Despite the interaction between HIV and armed conflict, few attempts have been made to deliver HIV care programmes in conflict zones.  It is considered too difficult to provide in a safe and effective way. A project run by Médecins Sans Frontières (MSF) in Bukavu, eastern DRC, suggests otherwise.

Bukavu city has 600,000 inhabitants and lies in a region bordering Rwanda which has experienced chronic conflict since 1996.  The MSF project began there in 2000, when the first Voluntary Counselling and Testing (VCT) site and two HIV clinics opened.

Between May 2002 and January 2006, 11,076 people received VCT, of whom 19 percent were HIV positive. 94 percent of these received follow-up care at the HIV clinics. By January 2006, 494 patients had started on antiretroviral therapy (ART).

In May 2004 intense fighting took place over 13 days within the city, resulting in hundreds of civilian deaths and many rapes. Thousands of people fled across the border into Rwanda. The expatriate MSF staff were evacuated from the city, but the pharmacy was not looted and basic services were maintained by a Congolese nurse.

Communication during this period was difficult but continued via radio broadcasts and word of mouth. By this time 66 patients had begun ART, but only 5 were forced to interrupt their ART, all of whom eventually re-established contact with the clinic and returned to treatment. Eight months after the conflict a focus group was held involving five patients and two nursing staff.

Significant reported findings of the programme included the following:

• During the period May 2002 – January 2006, good adherence to treatment was achieved by 99 percent of those receiving ART.
• Clinical outcomes compare favourably to other ART programmes in non-conflict resource-poor countries.
• Of the patients receiving ART at the time of the crisis, 14 had sufficient medical supplies, 3 were hospitalised and had access to medication, 41 came to the clinic for supplies during the fighting, 3 were able to collect medication at an MSF station in Rwanda and 5 had a significant interruption in their ART.
• The focus group patients reported physical and mental hardships, illness, geographical displacement, limitations in movement and the threat of violence and food scarcity.
• All patients believed their lives depended on continuing with their ART. 

The experience in Bukavu shows that providing HIV care, including ART, can be feasible and effective in situations of chronic conflict.  The risk of interrupting ART treatment and drug resistance can be minimised through good contingency planning, which should include:

• Educating patients about maintaining the correct drug dosage, how to interrupt treatment safely if required, and sources of medication and support during a crisis.
• Multi-skilled staff able to keep a programme running and stand-in for absent colleagues.
• Pre-established communication networks between staff and patients.
• Provision of 15-30 days emergency stock of ART and other medicines to patients.
• Secure drug storage at a number of secure locations to minimise the danger of looting.
• Decentralised care, making it easier and safer for staff and patients to access the clinics.
• Co-operation with HIV treatment facilities in neighbouring regions, for emergency access to medication and care for displaced patients.
• Providing treatment information cards to patients and keeping duplicate medical records separate from the clinic site.
• Partnership with other health services, and establishing communication links with all sides.

Source(s):
‘HIV treatment in a conflict setting: outcomes and experiences from Bukavu, Democratic Republic of Congo’, PLoS Medicine 4(5):e129 by H Culbert, D Tu, D P O’Brien et al, 2007.   doi:10.1371/journal.pmed.0040129

id21 Research Highlight: 4 April 2008

Further Information:
Daniel O’Brien
Médecins Sans Frontières (MSF) Holland
Public Health Department
Plantage Middenlaan
Amsterdam, Holland 1001 EA
Netherlands

Tel: +31 20 520 8031
Fax: +31 20 620 5170
Contact the contributor: daniel.obrien@amsterdam.msf.org

Médecins Sans Frontières (MSF) Holland

Other related links:
'The southern Africa crisis: food insecurity, HIV/AIDS and the international response'

'HIV and AIDS: greater accountability needed to deliver on universal access commitments'

'Evidence from South Africa: joint TB/HIV programme activities are more cost-effective'