BackgroundUnstable settings present challenges for the effective provision of antiretroviral treatment (ART). In this paper, we summarize the experience and results of providing ART and implementing contingency plans during acute instability in the Central African Republic (CAR) and Yemen.Case presentationIn CAR, MSF has provided HIV care in three conflict-affected rural regions; these were put on hold throughout the acute phase of violence. “Run-away bags” containing 3 or 4 months of ART were distributed to patients at MSF facilities. Among 1820 HIV patients enrolled into care, 1440 (79%) initiated ART. By December 2016, 782 (54%) patients were still under ART, 354 (25%) have been lost to follow up and 182 (13%) had died. In 2013, when violence disrupted services, 683 patients were receiving ART. Between September–December 2013, 594 (87%) patients received runaway bags and by February 2014, 313 (53%) of these patients returned to the clinic.In Yemen, when violence erupted, patients received a health card that included a helpline to call in case of drug shortages in admission to emergency stocks; this was not possible in CAR due to lack of a functioning telephone network. One thousand six hundred fifty-five PLWHA have been enrolled in care and 1470 (89%) initiated ART; 1056 (72%) are still followed on ART, 126 (9%) were lost to follow up, and 288 (20%) died. In January 2011 clashes began and by April 2011 MSF medical activities were interrupted. Of the 363 patients receiving ART, 363 (100%) received emergency bags to cover 9 months and by February 2012, 354 (98%) patients returned to care. In March 2015 a new wave of conflict affected Yemen, forcing HIV activities to revert to contingency planning.ConclusionsThis experience provides further evidence that provision of HIV treatment and emergency drug stocks can be successfully provided to most patients in both conflict-affected settings.

Background Antiretroviral therapy (ART) coverage in South Sudan is around 10%. Access to HIV care in settings with low ART coverage or conflict affected is still low; innovative strategies are needed to increase access and ensure continuation of ART during instability. A pilot HIV test and start project was implemented in a conflict-affected area of South Sudan. In a retrospective analysis, we determined the feasibility and outcomes of this intervention. Methods Programme data from July 2015 to June 2018 was analysed. The project involved five mobile teams offering HIV counselling and testing (HCT) and same day ART initiation at community level. Baseline and follow-up information on clinical, immunological and viral load (VL) was routinely recorded, as well as treatment outcomes. A semi-qualitative study was conducted to assess acceptability of the program among beneficiaries and community members. Results By June 2018, 14824 people received counselling and testing for HIV and 498 (3.4%) tested positive. Out of those 395 (79.3%) started ART. A total of 72 ART patients were organized in 26 Community ART Groups (CAGs) and contingency plan was activated 9 times for 101 patients. Kaplan-Meier estimated retention in care (RIC) at 12 and 18 months was 80.6% [95% CI: 75.9–84.5%] and 69.9% [95% CI: 64.4–74.8%] respectively. RIC was significantly higher at 18 months in patients under community ART groups (CAGs) (90.9% versus 63.4% p<0.001) when compared to patients on regular follow up. VL suppression at 12 months was 90.3% and overall virological suppression reached 91.2%. A total of 279 persons were interviewed about the MSF program perception and acceptance: 98% had heard about the programme and 84% found it beneficial for the community, 98% accepted to be tested and only 4% found disadvantages to the programme. Conclusions Our study shows that HCT and early ART initiation in conflict affected populations can be provided with good program outcomes. RIC and virological suppression are comparable with facility-based HIV programs and to those in stable contexts. This model could be extrapolated to other similar contexts with low access to ART and where security situation is a concern.

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