A POLICY CRITIQUE OF HIV/AIDS AND DEMOBILISATION

Johanna Mendelson Forman
Manuel Carballo1
Julio 2001

The objective of this paper is to draw out and encourage debate on the relationship between HIV and the policy challenges that it poses for security. It explores how demobilisation programmes need to incorporate a development perspective, bringing together public health practitioners and security experts, in order to address the pandemic and the future security needs of Sub-Saharan Africa, in particular. It is hoped that integrating two very different disciplines, public policy and public health, will mark the beginning of attempts to establish some practical guidelines for policymakers and field practitioners that focus on prevention. Most important, the paper makes an urgent request for a cross-disciplinary and cross-sectoral approach to tackling such a complex problem as HIV and the military. Development practitioners once shunned any working relationship with armed forces or defence ministries, but it is impossible now to avoid these institutions in countries with high rates of HIV/AIDS in the security sector.2


Introduction

HIV is one of the most rapidly spreading infectious diseases since the bubonic plague of the fourteenth century, testing the nexus between security and development more than any other contemporary issue. As the twentieth century drew to a close, more than 34 million people-some 24.5m of them in Sub-Saharan Africa- were living with the virus. It is estimated that this figure will rise to over 100m by 2005.3 World Bank President James Wolfenson stated in 2000 that HIV/AIDS is a critical threat to development, the rule of law and education in Africa.4 As a result, the Bank has made the fight against HIV/AIDS its highest priority. In April 2001, United Nations (UN) Secretary-General Kofi Annan challenged the global community to contribute $10 billion per annum to a comprehensive programme of action on HIV/AIDS.5 The UN General Assembly Special Session on HIV/AIDS, which convened in June 2001, and the July 2001 G8 summit in Genoa, Italy, sought to mobilise donors around the issue. They expressed support for investment in prevention and public education, and called on developed countries to make multi-year commitments. Although a recommendation for G8 states to commit half the funds ($5bn) needed to support the UN's global war on HIV/AIDS was also on the agenda, no formal conclusion was reached.

According to David Gordon, a senior analyst at the US Central Intelligence Agency's National Intelligence Council, the pandemic has impacted on Sub-Saharan Africa in seven key ways:


The virus aggravates the poverty-related factors that hinder and retard social and economic advancement and thus compromises stability. In some of the worst hit countries, otherwise sound public and private investment is proving uneconomic and unsustainable.7 The World Bank has identified the following elements as essential in promoting development and reducing poverty: macroeconomic growth; good governance; human capital; a favourable climate for investment; and growth in labour productivity. Each one of these elements is undermined by HIV/AIDS. As early as 1993, the World Bank's annual World Development Report acknowledged the macroeconomic impact of the pandemic, concluding that, on average, a high pre-valence rate-above 10% of the population-reduced a country's gross domestic product (GDP) by between 0.5 and one percent per annum.8 More recent studies by the Bank have confirmed this one-percent fall in growth.9 In Zimbabwe, for example, where the national HIV rate exceeds 25%, annual per capita growth is at least one percentage point lower than it would otherwise have been. As infection levels rise, per capita growth is likely to decline. When HIV prevalence reaches eight percent- approximately the rate in some 21 African countries today-the cost in per capita growth is estimated at around 0.4% per annum.10

Crucially, a lack of medical treatment, a weak resource base to treat curable diseases and a decaying health infrastructure in many parts of the developing world intensify the hostile conditions that support the spread of the virus. The problem is exacerbated, furthermore, by the pervasiveness of other infectious diseases, such as tuberculosis, and of other sexually transmitted diseases (STDs) that heighten the risk of contracting HIV. Moreover, the humanitarian emergencies of the past decade have accelerated the proliferation of HIV in Africa, as violence, displacement and brutality (rape) further undermine any prevention measures. (Given the long incubation period of the virus, checking its spread has understandably not been a priority under emergency conditions.) Even worse is the fact that conflict destroys already weak healthcare systems and thus any capacity for preventative or palliative care.11 As a result, the UN Development Programme (UNDP), the UN Children's Emergency Fund (UNICEF) and the World Health Organization (WHO) have made HIV prevention a central part of their development activities and their support for states in emergency situations. UNAIDS -the UN's co-ordination body on this issue-is responsible for providing direction, technical assistance and guidelines to countries, agencies and non-governmental organisations (NGOs).12

The UN Security Council acknowledged the scale of the problem on 10 January 2000, declaring HIV/AIDS in Africa a threat to international peace and security. By February 2000, the US National Security Council had formed an inter-agency working group and within three months it had pronounced HIV/AIDS a security danger, setting in motion efforts to create a separate Office of National AIDS Policy (ONAP).13 ONAP is working at the domestic and international levels to tackle the problem, preparing recommendations to channel increased funds to HIV prevention globally. For US development practitioners this has meant that support for HIV prevention can also be given to military institutions, since soldiers in many developing countries have been flagged as a 'population' with a very high level of HIV. To ignore them would compromise civilian HIV/AIDS initiatives: this is the rationale for working with demobilised soldiers and forces in the process of downsizing.14 In general, members of the armed forces are not targeted by health educators and lack systematic information, education and counselling. Consequently, US government agencies have had to look more closely at the links between war, the military and the spread of HIV.15


