Chapter Two (Minimum Initial Service Package [MISP]), three
activities should be conducted prior to any assessment in any new refugee
situation (including an emergency):
availability of free condoms
universal precautions against HIV/ AIDS transmission in healthcare
a person who will coordinate RH activities.
prevention, treatment and care services for STDs, including HIV/ AIDS,
should be made available to refugees at the earliest opportunity. By
taking the following steps, you will ensure that the services you provide
a situation analysis as soon as possible to help plan an appropriate
and comprehensive prevention and treatment service.
following information should be collected:
prevalence of STDs and HIV in the host and home country, region
or area (this information is available from the national AIDS programmes,
UNAIDS and WHO);
location of specific risk areas within the refugee community (for
example, where sexual services are bought and sold, high alcohol-consumption
areas, bars), to be targeted as priorities for specific activities;
cultural and religious beliefs, attitudes, and practices concerning
sexuality, reproductive health, STDs and AIDS. This information
can be obtained through qualitative research using focus groups,
interviews and, if possible, KABP (Knowledge, Attitudes, Behaviour
and Practices) surveys.
will also be necessary to:
situation analysis will indicate what STD and HIV/ AIDS interventions
are required and what is feasible. The following should be included
as basic elements of response to every refugee situation: universal
precautions in health-care settings, safe blood transfusion, access
to condoms, access to STD care, information, education and communication
(IEC) activities, and comprehensive care for people with HIV/ AIDS.
Universal Precautions in Health-Care Settings
Universal precautions are part of the MISP (Chapter Two) and are essential to prevent the transmission
of HIV from patient to patient, health worker to patient and patient
to health worker. Because people working under pressure are more likely
to have work-related accidents and to cut corners in sterilisation techniques,
infection-control measures adopted during crises must be practical to
implement and enforce.
guiding principle for the control of infection by HIV and other diseases
which may be transmitted through blood, blood products and body fluids
is that all should be assumed to be potentially infectious.
minimum requirements for infection control are as follows:
for frequent hand washing. Hands should be washed with soap and
water, especially after contact with body fluids or wounds.
of gloves for all procedures involving contact with blood or other
potentially infected body fluids. Gloves should be discarded after
each patient, or else washed or sterilised before reuse. Heavy-duty
gloves should be worn when materials and sharp objects are taken
of protective clothing, such as waterproof gowns or aprons. Masks
and eye shields should be worn where there is a possibility of exposure
to large amounts of blood.
handling of sharp objects. Puncture-resistant containers for sharps
disposal must be readily available, close at hand and out of the
reach of children. Sharp objects should never be thrown into ordinary
waste bins or bags.
of waste materials. People, particularly small children, struggling
to survive will scavenge. It is therefore vital to make waste disposal
safe. All medical waste materials should be burnt. Those items that
still pose a threat, such as sharp objects, should be buried in
a deep pit at least 10 metres from a water source. Medical waste
should not be disposed of in communal dumps.
disinfecting and sterilising. Pressure-steam sterilisers are recommended
for cleaning medical instruments between use on different patients.
If sterilisation is not available, or for instruments that are heat
sensitive, instruments must be cleaned and high-level disinfected
(HLD). HIV can be inactivated by boiling for 20 minutes or by soaking
in chemical solutions including a five per cent solution of chlorine
bleach for 20 minutes or in a two per cent glutaraldehyde solution
for 20 minutes.
handling of corpses. It is advisable for relief workers to wear
gloves and cover any wounds on hands or arms when handling corpses.
The relief worker should wash thoroughly with soap and water afterwards.
Special caution should be taken with body fluids as they may be
injuries at work. In cases of injury with a sharp instrument, the
wound should be washed thoroughly with soap and water. Splashes
of blood or other body fluid into the mouth or eyes should be rinsed
thoroughly with water or saline respectively. Further procedures
to be followed after an accidental exposure to blood have been developed
by Médecins Sans Frontières (MSF). Prophylactic treatment against
HIV transmission, known as Post Exposure Therapy (PET), may be warranted.
containing information about potential risks in the environment, how
to protect against those risks, and what to do in case of accidents
such as needle-stick injuries, cuts or blood splattering should be developed
and distributed to field workers. It is equally important to provide
clear information about what does not constitute a risk. The guidelines
should indicate when it is appropriate to use protective clothing and
why. Health workers should also be given guidance on how to avoid unnecessary
injections and other procedures involving sharp instruments.
If consistently and correctly used, condoms offer effective protection
against STDs, including the sexual transmission of HIV. Since many refugees
have already been exposed to this message, there may be a demand for
condoms in the early phases of a refugee situation. Condoms are contained
in the MISP (See Chapter Two) and should be made freely available for those
who seek them. Take every opportunity to raise awareness and promote
condoms as a method of protection against STDs, including HIV infection.
