A new security threat: HIV/AIDS in the military.

• Author: Sarin, Radhika

Addressing the United Nations General Assembly in 2001, U.S. Secretary of State Colin Powell likened the HIV/AIDS epidemic to a war that destroys countries and destabilizes regions: "I was a soldier. But I know of no enemy in war more insidious or vicious than AIDS--an enemy that poses a clear and present danger to the world."

Powell's assertion rests on the premise that HIV has compromised the very institution charged with maintaining security and stability--the military. Military populations are among the most vulnerable to HIV infection, and in many countries infection rates are several times higher in the military than among civilians.

Senior military officers and national defense ministries are beginning to recognize that HIV/AIDS is a security threat. Even the United Nations Security Council has discussed the issue at length. As a result, some progress has been made, at least with respect to international peacekeepers, in developing HIV/AIDS policies addressing risk, prevention, and treatment. In practice, however, there are considerable differences in how militaries approach the issue, particularly in their willingness to do HIV testing.

While HIV threatens all of the roughly 22 million soldiers in militaries around the world, those in the less-developed regions with high infection rates appear most vulnerable, although public data on HIV prevalence in the military are not comprehensive. Not all militaries want, or can afford, to test their soldiers. Some defense ministries, fearful of exposing military weakness, may conceal the full extent to which their troops are affected.

According to a recent assessment by the U.S. National Intelligence Council, HIV prevalence in the militaries of several sub-Saharan African nations ranges from 10 to 60 percent (see chart above). However, estimates often differ depending on the source. For example, the South African defense minister recently estimated that 17 percent of the national military was HIV-positive, but security analysts such as the Chemical and Biological Arms Control Institute (CBACI) think that estimate is too low, given that South Africa's adult HIV prevalence exceeds 20 percent. While South African media have reported that 50 to 70 percent of the military is HIV-positive, CBACI places the estimate between 40 and 50 percent, with some units as high as 90 percent.

While militaries in sub-Saharan Africa are the hardest hit (as is the region as a whole compared with the rest of the world), troubling levels of HIV infection have also been observed in national militaries elsewhere. In Cambodia, 12 to 17 percent of soldiers were estimated to be HIV-positive in 1999, while in neighboring Thailand, prevalence in the Royal Thai Army was 12 percent in 1993 and only fell below 3 percent in 1998 after massive government efforts. In Russia, where the disease is spreading rapidly, 1 in 3 Russian military recruits is rejected for drug-related chronic hepatitis or HIV, compared to 1 in 20 in 1985.

Susceptibility to disease has long been part of a soldier's life. The harsh physical conditions and social chaos of war have often created breeding grounds for infection and disease--the bubonic plague during the twelfth-century crusades, the huge pre-antibiotics flu epidemic of World War I, and the outbreaks of malaria and dengue during World War II. The toll can be staggering. During the Napoleonic wars, four French soldiers died from disease for every one killed in battle.

Modern medicine has sharply reduced the chances of entire armies being wiped out by epidemic disease. But all militaries remain vulnerable to a specific group of maladies called sexually transmitted infections (STIs). STI rates in military populations are generally two to five times higher than in civilian populations, and during times of conflict they can be 50 times higher.

Soldiers are at greater risk of contracting STIs for several reasons. The relative youth of many soldiers places them in the age group that is most sexually active. Soldiers are also trained to be aggressive and take risks in combat. Many observers believe this risk-taking ethos may increase risky behavior off the battlefield, including risky sex. For example, a study of Dutch sailors and marines on a five-month peacekeeping operation in Cambodia found that 45 percent had had sex with a prostitute or a local civilian. Having one STI can raise the odds of contracting another; studies show that people are two to five times more likely to contract HIV if they have some other STI at the time of intercourse with an HIV-infected partner.

Posting military personnel far from their homes and families for long periods is, according to the United Nations Programme on HIV/AIDS (UNAIDS), probably the single most important factor that heightens their risk of contracting STIs. Emotional stress, boredom, and loneliness have long led soldiers to engage in casual sex with civilians or pay for commercial sex. In the 1830s, for instance, one-third of the mostly bachelor British soldiers in India were hospitalized for an STI, compared to only 1 in 30 Indian soldiers, many of whom lived with their families. During the 1960s, the STI rate among American soldiers in Vietnam was nine times higher than among American soldiers at home and 15 times higher among American soldiers in Thailand. The French Army Health Services found that overseas assignments among the French military increased their risks of contracting HIV by a factor of five.

The duration of a distant posting also matters. A study of Nigerian...