HIV/AIDS in our Ranks

Nancy Mock, Dr.P.H.

Woodrow Wilson Center

June 4, 2002

Overview

• What is known about the magnitude of HIV/AIDS among African militaries?

• What are the implications for security and HIV risk in Sub-Saharan Africa (SSA)?

• What is being done to tackle HIV among the military and to build civil-military collaboration?

• What more needs to be done?

Background

• HIV as a major disaster in SSA for all population groups

• The role of the military is only a recent concern for the international community

• Military is seen as a part of the problem, not part of the solution

What is known about HIV risk among the military in Africa

• The theory:– Military represent one of the most sexually active age

groups– The culture of the military esteems risk– Stress of war results in risky behavior– Long absences from family results in need – Military are highly mobile populations, leading to

greater exposure opportunities– Military are commonly surrounded by opportunities for

casual sex

What is popular wisdom?• In virtually all countries of the world the

military is one of the groups most affected by HIV/AIDS.6

• Even in peacetime, UNAIDS estimates, HIV rates are 2-5 times higher among soldiers than for the populace as a whole.

• Although all militaries are affected by HIV/AIDS, those of the developing world are especially vulnerable.

Commonly cited statistics..

• AIDS is the number one cause of death in the Congolese Armed Forces.

• The rate of HIV/Aids infection in the South African National Defense Force may be as high as 60% to 70%

• US Defense Intelligence Agency estimates, according to which some 10-20 percent of soldiers in the Nigerian and Ivorian military were HIV positive, while 40-60 percent of soldiers in Anola and DR Congo affected. for Zimbabwe and Malawi estimates were said to rise as high as 70 to 75 percent. 6

• Close to one-third of Namibia's 15,000-strong National Defense Force is infected with HIV-AIDS,

• "HIV and Men In Malawi," said that between 25 and 50 per cent of soldiers are already infected by HIV 8

What these data mean for civil-military differentials (DIA/FMIC and UNAIDS, 1999)

Country Estimated prevalence among military

Estimated adult prevalence Ratio (military:adult)

Angola 40-60 2.8 14.4,21.6

DRC 40-60 6.4 1.6,3.9

Tanzania 15-30 10.8 .9,1.86

Congo (Brazzaville) 10-25 5.1 7.9,11.8

Cote d’Ivoire 10-20 2.9 3.48

Nigeria 10-20 5.1 2,4

Eritrea 10 8.1 1.9,2.5

A study of Nigerian troops

• Returning from peacekeeping operations in West Africa found infection rates more than double that of the country overall.

• The study also found that a soldier's risk of infection doubled for each year spent on deployment in conflict regions -- suggesting a direct link between duty in the war zone and HIV transmission.

conducted by the non-governmental Civil-Military Alliance to Combat HIV/AIDS (CMA),

The reality

• Few African militaries have the capacity to collect and analyze the data required to generate these estimates, most are based on small scale studies and non-probability sampling techniques

• For others, HIV status of military personnel is not public domain• Virtually no information is available on other critical information related to

knowledge/behavior/practices• Virtually no data is available for rebel troops and the paramilitary sectors• Indeed, the public domain data base for military populations is far worse than

that of civilian populations, which also is highly limited• Many now argue that differentials between civilian and military infection rates

may not be as extreme as common wisdom would have us believe• Infection levels probably vary substantially both within and between national

military populations

However, the context of African conflict and the transition to peace process gives us cause

for concern• Civilians are on the move in the form of forced

migration• Military are on the move• During transitions, peace keepers are deployed

cross borders• During transitions, military having differing HIV

prevalence, may be demobilized and reintegrated in to civilian life

People m

ove because of conflict

African Population Database: 1990 Population Density Distribution

Source: UNEP/GRID

Africa: Major Routes

Figure 1: Conceptual Framework of Principal Causes of HIV Risk in Conflict-Affected Populations

Violent Conflict

Social Ecology of HIV

Population Vulnerability

to HIV

HIV Hazard/ Exposure

Opportunity

Population HIV Risk

Conflict-associated factors that increase and decrease HIV risk

• Decrease– Increased isolation of

communities

– Increased death rates among high risk groups

– Increased death rates among HIV-infected

– Decreased casual sex associated with trauma and depression

– Disruption of sexual networks

• Increase– Increased interaction among

military/combatants and civilians– Increased levels of commercial sex– Decreased availability of STI and

other health services– Decreased utilization of health

services– Increased levels of malnutrition– Decreased access to knowledge

and means to prevent HIV transmission

– Large internal or regional population movements

– Emergence of norms of sexual predation and violence

These dynamics argue for…

• The importance of “joint” civil-military action against HIV/AIDS

• Opportunities to get ahead of epidemics in some conflict and post conflict settings

• The critical need to incorporate the military sector at these early times

• The important potential employment of ex-combatants within the context of “demobilization”

• The importance of “joint” civil-military action against HIV/AIDS

Note that data are even scarcer in these conflict/post conflict

settings..

What is being done now to tackle the problem of HIV in the military and to strengthen civil-military

collaboration

• A number of African militaries have active prevention and “care” initiatives

• Most of the key international initiatives now have incorporated civil-military strategies

• The United States Department of Defense now is engaged in mil-mil collaboration

• USG Agencies now have created mechanisms for interagency collaboration on this issue

Botswana

• Botswana provides one of the most comprehensive examples of a military sectoral response.

• HIV-positive military trainees, including ordinary recruits and officer cadets, complete their training and are assigned to duty.

• Irrespective of HIV status, all members of the BDF and their families receive education and counseling on HIV prevention.

• Except under explicitly stipulated conditions, HIV examinations are voluntary

• BDF members selected for training in countries requiring HIV screening can choose to be tested or to decline the training

Selected international agencies that promote civil-military collaboration in the fight against

HIV/AIDS• The Civil-Military Alliance for Combating HIV/AIDS:

advocacy, networking and educational program development

• Naval Health Research Center: DOD HIV/AIDS Prevention Program

• Africa Crisis Response Initiative: State Department-based training program for peacekeeping

• Africa Center for Strategic Studies: strategic conferences• Several academic centers that emphasize civil-military

collaboration (including Tulane University)

What remains to be done?

• Establish a culture of evidence-based management strategies within the military and civilian sectors and mechanisms for data sharing

• Pilot and disseminate results to enhance military participation in community HIV prevention, especially in the context of demobilization

• Look to other regional models of civil-military collaboration for “disaster management”. The Latin America and Caribbean region comes to mind

• Support long term institutional partnerships that will survive well beyond the funding cycles of donor agencies: networks, CMA, etc.

Also attack the underlying causes of high risk behavior among

militaries

Address the underlying factors that contribute to the high vulnerability of military personnel

• Changes to posting practices, • Changes to military culture. • Changes to military attitudes towards civilian

populations.

Finally, funds, funds, funds…

• A quote from Ambassador Holbrooke to keep things in perspective…

• “we spend billions of dollars on peace keeping, we spend millions to protect our peacekeepers from terrorist attacks and from hostile forces—but I don’t think we’re spending even $500,000 yet to protect them from HIV/AIDS”

Resources

• A list of Abstracts of HIV/AIDS in Conflict at USAIDhttp://www.usaid.gov/regions/afr/conflictweb/aids_bibl_journals.html 

• Resources available on the webHIV/AIDS & Conflict Resourceshttp://www.usaid.gov/regions/afr/conflictweb/aids_bibl.html

• Family Health International and UNAIDS websites

For more information…

Photo credit : AVERT

Visit:

www.certi.org

www.cdmha.org

www.tulane.edu/~mock