(The following essay is posted on behalf of Selma Scheewe. The author based this essay on her Thesis titled “Sexual Violence and HIV/AIDS in Conflict-ridden Darfur”, at the University of Groningen.)

Introduction

Sexual violence is a prominent aspect of many recent conflicts. In the media and the reports of humanitarian agencies, this sexual violence is often linked to the possible consequence of infection with the Human Immunodeficiency Virus (HIV). In the case of Rwanda, HIV/AIDS has even been identified as a "weapon of war," which is transmitted to women intentionally by using rape. The importance of addressing the risk of HIV/AIDS transmission in conflict and other emergency settings is increasingly recognised by humanitarian organisations.

However, the relationship between sexual violence in conflict settings and HIV infection has rarely been studied, even though a recent literature review concluded that conflicts are specific contexts which exacerbate vulnerabilities to HIV/AIDS as well as gender-based violence (GBV), and that anecdotal reports suggest a strong relationship between these factors. For example, as a consequence of the genocide in Rwanda there is a disproportionately large number of women infected with HIV/AIDS amongst rape survivors, these numbers together with anecdotal evidence suggests that their infection is a direct consequence of the sexual violence inflicted on them.

This essay discusses the main factors that play a role in assessing the risk of HIV infection amongst victims of sexual violence in what is generally considered the largest humanitarian catastrophe of today; the conflict in Darfur.

Sexual violence in Darfur

"Janjaweed would pass their hands touching the heads and legs of women, if a woman has long hair and fat legs and silky skin she is immediately taken away to be raped. There was panic among all of us and we could not move. They took girls away for long hours and brought them back later. Girls were crying, we knew they raped them. Some of us were raped in front of the crowd"¦I was sitting with the others on the bare floor, very exhausted, thirsty and scared. Two of them came to me, I resisted them and told them I did not want them but they did not like that. They hit me and decided to rape me in front of others, one of them came to me from the back and started raping me"¦I could not move after that."

Narrated by a Fur woman who at the time of the interview stayed in a camp for internally displaced persons (IDPs) in South Darfur.

The UN’s International Commission of Inquiry on Darfur concluded that rape and other forms of sexual violence are widespread and systematically used by the Janjaweed and Government soldiers, since the conflict started in 2003, next to other forms of violence such as killing of civilians, torture, enforced disappearances, destruction of villages and pillaging. Nevertheless, the actual figures of the numbers of rape occurring are impossible to establish. Women are at the risk of rape while facing an attack of enemy forces, while fleeing conflict, but also while living within the relatively protected boundaries of a refugee camp. In fact, many of the rapes occur while carrying out daily activities such as collecting firewood. The victims of rape in Darfur are generally women between 12 and 45 years old, belonging to "African" tribes, the Fur, the Massalit and the Zaghawa.

Factors that increase the risk of HIV infection

The risk of direct HIV transmission due to rape is affected by a range of physiological factors. When sexual intercourse is forced, abrasions and cuts are more likely to appear, increasing the risk of transmission. Reports show that sexually transmitted infections (STI) are common amongst the IDP population in Darfur, while there is strong evidence that STIs also increase the risk of HIV transmission. The practice of female circumcision is widespread in Darfur , increasing the risk for injury during sexual intercourse, and thus the risk of HIV infection. Moreover, women are biologically twice as likely as men to contract HIV during sexual intercourse , while this probability is even higher for young women and girls.

Literature on the relation between sexual violence and HIV/AIDS in non-conflict settings suggests that there can be other factors associated with rape that increase vulnerability to HIV infection in the long run, such as behavioural change amongst victims after rape. Rape in Darfur is surrounded by shame and stigma, and many cases occurred where women were ostracised by their own families and communities. For unmarried women and girls, being raped severely limits her chances of finding a marriage partner, while married women, may be abandoned by their husbands. At the same time, there are various forms in which rape survivors may be supported by the community, and their acceptance by the community has slightly increased as the numbers of rape cases rose.

The women who face social exclusion often also become economically vulnerable. Generally, poverty is associated with an enhanced risk of HIV infection, amongst other things because of the lack of access to health care. There are few livelihood strategies available to women alone. Data suggest from other refugee settings suggests that particularly ‘single women’ and girls who are unaccompanied engage in forms of transactional sex to survive. The demand for sexual services increases in conflicts especially through the presence of armed forces, and poses a high risk for HIV infection since it is often unprotected.

