6.Synopsis.Civil_Military_Collaboration

SYNOPSIS
HIV/AIDS Prevention and Control Series
Civil-Military
Collaboration
Series Editor
M. Ricardo Calderón
Latin America and Caribbean Regional Office
AIDSCAP/Family Health International
Project 936-5972.31-4692046
Contract HRN-5972-C-00-4001-00
The AIDS Control and Prevention
(AIDSCAP) Project, implemented by
Family Health International, is
funded by the United States Agency
for International Development.
2101 Wilson Blvd., Suite 700
Arlington, VA 22201
Tel: (703) 516-9779
Fax: (703) 516-0839

Family Health International (FHI) is a non-governmental
organization that works to improve reproductive health around
the world, with an emphasis on developing nations. Since 1991,
FHI has implemented the AIDS Control and Prevention
(AIDSCAP) Project, which is funded by the United States Agency
for International Development (USAID). FHI/AIDSCAP has
conducted HIV/AIDS prevention programs in 40 countries, and
the Latin America and Caribbean Regional Office (LACRO) has
implemented interventions in 14 countries within the region.
November 1997
For further information, contact:
2101 Wilson Blvd, Suite 700
Arlington,VA 22201
Telephone: (703) 516-9779
Fax: (703) 516-0839
Graphic Designer: Deborah Clark

The HIV/AIDS Prevention and Control SYNOPSIS Series
C I V I L - M I L I TA R Y
C O L L A B O R AT I O N
Series Editor:
M. Ricardo Calderón
Arlington,VA, USA
Prepared by:
Sven Groennings
Civil-Military Alliance to Combat HIV and AIDS
Hanover, NH, USA
Project Coordinator:
Mary L. Markowicz
Arlington,VA, USA
Published by the Latin America and Caribbean Regional Office of
The AIDS Control and Prevention (AIDSCAP) Project
Family Health International

The opinions expressed herein are those of the writer(s) and do not
necessarily reflect the views of USAID or Family Health International.
Excerpts from this booklet may be freely reproduced, acknowledging
FHI/AIDSCAP as the source.

T A B L E O F C O N T E N T S
Acronyms ii
Acknowledgements iii
Prologue v
Holographic Overview ix
Introduction 1
HIV/AIDS in the Military 3
Military and Civilian Populations: One Society 7
Toward Civil-Military Collaboration 9
Common Agenda 9
Mutual Benefits 11
Potential Partners 12
Possible Processes 13
CMC in Progress 17
Integrated Planning: Peru 18
Beginning Multiple Activities: Brazil 20
Training of Trainers: USA 20
Condom Social Marketing: Africa 21
Community Empowerment: Bolivia 22
CMC: A Belated Development 25
Lessons Learned 27
Recommendations 29
References 31
TABLEOFCONTENTS

ii Civil-Military Collaboration
A C R O N Y M S
AIDS acquired immune deficiency syndrome
AIDSCAP AIDS Control and Prevention Project
BCC behavior change communication
CBO community-based organization
CMC civil-military collaboration
CSW commercial sex worker
FHI Family Health International
HIV human immunodeficiency virus
LAC Latin America and the Caribbean
LACRO Latin America and Caribbean Regional Office
MOH Ministry of Health
NACP National AIDS Control Program
NGO non-governmental organization
PAHO Pan American Health Organization
PVO private voluntary organization
STI sexually transmitted infection
USAID United States Agency for International Development

Acknowledgements iii
A C K N O W L E D G E M E N T S
We would like to acknowledge and recognize the contributions,
work and efforts of the Implementing Agencies—NGOs, PVOs,
CBOs, NACPs/MOH, Social Security Institutes, private sector enter-
prises—with whom LACRO has worked and for all that we have
learned together in HIV/AIDS prevention and control.
We are especially grateful to Sven Groennings, the Washingtion
liaison of the Civil-Military Alliance to Combat HIV and AIDS, for
preparing this SYNOPSIS. The Civil-Military Alliance to Combat
HIV and AIDS is a global organization dedicated to the prevention
of HIV/AIDS in security and armed forces at home, during deploy-
ment on foreign soil and across the civil-military interface with
the general population. It emphasizes both the civilian and mili-
tary contexts of HIV/AIDS and promotes actions with the military
sector, civil-military collaboration, and military-to-military techni-
cal assistance. The Civil-Military Alliance has undertaken several
projects focusing on Africa and Latin America and the Caribbean
for USAID through the AIDSCAP Project of Family Health
International. For further information on the Civil-Military
Alliance, contact: 4 West Wheelock Street, Hanover, NH 03775
Telephone: (802) 649-5296.
We take this opportunity to thank all the staff members of
AIDSCAP/LACRO for their overall assistance: Joseph Amon,
Evaluation Officer; Polly Mott, Senior Program Officer; Marvelín
Parsons,Administrative Assistant; Molly Strachan,Associate
Program Officer; as well as former staff members: Mimi Binns,
Program Officer; Genie Liska, Finance Officer; Manuel Mongalo,
Finance Officer; Robert Martínez, Evaluation Officer; Melissa
Rosenberger,Associate Program Officer; Isabel Stout, Senior
Program Officer; Oscar Viganó, Communications Officer; and
other AIDSCAP staff for their insights and recommendations. In
addition, we are grateful to Peter Lamptey, FHI Senior Vice
President of AIDS Programs and Project Director of AIDSCAP, and
Tony Schwarzwalder, Deputy Project Director of AIDSCAP, for
their continued support of LACRO’s initiatives.
ACKNOWLEDGEMENTS

iv Civil-Military Collaboration
Finally, we wish to extend our appreciation to the Population,
Health and Nutrition Team in the Office of Regional Sustainable
Development of the USAID LAC Bureau, particularly James B.
Sitrick, Jr., for the support and funding of the Information
Dissemination Initiative and other LACRO programs.

Prologue v
P R O L O G U E
The HIV/AIDS Prevention and Control SYNOPSIS Series is a
summary of the lessons learned by the Latin America and
Caribbean Regional Office (LACRO) of the AIDS Control and
Prevention (AIDSCAP) Project. AIDSCAP is implemented by
Family Health International (FHI) and funded by the United
States Agency for International Development (USAID). The
series is a program activity of the LACRO Information
Dissemination Initiative and was created with several goals in
mind:
to highlight the lessons learned regarding program design,
implementation, management and evaluation based on five
years of HIV/AIDS prevention and control experience in
LAC countries
˙ to serve as a brief theoretical and practical reference
regarding prevention interventions for HIV/AIDS and
other sexually transmitted infections (STIs) for program
managers, government officials and community leaders,
non-governmental organizations (NGOs), private voluntary
organizations (PVOs), policy and decision makers, opinion
leaders, and members of the donor community
to provide expert information and guidance regarding cur-
rent technical strategies and best practices, including a dis-
cussion of other critical issues surrounding HIV/AIDS/STI
programming
˙ to share best practices from LAC for adaptation or replica-
tion in other countries or regions
to advance new technical strategies that must be taken
into consideration in order to design and implement more
effective prevention and control interventions
˙ to advocate a holistic and multidimensional approach to
HIV/AIDS prevention and control as the only way to effec-
tively stem the tide and impact of the pandemic
PROLOGUE

