HIV infection among internally displaced women and women residing in river populations along the Congo River, Democratic Republic of Congo.

Abstract

We conducted a reproductive health assessment among women aged 15-49 years residing in an internally displaced persons (IDP) camp and surrounding river populations in the Democratic Republic of Congo. After providing informed consent, participants were administered a behavioral questionnaire on demographics, sexual risk, reproductive health behavior, and a history of gender based violence. Participants provided a blood specimen for HIV and syphilis testing and were referred to HIV counseling and testing services established for this study to learn their HIV status. HIV prevalence was significantly higher among women in the IDP population compared to women in the river population. Sexually transmitted infection symptoms in the past 12 months and a history of sexual violence during the conflict were associated with HIV infection the river and IDP population, respectively. Targeted prevention, care, and treatment services are urgently needed for the IDP population and surrounding host communities during displacement and resettlement.

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ORIGINAL PAPER
HIV Infection Among Internally Displaced Women and Women
Residing in River Populations Along the Congo River,
Democratic Republic of Congo
Andrea A. Kim Æ Æ Faustin Malele Æ Æ Reinhard Kaiser Æ Æ Nicaise Mama Æ Æ
Timothe ´e Kinkela Æ Æ Jean-Caurent Mantshumba Æ Æ Michelle Hynes Æ Æ
Stacy De Jesus Æ Æ Godefoid Musema Æ Æ Patrick K. Kayembe Æ Æ
Karen Hawkins Reed Æ Æ Theresa Diaz
? Springer Science+Business Media, LLC 2009
Abstract
among women aged 15–49 years residing in an internally
displaced persons (IDP) camp and surrounding river popu-
lations in the Democratic Republic of Congo. After
providing informed consent, participants were administered
a behavioral questionnaire on demographics, sexual risk,
reproductive health behavior, and a history of gender based
violence. Participants provided a blood specimen for HIV
andsyphilistestingandwerereferredtoHIVcounselingand
testing services established for this study to learn their HIV
We conducted a reproductive health assessment
status. HIV prevalence was significantly higher among
women in the IDP population compared to women in the
river population. Sexually transmitted infection symptoms
inthepast12 monthsandahistoryofsexualviolenceduring
the conflict were associated with HIV infection the river and
IDPpopulation,respectively.Targetedprevention,care,and
treatment services are urgently needed for the IDP popula-
tion and surrounding host communities during displacement
and resettlement.
Keywords
Displacement ? Conflict
HIV ? Sexually transmitted infections ?
Introduction
The first case of HIV infection in the Democratic Republic
of Congo (DRC) was detected in 1983. Since then the HIV
epidemic has continued to spread in the general population,
primarily through heterosexual transmission. Overall, the
country has maintained relatively low HIV prevalence
compared to the rest of sub-Saharan Africa (\2 vs. 5.7%,
respectively) though the eastern regions of the DRC have
reported higher rates of HIV infection than the country as a
whole, reaching levels up to 5% in pregnant women
attending antenatal clinics (UNAIDS 2008a, b). Although it
is commonly implied that conflict in the eastern regions of
the DRC has contributed to high HIV prevalence in the
region, there is no epidemiologic evidence to support this
assumption.
From 1998 to 2003, a multi-country conflict in the DRC
known as ‘‘Africa’s first world war’’ led to an estimated
3.9 million deaths and 2.2 million internally displaced
persons (IDP) in the DRC (Coghlan et al. 2006; OCHA
2002). In conflict affected settings women are particularly
A. A. Kim (&) ? T. Diaz
Global AIDS Program, National Center for HIV, Hepatitis,
STD, and TB Prevention, US Centers for Disease Control
and Prevention, 1600 Clifton Rd., ME E-30, Atlanta,
GA 30333, USA
e-mail: aakim@cdc.gov
F. Malele ? K. Hawkins Reed
Global AIDS Program Democratic Republic of Congo,
US Centers for Disease Control and Prevention, Kinshasa,
Democratic Republic of Congo
R. Kaiser
International Emergency and Refugee Health Branch,
Coordinating Center for Environmental Health and Injury
Prevention, US Centers for Disease Control and Prevention,
Atlanta, GA, USA
N. Mama ? T. Kinkela ? J.-C. Mantshumba
Ministry of Health, Kinshasa, Democratic Republic of Congo
M. Hynes ? S. De Jesus
Division of Reproductive Health, Coordinating Center for Health
Promotion, US Centers for Disease Control and Prevention,
Atlanta, GA, USA
G. Musema ? P. K. Kayembe
Kinshasa School of Public Health, Kinshasa,
Democratic Republic of Congo
123
AIDS Behav
DOI 10.1007/s10461-009-9536-z

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vulnerable to increased risk for sexual violence, leading to
further morbidity including psychological trauma, unwan-
ted or complications in pregnancy, sexually transmitted
infection (STI), and HIV infection. Basic health services to
appropriately respond to the needs of women during crises
are often challenged, disrupted, or unavailable. As a result,
women’s health can be severely diminished during conflict,
with disease and transmission further exacerbated both
during and after the conflict.
