HIV/AIDS among Pastoralists & Refugees in North-East Africa: A Neglected Problem

The eight member states (Djibouti, Eritrea, Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda) of the Intergovernmental Authority for Development (IGAD) have the largest proportions of cross-border mobile pastoralists and refugees in Africa. Although all IGAD countries have had national HIV/AIDS prevention, care and treatment programmes since the late 1980s, the IGAD Regional HIV & AIDS Partnership Program was (IRAPP) established in 2007 to mitigate the challenges of HIV among neglected pastoral and refugee communities. 

This article assesses vulnerability of pastoralists and refugee communities to HIV and interventions targeting these groups in the IGAD countries. Outcomes from this study may serve as a baseline for further research and to improve interventions. Published articles were accessed through web searches using PubMed and Google Scholar engines and unpublished documents were collected manually. The search terms were HIV risk behaviour, vulnerability, HIV prevalence and interventions, under the headings pastoralists, refugees, IGAD and north-east Africa for the period 2001-2014. 

Of the 214 documents reviewed, 78 met the inclusion criteria and were included. Most HIV/AIDS related studies focusing of pastoral communities in IGAD countries were found to be limited in scope and coverage but reveal precarious situations. 

Sero-prevalence among various pastoral populations ranged from 1% to 21% in Ethiopia, Kenya, Somalia and Uganda and from 1% to 5% among refugees in Sudan, Kenya and Uganda. Socioeconomic, cultural, logistic, infrastructure and programmatic factors were found to contribute to continuing vulnerability to HIV. Interventions need to be further contextualised to the needs of those impoverished populations and integrated into national HIV/AIDS programmes. HIV/AIDS remains a major public health concern among the pastoral and refugee communities of IGAD countries. 

This calls for IGAD to collaborate with national and international partners in designing and implementing more effective prevention and control programmes. Furthermore, interventions must extend beyond the health sector and improve the livelihood of these populations.

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By:  Serbessa MK1, Mariam DH1, Kassa A2, Alwan F3, Kloos H4.

• 1 School of Public Health, College of Health Sciences , Addis Ababa University.
• 2 IGAD Regional HIV/AIDS Partnership Program-Programme Facilitation Office (IRAPP-PFO) , Kampala , Uganda.
• 3 Intergovernmental Authority for Development (IGAD) Secretariat , Djibouti.
• 4 Department of Epidemiology and Biostatistics , University of California , San Francisco , USA. 

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Hepatitis C Virus Epidemiology in Djibouti, Somalia, Sudan, and Yemen: Systematic Review and Meta-Analysis

OBJECTIVES:

To characterize hepatitis C virus (HCV) epidemiology and assess country-specific population-level HCV prevalence in four countries in the Middle East and North Africa (MENA) region: Djibouti, Somalia, Sudan, and Yemen.

METHODS:

Reports of HCV prevalence were systematically reviewed as per PRISMA guidelines. Pooled HCV prevalence estimates in different risk populations were conducted when the number of measures per risk category was at least five.

RESULTS:

We identified 101 prevalence estimates. Pooled HCV antibody prevalence in the general population in Somalia, Sudan and Yemen was 0.9% (95% confidence interval [95%CI]: 0.3%-1.9%), 1.0% (95%CI: 0.3%-1.9%) and 1.9% (95%CI: 1.4%-2.6%), respectively. The only general population study from Djibouti reported a prevalence of 0.3% (CI: 0.2%-0.4%) in blood donors. In high-risk populations (e.g., haemodialysis and haemophilia patients), pooled HCV prevalence was 17.3% (95%CI: 8.6%-28.2%) in Sudan. In Yemen, three studies of haemodialysis patients reported HCV prevalence between 40.0%-62.7%. In intermediate-risk populations (e.g.. healthcare workers, in patients and men who have sex with men), pooled HCV prevalence was 1.7% (95%CI: 0.0%-4.9%) in Somalia and 0.6% (95%CI: 0.4%-0.8%) in Sudan.

CONCLUSION:

National HCV prevalence in Yemen appears to be higher than in Djibouti, Somalia, and Sudan as well as most other MENA countries; but otherwise prevalence levels in this subregion are comparable to global levels. The high HCV prevalence in patients who have undergone clinical care appears to reflect ongoing transmission in clinical settings. HCV prevalence in people who inject drugs remains unknown.

Full article at: 

By:  Chaabna K1,2, Kouyoumjian SP1, Abu-Raddad LJ1,2,3.