vi Civil-Military Collaboration
AIDSCAP (1991–1997) was originally designed to apply the
lessons learned from previous successful small-scale prevention
projects (1987–1991) to develop comprehensive programs to
reduce the sexual transmission of HIV, the primary mode of
transmission of the virus. AIDSCAP applied three primary
strategies — Behavior Change Communication (BCC), STD
Prevention and Control, and Condom Programming — along
with supporting strategies of Behavioral Research, Policy
Development and Evaluation.
The success of this approach, based on the combination of
strategies and targeted interventions, has been widely docu-
mented. The AIDSCAP Project, in fact, has been recognized as
among the best and most powerful international HIV/AIDS pre-
vention programs to date.1
AIDSCAP has worked with over 500
NGOs, government agencies, community groups and universities
in more than 40 countries; trained more than 180,000 people;
produced and disseminated some 5.8 million printed materials,
videos, dramas, television and radio programs, and advertise-
ments; reached almost 19 million people; and distributed more
than 254 million condoms.2
However, the pandemic continues to escalate at a rate that
outpaces our successes. Thus, we need to build upon these suc-
cesses, learn from our experiences, and determine what has
worked and what is missing in order to respond with added
effect in the future. The magnitude and severity of the
HIV/AIDS pandemic calls for boldness, flexibility, wisdom and
openness. The world cannot afford to continue to fight
HIV/AIDS only with current thinking and tools. We must look
toward new thinking and strategies that complement and carry
the current state-of-the-art approaches forward in the fight
against HIV infection.
Therefore, LACRO endorses, promotes and elevates Gender
Sensitive Initiatives (GSIs), Civil-Military Collaboration (CMC),
Religious-Based Initiatives (RBIs), and Care & Management
(C&M) as the new prototype of technical strategies that must
be incorporated on par with the strategies

Prologue vii
implemented to date. Walls, barriers and biases have to come
down in order to unlock the strengths, benefits, potential, syner-
gy and/or resources of GSIs, CMC, RBIs and C&M.
More importantly, approaches that compartmentalize strategies
can no longer be justified. Despite the efforts to integrate and
coordinate amongst and between technical strategies and differ-
ent sectors of society, prevention programming is barely scratch-
ing the surface of what a real comprehensive effort should be.
One of the most important lessons learned about HIV/AIDS is
that it is not only a medical problem, nor is it exclusively a pub-
lic health problem. Rather, the pandemic is in addition a socioe-
conomic problem and, as such, threatens both the sustainable
development of developing countries and challenges the ethical
foundations of the developed world. HIV/AIDS has become a
challenge to health, development and humanity.
For lasting success, a genuine multidimensional approach is
urgently needed. One that demands new forms of wealth distri-
bution, educational opportunities and development; attempts to
resolve the inequalities in gender and power; acknowledges the
individual, environmental, structural and superstructural causes
of and solutions for the pandemic; and aims to balance the dis-
parity between the “haves” and the “have-nots”, resulting in
more sustainable, equitable, effective and compassionate efforts.
Therefore, the SYNOPSIS Series reaffirms that current HIV/AIDS
prevention and control strategies work, and contends that new
technical strategies are needed and can be effective and com-
plementary. The Series also strongly advocates for, and will dis-
cuss in a separate issue, the Multidimensional Model (MM) for
the prevention and control of the pandemic. This model must
guide national, regional and international planning and program-
ming in order to achieve measurable and significant gains that
can truly affect changes at the individual, societal, environmental
and structural levels.
We trust the reader will be open to our futuristic thinking and
will contribute to the further development of the strategies pre-

viii Civil-Military Collaboration
sented here as well as others. We hope the SYNOPSIS Series
will stimulate discussion and reflection, propel continued dia-
logue, and encourage the pioneering of new combinations of
innovative approaches.
M. Ricardo Calderón, MD, MPH, FPMER
Regional Director

Holographic Overview ix
H O L O G R A P H I C O V E R V I E W :
This SYNOPSIS booklet discusses the importance of civil-military
collaboration (CMC) through a holographic approach.
Holography is a special photographic technique that produces
images of three dimensional objects. This photographic record is
called a hologram, and one of its main applications is that any
fragment of the hologram can regenerate the entire image, even if
the fragment is extremely small. In other words, if a negative
from an ordinary picture is cut into two, the print from each half
would only show half of the picture. Conversely, if a holographic
negative is cut in two, the print from each half would show the
entire picture. If these halves are cut again, the print from any
one of the pieces will reconstruct the whole picture.3, 4, 5
Utilizing the holographic model,this booklet was written such
that any one of the sections (holograms) will provide the reader
with an understanding of the whole subject matter. First,we
describe the entire strategy or topic of discussion in one sentence,
the widespread definition and/or our own definition of the subject
(Hologram 1). Next,we present a one-paragraph abstract of the
topic,expanding upon the original definition (Hologram 2). Then,
we present the topic by providing a summary or recapitulation of
the main points of each of the sections of the booklet (Hologram
3). Finally,the entire strategy is again presented by virtue of the
complete text of the booklet (Hologram 4).
We anticipate that the Holographic Overview of civil-military col-
laboration will benefit both the seasoned professional and the
novice. It provides a quick, general overview of CMC as well as
context and background. It also directs the reader to specific
parts that may be of most interest or that the reader would like to
review first or at a later date. Thus, we hope this approach will
enable the reader to make fuller use of the booklet as a reference
guide, as it provides a simple and concise definition of CMC, a
brief description of the topic, a summary of the discussion, and
finally, the complete text—all in one document.
HOLOGRAPHICOVERVIEW

x Civil-Military Collaboration
The reader should note that while we have tried to include the
key issues surrounding CMC in this SYNOPSIS, the booklet is not
meant as an exhaustive discussion of all of the issues regarding
civilian and military collaboration.
T h e W h o l e S t r a t e g y
Hologram 1: The Definition
Civil-Military Collaboration in HIV/AIDS prevention and control
represents the joint efforts of combined human, physical and
economic resources of the civilian and military sectors in order
to reduce the spread and impact of the pandemic in each of the
sectors and society as a whole.
Hologram 2: The Abstract
Civil-military collaboration is an important strategy central to the
fight against the HIV/AIDS pandemic. In virtually all countries of
the world the military is one of the groups most affected by
HIV/AIDS. The infection rates for sexually transmitted infections
(STIs) are commonly two to five times higher in the military
than in comparable civilian populations in peace times, and
much higher in conflict situations.6
As studies have shown, HIV
transmission is greatly enhanced in the presence of an untreated
STI. Military populations, in general, have increased vulnerability
to HIV infection, compared to the general civilian populations.
Risk factors among the military include high rates of sexual part-
ner change, elevated rates of STIs, low rates of condom use with
commercial sex workers and other casual partners, and signifi-
cant mixing between groups having high and low risk behavior
patterns.7
Since military personnel typically infect or become
infected by civilians, neither of these sectors can resolve the HIV
problem in isolation. The military and the civilian sectors are
related in both the causes and the effects of HIV/AIDS, and thus,
they are stakeholders in one another’s success in combating the
pandemic.

Holographic Overview xi
Hologram 3: The Summary
HIV/AIDS in the Military
The HIV/AIDS pandemic poses a strategic threat to affected sol-
diers and has resulted in losses of skilled manpower and senior
leadership among many of the world’s armed forces.8
HIV sero-
prevalence of 20 to 40 percent has been reported among some
militaries in eastern and southern Africa, and over 50 percent in
countries where the virus has been present for more than 10
years. Military personnel are highly vulnerable to HIV infection
because they are regularly away from home for long periods,
away from their regular sexual partners, often in search of recre-
ation to relieve loneliness and stress, and free from home and
community restraints. Their occupation encourages risk taking,
gives them a sense of invulnerability and exposes them to alcohol
and drug consumption and commercial sex workers. Civil con-
flict and large-scale military conscription and/or deployment to
an area with high HIV prevalence represent high risk situations
and changes that have triggered HIV epidemics.7
Military and Civilian Populations: One Society
The military, whose mission is to protect all of society, also inter-
acts with all of society. Those serving in the military and their
families are drawn from all regions and sectors of a country and
typically serve in several regions during their years of service.
Furthermore, the knowledge, attitudes, beliefs and practices of
military populations are shaped by the same social, cultural, reli-
gious, educational, economic and political influences as their civil-
ian counterparts. Both the civilian and military sectors suffer the
socioeconomic and development effects of HIV/AIDS and are
related in both its causes and effects. Thus, they are stakeholders
in one another’s success in combating the pandemic.
Toward Civil Military Collaboration
Civil-military collaboration is a nascent HIV/AIDS prevention and
control strategy, and collaboration to date has taken place on a
very limited scale. Military and civilian sectors are increasingly
recognizing areas of common interest, particularly as the number

