THE

EFFECT OF VIOLENT CONFLICT ON AGE AT FIRST SEXUAL INTERCOURSE IN RWANDA

Elina Lindskog PhD Candidate Demography Unit at the Sociological Department Stockholm University elina.lindskog@sociology.su.se

Introduction

Rwanda has been considered to be one of the African countries most affected by AIDS and has also experienced civil war leading up to genocide in 1994. It is believed that conflict can affect the epidemiology of HIV/AIDS (Elbe, 2002; Hankins et. al. 2002; Mock et. al., 2004; Untied States Institute of Peace). Conflict disrupts individual lives and communities in ways that may exacerbate the spread of HIV/AIDS but also may inhibit the spread. The idea that violent conflict exacerbates the spread of HIV/AIDS has been question in empirical research and the concern has consequently shifted to stress on a research gap of the effect of conflict in the aftermath period of a conflict. This is the period marked by the return of refugees, soldiers demobilize, isolated populations returning to commercial networks, and contractors, peacekeepers, and aid workers pour in to provide aid for recovery, which increases exposure opportunity risk for HIV transmission within the population (Becker et. al., 2008; Spiegel et. al., 2007; de Waal, 2010). The relationship between HIV/ADIS and violent conflict is complex and contextualized. There are multiple mechanisms underlying this relationship and it needs to be understood uniquely for different geographical regions and for different time periods. Nonetheless violent conflict and HIV/AIDS interact to shape population health and development. This study will focus on the effect that the civil war and the genocide in Rwanda might have had on age at first sexual intercourse. I am interested in seeing if there will be a bump of women who experience their first sexual intercourse in regions experiencing high levels of violence during the conflict years. The genocide in Rwanda was a three-month period of state organized ethnic cleansing of the Tutsi population, where an estimated 800,000 Rwandans, mostly Tutsi were killed and an estimated 500,000 women were raped. Rape as a tactic of war is devastating for individual women and destroys family and community ties (Milillo, 2006). Rape during war times have historically gone under the radar and it is not until recently that rape has been defined as a weapon of war. A report prepared for the UN Commission on Human Rights, (McDougall 1998, pp. 4-5) defined war rape as a deliberate and strategic decision on the part of combatants to intimidate and destroy the enemy as a whole by raping and enslaving women who are identified as member of the opposition group (Farwell, 2004, pp. 392). I cannot directly see if rape is a factor behind any changes in the pattern of age at first sexual intercourse, but I can see if there is an increased risk of age at first sex during the Elina Lindskog Sida 1

conflict years. (I am well aware that there are other mechanisms than rape that needs to be explored in relation to an increased risk for first sex during the conflict period and this will be a next step in the working process of this paper.) I will use Rwandan Demographic and Health Survey from 1992, 2000 and 2005 data to estimate proportional-hazards (intensity-regression) models to identify the determinants of age at first sexual intercourse in Rwanda. The idea is to identify the region where the women lived during the violent conflict to match this information with conflict data from the Peace and Conflict Institute in Uppsala, where I have information on the intensity and the timing of the conflict at regional level. Today, I will present only preliminary models of regional variation, but I will describe the conflict data set that will be used to more accurately measure the degree of conflict in a given region at a given time in a womens life. Objectives This study aims to understand links between violent conflict as well as post violent conflict with individuals reproductive behaviors, in a context of already high HIV prevalence, which increases the exposure risk and vulnerability to HIV infection. In Rwanda the use of condom as a contraceptive method is less than 1%, this means that the sexual active population are exposed to a risk of HIV transmission if sexual behavior involves, over time, more than one partner. The risk of HIV infection is directly correlated to sexual behavior, nevertheless there are different pathways of HIV transmission and in this paper I will focus on one: age at first sexual intercourse. The median age of first sexual intercourse in Rwanda is 18.1 years old in 2002 (UNAIDS, 2002b). Rwanda is a country that has been hit hard with the HIV/AIDS epidemic with a young population where an estimate of 70% of the population is under age 25 (Babalola, 2004). It is therefore not surprising that young people represent a group highly burden by HIV/AIDS. Between 9-13.4% of female youth aged 15-24 years were estimated to be infected with HIV compared with only 4-6% of their male counterparts in 2001 (UNAIDS, 2002a). It is problematic that condom use has been and still is limited in Rwanda as 29% of male youth ages 15-19 and more than 12% of their female counterparts have had sex according to the 2000 Behavioral Surveillance Survey (BSS) (FHI/IMPACT, 2000). Another study showed that about 70% of boys and 80% of girls who were sexually active had already experienced first sexual intercourse by age 15 in Rwanda (Calvs, 1998). Elina Lindskog Sida 2