HIV/AIDS and the military

Military leaders in the developed and the developing worlds recognise the ramifications of the HIV/AIDS pandemic.16 In Nigeria, for example, an Armed Forces Programme on AIDS Control began in 1993-although initiatives date back to 1986-with publication of a handbook on HIV prevention and control.17 And the Rwandan Ministry of Defence is not only conscious of the danger that HIV/AIDS poses to its armed forces, but it also acknowledges that soldiers themselves can spread the disease.18 The ministry admitted that troops returning home from 'duty' in the Democratic Republic of the Congo (DRC) now pose a risk to their sexual partners and spouses.

Soldiers are particularly susceptible to the disease, since they are highly mobile and belong to a sexually active age group (15-45 years). In some cases, STD rates in the military are two-to-five times higher than those in the civilian population.19 Moreover, the presence of a genital ulcer, for instance, increases 10-300 fold the risk of contracting HIV from a single exposure. HIV infection results in a loss in military readiness, growing bouts of sickness and absence, and high replacement costs for trained personnel who fall victim to it.20 Furthermore, HIV/AIDS is impacting on peacekeeping operations, with some governments, such as South Africa and the US, becoming increasingly unwilling to contribute national contingents to high-risk zones.21 Conversely, host nations have also expressed concern. During the Balkans conflict of the 1990s, for example, there was an effort by Zagreb to keep African peacekeepers out of Croatia in case they became a vector of the HIV virus.

On 17 July 2000, the UN Security Council adopted resolution 1308, underscoring the 'need to incorporate HIV/AIDS prevention awareness skills and advice in aspects of the United Nations Department of Peacekeeping Operations' training for peace-keeping personnel'.22 At a follow-up meeting on 19 January 2001, it stated that its peacekeeping missions will each have an office to campaign on HIV/AIDS issues and peacekeepers will be provided with 20 condoms per month.23 According to Hirut Befecadu, the HIV/AIDS co-ordinator in Sierra Leone-at present, the location of the largest UN peacekeeping operation-'countries want their troops protected, and the population should be protected from the soldiers as well, because most of the troops come from places where AIDS is a problem'.24

Comparative studies of sexual behaviour of soldiers in France, the UK and the US have shown that military personnel (career and conscripted) are much more at risk of contracting HIV than members of the civilian population. A study (reported by UNAIDS in May 1998) of Dutch peacekeepers on duty in Cambodia in the early 1990s revealed that 45% had had 'sexual contact with sex workers or other members of the local population during a five-month tour'.25 Armed forces in Sub-Saharan Africa, meanwhile, have been described as sub-populations that engage in a high level of risk-taking; the rate of HIV infection among military personnel is at least twice that of the civilian population.26 Indeed, the incidence of HIV among Zimbabwean military personnel in 1995 was three-to-four times greater than that in the civilian population-the reported rate in the army was 25%.27

Since then, however, the situation has worsened for all groups. Southern African military authorities have reported HIV levels of 20-40% and even as much as 50-60%-Angola (40-60%), Congo-Brazzaville (10-25%), Côte d'Ivoire (10-20%), DRC (40-60%), Eritrea (10%), Nigeria (10-20%) and Tanzania (15-30%).28 Stuart Kingma of the Civil-Military Alliance to Combat HIV and AIDS estimated that, up until 1996, 34% of all deaths among active duty military personnel in the Congo were AIDS-related.29 A study completed in 2000 suggested that, of the close to three million deaths in the DRC since fighting began anew in 1998, only 10% were attributable to violence, and the remainder were due to disease.30 Lacking knowledge of first aid and poor medical facilities in the field, soldiers may be exposed to the virus through wounded comrades. More controversially, there is concern that they can spread HIV through rape and prostitution, and then have the potential to infect their spouses, who, for cultural and social reasons, often cannot resist or decline sexual intercourse. In turn, they continue this devastating cycle by giving birth to HIV-infected babies. Young women in Sierra Leone, who have been victimised and repeatedly raped by combatants, are a tragic example of this trend.31

Not surprisingly, there are significant discrepancies over prevalence rates. In part this is because of difficulties in obtaining data and in part it is due to the attitudes of national authorities. Namibian Minister of Defence Erriki Nghimtina refused in April 2001, for example, to define the exact percentage of personnel infected by HIV in the armed forces, declaring such information a 'sensitive intelligence issue'.32 Nevertheless, there is a growing fear that the uniformed services of Sub-Saharan Africa-military, police, customs, border and prison guards-will be decimated by the pandemic.33 That HIV/AIDS is a central issue for the police and the military is underscored by the fact that dealing with HIV/AIDS was the latest topic to be considered by the All Africa Congress of Armed Forces and Police Medical Services.34

Armies in Africa, the Caribbean and Southeast Asia, in particular, will suffer major losses within the ocer corps, as well as among the rank-and-.le, because of HIV. In the Caribbean, for instance, where statistics show a regional adult HIV infection rate of between two and seven percent, the level for specific countries, especially the Dominican Republic and Haiti, is much higher. Although the latter dissolved its army in 1995, the rate of HIV in the Haitian military at that time was 10%. Affected soldiers did not disappear, but, rather, were demobilised or entered the civilian police force.

