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HIV, AIDS and conflict in Africa: why isn't it (even) worse?

Published online by Cambridge University Press:  13 July 2010

COLIN MCINNES
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Abstract

The causes and consequences of HIV and AIDS are social are well as biomedical. Given the scale of the pandemic, understanding the social dimensions of HIV and AIDS is vital. One key argument is that there is a link between conflict and the spread of HIV. This appears to be particularly the case for sub-Saharan Africa where high levels of HIV prevalence are matched by violent conflict and state instability. Recent evidence however suggests that HIV prevalence does not always increase in conflict and that in some instances it may even reduce. This article attempts to explain why HIV has not increased in some sub-Saharan conflicts. To do this it moves beyond the use of risk factors to offer a new explanation based on susceptibility and vulnerability. It uses this explanation to examine four cases – Sierra Leone, Angola, Rwanda and the Democratic Republic of the Congo (DRC) – where conflict did not lead to a significant increase in the prevalence of HIV. The article concludes that, despite the fears of a few years ago, conflict does not readily act as a vector for the spread of HIV, though the potential for this to occur does still exist under certain circumstances.

Type
Research Article
Information
Review of International Studies , Volume 37 , Issue 2 , April 2011 , pp. 485 - 509
Copyright
Copyright © British International Studies Association 2010

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References

1 AIDS is a syndrome of infections and diseases which develops in human immune systems weakened by the virus HIV. Although often linked in the literature as one (typically ‘HIV/AIDS’), for this article it is appropriate to separate them. It is HIV which is spread by human-to-human contact and the article is concerned with the potential for conflict to accelerate this spread; but it is AIDS which kills.

2 UNAIDS, 2008 AIDS Epidemic Update (Geneva: UNAIDS/WHO, 2008), pp. 32–33Google ScholarPubMed . See also UNAIDS, 2009 Update Report, available at: {http://data.unaids.org/pub/Report/2009/JC1700_Epi_Update_2009_en.pdf}, which uses the 2008 data.

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4 High prevalence is defined as a rate above 3 per cent in the general population. See UNAIDS, 2008 AIDS Epidemic Update, p. 34.

5 UN Security Council [UNSC] Press Release SC/6781 (10 January 2000). Available at: {http://www.un.org/News/Press/docs/2000/20000110.sc6781.doc.html}.

6 UNSC Resolution [UNSCR] 1308 (July 2000), p. 2. Available at: {http://www.un.org/Docs/sc/unsc_resolutions.html}.

7 Although more recent empirical evidence supports the case for a link. See Zaryab Iqbal and Chris Zorn, ‘Violent conflict and the spread of HIV/AIDS in Africa’, Journal of Politics (forthcoming, 2010). I am grateful to the editors of JOP for permission to make reference to this forthcoming article.

8 For a fuller discussion of these risk factors see McInnes, Colin, ‘Conflict, HIV and AIDS: a new dynamic in warfare?’, Global Change, Peace and Security, 21 (February 2008), pp. 99–114Google Scholar .

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11 UNAIDS, On the Front Line 1st edition (Geneva/New York: UNAIDS, 2003), pp. 5–6Google ScholarPubMed ; NIE 99–17D, The Global Infectious Disease Threat, available at: {http://www.cia.gov/cia/publications/nie/report/nie99–17d.html}; Heinecken, Lindy, ‘Facing a merciless enemy: HIV/AIDS and the South African armed forces’, Armed Forces and Society, 29 (Winter 2003), p. 784CrossRefGoogle Scholar ; Ostergard, ‘Politics in the hot zone’, p. 343; ICG, HIV/AIDS as a Security Issue, p. ii, and Lessons from Uganda, pp. 2–3; Schneider and Moodie, The Destabilising Impact, p. 2.

12 See, for example, Docking, AIDS and Violent Conflict, p. 7. But in contrast see Alex de Waal, ‘HIV/AIDS and the military’, background paper to expert seminar and policy conference, AIDS, Security and Democracy, Clingendael Institute, The Hague (2–4 May 2005), p. 7.

