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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL
CHAPTER FIVE
Sexually Transmitted Diseases, Including HIV/AIDS


Contents:

Also Included:


The objectives of any activity in the area of sexually transmitted diseases (STDs), including Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), should be to prevent and treat STDs, reduce the transmission of HIV/ STD infections, and help care for those affected by AIDS.


Introduction

STDs, including HIV/ AIDS, spread fastest where there is poverty, powerlessness and social instability. The disintegration of community and family life in refugee situations leads to the break-up of stable relationships and the disruption of social norms governing sexual behaviour. Women and children are frequently coerced into having sex to obtain basic needs, such as shelter, security, food and money. In a refugee situation, populations that have different rates of HIV/ AIDS prior to becoming refugees may be mixed. Also many refugee situations are like large urban settings and may create conditions that increase the risk of HIV transmission.

STDs, which are a major public health problem in most parts of the world, were largely neglected until the appearance of HIV/ AIDS. Now, more attention is focused on conventional STDs (such as gonorrhoea, syphilis, chlamydia, etc.). They are among the most common, although undiagnosed, causes of illness in the world; and they have far-reaching health, social and economic consequences. STDs substantially increase the risk of HIV infection. Preventing and controlling STDs are key strategies in controlling the spread of HIV/AIDS.

The vast majority of HIV infections are sexually transmitted. Between five and ten per cent of HIV infections worldwide are estimated to be transmitted through infected blood and blood products, though this percentage is decreasing as blood for transfusions is more regularly tested for HIV. In refugee situations, it is essential to ensure that all blood for transfusion is tested and that universal precautions are enforced.

Mother-to-child transmission of HIV (MTCT), also called "vertical transmission", is the most common mode of HIV transmission in children. More than 90 per cent of HIV-infected

infants acquire their HIV infection from their mothers during pregnancy, delivery or during breastfeeding. When there is no intervention, the risk of MTCT ranges from 15 to 25 per cent in industrialised countries and from 25 to 45 per cent in developing countries. Transmission is affected by a number of factors, not all of which have been fully examined. These factors include:

  • high viral-load level in the mother's blood,
  • in cervio-vaginal secretions and, in breast milk, decreased maternal immune status, prolonged rupture of membranes (greater than four hours),
  • the mode of delivery, and intrapartum haemorrhage.

Studies show an additional 7 to 22 per cent risk of HIV transmission through breast-feeding. Late postnatal transmission after six months of age has been described in a number of studies. (See Annex 2 on MTCT and HIV and Infant Feeding.)

Interaction between refugee and local populations is likely to occur. It is therefore vital to liaise with host countries to ensure that comparable services are provided to local populations. Failure to do so would not only be counterproductive in the effort to prevent the spread of STDs and HIV, it could also result in conflict between the two populations.

Mandatory HIV testing of refugees is sometimes requested in the mistaken belief that this will help prevent HIV transmission. Under no circumstances should mandatory testing be pursued. Mandatory testing for HIV represents a violation of human rights and has no public health justification. (See Annex 1 on HIV testing in refugee situations.)
 

Reproductive health in refugee situations
Photos
An inter-agency field manual

Foreword

Preface

Acknowledgments
 

Chapters


1. Fundamental Principles

2. Minimum Initial Service Package (MISP)

3. Safe Motherhood

4. Sexual and Gender-based violence

5. Sexually Transmitted Diseases, including HIV/AIDS

6. Family Planning

7. Other Reproductive Health concerns

8. Young People

9. Surveillance and Monitoring
 

Appendices


a1. Information, Education, Communication

a2. Legal Considerations

a3. Glossary of Terms

a4. Reference Addresses


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©1999 United Nations High Commissioner for Refugees

This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged.


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Establishing STD & HIV/AIDS Programmes

As 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):

  • Guarantee availability of free condoms

  • Enforce universal precautions against HIV/ AIDS transmission in healthcare settings

  • Identify a person who will coordinate RH activities.

Comprehensive 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 are effective.


Assessment

Conduct a situation analysis as soon as possible to help plan an appropriate and comprehensive prevention and treatment service.

The following information should be collected:

  • the 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);

  • the 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; and

  • the 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.

It will also be necessary to:

  • liaise with local health authorities to define a management protocol for STDs;

  • and identify people in the refugee community who have been trained in HIV/ STD prevention.


Implementation

The 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.

