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The imperative to respond with appropriate and timely interventions to mass rape in conflict-affected areas

Spiegel, Paul Ba; Mills, Edwardb; Joffres, Michel Rc; Anema, Arankac,d

doi: 10.1097/QAD.0b013e3283420e7b

aPublic Health and HIV Section, United Nations High Commissioner for Refugees, Geneva, Switzerland

bFaculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada

cBritish Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Canada

dFaculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

Received 21 October, 2010

Accepted 27 October, 2010

Correspondence to Paul B. Spiegel, 94 rue de Montbrillant, 1211 Geneva, Switzerland. E-mail:

We very much welcome the study by Supervie et al. [1] assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. Although the study confirms previous findings of a relatively small effect of mass rape in conflict settings on the overall HIV prevalence in these countries [2], it advances the debate by modelling the incidence as well as prevalence.

Reduction of stigma and discrimination among women and girls who have been raped must be a major objective in all conflict settings. As both studies highlight [1,2], the indirect physical, psychological and socioeconomic effects of rape on women in the short and long term are enormous and difficult to quantify. There is a common perception that many rape survivors will become HIV-positive owing to rape. However, the evidence for this assertion is weak. The most commonly cited statistic that has fed this misconception is that 70% of female rape survivors of the 1994 Rwandan genocide were HIV-positive [3]. The correct interpretation of this unpublished data is that 70% of 1125 female rape survivors (primarily widows) who sought assistance were HIV-positive. A population-based survey in 1997 of 4800 women showed that 2.2% had been raped and that, of those, 15.2% were HIV-positive compared with 11.0% of women who were not raped; the difference was not statistically significant (P = 0.16) [4]. Given that conflicts in these regions tend to occur in rural and inaccessible settings with highly variable HIV rates, obtaining reliable estimates of HIV incidence and prevalence are challenging. However, it is important to dispel the myth that there is a high probability that women who have been raped will also become HIV-positive; rape survivors do not need the additional stigma and discrimination.

Depending upon the estimates of the variables chosen in a model, results can vary significantly. However, there is no question that the HIV incidence of rape will increase at the individual level and in specific settings at the community level (e.g. in various communities in eastern Democratic Republic of Congo), as both studies clearly state [1,2]. The recommendations in both studies are also very similar: essential interventions for survivors of rape must be provided to all survivors of such heinous acts in all contexts. The difficulty of actually doing so in some contexts was also stated in both studies.

The recommendation by Supervie et al. for the urgent need for stringent protocols for supporting women and girls subjected to rape in conflict situations already exists in numerous languages together with an e-learning tool by the WHO, the United Nations Population Fund and the United Nations High Commissioner for Refugees [5]. What is needed now is widespread training and implementation of these interventions, supported by appropriate funding.

Living in settings affected by conflict and being raped are likely the most devastating events that can occur in an individual's life. These individuals and communities should be a priority for protection, care, support and treatment. We would like to emphasize that beyond medical interventions, the provision of a stigma-free environment that provides protection to affected populations and the need to bring perpetrators to justice are also needed.

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1. Supervie V, Halima Y, Blower S. Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS 2010. [Epub ahead of print]
2. Anema A, Joffres MR, Mills E, Spiegel PB. Widespread rape does not directly appear to increase the overall HIV prevalence in conflict-affected countries: so now what? Emerg Themes Epidemiol 2008; 5:11.
3. Mujawayo E, Kayitesi Blewitt M. Violence against women: experiences from AVEGA's work in Kigali. In: Silent Emergency Seminar; 17–18 June 1999; London. London: London School of Hygiene and Tropical Medicine; 1999.
4. National AIDS Control Programme. National population-based serosurvey. Rwanda; 1997.
5. WHO, UNHCR, UNFPA. Clinical management of rape survivors in humanitarian settings; Geneva; 2004 and 2009.
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