HIV/AIDS in Rwanda HIV/AIDS has a profound impact on society and is seen as one of the greatest challenges of our time, as it affects every level of society. The main mode of transmission of HIV in sub-Saharan Africa is heterosexual intercourse. The HIV epidemic should be understood as a consequence of place (Webb 1997). Meaning that although HIV/AIDS is a medical condition, restricted to only a few modes of transmission, the social structure, political and economic setting in society can create an environment that increases vulnerability and potential exposure opportunity risk for HIV infection. There are many factors that drive the epidemiology of HIV, such as gender inequality, unsafe health practices, attitudes towards condom use, sexual behavior including number of partners, age of sexual debut etc., poverty, forced migration, political leadership and so on. The first survey conducted on a national level in 1986 estimated a HIV prevalence rate of 17.8 percent in urban areas and 1.3 percent in rural areas (Rwandan DHS, 2005). In 1988 Rwanda established an HIV sentinel surveillance system among pregnant women attending antenatal clinics and among STI- clinic patients. In 1988 and 1991, the first sets of surveillance data were made available. The data from 1991 indicated an HIV prevalence of 27 percent in urban areas, 8.5 percent in semi-urban areas, and 2.2 percent in rural areas (Rwandan DHS, 2005). The limitation of this data material is that does not reflect the diversity of the HIV epidemic. After the genocide in 1994, a new HIV surveillance system was set up in 1996 with ten sentinel sites. The data that was gathered that year indicated a higher infection rate of 27 percent in urban areas, 13 percent in semi-urban areas, and 6.9 percent among rural areas (Rwandan DHS, 2005). In 1997 a study based on a sample of 4800 people estimated an HIV prevalence rate of 11.1 percent (10.8 percent for men and 11.3 percent for women). The national sentinel surveillance system was expanded in 2002, with the number of sites increased to 24, resulting in more precise data than before. The data from 2002 estimated that the HIV prevalence varied between 2.6 percent and 3.6 percent in rural areas and between 7.0 percent and 8.5 percent in urban areas (Rwandan DHS, 2005). The data from 2003 does not differ significantly from 2002. HIV testing was included in the Rwandan DHS in 2005 which estimated HIV prevalence using a nationally- representative sample of men and women. The DHS estimate of HIV prevalence in the age group 15-49 is 3 percent. Among women age 15-49 it is 3.6 percent, higher than the men in the same age group. The infection ratio between women and men is therefore equal to 1.6 which means that 160 women are infected for every 100 men (Rwandan DHS, 2005).

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The diagram bellow illustrates an increase of estimated new HIV infections for all ages in Rwanda.

Source: http://www.aidsinfoonline.org/

Violent conflict and HIV/AIDS Almost all sub-Saharan African countries have experienced violent conflict directly, or border a country that has directly experienced violent conflict (Mock et al. 2004). Sub-Saharan Africa was according to Marshall caught up in a regional sub-system of violence in the 1980s (Marshall 2005). This trend rose sharply and is seen to have reached its peak between 1994-97, during a period when the genocide in Rwanda took place as well as the fighting in DRC, at the same time there was an ongoing violent conflict in Liberia, Sierra Leone, Somalia, Sudan, and Northern Uganda. It is argued that the HIV epidemic will act as a profound destabilizing force across the social, political, and economic landscape of Africa. Violent conflict is believed to have an indirect effect on the spreading of HIV/AIDS at an individual level through increased interaction among civilians and military/combatants personnel, known for having a high risk behavior, mass migration (refugees) and development of cultures of violence that promote sexual violence and predation (Hankins et al. 2002; Mock et al. 2004). Violent conflict is also believed to have an indirect effect on the spreading of HIV/AIDS at a community level in through the destruction of social and physical infrastructure that increases the risk of untreated sexually transmitted infections, poor health and malnutrition. Also through the destruction of public health education mechanism (e.g. mass media, health facilities, and formal

