Current HIV Research (v.15, #2)

Meet Our Executive Editor by Charles Mitchell (75-75).

Foreword: HIV in Military Populations by Deborah Birx, Richard Shaffer, Marc Bulterys (76-76).

Acknowledgements by Richard Shaffer, Marc Bulterys (77-77).

HIV/AIDS Securitization: Outcomes and Current Challenges by Aladdin H. Shadyab, Braden R. Hale, Richard A. Shaffer (78-81).
Background: The securitization (i.e., framing of a health issue as a security threat) of HIV/AIDS by the United Nations Security Council in 2000 changed the belief that HIV/AIDS is only a health issue. Although now accepted that HIV/AIDS represents a security threat, the consequences of securitization are still not widely established.

Methods: The purpose of this paper was to present an evidence-based review of the outcomes and current challenges associated with HIV/AIDS securitization in the context of national security.

Results/Conclusion: We provided an overview of HIV/AIDS securitization, followed by a discussion of the impact of securitization on peacekeeping personnel and uniformed services. We also reviewed the United States Government's response to securitization and potential risks and benefits of securitization.

Conducting HIV Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) Among Partner Military Populations by Caroline A. Macera, Stanley I. Ito, Braden R. Hale, Richard A. Shaffer, Anne G. Thomas, Janet Dickieson (82-89).
Background: Characterizing HIV infection and associated risk behaviors within military populations is critical for understanding the epidemic and informing prevention activities. However, the prevalence of HIV and related risk behaviors is often unknown. Further, militaries may not have the systems in place or the staff expertise to conduct HIV surveillance and risk behavior studies.

Methods: The Department of Defense HIV/AIDS Prevention Program (DHAPP), funded by the President's Emergency Plan for AIDS Relief and the US Department of Defense, provides technical assistance, management and administrative support for HIV/AIDS prevention, care and treatment for approximately 65 partner militaries. Collaborating with partner militaries in conducting Seroprevalence and Behavioral Epidemiology Risk Surveys (SABERS) and using the data to monitor the epidemic and inform activities is a key component of DHAPP.

Conclusion: This paper describes the methodology used to plan, adapt, implement and report SABERS studies.

Prevention Interventions for People Living with HIV in Military Settings by Michael P. Grillo, Margo Sloan, Che Wankie, Kelly Woodland, Elizabeth Reader, Bruce Porter, Caroline A. Macera, Richard A. Shaffer (90-94).
Background: Military HIV prevention programs and healthy living programs were developed in the mid-1980s to manage and support newly HIV-positive military personnel in the US military. Since then, a program developed by the Centers for Disease Control and Prevention with support from the Department of Defense HIV/AIDS Prevention Program (DHAPP), called Positive Health, Dignity and Prevention (PHDP), is currently being rolled out by DHAPP in partner militaries. The program, designed to reduce HIV transmission, is a package of interventions for people living with HIV (PLHIV), including risk reduction counseling, condom provision, disclosure counseling, testing of sexual partner(s) and children, adherence counseling, diagnosis and treatment of sexually transmitted infections, and provision of family planning services.

Methods: DHAPP has trained military and civilian personnel caring for military personnel, their families, and the civilians seen at military installations in sub-Saharan Africa, such as Rwanda, Democratic Republic of the Congo, Malawi, and Zambia. These programs have varying degrees of implementing the program with innovative ways of engaging PLHIV.

Results/Conclusions: Many successes are being achieved through the training of military and civilian personnel working for or at military health care settings. In 2015, one of DHAPP's goals for the PHDP program is to enhance the monitoring, evaluation, and reporting of PHDP to demonstrate PHDP service provision to at least 90% of HIV-positive patients over the next 5 years.

Global HIV Prevention, Testing, and Counseling in Military Populations by Michael P. Grillo, Margo Sloan, Che Wankie, Kelly Woodland, Elizabeth Reader, Bruce Porter, Richard Shaffer, Caroline A. Macera, Marc Bulterys (95-101).
Background: Compared with the general population in low- and middle-income countries, military members tend to be male, young, travel more frequently away from their main sexual partners, drink more alcohol and have a consistent source of income. All of these factors may lead to an increased risk of contracting HIV.