• 1Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar.
• 2Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, New York, United States of America.
• 3College of Public Health, Hamad bin Khalifa University, Doha, Qatar.

PLoS One. 2016 Feb 22;11(2):e0149966. doi: 10.1371/journal.pone.0149966. eCollection 2016.

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Estimating the Magnitude of Female Genital Mutilation/Cutting in Norway: An Extrapolation Model

Background

With emphasis on policy implications, the main objective of this study was to estimate the numbers of two main groups affected by FGM/C in Norway: 1) those already subjected to FGM/C and therefore potentially in need for health care and 2) those at risk of FGM/C and consequently the target of preventive and protective measures. Special attention has been paid to type III as it is associated with more severe complications.

Methods

Register data from Statistics Norway (SSB) was combined with population-based survey data on FGM/C in the women/girls’ countries of origin.

Results

As of January 1^st 2013, there were 44,467 first and second-generation female immigrants residing in Norway whose country of origin is one of the 29 countries where FGM/C is well documented. About 40 pct. of these women and girls are estimated to have already been subjected to FGM/C prior to immigration to Norway. Type III is estimated in around 50 pct. of those already subjected to FGM/C. Further, a total of 15,500 girls are identified as potentially at risk, out of which an approximate number of girls ranging between 3000 and 7900 are estimated to be at risk of FGM/C.

Conclusion

Reliable estimates on FGM/C are important for evidence-based policies. The study findings indicate that about 17,300 women and girls in Norway can be in need of health care, in particular the 9100 who are estimated to have type III. Preventive and protective measures are also needed to protect girls at risk (3000 to 7900) from being subjected to FGM/C. Nevertheless, as there are no appropriate tools at the moment that can single these girls out of all who are potentially at risk, all girls in the potentially at risk group (15,500) should be targeted with preventive measures.

Below:  FGM/C Percentage of girls and women already subjected to FGM/C in Norway by country of origin

Below:  Numbers of girls and women subjected to FGM/C type III by most represented countries of origin

Full article at:   http://goo.gl/QFkFuS

By:  Mai M. Ziyada, Marthe Norberg-Schulz, and R. Elise B. Johansen

Norwegian Centre for Violence and Traumatic Stress Studies, P.b. 181 Nydalen, 0409 Oslo, Norway

Samfunnsøkonomisk analyse (Formerly DAMVAD Norge AS), Olavsvei 112, 1450 Nesoddtangen, Norway

Mai M. Ziyada, Email: on.stvkn@adayiz.m.m.

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Countries with Highest Prevalence of Female Genital Mutilation, 2004-15

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Female Genital Mutilation/Cutting: Risk Management and Strategies for Social Workers and Health Care Professionals

Female genital mutilation/cutting (FGM/C) is a traditional practice originating in Africa. Its worst forms cause irreparable harm to girls and women and have no medical justification. Based on a literature review of global responses to FGM/C and conversations with Australian women who migrated from FGM/C practicing countries, this paper provides some background on FGM/C and its epidemiology, outlining its prevalence, types, and health risks and complications for women and girls. It discusses risk-prevention strategies, first, for health practitioners in identifying, screening, and supporting women affected by FGM/C and, second, for welfare and social workers and health care professionals to identify, work with, and prevent girls from being cut. Consistent with international trends in addressing the risks of FGM/C, the paper suggests practice responses for coordinated responses between professionals, communities from practicing countries, and governments of different countries.

Countries grouped according to prevalence, types I, II, and III and laws against FGM/C

Categories	Prevalence of girls and women of reproductive age who report having been cut, and Type of FGC/M	Countries	Countries with laws against FGM/C
1. Very high prevalence countries, almost universal	Over 80% of girls and women of reproductive age reported having been cut, 30% Type III	Somalia (98%), Guinea (96%), Djibouti (93%), Egypt (91%). Eritrea (89%), Mali (89%), Sierra Leone (88%), Sudan (88%).	Djibouti, Egypt. Eritrea, Guinea, Somalia, Sudan.
2. Moderately high prevalence countries	Between 51% and 80% of girls and women cut, predominantly Types I and II	Gambia (76%), Burkina Faso (76%), Ethiopia (74%), Mauritania (69%), Liberia (66%).	Burkina Faso, Ethiopia, Mauritania.
3. Moderately low prevalence countries	Between 26% and 50% of girls and women cut, predominantly Types I and II	Guinea Bissau (50%), Chad (44%), Cote D’Ivoire (38%), Kenya (27%), Nigeria (27%), Senegal (26%).	Chad, Cote D’Ivoire, Kenya, Senegal, Guinea Bissau, Nigeria.
4. Low prevalence	Between 10 and 25%, predominantly Types I and II	Central African Republic (24%), Yemen (23%), United Republic of Tanzania (15%), Benin (13%).	Central African Republic, Benin, United Republic of Tanzania.
5. Very low prevalence	Below 10%	Iraq (8%), Ghana (4%), Togo (4%), Niger (2%), Cameroon (1%), Uganda (1%).	Ghana, Niger, Togo.

