The HIV/AIDS Pandemic and Critical Policy Issues for the Armed Forces
By Robert Lalasz
While African and other developing-country nations are being decimated by the HIV/AIDS pandemic, militaries in these countries are estimated to suffer from HIV infection rates even higher than those for their civilian counterparts--ultimately posing a threat to force readiness and national and even regional security.
Yet those developing countries with vigorous defense-sector programs of HIV/AIDS prevention education show remarkable results in restraining the pandemic across all sectors, civilian as well as military. In this Wilson Center meeting sponsored by ECSP, Stuart Kingma and Rodger Yeager of the Civil-Military Alliance to Combat HIV and AIDS reviewed critical policy questions that militaries and civil administrations in developing countries must address in confronting their HIV/AIDS problems.
Militaries and the "Second Wave" of HIV/AIDS
With a "second wave" outbreak of HIV/AIDS "second wave" outbreak of HIV/AIDS poised to threaten Asia, Eastern Europe, the Caribbean, and Central America, Kingma and Yeager stressed that militaries in these regions can be a critical bulwark against the pandemic instead of contributing to it.
The main challenge, however, is to engender behavior changes in military attitudes, policies, and precautions regarding HIV. "The only successful means of attack on transmission comes through changes in behavior," Kingma said. "This is why addressing it substantively is so difficult, along with protection and care for infected."
"The security/defense sector in each country needs an agenda for urgent yet realistic policy development and support," he added. "Some are well on their way--Thailand, Cambodia, Uganda, and Senegal, among others." But Kingma cautioned that many of the most critical policy issues--especially mandatory testing for HIV--tread on touch legal, ethical, and cultural issues.
Civil-Military Policy Questions
Kingma outlined two kinds of issues related to HIV/AIDS in developing-country militaries: those that militaries share with civil society, and others that are specific to the military.
"The military doesn't exist in a vacuum," said Kingma. "There is always a civil-military interface, made real through chains of personal interaction: dependents, wives, contacts, affairs."
1. STI/HIV prevention
With no vaccine yet in sight for HIV or other sexually-transmitted infections (STI), "education is all we have," said Kingma. But he added that effective prevention education must be much more than information transfer: it needs to be incorporated into recruit training and reinforced before the first post-basic leave period ("the most dangerous time of all in the life of a sexually-active but deprived young person," said Kingma) as well as in officer and technician training, before and after deployments, and at discharge and demobilization.
"Let's face it," Kingma said. "The period of basic training is a period of social and sexual deprivation, but these other periods are all important times as well. Education is not being done consistently the way it needs to be done."
2. Male and female condom promotion, provision, and availability
While Kingma said that "mutual fidelity in a stable sex partnership is still the first line of defense versus HIV," he argued that condoms are the only practical and responsible strategy of the moment against infection. Further, he said that condom use must become a culture—-through prevention training that goes beyond group briefings and pamphlets.
"The Netherlands has a program of sex education and emerging sexuality that starts earlier in life than anywhere, to the point where sexual contact without a condom is the abnormal," Kingma said. "That's why [their soldiers] come back from peacekeeping with no HIV infection and one-tenth of the incidence of other STI of other militaries—-including the United States'."
3. HIV testing and counseling
While the U.S. military instituted compulsory pre-recruitment HIV screening and periodic testing during service back in 1985, that policy is not universal. The United Nations relies on voluntary testing and prevention programs instead of mandatory testing because of concerns about privacy and possible discrimination against soldiers as well as fears that a mandatory policy would be counterproductive.
Kingma said that a policy of compulsory HIV screening and testing is being adopted by militaries and police forces in an increasing number of countries. motivated by the burgeoning costs of AIDS care and retraining to fill the positions of people lost to AIDS. Despite the complications of compulsory testing, Kingma said that periodic testing can preserve force readiness and deployment capacity as well as help to (a) ensure longer service for those trained for technical or command positions, (b) adjust duty assignments, and (c) identify infected personnel and their partners for counselling and care.
But Kingma stressed that positive benefits from testing are dependent on keeping rules of confidentiality and informed consent so that HIV infection does not become a death sentence due to discrimination.
4. STI/AIDS treatment, care, and family/community support
Kingma said that defense ministries need to equitably balance the competing values of military readiness and national security versus treatment, care, and support for all those affected by the virus.
However, he added that striking such a balance becomes problematic for defense ministers who do not have sufficiently-funded health budgets. Kingma argued that national treasuries need to accord a fair share of their HIV-care budgets to defense establishments, and that financial, technical, and pharmaceutical support is urgently needed to help civilian and defense/security sectors in developing countries find the answers to the care and support demands they face.
5. The catalytic, complementary role of civil-military collaboration and inter-country military
"Countries with vigorous defense-sector programs in HIV/AIDS preventive education show results in restraining the epidemic across all sectors," Kingma said, citing Thailand, Uganda, Senegal, Cambodia, Zambia, Morocco, and Tanzania as examples. "The defense sector is critical for successful national AIDS control."