Objective: In response, the Department of Defense HIV/AIDS Prevention Program advocates for the integration of HIV prevention 'building blocks' into military health services to reduce the risk of acquiring HIV among foreign uniformed services.

Method: The building blocks include basic HIV education including outreach, condom promotion, enabling HIV policies, HIV testing services, screening for sexually transmitted infections, voluntary medical male circumcision where appropriate, prevention of mother-to-child transmission, and other supportive services.

Conclusion: The Department of Defense HIV/AIDS Prevention Programs supports implementation of these building blocks though partnerships with foreign militaries. This comprehensive prevention package, when closely linked with HIV treatment services, is the cornerstone of creating an HIVfree generation in military and surrounding communities worldwide.

Development and Implementation of the DHAPP Military eHealth Information Network System by Mary Kratz, Anne Thomas, Ricardo Hora, Delphis Vera, Mickey Lutz, Mark D. Johnson (102-108).
Background: As the Joint United Nations Programme on HIV/AIDS, the Global Fund, and the US President's Emergency Plan for AIDS Relief focus on reaching 90-90-90 goals, military health systems are scaling up to meet the data demands of these ambitious objectives.

Methods: Since 2008, the US Department of Defense HIV/AIDS Prevention Program (DHAPP) has been working with military partners in 14 countries on implementation and adoption of a Military eHealth Information Network (MeHIN). Each country implementation plan followed a structured process using international eHealth standards. DHAPP worked with the private sector to develop a commercial-off-the-shelf (COTS) electronic medical record (EMR) for the collection of data, including patient demographic information, clinical notes for general medical care, HIV encounters, voluntary medical male circumcision, and tuberculosis screening information.

Results: The COTS software approach provided a zero-dollar software license and focused on sharing a single version of the EMR across countries, so that all countries could benefit from software enhancements and new features over time. DHAPP also worked with the public sector to modify open source disease surveillance tools and open access of HIV training materials. Important lessons highlight challenges to eHealth implementation, including a paucity of technology infrastructure, military leadership rotations, and the need for basic computer skills building.

Conclusion: While not simple, eHealth systems can be built and maintained with requisite security, flexibility, and reporting capabilities that provide critical information to improve the health of individuals and organizations.

Voluntary Medical Male Circumcision among Rwanda Defense Force Members by Michael P. Grillo, Djeneba Audrey Djibo, Caroline A. Macera, Charles Murego, Eugene Zimulinda, Marcellin Sebagabo, Valentin Gatsinzi (109-115).
Introduction: Strong scientific evidence supports voluntary medical male circumcision as part of an overall HIV prevention strategy, but self-report information on circumcision status may be inaccurate. The study objectives were to obtain estimates of male circumcision within the Rwanda Defense Force (RDF), to assess the ability of soldiers to correctly report their own circumcision status, and to document the uptake of voluntary medical male circumcision (VMMC) in the RDF.

Methods: Data were collected from members of the Rwandan military during their annual physical examination. A self-administered questionnaire collected demographic and circumcision characteristics. Self-reported circumcision status was compared with the medical exam evaluation.

Results: Using questionnaires with complete data (n = 579), 69% of the study participants were circumcised by physical examination and there was a strong agreement with self-reported circumcision status (κ = 0.97). Almost half (44%) of all circumcisions had been performed within the past 2 years.

Discussion: These results suggest that self-report is an appropriate method to collect information on circumcision status in the Rwandan military. Many of the circumcisions occurred within the last 2 years, possibly as an effect of the successful scale-up of voluntary medical male circumcision in the Rwandan military utilizing effective messaging, demand creation, and positive news reported by the media.

