Mass rape and HIV in conflict-affected countries: despite relatively low incidence, researchers stress urgency of interventions for thousands of women in need

Mass rape during armed conflict may account for several thousand new cases of HIV per year in sub-Saharan Africa, according to an article in the journal AIDS.

Researchers drew this conclusion after analysing data from seven conflict-affected countries with high HIV prevalence: Burundi, Democratic Republic of Congo (DRC), Rwanda, Sierra Leone, Somalia, Sudan and Uganda.

According to their calculations, annual HIV incidence due to mass rape may range from four cases per 100,000 women and girls in Somalia to 20 cases per 100,000 women and girls in Uganda, the countries with the lowest and highest HIV prevalence, respectively, among the seven countries.

The countries with the most estimated mass rape-associated HIV infections per year were DRC, with a total of 1120 (median) (interquartile range [IQR], 527 – 2360), and Uganda, with a total of 2172 (median) (IQR, 1031 – 4668). The sum of the estimated number of infections for all seven countries was 4948 (median) (IQR, 2043 – 10,329).

Data limitations make it difficult to arrive at highly specific estimates regarding HIV transmission in conflict settings.

Variables that figure into such estimates include the proportion of women and girls who are raped, the proportion of assailants who have HIV and the probability of HIV transmission occurring with each act of rape.

The authors of the article, like other researchers examining this issue, needed to build their analysis on a complex series of assumptions.

Guided by what has been documented about rape in conflict settings, the authors allowed for the possibility that 1% to 15% of women and girls could be raped. Their assumptions about the lowest and highest HIV prevalence likely to be found among assailants took into account widespread indications that military forces in countries with large-scale HIV epidemics have higher-than-average HIV prevalence.

The authors drew on other literature to set the average probability of transmission per act of rape at 0.0028 to 0.032. (In Africa, the per-act probability of HIV being transmitted from an infected to an uninfected person during consensual heterosexual sex in the absence of sexually transmitted infections is estimated to be 0.0009.)

Although any range of estimates based on such broad parameters will itself be broad, the study findings still provide compelling evidence of the large-scale HIV prevention and treatment implications of conflict-associated rape.

Furthermore, mathematical modeling efforts to date, including this one, have not reflected indirect pathways by which rape may increase the number of HIV infections in a conflict-affected community. As the authors note, “Mass rape also indirectly increases HIV incidence through at least two other mechanisms: women who become infected through rape can transmit HIV to their future male partners and some survivors of rape may be infected with [another sexually transmitted infection] that increases their susceptibility to HIV.”

The authors also point out that rape survivors who become HIV-positive and pregnant are at risk of mother-to-child transmission of HIV.

Until recently it was speculated that mass rape in conflict-affected countries with large HIV epidemics might be helping to drive up or maintain overall national HIV prevalence levels. Key studies published in 2007 and 2008 showed that the available data did not support this hypothesis. Nonetheless, the sheer number of HIV cases thought to be attributable to mass rape calls attention to the need for HIV prevention and treatment programming as part of the response to conflict-related humanitarian crises.

Guidelines for addressing HIV in humanitarian settings, a recent publication by a United Nations-convened task force, recommends offering post-exposure prophylaxis (PEP) to rape survivors whose assailants may have exposed them to HIV.

However, the antiretrovirals used in PEP regimens may not be widely available in conflict settings. Even if they are, delays in accessing medical treatment may prevent rape survivors from benefitting from PEP, since it must be initiated within 72 hours of an episode of possible exposure to HIV.

The authors of the recent study echo the authors of the 2008 study that failed to find a link between mass rape and HIV prevalence by emphasising the importance of providing all rape survivors with appropriate medical and psychosocial services, including HIV-related services.

The group of researchers who published in 2008 stated, “Our findings must not be interpreted to say that widespread rape in conflict-affected countries does not pose a serious problem to women's acquisition of HIV on an individual basis or in specific settings. Although the increase in total prevalence is small compared with the overall population, it is horrific that tens of thousands of women acquire HIV from sexual violence during conflict.”

Meeting the HIV-related needs of rape survivors requires considerably more than providing access to PEP. Other relevant services include those relating to voluntary counseling and testing; prevention of mother-to-child transmission of HIV; and antiretroviral treatment.

Anema A et al. Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what? Emerg Themes Epidemiol 5: 11, 2008.

Supervie V et al. Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS, advance online publication, September 24, 2010.