Notes: Data from UNICEF 2013,4 and Macfarlane and Dorkenoo.15

Abbreviation: FGM/C, female genital mutilation/cutting.

Full article at:   http://goo.gl/h2My9U

By:  Susan Costello

School of Global, Urban and Social Studies, RMIT University, Melbourne, VIC, Australia

Correspondence: Susan Costello, School of Global, Urban and Social Studies, RMIT University, 360 Swanston Street, Melbourne 3001, VIC, Australia, Email ua.ude.timr@olletsoc.nasus

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Relation of Psychosocial Factors to Diverse Behaviors and Attitudes among Somali Refugees

Refugee studies have examined both resilience and adverse outcomes, but no research has examined how different outcomes co-occur or are distinct, and the social-contextual factors that give rise to these diverse outcomes. 

The current study begins to address this gap by using latent profile analysis to examine the ways in which delinquency, gang involvement, civic engagement, political engagement, and openness to violent extremism cluster among Somali refugees. We then use multivariable regression analyses to examine how adversity (e.g., discrimination, trauma, and marginalization) is associated with the identified latent classes. Data were collected from 374 Somali refugee young adults (Mage = 21.30 years, SD = 2.90, range 18-30, 38% female) from 4 different North American communities. 

Participants completed a structured survey assessing their experiences of adversity, delinquent and/or violent attitudes and behaviors (e.g., attitudes toward violent extremism, participation in delinquent behaviors, involvement in gangs), and positive outcomes (e.g., civic and political engagement). 

Our findings indicate that participants fall into 5 distinct groups, and that social-contextual and individual factors are uniquely related to those groups. Specifically, strong social bonds seem to be associated with positive outcomes. 

These findings point to the need to further examine both positive and negative outcomes, paying special attention to social-contextual factors.

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By:  Ellis BH, Abdi SM, Lazarevic V, White MT, Lincoln AK, Stern JE, Horgan JG.

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Violence & Reproductive Health Preceding Flight from War: Accounts from Somali Born Women in Sweden

Political violence and war are push factors for migration and social determinants of health among migrants. Somali migration to Sweden has increased threefold since 2004, and now comprises refugees with more than 20 years of war experiences. Health is influenced by earlier life experiences with adverse sexual and reproductive health, violence, and mental distress being linked. Adverse pregnancy outcomes are reported among Somali born refugees in high-income countries. The aim of this study was to explore experiences and perceptions on war, violence, and reproductive health before migration among Somali born women in Sweden.

Qualitative semi-structured individual interviews were conducted with 17 Somali born refugee women of fertile age living in Sweden. Thematic analysis was applied.

Before migration, widespread war-related violence in the community had created fear, separation, and interruption in daily life in Somalia, and power based restrictions limited access to reproductive health services. The lack of justice and support for women exposed to non-partner sexual violence or intimate partner violence reinforced the risk of shame, stigmatization, and silence. Social networks, stoicism, and faith constituted survival strategies in the context of war.

Several factors reinforced non-disclosure of violence exposure among the Somali born women before migration. Therefore, violence-related illness might be overlooked in the health care system. Survival strategies shaped by war contain resources for resilience and enhancement of well-being and sexual and reproductive health and rights in receiving countries after migration.