Sexual and Gender-Based Violence Attitudes and Experiences among Nine Sub-Saharan African Militaries by Vienna R. Nightingale, Bonnie R. Tran, Judith Harbertson, Antonio Langa, Michael Grillo, Olivier Kalombo, Anne G. Thomas (116-127).
Introduction: While sexual and gender-based violence (SGBV) is recognized as an important factor driving the HIV epidemic in sub-Saharan Africa, attitudes toward and prevalence of SGBV within sub-Saharan African military populations are unknown. Data on SGBV were collected from military service members of nine sub-Saharan African militaries. Attitudes related to SGBV and characteristics of those who commit and experience SGBV are reported.

Methods: Data for 8815 service members (8165 men and 650 women) aged 18 years or older who voluntarily participated in the Seroprevalence and Behavioral Epidemiology Risk Surveys from 2009 to 2014 were included in this secondary data analysis. Data were collected on demographics, HIV prevalence, SGBV attitudes, and experiences. Descriptive and bivariate statistical analyses were performed.

Results: 5% of men and 9% of women reported experiencing SGBV, and 6% of men reported they had ever committed SGBV. Men and women who had experienced SGBV were significantly more likely to agree with negative gender attitudes toward SGBV, and the majority of those who reported experiencing SGBV reported that SGBV was committed by someone outside of the military.

Conclusion: This is the first study to examine SGBV in sub-Saharan military populations during periods of limited conflict. It provides evidence that SGBV is experienced by both male and female service members at rates not typically found in previous research examining SGBV in other military populations. A better understanding of SGBV in sub-Saharan military service members is necessary to ensure appropriate services and interventions are part of the military infrastructure.

Prevalence and Risk Factors for Human Immunodeficiency Virus (HIV) and Syphilis Infections Among Military Personnel in Sierra Leone by Djeneba Audrey Djibo, Foday Sahr, J. Allen McCutchan, Sonia Jain, Maria Rosario G. Araneta, Stephanie K. Brodine, Richard A. Shaffer (128-136).
Context: HIV and syphilis infections are common in military personnel in sub-Saharan Africa, which impact combat preparedness and increase demands on the military health care system. The prevalence of HIV is estimated at 1.5% among the general population (15-49 years of age) of Sierra Leone, and the estimated syphilis prevalence ranged from 1.5% to 5.2% based on regional studies. We examined the prevalence and risk factors for these two common sexually transmitted infections in the Sierra Leone military personnel.

Methods: This cross-sectional study examined 1157 randomly selected soldiers from the Republic of Sierra Leone Armed Forces in 2013 using computer-assisted personal interviews and rapid testing algorithms. Descriptive statistics and logistic regression models were implemented to identify risk factors for HIV and syphilis separately.

Results: The mean age of participants was 38 years, 11.1% were female, and 86.5% were married. The seroprevalence of HIV and syphilis were 3.3% (95% confidence interval [CI]: 2.3%-4.3%) and 7.3% (95% CI: 5.9%-8.8%), respectively. Lower educational attainment in women, multiple sexual partners, unintended sex after alcohol use and use of condoms were independently associated with HIV status (p<0.05). After adjustment, HIV infection was associated with female gender, unintended sex after alcohol use, condom use at last sex, having multiple sexual partnerships in the same week and HIV testing outside of military facilities (p<0.05). Increasing age, positive HIV status and rural regions of residence were associated with syphilis seropositivity.

Conclusion: The prevalence of sexually transmitted infections among military personnel was higher than the general population of Sierra Leone. Several high-risk sexual behaviors that expose soldiers to HIV and syphilis could be addressed through prevention interventions.

HIV and Syphilis Prevalence and Associated Risks in the Cameroonian Armed Forces by Michael Grillo, Bonnie Robin Tran, Ubald Tamoufe, Cyrille F. Djoko, Karen Saylors, Kelly Woodland, L.T.C. Wangmene, Caroline Macera (137-145).
Background: Continued surveillance of the HIV epidemic is critical to monitor changes in trends and risk behaviors. A 2005 study in the Cameroonian Armed Forces (CAF) found an HIV prevalence of 11.3% among male and female service members. The purpose of the current study is to determine the 5-year change in the HIV prevalence, estimate the prevalence of syphilis, and examine factors associated with infection in the CAF.