13 See, for example, K. S. Subramanian, Impact of Conflict on HIV/AIDS in South Asia (2002), available at: {http://aidsportal.org/store/770.pdf}, p. 50. See also Singer, PW, ‘AIDS and international security’, Survival, 44 (Spring 2002), pp.150–151CrossRefGoogle Scholar . Though Ciantia sounds a note of caution, Ciantia, Filippo, ‘HIV seroprevalence in northern Uganda’, Journal of Medicine and the Person, 2 (December 2004), p. 174Google Scholar .

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16 Bennett, Correlation, p. 23.

17 Bennett, Correlation, p. 14. See also below.

18 Global Coalition on Women and AIDS, ‘Sexual violence in conflict settings and the risk of HIV’, Violence Against Women and HIV/AIDS, Information Bulletin Series, 2 (2004), p. 1Google Scholar . See also UNICEF, Children, Armed Conflict and HIV/AIDS (New York: UNICEF, 2003), pp. 2–3Google ScholarPubMed ; Mock et al., ‘Conflict and HIV’, p. 7; Subramanian, Impact of Conflict on HIV/AIDS, p. 49; Nguyen and Stovel, The Social Science of HIV/AIDS, p. 11; Mbow and Webb, ‘HIV/AIDS affected children’, p. 50.

19 Human Rights Watch, The War within the War: Sexual Violence against Women and Girls in Eastern Congo (New York: Human Rights Watch, 2002)Google Scholar .

20 Singer, ‘AIDS and international security’, pp. 152–3. See also Dan Thomas, ‘AIDS 2006: conflict makes girls and women even more vulnerable to HIV’, available at {http://www.unicef.org/aids/index_35317.html}, accessed on 12 May 2008; UNAIDS, ‘AIDS and conflict’; Bennett, Correlation, p. 13; Verstegen, HIV/AIDS, p. 4; [No author] ‘The Democratic Republic of Congo [DRC]: a country raped by all types of men’, Women's World, 34 (1999), pp. 22–3.

21 UNICEF, Children, Armed Conflict. But see also the case study on Rwanda below.

22 See for example Mock and others, ‘Conflict and HIV’; Bennett, Correlation, p. 15; Subramanian, Impact of Conflict, p. 51; Zwi, Anthony B., Ulgalde, Antonio and Roberts, Patricia, ‘Effect of war and political violence on health services’, Encyclopedia of Violence, Peace and Conflict Vol.1 (New York and London: Academic Press, 1999), pp. 683–685Google Scholar ; Bratt, ‘Blue condoms’, pp. 71–2; Elbe, ‘HIV/AIDS and the changing landscape of war’, p. 172.

23 Ellman, Tom, Culbert, Heather and Torres-Feced, Victoria, ‘Treatment of AIDS in conflict-affected settings: a failure of imagination’, The Lancet, 365 (January 2005), pp. 2 and 4CrossRefGoogle Scholar , although the authors also point out that the movement of people living with HIV or AIDS to refugee camps may make anti-retroviral therapies (ARTs) easier to administer. See also Tony Barnett, ‘Mapping the future of HIV/AIDS, Security and Conflict in Africa’, paper presented to Justice Africa/LSE AIDS Joint NGO/Academic Seminar, King's College, London (6 December 2005), p. 1.

24 Betsi et al., ‘Effect of armed conflict’, pp. 359–64.

25 Mock et al., ‘Conflict and HIV’.

26 Verstegen, HIV/AIDS, p. 5. See also Fourie and Schonteich, ‘Africa's new security threat’, p. 7.

27 Bratt, ‘Blue condoms’, p. 68; Schneider and Moodie, The Destabilising Impact, p. 8; Chalk, ‘Infectious disease’, p. 49; UNAIDS, On the Front Line, 1st edition, p. 6, Table 2.