“…they [the militia men] abused me. […] They think that if someone happens to see the genital organs of a married woman, the woman has to be stoned – stoned to death. […] It was just after the delivery I escaped. I had recently given birth.” (Woman 5)

“This with rape, I think is something new in Somalia. So, the general public or the people have not learned how to support and what kind of help is available. There are different women’s organizations helping. Not many know they exist. And before the war I don’t think there has been such an organization helping women that have been exposed to violence […] So, I think it will be that you keep it to yourself, in the small family.” (Woman 17)

Table 2

Themes and sub-themes on war, violence and SRH in Somalia

Theme	Subthemes
Violence is everywhere in war-torn Somalia	Controlled by the fear of violence
	Interrupted life and scattered families
	Childbearing – natural but hazardous
The silence of sexual and intimate partner violence	Rape happens, but who can intervene?
	Intimate partner violence is a family issue
Stoic women keep life together	We cannot dwell on what cannot be changed
	We have learnt to be strong

Full article at: http://goo.gl/LEWzzu

By: Ulrika Byrskog, Pia Olsson, Birgitta Essén, and Marie Klingberg Allvin

School of Education, Health and Social Studies, Dalarna University, S-791 88 Falun, Sweden

Department of Women’s and Children’s Health, Uppsala University, Akademiska sjukhuset, S-751 85 Uppsala, Sweden

Centre for Clinical Research, Nissers väg 3, S-791 82 Falun, Sweden

Ulrika Byrskog, Email: es.ud@ybu.

   

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Qualitative Interviews with Non-National Tuberculosis Patients in Cairo, Egypt: Understanding the Financial & Social Cost of Treatment Adherence

Limited data are available about the challenges of non-national TB patients undergoing long-term treatment courses in an urban setting. This study aimed to understand the financial and social cost of adherence of non-national TB patients in Cairo, Egypt as a means to inform the development of context-specific interventions to support treatment adherence. 

In 2011, 22 in-depth interviews were conducted with TB patients from Sudan, Ethiopia, Eritrea, Somalia and Djibouti to obtain qualitative data. Analysis was based on thematic analysis that aimed to identify recurrent themes and codes from the narratives. 

The study identified a number of factors that influence TB treatment adherence. Uncertain financial status due to limited or no employment was frequently discussed in interviews, which resulted in fear of not being able to support family, loss of pride, dependence on family and friends, fear of losing housing, food insecurity and limited food options. Respondents also feared infecting other household members and longed for opportunities to discuss their illness and treatment experiences with other individuals but their social networks were often limited. TB-related stigma was driven by shame and blame of infection. Respondents also believed stigma was based on their foreign origin. Stigma manifested in distancing and exclusion in various ways, resulting in isolation, psychological distress and reluctance to disclose TB status to others. Poverty-related factors and social context with a special focus on stigma should be considered when developing strategies for supporting long-term treatment courses for non-national patients in Cairo and other similar urban settings.

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By:  Lohiniva AL1, Mokhtar A2, Azer A3, Elmoghazy E4, Kamal E5, Benkirane M1, Dueger E1,6.

• 1Global Disease Detection and Response Program, U.S. Naval Medical Research Unit No 3, Cairo, Egypt.
• 2National Tuberculosis Program, Ministry of Health in Egypt, Cairo, Egypt.
• 3United Nations High Commissioner for Refugees, 7th District, Egypt.
• 4Cairo Association Against Smoking, Tuberculosis and Lung diseases, Cairo, Egypt.
• 5Refugee Egypt, Cairo, Egypt.
• 6Centers for Disease Control and Prevention, Atlanta, Georgia, USA. 

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“A Somali Girl is Muslim and Does Not Have Premarital Sex. Is Vaccination Really Necessary?” A Qualitative Study into the Perceptions of Somali Women in the Netherlands About the Prevention of Cervical Cancer

Below:  The health belief model

In this study, we have identified perceived barriers to the use of preventive measures across three major themes: (1) Somali women and preventive healthcare; (2) Language, knowledge, and negotiating decisions; and (3) Sexual standards, culture, and religion. Many issues have been identified across these themes, e.g., distrust of the Dutch health care system or being embarrassed to get Pap smears due to Female Genital Mutilation (FGM) and having a Dutch, male practitioner; or a perceived low susceptibility to HPV and cancer because of the religious norms that prohibit sex before marriage.

Current measures in the Netherlands to prevent women from developing cervical cancer hardly reach Somali women because these women perceive these kinds of preventative measures as not personally relevant. Dutch education strategies about cervical cancer deviate from ways of exchanging information within the Somali community.

Teachers can provide culturally sensitive information to young Somali women in schools. For Somali mothers, oral education (e.g., poetry or theater) about the Dutch health care system and men’s roles in HPV transmission may be useful.

An intersectional approach, grounded in the Health Belief Model (HBM), is recommended to promote equal access to preventive health care for Somali women.

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