As a result, military authorities face the immediate challenge of how to reduce the risk of exposure to HIV of individuals serving in the armed forces. This will, in turn, facilitate lower levels of HIV/AIDS once military personnel are demobilised and reintegrated into civilian communities. Regular military forces constitute a 'captive' audience that is disciplined and used to instruction, presenting a number of advantages with respect to HIV/AIDS education and, indeed, health awareness in general. Despite varying levels of learning, they are trained to accept and internalise new information. Consequently, HIV/AIDS education, advice and counselling for military personnel should, in principle, not only be feasible, but also it could be a way of reaching the communities and civilians that they come into contact with.35

According to a 1995-96 survey of global military policies on HIV/AIDS -carried out by the Civil-Military Alliance to Combat HIV and AIDS and UNAIDS- 62 respondents (of 119 militaries approached) made known that they were engaged in prevention tutoring, condom promotion and provision, testing and counselling. Responses were broken down according to region, owing to a stress on confidentiality. What the survey did not distinguish, though, was the degree to which programmes were consistent, funded and implemented. It concluded that advances in HIV/AIDS education among the armed forces would only be as successful as related progress in civilian society. The authors suggested that, in developing countries, integrating military and civilian healthcare offered the greatest potential to ease the burden on military and civilian resources. This would mean the incorporation of HIV/AIDS policies into the broader notion of national security.36

Military healthcare systems are already overburdened as a result of the HIV/AIDS pandemic and are also trying to deal with the long-term implications of providing healthcare to veterans under what appears to be an unending set of demands. Caring for people with AIDS, especially in poor countries, presents a number of problems in terms of access to even the most basic palliative drugs and treatments. The extent to which families (which may already have been affected by the disease) and communities are willing to commit themselves to the care of former combatants who may have been away for long periods is also a crucial issue. How and to what degree military forces can extend financial support to those families and communities that provide care for demobilised personnel also needs to be addressed. Commitment to this principle is evidenced by the fact that a number of military forces in Sub-Saharan Africa have already taken steps to ensure the livelihood of children orphaned as a result of AIDS-related deaths among military personnel.37


Demobilisation and reintegration

Africa is a region where security-sector reform, the downsizing of armies and the demobilisation and reintegration of former combatants are key priorities in the transition from war to peace. Given the generally high levels of HIV/AIDS in the armed forces, if demobilisation programmes do not include prevention and peer counselling, the reintegration of HIV-positive soldiers into new communities and the return of combatants to their original villages may result in a major proliferation of the virus. The multiphase nature of the demobilisation process presents a number of opportunities in terms of timing and logistical arrangements for introducing HIV-prevention initiatives and for providing and planning for the care and treatment of infected individuals. Although the situation with regard to demobilisation of regular troops may differ from that of irregular units and militias, which may or may not fall under the overall jurisdiction (and capacity) of national and multilateral agencies and forces, many of the same principles apply.

Demobilisation and reintegration have become standard components of the international community's post-conflict development portfolio and are central to re-establishing the foundations of peace. This was underscored in the August 2000 Report of the Panel on United Nations Peace Operations, chaired by former Algerian Foreign Minister Lakhdar Brahimi, which treated demobilisation as part of a larger effort undertaken on the 'far side of conflict'.38 According to the report, demobilisation programmes-a shorthand term used here to encompass the multi-staged process of disarmament, demobilisation, reintegration and reconciliation-embrace some of the broader issues that so many societies recovering from violent conflict must address in the reconstruction period. Whether demobilisation and reintegration were specified in formal peace accords (Bosnia-Herzegovina and El Salvador, for example), as part of a negotiated settlement (like in Mozambique) or undertaken by governments moving from authoritarian rule to more open forms of governance (such as Nigeria and South Africa), the downsizing of active forces has been a crucial first step in establishing an environment conducive to reconstruction.39

While peacekeepers or other national military organisations have disarmed fighters and destroyed weapons in the early phase of demobilisation, the development community has provided the means for former combatants to make the transition to civilian life, offering vocational training, farm materials, some education, community reintegration and psycho-social healing. None of this has been easy, and it is certainly a medium- to long-term investment.40 In addition, development actors have expressed reservations about working with militaries and their involvement in demobilisation programmes has frequently fallen short of meeting the broader needs of societies emerging from armed conflict. Fundamental to long-term stability-a precondition for development-is a total restructuring of the security sector.41

