38 Infectious diseases linked to AIDS are soaring. Tuberculosis (TB) -- the most important HIV-associated disease and already the leading cause of death in Africa among HIV-infected and AIDS patients -- has again reached epidemic proportions in many countries after decades of decline. TB also is making swift inroads into non-HIV infected populations. The proportion of women infected with HIV is increasing rapidly; by the year 2000, WHO predicts that more than half of newly infected adults will be women. Economic and social realities such as poverty, a lower level of education, and subordinate social status put women at particular risk of HIV infection. AIDS-related deaths among women will contribute to reduced productivity in Africa and other parts of the developing world because of the extensive agricultural role of women. Moreover, the loss of women to AIDS will result in decreased home care and will further strain beleaguered health care systems. WHO estimates there will be between 10 to 15 million orphans worldwide by the turn of the century. Many are abandoned and barely eke out a living, are without health care, and frequently do not attend school. They will swell the ranks of the unemployable, could become part of the alienated and increasingly criminal class in many cities, and are adding to the worldwide increase in street children. - Growing numbers of street children in Brazil, Colombia, and other countries are particularly vulnerable to infection because they are frequent targets of sexual abuse and because they often resort to prostitution and drug use. One-third of street children recently tested in Colombia were HIV-positive. AIDS also is beginning to reverse the hard-won gains in improved child health care in parts of the developing world. The US Census Bureau projects that the infant and child mortality rates will increase significantly in Thailand, more than doubling for infants and rising nearly fivefold for children. In Uganda by 1991, AIDS had halted improvements in infant mortality rates and by 1993 had risen beyond 1986 levels. Impact on Rural Areas. While AIDS impacts most visibly on the highly skilled, mainly urban workforce, the disease could also have a devastating impact on the countryside over the next several years. The UN Food and Agricultural Organization estimates that a quarter of the farms in the most affected countries in Africa may fail as the disease decimates the rural population. Moreover, as remittances from urban workers are often critical sources of income for family members who remain in the countryside, the illness and death of urban workers will mean fewer resources are available to rural communities and households. Impact on Development. The growing AIDS epidemic will compound the difficulty of sustaining development already underway. Even the methods of achieving marketbased development are being increasingly undermined by the consequences of AIDS. For example, the credit worthiness of those seeking loans for low-cost housing, farm improvements, or to expand small businesses is weakened if family incomes are reduced by illness and death. Labor mobility -- including rural-urban, among regions, and between countries -- has always promoted access to jobs and income, but migrant labor also spreads the infection. Education is vital for development, but children are leaving school early to care for ill relatives or because falling family incomes do not allow for payment of school fees. Moreover, since infected people die during their most productive years, tough decisions will have to be made regarding expenditures for training. For example, if AIDS reduces school graduates' work life by 15 years, then the payoff to investment in education is greatly reduced. Potential Human Rights Problems. Gains in personal and political freedoms could be endangered by the spreading epidemic. Pushed to respond to an increasingly difficult domestic situation, leaders could search for scapegoats or advocate repressive or discriminatory policies toward unpopular, ethnic, regional, or religious groups, or AIDS victims themselves. Governments could restrict movement across borders, refuse refugees from highly-infected countries, or take other legal measures. - At least 50 countries have some explicit requirement for HIV testing of foreigners. Cuba's aggressive AIDS control program of lifetime quarantine of those who test positive is a human rights concern that could increase if other countries attempt to emulate such controls. National Leadership Essential. Recognition of the problem and promotion of AIDS education and prevention programs by high level government officials is vital to the success of AIDS prevention. Many leaders, especially in the hardest-hit countries in Africa, have begun speaking out but some officials will likely remain on the sidelines, reluctant to court controversy for fear of losing foreign investment or domestic support. A few governments, like Thailand, have begun aggressive AIDS prevention programs, but those programs tend to be targeted only at high-risk groups, particularly sex workers, giving the mistaken impression that the bulk of the population is not at risk. -- Most African leaders have yet to translate words into action by putting AIDS at the top of the political agenda. Moreover, most leaders have spoken out more as a result of international donor pressure or a bid to gain aid rather than in response to domestic needs. Prevention Strategies and Cost Although anti-AIDS programs are widespread, there is little evidence that greater knowledge has changed attitudes and altered sexual behavior on a scale needed to slow the epidemic. While current programs may be worthwhile in terms of lives saved per dollar spend, in the developing world they are still small in scale. Condom use, education to promote behavior change and treatment for STDs are critical components of an effective HIV/AIDS prevention strategy. - - Many men are unreceptive to condom use, however, despite having multiple partners. Many Ugandans tell researchers that condoms stigmatize users as being promiscuous. Costs of Prevention. A strategy to stem the AIDS epidemic would require enormous resources, but there is no guarantee that even significant expenditures could stop the spread of the disease. However, WHO estimates that if all developing countries were to implement a basic HIV prevention project -- information on how to avoid infection, promotion of condom use, treatment of sexually transmitted diseases, and the maintenance of a safe blood supply -- about one-half of the 20 million new infections expected worldwide between now and 2000 could be averted. Such a program would cost about $1.5 to $2.9 billion a year. Currently, worldwide AIDS expenditure on AIDS prevention is about $1.5 billion a year, but only about $120 million a year is spent in developing countries where 85 percent of all infections occur. Thailand spends the most for AIDS prevention, with 1992 