28 UN, A Comprehensive Strategy to Eliminate Future Sexual Exploitation and Abuse in UN Peacekeeping Operations, Report A/59/710 (New York: UN, 2005), paras 3–10, 44 and 62. See also UNSC Press Release SC/8400 (31 May 2005), available at {http://www.un.org/News/Press/docs/2005/sc8400.htm}. Ironically, the ready availability of condoms to peacekeepers – distributed as a means of protecting them against HIV – was seen by some soldiers as an unofficial endorsement of sexual exploitation.

29 See, for example, Spiegel, Paul B., ‘HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action’, Disasters, 28 (September 2004), p. 323CrossRefGoogle Scholar .

30 UNAIDS, On the Front Line, 3rd edition (Geneva: UNAIDS/WHO, 2005), p. 26Google ScholarPubMed .

31 Alex de Waal, ‘HIV/AIDS and the military’, p. 8. De Waal's scepticism was reinforced by his doubt over the extent to which uniformed services experienced higher levels of HIV prevalence.

32 UNAIDS, On the Front Line, 3rd edition, p. 27; Netherlands Ministry of Foreign Affairs (NMFA), HIV/AIDS, Security and Democracy, Seminar Report, Clingendael Institute (4 May 2005), p. 5Google Scholar .

33 On possible initiatives to prevent the spread of HIV/AIDS in militaries, see UNAIDS, Uniformed Services Programming Guide (Geneva: UNAIDS, 2003)Google Scholar . See also Martin Foreman, Combat AIDS: HIV and the World's Armed Forces (London: Healthlink Worldwide, 2002), pp. 37–48Google Scholar ; UNAIDS Initiative on HIV/AIDS and Security: Third Quarterly Report (2002), available at: {http://www.who.int/hac/techguidance/pht/UNAIDS_initiative_HIV_security/en/}; ICG, Lessons from Uganda, pp. 3, 8–9 and 14. The UN's AIDS awareness card is available from {[email protected]}. For details on the card see UNAIDS Uniformed Services Programming Guide, p. 12.

34 Spiegel et al., ‘Prevalence of HIV infection’, p. 2007. See also Richard Walker, ‘UNHCR study challenges assumptions about refugees and HIV spread’, AIDSPortal news, available at: {http://www.aidsportal.org/News_Details.aspx?id=5215&nex=51}, accessed on 12 May 2008; UNAIDS, ‘AIDS and conflict’; de Waal, ‘HIV/AIDS and the military’, p. 8.

35 Ibid., p. 2191.

36 Anema, Aranka, Joffres, Michael R., Mills, Edward and Spiegel, Paul B., ‘Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what?’, Emerging Themes in Epidemiology, 5 (2008)CrossRefGoogle ScholarPubMed , available at: {http://www.ete-online.com/content/5/1/11}.

37 Zwi et al., ‘Effect of war’.

38 Data for this comparison was taken from: UNAIDS' annual epidemic updates (see n. 2); UN DPKO, Background Note: 31 December 2005, available at: {http://www.un.org/Depts/dpko/bnote.htm#unmil}, last accessed on 26 January 2006; US General Accounting Office, UN Peacekeeping: UN faces Challenges in Responding to the Impact of HIV/AIDS on Peacekeeping Operations, Report GAO-02–194 (Washington DC: US General Accounting Office, 2001)Google Scholar .

39 Spiegel et al., ‘Prevalence of HIV infection’, p. 2193; Iqbal and Zorn, ‘Violent conflict’.

40 See, for example, Ciantia, ‘HIV seroprevalence in northern Uganda’, p. 173–4; Mbow and Webb, ‘HIV/AIDS affected children’, p. 48; Nguyen and Stovel, The Social Science of HIV/AIDS, p. 12; Mock et al., ‘Conflict and HIV’, pp. 2–3.

41 These terms are adapted from the ‘Jaipur paradigm’ of Barnett and Whiteside, used to explain the relationship between HIV and state instability. Barnett, Tony and Whiteside, Alan, ‘The Jaipur Paradigm: a conceptual framework for understanding social susceptibility and vulnerability to HIV’, South African Medical Journal, 90 (2000), pp. 1098–1101Google Scholar .

