Although global prevalence rates have apparently levelled off since 2001 (UNAIDS 2007) in certain regions of the world, they are growing. The HIV and AIDS epidemic represents a huge and complex challenge to the humanitarian community whether in terms of poverty reduction, providing basic healthcare and welfare or dealing with the aftermath of man-made and natural disasters.  In the absence of a cure, prevention remains key to combating the virus, and much more needs to be done in meeting the need for prevention and treatment and also in providing care and support to groups who are often overlooked. A long-term and more targeted approach is vital including tackling the stigma and discrimination faced by marginalised groups and ensuring the greater involvement of local communities.

Around 25 million people have died from AIDS since 1981 and about 33 million are living with HIV today. For those most affected by HIV, whether the countries of sub-Saharan Africa or marginalised groups worldwide, the epidemic is undoubtedly a disaster. The impact of HIV in high-prevalence countries ranges from declining growth, productivity and employment to a breakdown in healthcare and education, food shortages and growing numbers of orphaned children. According to the World Bank Report of 2007, some 15 million children (under 18 years old) are orphaned as a result of AIDS. Worldwide, women, migrants, men who have sex with men, sex workers and injecting drug users are amongst the most vulnerable, in particular because of stigma and discrimination. Because HIV is an emergency as well as a disaster, it demands strong, well-targeted actions, by all.

Disaster relief and development organisations are increasingly accepting the need to integrate HIV and AIDS into all aspects of their humanitarian work. Whether distributing jerry cans or installing water pumps, examining what impact programmes will have on those affected by the epidemic and what impact the epidemic will have on programmes is vital. How widespread or targeted any HIV prevention programme should be, depends on whether the epidemic is generalised or concentrated in certain groups. The type of intervention will also depend on the stage of a disaster (emergency, post-emergency or long-term follow-up). Ensuring safe blood supplies may be an early priority. Fully integrating HIV interventions into reproductive and sexual health or tuberculosis control may come later. Guidelines on HIV in emergencies have been produced by a number of organizations but the issue of preparedness should be considered as particularly useful for HIV responses. But   the work of good but small-scale projects run by NGOs is no substitute for well-planned and well-implemented national programmes.

Vast numbers of people today are on the move between and within countries but the link between migration and HIV is complex. While HIV is often driven by poverty, it is also associated with inequality and economic transition. Economic growth and trade between neighbouring countries also increase labour migration, particularly of transport, mining, construction and other workers, and stimulate the sex industry along transport routes. Migrants are sometimes unfairly blamed for spreading HIV when the reality is that they are often the victims. Not all migrants are at equal risk, with undocumented female migrants among the most vulnerable to exploitation (human trafficking in particular) and abuse. International and regional cooperation is essential to stop trafficking. Recognition of migrants’ rights to health care, providing HIV education and decriminalising sex work are some of the ways to address the underlying causes of vulnerability to HIV.

Among countries with high rates of HIV, about half have been affected by major conflict between 2002 and 2005, with mass rape, forced displacement, breakdown in basic health care, disruption of social programmes and educational systems all increasing the risk of infection. When livelihoods are lost, both men and women can turn to sex work to survive. However, the link between conflict and HIV is complex. Women and children are often most vulnerable but armed personnel and even peacekeepers are also at risk both of acquiring and spreading HIV. By isolating and restricting the movement of populations, conflict can also hinder the spread of HIV and since refugees come from those areas, the belief that they spread the infection is often a myth. Prioritising basic HIV prevention from the earliest days of conflict, targeting those who are really the most vulnerable, avoiding interruptions in ART treatments and sustaining success by capacity-building – such as recruiting and educating healthcare professionals - are some of the major challenges.

When natural disasters strike, certain problems affect HIV-positive people more than others. Disruption of medical supplies can cause resistance to treatment for those on anti-retroviral drugs. Malnutrition is likely to speed up progression of HIV. Lack of clean water for food preparation and personal hygiene is especially dangerous for those with advanced HIV. HIV prevention programmes are also often disrupted and populations at higher risk of HIV may get forgotten. Better emergency responses must be planned which take into account the specific epidemiological situation in the disaster area. Cooperation between government health services, international donors and NGOs is essential, as is advanced preparation to ensure effective responses (including food security and the restoration of essential healthcare services) and strengthen the resilience of populations to cope when disaster strikes.

Spending on the response to HIV and AIDS in low- and middle income countries has significantly increased but is still well short of what is needed to provide universal access to prevention, treatment and support. Furthermore, what money that is available, too often fails to reach those most in need because of bureaucracy, ineffectual targeting and lack of coordination. The key challenges are to ensure that people living with HIV and those most at risk are at the centre of any response, that HIV programmes build on the strengths of local experts and research institutes and that programmes are evidence-based and results driven. Recommendations to make best use of the money available also include to stop ‘tying’ and earmarking aid, to improve coordination in order to stop wastage, to provide sustained and predictable funding, insist on responsible and transparent financial procedures and collaborative resource mobilization.

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