The female condom is not yet widely known; but, if available, it should
be used as an additional method of protection.
of good-quality condoms
There are many brands of condoms on the market. If an agency does not
have experience in procuring condoms, it may be desirable to contact
UNAIDS, UNFPA, UNHCR or WHO to facilitate the purchase of bulk quantities
of good-quality condoms at low cost. Annex 3 shows how to calculate the number of condoms
required. Good-quality condoms are essential for the protection of the
consumer and the credibility of the relief programme.
To ensure ongoing access in refugee situations, a system of distribution
must be in place. The system should include the following:
and instructions for their use should be available on request in
health facilities (especially where STDs are treated) and distribution
centres (such as food and non-food item distribution areas). Staff
should be trained in the promotion, distribution and use of condoms.
campaigns should be launched at football matches, mass rallies,
dance parties, theatres, group discussions, etc., to promote the
use of condoms and inform the public on how and where to obtain
between the refugee and local populations are likely to occur. Therefore,
condoms must also be made available to the wider host community.
This requires liaison with groups involved in AIDS prevention and
family-planning activities in the area.
the situation has stabilised, health workers must decide whether
or not to continue free distribution of condoms. The introduction
of some form of partial cost-recovery (social marketing) may be
considered in situations where this is feasible and appropriate.
When possible, the condom- distribution network can be extended
to community agents, shops, bars, youth and women's groups, etc.
Social marketing strategies in the host country or in the country
of origin could be extended into the refugee situation.
Safe Blood Transfusion
Blood transfusions must not be done if the facilities for safe transfusion,
including screening for HIV testing, do not exist. Safe blood transfusion
can be organised within the refugee settlement in major operations or
should be arranged with local health facilities following appropriate
discussions with the Ministry of Health. Should local health facilities
be used, support to these structures must be assured by the refugee
likehood of becoming infected with HIV through transfusion of infected
blood is well over 90 per cent. Measures to ensure the safety of blood
transfusion in refugee situations are extremely important.
main recommendations for preventing HIV infection and other blood-borne
diseases through blood transfusion are to:
only previously tested blood and only when clinically necessary.
blood substitutes, such as simple crystalloid (physiological saline
solution for intravenous administration) and colloids whenever possible.
blood from donors identified as being least likely to transmit infectious
agents in their blood. Selection of safe donors can be promoted
by giving clear information to potential donors on when it is appropriate
or inappropriate to give blood and by using a blood-donor questionnaire.
Voluntary, non-remunerated blood donors are safer sources than paid
donors. Personal information given by the donor must be treated
as strictly confidential.
reagents to perform HIV testing of donated blood. Screening for
HIV and other infectious agents should be carried out using the
most appropriate assays.
clear policies and protocols/ guidelines concerning the appropriate
use of blood for transfusion, the recruitment and care of donors
and the safe disposal of waste products, such as blood bags, needles
an experienced person to be responsible for refugee-specific blood
Access to STD Care
Because the risk of HIV transmission is greatly increased in the presence
of other STDs, early establishment and integration of STD services within
general health care services is a priority. STDs and their complications,
such as infertility and congenital syphilis, are a major cause of ill
health and are usually grossly under-reported. The prevention of STDs
involves the promotion of safer sex as well as early and effective case
finding, advise on notification of partners and case management.
services should be user-friendly, private and confidential. Special
arrangements may be necessary to ensure that women and young people
feel comfortable using these services. In many societies, women will
not seek treatment if the health professionals at the clinic are all
male, particularly if a physical examination is required. In these situations,
female health workers should provide services for women.
and effective case management involves the following:
health care providers
guidelines for case management, including case definition and management
availability of appropriate drugs
supply of condoms
secondary or informal providers of STD care
Training health care providers
Health care providers, including volunteer workers, should receive training
in prevention of STD/ HIV/ AIDS, be provided with information materials
and serve as channels for the distribution of condoms. Professional
health workers should be trained in the syndromic approach to STD management.
worker training should include the following topics:
recognition and diagnosis
treatment based on observed syndromes importance of confidentiality
for prevention/ counselling focused on specific population groups
promotion and provision
notification and management
STD Case Management
Treatment of symptomatic cases should be standardised on the basis of
syndromes and not dependent on laboratory analysis. A treatment protocol
(consistent with national protocols) based on syndromic case management
should be prepared and adopted. (See examples in Annexes 4 and 5.) The most effective drugs
should be used at the first encounter.
