A clear and dire warning emerges from interviews with panelists at the 12th World AIDS Conference, some of them key members of Geneva’s international community, and with other specialists in forced migration. They confirm, when basic health infrastructure disappears, or when health services are systematically denied to specific populations, a rise in HIV infection cannot be far behind.

NGO experts, in particular, argue that HIV prevention and counselling should remain a top priority, even in settings where other basic needs like food, water and shelter have become logistically difficult to provide. Some charge that UN agencies have balked at the idea of delivering HIV and STD services in refugee camps – not because it’s impossible, but simply because it’s too expensive.

In complex emergencies like the war in Bosnia, an obvious example is the use of widespread sexual violence. "If we look at Bosnia, Mozambique, Rwanda, Liberia, Sierra Leone, these are situations in which rape has been systematically used as a tool of war" Carballo continues.

Although data are not available for many conflicts, elevated rates of HIV infection followed the wars in Mozambique and Angola. Carballo said an estimated 30,000 to 40,000 women were raped during the war in Bosnia, and "we don’t believe those figures are particularly unique or unusual."

During the acute phase of a complex emergency, "you get a population of girls and women who find themselves either on the road or in camps," Carballo explains. "In the camps, they’re highly vulnerable to marauding groups, even including the people who are supposed to be guarding them." Women may also have to provide sex to buy additional security or food for themselves and their children.

The acute stage of a complex emergency may end fairly quickly, but Carballo says migrants’ vulnerability to sexual

Migrating South to North: ‘the belly of the beast’ Migrants are confronted with an entirely different set of problems if they reach the countries of the industrialised North, where the immediate crisis of war may be replaced by the grinding, day-to-day challenge of exclusion and stigmatisation. "When the issue of immigrants is raised, people ask what it has to do with bridging the gap," notes Reda Sadki, Paris-based executive director of Migrants contre la sida (MAHA). "But we’re part of the Third World, even if we live in the belly of the beast, in the rich North." He says immigrants face denial of health care, structural discrimination, and racist violence that "closely resemble the conditions...people living in the South." "The fundamental cause of HIV vulnerability is that the health care system is designed to keep out Third World people," Sadki adds. "Almost every country in the rich North denies access to care to people who have been designated as illegal or undocumented, including people with HIV/AIDS." At the most basic level, he charges that a person with a black or brown face is far more likely to be asked for his or her citizenship papers upon entering a hospital in the North for treatment. "That’s the starting point in a long chain of discrimination, violations, abuses, and denial of treatment, the most extreme form of which is deportation," Sadki says. Statistics are hard to gather, in part because government statistics overlook the existence of immigrant communities. During the 12th World AIDS Conference, MAHA circulated a questionnaire aimed at gathering "practical, country-by-country information" immigration controls and HIV/AIDS. "Our demand is for access based on need, not status – be it immigration status or economic status."

exploitation doesn’t end there. Even when refugees are integrated into receiving communities, "the economic structure of these communities is something too complex, difficult, or closed for refugees to fit into." As a result, "exposure to sexual abuse and exploitation becomes a much greater reality than it does in stable societies."

A number of responses to this situation have been put forward, from educating military troops on the sexual rights of women, to augmenting refugees' capacity to protect themselves.

Millicent Obaso of Nairobi, Kenya coordinates reproductive health services in refugee situations for the International Federation of the Red Cross (IFRC). She stresses the importance of meeting the immediate sexual health needs of refugees during the first six weeks of an emergency situation, when they are on the move from one country to another.

In relation to HIV/AIDS, Obaso says human behaviour is another concern. "We’ve learned that even those who are at war still have their sexual drives. The lawlessness and homelessness makes them feel that the consolation is probably in sex, and they need to be protected."

The IFRC supplies condoms to refugees in transit, and tries to deliver immediate assistance to women who are raped. In one successful pilot project, the organisation established a clinic on a riverboat between Congo and Rwanda. "Privacy is missing sometimes in that kind of setting," Obaso says. "But it’s better than nothing. A woman who is about to die may have her life saved."

In more stable refugee situations, the IFRC may play a role in evaluating the sexual health services that are provided. "Very little is done in the area of HIV/AIDS, partly because it’s expensive," Obaso explains. "Counselling takes a lot of time. And once you start it, you have to go the whole way. You can’t just counsel someone, then not help them if they want to know their HIV status." And if they’re infected, "you have a commitment to support them with that problem – not just through counselling, but with medical services."

Although the IFRC works with the UN High Commission on Refugees (UNHCR) to screen blood donations in some of the larger camps, Obaso says NGOs lack the resources to provide a full range of HIV/AIDS services. She suggests international agencies like UNHCR have also been reluctant to allocate funds for full-fledged HIV/AIDS programmes in refugee camps.

Mohamed Dualeh, UNHCR's senior public health officer, told The Bridge the agency has treated HIV/AIDS as a priority issue for the past five years, and works closely with UNAIDS to produce technical manuals and guidelines on AIDS in refugee camps and emergency settings. He says UN agencies and their operational partners ensure that four basic interventions take place in every refugee camp – access to information and skills, access to condoms, screening of all donated blood, and observance of universal medical precautions.

Providing treatment can be more problematic, he says, because "we try not to antagonise the national AIDS control programmes....But community support and food are an integral part of health care for refugees, and that's what all our operational partners are doing."

Sow says the first order of business in a complex emergency is to re-establish a minimum range of health services. HIV prevention is often seen as a secondary concern. "People may say the first priority is shelter, nutrition, and minimum health, and we can deal with HIV/AIDS later. But in my view, we can’t do that."

Judge Michael Kirby of Australia, president of the International Commission of Jurists, paid special attention to HIV/AIDS prevention efforts when he served as the UN Special Representative in Cambodia from 1993 to 1996.

"Asian societies can teach Western societies that issues of human rights are not just what happens at police stations and in prisons, but what happens in hospitals, in schools, and in the fields," he says. "Countries that have suffered so much, like human beings who have suffered so much, tend to go into denial."

In Cambodia, UN efforts to spread HIV/AIDS information through public posters and educational campaigns "ran into the same kind of resistance one sees in every society, based on cultural and religious attitudes of modesty, chastity, and denial," Kirby recalls. After the dislocation of war and genocide, "it may be very difficult to get the messages through. The communication infrastructure may have broken down, or may be controlled and selective in its outlets, and the recipients of the information may be extremely suspicious of the official information they receive.

With refugees, as with the general population, "the most effective way to prevent the spread of HIV/AIDS is to protect the people who are...most at risk," he stresses. "Adopting punitive measures and looking at the question on a macro level turn out to be ineffective, and likely counterproductive." Rather than attempting to punish or isolate refugees based on their serostatus, "the strategy should be aimed at behaviour modification in a way that protects people at risk."