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education), which has a negative effect on public health-related knowledge, attitudes and practices. The health sector might suffer extensive damage during violent conflict through loss of health infrastructure, both in terms of personnel and physical infrastructure. Rwanda was estimated to have lost more than 80% of its health personnel through death or flight during the genocide (Mock et al. 2004). Even though researchers agree in general on a relationship between conflict and HIV (during conflict or in the aftermath of a conflict), the relation is complex and contextualized. Some countries have experienced conflict but still have a lower HIV infection compared to countries that have experienced relative peace. This is explained by exposure opportunity and risk. Even though there is an increased vulnerability connected to population during a violent conflict, isolation of communities may reduce the exposure to HIV and hence decreases the risk for HIV transmission (Mock et al. 2004). After a conflict subsides the exposure might increase as isolated populations become mobile again thereby opening up for mixing of populations (Spiegel et al. 2007). Another important dimension in conflict analysis is point of conflict onset, duration, and scale of conflict. Longer-duration and large-scale conflict generally leads to greater cumulative effects of conflict on social infrastructure (Mock et. al. 2004). Vulnerability tends to increase during a conflict but rarely decreases quickly in a post-conflict setting due to changes in society that might have occurred during conflict (Mock et. al. 2004). It is however, important to note that conflict enters peoples lives at different points, and are therefore more or less vulnerable to the effects of conflict. Sexual related violence African women tend to have a subordinate role in relation to their spouse/partner when it comes to negotiating contraceptive methods and terms of sexual relations, thus making them more vulnerable to the risk of HIV infection. Low use of contraceptives (prophylactic) due to access difficulties increases the exposure risk of HIV. Womens more vulnerable sexual reproductive role can be intensified during violent conflict if there for example is an increase of rapes (which most probably are unprotected sex). This is the case in Rwanda were it is estimated that hundreds of thousands women were raped. The genocide in Rwanda is one example of a conflict notorious for rape being used as a weapon of war, were soldiers and combatants use sexual violence as a tactic of war to disrupt the opponent ethnic group and to control civilian population. Sexual violence targeting women and girls has been used in all recent conflicts, which includes the former Yugoslavia, Sierra Leone, India (Kashmir), Rwanda, Sir Lanka, the Democratic Republic of Congo (DRC), Angola, Sudan, Elina Lindskog Sida 5

Cte dIvoire, East Timor, Liberia, Algeria, the Russian Federation (Chechnya), and northern Uganda (LaShawn Jefferson). Rape has been viewed as merely a byproduct of war, but as militaries and insurgency groups increasingly have used rape as a way of achieving political goals such as ethnic cleansing and genocide the international media and foremost feminist activist, and scholars begun to bring public awareness to the use of rape as a tactic of war, used as a weapon (Farwell, 2004). Rape as a weapon attacks womens physical and emotional sense of security while simultaneously launching and assault, through womens bodies, upon the genealogy of security as constructed by the body politic (Koo, 2002, p. 525). War rape is an instrument of terror, domination, torture, humiliation et cetera with the purpose to control the civilians that might even lead to genocide (Farwell, 2004). Rape as a tactic of war is embedded in deep roots of ethnic hatred, which evidently has been in some cases symbiosis with ethnic cleansing and the aim of destroying the opponents sense of identity. Many feminist emphasize that gender related violence during war builds on the cultural norms within society and gender relations that are already built into the dynamics of society, gender relations are therefore viewed as an ongoing conflict between the sexes. However, during periods of violent conflict these pre-existing gender relations placing women in a subordinate position are intensified and take an extreme form (Kelly, 2000). Men who are accustomed to exercise control over womens reproductive and sexual activities in periods of peace continue to do so but with more violent aggression during periods of war (Jefferson, Milillo, 2006). War rape is used as a strategy to carry out political objectives of ethnic cleansing, which is accomplished through a racist and genocidal intent to contaminate the blood and genes of the opponent group (Farwell, 2004). War rape does not only humiliate the victims but also their spouses/fathers and entire families and communities are shamed by rapes and hence make it more difficult for women to return home. War rape damages the solidarity and identity of communities, destroying group spirit and moral strength (Farwell, 2004). Under reporting of war related rapes are also problematic, so is the legal process of having someone convicted for war related rapes. In addition to the emotional and physical pain that victims of rape experience there is furthermore an increased risk of STI infection, such as HIV. There are cases where the transmission of HIV is a deliberate plan in line with the notion of ethnic cleansing. The concept of vulnerability, exposure opportunity and risk The concept of vulnerability implies that an individual or group is more likely to experience adverse effects, risk, when exposed to a hazard. Vulnerability encapsulated a growing recognition that the extent to which people suffer from calamities of any kind depends on both their likelihood of being Elina Lindskog Sida 6

