Comment & analysis
HIV/AIDS and Africa’s military: Are we winning this war?
2008-12-02, Issue 409
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That HIV/AIDS has become a humanitarian and security crisis across the Africa is an indisputable fact.
Statistics aren’t likely to change overnight, and Africa remains the most affected continent with Sub-Saharan Africa accounting for more than 67% of 33 million HIV positive people across the globe. It is therefore no coincidence that HIV/AIDS is considered to be an incessant mode of destabilization on the African continent; an inherent security risk that threatens to disrupt gains in health, development, infrastructure and human development. In fact, while 25% of the continent remains engaged in conflict, in some quarters, HIV/AIDS is considered to be “more destabilizing than the wars currently raging on the continent”
While debates continue - mandatory testing versus human rights; condoms versus abstinence and medical science versus traditional medicine - little is known regarding the extent to which African militaries, responsible for much of the rebuilding and maintenance of peace in post-conflict African states are being affected by HIV/AIDS. While concern over how HIV/AIDS affects Africa’s armed forces has increased since the late nineties, there seems to a plethora of gaps in the mainstream understanding of where African armies really stand, as a high risk population group.
HIV is a multifaceted virus, emerging and spread in varying contexts. Some of these include reasons include: socio-economic strife, mobile employment and high risk employment, high incidence of transactional sex and gender imbalances. Military personnel face all of these challenges, which inadvertently place them at the top end of high risk populations, together with truckers, miners and sex workers. What makes military personnel especially at risk is the amount of time spent away from home, stressful and difficult conditions and believe it or not, boredom and lack of entertainment that inadvertently provide military personnel, armed with financial resources, to wander off for sexual escapades. However, the difference between military personnel and the other high risk populations is essentially the crucial factor of secrecy that comes with being part of the military.
In fact, not only is the debate stunted by a lack of statistical data - the very nature of the military as instruments of public and yet national interest - make unearthing an issue like HIV in the military a rather complex affair. Both the military and HIV/AIDS are themes characterized with incessant concealment. HIV/AIDS is permanently surrounded by a cloud of Human Rights sensitivities; confidentiality clauses that serve to protect victims of HIV. This culture of concealment associated with HIV – good intentions granted – mixed with the culture of machismo-protection of military intelligence makes dealing with the crisis of HIV in the military even more intricate.
Without the right treatment, diet, living conditions and attitude, the virus is difficult to manage and affects the mental and physical capacities of HIV positive people. Living and working as a soldier requires the maximum capacities of reflex, concentration and patience that HIV easily undermines without the necessary treatment and counseling.
By implication, knowing the extent to which African forces are affected by the HI-virus is crucial for the continued development of the continent; the maintenance of peace and vanguard of rebuilding societies in post-conflict zones and for the very real containment of the virus in an ever shrinking world.
This paper seeks to make sense of the conundrum of opinion concerning the affect of HIV on Africa’s military and highlights how particular defense forces have, contrary to popular belief, responded to the crisis.
African militaries = HIV time bombs?
Even though statistics are difficult to collate, it was generally accepted that in peace time, defense forces across Africa have a HIV prevalence rate of 2 to 5 times the rate of their civilian populations. These statistics, from studies conducted in the late nineties provided the impetus for extreme blanket analyses that predicted the undermining of Africa’s security. This is now being widely contested as a generalization, with evidence suggesting that in South Africa, the rate amongst soldiers is marginally higher than civilians, while in the Ethiopian defense force, the rate is actually lower than the general population. But in Cameroon and Ghana – both with generally low prevalence levels – their respective armies had prevalence rates were one and half times, and two and a half times the general population The general consensus therefore, is that African armed forces have a higher prevalence rate than civilian populations, but not necessarily 2 to 5 times their civilian prevalence rates.
And whilst these studies have been regarded as reliable data, there still remains significant confusion over the extent to which defense forces are affected. A clear example of this is the South African Defense Force (SANDF). It has been often suggested that HIV prevalence in the SANDF was abnormally high, between 50% and 70%, when official figures relay an estimate of 23%. Another prime example is Angola’s Defense Force, with initial estimates suggesting around 55%, when official reports indicate that rate is not more than 11%. This is by no means an attempt to delegitimise largely accurate analyses or to subvert attention away from a crisis. In fact, according to the CHG Report , HIV prevalence of over 5% is already considered a significant erosion of operational capability, for ill-health does mean armies cannot operate at full capacity or be available for peacekeeping activities at the scale needed. Instead, the focus here is merely a reminder that statistics merely tell half the story, and need to be consumed critically.
