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

1. 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

2. 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.

3. 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. HIV prevalence in military personnel in Africa Sources: Nigeria AIDS bulletin No 15, May 20, 2000; The Mail & Guardian, Pretoria, March 31, 2000; UNAIDS/WHO 1999 estimate

4. HIV prevalence in Nigerian military personnel according to years of duty as peacekeepers, 1998 - 1999 HIV prevalence (%) 16 14 12 10 8 6 4 2 0 1 2 3 Years of duty as peacekeepers Source: Adefolalu A. 3rd All African Congress of Armed Forces and Police Medical Services, 1999, Pretoria

5. 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

6. 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.

7. 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. Recommendations* from UNAIDS mission to assess HIV transmission risk factors, in conflict situations(Eritrea – Ethiopia, October 2000) * Presented during the UNAIDS Expert Strategy Meeting on HIV/AIDS as a security issue held in Swedint, Sweden (11-13 December 2000).

8. 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)

9. 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(Eritrea – Ethiopia, October 2000)

10. 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)

11. 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(Eritrea – Ethiopia, October 2000)

12. 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

13. 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).

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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

20. 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)

21. 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. Lessons Learned and Recommendations (cont’d)

22. 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. Lessons Learned and Recommendations (cont’d)

23. UNITED NATIONS ERITREA November 2001