exposed to hazards or shocks and their capacity to withstand them, which is related to their socio- economic circumstances (Dilley et. al., 2000). Factors that are commonly associated with vulnerability are poverty, poor social infrastructure and attitudinal factor, and low education/knowledge. Other factors related to conflict and HIV are migration patterns, sex-related knowledge and attitudes, population health status and level of commercial sex. There are different so called high-risk groups including women, demobilized soldiers, refugees, child soldiers, orphans and child-headed households. Hazard or shocks refer to unpredicted events which affect communities, such as violent conflict and HIV exposure opportunity to populations. In southern Africa high population density, good physical infrastructure, economic-motivated mobility, high poverty levels, and large wealth differences between and within countries all sustain high HIV opportunity risk. The risk for HIV is dampened when war, for example, creates isolation and thus reduces exposure, but war can also lead to increased sexual mixing of populations with different levels of infection (e.g., mobile military populations and civilians) that in turn can increase the exposure opportunity for HIV transmission. The concept of risk must be seen in relation to how vulnerable people are in their everyday life. Disasters such as a war or genocide hinders economic and human development both at a household level, through the loss of family member, livestock, crops, homes etc. and at a national level through the destruction of infrastructure, human capital etc. There is also a time dimension built into the definition of vulnerability as it can be seen in the terms of damage done at the time of the hazard as well as repercussion for the future. It is also important to note that vulnerable groups are not just victims or passive recipients, people tend to have extraordinary capacity for self-protection and group action. In other words the processes that generate vulnerability are countered by peoples capacity to resist, avoid, adapt to those processes, and to use their abilities for creating security (Mock et. al. 2004).

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The figure below illustrates links on how conflict shocks might affect vulnerability and exposure opportunity of HIV risk of the population.

Fig. 1 Conceptual Framework of Principal Causes of HIV Risk in Conflict-Affected Populations (Mock et al. 2004) Adapted by Elina Lindskog 2012. The figure illustrates how the underlying determinants, regional ecology of HIV and violent conflict, exhibit measurable effects on both vulnerability and exposure opportunity, and how they interact with each other. Conflict shocks can weaken a communitys ability to `protect a population from being vulnerable to the HIV infection, or it can influence exposure opportunity itself. Vulnerability and exposure opportunity are the basic determinants of population-level risk (Mock et al. 2005). The regional ecology of HIV and violent conflict are here seen to be linked and to further influence a possible link to population vulnerability and exposure opportunity to HIV, which ultimately increases the population risk of HIV infection in a feedback loop. Violent conflict may at an individual level produce variation in sexual behavior, including sexual contacts that are more or less conducive to the spread of HIV. At a community or societal level conflict might disrupts the distribution of contraceptives, and destroy infrastructure that are relevant for distributing health related information. Difficulties in accessing contraceptives (in this case condoms) results in low contraceptive use increasing the exposure opportunity of HIV, feeding back to the flow of the figure. This study focuses on one specific pathway (age at first sexual intercourse) and how it feeds into the concept of vulnerability, exposure opportunity and risk of sexual transmitted diseases, here HIV infection. In sum, this figure draws attention to mechanisms by which vulnerability links to exposure opportunity, which links on to population HIV risk, and how this may increase or decrease during conflict depending on the context of the conflict (Mock et. al., 2004). HIV and gender together with an understanding of the concepts vulnerability, exposure opportunity, and risk are fundamental for