42 Quinn, T. C., ‘Global burden of the HIV pandemic’, The Lancet, 348 (July 1996), pp. 99–106CrossRefGoogle Scholar ; Zhu, Tuofu, Korber, Bette T., Nahmias, Andre J., Hooper, Edward, Sharp, Paul M and Ho, David D., ‘An African HIV-1 sequence from 1959’, Nature, 391 (February 1998), pp. 594–597Google Scholar .

43 Mock et al., ‘Conflict and HIV’, p. 11; Quinn, ‘Global burden’.

44 Note also that since refugee flows are changes caused by conflict they fall under vulnerability rather than susceptibility, and are considered below under dissasortive mixing.

45 UNAIDS, 2008 AIDS Epidemic Update, pp. 88–9; England, Roger, ‘The writing is on the wall for UNAIDS’, British Medical Journal, 336 (May 2008), p. 102CrossRefGoogle Scholar .

46 Ostergard et al., ‘The relationship between HIV/AIDS’, p. 21.

47 Although evidence of malnutrition increasing the risk of acquiring HIV is limited there is a strong impact on the development of AIDS in people living with HIV. Mock et al., ‘Conflict and HIV’, 9; UNAIDS, ‘HIV, food security and nutrition’, Policy Brief (May 2008)Google ScholarPubMed , available at: {http://data.unaids.org/pub/Manual/2008/jc1515a_policybrief_nutrition_en.pdf}.

48 See, for example, Spiegel, ‘HIV/AIDS among conflict-affected and displaced populations’, p. 323; Verstegen, HIV/AIDS, 25; Mock et al., ‘Conflict and HIV’, pp. 4 and 7; UNAIDS, ‘AIDS and conflict’.

49 Robert L. Ostergard, Matthew R. Tubin and Erin Schweber, ‘The relationship between HIV/AIDS and rape: evidence from South Africa’, paper presented to annual ISA Conference, San Francisco, (March 2008), especially pp. 2 and 5; Ciantia, ‘HIV seroprevalence’, p. 172; Mock et al., ‘Conflict and HIV’, p. 7.

50 Though note that the UNAIDS methodology has evolved over the years to improve accuracy.

51 Much of the information on the conflict is taken from the UCDP entry on Sierra Leone, {http://www.ucdp.uu.se}, last accessed on 15 September 2008. Hereafter UCDP, Sierra Leone.

52 Sierra Leone: Country Report on Declaration Commitment to HIV and AIDS (2006–07), unpublished version of report prepared for the UN General Assembly on HIV and AIDS, p. 42. Hereafter UNGASS, Sierra Leone. See also data in UNHCR, The state of the World's Refugees 2006, especially annexes 2 and 4–6, available at: {http://www.unhcr.org/static/publ/sowr2006/toceng.htm}.

53 UN DPKO, UN Mission in Sierra Leone, available at: {http://www.un.org/Depts/dpko/missions/unamsil/index.html} last accessed in 2004.

54 Reinhard Kaiser, Paul Spiegel, Peter Salama, William Brady, Elizabeth Bell, Kyle Bond and Marie Downer, HIV/AIDS Seroprevalence and Behavioral Risk Factor Survey in Sierra Leone, April 2002 (Atlanta, GA: Centers for Disease Control and Prevention, 2002), p. 5Google Scholar . Hereafter CDC, Sierra Leone.

55 Statement by HE Mr Allied Ibrahim Kanu to the 26th Special Session of the UN General Assembly, available at: {http://www.un.org/ga/aids/statements/docs/sierrae.html}, last accessed on 19 September 2008; UNGASS, Sierra Leone, p. 7.

56 CDC, Sierra Leone, pp. 67–8; WHO/UNAIDS, Epidemiological Fact Sheet on HIV and AIDS: Sierra Leone, July 2008 Update (Geneva: WHO/UNAIDS, 2008), p. 5Google Scholar ; WHO, Country Health System Fact Sheet 2006: Sierra Leone (Geneva: WHO, 2006)Google Scholar .