The 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.

The minimum requirements for infection control are as follows:

  • Facilities for frequent hand washing. Hands should be washed with soap and water, especially after contact with body fluids or wounds.

  • Availability 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 for disposal.

  • Availability 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.

  • Safe 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.

  • Disposal 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.

  • Cleaning, 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.

  • Proper 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 potentially infectious.

  • Treating 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.

Guidelines 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.

Access to Condoms
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.

Procurement 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.

Condom distribution
To ensure ongoing access in refugee situations, a system of distribution must be in place. The system should include the following:

  • Condoms 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.

  • Promotional 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 them.

  • Contacts 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.

  • Once 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 programme.

The 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.

The main recommendations for preventing HIV infection and other blood-borne diseases through blood transfusion are to:

  • Transfuse only previously tested blood and only when clinically necessary.

  • Use blood substitutes, such as simple crystalloid (physiological saline solution for intravenous administration) and colloids whenever possible.

  • Collect 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.

  • Provide reagents to perform HIV testing of donated blood. Screening for HIV and other infectious agents should be carried out using the most appropriate assays.

  • Develop 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 and syringes.

  • Appoint an experienced person to be responsible for refugee-specific blood transfusion services.


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.

STD 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.

Appropriate and effective case management involves the following:

  • training health care providers

  • providing guidelines for case management, including case definition and management protocol

  • consistent availability of appropriate drugs

  • consistent supply of condoms

  • monitoring

  • identifying 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.

Health worker training should include the following topics:

  • syndrome recognition and diagnosis

  • effective treatment based on observed syndromes importance of confidentiality

  • education for prevention/ counselling focused on specific population groups

  • condom promotion and provision

  • partner notification and management

  • monitoring


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.

Initial 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.

Partners 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.

Applying 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.)

The elements of comprehensive care include:

  • clinical management, involving early diagnosis of HIV-related illnesses, rational treatment and planning for follow-up care;

  • supportive care to promote and maintain hygiene and nutrition;

  • education of individuals and families on HIV prevention and care;

  • counselling to help individuals make informed decisions on HIV testing, reduce stress and anxiety and promote safer sex; and

  • social support, including information and referral to support groups, welfare services and legal advice.

  • A 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.

The introduction of comprehensive care for HIV/ AIDS in refugee situations involves:

  • sensitising health workers to HIV-related illnesses and AIDS;

  • developing 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 populations;

  • adapting 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;

  • drawing up an essential drug list for care of HIV-related illnesses and establishing mechanisms to ensure the procurement and supply of these drugs;

  • training health care workers in the use of the clinical guidelines;

  • introducing 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;

  • including those people living with HIV/ AIDS in training programmes;

  • ensuring 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;

  • developing 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.


Monitoring

Data 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.

  • Indicators to be collected from the health-facility level

    • percentage of blood screened for HIV before transfusion and per cent found positive for HIV

    • incidence of STDs

    • practice of universal precautions
       

  • Indicators collected at the community level

    • outlets for condoms distribution

    • knowledge of correct condom use

    • condom use
       

  • Indicators concerning training and quality of care

    • training of health workers in syndromic case management

    • quality of STD case management
       

(Refer to Chapter Nine -- Surveillance and Monitoring.)

From MISP

Guarantee availability of free condoms

Enforce universal precautions
 

  • HIV/ STD/ AIDS situational analysis is undertaken

  • Trained people from refugee community are identified

  • Information, education and communication programmes are in place

  • Universal precautions in health settings are practiced

  • Free good-quality condoms are regularly available and accessible

  • System of condom distribution is in place

  • Safe blood transfusion services are in place, guidelines disseminated, HIV test kits available, staff trained

  • Management protocols for STDs are defined and disseminated

  • Drugs for STD treatment are on hand

  • Staff are trained/ retrained on syndromic case management

  • System for partner notification and treatment are instituted

  • Voluntary counselling and testing (VCT) services are in place (as appropriate)

  • Home-based care for people with AIDS is in place

  • Counselling and support services for people with HIV/ AIDS are in place
     


Annexes to this chapter

Annex 1
HIV Testing in Refugee Situations

Annex 2
Mother-to-Child Transmission and HIV and Infant Feeding

Annex 3
Formula for Calculating Condom Requirements

Annex 4
STD Treatment Based on Syndromic Approach

Annex 5
Drugs for Treatment of STDs

Annex 6
Flow Chart on Suspected Symptomatic HIV Infections

Annex 7
WHO Essential Drugs for HIV/ AIDS Management

Annex 8
Sexually Transmitted Diseases: Example for estimating of drug requirements and costs for a population of 200,000


Further Readings

"Essential AIDS Information Resources", WHO/ AHRTAG, Geneva/ London, 1994.