HIV/AIDS prevalence in Darfur and the armed forces

There are also factors that suggest that the risk of HIV infection in Darfur as a consequence of rape might be limited. The very little data available on HIV/AIDS in Darfur indicates that the prevalence is ‘relatively low’; Sudan is considered to be in the early stages of a generalised HIV/AIDS epidemic. While this should be interpreted with caution, the situation is clearly different from Rwanda where it was already known that the HIV prevalence rates where relatively high in the population as a whole at the onset of the conflict.

Moreover, HIV/AIDS can only be transmitted directly during rape if the perpetrator is HIV positive. Several studies indicate that infection rates among many military groups are often high, about two to five times higher than amongst the civilian population , while others stress that there are also protective factors and not enough is known about these patterns. In addition, there are too few indications of the HIV prevalence rates amongst the different military groups in Darfur to draw any conclusions on this. Nevertheless, it should be noted that in a time of mass rape and multiple assailants during rape, like is the case in Darfur , perpetrators may also become infected, and recently infected individuals are physiologically most infectious.

Women’s vulnerability to HIV/AIDS in conflict settings

The risk of HIV infection for women who are raped should be interpreted in the larger context of HIV/AIDS transmission in conflict settings, and women’s vulnerability in these settings. Many of the factors that are conducive of the transmission of HIV/AIDS are prominent in conflict situations such as population mobility, displacement and the breakdown of the health system (incl. unsafe blood transfusions). In addition, the conflict has led to a widespread destruction of livelihoods and increased poverty. Conflict also affects the social structures that under normal circumstances provide a supportive and protective network for community members. Female-headed households are common especially in IDP camps and are generally considered to be more economically vulnerable. These women may also be at an increased risk of HIV infection, for example by resorting to high-risk livelihood strategies.

Implications for humanitarian intervention

Considering the widespread use of sexual violence in Darfur and other recent conflicts, it is crucial that humanitarian organisations address the risk of HIV infection as a consequence of rape. Next to general awareness raising and HIV prevention campaigns, specific prevention strategies to address the short term and long term HIV risks for rape survivors are of major importance. In response to the risk of direct transmission of HIV through rape, post-exposure prophylaxis (PEP) is being provided by a number of humanitarian agencies in Darfur. PEP can prevent HIV infection if administered within 72 hours after the rape and if strictly taken for 28 subsequent days. However, in practice there are a number of factors that decrease the effectiveness of PEP, namely; late reporting due to lack of awareness and access to treatment, not finishing the long treatment regimen, and the relatively high expenses associated with PEP.

Considering the long-term risk of HIV infection amongst rape survivors and the risk of infection amongst vulnerable (IDP) women, interventions aimed at strengthening social support mechanisms and creating livelihood opportunities for women are crucial. However, the humanitarian approach to HIV intervention in emergency settings has been criticised of having a too strong medical focus, with very little attention for social aspects. Within the humanitarian gender-based violence programs on the other hand, these aspects are more prominent but not explicitly linked to HIV/AIDS. Guidelines for example recommend strengthening or re-building of family and community support systems and strategies to achieve women’s empowerment; such as offering literacy programs, vocational training, income generating activities and leadership training. Little information is available which shows to what extent these activities are successfully implemented in Darfur. For example, it has proven challenging to offer income generating activities for women in IDP camps that generates the same or higher returns than collecting and selling firewood.

Conclusion

Women who have been raped during conflict are likely to be at an increased risk of being infected with HIV/AIDS. This risk depends amongst other things on the HIV prevalence in the region and specifically amongst perpetrators (armed forces), on physiological factors, and on the impact of sexual violence on women’s lives and vulnerability to HIV/AIDS in conflict and post-conflict settings. So far, too little is known about these factors to draw any firm conclusions; much more solid empirical research is needed in this area. This knowledge can be used to determine the relative importance of different approaches to HIV prevention amongst rape survivors; aimed at preventing direct transmission or long term vulnerability. A better understanding of the relation between sexual violence and the risk of HIV infection can also contribute to the improved integration of HIV and gender-based violence interventions within humanitarian settings. Ultimately this will save women, already traumatised by the sexual violence inflicted on them, from the death sentence of HIV/AIDS.

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