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the discussion on womens vulnerability to HIV infection through a conflict crisis or the aftermath of a conflict. The level of womens vulnerability to HIV infection is also related to a time dimension, the duration and onset of the conflict as well as the scale and geographical location of the conflict. This will be discussed further in the data and methods chapter, where years (or months) of conflict and region are seen as indicators of the violent conflict in Rwanda. Regions in Rwanda Rwanda is a small but densely populated country with 9.7 million inhabitants (2009) with 401 people per km2. Its neighboring countries are The United Republic of Tanzania, Burundi, Uganda, and Democratic Republic of Congo. Rwanda has a substantial annual population growth (in 2009). The population growth rate was 2.5 percent a year in the period 2000-2005 which contributed to serious development problems. Rwanda belongs to the group of very low-income countries, where a vast majority of the inhabitants live in rural area, and 90 percent of the population work in agricultural (Muhoza et. al., 2009). The genocide affected the whole of Rwanda, but it unfolded unevenly across the country. Several areas in Rwanda such as Gitarama and Butare resisted the calls to genocide. In these regions, Hutu and Tutsi fought together against leaders of the genocide without success (Buss, 2009). In one location Giti, in the region Byumba, the genocide never took place (Straus 2006, Chap. 3). Below is a map with information on the geographical distributions of the 12 different regions in Rwanda.

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http://mappery.com/map-of/Rwanda-Regional-Map

Data and descriptive statistics For this study I will use 2 different sources of data sets (Rwandan DHS from 1992, 2000, and 2005 and UCDP GED data). The RDHS provides information on womens reproductive and sexual behavior in Rwanda and the UCDP GED data (Uppsala Conflict Data Program - Georeferenced Event Dataset), gives information on the intensity, location and timing of the conflict in Rwanda. The idea is to combine these two data sources to identify the intensity and the regional location of the violent conflict with information from the RDHS on the regional residence of the women since age 12. I am interesting in seeing if I will detect a bump of women experiencing their first sexual intercourse during the conflict period. To study mechanisms that theoretically support changes in the pattern of age at first sexual intercourse detected in the models. RDHS 1992, 2000, and 2005:

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This study applies event-history analysis of age at first sex risks. I calculate the relative risks of first sex by an assortment of categories of variables. I follow individual women from the Rwandan DHS 1992, 2000, and 2005 from age 12 to the event (first sex), or at censoring, at the time of the survey (and in table 6 and 7, at marriage). I estimate proportional-hazards (intensity-regression) models of the timing of first sex. The basic time variable in the model is age and calendar year. The total nr of women in the RDHS is 28,293 observations. In the RDHS 1992 the total nr of women was 6.551, in the RDHS 2000 the total nr of women was 10,421, and for the RDHS 2005 the total nr of women was 11,321. Detailed information on these surveys and sampling design are available in the main reports (RDHS 1992, 2000 and 20051). My unit of analysis is person-month at risk for individual woman between 12-49 years of age and outcome that I am interested in this study is age at first sexual intercourse.
Table 1. Summary statistics of RDHS 1992, 2000, and 2005 for all women from aged 12 Location grew up Percentage who always have lived or at least since age 12 City Countryside Region Kigali Kigali ng Gitarama Butare Gikongoro Cyangugu Kibuye Gisenyi Ruhengeri Byumba Umutara Kibungo Education 9.77 12.54 10.79 12.02 9.22 7.94 7.05 7.02 6.09 7.36 5.27 4.95 14.67 11.07 8.34 10.89 8.59 5.95 5.84 5.07 11.13 6.58 6.81 5.06 14.87 85.13 28.60 71.40 12.68 11.73 9.36 11.30 8.91 6.80 6.30 5.90 8.98 6.91 6.11 5.03 22.98 77.02 Percentage who have not lived since age 12 Percentage of the total sample size of women

http://www.measuredhs.com/

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No education Up to primary Post primary Age category 12-15 15-18 18-21 21-24 24-30 30-49 N

23.51 67.38 9.11 41.46 32.09 16.25 6.20 3.95 0.05 11,426

30.22 56.06 13.72

27.50 60.67 11.83

38.51 32.31 18.31 7.31 3.53 0.03 16,629

40.21 31.59 18.31 6.79 3.08 0.03 28,293

The summary statistics gives information on the distribution in percentage of women who have always lived at the current place of residence or at least from age 12. The total nr of women who always have lived in the same current place of residence or at least from age 12 are 11,426 and 16,629 women have not and 54 women are missing out of a sample size of 28,109 women. The reason for creating variable to detect women who have always or at least from age 12 lived in current place of residence is so that I can be sure that they experienced the conflict of the region at given point in time. I have no means to find out where the women lived before they moved into their last place of residence; hence I cannot be sure of their exposure to the conflict for those who have had first sex before they moved to the last place of residence. Out of the total sample size of 28,109 women, 4,709 women were not married at the age of first sex, 14,783 report of having their first sex within marriage or at union, and 8,569 women have not had sex. Of the 4,709 women who were not married at the age of first sex 1,436 women had lived at current place of residence since age 12 or always. The second model will censor at marriage, but both models will select sample on women who have always or at least since age 12 lived in current place of residence. UCDP GED data: To better interpret the results from the models it is certainly important to build on previous research regarding the war history at regional level. However, the UCDP GED data provides annual data from Elina Lindskog Sida 12