Kingma added that there is also growing but not fully-conclusive evidence that, when the defense sector of a country is well-represented on that country's national AIDS council and when defense cooperation and interaction is dynamic with the national AIDS program, prevention makes much more progress in both sectors.
Military Policy Questions
1. The military workplace as a unique setting for HIV risk and risk management
Kingma argued that HIV/AIDS-related policy issues take on expanded and critical significance when peace breaks down. "At these times, the military may be the only institution able to restore and manage a transition to peace and stability," he said. "Hence, it's crucial that militaries address prevention and treatment in their own houses."
Kingma also noted that militaries draw recruits from the age group at highest risk for STI, and that some circumstances of military life—-frequent travel, distant postings, stress and boredom, the habits of professional risk carried over into social contacts, and the attraction of military installations to sex workers—all enhance the risk of STI and HIV transmission to military personnel.
"And the risk environment is further enhance when the military are involved in missions characterized by open conflict, post-conflict peace enforcing, massive displacement, and other humanitarian emergencies," Kingma said. Unlike other groups, however, militaries are seldom considered appropriate as recipient of donor funds for HIV prevention programs.
2. Military command and control structures as facilitators of and impediments to HIV prevention and management
While militaries' span of control and chain of commands provide some of the best means to induce change over a wide range of behaviors, Kingma said that changing the sex practices of soldiers who were off-duty or deployed in war was still difficult.
"The answer must go beyond codes of conduct," he said. "We have to become more proactive." He noted that commanding and medical officers respond to somewhat different mandates (maintaining deployable force strength versus maintaining a healthy force), and that since HIV/AIDS is not perceived as a "war-stopper," it was easy for commanders to fall back on the quick fixes of pre-recruitment screening for HIV, a few lectures, and a pamphlet.
"Commanders need to be sensitized to the issues and the sense of urgency," Kingma added. "It's essential that these critical policy questions lead to dynamic and proactive programming in the military establishment."
3. The physical impact of military training and service on the progression of HIV infection to symptomatic AIDS
Although some argue that strenuous military training and service hasten progression of those with living with HIV to symptomatic AIDS, Kingma said studies of the question thus far have been inadequate. "We have been encouraging military medical services to research these factors in greater detail," he said. "The answers will shed light on the validity of HIV screening of recruits."
4. The relationship between length of deployment in operational areas and risk of HIV infection
Kingma said that length of deployment is one variable that strongly influences one's final vulnerability to STI infection. For example, Nigerian military contingents involved in regional peacekeeping efforts in Liberia and Sierra Leone demonstrated a cumulative risk factor increase of 2 percent per annum of deployment.
The military experience, he added, confirms the increased vulnerability of other sectors that are also characterized by a high degree of mobility: long-distance transport workers, migrant labor, international refugees, and mobile sex workers.
"Will commanders accept the need for ordering shorter tours of deployment and for allocating adequate resources so that preventive education, condom promotion and peer counseling are reinforced prior to and after deployment?" Kingma asked.
5. Special HIV-related issues of participation in regional and international peacekeeping missions and humanitarian emergencies
Kingma noted that HIV thrives in climates of conflict and socio-economic and political disintegration. "The culture of violence turns into a structural risk environment for transmission," he said. "And sudden and absolute poverty of displacement populations makes many turn to sex for sale." He stressed that every operational group present in peacekeeping and humanitarian situations is vulnerable to HIV transmission.
Indeed, in recognizing in January 2000 that HIV was a threat to international health and security, the UN Security Council also mandated enhanced prevention activities for UN peacekeepers before, during, and after deployment.
Kngma, however, said that HIV prevention is underfinanced at UNDPKO, and most troop-contributing countries cannot afford to contribute monies for these activities.
6. Risk and risk reduction during demobilization, reinsertion, and reintegration into civil society.
Countries worldwide face challenges relating to downsizing and demobilizing troops that are HIV-positive. Johanna Mendelson and Manuel Carballo have written that "if demobilization programs do not include prevention and peer counseling, the reintegration of HIV-positive soldiers into new communities and their original villages may result in a major proliferation of the virus."
However, Kingma added that demobilization offers an opportunity for discharged troops to become agents for change in their home communities—but only if these troops are offered HIV prevention education, counseling, testing, care, and support.
In discussion with the audience, Kingma and Yeager said that the issues of HIV/AIDS testing for UN peacekeeping contingents is are "exquisitely complex and difficult." Kingma noted, for example, that a number of troop-contributing countries have objected to a change in UN policy as a challenge to their continued participation.
"Many defense ministries are funding their entire budgets on the funds the UN contributes to them for peacekeeping," Kingma said. He added, however, that the issue is under active discussion and review, and that language in the new UNDPKO policy now under development is "getting stronger and stronger" for banning from the peacekeeping field any soldier who is HIV-positive.
"The ramifications [of mandatory testing] extende to the UN, the World Bank, and the diplomatic core," Kingma said. "It's a Pandora's box, and the moral standing of peacekeeping forces is pushing the discussion."
Civil-Military Alliance to Combat HIV and AIDS: Publications
The Second Wave of the HIV/AIDS Pandemic: A Conference Report from the CSIS Task Force on HIV/AIDS