The proliferation of HIV/AIDS in the armed forces demands that there be a major re-evaluation of demobilisation and the entire question of security, and it makes it all the more important that development agencies engage with the military. Even under the most ideal of circumstances, there are a number of potential problems that need to be addressed in the conceptualisation of demobilisation. The relationship between those being demobilised and the receiving communities needs to be considered. Demobilisation never takes place in a vacuum: it involves many parties and it occurs in environments that are often changing and unstable for a variety of reasons. Communities that have been exposed to conflict may still feel insecure and are often antagonistic and resistant to the reinsertion of former combatants. The possible association made between former fighters and the prevalence of HIV/AIDS only adds to the sense of insecurity felt by these communities. Planning for demobilisation and related HIV/AIDS interventions must, therefore, address the needs and fears of the community as comprehensively and as early as possible. Community participation has been promoted by international agencies, such as UNICEF and WHO, and has proved effective in more general public health interventions throughout the world, from Guatemala to Indonesia.

If demobilisation programmes were once designed to fill the gap between relief and development, they must now also encompass disease prevention and education, as many soldiers may return to their communities infected with HIV, or serve as vectors in previously unaffected parts of a country. This was certainly a challenge in the downsizing of the Nigerian army in 1998-99, when troops returning from serving with the Economic Community of West African States' Monitoring Group (ECOMOG) in Liberia and Sierra Leone had a reported HIV prevalence rate of 12%. However, the Nigerian government was unable to provide support for HIV/AIDS initiatives as part of the downsizing process. Even after requesting and receiving assistance from the UK and the US to reduce the size of the armed forces, little was done in relation to HIV and the military.42


Integrating HIV prevention into demobilisation

Demobilisation is often the most expensive element of any post-conflict programme. That so many organisations are involved in post-conflict reconstruction, demobilisation and general HIV prevention creates an opportunity to rationalise human and financial resources. To date, though, there have been few attempts to do so-either within and/or between different organisations-in a way that is likely to lead to coherent and cost-effective approaches.43 This said, the United States Agency for International Development (USAID) is now working with ministries of defence and community healthcare actors, with programming already taking place regionally in East Africa, as well as in Namibia and South Africa. An official from the Namibian Ministry of Defence has been seconded to USAID to co-ordinate the effort. (USAID is also involved in Ethiopia and Nigeria.)44 Other donors, such as the World Bank, are introducing HIV/AIDS initiatives into the formulation of loans and grants designed to alleviate poverty in general and to deal more specifically with the needs of former combatants.

The World Bank is also including HIV/AIDS counselling, screening and prevention in its current support for demobilisation efforts in Ethiopia and Eritrea. Incorporating a pilot counselling and testing programme, the initiative, which started in 2000 in Ethiopia, focuses on helping former fighters to prepare for the possibility of being diagnosed HIV-positive. An interesting feature of the programme is that it is providing a more reliable picture of the extent to which soldiers are vulnerable to infection. It was originally estimated that the Ethiopian military had a 10% HIV prevalence rate, but this dropped to six percent following the commencement of testing. The programme has now entered a second phase, and, according to the World Bank Programme Officer, Florian Fichtl, it is proving highly effective.45 USAID, for its part, has started to train military peer counsellors to work within the Eritrean armed forces, and is sponsoring a community education programme to sensitise the civilian population to the prospect of the reintegration of HIV-positive soldiers.

Bilateral donors have also come to recognise the importance of HIV prevention in the context of demobilisation and reintegration, as well as the relationship between HIV/AIDS and security forces. The US government, for example, has granted funding for technical assistance to ministries of defence in Sub-Saharan Africa, channelled through the Leadership in the Face of an Epidemic (LIFE) initiative-a special programme designed to increase the capacity for prevention.46 LIFE has established four policy prerequisites for supporting HIV-prevention efforts in Sub-Saharan Africa (on the understanding that states with defence relationships with the US will probably receive more resources).


Because of these criteria, the US Department of Defense did not consider Eritrea a priority country for funding, despite the high rate of HIV/AIDS in its armed forces. Cases where support has been provided under the LIFE initiative include provisions for the South African military health service, as well as for the militaries of Kenya and Nigeria. The US Department of State, furthermore, has provided HIV/AIDS awareness training through its African Crisis Response Initiative (ACRI), reaching troops, leaders and commanders.48 ACRI uses social workers from the Centre for Disease Control and from USAID to provide training during its regular sessions. Other governments have also extended support for capacity building-the most important of which are the Netherlands, Norway, Sweden and the UK.

