Before the political turmoil of the mid-1990s, more studies had been done to understand the HIV epidemic in Rwanda than in most developing countries. The pattern of infection recorded there was a familiar one: high rates in urban areas (more than 10% of pregnant women infected) but far lower rates in the rural areas that were home to the bulk of the population (just over 1%).
The political difficulties of recent years not only interrupted HIV surveillance; they changed the shape of the epidemic. By 1997, when a well-designed survey of HIV was carried out in the general population, little difference remained between urban and rural rates. Both were just over 11%. Among teenagers, infection was actually higher in rural areas than in cities. And it was appallingly high at the youngest ages: among 12, 13 and 14 year olds, a full 4% were already HIV-infected.
Many of the changes can be ascribed to the huge population movements during and after the years of ethnic conflict. Nearly three-quarters of the 4700 people surveyed in 1997 had lived elsewhere in the preceding three years–an astonishingly high turnover for this largely rural country. Migrants who had spent the years of conflict outside Rwanda had lower rates of HIV infection than those who endured the troubles inside the country. Most of these people are recently returned from Uganda and Tanzania, countries where HIV prevention campaigns are relatively strong.
HIV prevalence among people who said they had spent the conflict years in refugee camps was 8.5%. Most of these people had fled from rural areas where pre-conflict HIV prevalence was just 1.3%. That suggests a six-fold increase in HIV infection among refugees in the camps. Overcrowding, violence, rape, despair and the need to sell or give away sex to survive are all likely to have contributed to this huge leap in infection.
Wars and armed conflicts generate fertile conditions for the spread of HIV. Rape–inside or outside refugee camps–has doubtless played a part in spreading the virus in Rwanda. Some 3.2% of women surveyed reported being raped, over half of them during the conflict itself. Two-fifths of them were teenagers. Among women who had been raped 17% were HIV-positive, compared with 11% of those who had not. Women who reported rape were three times as likely as those who were not raped to have suffered from genital sores, another STD.