In 2002 alone, the Malawian Defense force lost 131 personnel mainly to AIDS related illnesses. UNAIDS reported in 2003 that HIV was threatening to decimate more Malawians than any conflict the small nation has ever been involved in. It was estimated in 2005 that HIV positive personnel in the Zambian Defense Force (ZDF) numbered more than the 16.5% that would be found in Zambia’s civilian population. As a result the medical service was said to be battling to provide the necessary HIV/AIDS related care to military personnel in need of medication, counseling and other types of support that were crucial to keep personnel healthy, functional and in good spirits.
Likewise, it was revealed in early 2008 that approximately 55% of Zimbabwe’s troops were HIV positive, and up to 75% of these troops would succumb to the disease within the year. While reports indicate that the rate of HIV in Zimbabwe has reduced over the past couple of years, the Zimbabwe Human Development report indicates that infections in the military far outweighed the general population rate of 24.6%. According to the Pan-African Treatment Access Movement (PATAM), the situation was compounded by a lack of HIV/AIDS intervention programmes in the army. This is hardly surprising, considering Zimbabwe’s current economic crisis. The World Food Programme announced in October 2008 that unless rapid supplies would arrive, Zimbabwe would run out of food by January 2009. The report further noted that the young soldiers recruited were trained to be fearless and aggressive, qualities they often carried into their personal, civilian and sexual lives.
As may be easily deduced, the situation in Southern African nations is far from ordinary or functional, with the impact on particular defense forces in the region highly suggestive of a crisis in these states. At the same time, the case of Southern Africa is hardly surprising, considering the incidence of HIV in the region itself, which is said to be a staggering seventeen times higher than the global average. In 2007, 75% of all AIDS related deaths were located in sub-Saharan Africa, while according to 2002 South African government statistics; seven out of ten military deaths were AIDS related.
A study of returning Nigerian soldiers, conducted by the Civil Military Alliance to combat HIV/AIDS (CMA), found that rates of infection were double than that of Nigeria’s civilian population. Statistics in Cameroon point similarly to a clear difference between infection rates between civilian and armed forces. Here it is claimed that the civilian HIV rate in 2004 was around 5.6%, while armed forces were close to 15%. However, police recruits were 16.4% and truckers were found to be 18%. As these statistics demonstrate once more, an uncritical approach towards statistics could easily conclude, in this case, that joining the army means a high probability of contracting HIV.
While evidence suggests this to be the largely the case, the case of Ethiopia’s HIV testing and prevention programme suggests that if emphatically addressed, this would remain but a generalization. But the Ethiopian case is a unique one, with even the nature of the war different to “normal” African conflicts which include violence spilling onto the general population.
Fresh evidence suggests that not only are African military forces in many other parts of Africa most definitely not in self-destruct mode as a result of HIV, but the rate of HIV does not compromise their effectiveness as a defense force nor does it spell the possibility of being invaded by an opportunistic warring nation. Moreover, there are armies with effective but unpublicized HIV/AIDS programmes that are making a difference, defense forces that recruit rural youth with low HIV prevalence and conflict-affected populations with low HIV rates.
HIV/AIDS expert Alan Whiteside along with other authors drive home this point in a 2004 report in which they argue further that these alarmist views ignore the diversified nature of the HIV levels at different ranks, which are invariably differentiated by social context, demographics, patterns of deployment, amongst other factors. This only serves as to provide an unsustainable concoction of realities on the ground. While rape and transactional sex are indictments to rising HIV rates across the continent, analysts would be hard pressed to disagree that HIV/AIDS has also been pinned as a justification for continued failure in the economy or political performance. At the same time, the evidence does exist (even if in sporadic accounts) that young men at war will indulge in unsafe sexual activities, increasing the chance of contracting HIV.
Recruitment, Care & Human Rights
The Inter-states Defense and security committee of the military health services working group (ISDC-MHS) was formed in 1999 to specifically but not limited to, addressing HIV/AIDS in the defense forces of the region but also towards managing malaria, diarrhea and stress management. In January 2000, the UN Security council adopted Resolution 1308 (2000), indicating that the affect of HIV on the defense forces could be a threat to international peace. This resolution further indicated a shift from traditional understandings of security as absence of conflict to a more extensive understanding of human security. This resolution further obliged the UN to ensure that peacekeepers were trained and that countries supplying troops were given testing and treatment. Commitment from the UN advanced a further level in 2001 when the General Assembly called on countries to integrate programmes and activities related to HIV for emergency contexts.