USAID has also revised its operational guidelines for supporting HIV prevention, allowing members of the armed forces to receive training and education in areas where to ignore the problem would have an adverse impact on civilian programmes.49 Similarly, the Canadian International Development Agency (CIDA), the Gesellschaft für Technische Zusammenarbeit (GTZ) of Germany, the Swedish International Development Agency (SIDA) and the UK Department for International Development (DFID) are all at different stages of planning and implementing HIV/AIDS initiatives linked to the security sector and demobilisation.


Cantonment

The cantonment of combatants, which is intended to create space for former fighters to return to civilian life, presents a unique opportunity to introduce a number of activities pertinent to HIV prevention. While the length of cantonment varies, it is well known that the shorter the period of assembly, the more likely it is that demobilisation will be successful.50 But this is not the only criterion. In situations where cantonment fails, it is usually because of a lack of appropriate programmes and because those being demobilised do not see any benefit in the process. Failure can also reflect a delay between donor promises of assistance and the receipt of any form of material benefits. In Somaliland, for example, 5,000 former combatants spent eight months in a camp before abandoning the programme in 1993.51 In terms of tackling the spread of HIV, cantonment could provide an environment conducive to counselling, testing, education and prevention. Such a process would need to identify options for those too sick to work and in need of ongoing healthcare. This would require time, substantial external resources and the political will of the host nation.

In addition, cantonment may provide the space to assess the scale of HIV infection among state and non-state forces. An obvious but costly initial step is to conduct HIV antibody testing and to offer counselling, following all internationally accepted principles of voluntary participation and confidentiality. At a minimum, the period of cantonment should be used to screen former combatants for STDs and to provide them with treatment. Working on STDs may also provide a window to broach the subject of HIV/AIDS. Confidential health records could be created with particular reference to STDs and potentially HIV/AIDS. But it needs to be recognised that establishing a surveillance system based on health records would be difficult under even the most ideal of circumstances. It would be valuable to establish links with health authorities in 'reinsertion' areas, providing insight, for instance, on whether high-risk ex-combatants are moving into areas with a low, medium or high level of HIV.

Breaking the cycle of STDs is a way to reduce the risk of HIV transmission, especially if medical treatment is supplemented by intensive information, education and counselling, which places emphasis on the responsibility of former combatants to prevent the spread of HIV and STDs to their families and communities. Linking this information to that which is routinely given during cantonment-on issues like social integration and the provision of economic incentives-could be particularly useful. Knowledge, attitudes, beliefs and practices surveys could also be carried out to assess how former combatants perceive the problem of HIV/AIDS, as well as other health and social challenges confronting them and the communities to which they will return.


Reintegration of combatants

Another key opportunity for HIV-prevention activities is in the period of discharge from the cantonment centres, when former combatants are provided with logistical, financial and other benefits. The actual process of reintegration is fraught with problems; the success of any reintegration process depends on how 'receiving' communities view ex-combatants and the role they are going to play in society. Generally, the arrival of former combatants into urban and rural communities is perceived as a threat. From an economic standpoint, they may be viewed as competition for scarce jobs, land and housing. And from a social perspective, they are often considered 'outsiders', and, moreover, dangerous, because of their former occupation and the increasing association between HIV and the armed forces. Consequently, communities need to be adequately prepared and to be given information to prevent the further stigmatisation of infected individuals.

In developing reintegration programmes, donors should consider the provision of training in the health area to be as important as other more traditional types of vocational tuition. Indeed, small enterprise schemes could include the social marketing, logistical management and distribution of condoms. It is possible that some of the stigma attached to being a former fighter may be reduced by providing ex-combatants with HIV-prevention skills and presenting them as people with a capacity to serve the community, especially as peer counsellors or health aides. Although this approach may be risky (it has yet to be fully tested), it could help to support weak health infrastructures. Local NGOs specialising in healthcare, international organisations and local civilian HIV prevention facilitators could provide this training. As with demobilisation, the importance of time flexibility must be stressed, since such training would have to take place during the cantonment phase.

However, not all ex-combatants are likely to be suitable-they may not be sufficiently educated or interested in providing such a service. On the whole, however, the discipline of regular forces, in particular, may mean that they are more receptive to undertaking the intensive training required for such a role. But training will not guarantee success. Moreover, the creation of new careers or long-term livelihoods needs to take into account the physical condition of each veteran. Uganda, for instance, is considering a proposal to allow military-owned land to be farmed by HIV-positive former soldiers, providing employment for veterans, and the production of extra food for those too sick to work. It is also proposed that veterans work in the agricultural sector to help support the extended families of AIDS orphans.52

In Sub-Saharan Africa, where the resources for HIV prevention are limited at best and non-existent at worst, the structured and externally financed demobilisation of military personnel presents a number of opportunities for innovative and creative solutions. Many of the region's armies are capable of delivering healthcare and providing community education and logistical support to villages. With sound training and follow-up supervision, some demobilised military personnel could work with active duty forces to become 'agents of change', specifically in regard to HIV prevention. They could be trained in the organisation of discussion groups, the provision of counselling and the marketing and distribution of condoms, and they could assist in carrying out urgently needed community-based surveillance of changing attitudes and behaviour regarding HIV/AIDS.