"Guidelines for HIV Interventions in Emergency Settings", UNHCR/ WHO/ UNAIDS, Geneva, 1996.

"Working with Young People: A Guide to Preventing HIV/ AIDS and STDs", Commonwealth Secretariat, WHO/ UNICEF, London, 1996.

On universal precautions:

"A Practical Guide to Infection Control: How to Use Universal Precautions and Plan for Essential Supplies", WHO, Geneva, 1995.

"Guidelines on Disinfection and Sterilisation", Médecins sans Frontières (MSF), Brussels, 1994.

"Guidelines on Procedures to be Followed after an Accidental Exposure to Blood", MSF, Brussels, 1997.

On access to condoms:

"Managing Condom Supply Manual", WHO, Geneva, 1994.

"Specifications and Guidelines for Condom Procurement", WHO, Geneva, 1995.

"The Female Condom: An information pack", WHO/ UNAIDS, Geneva.

"The Female Condom and AIDS" UNAIDS Point of View, Geneva, 1998.

"The Male Latex Condom" WHO/ UNAIDS, Geneva, 1998.

On safe blood transfusion:

"Blood Needs in Disaster Situations: Practical Advice for Emergencies", Transfusion International, No. 59, March 1993.

"Blood Safety" UNAIDS Point of View, Geneva

"Blood Safety" UNAIDS Technical Update, Geneva

"Guide for Planning Operations for Refugees, Displaced Persons and Returnees: from Emergency Response to Solutions", International Federation of Red Cross and Red Crescent Societies, Geneva, 1993.

"Guidelines for the Appropriate Use of Blood", WHO, Geneva, 1989.

"Use of Blood Plasma Substitutes and Plasma in Developing Countries", WHO, Geneva, 1989.

On HIV testing and counselling:

"Counselling and HIV/ AIDS" UNAIDS Technical Update, Geneva, 1997.

"Guidelines for Blood Donor Counselling on Human Immunodeficiency Virus (HIV)" International Federation of Red Cross and Red Crescent Societies/ WHO/ GPA Geneva 1994 (WHO/ GPA/ TCO/ HCS/ 94.2)

"Policy of HIV Testing and Counselling" UNAIDS, UNAIDS/ 97.1

"Recommendations for the Selection and Use of HIV Antibody Tests", WHO Weekly Epidemiological Record, No. 20: 145-9, Geneva, 1997.

"Voluntary Counselling and Testing" UNAIDS Technical Update, Geneva, 1999.

On the management of STDs:

Adler, M., and S. Foster, J. Richens, and H. Slavin. "STD Infections: Guidelines for Prevention and Treatment", ODA/ DFID Occasional Paper, London 1996.

"Management of Sexually Transmitted Diseases", WHO, Geneva, 1994.

"Prescribing Information: Drugs Used in Sexually Transmitted Diseases and HIV infection", WHO, Geneva, 1995.

"Sexually transmitted diseases: policies and principles for prevention and care" UNAIDS/ WHO Geneva, 1997.

"STD Case Management Workbooks" WHO/ GPTCO/ PMT/ 95.18A, Geneva, 1995.

"The public health approach to STD control" UNIADS Technical Update, Geneva, 1998.

On comprehensive care:

"AIDS Home Care Handbook", WHO, Geneva, 1993.

"Guidelines for the Clinical Management of HIV Infection in Adults", WHO, Geneva 1991.

"Guidelines for the Clinical Management of HIV Infection in Children", WHO, Geneva 1993.

"HIV/ AIDS Counselling: A Key to Caring: Guidelines for Policy Makers and Planners", WHO, Geneva 1995.

On standard treatment and essential drugs for HIV/ AIDS management:

"Access to drugs", UNAIDS Technical Update, Geneva, 1998.

"Standard treatments and essential drugs for HIV-related conditions", WHO/ DAP, Geneva, 1997.

"WHO Model Prescribing -- Drugs used in HIV Infections", WHO/ EDM, Geneva, 1999.
 


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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL