HIV/AIDS in the Ranks: Responding to AIDS in African Militaries

By Jennifer Wisnewski Kaczor

4 June 2002—With some sub-Saharan African countries having up to 60 percent of their populations infected with HIV, security policymakers and researchers are increasingly regarding AIDS as a security issue. But one aspect of AIDS that has received less attention is the HIV-infection crisis within sub-Saharan African militaries. Even during peacetime, military personnel globally have higher rates of sexually transmitted infections then their surrounding populations—and HIV-infection rates for African militaries are even higher.

These figures raise troubling questions for the readiness of these militaries, the health of non-combatants in conflict and peacekeeping zones, and ultimately the political stability of many African countries. In this Wilson Center meeting, Dr. Nancy Mock provided an overview of current research on HIV and security, and Captain Stephen Talugende of the Uganda People's Defense Forces related the Ugandan military's experience with HIV prevention programs.

Conventional Wisdom and the Data Dearth

Mock presented what she called the conventional wisdom on HIV prevalence in African militaries, which theorizes that military populations are particularly vulnerable to HIV infection because (a) they are in the most sexually active age group, (b) the culture of the military promotes risk-taking behavior, (c) military members are highly mobile and live away from their families, and (d) military members have cash available to purchase sex. Mock said that UNAIDS estimates HIV rates to be two to five times higher among soldiers in some African countries than for those country's non-military populations, with these rates rising for both groups during times of conflict and war. Uniformed service members of less-developed countries, said Mock, are especially vulnerable to HIV infection.

Mock then turned to the impact of HIV on military forces in sub-Saharan Africa, citing some shocking 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 60-70 percent;
• According to U.S. Defense Intelligence estimates, 40 to 60 percent of soldiers in Angola and the Democratic Republic of the Congo are infected with HIV. For the Zimbabwean and Malawian armed forces, estimates are as high as 70 to 75 percent.

Mock cautioned, however, that few African militaries have the capacity to collect and analyze the data required to generate estimates of HIV infections; most extant statistics are based on small-scale studies and non-probability sampling techniques. For others, such information is classified as a matter of national security.

The reality, Mock said, is that very little reliable data exist for prevalence rates within African uniformed services, and data for rebel troops and paramilitary groups are even more difficult to get. In addition, data on knowledge/behavior/practices do not exist. Mock said this data dearth leads some analysts to conclude that prevalence differentials between African civilian and military populations may not be as high as conventional wisdom purports.

The Relationship Between HIV and Security

Mock also noted that, contrary to conventional wisdom, HIV-prevalence data among general African populations suggest that countries with less conflict tend to have higher rates of infection. She hypothesized that peace and stability bring improved transportation infrastructure and increased trade and movement of economic goods within and among countries. This ease of movement and increased economic activity then provide a vector of transmission for the disease. (See Box 1 for the factors that increase or decrease susceptibility to HIV-infection during conflict.)

Box 1. Factors that Increase or Decrease Vulnerability to HIV Infection During Times of Conflict

Factors that increase vulnerability:

• 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 movement;
• Emergence of norms of sexual predation and violence.

Factors that decrease vulnerability:

• 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.

But Mock suggested that current analyses do not provide a clear picture of the complexity of the relationship. Though overall prevalence rates suggest that infection rates rise during peacetime, she cautioned that very little comparative data is collected in countries during and after conflict. Mock suggested, however, that societies during and after conflict are particularly vulnerable to HIV infection because: (a) conflict displaces people from their homes; (b) militaries are on the move; (c) during transitions, peacekeepers are deployed across borders; and (d) during transitions, military members with HIV may be reintegrated without testing, counseling, or treatment.

Recommendations

Mock suggested a number of recommendations to address HIV prevalence in the military:

• Establish a culture of evidence-based management strategies within the military and civilian sectors as well as mechanisms for data sharing;
• Conduct pilot studies of baseline prevalence rates and disseminate their 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" such as collaborations in Latin America and the Caribbean region;
• Support multi-sector approaches that build partnerships and networks among military and civilian government and non-governmental institutions—efforts that will survive well beyond the funding cycles of donor agencies.

Uganda: A Program for Success

Talugende next related his experience administering the Post Test Club in the Ugandan People's Defense Forces. The Post Test Club was formed in 1990 to: (a) lobby for better care and support of AIDS patients by the Ugandan military authorities; (b) create partnerships with other support organizations; (c) take active involvement in HIV prevention through public speaking, community education, and peer health education; (d) implement childcare and orphan care; and (e) provide treatment for members.

Talugende attributed the drop in the Ugandan military's HIV prevalence rate—from over 10 percent in 1990 to less than 7 percent today—to the efforts of the Club. He said that over 7,000 service members and families now participate in the Club's voluntary programs. According to Talugende, the program has strengthened and encouraged openness about HIV/AIDS in the Ugandan military as well as reduced the stigma and discrimination suffered by infected service members. "The Club," he said, "builds confidence and hope, maintains the military's professionalism, and is cost-effective."

Challenges Remain

But Talugende also noted continuing challenges facing the project—particularly, a lack of drugs and medications as well as limited administrative support and training for volunteer educators in public speaking and communication. Talugende also said that the death and ill-health of committed Club members made continuity of leadership and participation in the organization a particular challenge.

Open discussion focused on the data questions raised by Mock, who reasserted that an evidence-based management strategy was absolutely critical to the success of treating HIV in Africa. Some attendees argued that not enough reliable data existed to justify to the U.S. military that HIV is a security issue. Others questioned whether the secrecy of military culture would ever allow implementation of an evidence-based approach to HIV infection. But both Mock and Talugende felt that these norms were changing and that a strong data-based case would prompt the United States to fund HIV prevention programs among developing country (and especially African) uniformed services.

Will the epidemic prevent African nations from fielding military forces? Talugende felt that, because a person can live for some time with the virus without showing symptoms of AIDS, African nations would still be able to field armies and participate in peacekeeping missions—a concern raised by some groups studying this issue.

Glossary

HIV/AIDS rates higher in the military:From "Men and AIDS: A gendered approach" (available on-line at www.unaids.org/wac/2000/wacmene.doc): "Men in the military are at increased risk of HIV and other STIs. Away from home and from their regular sex partners, sexual activity; both consensual sex and rape; may increase. Several studies confirm higher rates of HIV infection among military personnel: 22 percent of military personnel tested HIV positive in the Central African Republic (compared with 11 percent in the overall adult population). Unprotected sex between men in the military, generally hidden, may also contribute to HIV transmission."

Evidence-based management strategies: The systematic and disciplined use of current best evidence in making managerial decisions in specific business or government situations; a technique often used in the health industry.