No data currently exist on the prevalence of and risks for
HIV infection among female IDP and their female coun-
terparts residing in surrounding host communities in the
DRC. Yet these baseline data are needed to assess the
epidemic level in this population and target programs to
improve reproductive, sexual, and psychosocial health
services for women in conflict affected regions. This report
describes the results of an analysis of HIV, STI, and sexual
risk as part of a larger reproductive health assessment
conducted after the conflict in the DRC among adult
females residing in an IDP camp and host communities
along the Congo River, near the capital city of Kinshasa.
Methods
From February to April 2005, we conducted a two-stage
random sample household survey among adult women of
reproductive age residing in one IDP camp and two sur-
rounding river communities along the Congo River.
Households were randomly selected from existing com-
munity records that listed the total number of the
households in the community and the total number of
people living in the household. One woman per household,
aged 15–49 years, was randomly selected and invited to
enroll in the survey at a central location within the survey
sites. Sample sizes were calculated using the following
formula: N ¼Z2?pq
score value at 95% confidence level (1.96), p = estimated
HIV prevalence (5%), q = 1-p, and e = desired level of
precision (2%). Sample sizes were adjusted for an antici-
pated refusal rate of 20% in the IDP camp and 30% in the
river communities.
At the site, potential participants were provided a
detailed explanation of the purpose and procedures for the
study, including blood specimen collection for anonymous
HIV and syphilis testing and an interviewer-administered
questionnaire. Women were informed that participation
was entirely voluntary and were free to take part in either
the questionnaire, blood draw, or both. All women were
provided a copy of the consent form and allowed time to
make a decision on participation.
The questionnaire collected information on demo-
graphic characteristics, reproductive health behavior,
e2 , where N = sample size, Z = critical z
sexual behavior within the past 12 months, STI symptoms
(e.g., abdominal pain, vaginal discharge, foul smelling dis-
charge, burning pain on urination, genital ulcers, sores, rash,
swelling in the groin area, or genital itching) in the past
12 months,andahistoryofforcedvaginaloranalsexduring
the conflict (hereafter termed ‘‘history of sexual violence
during the conflict’’) and/or after the conflict by persons
outsideofthefamilysuchassoldiers,militia,policeofficers,
and guards. The time period during the conflict was defined
as any time between 1998 and the June 2003 Peace Accord.
Women were informed that syphilis results would be
returned from on-site rapid testing, and HIV test results
would not be returned. All participants received referral
vouchers for free voluntary counseling and HIV testing
(VCT) services at temporary VCT sites established by this
project at local health facilities within the survey sites. Par-
ticipants were strongly encouraged to use these services,
which were available during and 2 weeks after the survey.
HIV test results from the survey could not be returned for
several reasons. All data collected for the survey were
anonymous and unlinked to personal identifiers; therefore
participants could not be located after data collection. In
addition,VCTcenterscouldprovidehighqualitycounseling
services and referrals, and others in the participant’s
householdcouldavailthemselvesoftheseservicesifdesired.
Further, in DRC there is a high risk of HIV-infected persons
beingstigmatizedbothathomeandinthecommunityshould
others inadvertently discover their HIV-infected status.
Finally, the current policy of the DRC National AIDS Con-
trol Program during the time of the study (and still in effect
today)doesnotrequirepatientswhotestforHIVinfectionin
research activities to receive their test results.
Specimens were tested on-site for Treponema pallidum
antibodies using Determine (Abbott, IL, USA) rapid
syphilis test, and treatment was provided for reactive tests.
Rapid plasma reagin (RPR) and T. pallidum particle
agglutination (TPPA) testing were conducted at the
national reference laboratory, after completion of data
collection. Active syphilis infection was defined as positive
RPR and TPPA serologies. Specimens only positive by
TPPA were defined as having history of syphilis infection.
