UNAIDS Asmara, February 2001 Prevention of HIV Transmission Amongst Uniformed Services, Including Armed Forces and UN Peacekeepers: The Experience of

UNAIDS Asmara, February 2001

Prevention of HIV Transmission Amongst Uniformed Services, Including Armed Forces and UN Peacekeepers:The Experience of Eritrea

UNAIDS Eritrea

December 2001

Dominique Mathiot12 December 2001

Prevention of HIV Transmission Amongst Uniformed Services, Including Armed Forces and UN Peacekeepers:

The Experience of Eritrea

Facts about HIV in the military in Sub-Saharan Africa, including

among peacekeepers.

Background on the situation in Eritrea and Ethiopia.

The Eritrean Experience: a combined approach to HIV

prevention and care in the national military and in the United

Nations Mission to Ethiopia and Eritrea (UNMEE).

Lessons learned and recommendations.

Nigeria: 11% among peacekeepers returning from Sierra Leone and

Liberia vs 5% in adult population.

South Africa: 60-70% in military vs 20% in adult population.

Close to one-third of Namibia’s 15,000-strong National Defence Force is

infected with HIV/AIDS.

A new international study by the London-based PANOS Institute

indicates that between 25 and 50 percent of officials employed in

Malawi’s army, are already HIV positive and will die within four years.

Sources: Nigeria AIDS bulletin No 15, May 20, 2000; The Mail & Guardian, Pretoria,

March 31, 2000; UNAIDS/WHO 1999 estimate

HIV prevalence in military personnel in AfricaHIV prevalence in military personnel in Africa

HIV prevalence in Nigerian military personnel HIV prevalence in Nigerian military personnel according to years of duty as peacekeepers,according to years of duty as peacekeepers,1998 - 19991998 - 1999

Years of duty as peacekeepers

0

2

4

6

8

10

12

14

16

1 2 3

HIV prevalence (%)

Source: Adefolalu A. 3rd All African Congress of Armed Forces and Police Medical Services, 1999, Pretoria




Border conflict escalated to open war in May 1998.

New round of conflict erupted between both countries in May 2000.

Ceasefire in June 2000.

In July the UN Security Council approved a peacekeeping mission to be

deployed to ensure the ceasefire as further peace-building is undertaken.

Security Council Resolution 1308, adopted on 17 July 2000, highlights the

close relationship between conflict, displacement and HIV and also

recognizes HIV as an important security issue.

Peace Agreement signed between Eritrea and Ethiopia in Algiers, on 12

December 2000.

Background on the situation in Eritrea and Ethiopia




In Eritrea, a very high percentage of young people 18-40 are currently

serving on the front lines, of which at least 30% are women.

The current conflict has sapped resources, created massive population

displacement, and intensified the risk of HIV transmission.

In October 2000, a mission was commissioned in Eritrea and Ethiopia by

UNAIDS Humanitarian Office to assess the current situation with regard to

HIV/AIDS, and ascertain the HIV transmission risk factors, in conflict

situations and amongst uniformed services including peacekeeping

operations, in accordance with the United Nations Security Council

Resolution 1308, stressing that the HIV/AIDS pandemic, if unchecked, may

pose a risk to stability and security.

Appropriate representatives from the Peacekeeping Mission

should be involved in the local UN Theme Group and UN

Technical Working Group on HIV/AIDS and in the Joint

National Strategy Planning exercises.

National security forces should be represented in the National

Secretariat on HIV, in the UN Theme Group, and in the

Technical Working Group on HIV/AIDS/STD control.

* Presented during the UNAIDS Expert Strategy Meeting on HIV/AIDS as a security issue held in Swedint, Sweden (11-13 December 2000).

Recommendations* from UNAIDS mission to assess HIV transmission risk factors, in conflict situations

(Eritrea – Ethiopia, October 2000)

Prevention activities should be implemented both during

conflicts (if they possibly can) as well as quickly in post-

conflict situations. Such activities should be designed to

be sustainable.

Training activities within the uniformed services should be

provided by other uniformed service personnel (i.e. soldier

to soldier educators). Respect for rank and position should

be constructively used to promote the notions of safe sex

and other personal protection options as well as

protection of families.

Recommendations from UNAIDS mission to assess HIV transmission risk factors, in conflict situations(Eritrea – Ethiopia, October 2000)

Demobilizing combatants can be very effective change agents in

their communities if provided with knowledge and tools prior to

their return to their homes. National militaries should be

supported to identify potential peer educators within the ranks

and to train them effectively

An alliance between the Peacekeeping Mission and the National

Security Forces should be forged to jointly strengthen the

efforts of the uniformed services to combat the spread of

HIV/STD within the ranks and to protect civilian society.

