Eritrean refugees desperate for HIV services

Every evening as the sun sets over the hills of northern Ethiopia, young couples can be seen strolling past the coffee shops and pool halls of Shimelba refugee camp.

An estimated 10,000 refugees live in Shimelba. The camp resembles a mini-Asmara - a slice of life from Eritrea’s capital city, recreated in rural Ethiopia by Eritreans fleeing an authoritarian government and lengthy military service.

The refugees are predominantly young and urban; many are former soldiers and all are living together in an atmosphere of stifling boredom - perfect conditions for the spread of HIV. Yet no one knows how widespread the virus has become as no testing is available in the camp.

Instead, the camp’s doctor is left to make an educated guess from examining his patients, both those who are still living and those who have died. The picture doesn't look good to Dr. Teferie Tadeje, of the Agency for Refugee and Returnee Affairs (ARRA) - the Ethiopian government agency responsible for the camp. He said that after malaria, HIV/AIDS is the biggest health threat to camp residents.

A traditional cultural aversion to talking about sex is compounded by the lack of treatment available in the camp. "This is one area in which the refugees are let down," admitted the doctor.

Clear clinical manifestations of HIV/AIDS are becoming increasingly common at Tadeje’s surgery, and the incidence of other diseases commonly associated with the virus suggest the HIV prevalence, though hidden, is significant.

"In the first six months of the year we had 152 cases of sexually transmitted infections; that is a very high rate which suggests HIV," Tadeje said. "We have 26 patients with tuberculosis, [and they’re] increasing year on year."

"Some patients come to you and you give them the standard treatment for their condition, but the response is not what you would expect," he added. "That suggests there is something else behind it."

Results from the nearest HIV testing center 20 kilometres away in the local town of Shirauro appear to confirm Tadeje’s fears. Of the roughly five refugees a week who manage to obtain the permit needed to leave the camp and travel to the center, the clinic's counsellor, Sister Genet Desta, estimated that on average, three test positive.

"The bar girls sleep with the refugees, they sleep with the military ...rates are rising," she said.

RISK FACTORS

The majority of the camp’s residents come from the Tigrinya ethnic community and migrated from cities where HIV rates are much higher than in Eritrea's rural areas.

There are few families in the camp. Mahmud Ahmed, a member of the camp's residents' committee, estimated that at least one-third of the children are living without their parents. The figure for sexually active youth is even higher.

"If you are living with your parents you have to behave in a disciplined manner, but if you are alone you act more freely; you are going to be more promiscuous," he said. "That's exactly what happens here."

Many refugees are former soldiers who were exposed to a high risk of sexually transmitted infections through commercial sex before escaping conscription. In addition, crossing the border from Eritrea into Ethiopia often requires paying off soldiers, and for women that can involve sex.

"Most women tell me that they gave sex as an alternative [to money] when crossing the border," Tadeje said. "Sometimes they are gang raped. Most of them who arrive here have chronic inflammatory infections and sexually transmitted diseases - it's a good indication that what they tell us about sexual assault is true."

Mark Roeder, field protection officer with the United Nations refugee agency, UNHCR, said that with four men for every woman in the camp, "you already have a problem." Sex is the only service many women have to sell, providing a little money for extra food and new clothes.

"Most women in the camp will sleep with someone from time to time for money," confided one young refugee now staying in the local town. "You do what you have to do to get by."

Sex can also provide an escape route from the dusty, isolated camp to the world beyond. "Many women have a need to marry someone with a hope of resettlement," said Tadeje. "So they repeatedly change their sexual partners, as they see who is more likely to get priority."

ISOLATED AND OSTRACIZED

With no treatment available and high levels of stigma, HIV-positive refugees struggle to survive in the camp.

When Adam Mussa went public with his HIV positive status, his community, the Eritrean Kunamas - traditional agriculturalists who migrated en masse after supporting the Ethiopians in the two countries' bitter war, soon shunned him. Now he drifts in and out of sleep on a hard, mud bed, waiting to die. His carer, Deshele Kibrea, a Tigray man who took him into his home, remembers when Mussa had the energy to speak with passion about why he had chosen to disclose.

"He'd say, 'My aim was to save people from dying from HIV. I want people to see it like any other disease - to see it like malaria or cancer.' He was a very brilliant and strong man," Deshele said. "But after he disclosed this his own friends and family started to run away from him."

That level of stigma will only change, added Deshele, when camp residents can access HIV testing and treatment: "People need VCT [voluntary counselling and testing], then after that, when there are more people who know their status, more people will help them. People need to find ways to live with AIDS before the stigma reduces."

URGENT NEED FOR HIV SERVICES

Camp resident Lydia Tesfaye, who works with victims of gender-based violence, said there is a growing demand for better HIV/AIDS services in the camp.

"To check status we need a pass permit and that can be difficult," she said. "Then, if people have positive results they need counselling and that doesn't just happen on one short visit outside; they need it readily available here in the camp."

But there is little point in providing testing without drugs, said Demeke Yitagew, HIV/AIDS programme officer with the International Rescue Committee, which currently runs sensitisation workshops and condom distribution in the camp.

"If you forget about the ART [antiretroviral therapy] then people who should be testing will ask, 'what is the point?'," Demeke said.

UNHCR's Roeder said that whilst he would like to see the problem addressed, "it's a question of priorities. Is it correct to make the cut with VCT or with plastic sheeting that could prevent malaria?"

Tadeje believes the solution is for the camp to integrate with Ethiopia's public health system. Only then can camp residents access treatment for AIDS-related complications.

Adam Mussa tried to live with the virus. He made the day-long journey to the Tigray capital, Mekele, and back again, becoming the first camp resident to buy life-prolonging anti-retroviral drugs. However, opportunistic infections had already taken a firm hold of his body.

"You can see that he is nearing his end now," Deshele said. "But this is not for him alone; others will follow, and the same thing should not be allowed to be repeated."

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