WASHINGTON—Health is a readiness issue for militaries around the world and HIV is one of the many health issues that militaries must address. In FY 2001, Congress appropriated $10 million to establish the Department of Defense HIV/AIDS Prevention Program (DHAPP). Since then, the program has been working to help militaries around the world prevent HIV/AIDS transmission among their uniformed personnel.

“The fundamental reason for this program is that all militaries consider health as a readiness issue, and one of the health issues in many militaries around the world is preventing and dealing and treating HIV among military members and their families,” said Richard Shaffer, Ph.D., director of DHAPP, which is headquartered at the Naval Health Research Center in San Diego.

The HIV/AIDS assistance provided to foreign militaries through this program is one part of the overall HIV prevention effort coordinated through the U.S. State Department. The program receives most of its funding through the President’s Emergency Plan for AIDS Relief (PEPFAR), a U.S. program that works with other countries to provide HIV treatment, prevention and care. “We are the military part of the PEPFAR program,” Dr. Shaffer said. “DoD sits at the PEPFAR table. We are currently supporting HIV activities in 73 militaries around the world. The majority of those are on the continent of Africa, but they are also on all continents.”

HIV/AIDS in Militaries

Deployed military personnel are often at risk for contracting and spreading HIV for a variety of reasons. According to the Joint United Nations Programme on HIV/AIDS, members of the armed forces often have the financial resources to purchase sex where they are stationed. In addition, communities in conflict have often lost their means of livelihood and, as a result, sex industries grow around military bases in response to demand.

While not all militaries around the world know their HIV rates, some do. For example, according to the DHAPP country report for Angola, in 2003 a military prevalence study estimated rates of seroprevalence at 3 percent to 11 percent in its military, depending on the location. HIV prevalence rates were highest near the border of Namibia at 11 percent.

The U.S. military has been dealing with HIV in its own ranks since 1982 and currently has an HIV rate of about 0.3 per 1,000 individuals, according to Dr. Shaffer.

Many militaries in Africa had a later onset of the HIV epidemic than the U.S. and therefore started grappling with formulating HIV/AIDS policies in later years. “It took us a good 10 years to get a handle on our policies,” he said. “We spent most of the ‘80s trying to deal with how to institute a testing program. To me, it is a very interesting historical parallel between what our military went through in the ‘80s and what many of these militaries are going through now with resources and the epidemic. The U.S. military, frankly, has been through a lot of these things thatAfrican militaries are going through now,” he said.

Education Assistance

DHAPP provides education support to militaries in the areas of prevention, care and HIV treatment. “Our programs goal is to provide both technical assistance and funding resources assistance to these militaries to basically augment and continue to grow their own program,” Dr. Shaffer explained.

For example, one way in which the program provides assistance is through a training program that U.S. foreign military medical personnel can attend in the U.S. through the Military International HIV Training Program (MIHTP). The program is a collaborative effort involving the Naval Medical Center San Diego; the University of California, San Diego and San Diego State University. Foreign military physicians come for a four-week training program in HIV/AIDS clinical management and learn about epidemiological surveillance, laboratory diagnoses of HIV, caring for HIV patients and setting up prevention programs.

“Also, we support a number of HIV training programs. Those are smaller, but more focused programs that are in the region and we bring countries in those regions into those,” Dr. Shaffer said. “We have a number of traveling education programs and we also, equally important, will provide resources for military members to go to other training programs in their country or their region supported by their own ministries of health or by other U.S. government agencies. ”

DHAPP also provides help with developing HIV curriculum tailored for militaries. In addition, the program helps militaries provide capability to increase or establish HIV testing and to provide education and training on how to do counseling around training, among other things. “We will provide laboratory infrastructure, training for laboratory technicians. We provide training to militaries on policy development when it comes to HIV, and training to militaries on clinical management of HIV for military physicians and healthcare providers. We also provide a large amount of materials to militaries when it comes to mass media campaigns,” he said.

Prevention and Testing

While the knowledge of how to prevent HIV is common, what is not as widely recognized is the importance of having military leadership involved with the HIV program. “As we know from the U.S. military, the most successful medical programs are those that are embraced by the line and warfighter leadership of the military—that are not just considered medical programs. So, probably one of the more important gaps that we help fill is helping the militaries to recognize that HIV is a leadership issue, as much as a medical issue. We help them with policy development with getting the message out to their senior leaders; that is one of the biggest gaps we find,” explained Dr. Shaffer.

The stigma surrounding HIV and HIV testing, for example, is an issue that can be addressed when military leaders support the military’s HIV program. “Issues that often have stigma, the way it gets changed is through the leadership—whether it is in our military or in other [militaries],” he continued. “You will see militaries where the person will make absolutely no attempt to find out what their status is because of concern of what it will do to their military career, but other militaries where they are absolutely open with it and people living with HIV are coming forward and being peer educators.”

Since the establishment of the program, much progress has been made, Dr. Shaffer said. “When the U.S. military started this program back in 2001 no militaries in Africa had a policy for HIV within their military,” he noted. “That was mainly because the HIVepidemic in African militaries is relatively new; it is a lot more recent than the epidemic in the U.S. military.” Now, about 50 percent of the militaries that the program assists have formal documented policies for dealing with HIV in their military. While that is up from 7 years ago, there is still long way to go. “Fifty percent of militaries now have formal documented policies for dealing with HIV in their military, which is a very impressive increase in that kind of programmatic improvement,” he said.

In addition, 100 percent of the militaries offer some form of HIV testing. However, the type of testing offered varies from military to military and comes in many different forms, such as recruit testing, mandatory testing, pre-deployment testing or voluntary testing. The use of the testing results also varies from military to military.

Facing the Problem

Dr. Shaffer noted that he is impressed that many of the militaries they work with have been willing to tackle HIV/AIDS among their ranks before it has manifested as a major problem. “I keep thinking back to in our military. If we were trying to devote a large number of resources to the prevention of a problem that we don’t actually have, we would have a tough time selling that program,” he said.

He also said that the number of militaries that have a general or very senior person running their HIV prevention program is impressive. “I think that is impressive in itself that, although maybe in our military the HIV program is dealt with by the medical department or in some cases by the line leadership, you’ll find that when you go to a partnering military, whether it is in Africa or in other places, they have assigned very senior members to these issues,” he said.