xii Civil-Military Collaboration
of infected women rises. Women are emerging as a natural bridge
for CMC due to the positions they hold within the military, within
military families, and within the civilian community supporting
the military. The mutual benefits of CMC are classified within the
following five areas: setting policy, convening power, expanding
reach, exchanging information and know-how, and sharing
resources. Many different types of partnerships and collaboration
processes are emerging, including joint civil-military conferences
at the national and international levels. Partners for collaboration
include the Ministries of Health and Education, National AIDS
Control and Prevention Commissions or Councils, NGOs and
PVOs, and religious-based organizations.
CMC in Progress
Current CMC efforts to combat HIV/AIDS are taking place in
a variety of ways. In Peru, COPRECOS (Commission for the
Prevention and Control of HIV/AIDS in the Armed Forces)
operates within the overarching cross-sectoral framework of
PROCETSS (Program for the Control of STIs and AIDS), the
national planning and administrative system for the campaign
against HIV/AIDS. Brazil is in the early stages of implementing a
variety of activities. A“Protocol of Intentions”frames cooperation
between each of the three military services and the Ministry
of Health, and a Permanent Interministerial Council has been
established to address health problems. The American Red Cross
assisted the U.S. Navy in preparing a comprehensive prevention
program, with the potential to reach an estimated 900,000 per-
sonnel. To date, more than 1,600 Navy Instructor-Trainers have
been trained through a training of trainers component. In Africa,
condom social marketing, low-cost mass purchasing of condoms
from a private organization and sale at a subsidized cost to the
consumer, is a strategy being implemented effectively. Bolivia’s
Sentinel of Health system is based on the principle that“one
can apply to the defense of life the concepts used in defense
of the country…the health of the families can be improved if all
soldiers, upon returning to their community, teach all that they
have learned.”9

Holographic Overview xiii
CMC: A Belated Development
Progress toward civil-military collaboration in HIV/AIDS has been
slow and is only now beginning to escalate a decade into the pan-
demic. Collaboration has been delayed for a variety of reasons.
Initially, the military focused on the problem internally, and mili-
tary medical systems in many countries were slow to launch
HIV/AIDS prevention programs. Collaboration has also been
inhibited by a prevailing civilian mistrust of the armed forces in
many developing countries, including a military practice of treat-
ing health data as military intelligence in order to ensure national
security. As a result, the military were typically not included or
only marginally involved as national planning systems to combat
HIV/AIDS developed.
Lessons Learned
Civil-military collaboration has been slow to develop due to the
military’s initial internal focusing on its own HIV/AIDS problem as
well as the military’s exclusion from national planning efforts. As
the pandemic affects all of society,a coordinated and multi-sectoral
response is required,one that includes the military sector. The
function of the military is to protect society,and it is this social ser-
vice of protection that must also include the health of the individ-
ual and the collective health of the country’s population. The civil-
ian and military populations possess human,physical and econom-
ic resources which are synergistic and complementary.
In terms of civilian and military partnerships, it is increasingly
being recognized that common agendas and mutual benefits exist
amongst and within different governmental and non-governmen-
tal institutions, including regional and international organizations.
CMC builds on both the functional complementarities and com-
monalities among the sectors and makes more effective use of
resources. The military typically has a presence in all geographic
areas of a country, thereby having the potential to reach millions
of individuals. The military also possesses convening power, the
ability to focus the attention of the government on a particular
subject and elevate it to the national policy level. Regional
approaches are effective as they enable cross-national sharing of
programs, initiatives, and policies that can lead to mutual assis-

xiv Civil-Military Collaboration
tance across countries and regional utilization of expertise.
Cultural affinity and common languages facilitate regional
approaches.
International support, as well as a brokering and/or coordinating
body, is essential to bring together the international organizations,
donors, experts and the civilian and military sectors. To be suc-
cessful, program development: (a) must be sensitive to the vari-
ous cultural contexts, affinities and differences at every level
inside and outside national boundaries; (b) needs more attention
and time to provide innovative HIV/AIDS prevention and control
models; and (c) should be based on, but not limited to, current
needs in policy knowledge, training of trainers assistance, and
international exchange of preventive and cost-effective efforts.
Recommendations
Actions recommended to advance CMC include: (a) information
dissemination regarding current efforts and lessons learned; (b)
advancement of the brokering role to bring interested parties
together; (c) expansion of the focus on the military to include
peacekeeping troops, police, prison guards, and maritime person-
nel; (d) utilization of key personnel of more mature programs to
assist those programs under development; (e) policy dialogue to
establish an environment conducive to civilian and military coop-
eration; (f) planning and implementation of joint endeavors with
potential for expansion and replication; and (g) monitoring and
evaluation of interventions in order to strengthen, diversify and
expand CMC programming.

Hologram 4: The Detailed Description
I N T R O D U C T I O N
Civil-military collaboration (CMC) is an important strategy
central to the fight against HIV/AIDS for two main reasons: the
military is one of the groups most affected by the pandemic in
virtually all parts of the world; and military personnel typically
become infected by civilians, and similarly the military infect
civilians. As its HIV/AIDS problem is not purely military, the mili-
tary cannot solve it internally nor single-handedly. It is not solely
a public health problem, but also a
political, economic and security threat
requiring a coordinated, multi-sectoral
response. Therefore, civil-military col-
laboration becomes an essential techni-
cal strategy in HIV/AIDS prevention.
Furthermore, CMC can be advanta-
geous in testing, counseling, care,
research, training of personnel, condom
social marketing, outreach to families
and community relations as well as in
providing educational materials and
programs for prevention.
The military is defined at its core as the
uniformed personnel of the army,navy
and air force but is often expanded to
include the coast guard,the military’s
civilian personnel,military families and
child soldiers. Two large peripheral
groups,the national police and seafar-
ers,have military characteristics and are
sometimes included in discussions of
the military. In Peru,for example,the
national police are included in an inte-
Introduction 1
INTRODUCTION
Civil-military collaboration
is an important strategy central
to the fight against HIV/AIDS for
two main reasons: the military
is one of the groups most
affected by the pandemic in
virtually all parts of the world;
and military personnel typically
become infected by civilians,
and similarly the military
infect civilians.

grated HIV/AIDS/STI planning system for its armed services.
Seafarers are also a closely related occupation with parallel
lifestyles,including high pay,extensive travel,long periods away
from home,shipping functions on behalf of the military,and some-
times naval reserve officer status. For
the purposes of this booklet,however,
the military is defined as the former,the
uniformed personnel of the army,navy,
and air force as well as the coast guard,
the military’s civilian personnel,military
families and child soldiers.
Civil-military collaboration is an emerg-
ing technical strategy that now has
momentum; the forces of impetus are
advocacy and the creation of processes
by which it will occur. Accordingly, this
booklet is intended to be an instrument
of leadership for new ventures; its cen-
tral purpose is to stimulate creative
civil-military responses to the HIV/AIDS
problem. The opening sections set the
stage for collaboration by presenting
the military problem and the perspective that the military and
civilian sectors are closely related parts of a society and stake-
holders in one another’s success in the struggle against HIV/AIDS.
Next, the booklet considers possible civil-military agendas and
processes for achieving collaborations between the military and
civilian sectors of government and non-governmental organiza-
tions (NGOs). Thereafter, it illustrates the practice of collabora-
tion by presenting brief vignettes of various kinds of activities
occurring in different countries. Finally, following a discussion of
why CMC generally has been slow to develop but is now becom-
ing a necessary and vital technical strategy, the booklet sets forth
lessons learned to date and concludes with recommendations.
2 Civil-Military Collaboration
For the purposes of this
booklet, the military is defined
as the uniformed personnel of
the army, navy, and air force as
well as the coast guard, the
military’s civilian personnel,
military families and child
soldiers.

