Recent research into the effect of mass rape on HIV in conflict situations has highlighted the need for better post-rape care services for affected women and girls.
Published in AIDS, the official journal of the International AIDS Society, the study, entitled Assessing the Impact of Mass Rape on the Incidence of HIV in Conflict-affected Countries, found that mass rape could cause about five new HIV infections per 100,000 females per year in the Democratic Republic of Congo (DRC), Sudan, Somalia and Sierra Leone, double that number in Burundi and Rwanda, and 20 new infections per 100,000 women per year in Uganda.
According to Sally Blower, one of the authors of the new study, women and girls infected through mass rape could act as bridges for HIV into the general population by infecting their sexual partners or their children through mother-to-child transmission.
The study found that under extreme conditions, mass rape could lead to as many as 10,000 women and girls becoming infected with HIV every year in the DRC, with that figure rising to up to 20,000 in Uganda.
Measuring HIV incidence in conflict situations with little data available is notoriously difficult. The authors used mathematical modelling to estimate the number of new infections based on four factors - the number of uninfected women and girls aged 15-49; the proportion of the population raped during conflict; the prevalence of HIV among assailants and the probability of HIV transmission per act of rape.
A separate, 2007 study by among others, Paul Spiegel, the UN Refugee Agency's chief of public health and HIV, found insufficient data to support the conventional wisdom that conflict, forced displacement, and wide-scale rape increased HIV prevalence in the general population, or that refugees spread HIV infection in host communities.
"We used the same data and mathematical modelling as the Spiegel study, but found that while HIV prevalence in the general population was unlikely to be affected by mass rape, incidence - the number of new infections - could be significantly affected by mass rape," Blower told IRIN/PlusNews.
They concluded that interventions and treatment such as post-exposure prophylaxis - a regimen of antiretrovirals administered to rape survivors to prevent HIV infection - and counselling targeted to rape survivors during armed conflicts could reduce HIV incidence.
"During conflicts, many women can be forced to migrate and seek shelter in camps, often separating them from social and safety networks and exposing them to sexual violence," the authors noted. "Focusing targeted interventions in refugee camps may be an effective means for reaching rape survivors."
She suggested that the findings of Spiegel's study may have been misleading for programmes aimed at preventing HIV in some conflict-affected countries.
"When we did our research, our purpose was to prove wrong a widely held belief that women raped in conflict were also highly likely to be HIV-positive," Spiegel told IRIN/PlusNews. "One often quoted false statistic is that a very high percentage of women raped during the Rwandan genocide were HIV-positive, which stigmatized this group of women."
"The availability of post-rape care is a basic human rights and public health issue - women and girls raped in conflict need to be provided with proper post-exposure prophylaxis, sexually transmitted infection diagnosis and care and counselling," he added. "We hope the new research will increase efforts to provide appropriate services to affected women."
Obstacles to post-rape care
The research comes in the wake of reports of the mass rape of more than 300 women in North Kivu, eastern DRC. The DRC's conflict-affected east has a history of sexual violence but several obstacles have prevented effective handling of post-rape care.
Many rapes take place in remote settings where women have little or no access to proper post-rape care or are unaware what action should be taken in the event of rape. According to a 2009 study of sexual violence in South Kivu by the NGO Malteser International, many women never come forward due to fear of stigmatization by their families and communities and of repercussions by perpetrators.
Protracted insecurity and kidnappings can also hinder women's access to emergency post-rape care services, the Malteser study found. To be effective, post-exposure prophylaxis must be administered as soon as possible - and no later than 72 hours - after a rape has occurred.
"Services are not always evenly available, and stigma is still a huge concern - many women go very far away from their home areas to seek services where they won't be recognized," said Banu Atunbas, the head of mission for the international medical NGO Médecins Sans Frontières (MSF) in the DRC. "If women do come forward, the health system is not always able to deal with all their concerns - PMTCT [prevention of mother-to-child transmission], for example, is not widely available as part of post-rape care services."
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MSF, which runs clinics in both North and South Kivu, has this year alone reported thousands of displaced citizens trapped by conflict and unable to access health care, and has had one of its hospitals raided by Congolese soldiers who removed some wounded patients.
According to Altunbas, one of the biggest problems with rape in the region is impunity; few perpetrators are ever brought to justice.
"As long as we keep treating women and never bringing the perpetrators to justice, it's like we are treating people for cholera without removing the contaminated water that is the source of the infection," she said. "We will just have to keep treating them, but it is not a final solution."