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