H I V / A I D S I N T H E M I L I T A R Y
The infection rate for sexually transmitted infections (STIs) is com-
monly two to five times higher in the military than it is in the civil-
ian population.6
During times of war and civil strife,the rate can
become up to 100 times higher. As studies have shown,HIV trans-
mission is greatly enhanced in the presence of an untreated STI.
Some militaries in eastern and southern Africa are reporting HIV
prevalence of 20 percent to 40 percent and as high as 50 percent
in countries where the virus has been present for more than 10
years. In Asia, the data on HIV infections among the military are
stunning: for example one-fifth of the soldiers in one province in
Cambodia and 13-14 percent of recruits from the northern
provinces of Thailand were seropositive. Interestingly, at one mili-
tary camp in Rwanda, 70 percent of the soldiers reported being
more afraid of HIV than of being at war. It is likely that United
Nations and other peacekeeping forces have a higher probability
of becoming infected with HIV than of being killed in military
action.
Most military personnel are in the age group at greatest risk of
contracting HIV: 15 to 35 years of age. This is the sexually most
active and most infected age group in any country’s population.
Military personnel are highly vulnerable to infection as they are
regularly away from home for long periods, away from their regu-
lar sexual partners, and often search for recreation to relieve lone-
liness and stress. They are in an occupation that encourages risk-
taking, and their training gives them a sense of strength and invul-
nerability. Off-duty soldiers and navy sailors are free from home
and community restraints, often consume alcohol and sometimes
drugs, and have money to spend. They belong to a culture that is
especially macho and considerably sexist. The special circum-
stances of the military lead commercial sex workers (CSWs) to be
near military bases; indeed, the presence of military bases leads to
increases in the number of CSWs.
HIV/AIDSINTHEMILITARY

Large numbers of military personnel engage in casual and com-
mercial sex. In peacetime, 45 percent of the Royal Dutch Navy
were found to have had sex with CSWs or other members of
local populations while on mission.10
There were parallel findings
in the United States Navy: in a study of 1,744 crew members on
11 ships who were on a six-month deployment, 42 percent
reported contact with one or more CSWs and 10 percent had
contracted a STI. A 1991 survey of more than 18,000 U.S. army
soldiers found that half perceived themselves to have been at risk
of infection during the previous two years. The soldiers reported
a much greater number of contacts with high-risk partners than
the civilian population.
Port cities and garrison towns tend to
have higher risk factors for the trans-
mission of HIV. Port cities are centers
for trucking, shipping and trading, are
visited by countless seafarers and
sailors, and typically have large concen-
trations of CSWs. The cities and towns
that develop near naval and army bases
to supply them with goods and ser-
vices, commonly known as garrison
towns, often have similar risk factors.
The interaction between the civilian
and military populations in these areas
is demonstrative of the need for collab-
oration between the two sectors on
issues which affect both, such as
HIV/AIDS.
War typically has spread sexually transmitted diseases as popula-
tions are displaced, women sell sex to provide for their families,
soldiers turn to CSWs, and rapes occur. “The classic association of
war and disease substantially accounts for the presently observed
geographical distribution of reported clinical AIDS cases in
Uganda.”11
There have been reports from Bosnia and Rwanda that
rape has become a weapon of war, possibly spreading HIV.
During the recent period of inter-tribal killings, tortures, burnings
The infection rate for sexually
transmitted infections (STIs) is
commonly two to five times
higher in the military than it is
in the civilian population.
During times of war and civil
strife, the rate can become up
to 100 times higher.6

and lootings in Rwanda, women were often told they were about
to get HIV before they were raped by soldiers.12
A case study initiated during the civil war in Liberia indicated that
foreign troops contribute to child prostitution and take advantage
of the extreme poverty of local women and girls. This research
was conducted as a result of the concern of the increasing preva-
lence of HIV/AIDS. The study also found that the military person-
nel perceived the use of young girls for sex as a means of avoid-
ing HIV infection, based on the misconception the girls were too
young to be HIV-positive.13
Another particular problem of civil wars and ethnic conflicts is
the use of children as soldiers. Child soldiers are typically under
the age of 18, with some as young as 7. Globally, it is estimated
that there were more than 250,000 child soldiers in 1995-1996,
predominantly in Africa but also found in Asia and among Latin
American countries, such as Guatemala and Peru. Many of these
young people become sexually active or are exploited sexually in
these circumstances.
Even as the fighting subsides and troops return home, there is a
danger that HIV/AIDS will continue to spread into the general
population. When the 150,000 Cuban troops returned from
Angola and Mozambique, HIV/AIDS was found to be their second
most prevalent disease.12
As a result of HIV/AIDS, militaries in some countries, particularly
those in eastern and southern Africa, are losing continuity at the
command level as well as among personnel within the lower
ranks. Militaries face increased recruitment and training costs for
replacements and a growing need for international training of
replacements. Overall, they face a potential reduction in the
nation’s preparedness, internal stability and external security.14
Furthermore, some foreign policy analysts see HIV/AIDS in the
militaries of developing countries as a threat, not only to the well-
being of the nation, but to the peacekeeping troops that may
have to go in to maintain peace or to quell upheavals.

M I L I T A R Y A N D C I V I L I A N
P O P U L A T I O N S : O N E S O C I E T Y
There is no way to isolate the military from the rest of society; it
is an integral part of society. Its mission is to protect society, and
as such, it must interact with society. The military and their fami-
lies generally constitute five percent of any society, are drawn
from all regions and sectors of a country, and normally serve and
live in several regions throughout their years of service.
Moreover, the military mind is not purely military. It is in part
shaped by civilian relationships. The fundamental knowledge, val-
ues and attitudes of military personnel were shaped prior to their
military service by families, education, religion, peers, and prevail-
ing cultural practices. It is mainly prior to military service that
men develop their self-image and their attitudes toward women.
It is the combination of such culturally determined influences
with circumstances such as loneliness, availability of sexual temp-
tations, and the stressful conditions of war and peacekeeping that
determine individual vulnerability to risky behavior leading to
HIV infection.
Figure 1 illustrates the social context of military personnel,with
the military individual as the central focus. In the immediate circle
are families and sex partners,represent-
ing the closest relationships. The outer
circle is composed of the institutional
civilian elements with which the indi-
vidual and his/her immediate circle
interact,including government pro-
grams,commercial enterprises,and
NGO leaders in religious,social and pro-
fessional organizations. The interaction
at the various levels between civil and
military entities demonstrates the inte-
gral role of military personnel in a soci-
ety and the need for civil-military collab-
oration in the fight against HIV/AIDS.
Military and Civilian Populations: One Society 7
MILITARYANDCIVILIANPOPULATIONS:ONESOCIETY
The military and civilian sectors
are related in both the causes
and the effects of HIV/AIDS.
They are stakeholders in one
another’s success in combating
HIV/AIDS.