57 UNGASS, Sierra Leone, pp. 4 and 6; Larsen, Mandi, Casey, Sara, Sartie, Moi-Tenga, Tommy, Judith, Musa, Tamba and Saldinger, Martha, ‘Changes in HIV/AIDS/STI knowledge, attitudes and practices among commercial sex workers and military forces in Port Loko, Sierra Leone’, Disasters, 28:3 (2004), pp. 240–1CrossRefGoogle Scholar .

58 UN Population Division, Word Population Prospects: The 2006 Revision Population Database Sierra Leone country profile, available at: {http://esa.un.org/unpp/p2k0data.asp}, last accessed on 17 October 2008.

59 See for example WHO/UNAIDS, Epidemiological Fact Sheet: Sierra Leone, p. 9.

60 Data from World Bank {http://ddp-ext.worldbank.org/ext/DDPQQ}, last accessed on 24 October 2008.

61 See for example UCDP, Sierra Leone; Larsen et al., ‘Changes’, p. 240.

62 UNGASS, Sierra Leone, p. 5.

63 See annual UNDP Human Development Reports available from {http://hdr.undp.org}.

64 Respondents to the CDC survey suggested that only 10 per cent of displaced persons sought refuge outside Sierra Leone, mostly in Guinea and Liberia. CDC, Sierra Leone p. 8.

65 Larsen et al., ‘Changes’, pp. 242–3.

66 UNGASS, Sierra Leone, p. 12; Larsen et al., ‘Changes’, p. 241.

67 CDC Sierra Leone, p. 62.

68 UCDP, Sierra Leone.

69 UNGASS, Sierra Leone, pp. 6, 18 and 45–62.

70 UNGASS, Sierra Leone, especially p. 13.

71 WHO, Country Health System: Sierra Leone; UNGASS, Sierra Leone, p. 5.

72 Larsen et al., ‘Changes’, pp. 239, 246 and 251; CDC, Sierra Leone, pp. 8 and 11.

73 Angola country page from UCDP database, available at: {http://www.ucdp.uu.se} last accessed on 6 October 2008. Hereafter UCDP, Angola.

74 See IISS Military Balance (various publishers) for period.

75 Bing, Eric G., Cheng, Karen G., Ortiz, Daniel J., Ovalle-Bahamon, Ricardo E., Ernesto, Francisco, Weiss, Robert E. and Boyer, Cherrie B., ‘Evaluation of a prevention intervention to reduce HIV risk among Angolan soldiers’, AIDS Behaviour, 12 (March 2008), p. 393CrossRefGoogle Scholar .

76 UNAIDS, Epidemiological Fact Sheet on HIV and AIDS: Angola – 2008 Update (Geneva: UNAIDS/WHO, 2008)Google Scholar , especially p. 9.

77 Data mined from {http://hdrstats.undp.org/buildtables/rc_report.cfm} and UNHCR State3 of the World's Refugees 2006.

78 UNAIDS, Epidemiological Fact Sheet: Angola – 2008, pp. 5, 8 and 11; UNAIDS, Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections: Angola – 2004 Update (Geneva: UNAIDS/WHO/UNICEF, 2004), pp. 2 and 4Google Scholar ; UNAIDS, Fact sheet: Sub-Saharan Africa (Geneva: UNAIDS/WHO, 2007)Google Scholar ; WHO, Country Health System Fact Sheet 2006: Angola (Geneva: WHO, 2006).

79 UN Population Division, Word Population Prospects: The 2006 Revision Population Database, Angola country profile, available at: {http://esa.un.org/unpp/p2k0data.asp}.

80 For example, Eric G. Bing, Daniel Ortiz, Ricardo E. Ovalle-Bahamon, Karen G. Chen, Fannie H. Huang, Francisco Ernesto and Naihua Duan, ‘HIV/AIDS behavioural surveillance among Angolan military men’, AIDS Behaviour, accessed from PubMed PMID 17641966, p. 578.