The way forward

Despite the many complexities and challenges associated with demobilisation, the process is also replete with opportunities. The number of international organisations committed to HIV prevention has increased dramatically since 2000, and so, too, has the funding that has been made available in this area. The combined resources of these groups dwarf anything that has ever been invested in health and social development. The next task is to apply these resources rationally in order to bring about greater human and national security through HIV prevention and demobilisation. Doing so will not be easy, but it is feasible. A sound body of experience of education and training now exists in both the military and civilian spheres. It should be drawn on, tested further and incrementally implemented through national programmes based on best practice and lessons learned.53

In some states, especially those in Sub-Saharan Africa, armed forces may be the only institutional structure capable of meeting the logistical needs of HIV-prevention programmes and delivering basic medical services to those already afflicted in the civilian community. Indeed, the pandemic may demand that many of the region's militaries assume additional duties to full not only the needs of their own soldiers and veterans, but also those of populations in areas outside capital cities where the military may be the only state presence. The financial impact of these additional responsibilities will necessitate important budgetary decisions, affecting civilian and military healthcare provisions. The allocation of human and financial resources for the armed forces must, therefore, be reconsidered in light of the impact of HIV/AIDS on militaries in developing nations. This will involve policy dialogue between multilateral and bilateral donors and national authorities in the host state on appropriate roles and missions. Most donors have made downsizing a condition for co-operation. A reduction in the size of the military may result in some financial savings for the host nation, but it might also hasten the spread of HIV, as discharged personnel return to their communities.

The following policy recommendations could help to establish the necessary context for progress in preventing infection and could guide donors that cannot afford to ignore the impact of HIV on their broader security-sector programmes.


Clearly, highly mobile populations that engage in risk-taking behaviour, which increases their exposure to HIV, must be targeted. As this article has underscored, both military and demobilised personnel fit this profile. If, as the World Bank contends, HIV/AIDS is 'the single biggest threat to economic development', then development agencies must create policy frameworks that encourage cross-sectoral collaboration and provide the necessary funding to generate solutions. The process of building trust and understanding of how development workers adapt to military settings is yet to take hold in all parts of the world, although the unfolding crisis in China, the Caribbean and the former Soviet Union will probably move security-sector HIV/AIDS programming into the mainstream of development assistance. HIV prevention must, therefore, become part of the larger portfolio now being called 'security-sector reform'.