Methods: Participants were male and female service members 18 years of age or older who were stationed at one of the 10 military garrisons selected for participation. The military garrisons included in this study were proportionally representative of the CAF by geographic region. Military companies and individuals within the selected garrisons were randomly chosen to participate in the study. Demographic and behavioral risk data were collected from September-November 2011 using personal interviews. Blood was collected for HIV and syphilis testing.

Results: Of 2,523 participants tested, 6.0% screened positive for HIV [includes 5.3% who screened positive for HIV only and 0.7% who screened positive for both HIV and syphilis], and 3.1% screened positive for syphilis only. Analyses examining risk factors associated with HIV/syphilis infection (i.e., infected with HIV, infected with syphilis, or co-infected with both HIV and syphilis) were restricted to 2,255 men who reported ever having sex. In a multivariate logistic regression model, the odds of testing positive for HIV/syphilis were higher among men who were separated, divorced, or widowed (adjusted odds ratio [AOR]=3.13, 95% confidence interval [CI]: 1.24–7.89), had sex with sex workers (AOR=1.64, 95% CI: 1.19–2.27), and reported a genital sore/ulcer in the past 12 months preceeding the survey (AOR=1.73, 95% CI: 1.05–2.86). Higher HIV knowledge was protective against HIV/syphilis infection (AOR=0.73, 95% CI: 0.54–0.99). While the overall HIV prevalence in this sample of military personnel was lower than previously reported (6.0% [95% CI: 5.12–6.97] in 2011 vs. 11.3% [95% CI: 10.01–12.68] in 2005; confidence intervals do not overlap), several factors associated with HIV/syphilis infection were identified including being separated, divorced, or widowed, having sex with a sex worker, and reporting a genital sore/ulcer in the past 12 months.

Conclusion: HIV and syphilis education among all military personnel as they enter service and proceed forward is important to reinforce prevention methods and practices.

Virological Suppression and Patterns of Resistance Amongst Patients on Antiretroviral Therapy at 4 Nigerian Military Hospitals by Keshinro Babajide, Ojor Ayemoba, Kene Terfa, Julie Ake, Trevor A. Crowell, Yakubu Adamu, Tahir Mohammed, Ifeanyi Okoye, Sunday Odeyemi, Keith Crawford, Lindsay Hughes, Ezekiel Akintunde, Tahir Umar, Tiffany E. Hamm, Ogbonnaya S. Njoku (146-151).
Background: In resource-constrained settings, plasma HIV-1 RNA quantification has not been routinely available for the monitoring of response to antiretroviral therapy. This study evaluated virological suppression rates amongst patients on first-line ART in four Nigerian military hospitals.

Methods: We conducted a cross-sectional study of 325 randomly selected adult clinic clients (≥18 years old) on first-line ART regimens at four Nigerian military hospitals. Plasma HIV-1 RNA was assayed using a Roche COBAS TaqMan48 with High Pure System. Virological failure was defined as HIV-1 RNA >1000 copies/ml. Specimens with HIV-1 RNA >1000 copies/ml were referred for genotyping.

Results: HIV-1 RNA results were obtained in 322 participants. Two hundred and seventy-eight study participants (86.3%) had HIV viral RNA < 1000 copies/ml, including 273 (84.8%) with HIV- 1 RNA <400 copies/ml. HIV drug resistance genotyping results were obtained in 35 of 44 study participants with HIV-1 RNA >1000 copies/ml. Only 14% (5/35) had no resistance mutations. Of the remainder, 10% (3/30) had no nucleoside analogue mutations while 33% (10/30) had only M184V along with non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations (K103N or Y188C). 25% (5/25) of participants failing on Zidovudine had more than two thymidine analogue mutations (TAMs).

Conclusion: We observed a high virological suppression rate among the study participants. However, a large proportion of virologically unsuppressed clients had identifiable resistance mutations. The study demonstrates that viral load monitoring is feasible at Nigerian military hospitals and supports the current WHO HIV treatment guidelines which emphasize virological monitoring of patients on ART for early detection of treatment failure.