HIV antibodies were detected in an off-site laboratory
using the Determine HIV-1/2 (Abbott, IL, USA) and Uni-
gold HIV 1/2 (Trinity Biotech, Dublin, Ireland)) rapid tests
in parallel. Specimens were classified as HIV positive if
dually reactive. Discordant results were tested by the
Oraquick rapid test (Orasure, PA, USA) and classified as
HIV positive if reactive.
Study participants were assigned a sampling weight to
account for differences in selection probabilities. Bivariate
analysis was conducted to assess potential associations
between select variables and HIV infection. Variables
associated with HIV infection at a 0.2 significance level or
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deemed to be important confounders were tested in mul-
tivariate analysis. Variables that remained associated with
HIV infection at a 0.05 significance level in the multivar-
iate analysis were reported as significant correlates of HIV
infection. Ninety-five percent confidence intervals (CI) for
proportions, odds ratios, and adjusted odds ratios (AOR)
were calculated using a binomial exact distribution. All
analyses were controlled for sampling design and sampling
weights. To account for sample sizes that were close to the
population size, the finite population correction factor was
applied to adjust the standard errors for seroprevalence
estimates for the river population and the IDP population.
Results
The first river community had 3,114 households (N =
20,602 persons); 569 (18.3%) households were selected,
from which 495 women (87.0%) completed interviews, and
494 (86.8%) provided blood samples (Table 1). The second
river community had 3,758 households (N = 13,278 per-
sons), of which 581 (15.5%) were selected; 568 women
(97.8%) completed interviews, and 565 (97.2%) provided
blood samples. The IDP camp had 345 households (N =
1,226 persons), of which 245 (71.0%) were selected from
which 225 (91.8%) completed interviews and provided
blood samples. There were no significant differences in
reported demographics (age, marital status, education, and
residency status), sexual risk behavior, STI symptoms in the
past 12 months, and serology results between the two river
communities; therefore, results for the two river communi-
ties were combined and hereafter referred to as the river
population.
Participants in the river population were slightly
younger than women in the IDP population (median age:
26 vs. 28 years). The majority of participants in the river
and IDP population reported being currently married or
living with a man (95.4 vs. 84.7%, respectively); however,
married participants in the IDP population were more
likely to report not living with their husbands compared to
married participants in the river population (13.9 vs. 6.2%,
P\0.01). No significant differences were observed in the
reported number of years of education in the river and IDP
population.
In the river population, 0.4% (CI 0, 0.8) self-reported
being a refugee from another country and 4% (CI 2.8, 5.1)
reported being an IDP (Table 2). However, respondents
from the IDP population predominately reported being an
IDP [75.6% (CI 70.0, 81.2)] compared to refugees from
other countries [24.4% (CI 18.8, 30.1)]. Most IDP reported
their original residency as Equateur or Orientale province
located in the northern region of the DRC, while nearly all
refugees in the IDP population (98%) originated from
Sudan. The median length of stay in the IDP population
was 5 years (interquartile range (IQR) 5–5) and 1 year
(IQR 0–3) in the river population.
No significant differences were observed in the reported
age of sexual debut, number of sexual partners in the past
12 months, and proportion reporting condom use at last
sexual intercourse in the river and IDP population. How-
ever, participants in the IDP population were more likely to
report a history of sexual violence during the conflict
compared to the river population (11.1 vs. 1%, P\0.01).
In addition, reported STI symptoms in the past 12 months
were higher in the IDP population compared to the river
population (60.4 vs. 52.2%, P = 0.02).
HIV prevalence was 3.1% (CI 2.1, 4.1) in the river
population and 7.6% (CI 4.1, 11.0) in the IDP population.
VCT uptake was 20 and 90% among participants from the
river and IDP population, respectively. Active syphilis was
detected in 0.5% (CI 0.1, 0.9) of the river population and
4.0% (CI 1.4, 6.6) of the IDP population. Two participants
in the study with reactive rapid syphilis tests refused
treatment. In a sub analysis of participants in the IDP
population who reported being refugees from another
country (n = 55), HIV infection was detected in 7.3% (CI
0, 14.1) and active syphilis infection was detected in 1.8%
(CI 0, 5.3). In the IDP population, the proportion of women
who reported a history of sexual violence during the con-
flict was lower among refugees compared to IDP (1.8 vs.
14.2%, P = 0.01).
