Limpopo workshop on the security aspects of HIV/AIDS

On 25 – 28 June 2004, Pugwash Meeting no. 297 was held in Limpopo, South Africa.

Threats without enemies: the security aspects of HIV/AIDS – A second exploratory workshop

Workshop Report compiled by Gwyn Prins (assisted by Barry van Wyk and workshop participants, edited by Euníce Walker)

On entering the new millennium, the Pugwash Council considered how to interpret the basic mission of the Movement in view of many new threats to international peace and security. These new threats – of which HIV/AIDS is a case in point – cannot easily be attributed to a specific enemy, if at all: they are threats without enemies and the more insidious for this fact.

Aware of this, the Pugwash Council agreed to the proposal made by the South African Pugwash Group to convene two exploratory workshops to examine different dimensions of the HIV/AIDS pandemic as a security issue.

The first of these workshops took place in the Western Cape province of South Africa in February 2004. The report and selected materials are available online.

The second workshop delved deeper into and extended the agenda of the first. Seventeen experts gathered at Mabula Lodge in the Limpopo province of South Africa in late June 2004 to engage the Pugwash principle of “thinking in a new way” on the HIV/AIDS pandemic. Pugwash gratefully acknowledges support provided by the Rockefeller Brothers Fund for this project.

As is the convention at Pugwash gatherings, the workshop was held under the Chatham House Rule on a non-attribution basis with all the participants representing themselves as individuals only. Disciplines represented at the workshop included political science, military and historical studies, virology, medical physiology, surgery and general medicine, national intelligence analysis, development economics, biochemistry, security analysis, defence planning and humanitarian assistance. Through the lens of the Pugwash Mission, these disciplines were focused onto a wide agenda, described below. As the workshop progressed, it was generally felt that the very act of combining disciplines that would otherwise rarely if ever meet, produced absorbing, informative sessions and novel insights. The workshop also gave rise to practical outcomes and an agreed impulse for a further workshop to review progress in 2005.

HIV/AIDS as a security issue

Professor Gwyn Prins of Columbia University and the London School of Economics and Political Science (LSE) introduced the opening session. He set the context for the workshop and primarily described the evolving policy debate on the constructions of HIV/AIDS as a security issue.

In 2005, it will be the fifth anniversary of the UN’s formal recognition of HIV/AIDS as a security issue. With the passing of Resolution 1308 on 17 July 2000, the Security Council forged a direct and formal link for the first time between its responsibility for maintaining international peace and security and the HIV/AIDS pandemic.

It was argued that, in a narrow construction, HIV/AIDS needed to be considered on a par with other conventional defence or security issues especially in the regions currently worst afflicted. The military, police and other key civil servants are in the very eye of the storm: as other aspects of governance and civil society are weakened by the vicious spiral of poverty and pandemic illness, the importance of these agents normally becomes enhanced. However, in sub-Saharan Africa, precisely these agents are preferentially affected. An illustration of this debilitating process was the example given of Ugandan soldiers who were sent to Cuba. Upon arrival it was established that a large proportion were HIV-positive.

HIV/AIDS poses a serious methodological test for security analysts. By definition, the epidemic requires a multivariate analysis. As a long-wave phenomenon – HIV/AIDS is so savagely unusual in that it hits three generations simultaneously and, based on the epidemiologist, Professor Roy Anderson’s calculations, will challenge humanity over a minimum of 130 years – it falls completely outside the attention span of policy makers and politicians. It is thus difficult to persuade policy makers to entertain the requirements of HIV/AIDS analysis, for these are not always commensurate with the dictates of “common sense” or conventional instincts. Yet, the analysis dimension of the HIV/AIDS pandemic is vital and was further discussed during two sessions towards the end of the workshop.

South Africa, it was noted, is currently at the epicentre of the HIV/AIDS pandemic. It was argued that, consequently, South Africa’s response is not only important for its own progress and survival, but that the success or failure of the encounter between one of the world’s most important current social experiments and this pandemic has wider global significance. South Africa – where a degree of moral courage and maturity is evident – is definitely a suitable place for a constructive debate on and engagement of the security concerns associated with HIV/AIDS.

Current statistics indicate that the first wave in Southern Africa is now approaching the end of its first phase. The “death” phase follows. A rising second wave of the global epidemic is set to confront the Asian sub-continent soon, as well as North-East and West Africa. Ironically, the epidemic in Ethiopia is currently exacerbated by the cessation of the conflict with neighbouring Eritrea. During the conflict, soldiers were physically confined by the war, but with the advent of peace, soldiers and followers have returned home and have taken the disease with them. This observation was met by the weary despondency of one participant: the epidemic is caused by war; the epidemic is also caused by peace, he noted. So what should be done? Further examples were given of the complexity of the issues involved in the pandemic. The downplaying of the scale of infections in India by the government AIDS commission led by Mrs Datta-Ghosh when compared to the opinion of most international experts is of a different source to the “denialism” encountered in South Africa, where the country’s President is on record doubting the aetiological mechanism linking HIV to AIDS. This is not the case in India; rather the impulse appears to be a mixture of national pride with irritation about foreigners’ decreeing what should be done. The impending threat of HIV/AIDS to the sub-continent, however, makes the present moment crucial in trying to contain HIV/AIDS.