1. The authors would like to express their gratitude to Roxanne Bazergan, Research Associate at the Centre for Defence Studies, King's College London, for her outstanding skills, assistance and support in the preparation of this article. This paper draws on an earlier investigation into demobilisation programmes and HIV/AIDS, prepared for the Complex Emergency Response and Transition Initiative programme of USAID and Tulane University, New Orleans, Louisiana.
2. Marley, A.D., 'Military Downsizing in the Developing World: Process, Problems and Possibilities', Parameters, vol. 27, no. 4, (Pennsylvania: US Army War College, 1997), p. 140.
3. Statistics released by the Office of National AIDS Policy, Washington, DC, 2001.
4. As quoted in the Fourth Report of the Secretary General on the United Nations Mission to Sierra Leone, United Nations, 19 May 2000.
5. The announcement was made at the Organisation of African Unity meeting in Abuja, Nigeria, where the subject was HIV/AIDS, Tuberculosis and other Infectious Diseases, www.un.org/news/ossg/sgcu0101.
6. 'Plague Upon Plague: AIDS and Violent Conflict in Africa', presentation by David Gordon at the United States Institute of Peace, Washington, DC, 8 May 2001. Also see United States Institute of Peace, 'AIDS and Conflict', Peacewatch, vol. viii, no. 4, June 2001.
7. World Bank Development Committee, Intensifying Action Against HIV/AIDS: Responding to a Development Crisis, Issue Note, 17 April 2000.
8. World Bank, World Development Report 1993, (Oxford: Oxford University Press, 1993), p. 20.
9. World Bank Development Committee, op. cit., pp. 2-3.
10. Ibid., p. 3.
11. Reid, E., 'A Future, If One is Still Alive: The Challenge of the HIV Epidemic', in Moore, J., (ed.), Hard Choices: Moral Dilemmas in Humanitarian Intervention, (Lanham: Roman and Littleeld, 1998), pp. 269-285.
12. 'AIDS and the Military', UNAIDS Best Practice Collection, May 1998.
13. 'Chronology of LIFE Initiative, Key Administration Events', US Department of Defense (undated).
14. In April 2000, USAID revised its policy guidelines for the use of Child Survival Funds-the source of money for HIV/AIDS projects-to encompass this concept about providing programming to military institutions. See www.usaid.gov.
15. The Department of Defense through the Fiscal Year 2000 Defense Appropriate Bill set up the Leadership in the Face of an Epidemic (LIFE) initiative. Its aim is to work with African defence ministries in establishing HIV/AIDS education and prevention programmes. LIFE was funded for one fiscal year and was granted a one-time budget of $10m to support activities in Africa.
16. Civil-Military Alliance to Combat HIV and AIDS: Alliance Special Report, 26-28 October 1998, Dakar Senegal. At this meeting, Côte d'Ivoire, Gambia, Ghana, Liberia, Nigeria, Senegal and Sierra Leone produced a consensus statement that reflected the regional militaries focus on prevention of STDs and HIV. This document marked an important recognition of the pandemic among military leaders.
17. Yeager, R. and Kingma, S., A Civil-Military Response to the HIV/AIDS Epidemic in Nigeria, The Civil-Military Alliance to Combat HIV and AIDS, February 2000 (unpaginated).
18. Ntarindawa, J., Armed Forces HIV/AIDS Control Stra-tegies and Activities, Ministry of Defence, Republic of Rwanda, January 1999.
19. See 'AIDS and the Military', op. cit., p. 3.
20. Yeager, R. and Kingma, S., HIV/AIDS: Destabilizing National Security and the Multinational Response, unpublished manuscript, 2000.
21. HIV/AIDS as a Security Issue, International Crisis Group Report, 19 June 2001, pp. 21-22.
22. See the lead article by Roxanne Bazergan in the Conflict, Security and Development Group's Bulletin, issue number 7, August-September 2000, pp. 1-4. Available online at csdg.kcl.ac.uk.
23. Beginning in January 2000, after the Security Council's special session on HIV/AIDS and the passage of resolution 1308-emphasising the link between HIV and the maintenance of international peace and security, and drawing attention to the impact of the pandemic on peacekeeping forces and support personnel-efforts were made to develop a more collaborative approach between UN agencies. UNAIDS was tasked with drafting a strategic plan for implementation. See the Report on Internal AIDS Discussion on Follow-Up to Security Council Resolution, 14 September 2000, Washington, DC,and Geneva, Switzerland. At the 19 January 2001 meeting, Peter Piot, Executive Director of the Joint United Nations Programme on HIV/AIDS, and Jean-Marie Guehenno, Under-Secretary-General for Peacekeeping Operations made commitments towards better co-ordination and action.
24. Robinson, S. and Murphy, T., 'As it recovers from its brutal 10-year civil war, Sierra Leone must now face up to the new enemy: AIDS', Time, 16 July 2001, vol. 158, no. 3. Taken from a peacekeeping listserve accessible at pmcs@yahoo.com.
25. 'AIDS and the Military', op. cit., p. 3.
26. For an in-depth examination of the impact and consequences of HIV/AIDS on the militaries of southern Africa, especially of South Africa, see Heinecken, L., 'Strategic implications of HIV/AIDS in South Africa', Journal of Conict, Security and Development, issue 1:1, (London: Centre for Defence Studies, King's College London, 2001), pp. 109-115.
27. World Bank, World Development Report, 1999, (Oxford: Oxford University Press, 1999).
28. For specific reference to prevalence rates in Sub-Saharan Africa, based on intelligence data, see 'HIV/AIDS as a Security Issue', op. cit., p. 19.
29. Kingma, S., 'AIDS Prevention in Military Populations-Learning the lessons of history', International AIDS Society Newsletter, 4 March 1996.
30. See Vick, K., 'Toll of Congo War is Called Apocalyptic', International Herald Tribune, 2 May 2001. Available online at www.heraldtribune.com.
31. Robinson, S. and Murphy, T., op. cit. No one is sure of the rate of infection in Sierra Leone, but the World Health Organization believes that almost three percent of the country's 4.7m people are HIV-positive.
32. See 'HIV/AIDS as a Security Issue', op. cit.