After controlling for age, age of sexual debut, number of
sexual partners in the past 12 months, residency status
(local resident, refugee, or IDP), original residence, history
of sexual violence during the conflict, past history of
syphilis infection, active syphilis infections, and any STI
symptoms in the past 12 months, we found any STI
symptoms in the past 12 months (AOR = 3.9; CI 1.6, 9.9;
Table 1 Sample size, DRC reproductive health and seroprevalence survey 2005
Site HouseholdsPopulation size Attempted contactsCompleted interviews Provided blood for testing
River population 1 3,114 20,602 569495494
Rover population 23,75813,278 581568565
IDP camp345 1,226245225 225
Total1,2881,284
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Table 2 Proportion of select demographic, sexual risk, and biologic variables among women residing in river and internally displaced populations and associations with HIV infection, DRC
reproductive health seroprevalence survey 2005
Select variables
River population (N = 1,063)
Internally displaced population (N = 225)
N
Proportion
(95% CI)
HIV positive
N (%)
Odds ratio
(95% CI)
Adjusted odds
ratio (95% CI)
P value N
Proportion
(95% CI)
HIV positive
N (%)
Odds ratio
(95% CI)
Adjusted odds
ratio (95% CI)
P value
Demographic variables Age group
15–24 years
456 43.1 (40.1, 46.1) 10 (2.2)
1.0
1.0
–
83 36.9 (30.6, 43.2) 5 (6)
1.0
1.0
–
25–34 years
391 37.0 (34.1, 39.9) 16 (4.1)
1.9 (0.9, 4.2)
1.7 (0.7, 4.0)
0.23
84 37.3 (31.1, 43.6) 9 (10.7)
1.9 (0.6, 5.8)
1.1 (0.3, 3.9)
0.81
35–49 years
211 19.9 (17.6, 22.4) 7 (3.3)
1.5 (0.6, 4.1)
1.3 (0.4, 3.8)
0.64
58 25.8 (20.0, 31.5) 3 (5.2)
0.8 (0.2, 3.7)
0.5 (0.1, 2.7)
0.66
Residency status
Local resident
1,011 95.6 (94.4, 96.9) 30 (3.0)
1.0
1.0
–
0 –
0
NA
NA
–
Repatriated refugees
4
0.4 (0, 0.8)
0
NAb
NA
0.99
55 24.4 (18.8, 30.1) 13 (7.7)
0.1(0.3, 3.0)
1.3 (0.4, 4.5)
0.81
IDP
42
4.0 (2.8, 5.1)
3 (7.1)
2.5 (0.7, 8.6)
2.8 (0.8, 10.1)
0.12
170 75.6 (70.0, 81.2) 4 (7.3)
1.0
1.0
–
Sexual risk variables
Age at first sex
\15 years
171 18.0 (15.5, 20.4) 3 (1.8)
1.0
1.0
–
50 23.2 (17.5, 28.8) 1 (2.0)
1.0
1.0
–
15–24 years
778 81.7 (79.3, 84.2) 27 (3.5)
2.0 (0.6, 6.7)
2.4 (0.7, 8.0)
0.17
166 76.8 (71.2, 82.5) 16 (9.6)
5.2 (0.7, 40.4) 5.6 (0.7, 45.0)
0.09
25 ? years
3
0.3 (0, 0.7)
0
NA
NA
0.99
0 –
0
NA
NA
–
Number of partners in the past 12 months
0 partners
54
5.5 (4.1, 7.0)
4 (7.7)
1.0
1.0
–
25 11.6 (7.3, 15.8)
0
NA
NA
–
1 partner
825 84.9 (82.6, 87.1) 25 (3.0)
0.4 (0.1, 1.1)
0.4 (0.1, 1.4)
0.16
157 72.7 (66.7, 78.6) 15 (9.6)
1.0
1.0
–
2 ? partners
93
9.6 (7.7, 11.4)
3 (3.3)
0.4 (0.1, 1.9)
0.4 (0.1, 2.0)
0.23
34 15.7 (10.9, 20.6) 2 (5.9)
0.6 (0.1, 2.7)
0.5 (0.1, 2.7)
0.95
History of sexual violence during the conflict
No
1,050 99.0 (98.4, 99.6) 33 (3.2)
1.0
1.0
–
200 88.9 (84.8, 93.0) 12 (6.0)
1.0
1.0
–
Yes
11
1.0 (0.4, 1.7)
0
NA
NA
0.99
25 11.1 (7.0, 15.2)
5 (20.0)
3.9 (1.3, 12.3) 4.2 (1.03, 16.9) 0.05
History of any STI symptoms in the past 12 months
No
506 47.8 (44.7, 50.7) 8 (1.6)
1.0
1.0
–
89 39.6 (33.2, 45.9) 4 (4.5)
1.0
1.0
–
Yes
554 52.2 (49.3, 55.3) 25 (4.5)
3.0 (1.3, 6.6)
3.9 (1.6, 9.9)
\0.01
136 60.4 (54.1, 66.8) 13 (9.6)
2.2 (0.7, 7.1)
1.8 (0.5, 6.2)
0.81
Biological variables
Active syphilis infectionc
No
1,055 99.5 (99.1, 99.9) 33 (3.1)
1.0
1.0
–
216 96.0 (93.4, 98.6) 15 (6.9)
1.0
1.0
–
Yes
5
0.5 (0, 0.9)
0
NA
NA
0.99
9 4.0 (1.4, 6.6)
2 (22.2)
3.8 (0.7, 20.1) 3.0 (0.3, 31.3)
0.28
Lifetime exposure to syphilis infectiond
No
1,030 97.2 (96.2, 98.2) 31 (3.0)
1.0
1.0
–
192 88.3 (80.7, 90.0) 12 (6.3)
1.0
1.0
–
Yes
30
2.8 (1.8, 3.8)
2 (6.7)
2.3 (0.5, 10.1) 3.1 (0.7,14.4)
0.15
33 14.7 (10.0, 19.3) 5 (15.2)
2.7 (0.9, 8.2)
1.5 (0.3, 7.3)
0.68