spending of$45 million. Total AIDS spending on prevention in Africa is only about $90 million, less than 10 percent from host-nation government funds. - Developing country leaders are likely to turn to donors with a host of increased assistance needs, and international cooperation will be needed to set priorities and fund programs in the anti-AIDS effort. At least some countries would probably respond positively to suggestions that the AIDS epidemic has made imperative more realistic planning of future development efforts, a more careful use of human and financial resources, and serious AIDS prevention efforts. In return, however, the United States and the West will be expected to underwrite broader and more costly assistance programs to cope with the disease. Impact of AIDS on Military Forces In terms of military significance, HIV/AIDS is not a "war-stopper;" it will not immediately render large numbers of field troops unfit for combat. However, as the HIV/AIDS pandemic erodes economic and security bases of affected countries, it may be a potential "war-starter" or "war-outcome-determinant." HIV directly impacts military readiness and manpower, causing loss of trained soldiers and military leaders and shrinkage of recruit and conscript pools. Military populations are at heightened risk for HIV/AIDS. Militaries typically comprise large groups of young, sexually active men who are conditioned to feelings of invincibility and bravado, have money and time to spend on prostitutes and other forms of casual sex, and are removed from traditional mores and societal constraints on their behavior. In addition to their higher risk of contracting hIV/AIDS, military forces also are a significant factor in spreading the disease. Peacekeeping and demobilization present particular dangers in this regard. Worldwide peacekeeping operations will become increasingly controversial as militaries with high infection rates find it difficult to supply healthy contingents. Infected troops could be a risk to populations in host countries, and, given battlefield conditions, a risk to the troops with whom they serve. Moreover, peacekeepers from lower incidence countries may contract AIDS during operations in high incidence areas and spread it on their return home. The UN will have to grapple with politically sensitive choices, such as refusing HIV-infected troops, leading to charges of racial bias and meddling in what most militaries consider to be national security concerns. Growing efforts to demobilize in many regions, including Latin America, Southeast Asia, and Africa, in part prodded by economic considerations and Western donors, may exacerbate the epidemic, particularly if released soldiers take advantage of incentives to return to rural areas, which usually have lower infection rates than cities. On the other hand, former soldiers who remain in cities probably will add to urban health problems. HIV and AIDS impose enormous economic burdens on military health care organizations. The cost of AIDS treatment may divert funds and resources from other vital medical services. As most military medical systems are not equipped to deal with long-term care, military AIDS patients may be diverted into already overburdened civilian health care systems or released without treatment to their homes. Regional Assessments. The pandemic's effects on military forces are most pronounced in Africa. South and Southeast Asia and, to a lesser degree, Latin America, may follow the African model in five to 15 years. - Africa. AIDS is a significant operational problem for many Sub-Saharan militaries. With HIV infection rates in some forces exceeding 60 percent, a serious degradation of military capabilities may begin soon. Within the next five to 10 years, most militaries in the region will experience loss of readiness from decreased force levels. More importantly, HIV infection and AIDS among military leaders and skilled technicians will have an impact far greater than in numbers alone as hard to replace leadership experience and technical capabilities are lost. Asia. The militaries of India, Burma, and Thailand could begin to experience the adverse effects of AIDS in the next five years as rising HIV infections among young men decrease conscript pools and as an increasing number of officers, senior NCOs, and trained technicians become ill and die. HIV/AIDS could begin to degrade military manpower pools and readiness in Vietnam, Cambodia, and Indonesia within the next 10 years. Latin America. Haiti's military is already severely impacted and will suffer serious personnel and leadership losses in the next five years. In 10 years, HIV/AIDS will play an increasing role in the militaries of Brazil, Honduras, and the Dominican Republic. On a more positive note..As the world's militaries have common features that place them at greater risk of HIV/AIDS, they also share characteristics that may favor effective responses to HIV/AIDS. These include command, control, and communications systems that facilitate rapid dissemination of policy and directives, higher literacy rates among senior personnel who can pass on education materials to subordinates, better funded health systems that are often independent of civilian systems and less subject to non-medical pressures (funding, politics, etc.), less and a leadership that views HIV/AIDS control as being in their vital interests. Militaries are also less likely to have reservations about mandatory testing programs (although they may not publish results). Implications for the United States The negative effects of HIV/AIDS in AFRICA, Asia, and Latin America in the next five to 15 years will have consequences for the United States. - US military personnel, operating in high-incidence countries, will be at increased risk of exposure to HIV/AIDS. Medical cooperation between US and allied or coalition forces will be difficult if high HIV incidence exists in non-US troops. It is virtually impossible to employ universal blood precautions under combat medicine conditions forward of the first hospital in the evacuation chain. Therefore, US medical personnel may be forced to choose between diverting or even refusing foreign patients or placing US health care workers at elevated risk. US military personnel may also be at higher risk of exposure to HIV-associated and possibly multi-drug resistant tuberculosis. - The US could find itself embroiled in the explosive problem of devising UN guidelines for the participation of HIV-infected militaries in peacekeeping. Many otherwise qualified potential students have declined training in the West due in part to the requirement of US and other Western militaries for students to be free of HIV infection. The loss of such training opportunities, which are viewed as mechanisms to promote civilian control over the military, democratic principles, and respect for human rights, and slow the transformation of the military into an apolitical institution in many countries. |