1989-2010 and supplies information on violent conflict events at regional level. It must be stated that the UCDP GED data provides estimations of events and deaths collected from various sources, such as BBC Monitoring Service, Reuter, Africa Rights, Human Right Watch etc. (UCDP GED, codebook 2011). There was such turmoil in Rwanda during the genocide that there is impossible to know how many actually died and the movement of men, women and children around the country at this time period. The basic unit of analysis in the UCDP GED is an event, which implies a phenomenon of lethal violence occurring at a given time and place. An event is defined as: The incidence of the use of armed force by an organized actor against another organized actor, or against civilians, resulting in at least 1 direct death in either the best, low or high estimate categories at a specific location and for a specific temporal duration (UCDP GED, codebook 2011). In the case of Rwanda the event was either recorded as stat-based armed conflict or one-sided violence and the event type variable was recorded as a single event, summary event and continuous event. This information is important in understanding the characteristics of the events. Table 1 describes the distributions of conflict events during the years 1990- 2009 and it is apparent that the year of the genocide experienced an elevated numbers of conflict events over all the regions except for Kibuye (which I suspect is a programming error, I believe this might be Umutare region). There is a total of 431 conflict events recorded in the data. There seems to have been an intense presence of events (violent conflict) in especially Kigali, Kigali-Ru, Butare, and Gitarama, however many events does not necessarily related to high estimated number of deaths. Table 2 will provide an overview of the estimated number of deaths at regional level. Table 1. Calendar Year of Event at Regional Level in Rwanda
Butare Byumba Cyangugu Gikongoro Gisenyi Gitarama Kibungo 0 0 0 0 37 0 0 0 0 0 0 0 37 24 13 11 4 7 0 0 3 2 0 0 0 64 0 0 0 0 2 2 1 1 0 0 0 0 7 0 0 0 0 8 2 0 1 0 0 0 0 11 4 3 0 14 4 1 2 18 18 1 6 0 71 0 0 0 0 17 0 1 6 16 0 1 0 41 0 0 0 0 8 0 1 0 1 0 0 0 10 Kibuye 0 0 1 1 6 0 1 4 4 0 0 0 17 Umatare Kigali Kigali-Ru 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 5 1 43 0 0 1 0 0 0 0 51 0 0 5 6 18 0 1 1 2 0 0 0 33 Ruhengeri 0 17 7 8 3 0 1 22 20 0 10 0 88 Total 29 33 30 34 153 5 8 57 63 1 17 0 431

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2001 2009 Total

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Table 2. Best Estimated Number of Fatalities by Calendar Year at Regional Level in Rwanda, based on the sources pulled together for this data set.
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Total

Butare 0 0 0 0 62832 0 0 0 0 0 0 62832

Byumba Cyangugu Gikongoro Gisenyi 1605 8 114 16 388 0 0 15 54 0 0 2200 0 0 0 0 488 16 3 40 559 0 0 1146 0 0 0 0 43754 4014 0 6 0 0 0 47768 648 398 0 316 443 111 50 802 0 29 0 2213

Gitarama Kibungo Kibuye 0 0 0 0 2345 0 15 59 576 0 0 2995 0 0 0 0 5735 0 9 0 8 0 0 5743 0 0 42 38 6003 0 15 39 0 0 0 6137

Umatare 0 0 0 0 0 0 0 0 0 0 0 0

Kigali 200 0 2 1 4861 0 0 13 0 0 0 5077

Kigali-Ru 0 0 720 39 7030 0 8 4 105 0 0 7906

Ruhengeri 0 618 14 269 1 0 50 851 275 0 0 2078

Total 2453 1024 892 679 133880 4141 150 1829 1577 29 0

The map below illustrates the distribution of deaths in Rwanda from 1990-2009.