Both the civilian and military sectors suffer the economic
effects of HIV/AIDS. HIV/AIDS burdens and retards a country’s
economic development and limits the resources available to all
sectors, impacting both the civilian and military populations. It
strikes most severely the age group of young adults who are in
or are entering their most productive years, the stage of life at
which society hopes to recoup its investment in its youth. It
can inhibit foreign investment as it increases workforce absen-
teeism and turnover, reduces productivity and increases costs of
training. It overburdens hospitals and health budgets and hurts
families that lose income while acquiring costs of care and
funerals. HIV/AIDS negatively impacts the tax base, reducing
funds available for schools, infrastructure, health care and the
military. Thus, the military and civilian sectors are related in
both the causes and the effects of HIV/AIDS. They are stake-
holders in one another’s success in combating the pandemic.
Figure 1

T O W A R D C I V I L - M I L I T A R Y
C O L L A B O R A T I O N
As indicated by the case studies presented in this booklet, various
types of civil-military collaboration are occurring. It is not yet a
widely-implemented technical strategy, but countries are begin-
ning to see its advantages and benefits. Most, however, are at the
stage of exploring very basic questions: What substantive con-
cerns might the two sectors have in common? What can collabo-
ration accomplish? How can it happen? What can we learn
about the scope and design of existing collaborations? What has
been done that we may consider a best practice?
Elements of a Common Agenda
As the HIV/AIDS pandemic affects both the civilian and military
sectors, the first step in developing collaboration between the
two is the defining of common areas of interest. Listed below are
topics pertaining to and concerning both sectors:
a national strategy for fighting HIV/AIDS, based on a national
assessment of problems and needs
the impact of HIV/AIDS on economic development, tax rev-
enue, and support for services in health and health education
cultural influences, including religion, which affect behavior
and the design of the response to the HIV/AIDS problem
civilian employees of the military
women in the military and in the community, wives and
military families
military widows and orphans
commercial sex workers
the health of recruits
demobilization
hosting of foreign troops
blood safety
testing and sentinel surveillance
epidemiology and research
care in hospitals and home care
medical, nursing and counselor training
TOWARDCIVIL-MILITARYCOLLABORATION

training of trainers for preventive education
education programs and materials
media campaigns
condom social marketing
human rights: confidentiality and discrimination
program monitoring and evaluation
models from other countries
A focus on women is emerging as a leading topic for civil-military
collaboration. Women are increasingly becoming infected with
HIV, and reports indicate approximately half of newly infected
adults worldwide are women. This is an
issue which will have a profound
impact on the military. Women are serv-
ing in the armed forces in increasing
numbers. Military men interact with
civilian women who are wives, girl-
friends, casual sex partners, or commer-
cial sex workers.
Thus, women are emerging as a natural
bridge for civil-military collaboration
due to the positions they hold within
the military, within military families, and
within the civilian community support-
ing the military. International organiza-
tions, such as the Commission of the
European Union, USAID, UNAIDS, the
Pan American Health Organization
(PAHO),AIDSCAP/Family Health
International,The Latin American Union
Against Sexually Transmitted Diseases
(ULACETS) and the Ford Foundation,
have recommended that women
become a special focus and vehicle for
CMC.
Programmatically, discussions about
focusing on women have included sug-
Women are increasingly
becoming infected with HIV,
and reports indicate approxi-
mately half of newly infected
adults worldwide are women.
Women are emerging as a
natural bridge for civil-military
collaboration due to the
positions they hold within the
military, within military families,
and within the civilian
community supporting and
serving the military.

gestions to create civil-military women’s organizations; design
gender-sensitive training programs within the military; improve
STI diagnosis and treatment of women, including provision of
counseling and support services; and train both male and female
military recruits to work in community HIV-prevention programs.
Mutual Benefits
The benefits to civil-military collaboration can be summarized as
follows:
Setting Policy: Creating working coalitions of civil, military and
private agencies has the potential to elevate HIV/AIDS to the
national policy level and to make HIV/AIDS a national priority.
Convening Power: In many countries, the status of the military
is such that it can focus the attention of the government on a par-
ticular subject; in other words, it has“convening power”. The
joint interest of military and civilian agencies can lead to policy
attention at the highest levels.
Expanding Reach: Due to the fact that military bases are spread
across a country’s regions,the military can complement and rein-
force civilian programs,potentially reaching large numbers of peo-
ple who otherwise may not easily or effectively be served. Thus,
nation-wide program implementation becomes a possibility.
Exchanging Information and Know-how: Opportunities
exist for both sectors to learn from each other, particularly in the
areas of epidemiology, program development, achievements and
constraints, and best practices. In many countries, HIV preven-
tion, care and counseling have been slower to develop for mili-
tary men and women than for civilians. However, some of the
militaries that have tested their personnel have epidemiological
data that could be mutually beneficial in identifying concentra-
tions of HIV transmission, needs for surveillance and other
research, and possible areas of collaboration.
Sharing resources: In order to improve efficiency and cost-
effectiveness, and in light of decreasing budgets and increasing

costs associated with HIV/AIDS, resource-sharing becomes a
major advantage. Practical possibilities for cooperation include:
distribution of materials for the civilian sector by military air-
planes and vehicles
design of joint prevention programs in targeted communities
development of programs whereby demobilized soldiers are
trained and utilized in HIV-prevention campaigns in their
home communities
joint resource centers providing telephone and computer
access for individuals to obtain information on treatment
sharing of hospitals for AIDS patients
use of civilian counselors for military personnel and families
use of civilian trainers and trainers of trainers for military pro-
grams; civilian certification of military trainers
nationwide testing and counseling centers for both civilian
and military use
military use of civilian educational materials
joint special training programs for nurses
civilian training of home care providers serving military
personnel
Potential Partners
Perhaps the most logical partners for
the military are the Ministries of
Health and Education. In virtually
every country, the Ministry of Health
(MOH) plays a leading role in techni-
cal leadership and in the provision of
preventive as well as healthcare ser-
vices. Furthermore, the MOH typically
hosts the National AIDS Control
Program (NACP). The Ministry of
Education also seems a likely partner
in that it is responsible for the educa-
tion of the country; a joint activity
might be the development of a sexual
health curriculum with an
HIV/AIDS/STI component. The
Benefits of CMC:
Elevation of HIV/AIDS to
national policy level
Power to convene groups at
highest level
Expanded geographic reach
Exchange of information and
expertise
Resource-sharing

Ministry of Defense is already an implicit partner since we are
discussing military collaboration.
The National AIDS Control and Prevention Commissions are top-
level, multi-sectoral political entities charged with setting poli-
cies, advocating for HIV/AIDS prevention programs, and generat-
ing resources for interventions. These may serve as potential
partners for CMC, depending upon their level of effectiveness in
the country.
Generally speaking, non-governmental organizations have had
limited resources and often represented too many interests to
be of use to the military, but this situation is changing. NGOs
are growing in size and expertise, focusing on women, forming
national and regional networks, receiving increased internation-
al funding and technical support, and helping to place HIV/AIDS
on the national agenda. Two private voluntary organizations
(PVOs) with which military partnerships currently exist are The
Red Cross, in training trainers to conduct educational sessions,
and Population Services International (PSI), in condom social
marketing.
The strongest cultural force in many countries is the church,
whose influence encompasses both its civilian and military mem-
bers. Thus, religious organizations present another unique oppor-
tunity for collaboration. In Italy, for example, the military chaplain
joins the medical doctor and commanding officer in leading HIV
preventive education; these three people are the most authorita-
tive figures in the lives of the soldiers. In the civilian sector, many
religiously-based service agencies provide HIV/AIDS counseling,
care and hospice. Therefore, religious-based organizations are also
potential partners for CMC.
Possible Processes
Civil-military collaboration may involve the following processes:
convening meetings to discuss shared problems, objectives and
possible topics for cost-effective collaboration
designing joint activities

developing joint pilot projects, for example, in garrison com-
munities where military and civilian personnel interact
integrating joint activities into the framework of national
planning
Joint civil-military seminars have occurred in the African and Latin
American regions, sponsored by combinations of international
organizations. Joint conferences within countries have also been
held and are becoming more frequent. In 1996 in Chile, for
example, military officials invited representatives of schools and
the Red Cross to conferences in both the northern and southern
regions, thereby beginning local-level discussions in which both
civilian and military sectors participated. The Dominican
Republic brought its civilian and military sectors together in a
national conference,“HIV/AIDS: A Challenge to Development”,
in July 1996. The combined theme of health and economic
issues, in both of which the two sectors are stakeholders, under-
scored the commonality of military and civilian interests.
A current set of linked processes suggests how a multi-level
approach may be used to maximize effectiveness in advancing
CMC. Three process models are connected:
1. The first model is one of inclusion-at-the-creation. In forming
its Central American Regional Chapter during the Regional
Seminar in Honduras in July 1997, the Civil-Military Alliance
involved leaders of ULACETS and PASCA (the USAID-funded
Central American AIDS Action Project), as well as representa-
tives of the Congress of Military Health for Central America
and Mexico. This process enabled all present to discuss com-
mon areas of interest in CMC. A follow-up meeting is sched-
uled for October 1997, at which time the Congress will con-
sider ways to make HIV/AIDS and CMC prominent aspects of
the broader regional concern for military health. NGOs will
also be invited to participate in the Congress.