81 Data from World Bank {http://ddp-ext.worldbank.org/ext/DDPQQ}, last accessed on 24 October 2008.

82 Data from UNDP Human Development Report various years, available at: {http://hdr.undp.org}.

83 UNAIDS, Epidemiological Fact Sheet: Angola – 2008, p. 15; Bing et al., ‘Evaluation of a prevention intervention’, pp. 389 and 393; Bing et al., ‘HIV/AIDS behavioural surveillance’, pp. 580 and 583; UNAIDS, Epidemiological Fact Sheet: Angola – 2004 and 2008.

84 For example, Aceijas, Carmen, Stimson, Gerry V., Hickman, Matthew and Rhodes, Tim, ‘Global overview of injecting drug use and HIV infection among injecting drug users’, AIDS: Official Journal of the International AIDS Society, 18 (19 November 2004)CrossRefGoogle Scholar ; Buve, Anne, Kizito Bishikwabo-Nsarhaza and Gladys Mutangadura, ‘The spread and effect of HIV-1 infection in sub-Saharan Africa’, The Lancet, 359 (2002), pp. 2011CrossRefGoogle Scholar ; UNAIDS, Angola: Progress towards universal access and the Declaration Commitment on HIV/AIDS, figures 8 and 10, available at: {http://cfs.indicatorregsitry.org/country_factsheet.aspx?ISO=ANG}, last accessed on 28 October 2008.

85 UNAIDS, Epidemiological Fact Sheet: Angola – 2008, p. 15; UNDP, Human Development Report 2007 Data, available at: {http://hdrstats.undp.org/buildtables/rc_report.cfm}, last accessed on 20 October 2008; WHO, Country Health System 2006: Angola.

86 Much of the information on the conflict is taken from the UCDP's country page, hereafter UCDP Rwanda, available at: {http://www.ucdp.uu.se}, last accessed on 15 September 2008.

87 UCDP, Rwanda.

88 See for example Donovan quotation below.

89 See UNHCR, The State of the World's Refugees 2000, pp. 245–73, available at: {http://www.unhcr.org/static/publ/sowr2000/toceng.htm}.

90 Kayirangwa, E., Hanson, J., Munyakazi, L. and Kabeja, A., ‘Current trends in Rwanda's HIV/AIDS epidemic’, Sexually Transmitted Infections, 82 supplement 1 (2006), p. i29CrossRefGoogle Scholar , available at: {www.stijournal.com}, last accessed on 20 October 2008.

91 Komisiyo Y'Igihugu Ishinzwe Kurwanya, UN General Assembly Special Session on HIV/AIDS: Country Report – Rwanda hereafter UNGASS Rwanda (draft 2008), p. 14; UN Population Division, Word Population Prospects: The 2006 Revision Population Database, Rwanda country profile, available at: {http://esa.un.org/unpp/p2k0data.asp}, last accessed on 17 October 2008.

92 UNDP, Human Development Report 2007 Data, available at: {http://hdrstats.undp.org/buildtabls/rc_report.cfm}, last on accessed 3 October 2008. See also, UNAIDS, Epidemiological Fact Sheet on HIV and AIDS: Rwanda – 2008 Update (Geneva: UNAIDS/WHO, 2008), p. 4Google Scholar ; World Health Organisation, Country Health Fact Sheet 2006: Rwanda (Geneva: World Health Organisation 2006)Google Scholar ; UNGASS Rwanda, p. 14.

93 UCDP, Rwanda.

94 Data from the World Bank available at: {http://ddp-ext.worldbank.org/ext/DDPQQ}; and from the Rwanda National Institute of Statistics at: {http://statistics.gov.rw}.

95 UNAIDS, Epidemiological Fact Sheet: Rwanda, p. 6. See also Treatment and Research AIDS Center, HIV Sentinel Surveillance among Pregnant Women attending Antenatal Clinics, unpublished paper sponsored by Republic of Rwanda Ministry of Health and US Centers for Disease Control and Prevention (2002), pp. 11 and 14; and Kayirangwa et al., ‘Current trends’, p. i28.

96 Kayirangwa and others, ‘Current trends’, p. i28–9; Aisha Yousafzi and Karen Edwards, Double Burden: A Situation Analysis of HIV/AIDS and Young People with Disabilities in Rwanda and Uganda (London: Save the Children, 2004), pp. 57–58Google Scholar .