Source: http://www.ucdp.uu.se/ged/index.php#

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Preliminary results Table 3 shows that the risk for first sexual intercourse for all women from age 12 is highest for the age group 21-24, this means that the typical Rwandan woman does not have an early sexual debut, common in many East African countries. The coefficients show that the risk is reduced over time, except for the bump up in 1994. The coefficients show that first sexual intercourse occurs earlier in regions with values significantly more than 1, and later in regions significantly less than 1, compared to Kigali City (fixed at 1). To detect possible deviations from the regional norm that could be associated with conflict, I tested an interaction between calendar year of 1994 and region, see table 4. Tabel 3. Piece-wise constant baseline intensity model A of age at first sexual intercourse since turning age 12 (sex or marriage)
Age 12-15 15-18 18-21 21-24 24-49 Place of residence Rural Urban Calendar year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Region City of Kigali Kigali ngali Gitarama Butare Gikongoro Cyangugu 1 5,75 *** 14,2*** 18,7*** 17,8*** 1 1.15*** 1 0,95 0,85** 1,09 1,59*** 1,29*** 0,95 0,94 0,91* 0,78*** 0,60*** 1 1,16*** 0,98 0,92** 1,17*** 0,97

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Kibuye Gisenyi Ruhengeri Byumba Umutara Kibungo No, of subjects = 27823 Number of obs = 274484 No, of failures = 19255 Time at risk = 2435191 LR chi2(28) = 16989,68 Log likelihood = -19880,92 Prob > chi2 = 0,0000 *p<.1 **p<.05 ***p<.01

1,07** 1,31*** 1,19*** 1,11** 1,26*** 1,34***

In table 4 the interaction effect between calendar year of 1994 and regions for all women age 12 shows and increased risk of earlier sexual debut in all regions especially Kigali ngali, Gikongoro, Gisenyi, Byumba, Umatara and Kibungo. These regions were highly affected by the conflict. What is surprising is that Gitarama and especially Butare did not show as high risk. (This might maybe be explained partly by the resistance of the genocide in these regions, something that I will investigate further.) Table 4. Interaction between calendar year of 1994 and all the regions for all women from age 12 (sex or marriage)
Region City of Kigali Kigali ngali Gitarama Butare Gikongoro Cyangugu Kibuye Gisenyi Ruhengeri Byumba Umutara Kibungo Number of obs = 274484 1994 1,60** 2,63*** 1,66** 1,60** 2,77*** 1,98*** 1,60** 2,75*** 1,98*** 2,21*** 2,24*** 2,20***

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No, of failures = 19255 Time at risk = 2435191 LR chi2(160) = 17232,67 Log likelihood = -19759,425 Prob > chi2 = 0,0000 *p<.1 **p<.05 ***p<.01 Goodness of fit - Prob > chi2 = 0.0000

The interaction effect of calendar year and age, presented in the graph bellow, shows a bump in the conflict year for all ages groups. In order to more fully understand regional differences I need to deepen my understanding of the war history at regional level. Table 5 shows the pattern for women who have had sex before marriage and it seems to follow the same pattern as table 3, with an exception that the age group with the highest risk of experiencing the event is now between ages 18- 21.

Rela\ve Risks of First Sex in Rwanda

2,50 2,00 1,50 1,00 0,50 0,00 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 12-15 15-18 18-21 21-24 24-49

Tabel 5. Piece-wise constant baseline intensity model B of age at first sexual intercourse since turning age 12 (sex before marriage)
Age 12-15 15-18 18-21 21-24 24-49 1 3,81*** 6,54*** 5,07*** 5,02***

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Place of residence Rural Urban Calendar year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Region City of Kigali Kigali ngali Gitarama Butare Gikongoro Cyangugu Kibuye Gisenyi Ruhengeri Byumba Umutara Kibungo No. of subjects = 27823 Number of obs = 274484 No. of failures = 4535 Time at risk = 2435191 LR chi2(28) = 2360.92 Log likelihood = -12917.755 Prob > chi2 = 0.0000 *p<.1 **p<.05 ***p<.01 1 0,62*** 1 0,91 0,91 1,11 1,28** 0,94 0,86 1,00 0,90 0,78** 0,68*** 1 0,85** 0,94 0,96 0,98 0,88* 0,80** 1,15* 0,97 0,94** 0,82** 1,22**