2. The second is a two-step process model involving countries
selected because of their potential for regional and sub-region-
al leadership in program development. Representatives from
five countries — Bolivia, Brazil, the Dominican Republic,
Honduras, and Peru — presented epidemiological data at the
Regional Seminar in Honduras and discussed program develop-
ment in their countries, with special attention on the aspect of
CMC. A second phase will occur at the XI Latin American
Congress on STI and V Pan-American Conference on AIDS to
be held in Lima, Peru, in December 1997. These same coun-
tries will provide follow-up reports on developments in nation-
al planning, including civil-military collaboration.
3. The conference in Lima itself pro-
vides a third process model: hemi-
spheric feedback to the civilian sec-
tor. As military participants will be
included in panels throughout the
conference program, this sends a sig-
nal to civilian HIV/AIDS/STI profes-
sionals across the hemisphere that
CMC is an emerging technical strate-
gy in partnership development and
program implementation that should
be incorporated in all Latin American
countries.
The Dominican Republic
brought its civilian and military
sectors together in a national
conference, “HIV/AIDS: A
Challenge to Development”,
in July 1996. The combined
theme of health and economic
issues, in both of which the two
sectors are stakeholders,
underscored the commonality
of military and civilian interests.

C M C I N P R O G R E S S
As stated previously, although civil-military collaboration is not a
widespread technical strategy, it is occurring within countries and
amongst countries and regions. In fact, the majority of the 63
countries responding to the Civil-Military Alliance’s 1995 global
survey,“HIV/AIDS Prevention,Testing and Care in Military Medical
Practice”15
, indicated the military use civilian trainers for preven-
tive education to supplement inadequate numbers of military
trainers, to complement military trainers on special topics, and/or
to rely entirely on civilian trainers of trainers.
As Figure 2 illustrates, HIV/AIDS prevention and control efforts
are taking place in three realms. The first occurs within the mili-
tary itself, the second within the civilian population, and the third
is an intermingling of the two sectors.
CMC in Progress 17
CMCINPROGRESS
Figure 2

The following five vignettes present examples of the third realm,
current CMC. Three are based on policy decisions at the national
level involving the military and the Ministry of Health, and the
other two are collaborations between the military and PVOs.
These are not the only models that exist, but they are included to
demonstrate the types of activities that are possible as well as to
stimulate thinking for future collaborations.
Integrated Planning: Peru
Peru has created a national planning and administrative system
for its campaign against HIV/AIDS. The civilian and military sec-
tors are independent but coordinated. The overarching cross-
sectoral framework is PROCETSS (Program for the Control of
STIs and AIDS/Programa de Control de Enfermedades de
Transmisión Sexual y SIDA), a three-tier administrative system
operating at the national, regional and local levels. It is based
on the premise that “coordination establishes a relationship
between independent collaborators and respects the autonomy
of the parts”.16
PROCETSS’ macro objectives are to achieve: integrated atten-
tion to HIV/AIDS/STI; interventions to change behavior; nation-
wide epidemiological surveillance; and the strengthening of
institutional capabilities across the country. There are seven
points of common operational guidance for all three imple-
menting levels:
1. Health services should be accessible, acceptable, and of quality.
Accessibility in part means“the guarantee of autonomy, priva-
cy, confidentiality, and no discrimination”.
2. The control of STIs is the basic strategy for the control of
HIV/AIDS.
3. Counseling is to occur before and after testing.
4. Sentinel surveillance is to be developed.
5. The World Health Organization’s Prevention Indicators will be
used as measures for evaluation.
6. Urban areas are to have priority.
7. Management, human resources and equipment will be
improved at all levels.

PROCETSS links the three levels of
implementation functionally. The
responsibility of the national level is to
provide regulations and standards;
assure fulfillment of objectives by coor-
dination and supervision, consistent
with the protection of human rights;
provide technical assistance; design,
implement and evaluate a sequential
sexual education program in the school
curriculum with the education sector;
undertake a public campaign reaching
politicians, the media, representatives
of churches and places of employment;
and evaluate program cost-effectiveness
and socio-economic impact. The
regional level designs and proposes
regional responses congruent with the
national framework, and submits opera-
tional reports and epidemiological data
to the national level. The local level
designs and proposes local programs
that are consistent with the national framework and are sensitive
to local culture, coordinates with community organizations, and
submits operational reports and epidemiological data to the
regional level.
Within this overall framework, the armed forces and national
police have developed their own integrated planning system,
COPRECOS (Committee for the Prevention and Control of
HIV/AIDS in the Armed Forces and National Police/Comité de
Prevención y Control del SIDA de las Fuerzas Armadas y Policía
Nacional de Perú). It operates within the PROCETSS system and
integrates planning for Peru’s armed forces and national police. It
has a common set of objectives for all the armed and national
police forces: securing of safe blood supplies; arranging for the
availability of testing; improving the epidemiological information
system and laboratory procedures; providing psycho-social care
and family counseling; and developing preventive education pro-
CMC in Progress 19
Peru’s integrated civil-military
national, regional and
local level HIV/AIDS planning
and administrative system is
based on the premise
that “coordination establishes
a relationship between
independent collaborators
and respects the autonomy
of the parts.”16

grams. The plan designates lead hospitals and calls for education
programs within the military schools and training centers. It
defines the projects to be implemented toward achieving each
objective and specifies organizational responsibility, indicators of
success, documentation requirements and budget requirements.
It operates in parallel to the three PROCETSS levels, coordinates
with and provides reports at all three levels, and participates in
the national outreach campaign.
Peru shared this planning model with military representatives
from 11 Latin American countries in Lima in May 1995.
Subsequently, five additional countries have adopted or adapted
the COPRECOS model: Bolivia, Brazil, Chile, the Dominican
Republic and Honduras.
Beginning Multiple Activities: Brazil
Brazil is in the early stages of implementing a variety of activities.
A Commission for the Prevention and Control of HIV/AIDS in the
Armed Forces (COPRECOS/Brazil) has been created. A“Protocol
of Intentions”frames cooperation between each of the three mili-
tary services and the Ministry of Health, and a Permanent
Interministerial Council has been established to address health
problems. The original protocols have been expanded to include
regional and functional activities, focusing primarily on the
Amazon and frontier regions; service to indigenous populations;
sanitation, surveillance, equipment and plasma needs; and the
production of medications in pharmaceutical laboratories.
A 1995 agreement between the Ministry of the Army and the
Ministry of Health instituted a “permanent program of mutual
cooperation to prevent the spreading of HIV”. The Army, in
cooperation with the Ministry of Health, is beginning an HIV
prevention program for indigenous, frontier and Amazon region
populations.
The Ministries of Health and the Army initiated a General
HIV/AIDS/STI Coordination Program in 1996 directed toward the
18-year olds presenting for military service. This CMC is enabling
a statistical sample of over a million male youths.17

