Conflicts and humanitarian crises create new HIV vulnerabilities

Garnering a standing ovation at IAS 2025, Sameer Sah, from Medical Aid for Palestinians, provided a devastating first-hand account of what’s been happening for nearly two years in Gazan healthcare settings. While the territory has typically had very few cases of HIV, the volatile situation is now a potential hotbed for many infectious diseases, including HIV. “There were 80 cases of HIV in Gaza. Now the number is unknown,” Sah stated.  

At the 13th International AIDS Society Conference on HIV Science (IAS 2025) held in Kigali, Rwanda last week, there was a special session dedicated to providing HIV services in regions with humanitarian crises and conflicts. Rwanda’s recovery from the 1994 genocide – especially the immense progress made in terms of HIV outcomes – was contrasted with current crises.

The session also highlighted the challenging work that Médecins Sans Frontières is carrying out in multiple conflict regions globally, with some of the lessons learned on how best to reach people with HIV.

Attacks on healthcare facilities – and providers

Sah outlined how conflict regions such as Gaza are prone to infectious disease outbreaks. In addition to crumbling infrastructure, interruptions to safe water access, and sewage contamination, there are increases in gender-based violence, including sexual assault. Essential resources are in short supply of crucial items – including condoms, clean syringes and needles, and most critically, antiretroviral medications for both treatment and post-exposure prophylaxis. 

This is taking place against a backdrop of attacks on healthcare facilities and healthcare providers in multiple countries. In 2024, there were over 3600 attacks on healthcare facilities – 36% of these took place in occupied Palestine. Attacks on health care have increased substantially from previous years, 15% more than 2023, and 62% more than 2022. Across 23 countries and territories, 900 healthcare workers were killed last year – nearly half of these were from Lebanon, and a quarter from occupied Palestine. Additionally, 140 healthcare workers were kidnapped, 40% of them in three countries: Nigeria, Myanmar and the Democratic Republic of Congo. There were 1111 incidents where health facilities were damaged or destroyed – over 80% of these were in Myanmar, Sudan, Palestine and Ukraine alone. Of the 470 healthcare workers who were arrested or detained, 55% were held by Israeli forces.

Providing HIV care in conflict areas

Dr Daniela Garone from Médecins Sans Frontieres (MSF) noted that there is limited data on people living with HIV in humanitarian crisis settings. The last official data from 2016 estimates that of the 479 million people then living in conflict settings, at least 2.6 million had HIV. It’s challenging to say how much this has changed in recent years, but it’s likely much higher now. She estimated that one in every 14 people living in humanitarian contexts have HIV, including 157,000 children, 162,000 adolescents and 99,000 pregnant women. Access to antiretroviral therapy (ART) is dire: 43% of pregnant women and 79% of adolescents lacked access.

Across 14 countries with armed conflict and 17 countries with internal instability in 2024, MSF has supported numerous HIV services. This has included maintaining 14,089 people on ART and starting ART for 5024 people. There were a total of 6658 new HIV diagnoses, with 4963 people presenting with advanced HIV disease. In settings such as the Nord Kivu conflict region of the Democratic Republic of Congo, HIV prevalence is around 3%, compared to a national prevalence of 0.7%. This region has seen a long period of active conflict, with mobile populations vulnerable to acquiring HIV. There is a dramatic drop-off in viral suppression in regions such as these, with only 18% of those taking treatment virally suppressed. MSF has supported Nord Kivu by transporting medications across frontlines, providing stock during Ministry of Health shortages, and supporting existing health services, such as contact tracing and linkage to care, where possible.

In the Cabo Delgado province of Mozambique, ongoing violence has caused thousands to flee their homes. Many were already living in precarious conditions due to climate events. This province has a HIV prevalence of 13.2%, with only 55% of the approximately 165,000 people living with HIV virally suppressed. MSF was able to expand HIV testing in this region and get 10,000 people on PrEP. Among 14,800 people MSF tested for HIV in Yambio in South Sudan, there was a 3.4% HIV prevalence. Most (79%) were started on ART and 65% of these were retained in care at 18 months, with an 89% viral suppression rate among the 238 people tested.

Key challenges when it comes to providing HIV care include stigma, service and supply chain disruption, displacement and fragmented services, with HIV services often lacking integration with other healthcare services. Garone also emphasised the intersectional challenges faced by many in these regions, especially for already vulnerable groups, such as sexual and gender minorities, and young girls and women.

In the Haut-Mbomou region of the Central African Republic, there is an HIV prevalence of 12%, compared to the national HIV prevalence of 3.6%. Here, community ART groups have been an effective way of ensuring continued ART supply. Of 1573 people with HIV followed by MSF between 2016 and 2023, 88% have been enrolled in differentiated service delivery models, including 70% in community ART groups. Those enrolled in these community mechanisms had a nearly four times lower hazard of being lost to follow-up, and their risk of death was reduced by over twofold. These groups work by facilitating treatment adherence, peer support, reducing stigma and pressure on healthcare facilities.

Effective responses in times of crisis

Differentiated service delivery is essential to ensuring HIV care in places afflicted by humanitarian crises. Dr Darwin Dorestan of Georgetown University presented data from Haiti, showing how a Drug Dispensing Points (DDP) model was an efficient way of providing HIV care and ensuring viral suppression in a highly displaced population. Amongst 11 million people, ongoing violence and instability has led to the internal displacement of around 1 million. With a prevalence of 2.2%, only 120,000 people were on ART. Haiti has seen severe fuel shortages, limiting the transport of medications and lockdowns that have placed restrictions on healthcare access.

DDP services provide nationwide ‘pharmacy chains’ in strategic areas, avoiding so-called ‘red zones’ – areas deemed too dangerous for access. They provide for multiple delivery options and proximity to communities, with flexible hours – many of them provide an around-the-clock service.

The DDP setup process involved researchers, along with Ministry of Health and private sector partners, identifying key strategic community sites. Of 159 potential sites, 57 were selected to host DDPs. Community-based workers at these sites were trained by healthcare providers, and they were equipped with digital tools linking them with the Haitian National Dispensing Interface Platform. Local stakeholder engagement was central to this process, with service models tailored to the communities’ needs. While many DPPs are hosted by pharmacies and community centres, one of the selected sites was a voodoo temple, with priestesses providing DDP services.

The DDP service led to over 11,000 ART refills between 2020 and 2024, with 98% viral suppression rate among those on ART. This model helped reduce stigma and improve retention in care. More than 88% of ART pickups occurred outside the person’s usual district of residence, indicating the effects of displacement.

“It is possible to make a difference and to develop a resilient HIV response through this model,” Dorestan concluded. “Put the community at the wheel – even in the most fragile and dangerous environments.”

Sah ended his presentation with two sobering photos of him standing in Gaza, taken two years apart. In the first, taken in July 2023, the Al-Shifa hospital complex behind him is pristine. In the March 2025 picture, it has been reduced to rubble.