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 Table 6. Interaction between calendar year of 1994 with all the regions for all women from age 12 (sex before marriage)
Region City of Kigali Kigali ngali Gitarama Butare Gikongoro Cyangugu Kibuye Gisenyi Ruhengeri Byumba Umutara Kibungo Number of observations= 274484 No. of subjects = 27823 No. of failures = 4535 Time at risk = 2435191 Log likelihood = -12828.862 LR chi2(160) = 2538.71 Prob > chi2 = 0.0000 *p<.1 **p<.05 ***p<.01 Goodness of fit - Prob > chi2 = 0.0185 1994 1,00 0,83 1,17** 0,87 1,37** 1,21** 0,69 0,99 0,93 1,27 0,81** 1,21

In table 6 the interaction effect between calendar year of 1994 and regions for all women age 12 who had sex before marriage shows and increased risk of earlier sexual debut in all regions especially in Gitarama, Cyangugu, Gikongoro, Byumba and Kibungo. Gikongoro is the region most highly affected by the conflict, together with Butare. The graph bellow shows the relative risk of first sex during the conflict period with the regions organized from high conflict regions to lower conflict regions in regards to estimated number of civilian deaths.

Elina Lindskog

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Rela\ve Risk of First Sex in Rwanda, during the conict period

2,50 2,00 1,50 1,00 0,50 0,00 1993 1994 1995

Discussion The aim of this study is to understand links between violent conflicts with individuals reproductive behavior in a context of high HIV prevalence. The focus of this paper is to study the effect of violent conflict on age at first sexual intercourse. My interest is to see if there is a change in the pattern of age at first sex during a period from 1990-2000. Table 5 shows the risk for women who have all experienced first sex before marriage since age 12. I do realize that there was extensive movement in Rwanda during the conflict both internally but also across borders. This movement of people is not captured in the data and one might speculate that it is the women that moved that were direct targets for the violent conflict and genocide. This is a limitation that I am well aware of, but I still find it interesting to see if the data captures any changes during this time period. The next step is to match the conflict data with the RDHS to get more information the timing, duration and onset of the conflict at a regional level in Rwanda. This data will partly be presented with geographical maps.

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Reference Babalola S. et. al. The correlates of safe sex practices among Rwandan youth: a positive deviance approach. African Journal of AIDS Research 2002, 1: 1121 Bledsoe C. et. al. Reproductive Mishaps and Western Contraception: An African Challenge of Fertility Theory. Population and Development Review, Vol. 24, No. 1 1998. pp.15-57 Caldwell J. et. al. The Cultural Context of High Fertility in sub-Saharan Africa. Population and Development Review, Vol. 13, No. 3. 1987. pp.409-437 Elbe S. HIV/AIDS and the Changing Landscape of War in Africa. International Security, Vol. 27, No 2. 2002 pp.159-177 Grabbe K. et. al. Knowledge, Use, and Concerns about Contraceptive Methods among Sero-Discordant Couples in Rwanda and Zambia. Journal of Womens Health. Vol 18. No 9. 2009 Marshall M. G. Conflict trends in Africa, 1946-2004: A macro-comparative perspective. Available at http://www.systemicpeace.org/ Measure DHS: Rwanda, Demographic and Health Survey 2005. Report 2005 Miller K. et. al. Clinic- Based Family Planning and Reproductive Health Services in Africa: Findings form Situation Analysis Studies. Population Council 1998 Mock N. et. al. Conflict and HIV: A framework for risk assessment to prevent HIV in conflict-affected settings in Africa. Emerging Themes in Epidemiology 2004, 1:6 Ndaruhuye D.M. et. al. Demand and Unmet Need for Means of Family Limitation in Rwanda. International Perspectives on Sexual and Reproductive Health. Vol. 35, No 3. 2009 pp. 122-130 Spiegel P. et. al. Prevalence of HIV infection in conflict-affected and displaced people in seven sub- Saharan countries: a systematic review. Lancet 2007; 369 pp. 2187-95 United States Institute of Peace: AIDS and Violent Conflict in Africa. Special Report www.usip.org United States Institute of Peace: AIDS and Violent Conflict in Africa. Peace Watch. Vol. VII, No. 4 2001 UNAIDS: Report on the global AIDS epidemic. Executive summary 2008 www.unaids.org Walker L. et. al. Waiting to Happen HIV/AIDS in South Africa. Cape Town 2004 Wisner B. et. al., At Risk. Natural hazards, peoples vulnerability and disaster. Routledge 1994 Elina Lindskog Sida 21