Training of Trainers: The United States
Another example of a civil-military joint effort is the collaboration
between The American Red Cross and the U.S. Navy. Beginning
in 1991,The Red Cross assisted the Navy in preparing a compre-
hensive prevention program for its 6,000 Navy and 4,000 Marine
Corps units, with the potential to reach an estimated 900,000 per-
sonnel. A training of trainers component was also included, and
to date, more than 1,600 Navy Instructor-Trainers have been
trained. Instructors receive dual certification from the Navy and
The Red Cross. Many Navy personnel have subsequently volun-
teered to serve as instructors for Red Cross civilian groups. The
Navy utilized existing manuals, booklets and other training materi-
als from The Red Cross as well as Navy-specific materials. The
American Red Cross materials are available in Spanish and are
being utilized in seven Latin American countries.
Social Marketing: Africa
Most militaries promote condom use and distribute condoms for
free to their personnel. An alternative to free distribution for the
military is the social marketing of condoms,whereby low-cost
mass quantities of condoms are purchased from a private organiza-
tion and sold at a subsidized cost to the consumer. This approach
has the benefit of reducing costs to the military. Studies have indi-
cated that people are more likely to use condoms they pay for
than those they receive for free,for the simple reason they per-
ceive the condoms purchased to be of superior quality.18
The leading organization in this field, Population Services
International (PSI), has offices in Latin America but has not yet
begun to work with the military sector. It is working with the
military in Africa (Rwanda, Mozambique and Zambia), and the
examples of Rwanda and Mozambique are presented here.
In Rwanda, funds for condom purchase under a World Bank loan
have been used to buy the socially-marketed brand,“Prudence
Plus”, which has good name recognition and is the preferred
brand of the soldiers. The military now buys 100,000 condoms
per month. To promote condom usage, the project began a
mobile video unit campaign at seven military bases in 1996. New
CMC in Progress 21

radio spots were produced, and the pro-
ject devoted its“Prudence Time”, a 15-
minute Sunday radio show, to themes
specific to the military. The project also
published three articles in the military
newspaper in January 1997, including
an interview with the project director
regarding the sale of condoms to the
military. The project is scheduled to
visit five bases in 1997 and to sponsor a
week-long sporting event.
PSI/Mozambique has undertaken com-
munications activities targeting military
personnel and police. Community-
based peer educators trained by the
project have visited military bases to
educate audiences on HIV/AIDS/STIs
and the importance of consistent and correct condom use. The
educators have effectively used music and drama to communicate
their messages. A play,“So A Vida Ofrece Flores”(Only Life Offers
Flowers), is used to elicit an emotional response in the audiences,
increase their awareness of AIDS as a disease which could alter
their lives, and motivate them toward safer sexual behavior.
Other skits focus on STIs and are used in conjunction with con-
dom demonstrations.
Community Empowerment: Bolivia
Initiated in 1989, Bolivia’s Sentinels of Health program is a com-
munity-integrated, civil-military national system with the potential
for long-term impact. Its underlying principles are that“one can
apply to the defense of life the concepts used in defense of the
country”and that“the health of Bolivian families can be improved
if all soldiers, upon returning to their community, teach all that
they learn”.9
Figure 3, a Swiss military poster, provides an exam-
ple of this protective service of the military.
A sentinel,“el centinela”,is a sentry or person who is on guard. In
Bolivia,“sentinels”guard the people’s health as an essential ele-
“…one can apply to the
defense of life the concepts
used in defense of the country”
and “the health of Bolivian
families can be improved if all
soldiers, upon returning to
their community, teach all
that they learn.” 9

ment of the nation’s defense. During the first three months of mil-
itary service,recruits complete a course on health and become
certified“Sentinels of Health”. Within a few years,as many as
400,000 young men will have completed the health training.
In this cooperative program, the mili-
tary provides the instructors. The
National Health Secretariat does the
strategic planning, establishes the stan-
dards, and performs the project evalua-
tion. Certification of the sentinels is
jointly issued by the Ministry of
Defense and the Ministry of Housing
and Social Development, and the certifi-
cate also bears the emblems of UNICEF,
WHO, and PAHO.
During the training, each sentinel
receives a 140-page booklet, Para la
Vida, which has been adapted from
NICEF/WHO/UNESCO publications.
Soldiers learn about common diseases
and their causes, including malaria, yel-
low fever, tuberculosis, diarrhea, alco-
holism, HIV/AIDS/STIs, among others.
Additional topics are covered, such as
hygiene, nutrition, safe water, construc-
tion of latrines, hazards of rubbish
dumps, oral rehydration, and maternal
and child health.
The instruction uses military analogies,
such as sentinels are to“fight the ene-
mies of health”,“protect the frontiers of
the body”,and to think in terms of using
intelligence,strategy,tactics and tech-
niques to defend the body. HIV is a
“powerful,mortal enemy that directly
attacks our defenses;it is a specialist in
CMC in Progress 23
The health instruction for
Bolivia’s Sentinels of Health
uses military analogies, such as
sentinels are to “fight the ene-
mies of health”, “protect the
frontiers of the body”, and to
think in terms of using intelli-
gence, strategy, tactics and
techniques to defend the body.
HIV is a “powerful, mortal
enemy that directly attacks our
defenses; it is a specialist in the
art of camouflage”. As part of
the system of defense, soldiers
are taught how to fight this
health “microwar”.

the art of camouflage”. As
part of the system of defense,
soldiers are taught how to
fight this health“microwar”.
The sentinels are to have
multiple effects when they
return to their home com-
munities upon completion
of military service. They are
not only to become a genera-
tion of educated fathers who
will know how to take care
of their families, but also
community educators who
know how to apply their
knowledge to motivate oth-
ers in the community and to
direct their activities as
agents of change.
The sentinel is registered within the community and works with
local authorities as a member of a health team. The communities
keep records on how the sentinels are utilized and report
monthly on the sentinel’s activities, such as conducting educa-
tional sessions or organizing the clean-up of dumps. At periodic
meetings, district health directors evaluate the utilization and
impact of the sentinel program. In some districts the local
health authorities undertake community projects in collabora-
tion with military units in order to optimize the use of existing
resources. For the Bolivian people, the military and civilian sec-
tors have agreed on a joint mission and collaborative effort to
improve the quality of life.
Figure 3
Source: Civil-Military Alliance to Combat HIV and AIDS

C M C : A B E L A T E D D E V E L O P M E N T
Civil-military collaboration has been relatively slow to develop for
a number of reasons. Initially, the military focused on the prob-
lem internally, and military medical systems in many countries
were slow to launch HIV/AIDS prevention and care programs.
Unlike civilian systems, the military specialize in dealing with
immediate threats to unit readiness and generally are not well-pre-
pared to address long-term illnesses. Military commanders are
more concerned with medical problems that can incapacitate
their forces in the immediate future. Thus, HIV/AIDS posed a
unique challenge for the military.
As the problem became more compelling, particularly between
1985 and 1992 in most countries, each separate military service
became busy and concerned with its own growing and increas-
ingly complex HIV/AIDS agenda. They focused on three areas:
1) problem assessment, testing and blood safety; 2) prevention
programs emphasizing education and condom promotion; and
3) care of personnel, including counseling and provision for sur-
vivors. These activities forced each of the services to simultane-
ously face issues of staff development, budget and cost effective-
ness, human rights and entitlements.
By 1990, most countries were developing national AIDS agencies
whose functions were national planning and program develop-
ment. Typically, the military were not included or were included
only marginally. In some countries, collaboration was further
inhibited by civilian animosity toward the military stemming from
civil wars, political differences and/or military dictators as govern-
ment leaders. The military, however, has been a missing link in
cross-sectoral planning.
The conditions for civil-military collaboration are improving, how-
ever, particularly as both sectors recognize they are one popula-
tion with a common enemy, HIV/AIDS. Commonalities between
the sectors are becoming better understood. NGOs have
improved their capacity for effective partnerships. International
CMC: A Belated Development 25
CMC:ABELATEDDEVELOPMENT

donor agencies are encouraging the next step of developing
cross-sectoral approaches. Precedence of CMC already exists in
building roads, bridges and even housing. Program experience
from both sectors are forming the basis of discussions and assist-
ing in the development of collaborative efforts. Regional meet-
ings on HIV/AIDS are concluding that civil-military collaboration
is essential to combat the pandemic.

