The military has been traditionally concerned about STIs and has promoted condom use for a long time. There are data indicating that the prevalence of HIV and STIs among military personnel is higher than among the average population in many countries. For example, data from a rural blood bank in Mozambique showed that 39% of military blood donors were HIV-positive, compared to 15% of non-military donors. Almost 75% of the HIV-infected soldiers also tested positive for syphilis. Estimates of HIV prevalence among the military in Angola and the Democratic Republic of the Congo range between 40 and 60%. UNAIDS estimates that during periods of peace, STI rates among the armed forces are generally 2-5 times higher than in comparable civilian populations. The difference can be even greater in times of conflict.

In light of these high rates of HIV/STIs among military personnel, it is urgent to design effective intervention programmes for this population. Many governments realise that, given the high costs of caring for HIV-infected soldiers and their families by military health services, it is essential to invest in HIV prevention.

The UNAIDS response

In 2000, the United Nations (UN) identified HIV/AIDS as a growing security threat. UNAIDS established the UNAIDS Office on AIDS, Security and Humanitarian Response (SHR), which adopted a Strategic Action Plan in 2002. This "Strategic Action Plan for HIV/AIDS interventions among uniformed services with a special emphasis on young recruits" was designed as a generic model to support governments in formulating interventions. The overall aim is to provide selected countries with the necessary resources and support in order to initiate an effective and durable HIV/AIDS programme for uniformed services, in particular, young recruits.

Components of the Strategic Action Plan are:

• Generic guidelines aimed at UNAIDS staff, implementing partners and national entities to guide them in the formulation of projects.
• A guide to peer education training, to be published in 2003, that covers basic information for the training of trainers, peer educators and other persons directly involved in training.
• A guide designed to provide an overview of HIV/AIDS/STI programming options for planners.

Although military personnel are highly susceptible to HIV/STI infections as a group, the structure of the military also offers a unique opportunity for HIV/AIDS prevention and education: large audiences living in a disciplined, highly-organized setting. In various countries, such as Ethiopia, Kenya and Thailand, special prevention, counselling and training programmes have been set up for this group.

Ethiopia: training the army on HIV/AIDS

In October 2001, the UN Mission in Ethiopia and Eritrea (UNMEE), together with the Ethiopian army, organised a two-week training course for HIV/AIDS educators who mainly work for the Ethiopian National Defence Forces. One training goal was to develop a five-year strategic plan for HIV/AIDS control in the armed forces. The training activities are part of a UN requirement to establish a task force on HIV/AIDS to plan for prevention and control of the disease wherever it has peace-keeping forces. The training, attended by 24 soldiers and two UNMEE staff, will create an initial cadre of peer trainers to lead other members of the armed forces in developing anti-HIV/AIDS action plans. Similar trainings have also been conducted in Eritrea.

Kenya: voluntary and anonymous testing and counselling

Between 50-60% of all beds at the Kenyan Armed Forces Memorial Hospital are occupied by military men and women with HIV/AIDS-related infections and at least 6-10 soldiers die each week as a result of AIDS. In response, the Kenyan government set up an AIDS Control Unit at the Department of Defence. The Kenyan army operates 16 Voluntary Counselling and Testing (VCT) Centres where soldiers can be tested anonymously for HIV. Sixty-four counsellors, including three who are open about their positive HIV status, have been trained. Military medical staff have also attended a tuberculosis management course to aid in screening all TB patients for HIV and all HIV patients for TB. Condoms are now available and easily accessible in the barracks.

Thailand: reducing the incidence of HIV

The Royal Thai Army was one of the first armed forces that made a serious attempt to curb the spread of AIDS among its personnel. UNAIDS is currently developing a best practice publication based on the Thai example. A behavioural change intervention focusing on consistent condom use, and reducing brothel patronage and the use of alcohol at a Thai army base, showed that it is possible to decrease the number of new HIV/STI infections. Young conscripts who received intensive HIV education were followed from their entrance into the army in 1993 to May 1995. Compared to control groups of conscripts who did not receive the education, they were seven times less likely to catch an STI. During this period, the incidence of HIV was halved among the participating soldiers.

Examples like these can be found everywhere. Unfortunately, there are also negative responses. Several countries demand HIV testing of their new recruits and refuse any applications from HIV-infected soldiers, claiming that "we need healthy soldiers; people with HIV cannot fight". Other countries dismiss soldiers and officers who are found or suspected to be HIV-positive, or remove them from active service. According to UNAIDS, HIV testing in military settings was carried out in some form by 93% of 62 countries that were examined in a 1995 survey. Forty-three countries stated that they impose mandatory testing. UNAIDS and other international organizations strongly oppose compulsory testing.

Conclusion

Although members of the armed forces are highly vulnerable to HIV/STIs, the very nature of the military's hierarchical organization creates opportunities for interventions. Governments and military leaders are increasingly seizing this opportunity to contribute to the fight against AIDS among their armed forces. However, they should not take the "easy road" and conduct mandatory testing of their soldiers; rather, they should encourage the establishment of high-quality VCT services for their personnel, along with other HIV/AIDS prevention, care and support activities.