Military populations are as much, or, more at risk of HIV infection than the population at large due to their relatively youthful, mobile members. High rates of infection can hamper international peacekeeping as well as national and regional operations. That is why the United States has been promoting the health and wellness of foreign military personnel worldwide. The Defense Department's HIV/AIDS' prevention program seeks to stem and reverse the devastating effect of AIDS in foreign military communities.

In the new era of rapid international travel, porous borders, and unstable nation-states, emerging infectious diseases have become significant threats to global security and development. Among these diseases, HIV/AIDS is uniquely destructive because the suffering is not limited just to those infected. The loss of many of their most educated and productive citizens can cripple the economies of countries heavily afflicted by HIV/AIDS; many African nations have seen decades of economic gains reversed. The loss of teachers deprives the next generation of an education. The death of parents leaves millions of orphans.

HIV/AIDS represents a grave threat to international security and the global economy. In his speech to the United Nations General Assembly on September 21, 2004, President George W. Bush singled out AIDS as "the greatest health crisis of our time."

Military populations are at as much, or more, risk of HIV infection as the general population because of the relative youth of service members as well as their mobility. Military forces with significant HIV rates cannot engage as effectively in peace-keeping efforts, and may not be able to maintain their own nation's security, which in turn may lead to regional instability and increased conflict. Thus, U.S. national security interests are served by promoting the health and well being of foreign uniformed military personnel.

Since 1999, the Department of Defense HIV/AIDS Prevention Program (DHAPP), located in San Diego, California, has served as executive agent for the United States' HIV/AIDS military-to-military HIV prevention efforts. Administered by the U.S. Navy's Naval Health Research Center, the AIDS Prevention Program can draw on nearly 20 years of experience in the field of HIV/AIDS epidemiology and prevention. As of 2004, the AIDS prevention program has served in or worked with 41 countries in sub-Saharan Africa, Central Asia, the former Soviet Union, and the Pacific Rim.

Two other Department of Defense programs are involved in HIV/AIDS. The Defense Security Cooperation Agency may construct rudimentary structures serving as voluntary counseling and testing (VCT) centers, HIV/AIDS clinics, or laboratories. The agency may also provide serviceable or functioning excess DOD property, and supports the Foreign Military Sales program, which recently purchased HIV/AIDS-related laboratory equipment. Also, the U.S. Military HIV Research Program conducts molecular epidemiological surveillance of HIV samples and participates with the National Institutes of Health in conducting HIV vaccine trials.

Abroad, the AIDS prevention program works closely with foreign military services and U.S. State Department personnel to improve foreign militaries' ability to cope with the burden of HIV/AIDS. Additionally, the program seeks stronger links with nongovernmental organizations (NGOs), recognizing that in many instances NGOs possess superior experience, sustainability, and access in foreign countries.

The AIDS prevention program's Request for Proposals process to solicit NGO involvement has proven unusually cost-effective. For example, Drew University contracted with the program to start an HIV education program for the Angolan military; in less than two years, nearly half of all active-duty members have been reached. In many countries DHAPP-sponsored projects are the first joint efforts between militaries and NGOs.

The AIDS prevention program provides funding for surveys on knowledge, attitudes, and practices among foreign troops, as well as educational and training materials. These surveys and materials are developed and utilized in culturally appropriate contexts, with the full participation and approval of the host nation's military establishment. In addition, the AIDS prevention program provides support for the diagnosis and treatment of sexually transmitted illnesses, which are known risk factors for the transmission of HIV. A major focus has been the expansion of voluntary counseling and testing facilities to identify those infected with HIV and offer support services as well as referral to medical treatment. Simultaneously, the AIDS prevention program has supported efforts to reduce the ostracism and stigmatizing of those with HIV/AIDS, to improve their lives, and to encourage use of the counseling and testing centers. The AIDS prevention program also assists those militaries that wish to conduct force-wide HIV testing, which provides the most valid estimate of the epidemic's magnitude, as well as a method of assessing the efficacy of prevention efforts.