Recommendations from UNAIDS mission to assess HIV transmission risk factors, in conflict situations


All peacekeepers should have unlimited access to information about the

epidemic and how to protect themselves (health education).

All peacekeepers should have unlimited access to condoms. Those

contingents, which are not provided condoms by their own command

structures, should be provided condoms by the DPKO, and condoms

should be included in the logistic supply system. In partnership with

local UN agencies, it should be ensured that supply is uninterrupted.

Recommendations from UNAIDS mission to assess HIV transmission risk factors, in conflict situations(Eritrea – Ethiopia, October 2000)

There should be clear guidelines on the responsibility for HIV orientation

of peacekeepers, the role of the local UN Resident Coordination

system, the provision and procurement of condoms, and for

continuous awareness efforts and monitoring.

As needed, UN agencies should obtain HIV/IEC materials from

Peacekeeping donor countries to ensure that materials in appropriate

languages are available.

Recommendations from UNAIDS mission to assess HIV transmission risk factors, in conflict situations





In line with the recommendations from the assessment mission, UNMEE is

represented by the DSRSG in the UN Theme Group on HIV/AIDS, since November

2000, and in the Technical Working Group by the Chief Medical Cell (HIV/AIDS Policy

Officer when s/he will be appointed). Likewise, the Eritrean Defense Force (EDF)

Health Service is represented in the UN Technical Working Group on HIV/AIDS since

February 2001.

On 26 January 2001, the UNMEE HIV/AIDS Task Force was formally established, with

representatives from all main contingents, UNMEE FHQ, as well as UNAIDS,

NACP/MOH and the EDF Health Service.

The Eritrean Experience: Process and Achievements To Date




With support from UNAIDS SPDF, the EDF developed and implemented a prevention

project for personnel of the Eritrean Defense Force and the National Service Corps”

in 1999-2000 (during the conflict). The 2nd Phase of the EDF project, entitled

“Accelerating Prevention Activities and Developing Care and Support Programmes in

the Eritrea Defense Force”, was approved by UNAIDS in December 2000 (US$180,000

from PAF funds), and effectively launched in May 2001 (post conflict). The project

main objectives are: 1) to increase the awareness about HIV prevention among the

youth serving in the Eritrean Defense Force and the National Service Corps; 2) to

establish care and support services for people living with HIV/AIDS (PLHA), and 3) to

increase the knowledge and practice of managing sexually transmitted infections of

all key medical personnel by using the syndromic management approach.

From February to March 2001, HIV/AIDS Awareness training sessions were organized

for over 100 UNMEE HQ staff (3 sessions in Asmara and 1 session in Addis Ababa).




On the basis of a recommendation from the TG, the UNAIDS Humanitarian Office

fielded a four-week technical assistance mission to Eritrea on HIV and Military

Populations to assist with (i) the launching of the 2nd Phase of the EDF Project

“Accelerating Prevention Activities and Developing Care and Support Programmes in

the Eritrean Defense Force” (UNAIDS PAF) and (ii) the formulation and

implementation of a comprehensive HIV/AIDS programme for UNMEE. The mission,

which effectively took place from 15 April to 13 May 2001, was carried out by a

Captain from the Uganda People’s Defence Forces.

Implementation of the 2nd Phase of the EDF Project was effectively initiated through

the organization of a Planning and Consensus Workshop held in Asmara, 8-10 May.

The main outcomes of the workshop are: (i) a common understanding and

consensus on the 2nd Phase of the EDF Project was reached among participants and

main stakeholders, and (ii) the development of a detailed implementation plan.

Representatives from UNMEE attended the workshop.




Following this workshop, UNAIDS provided technical assistance for the organization

and facilitation of a planning workshop on 15 June, attended by representatives from

each contingent and UNMEE FHQ. The UNMEE HIV/AIDS Programme developed

during this planning workshop was formally approved by UNMEE HIV/AIDS Task

Force during its meeting of 10 July (see document).

Two one-week Training of Trainers Workshops (TOT) on Peer Facilitation were

conducted during the period 16-28 July for EDF (37 participants) and UNMEE (13

participants), with the technical assistance from UNAIDS (consultant on HIV/AIDS ad

military populations) and FHI. This TOT provided an opportunity to utilize and test the

draft “Uniformed Services HIV/AIDS Peer Leadership Guide” produced by FHI, in

collaboration with the Uniformed Services Task Force (FHI/CMA/The Futures Group

International/DOD Life Initiative/USAID/UNAIDS), working with military and police

representatives from Ghana, Nigeria, Eritrea and South Africa.




Following a commitment from DANIDA, a UNFPA/UNAIDS team drafted a concept

paper on “HIV/AIDS and Demobilization” in March 2001. A key strategic approach will

be to identify up to 1000 “change agents” among young women and men serving in

the EDF and in the NSC with the aim to foster awareness and build skills to respond

to HIV/AIDS challenges within communities across the nation.