33. Heinecken, L., 'AIDS: the New Security Frontier', Conflict Trends, vol. 4, (Durban, South Africa: The African Centre for the Constructive Resolution of Disputes, 2000), p. 14. No specific statistics are available on HIV/AIDS rates in the police forces of Sub-Saharan Africa. However, since the police forces (like the military) of many countries often constitute part of the same administrative structures, it is not unreasonable to suggest that they also represent a highly vulnerable population in terms of HIV/AIDS.
34. The All Africa Congress of Armed Forces and Police Medical Services-formed in 1989 as a mechanism for African military and police health services to exchange and share information-is open to OAU and UN member countries. Its most recent meeting (at the time of writing) was in 2000.
35. Civil-Military Alliance to Combat HIV and AIDS, 'Winning the War against HIV and AIDS-A Handbook on Planning, Monitoring and Evaluation of HIV Prevention and Care Programs in the Uniformed Services', UNAIDS Best Practice Collection, DC-ROM, 1999.
36. Yeager, R., Hendrix, C. and Kingma, S., 'International Military Human Immunodeficiency Virus/Acquired Immunodeficieny Syndrome Policies and Programs: Strengths and Limitations in Current Practice', Military Medicine, Association of Military Surgeons United States (AMSUS), vol. 165, February 2000, pp. 87-92.
37. See Whiteside, A. and Sunter, C., AIDS: The Challenge for South Africa, (Capetown, South Africa: Human and Rousseau Faleberg, 2000), pp. 95-96. This addresses the specific issue of how the pandemic is affecting children, suggesting that many of the young boys in Liberia and Sierra Leone may well be HIV/AIDS orphans.
38. Report of the Panel on United Nations Peace Operations, United Nations, 21 August 2000.
39. A formal peace accord conveys the power of a contract, an agreement that is enforceable if it is violated by one of the parties. A negotiated settlement is nothing but a promise, and thus more difficult to enforce. Demobilisation or downsizing exercises that take place under the terms of a peace accord are also subject to support by external donors, as part of the post-conflict reconstruction assistance that is negotiated.
40. For perhaps the best study of the disarmament, demobilisation and reintegration process, see Berdal, M., Disarmament and Demobilisation after Civil Wars, Adelphi Paper 303, International Institute for Strategic Studies, (Oxford: Oxford University Press, 1996).
41. For an in-depth discussion of this subject, which is beyond the scope of this article, see, in particular, Smith, C., 'Security-sector reform: development breakthrough or institutional engineering?', Journal of Conflict, Security and Development, issue 1:1, (London: Centre for Defence Studies, King's College London, 2001), pp. 5-19, and Hendrickson, D., A Review of Security-Sector Reform, Working Papers, no. 1, The Conflict, Security and Development Group, (London: Centre for Defence Studies, King's College London, 1999). Programmes developed by Germany, the Netherlands and the UK have begun to integrate security-sector reform into their approaches to disarmament, demobilisation, reintegration and reconciliation. The US government is far behind in this regard, as is the World Bank, which is one of the main sources of support for such initiatives.
42. Yeager, R. and Kingma, S., A Civil-Military Alliance Response to the HIV/AIDS Epidemic in Nigeria, The Civil-Military Alliance to Combat HIV and AIDS, February 2000.
43. United Nations, Executive Committee on Humanitarian Assistance, Working Group on Disarmament, Demobilisation and Reintegration, 19 July 2000. 'Harnessing the Capacities in Support of Disarmament, Demobilization, and Reintegration of Former Combatants' produced a set of recommendations on the division of labour between UN agencies to support disarmament, demobilisation and reintegration processes.
44. Author interview with the Global Population and Health Bureau Information Officer, Gabrielle Bushman, and with the USAID Africa Bureau Program Officer, Ajit Joshi, July 2001.
45. HIV/AIDS as a Security Issue, op. cit., p. 19. Interview with Mr Florian Fichtl, African Division, World Bank, August 2001.
46. Yeager, R., Hendrix, C. and Kingma, S., op. cit.
47. US Department of Defense, 'Life Initiative: HIV/AIDS in Africa, DOD Response', Briefing Paper, 18 September 2000.
48. Ibid.
49. USAID, Agency Guidelines on the Use of Child Survival Funds, April 2000, which includes provisions for the support of military personnel and foreign defence ministries.
50. Demobilization and Reintegration of Military Personnel in Africa: Evidence from Seven Country Case Studies, report number IDP-130, (Washington, DC: World Bank, 1993).
51. Kingma, K. and Sayers, V., 'Demobilisation in the Horn of Africa', Brief 4, Proceedings of the International Resource Group on Disarmament and Security in the Horn of Africa Workshop, 4-7 December 1994, Addis Ababa, Ethiopia, (Germany: Bonn International Center for Conversion, June 1995), p. 16. The report features many other examples of lessons learned from the cantonment phase of demobilisation programmes in the Horn of Africa and elsewhere. See also United Nations Development Programme, 'Talking Peace in Somalia: Somali Civil Protection Program Workshop: Demobilization and Reintegration in Somalia: A Common Approach', Nairobi, Kenya, January 2001.
52. See 'Preventing and Coping with HIV/AIDS in Post-Conflict Societies: Gender Based Lessons from Sub-Saharan Africa', symposium documentation, 26-28 March 2001, Durban, South Africa. This collection of papers focuses on creative approaches that different non-governmental organisations have advanced in working with HIV/AIDS and its victims at the community level. The conference was co-sponsored by The African Centre for the Constructive Resolution of Disputes, the International Center for Health and Migration, Tulane University's Payson Center for International Development and Technology Transfer, and USAID.
53. US Department of State, Bureau of Oceans and International Environmental and Scientific Affairs, US International Response to HIV/AIDS, 16 March 1999.
54. Relationship of HIV and STD Declines in Thailand, UNAIDS Best Practices Collection, June 2000.