CURRENT STATUS OF THE HIV EPIDEMIC IN THE SA NATIONAL DEFENCE FORCE – JUNE 2002

HIV epidemics in military populations are frequently discussed in documentation distributed by UNAIDS, the worldwide leading authority wrt HIV and AIDS and its impact.
According to UNAIDS documentation

• Military populations throughout the world are among the most susceptible populations to HIV infection. Some of the risk factors that increase their susceptibility are that they are mostly young and sexually active, are often away from their home environment, governed more by peer pressure than social convention, are inclined to feel invincible and take risks and are surrounded by opportunities for casual sex.
• Based on the above-mentioned factors, the military community is considered to be a high-risk environment for HIV transmission.
• Deployment to unsettled areas further increases their chances of acquiring HIV, as they are exposed not only to socially disrupted settings, but also to the possibility of infection through wounding and contaminated blood.
• In addition, HIV transmission is considered to occur with higher frequency where other Sexually Transmitted Infections (STIs) are present. Peacetime STI infection rates among military populations have been found to be two to five times higher than in civilian societies and evidence suggests that some soldiers consider the acquisition of an STI to be a symbol of sexual prowess and proof of manhood. According to the UN the military risk for acquiring STIs increases by as much as 100 times that of civilians during wartime.

The current data available for the SANDF seems to indicate that statements with regard to the increased prevalence of HIV in military populations universally may not be applicable to our own military population.

The impact of the HIV epidemic in the military and security environment is provided by both UNAIDS (Civil-Military Alliance) and the UN Security Council. According to these authorities the HIV epidemic may cause loss of continuity at command level and within the ranks, increased costs for recruitment and training of replacements and a reduction in military preparedness, internal stability and external security. HIV/AIDS can easily lead to regional destabilisation and that it is a potential war-starter.

The HIV epidemic in the SANDF has been closely monitored since the performance of voluntary HIV tests as was required for the preparation of soldiers for the Blue Crane Peacekeeping Exercise. Preparation for this exercise identified HIV as the biggest threat to the health of our soldiers, our ability to participate in peacekeeping operations where healthy and fit members are a prerequisite and our ability to fulfill our Constitutional obligation as the Department of Defence.

The aim of this document is to provide the current status of the HIV epidemic in the SANDF according to the information currently available.

The document discusses the sources of data available to determine the status of the epidemic and provides an analysis of the data available.

The document further compares the situation of the SANDF with that of the general population and the commonly held view of HIV impact in military populations according to UNAIDS.

Data as set out hereunder with regard to the HIV epidemic in the DOD are based on the following sources:

• Questionnaires to determine the knowledge, attitudes and sexual practices (KAP Study) of members of the DOD.
• General HIV/AIDS diagnosis information from the Health Information System.
• Information from Concurrent Health Assessments.
• Other datasets and extrapolations.
• Death Statistics in the SANDF.

The determination of current knowledge, attitudes and sexual practices is an important component of any HIV impact assessment. Information obtained in this regard cannot provide an indication of the current status of the epidemic, but it does provide valuable information for the focussing of prevention programmes and results of such assessments can support data obtained from other sources.

The SAMHS has recently completed such a KAP study and the results of the study are utilised in the analysis of data in the rest of the document.

The Health Information System (HIS) of the SANDF can provide readily accessible data wrt HIV/AIDS and related diseases in the SANDF. The following factors, however, make this information difficult to interpret:

• The medical information captured on the HIS is medically confidential, but there is a wide-spread practice of caution in the allocation of an HIV diagnosis by Health Care Providers due to a fear that the information may be accessed by unauthorised personnel.
• Medical information of members can be requested by insurance companies after the death of members through a consent form that members have to sign before being provided life insurance. If members have died due to HIV, the insurance company will refuse payout of the policy in the case where HIV was specifically excluded. In the interest of their patients, medical officers are therefore cautious to record HIV diagnosis on the HIS.
• The allocation of similar diagnosis codes for conditions is fraught with technical difficulties, lack of knowledge and individual preferences among Health Care Providers. This is further complicated by the fact that HIV causes a wide variety of pathology (eg TB, other infections etc). This creates confusion as to which diagnosis code must be utilised.
• Members often have HIV testing performed outside of the military. Such an HIV diagnosis of a member of the SANDF may subsequently not be captured on the HIS.
  All of the above has contributed to the unavailability of reliable data from the HIS with regard to the current state of the HIV epidemic in the SANDF.

In 1999, the Plenary Defence Staff Council of the DOD approved the concept of Concurrent Health Assessments for soldiers who participate in peacekeeping operations.
The main objectives of the health assessments are as follows:

• To ensure that the SANDF have a sufficient number of healthy members identified for participation in peacekeeping operations when the need arises.
• To identify diseases early in order to ensure early intervention and rehabilitation to optimum levels of health.

These assessments evaluate the health of members by following a multi-disciplinary approach and comprise the following:

• Medical Assessments
• Oral Health Assessments
• Social Assessments
• Psychological Assessments
• Fitness Assessments
• Immunisation Status Assessment

In addition to addressing the objectives as measured, the health assessments provided valuable data with regard to the total disease profile of members and the HIV prevalence and incidence in the SANDF.

Although the data obtained through the assessments is relatively accurate, caution should be exercised in direct extrapolation of the results to the rest of the SANDF due to the following factors:

• HIV tests are voluntary and are only performed after pre-counselling and signing of an informed consent document, and therefore a small percentage of these soldiers refused an HIV test.
• Members that were assessed have a particularly high risk profile that is not true for the total SANDF population. It can therefore be possible that results obtained from these assessments are artificially high.
• On the other hand, the members who participate in peacekeeping missions have a vested interest in maintaining an HIV negative status. It may therefore also be true that this group could have an artificially low HIV prevalence, compared to the rest of the SANDF population.