The EDF Health Service submitted in May 2001 a proposal to the DOD Life

Programme for an amount of US$200,000 in response to their call for proposals. An

amount of US$150,000 was approved. In the same time, a proposal submitted by PSI

was approved for a total amount of US$300,000.




Following the initial TOT on peer facilitation, peer leadership training in ongoing in

the EDF (all front lines) and in UNMEE (INDBAT, JORBAT, KENBAT, Bangladesh

COY).

Terms of Reference for UNMEE HIV/AIDS Task Force were drafted and approved in

August.

UNMEE participated in the planning and implementation of World AIDS Day activities,

even contributing US$9,360 through its Quick Impact Fund.

UNMEE also improved its condom distribution system and is currently getting ready

to distribute the HIV/AIDS Awareness Card to all mission personnel while conducting

a behavioral surveillance survey (BSS).

In October 2001, UNMEE facilitated the organization and facilitation of a TOT

Workshop on Peer Facilitation for the Ethiopian Armed Forces and has been

requested to facilitated a second one.




In various contingents, trained facilitators are also requested by the EDF to provide

technical assistance.

Following increased demand for VCT, a Statement concerning the availability of

voluntary counseling and testing (VCT) services in the mission area was drafted and

reviewed by the UNMEE HIV/AIDS Task Force in November 2001.

EDF and UNMEE agreed to collaborate on a best practice document: “The HIV

Prevention and Care in Military and Peacekeeping Situations: Case Study in Eritrea”.

On the basis of the DPKO-UNAIDS Cooperation Framework, an HIV/AIDS Policy

Officer will soon be posted in UNMEE FHQ in Asmara.




Considering the establishment of a large peacekeeping mission in a particular

country as an added HIV risk factor is misleading. Although UN/DPKO policy does

not support mandatory testing prior to deployment, most troop-contributing

countries do. However, peacekeepers will find themselves in a higher level of

vulnerability due to separation from family, isolation, lack of knowledge/

understanding of culture and customs of host countries, higher income and

opportunities for sex, UN “status”, etc.

Level of awareness on HIV/AIDS among military personnel of most troop-

contributing countries is in our experience very superficial. Peacekeepers are

seldom prepared for the added factors of vulnerability that come with their posting

in a conflict or post-conflict situation.

Lessons Learned and Recommendations




With regard to the spread of HIV, peacekeeping missions should not be viewed as

part of the problem, but, rather, as part of the solution. The UN mandate, and

recent DPKO-UNAIDS Cooperation Framework provide a unique opportunity to

address HIV/AIDS in a systematic manner. Furthermore, HIV/AIDS might

constitutes for countries in conflict, particularly in the African context, an entry

point for renewed discussion/interaction and, ultimately, for peace (i.e. decision

from UN country teams of Ethiopia and Eritrea to organize a joint capacity

building workshop for national members of the respective UN Technical Working

Group on HIV/AIDS).

The “military to military” approach to prevention works, not only within a national

army, but also between military of different armies (in this case, EDF and EAF and

peacekeeping contingents from various countries).

Lessons Learned and Recommendations (cont’d)




Participation of UNMEE representatives in the national UN TG/TWG mechanisms

was key for ensuring development by the peacekeeping mission of its own

HIV/AIDS programme as well support to the national response.

Each peacekeeping mission should endeavor to develop its own HIV/AIDS

programme at the earliest stage possible, using processes that will ensure the

participation of all contingents.

DPKO will need to discuss with troop-contributing countries practical ways too

ensure continuity of leadership and technical assistance in the mission area,

taking into account the issue of frequent rotation of both civilian and military

personnel.





DPKO will also need to discuss with troop-contributing countries the systematic

inclusion – from the time of deployment – of at least one experienced HIV/AIDS

counselor for contingents that have a strength of over 200 troops, and that are

deployed for a period of six months or more.

Along with the fielding of HIV/AIDS counselors, DPKO will also need to discuss

with troop-contributing countries and/or provide guidelines re the supply of rapid

test kits for VCT purposes. Here again, in our experience, not only HIV/AIDS

counseling is not available, but neither are rapid test kits, and medical officers can

only refer their clients to often-limited national capacities in this area.

DPKO and UNAIDS UN agencies should work together to obtain BCC/IEC

materials from troop-contributing countries to ensure availability of materials in

appropriate languages.


UNITED NATIONSERITREA

November 2001

Documents

UNAIDS Asmara, February 2001 Prevention of HIV Transmission Amongst Uniformed Services, Including Armed Forces and UN Peacekeepers: The Experience of