Between 2003/4, the African Union initiated the concept of an African standby force (ASF) as a means of organizing peacekeeping missions and launching the Common Security and Defense Policy (CSDP) towards developing a common defense and security guidelines. HIV/AIDS formed an important part of this policy and the initial guidelines for the ASF and its sub-regional brigades. Of the more crucial aspects of this charter was the commitment that the adoption of the African Union’s standards for HIV and AIDS in peace support operations should equal or surpass those principals set by the UN. This naturally meant that all contributing or troops supplying countries had to develop HIV/AIDS policies and practices that reflected the standards of the UN and AU. The African union, acting on the advice of Lt-Gen. Tsdkan Gebretensae designed a “command centered approach” that focused on developing a set of seven policies.
1. Mandatory and voluntary testing
2. Admin & Management of treatment & the rights of HIV positive people
3. Human Resource Management & development
5. Rights of soldiers’ dependents & associated civilian population
6. Developing toolkits & to collate the fight against HIV/AIDS with core military
7. Create monitoring structure
Indeed, since 2000, more African defense forces have advanced on more serious HIV programmes and policies, sobering up alarmist analyses to a large extent. There was a shift and a refocus from the blanket approach to African militaries adopted by many analysts and the mainstream media in the nineties and even in the early turn of the 21st Century, where it was continuously bellied that all African forces were on the literal meltdown.
Ethiopia, South Africa, Senegal, Namibia and Zambia’s defense forces, amongst other countries, have all displayed an adeptness to respond to the AIDS pandemic, some, even before national government and even in contradiction to. However, while certain African defense forces reacted positively towards the impending crisis, the vast majority of African defense force has reluctantly trotted along, paying the now mandatory attention to the virus.
The SANDF have run education and knowledge courses such as the Masibambisane “beyond awareness” campaign and Phidisa project outlined a 2004-2009 plan which sought to research and create health programmes to prolong the lives of HIV positive personnel. The Phidisa programme is specifically “focused on improved clinical management, psychosocial support, and the development of effective family-oriented care for HIV-affected military families”. Phidisa set up six research locations to provide treatment to HIV positive personnel, as well as conduct research into other critical diseases affecting the military. According to Professor Lindy Heineckin, “military personnel also have to undergo a yearly comprehensive health assessment, and this includes an HIV test”
Certain defense forces, like the Namibian Defense Force developed a HIV/AIDS strategic plan 2004-2009 which focuses on prevention all the while aiming to the force’s ability to provide care, treatment and support services. Within two years of the programme, voluntary counseling and testing points were set up at all NDF sites and 40 unit coordinators had been trained. While the Namibian case showcases a proactive approach, there have been implementation and financial hassles.
According to Colonel Dr. Lawson Simapuka of the Zambian Defense Force (ZDF), HIV positive personnel are offered counseling and treatment, including ARVs to manage their health. While these soldiers are still deployed, their activities are confined to non-combat tasks. But whilst these structures exist in the ZDF’s advanced HIV/AIDS programme, stigma and discrimination still endure, high levels of hospital admission remain debilitating and if a HIV positive soldier dies of an AIDS related illness, the family of the deceases does not receive full benefits.
In contrast, the Mozambican Military’s response to HIV/AIDS has been largely underdeveloped, with partnerships between local and international bodies only recently emerging. With the armed forces estimated at around 39%, AIDS is typically overburdening a health system that simply does not have a military specific health service . However, what is specifically important to note is that the Mozambican response has failed precisely because of the nature of its generality, and lack of poignant attention to a specific population group.
Botswana’s Defense Force’s HIV/AIDS programme is reportedly a model of best practice and recommended, while the Umbutfo Swaziland Defense force’s (USDF) HIV/AIDS programme is also considered an example of good practice in managing the pandemic. Characterized by a strong focus on leadership, research and collaboration between state and non-state actors, the USDF policy seeks to address the entire cycle of human resource management, from recruitment to induction to mentoring. But while the programme is said to be multisectoral, HIV/AIDS prevalence in the little Southern African kingdom hardly appears on the decline. Accessing the necessary data to showcase a possible improvement is problematic, hinting to the same syndrome most AIDS policies and initiatives suffer on the continent: the disease of rhetoric and inaction.
