Systemic Factors and Barriers That Hamper Adequate Data Collection on the HIV Epidemic and Its Associated Inequalities in Countries With Long-Term Armed Conflicts: Lessons From Colombia

Abstract

Although advances in treatment and diagnosis have transformed HIV into a chronic disease in high-income countries, a spectrum of structural, political, sociocultural, and health system barriers hamper early diagnosis and timely treatment of HIV in many middle- and low-income countries. In most Latin American countries, in spite of the great improvement in access to antiretroviral therapy, a large proportion of individuals infected with HIV do not know their status.

In Colombia, the Joint United Nations Programme on HIV/AIDS currently estimates a much larger number of HIV cases than the number reported by Colombian authorities. Potential reasons for underdiagnosis and underreporting include sociocultural factors such as social stigma, restrictions in access to health care, a lack of public health research and robust surveillance systems, and the particular recent history and social situation related to the armed conflict the country has suffered through for several decades.

Lessons from Colombia may be helpful in monitoring, understanding, and tackling the HIV epidemic in countries with long-term armed conflicts.

According to data from the Joint United Nations Programme on HIV/AIDS (UNAIDS), in 2016 there were 36.7 million people living with HIV worldwide, almost 21 million of whom had access to antiretroviral therapy (ART) as of the middle of 2017.¹ Also in 2016, 1.8 million people were newly diagnosed with HIV, and 1 million died from AIDS-related illness.¹ In Latin America, although access to ART has greatly improved during the past decade, with nearly 600 000 people currently receiving treatment,² only approximately a third of the 1.8 million people with HIV in Latin American countries are being treated.¹

With the aim of ending the global AIDS epidemic, UNAIDS set new goals in 2014 to control HIV infection. These goals are articulated in the “90-90-90” strategy. The strategy calls for 90% of all people with HIV to know their status, 90% of all people diagnosed with HIV to receive ART, and 90% of all people receiving ART to achieve viral suppression by 2020.³ If the strategy is successful, the HIV epidemic should be ended by 2030. Nonetheless, this positive epidemiological transition from a fatal to a chronic illness is not taking place in most Latin American countries and many low-income countries, especially among the most deprived people.

Proximal biological and behavioral determinants of HIV transmission or delayed diagnosis occur within the context of wider interrelated structural determinants. Social, cultural, organizational, community, economic, and legal issues such as illiteracy, high unemployment rates, poverty, food insecurity, poor health system infrastructure, inadequate housing, and stigma complicate prevention, diagnosis, and treatment of HIV. For example, it is known that experience with stigma related to HIV infection, a social and psychological process in which infected people struggle to cope with misperceptions, social separation, and discriminatory actions associated with their status, is significantly associated with late care.⁴ Likewise, social and cultural norms may lead those at highest risk for HIV to avoid HIV testing or timely treatment, resulting in inequities between those who do and do not have access to appropriate care.⁵

Advances in early diagnosis and treatment have transformed HIV into a chronic disease in high-income countries.⁶ Adherence to ART leads to viral suppression, which substantially reduces the risk of HIV transmission even when condoms are inconsistently used.⁷ However, there are still many delays in access to testing, diagnostic services, and care, allowing the secondary consequences of AIDS to continue. In high-income countries, Black race/ethnicity, male gender, young age, and low socioeconomic status are the most commonly observed determinants of delayed entry into care.⁸

Meanwhile, factors such as long distance from home to a health facility, lack of coordination across services, and limited community involvement in the program planning process are key barriers to access ART.⁹ Sociocultural determinants of access to care among people with HIV also differ between high-income and low-income countries, influencing the approaches of researchers, international donors, and policymakers: in low-income countries research on access to HIV/AIDS services focuses mainly on socioeconomic and health system factors, whereas in high-income countries the focus is primarily on medical and psychosocial factors.¹⁰

BARRIERS TO DIAGNOSIS AND TREATMENT OF HIV

Accurate estimates of the HIV epidemic in Colombia are lacking. As shown in Table 1, figures on HIV prevalence and incidence greatly differ between Colombian sources^11,12 and with UNAIDS estimates.¹³ Moreover, Colombian sources have also often provided discordant figures. For instance, the Ministry of Health and Social Protection reported a decrease in the HIV prevalence estimate from 0.59% to 0.50% between 2009 and 2012¹²; however, this figure is still higher than that reported by the Colombian Ministry of Health and UNAIDS.¹¹ Ministry of Health figures rely on direct reporting, whereas UNAIDS provides estimations. It is likely that the real prevalence and incidence of HIV in Colombia are somewhere closer to the figures provided by UNAIDS, basically owing to underdiagnosis and underreporting limitations.