L E S S O N S L E A R N E D
1. Just as the HIV/AIDS pandemic is not exclusive and impacts
all of society, the response to it must not exclude any sectors.
Thus, a coordinated, multi-sectoral approach is required, one
that includes the military sector.
2. Civil-military collaboration has been slow to develop due to
initial internal focusing on its HIV/AIDS problem by the mili-
tary as well as the military’s exclusion from national planning
efforts.
3. Civil-military collaboration builds on both functional comple-
mentarities and commonalities among the sectors and makes
more effective use of resources.
4. The military sector is unlike any other, particularly in Latin
America, in its ability or power to convene large military and
civilian population segments. It typically has a presence in all
geographic areas of a country, including the small towns; thus,
it has the potential to reach millions of individuals.
5. The mission of the military is to protect the population and
the country as a whole. This social service of protection must
also include the health of the individual and the collective
health of the country’s population. Therefore, the military
must participate in HIV/AIDS prevention and control pro-
grams through civil-military collaborations.
6. Regional approaches are effective because they attract civilian
and military leaders at the highest levels and provide a forum
for cross-national sharing of programs, initiatives, policies and
problems. They can lead to mutual assistance across countries
and, ultimately, to regional utilization of expertise.
7. International financial and logistical support is crucial to con-
vening regional meetings, developing the agenda, and promot-
ing civil-military collaboration as a viable technical strategy.
Lessons Learned 27
LESSONSLEARNED

Furthermore, a brokering and/or coordinating body is essen-
tial to bringing together the international organizations,
donors, experts, and civilian and military sectors from various
countries. This brokering agent must plan the agenda, stimu-
late strategic thinking, raise funds, serve as the liaison between
all parties, coordinate the logistics, and prepare reports for dis-
semination.
8. Cultural affinity facilitates regional approaches. In Africa,
four common languages — English, French, Portuguese and
Swahili — help enormously with communications. In Latin
America, the Spanish language, the similar Portuguese lan-
guage, and shared cultural institutions and mores contribute to
mutual understanding and interest in collaboration. In con-
trast, the cultural separation of the English-speaking Caribbean
has been a barrier to joint programming with Central America.
9. Program development must be sensitive to cultural issues. At
one level, culture is a major determinant of individual sexual
behavior; behavioral intervention strategies must be sensitive
to an individual’s culture and to cultural differences. At anoth-
er level, failure to consider cultural context can lead to politi-
cal trouble. Indeed, cultural issues can contribute to avoid-
ance of HIV/AIDS issues at the highest levels, where leaders
can face political risk by addressing homosexuality, bisexuality,
the use of condoms, church doctrine, sex education, the sexu-
al behavior of military personnel and sex-based politics.
10.Partners of the military sector can include NGOs and PVOs as
well as Ministries of Health and Education. It is possible to
develop a civil-military agenda in collaboration with regional
military health organizations, such as the Central American
Congress for Military Health, and to introduce CMC into the
agendas of largely civilian professional medical associations.

R E C O M M E N D A T I O N S
Recommendations to further advance civil-military collaboration
include:
Dissemination of information on CMC, such as the rationale for
collaboration, agenda possibilities, processes leading to collabo-
rations, models for replication, and results from existing collab-
orations
Advancement of the brokering role in bringing the parties
together
Expansion of the focus on the military to include peacekeep-
ing troops, police, prison guards and maritime personnel
Utilization of leaders of well-developed programs to assist in
developing programs in other countries
Development of policy frameworks that will facilitate collabo-
rations and that will ensure international and local military per-
sonnel receive mandatory training on the UN Conventions on
the Rights of the Child and education on HIV/AIDS/STI pre-
vention
Development of joint projects with potential for replication or
adaptation beyond the immediate site
Evaluation of policies and programs in order to determine the
most effective approaches
Civil-military collaboration is a nascent strategy in HIV/AIDS
prevention and control with the potential for expansion and
replication. The process of developing civil-military collabora-
tions will create dialogue on policy issues, promote new
approaches to problem-solving, and stimulate new partnerships
and capabilities within communities, countries and society as a
whole. We may expect the impetus for CMC to vary with the
RECOMMENDATIONS
Recommendations 29

extent of the HIV/AIDS problem. In countries where the epidem-
ic is advanced and seroprevalence is high, there is an urgent need
for CMC. However, even in countries with low HIV prevalence,
this may be the moment to achieve the greatest impact with a
comprehensive and integrated civil-military program.

R E F E R E N C E S
1. Development Associates, Inc. Management Review of the
AIDSCAP Project. Washington: Development Associates,
1995.
2. Family Health International/AIDSCAP. Making Prevention
Work: Global Lessons Learned from the AIDSCAP Project
1991-1997. Washington: Family Health International/AID-
SCAP, 1997.
3. “Holography.”Colliers Encyclopedia. 1996 ed.
4. “Holography.”Encyclopedia Americana. 1997 ed.
5. Babbie, Earl. The Practice of Social Research. 6th ed.
Belmont, CA: Wadsworth Publishing Co., 1992.
6. Kingma, Stuart J. “AIDS Prevention,Testing and Care in
Current Military Practice.” International Conference on AIDS,
July 7-12, 1996, 11 (1): 47. Abstract No. Mo.D.350.
7. Temoshok, L.R., and Stuart J. Kingma. “HIV Exposure Risk in
Military Populations: An Uncharted Prevention Frontier.”
International Conference on AIDS, July 7-12, 1996,
11 (1): 48. Abstract No. Mo.D.354.
8. “The Impact of AIDS on Military Institutions.”Civil-Military
Alliance Newsletter. July 1995.
9. Ministerio de Desarrollo Humano, Secretaria Nacional de la
Salud. Centinela de la Salud. La Paz, Bolivia: Ministerio de
Desarrollo Humano, Secretaria Nacional de la Salud, 1995.
10. Piot, Peter. Keynote Address. NATO Medical Committee
Symposium on HIV Prevention. 23 Feb. 1996.
11. Smallman-Raynor, M.R. and A.D. Cliff. “Civil War and the
Spread of AIDS in Central Africa.”Epidemiology and Infection.
1991 Aug; 107 (1):69-80.
12. “HIV as a Weapon of War.”Civil-Military Alliance Newsletter.
April 1995.
REFERENCES
References 31

13. Elliott, L. “Child Prostitution: A Case Study in Military Camps
in Liberia.”International Conference on AIDS, July 7-12,
1996, 11 (1): 254. Abstract No. Tu.D.136.
14. Yeager, Rodger. “Military HIV/AIDS Policy in Eastern and
Southern Africa: A Seven Country Comparison.”Civil-Military
Alliance Occasional Paper Series. 1996.
15. Yeager, Rodger and Craig W. Hendrix. “Global Survey of
Military HIV/AIDS Policies and Programs.”Civil-Military
Alliance Newsletter. January 1997.
16. Ministerio de Salud. Doctrinas, Normas y Procedimientos
para el Control de las ETS y el SIDA en el Perú. Lima, Perú:
Ministerio de Salud, 1996.
17. Ministerio da Saúde. Relatorio de Atividades 1996,
Perspectivas para 1997. Vol. I. Brasilia, Brasil: Ministerio da
Saúde, Secretaria Executiva/Gabinete do Ministerio,Assessoria
Especial, 1997.
18. Lewis, Maureen A. “Do Contraceptive Prices Affect Demand.”
Studies in Family Planning. 17:3. May/June 1986.

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