97 Donovan, Paula, ‘Rape and HIV/AIDS in Rwanda’, The Lancet Supplement, 360 (December 2002), p. s17CrossRefGoogle Scholar .

98 Kayirangwa and others, ‘Current trends’, p. i27.

99 Donovan, ‘Rape and HIV/AIDS’, p. s18.

100 UNAIDS, 2007 AIDS Epidemic Update, p. 18.

101 Anema, Aranka, Joffres, Michael R., Mills, Edward and Spiegel, Paul B., ‘Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what?’, Emerging Themes in Epidemiology, 5 (2008)CrossRefGoogle ScholarPubMed , available at: {http://www.ete-online.com/content/5/1/11}.

102 UNGASS, Rwanda, pp. 13 and 16.

103 Kayirangwa et al., ‘Current trends’, p. i27.

104 Democratic Republic of Congo (Zaire) country page from UCDP database, available at: {http://www.ucdp.uu.se}, last accessed on 6 October 2008. Hereafter UCDP, DRC.

105 Congo Democratic Republic National Multisectoral Programme for the Response to HIV/AIDS, Report on the Implementation of the Declaration of Commitment of the heads of State and of Government for the Response to HIV/AIDS in the DRC Draft (31 December 2005), hereafter UNGASS, DRC 2005 (Kinshasa: PNMLS/UNAIDS, 2005), p. 3. See also UNHCR State of the World's Refugees 2006 annexes 2 and 4–6, and State of the World's Refugees 2000, pp. 254–65 and pp. 268–71.

106 Initial data was available in 1984, but after 1993 this becomes much more sporadic until the early years of the new millennium.

107 Congo Democratic Republic National Multisectoral Programme for the Response to HIV/AIDS (PNMLS), Rapport National de suivi UNGASS, hereafter UNGASS, DRC 2007 (Kinshasa: PNMLS, 2007), p. 11Google Scholar ; WHO/UNAIDS, Epidemiological Fact Sheet on HIV and AIDS: Democratic Republic of Congo, 2008 Update (Geneva: WHO/UNAIDS/UNICEF, 2008), p. 5Google Scholar ; Kinoshita-Moleka, R., Smith, J. S., Atibu, J., Tshefu, A., Hemingway-Foday, J., Hobbs, M., Bartz, J., Koch, M. A., Rimoin, A. W. and Ryder, R. W., ‘Low prevalence of HIV and other selected sexually transmitted infections in 2004 in pregnant women from Kinshasa, the Democratic Republic of Congo’, Epidemiology and Infection, 136 (2008), pp. 1290–1296CrossRefGoogle Scholar ; Mulanga, Claire, Bazepo, Samuel Edidi, Mwamba, Jeanne Kasali, Butel, Christelle, Tshimpaka, Jean-Willy, Kashi, Mulowayi, Lepira, Francois, Carael, Michel, Peeters, Martine and Delaporte, Eric, ‘Political and socioeconomic instability: how does it affect HIV? A case study in the Democratic Republic of Congo’, AIDS, 18:5 (March 2004)CrossRefGoogle Scholar , available at: {http://www.aidsonline.com}, last accessed on 28 October 2008, pp. 905–10; WHO, Country Health System fact sheet 2006: DR Congo (Geneva: WHO, 2006)Google Scholar .

108 WHO/UNAIDS, Epidemiological Fact Sheet on HIV and AIDS: Democratic Republic of Congo, 2004 Update (Geneva: WHO/UNAIDS, 2004), p. 2Google Scholar .

109 WHO/UNAIDS, Epidemiological Fact Sheet: DRC 2004, pp. 4–5.

110 Spiegel, ‘HIV/AIDS among conflict-affected’, p. 325.

111 Mulanga et al., ‘Political and socioeconomic instability’.

112 UN Population Division, Word Population Prospects: The 2006 Revision Population Database, DRC country profile, available at: {http://esa.un.org/unpp/p2k0data.asp}, last accessed on 17 October 2008; UNGASS, DRC 2005, p. 3; WHO/UNAIDS, Epidemiological Fact Sheet: DRC 2004, p. 3.