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P value\0.01) to be significantly associated with HIV
infection in the river population and a history of sexual
violence during the conflict (AOR = 4.2; CI 1.03, 16.9; P
value = 0.05) to be significantly associated with HIV
infection in the IDP population.
Because a history of sexual violence during the conflict
was associated with HIV infection for female IDP we
further explored causality by assessing whether a dose
response relationship existed between the number of
reported forced sex events during the conflict and HIV
infection. A dose response relationship was not observed in
the bivariate analysis (P[0.2); therefore the number of
forced sex events was not included as a variable in the final
model for the IDP population.
Discussion
HIV prevalence among participants residing in the river
population was similar to national HIV prevalence esti-
mates reported by UNAIDS among adults living in the
DRC during the same time period (3.2%; UNAIDS 2006).
In contrast HIV prevalence among female IDP was over
two times higher. Absolute estimates of HIV prevalence
among adults in the DRC were lower than rates observed in
neighboring countries of Angola (3.7%), Congo (5.3%),
Tanzania (6.5%), Uganda (6.7%), Central African Republic
(10.7%), and Zambia (17.0%; UNAIDS 2006). Prolonged
conflict in the DRC may have minimized HIV acquisition
on a population level through reductions in mobility and
sexual contact with these outside communities (Mock et al.
2004; Spiegel 2004; Spiegel et al. 2007). However, the
higher HIV prevalence detected among female IDP in this
survey underscores a potential for increased transmission
among women in the context of displacement in the DRC.
Potentialcontributingfactors
observed in female IDP compared to females in the river
population may include population movement from higher
prevalence areas from which IDP originate to lower prev-
alence host communities, sexual mixing and unprotected
sex between IDP and new social networks in host com-
munities, and increased HIV transmission through conflict-
related sexual violence towards female IDP (Amowitz et al.
2002; Mock et al. 2004; Spiegel 2004; Spiegel et al. 2007).
This survey found that a history of sexual violence
during the conflict among female IDP was significantly
associated with HIV infection. It is difficult to infer a
causal association given that a dose-response relationship
was not observed for the association. In addition the survey
was cross-sectional in design, and there may have been
possible confounding by higher HIV prevalence in the
respondent’s native regions. Still, the worrisome rate of
sexual violence (approximately one women in ten affected)
tohigherprevalence
Table 2 continued
Select variables
River population (N = 1,063)
Internally displaced population (N = 225)
N
Proportion
(95% CI)
HIV positive
N (%)
Odds ratio
(95% CI)
Adjusted odds
ratio (95% CI)
P value N
Proportion
(95% CI)
HIV positive
N (%)
Odds ratio
(95% CI)
Adjusted odds
ratio (95% CI)
P value
HIV infection
No
1,026 96.9 (95.9, 97.9) –
–
–
–
208 92.4 (89.0, 95.9) –
–
–
–
Yes
33
3.1 (2.1, 4.1)
17 7.6 (4.1, 11.0)
aAdjusted for age; age of sexual debut; number of partners in the past 12 months; residency status; original residence; history of sexual violence during the conflict; past history of syphilis
infection; and any STI symptoms in the past 12 months
bNA Not applicable
cSpecimens with positive RPR and TPPA serologies were defined as active syphilis infections
dSpecimens with positive TPPA serologies were defined as having a past history of syphilis infection
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