TABLE 1—

HIV Prevalence and Annual Number of New Cases in Colombia: Colombian and UNAIDS Estimations, 2012–2016

	Colombia				UNAIDS
Year	No. of Cases (All Ages)	Prevalence Among All Ages, %	Prevalence Among Those Aged 15–49 Years	No. of New Cases per Year (All Ages)	Estimated No. of Cases (All Ages)a	Estimated Prevalence Among Those Aged 15–49 Years, % (Range)a	Estimated No. of New Cases per Year (All Ages)a
2012	37 325	0.08	…	…	150 000 (110 000–190 000)	0.5 (0.3–0.7)	6500 (4800–8500)
2013	46 348	0.10	…	…	140 000 (110 000–180 000)	0.5 (0.4–0.6)	6300 (4600–8300)
2014	53 408	0.12	0.18	4882	120 000 (97 000–140 000)	0.4 (0.3–0.5)	6100 (4400–8100)
2015	61 174	0.13	0.19	7437	120 000 (99 000–150 000)	0.4 (0.3–0.5)	5800 (4100–7800)
2016	73 465	0.15	…	8209	120 000 (100 000–150 000)	0.4 (0.3–0.5)	5600 (3900–7500)

Note. UNAIDS = Joint United Nations Programme on HIV/AIDS. Ellipses indicate data not reported.

^aSignifies the boundaries within which the actual numbers fall on the basis of the best available information.¹

Most Colombians who undergo screening for HIV do so following a clinician’s recommendation related to a medical indication (60%); a smaller percentage seek HIV testing on their own (22%). Meanwhile, close to half of patients (42.4%) are diagnosed late, when they present with HIV-related symptoms or are diagnosed with AIDS.¹¹ According to studies conducted in the general population, only 19.7% of people aged between 18 and 69 years have been screened for HIV at least once in their lives.¹⁴ Underdiagnosis of HIV has recently been observed in key populations at risk, such as men in Bogotá who have sex with men.¹⁵

Several factors may play a role in the lack of timely diagnosis of people living with HIV across Colombia. In major cities such as Medellín, it has been shown that sociocultural assumptions built around those at risk for HIV are a barrier for at-risk individuals in seeking health services. People with HIV avoid services because of fear that they will be met with discrimination by health care professionals or stigmatized by society on the basis of dominant religious beliefs and false attitudes and beliefs about HIV transmission.¹⁶ Similar barriers have been reported by adolescents and young adults in other urban settings. Moreover, the ease with which knowledge and attitudes regarding infection, susceptibility to infection, and self-efficacy in terms of prevention of HIV infection can be evaluated declines as age increases.¹⁷

Once individuals are diagnosed with HIV, access to treatment and follow-up is not universally available, even though the Colombian health system is theoretically intended to ensure universal access to health care. Furthermore, there are gaps in the national treatment guidelines. In 2006, the Ministry of Health established a comprehensive care program management model for people infected with HIV. A care guide accompanied the model, with recommendations for initiation of ART as well as clinical and psychosocial follow-up.¹⁸ This guide should had been updated every two years; however, it was not updated until 2014, and no further revisions have been drafted. Thus, current guidelines for management of HIV do not include key points regarding the World Health Organization’s recommendations on treatment initiation. Arguably, the best currently available tools for Colombian physicians to support decisions regarding ART are the manuals edited by the World Health Organization and the Pan American Association of Infectious Diseases.¹⁹

ASSOCIATION OF HIV WITH COLOMBIA’S CONFLICT

Violence and conflict are major public health challenges in Colombia. The current population of 50 million includes survivors of the 1948 to 1958 “La Violencia” civil war, during which at least 200 000 people were killed. A long-term armed conflict that began in the mid-1960s and involved all of the country’s powerful social groups (governments, revolutionary guerrillas, paramilitary groups, economic corporations, landowners, cattle ranchers, and drug cartels) has only recently come to a halt. The country is immersed in a “postconflict” era. Although efforts have been made to advance a peace process, people are struggling to rebuild their lives, and violence, massive internal displacements, and drug trafficking, among other relevant problems, are still very present in today’s society.

Although there is a lack of accurate data on new HIV cases and underreporting occurs across sociodemographic and ethnic groups, as well as in some geographical areas, the HIV epidemic in Colombia seems to be concentrated in areas with high levels of violence, displacement, and lack of access to public health services and health care. A study published in 2011 revealed a higher incidence of HIV from 2002 to 2008 in regions where the armed conflict was more intense.²⁰ In fact, Colombia has the world’s largest internally displaced population (approximately 7.4 million people),²¹ the majority of whom are young women from disintegrated families living in poverty and precarious social and psychological conditions. Although new studies must be conducted with better data and improved methods, current evidence suggests the influence of interacting systemic factors in the evolution of the epidemic in times of conflict and recovery. This complex situation can be illustrated with examples of sexual violence against women and girls and stigma among combatants (e.g., soldiers and guerrillas).