113 Data from the World Bank at: {http://ddp-ext.worldbank.org/ext/DDPQQ}.

114 Mulanga and others, ‘Political and socioeconomic instability’.

115 UNDP, Human Development Report 2007 Data, available at: {http://hdrstats.undp.org/buildtabls/rc_report.cfm}, last accessed on 3 October 2008.

116 There are a number of examples of HIV prevalence reaching a plateau within communities. See, for example, Fowke, K. R., Nagelkerke, N. J., Kimani, J., Sominsen, J. A., Anzala, A. O., Bwayo, J. J., MacDonald, K. S., Ngugi, E. N. and Plummer, F. A., ‘Resistance to HIV-1 infection among persistently seronegative prostitutes in Nairobi, Kenya’, The Lancet, 348 (November 1996), pp. 1347–51CrossRefGoogle Scholar ; Brown, Tim, Sittrai, Werasit, Vanichseni, Suphak and Thisyakorn, Usa, ‘The recent epidemiology of HIV and AIDS in Thailand’, AIDS, 8 (1994), suppl 2 pp. S131–41Google Scholar ; Meda, Nicolas, Ndoye, Ibra, M'Boup, Soulemayne, Wade, lpha, Ndiayee, Salif, Niang, Cheikh, Sarr, Fatou, Diop, Idrissa and Carael, Michel, ‘Low and stable HIV infection rates in Senegal’, AIDS, 13 (July 1999), pp. 1397–1405CrossRefGoogle Scholar .

117 WHO/UNAIDS, Epidemiological Fact Sheet: DRC 2008, pp. 12 and 15; UNGASS, DRC 2005, pp. 14–15; R. Kinoshita-Moleka et al., ‘Low prevalence of HIV’, pp. 1290–6; Judith M. Vandepitte, Faustin Malele, Dieu-Merci Kivuvu, Samuel Edidi, Jeremie Muwonga, Francois Lepira, Said Abdellati, Joelle Kabamba, Catherine van Overloop, Anne Buve, ‘HIV and other sexually transmitted infections among female sex workers in Kinshasa, Democratic Republic of Congo, in 2002’, Sexually Transmitted Diseases, 34:4 (April 2007), available at: {http://www.stdjournal.com}, last accessed on 28 October 2008.

118 For example, Puechguirbal, Nadine, ‘Women and war in the Democratic Republic of Congo’, Signs: Journal of Women in Culture and Society, 28:4 (Summer 2003), pp. 1271–1281CrossRefGoogle Scholar ; World Food Programme, ‘War on women: rape legacy of DRC conflict’, available at: {http://wfr.org/newsroom/in_depth/Africa/CongoDr/031107_WarWomen}, last accessed on 11 December 2008; CBS News, ‘War against women: the use of rape as a weapon in Congo's civil war’ (17 August 2008), available at: {http://www.cbsnews.com}, last accessed on 11 December 2008.

119 Spiegel, ‘HIV/AIDS among conflict-affected’, p. 325.

120 Anema et al., ‘Widespread rape’.

121 Mulanga et al., ‘Political and socioeconomic instability’.

122 UNAIDS, Democratic Republic of Congo: Progress towards Universal Access and The Declaration Commitment on HIV/AIDS, available at: {http://cfs.indicatorregistry.org/country_factsheet.aspx}, last accessed on 30 October 2008.

123 WHO/UNAIDS, Epidemiological Fact Sheet 2004: DRC, p. 9; R. Kinoshita-Moleka et al., ‘Low prevalence of HIV’; WHO, Country Health System: DRC.

124 I am grateful to Julia Braxton for making this point to me. See Julia Buxton, ‘Deconstructing the addiction to the war on drugs’, paper presented to the annual BISA Conference, Exeter (December 2008). See also UNAIDS, 2008 AIDS Epidemic Update, p. 43.

125 Elbe, ‘HIV/AIDS and the changing landscape of war’.