Nowhere else in the world has HIV hit harder than Sub-Saharan Africa, where nearly one in 20 people are living with the virus. The region is also a hot spot for armed conflict (this year is likely no exception), leading students in the region to wonder whether war might help to spread HIV. But according to a new paper, HIV infections spread most rapidly in the five years prior to armed conflict, indicating the connection between HIV and war is subtler than previously thought.
It's not that war doesn't have great potential to spread disease, Brady Bennett and colleagues from the Brown University School of Public Health write in PLoS One. War brings with it increased sexual violence, and it can disrupt health-care systems that might otherwise prevent the spread of HIV and other diseases. But on the other hand, war can disrupt transportation networks, which in turn isolates communities, preventing HIV infections from expanding. Meanwhile, empirically speaking, some of the countries with the least violence—Swaziland, for example—have the highest rates of HIV infection, while countries with the most violence, such as Nigeria and Sudan, have much lower rates. So what's up? What does war have to do with HIV?
HIV infections spread most rapidly in the five years prior to armed conflict, indicating the connection between HIV and war is subtler than previously thought.
Bennett and his co-authors don't attempt to sort out every detail, but they do present a more detailed analysis than anything that's previously been attempted, thanks in part to HIV-infection data collected by UNAIDS and armed conflict data from the Uppsala Conflict Data Program at Uppsala University. Between 1990 and 2012, all but 14 of the 36 sub-Saharan countries the researchers studied experienced some kind of conflict, whether it was relatively mild (fewer than 25 battle-related deaths) or more intense (greater than 1,000 such deaths).
Controlling for the level of economic development, the number of refugees fleeing war, and the duration of fighting, the researchers estimated there were about 2.1 more new HIV infections per year on average in the five years before a war began, compared with no-conflict years, which the team defined as more than five years prior to or five years after the conflict. Contrary to some expectations, new infection rates were the same during wartime and periods of peace. Similarly, focusing only on nations that experienced at least one armed conflict between 1990 and 2012, more intense battle was associated with a decline in the number of new HIV infections.
While the authors regard their study as a first step toward a deeper understanding of HIV and military action in Africa, these results could have substantial impact. "The years preceding a conflict may represent a critical period during which clinicians and public health professionals should be most active in HIV testing, treatment provision, education, and advocacy," they write. "In order for adequate testing and education to occur, there must be cooperation from domestic policy makers and foreign nations providing aid to the people of the warring nation."
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