The AIDS prevention program also participates in the expansion of health care infrastructures. In the past, this support has ranged from the construction and refurbishment of health care facilities, to the provision of computers, printers, Internet access, and other information management tools, to the purchase of laboratory equipment (HIV diagnostic kits, CD4 cell counters, and other sophisticated medical devices).

The AIDS prevention program is a major supporter of HIV/AIDS education. Program activities include a collaborative effort with the University of California-San Diego and the Naval Medical Center-San Diego, in which foreign military physicians are brought to San Diego for a one-month intensive course on clinical epidemiology, HIV basic science, clinical experience with HIV care (including the use of anti-retrovirals) and social, psychological, and spiritual aspects of care for HIV/AIDS patients. To date, 44 persons have participated in this course. Overseas, the program sponsors two- to three-day regional workshops for foreign military representatives at which health care workers from various countries discuss issues of regional health care and research. Soon, the program hopes to expand training opportunities to include a military HIV course in Uganda, in conjunction with the Infectious Diseases Society of North America.

A firm principle of the AIDS prevention program has been support for the HIV/AIDS strategies of individual countries, based on their own identification of needs, rather than imposing an external solution. Typically, a host nation will approach the AIDS prevention program either directly (e.g., through its website, http://www.nhrc.navy.mil/programs/dhapp/index.html) or via the U.S. embassy. Once a relationship is established, the host nation then submits a funding proposal via the embassy; the program can offer assistance with preparing the proposal, up to and including visits to the host nation by program staff.

After the proposal has been submitted, its merits are evaluated, based on the perceived need for assistance, the elements of the proposal itself, and the funding priorities of the secretary of defense and the relevant regional Combatant Command. Additional yearly proposals can then be submitted for follow-on funding. This process ensures that funds are allocated where the need is greatest, and eliminates duplication of efforts of other U.S. government agencies or NGOs. The AIDS prevention program's goal is for host nations to expand their permanent health care capabilities, which will become self-sustaining within a few years; thus, the program facilitates a true partnership of equals between the United States and foreign nations.

A significant example of this philosophy has been the groundbreaking Phidisa trial in South Africa. This HIV treatment study, the largest of its kind ever attempted, is a collaborative effort of the South African National Defense Force, the National Institute of Allergy and Infectious Disease, and the AIDS prevention program (representing the Department of Defense). The program's clinical director, retired Captain Stephanie Brodine, is a member of the trial's executive committee, and the program has sponsored 15 U.S. military physicians as clinical workers in South Africa. When fully enrolled, Phidisa will offer HIV/AIDS care (including National Institute of Health-funded antiretroviral drugs, when indicated) to up to 50,000 South African military personnel and family members.

The most important recent development in DHAPP has been the collaboration with the President's Emergency Plan for AIDS Relief (PEPFAR). This unprecedented, $15-billion effort aims to provide highly effective antiretroviral therapy to two million AIDS patients within five years. AIDS prevention program representatives are closely involved in the evaluation and monitoring processes of PEPFAR. Cooperation between these programs ensures that the United States speaks with one voice in the field of global HIV/AIDS prevention and treatment, and reduces duplication of effort. In many cases, the teamwork of the AIDS prevention program and the AIDS relief plan has fostered closer host nation relationships between military and civilian health care authorities.

In the four years since the AIDS prevention program's inception, it has expanded to a truly worldwide effort. The program strengthens the relationships between the U.S. and foreign countries by helping to stem and — it is hoped — to reverse the devastation wrought by AIDS on foreign militaries. If AIDS and its attendant risk of economic destruction, social upheaval, and political instability, are to be contained, a massive, coordinated, and sustained effort will be required.

Navy Lieutenant Commander Matthew L. Lim, MD, is a program manager with the U.S. Department of Defense HIV/AIDS Prevention Program and is a Fellow of the American College of Physicians. He is board certified in Internal Medicine and Infectious Diseases.