drug requirements should be based on available data from the country
of origin or estimated as indicated in Annex 8. Monitoring activities will then serve to review
real needs. If IEC efforts are effective, if services are user-friendly
and people from outside the camp are attending the health facilities,
the need for drugs may increase rapidly.
of patients with an STD are likely to be infected themselves and should
be treated. Each patient should be provided with contact slip(s) to
be given to his/ her sexual partner(s). On the basis of these slips,
partners should have access to the same treatment as the patient who
presented first. The process should be confidential, voluntary and non-coercive
and include all sexual partners of each STD patient.
a syndromic approach to STD case management allows effective care for
symptomatic cases without the need for laboratory support. The exception
to this is systematic testing for syphilis in pregnant women. This type
of testing is cost effective even in sites where the prevalence of syphillis
in the general population is as low as one per cent.
Information, Education and Communication (IEC)
Information, education and communication activities are central to a
successful HIV/ AIDS and STD strategy in all situations. IEC includes
a variety of activities at different levels, from intensive person-to-person
education to mass dissemination of information. (For further information
on IEC, refer to Appendix One.)
Comprehensive Care for People with HIV/ AIDS
Comprehensive care for people with HIV-related illnesses should be seen
as a component of basic care in any refugee situation. This is especially
important when refugees come from an area where HIV-related illnesses
are a major cause of morbidity and mortality. (The WHO flow chart for
suspected symptomatic HIV infection for the purpose of clinical management
is provided in Annex 6.)
elements of comprehensive care include:
management, involving early diagnosis of HIV-related illnesses,
rational treatment and planning for follow-up care;
care to promote and maintain hygiene and nutrition;
of individuals and families on HIV prevention and care;
to help individuals make informed decisions on HIV testing, reduce
stress and anxiety and promote safer sex; and
support, including information and referral to support groups, welfare
services and legal advice.
home-based care system, to which people with advanced HIV infection/
AIDS-related illnesses can be discharged from inpatient care, should
be established early in refugee situations.
introduction of comprehensive care for HIV/ AIDS in refugee situations
health workers to HIV-related illnesses and AIDS;
a policy on the role of voluntary and confidential HIV tests (with
related pre-and post-test counselling) for clinical diagnosis (see
Annex 1). If host countries offer voluntary counselling
and testing services to the local population, initiate discussions
to determine the possibility of extending these services to refugee
existing clinical and nursing guidelines for case management of
HIV-related illnesses in primary and secondary care in refugee settings.
This should include guidelines on discharge and referral of people
with HIV-related problems, either for more sophisticated care or
to home-based care;
up an essential drug list for care of HIV-related illnesses and
establishing mechanisms to ensure the procurement and supply of
health care workers in the use of the clinical guidelines;
counselling training for health and lay workers and developing guidelines
for counselling. This can be integrated into counselling for other
problems related to the refugee situation. It will be helpful if
staff involved in this activity are not subject to frequent rotation;
those people living with HIV/ AIDS in training programmes;
that HIV-related care is fully integrated into basic curative services
and that prevention components (such as supply of condoms) and STD
treatment are provided;
community support for AIDS care by:
-- exploring community potential for stigma and discrimination;
-- exploring community capacities and commitment;
-- encouraging the development and training of self-help and other
community-based support groups; and
-- starting community-based care and support activities, using the
self-help groups that have been established.
on the number of STD and HIV/ AIDS cases presenting for treatment or
detected in health services are essential for planning services and
as indicators of trends in STD prevalence in the community. Always suspect
under- reporting of STDs and HIV/ AIDS. Managers of health care programmes
may want to check for the presence of informal networks of treatment
for STDs, such as in local markets.
to be collected from the health-facility level
collected at the community level
concerning training and quality of care
to Chapter Nine -- Surveillance and Monitoring.)
availability of free condoms
STD/ AIDS situational analysis is undertaken
people from refugee community are identified
education and communication programmes are in place
precautions in health settings are practiced
good-quality condoms are regularly available and accessible
of condom distribution is in place
blood transfusion services are in place, guidelines disseminated,
HIV test kits available, staff trained
protocols for STDs are defined and disseminated
for STD treatment are on hand
are trained/ retrained on syndromic case management
for partner notification and treatment are instituted
counselling and testing (VCT) services are in place (as appropriate)
care for people with AIDS is in place
and support services for people with HIV/ AIDS are in place
HIV Testing in Refugee Situations
Mother-to-Child Transmission and HIV
and Infant Feeding
Formula for Calculating Condom Requirements
STD Treatment Based on Syndromic Approach
Drugs for Treatment of STDs
Flow Chart on Suspected Symptomatic
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