Unsurprisingly, with the effects of the disease in central and North African countries significantly lower than Sub-Saharan countries, defense forces, barring exceptions, of these regions have not approached HIV with the vigor it deserves. One of the more notable exceptions was the Moroccan Royal Armed Forces (MRAF), who had implemented a prevention programme as early as 1996. The MRAF’s peer advocacy programmes had reached over 60,000 soldiers, but a lack of funding ended the programme in 2001. Another positive case was the UN’s partnership with the Ethiopian National Defense Force (ECDF), which identified HIV/AIDS as a command issue in 1996 as well, and created a thorough prevention programme in 2001, which focused on testing. Similarly, the Ugandan People’s Defense Force (UPDP) have run a HIV programme since the late eighties, focusing on prevention through health education, voluntary counseling and testing, homecare and aimed at strengthening the military’s ability to run programmes. Burkina Faso began an education programme in 2001, which fitted within the national anti-AIDS programme.
While the programmes have displayed political commitment in parts, the human rights dimension remains largely unresolved. The facts remain that African militaries are more likely to recruit and promote HIV negative personnel at the expense of HIV positive personnel. Human Right activists are vehemently in opposition to such practices, but the general conception is verily the notion of ‘fair’ discrimination, of which, most are willing apply in this case.
The fact remains that most African military forces screen for HIV as part of the recruitment process, whether secretly or not. For example, the Malawian army had recommended to government in 2001 to recruit only HIV negative soldiers, and while this hadn’t been passed by government, there were indications screenings were taking place with HIV being a key criteria. While the Malawian defense force has denied conducting these secret evaluations, they did admit that soldiers were put through a rigorous selection process with only those who were strong and healthy enough chosen. Similarly, while the Ethiopian programme has been lauded by many experts, human rights activists have expressed serious concern with the procedures, incentives and processes regarding promotions in the Ethiopian defense force. It was reported that the army uses HIV test results to sensitize personnel by suggesting in manuals and procedure documents that those who remain HIV negative would be regularly promoted while HIV positive personnel would lose such rights. Interestingly, while the Uganda People’s Defense Force (UPDP) has posited a non-discriminatory approach to HIV positive soldiers, this programme still manages to direct less strenuous jobs for HIV positive soldiers, which effectively means HIV positive soldiers are discriminated - fairly or unfairly – dependent on your take on the human rights dynamics involved. But while the Ugandan programme aimed to reduce the rate of infections in the army, it aimed to do reduce the prevalence rater by also only recruiting HIV-negative soldiers, which, together with the existing plan of action of voluntary, anonymous and confidential HIV testing, is categorically unsustainable and contradictory.
Analysts argue that soldiers are more likely to contract HIV after years in the army and the issue should not be reduced to merely the time of recruitment. Therefore recruiting HIV negative personnel without enough processes, educative practices and capacity for treatment is short sighted and farcical. Following this line of thought, the All African Congress of Armed forces and Police Medical services found that Nigerian personnel have double the possibility of contracting HIV within three years of joining the army. As an extension to this line of logic, if military personnel have a larger chance of contracting HIV during their time in service, surely it is an occupational hazard that the military cannot deny responsibility from?
Interestingly, the scenario becomes a tad more complex if one considers that the UN pressures the host country to conduct testing on troops before deployment for peacekeeping operations. While this is not a mandatory requirement, the UN highly recommends testing of peacekeepers before and after deployment, and while there has not been adequate post-deployment research conducted, evidence exists to suggest that even peacekeepers are responsible for the spread of HIV. Such practices continue largely uninterrupted, as debates still ensue regarding the military as a special case, especially with the type, cost and importance of the military to national interest.
The year 2008 did include a watershed event in the history of HIV/AIDS and the military. The SANDF, like most African defense forces, exclude HIV positive people from recruitment, foreign deployment and promotion. However, two HIV positive soldiers who suffered discrimination as a result of their HIV status took the SANDF to court in early 2008, to contest the SANDF’s policy on HIV-positive recruits. The South African High Court’s ruling affectively meant that the SANDF could no longer simply discriminate on the grounds of HIV. Moreover, within six months, the SANDF was tasked to amend its health classification policy that would allow for “individualized health assessments of recruits and current members of the armed forces”. The end of this blanket approach to those with HIV is especially significant for Africa’s military; however, with six months already passed, the SANDF has yet to release their reviewed policy.