Sexual abuse including rape, mainly of women and children, is a common part of the armed groups’ violent action.²² Both guerrillas and paramilitaries often force prostitutes into sexual slavery in areas under their control. The women are forced to have unprotected sex with enemy clients as a means of extracting information from them. Thus, the clients and the women are at increased risk for both contracting sexually transmitted diseases and suffering reprisals from opposing groups that consider them enemy spies. These conditions may encourage young women to become sexually active and see prostitution as a viable source of income. All of these factors make these women particularly vulnerable to HIV infection. Moreover, sexual health and education programs are lacking in high-conflict zones.

Long-term armed conflict has led to chronic exposure to violence, displacement, and engagement in high-risk sexual behavior in Colombia. These factors, however, do not operate as isolated entities unattached from their social meso-level contexts and macro-level structural elements; rather, they interact in complex systemic and dynamic ways. Along with a poor health system infrastructure, these factors have fueled the HIV epidemic and resulted in delayed testing and treatment seeking among individuals at risk. For example, Colombian soldiers spend long periods away from their families, have no or limited access to health education, and often engage in high-risk sexual activities.²² Soldiers are more likely to contract sexually transmitted diseases than are civilians and typically lack access to treatment. Also, paramilitaries often threaten to engage in “social cleansing” operations among groups of people living with HIV. In addition to social stigma, the presence of armed groups plausibly discourages people from undergoing testing for HIV.

POTENTIAL LESSONS FOR COUNTRIES WITH ARMED CONFLICTS

The connection between armed conflicts and the spread of HIV has been under study for many years. An investigation of 43 sub-Saharan African countries from 1997 to 2005 showed strong positive associations between civil war and HIV prevalence. In Rwanda, for instance, the 1994 genocide contributed to the epidemic expanding to rural areas because populations were mixed together in refugee camps in neighboring countries. However, other studies have not revealed any evidence of this link, suggesting that conflicts are more complex than previously thought and that they do not inevitably lead to increased HIV prevalence.²³ Some conflicts have resulted in little change in HIV incidence, and others have even led to reductions, suggesting that conflicts might act as a “brake” on the spread of HIV. Examples of the latter phenomenon include the cases of Burundi (1993–2005), Sierra Leone (1991–2002), and the long conflict in Angola (1975–2002); in these instances, the HIV incidence was lower than in neighboring countries, probably because of the restricted mobility caused by the conflict.²³

There are two plausible reasons for the differential effects of conflict on HIV incidence. First, collection of data in conflict situations generally is problematic and heterogeneous. For example, high-quality HIV statistics are drawn overwhelmingly from the richest areas of the country, with substantial underrepresentation of poor rural areas under conflict. Indeed, often there are insufficient data to demonstrate whether refugees fleeing a conflict have a higher prevalence of HIV infection than do members of their surrounding host communities.²³ There are some alternative ways of measuring HIV prevalence in low-income countries; for example, GIS technology can be used to supplement health needs assessments in conflict settings. The maps produced can be effective in breaking down large data sets into simplistic and easily interpretable information.²⁴ One important lesson from the Colombian experience is that, to adequately assess HIV prevalence as well as rates of testing and entry into treatment, there is a need for high-quality conflict-related surveillance information systems that are both comprehensive and systemically integrated.

The second reason for the difference is even more profound. Long-term armed conflicts should be approached as complex systems models of public health crises in which the health of populations and inequities in access to health are contingent on multiple interdependent social, economic, and health elements within a connected historical and political whole.²⁵ Therefore, the lack of satisfactory causal models linking long conflicts and HIV indicates the need to undertake a systemic integrated analysis that will allow an understanding of the interlinked circumstances in which groups of people live and survive as well as the types of policies and interventions implemented among these groups.

Violence in Colombia has long been described as a public health problem.²⁶ Long-term exposure to violence perpetrated by powerful groups against powerless victims has ripped the country’s social fabric. The threads of this fabric have been compromised by layers of interconnected challenges including social inequalities and poor landless farmers; political corruption and impunity; massive migration and internal displacement; unemployment, informal work, and poverty; economic societal costs; lack of health care and education; homicides and kidnappings; high levels of incarceration and drug use; violence, fear, and insecurity; sexual abuse; and suffering, trauma, and long-term psychological afflictions over multiple generations.

Héctor Abad Gómez, a pioneer of Colombian public health who had a holistic view of health, was himself assassinated in 1987. His ethical principles and political ideas led him to develop public health interventions for the worse off, but he did not live long enough to witness the evolution of the HIV epidemic in his country. His tireless attempts to apply social measures to improve the health of the Colombian people and reduce inequalities and his fearless deep analyses of the causes of violence and the need for change in the country are examples to be followed. As is probably the case in many countries, only through a profound understanding of the long-term armed conflict in Colombia will it be possible to know the real picture of the HIV epidemic and to implement and evaluate public health interventions and health care reforms that effectively lead to the diagnosis, treatment, and prevention of HIV.