The first Concurrent Health Assessments were performed in March 2000, and the HIV prevalence in this group of members was calculated at 17%. To date, this figure is the most reliable indication of the HIV prevalence in the SANDF due to the following reasons:

• The size of the group is statistically significant considering that more than 10% of members in the SANDF were tested.
• A limited amount of bias as mentioned occurred in the process.

This figure of 17% is further supported by various studies performed in other male-dominated, skilled and semi-skilled private companies during the same period. These studies found that the general HIV prevalence in civilian companies with similar demographics and skill base as the SANDF was also approximately 17% during 1999/2000.

The KAP study as mentioned previously provides additional support for the low HIV prevalence, as members generally have high levels of knowledge wrt HIV/AIDS and have a positive attitude towards HIV prevention and condom use. Although the study does not show a high level of safe sexual practice, the high knowledge levels and positive attitudes found are definite factors that lower the risk of members of the SANDF.

Subsequent assessments showed a steep decline in HIV prevalence in the soldiers being assessed for peacekeeping missions. This, combined with the much lower numbers of members assessed, make the results of the assessments unreliable for extrapolation to the general SANDF population.

Although the HIV data obtained from Health Assessments after March 2000 can therefore not provide an indication of HIV prevalence, the data can be used to determine the incidence of HIV in the SANDF, as comparison of the data can track the HIV status of a single member over time.

The data available shows an HIV incidence of 0.19 per 100 in 18 months. This figure would support the HIV prevalence of 17% found in the March 2000 Health Assessments.

At the end of 2000 a dataset was requested of all the HIV tests that were performed, mainly by SAMHS laboratories, for the year 2000. According to the data available on the Health Information System, the percentage of HIV positive test results for all HIV tests performed in the SANDF was calculated as 21.5%. Relevant details with regard to this figure are as follows:

• The figure cannot be used as an indication of HIV Prevalence as it does not reflect a homogenous group and as as the tests were performed for the following reasons:
  • Voluntary tests performed during Concurrent Health Assessments.
  • Tests performed following requests by members and dependants.
  • Tests performed on members and dependants following a clinical suspicion of HIV infection at consultation.
• The percentage of 21.5%, including some dependants, may therefore be considered to represent a worst-case scenario with regard to the burden of HIV disease in the SANDF.
• It must be noted that members and dependants did all the tests mentioned above after counselling and informed consent according to policy.

If the HIV Prevalence of 17% obtained during the March 2000 Concurrent Health Assessments is projected to 2002 by using the growth rate obtained from the figures released by National Health during the annual ante-natal HIV survey, the current HIV prevalence of the SANDF can be considered to be 22%. The HIV prevalence of 22% as projected from March 2000 is therefore the best current HIV prevalence percentage available if the HIV prevalence growth rate equalled that of the national HIV prevalence figures. As it is believed that there are deciding factors that limit the growth epidemic in the military, this can also be considered as a worst-case scenario.

Statistics with regard to the cause of death of members of the SANDF should be able to provide a relative indication of the maturity and severity of the HIV epidemic in the SANDF.
Accurate data with regard to HIV or HIV related disease can however not be provided due to the following:

• End-stage HIV is characterised by the occurrence of opportunistic diseases, and these diseases ultimately cause the death of the member. Medical Practitioners in general therefore consider themselves to be legally covered if they provide the opportunistic disease as cause of death on documentation.
• Death certificates are by their nature not medically confidential, and this adds further motivation to Medical Practitioners for not also mentioning HIV or AIDS on these documents.

Recent changes in the design of death certificates provide for the provision of a “public” cause of death, and a medically confidential section that may contain information such as medical conditions that has attributed to the cause of death. Introduction of these new death certificates are slow, and the certificates are still viewed with suspicion by Medical Practitioners in general.

In 1999, the SANDF Group Life Insurance Scheme requested an independent actuarial analysis of available death statistics to determine the financial stability of the scheme. The results of the analysis showed that the SANDF had the same “death profile” as the civilian population of South Africa at the time of the analysis.

This would therefore imply that the maturity and severity of the HIV epidemic in the military could not be significantly higher than the adult HIV prevalence as determined by National Health for 1999/2000.

The HIV epidemic in the SANDF seems to mirror that of the general population. This is contrary to the popular view that military populations could have an HIV prevalence that is 2-5 times higher than civilian populations in peacetime, and up to 100 times higher during war according to UNAIDS and the international Civil Military Alliance. It is possible that the SANDF policy of pre-employment testing may be a large contributory factor to this finding.

The data currently available can only provide information wrt the status of the epidemic in the SANDF in 2000. According to the data available, the HIV prevalence has been confirmed as being 17%, and the HIV incidence as 0.19% per year.

The data available also indicates that the rate at which members seroconvert from HIV negative to HIV positive is highly variable. High HIV incidence rates may be linked to units who are exposed to operational environments where there is a high risk for HIV transmission.

A study is being planned for 2003 where a proper and statistically representative sample of the SANDF would be tested. This would be the only way that the true HIV prevalence could be determined, and would obviate the need for the integrated data analysis process reflected in this document.

According to the UN Security Council, the impact of HIV on the operational capability of the military could be catastrophic, and the DOD response to the epidemic has been developed to reduce the transmission of HIV to members and to prevent the occurrence of reduced operational capability. Programmes to achieve behaviour change, such as Masibambisane, are therefore crucial to limit the impact of HIV on the DOD.

Considering the evidence available, the HIV Programme of the Department of Defence seems to be effective in limiting the transmission of HIV in the military population, and ensuring that the DOD remain able to deliver on their mandate as provided in the Constitution.