While human rights activists have lauded the ruling, the debate on the logic of such a ruling continues, especially with regards to the impact HIV could have on the readiness on a defense force with HIV positive soldiers and peacekeepers potentially weakened through HIV/AIDS and the related affects on the larger community. This might be so, but what this ruling serves to accomplish, is a shifting of mental models in the military to HIV. Whereas the military was able to reject and dispose of HIV positive people, this ruling forces the military to assume more leadership and responsibility to managing the pandemic within their ranks, rather than attempt to quarantine those with HIV in less strenuous positions or by refusing to recruit or promote HIV positive people within the military.
At the 2006 AIDS Conference in Toronto, the military was identified as both an important player in the fight against HIV/AIDS in conflict and post-conflict zones and if not managed, a serious violator in perpetuating the spread of HIV/AIDS, given the high-risk factors of military personnel. At the same time, while HIV/AIDS was being taken more seriously by the Military, it was unanimously agreed upon that HIV prevalence rates had indeed increased in the military and peacekeeping forces and there was often complete denial of an urgent need to respond from certain military institutions.
The focus of the military towards HIV/AIDS has predictably leaned towards prevention rather than palliative, labour-intensive care. It is a no-brainer that Defense forces have and would look towards recruiting HIV negative soldiers and attempt to prevent a HIV positive soldier from completing rigorous tasks in the line of duty. ARV treatment is expensive and HIV/AIDS requires labour intensive care even if modern medication might allow HIV positive people live an ordinary, healthy life. However, the reality for many African armed forces as summed up by Prof Heinecken is that “the costs of managing this disease is beyond their administrative and financial capacity”, and the verdict is still out, regarding the normality of soldiers’ life in adequately dealing with the stress of managing HIV in a conflict zone.
HIV/AIDS is most certainly not a standard virus that is aggravated under predictable conditions. Thus while older and longer serving soldiers are more vulnerable to contracting the virus through unsafe practices, this is most definitely cannot be a standard conclusion. The conditions of deployment, quality and insistence of HIV prevention programmes and demographics of the army are therefore incumbent to understanding the intensity of HIV in the army.
In the developing world, HIV/AIDS is already acknowledged as an expression of socio-economic strife and the nexus between rising cases of HIV prevalence and poverty is not due to discontinue with the onset of the current worldwide recession and generally poorer socio-economic conditions, only serving as to make prevention and treatment programmes even more difficult to administer.
Addressing the issue requires out of the ordinary HIV/AIDS prevention and Human resource strategies campaigns. Since the military operates on a totally different set of rules, that are nonetheless governed by the national constitutions, African defense forces will need to specify what functional health ought to be, so that only HIV positive personnel in a latter phase of AIDS, with a rapidly depreciating CD4 count is sidelined from major army responsibility. A blanket approach perpetuates low self esteem, denigrates human rights and advances the notion of stigma.
Over and above the human rights implications, the tendency to isolate HIV positive personnel from core aspects of the army is most definitely not a solution. African militaries need to confront the pandemic with a multifaceted perspective that seeks to improve health care standards in conflict zones, while taking care to pay attention to finer details of providing contraceptives, sterile equipment and facilities that do not exacerbate the crisis. Moreover, there needs to be shift in the manner in which HIV positive personnel are treated, in that African militaries must aim to address HIV sustainably and not through stop-start measures of blockading or denying entry to HIV positive recruits. This is also crucial in the larger struggle against stigmatization towards creating avenues for education and counseling to thrive.
As Peter Piot noted, “conflict and HIV are entangled as twin evils”, the advent of the AIDS has not only shifted weapons of war into new domains, the syndrome has also beckoned a rethinking and a challenging of preset ideas of war and impact on local space, both during and post-conflicts. HIV/AIDS has shifted crucial components of armed conflicts: combatants, manner of conflict and social consequence. It is an indisputable fact that HIV/AIDS has been used as weapon of war in Africa and this furthers a vicious cycle in which conflict and HIV/AIDS are accountable for affecting the effectiveness of national defense forces; negates economic development; stunts human and social development and leaves an implant on the local population.
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* Azad Essa is a freelance journalist and researcher based at IOLS-Research, UKZN.
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