It was emphasised that the gross number of infections does not necessarily correlate to the scale of the security threat. It is not the absolute number of infected people that is crucial, but rather the prevalence rate. Beyond this, once a situation is openly and accurately described, a second hurdle must be overcome. Increasingly, as a result of money from PEPFAR (the US President’s Emergency Plan for AIDS Relief for the 14 most affected countries) and from the Global Fund (leveraged in important part by PEPFAR), it is now not a lack of money that becomes the problem, but rather a lack of capacity to absorb and apply such funds quickly and in large enough quantity in many affected regions relative to the task at hand. Money will always have some effect, but it can dangerously morph into a distorting and disruptive corrupting agent, rather than a means for salvation and relief. Despite the refusal of many AIDS activists, such as Professor Jeffrey Sachs (who advises Kofi Annan on the UN’s Millennium Development Goals) to accept the point fully, capacity-building in the face both of the loss of skilled personnel and the preponderant role of the informal over the formal sectors in the political economies of many post-colonial new states, has become an international facet of HIV/AIDS intervention that is increasing in importance and that cannot be avoided.

During the second wave of the global HIV/AIDS epidemic – of specific significance to the broader construction of security in sub-Saharan Africa, and more widely via the oil markets – HIV/AIDS is set to have a substantial impact on Nigeria. Currently, the country seems to have prevalence rates similar to those in South Africa in the mid-1990s (11-13%). At the same time, West Africa is set to become strategically much more important to the United States, primarily due to its informal but increasingly well-publicised strategy of diversification of oil supplies. Currently, 14% of US oil is imported from West Africa. If the international price of oil remains consistently above US $20 bbl (at the time of writing, the price is spiking to unprecedented levels of more than twice this), West African offshore oil becomes profitable and will perhaps supply as much as a quarter of US oil within 15 years. As a result of intensified exploration, more new oil reserves have been found in and off the Congo and Niger deltas than anywhere else in the world in recent times. The increased strategic importance of West Africa, however, will occur concurrently with the second wave of the HIV/AIDS pandemic in Africa, specifically in this region. There will undoubtedly be a severe “tipping point”. When the new royalty income coincides with rising infection rates and eroding governance and civil society functions, will this income be used as a force for good, or will it simply help to pour petrol onto the flames of civil war that have subsided but have never been quenched, for example, in the Congo basin?

Central and Eastern Europe are also in the second wave. The Eastern and Central European epidemic has been greatly exacerbated by another irony: the liberalisation of society (glasnost) following the collapse of the USSR. Increased promiscuity resulted from this collapse, and the epidemic also spread outwards from the emptying prison systems where it had brewed among drug users and as a result of homosexual sex. In the “stans” of the former Soviet Union, oil and AIDS are becoming conjoined, in a similar way as in West/Central Africa.

The third wave of the global HIV/AIDS epidemic is the one that will confront China. The workshop was reminded that the aetiology was quite different, with the role of blood-selling in the 1990s an unusual driver in the Chinese countryside.

Knowledge of HIV/AIDS and its virological, epidemiological, political and social constructs has been steadily increasing for the last 25 years. Now, however, the dimension of HIV/AIDS as a security issue has been added. Richard Holbrooke, the former US Ambassador to the UN, was the first to call for the recognition of HIV/AIDS as a security issue and was instrumental in the passing of Resolution 1308 of the UN Security Council.

Countries with advanced HIV/AIDS epidemics may face particularly severe challenges arising from grave reduction in the average life expectancy. The will of people to reproduce comes increasingly into question. Yet, the history of Southern Africa reflects people with the most phenomenal capacity to survive (to live physically and socially) and to maintain the coherence of the moral community in the face of extraordinary stress. After surviving apartheid and its distorting effects in the region, this resolve now has to be applied differently to face the challenges of HIV/AIDS. While acknowledging the strength of this sad inheritance, one participant cautioned several times of the danger that the mobilization of social and political energies might be compromised or deflected if the language used to portray the threat posed to society was not carefully attuned to local sensibilities. This, he suggested, was an important part of the success in the popular mobilization in Uganda.

Prins then introduced another issue that was to run prominently throughout the workshop. Policy makers areonly activated by indicators and warnings that signal thresholds. An HIV/AIDS prevalence rate of more than 10% has recently been suggested (by David Gordon, now Deputy Director of the US National Intelligence Council) as a threshold to trigger the collapse of a state. Yet, the validity of the 10% threshold is open to debate, since a 10% prevalence in Botswana, for instance, did not trigger the collapse of society. In effect, as Gordon himself has stated, the 10% threshold concept requires engagement and debate on political, social and microbiological levels.

HIV/AIDS statistics: thoughts about knowledge, complexity, cost and value

The problems and potential of the rapidly evolving world of HIV/AIDS statistics, including the question of establishing validated indicators and warnings, were examined in the next session. Professor Tony Barnett, ESRC Professional Research Fellow of the Development Studies Institute, London School of Economics, introduced the session.

What most epidemiological statistics seek to represent, Barnett maintained, is seroprevalence, i.e. the percentage of a susceptible population known or assumed to be infected with a disease agent. It follows, therefore, that the course of the epidemic depends on the relation between the density of susceptible people and the density of infectious individuals. The critical variables to probe are whether the epidemic curves indicate a generalised or a concentrated epidemic; whether they are rising or declining; at what rate they are fluctuating; when they will peak; and whether endemic disease progression might result in “aftershocks” or new outbreaks.

HIV/AIDS epidemics can be classified as low-level (in which no single group has a prevalence rate of more than 5%); concentrated (in which prevalence rates among pregnant women in urban areas remain under 1%, but certain high-risk groups have breached the 5% prevalence rate); and generalized (in which prevalence among pregnant women remain consistently above 1%).

In low-level and concentrated HIV/AIDS epidemics, prevalence estimates are based primarily on surveillance data collected from intravenous drug users, sex workers, men who have sex with men, STI clinics, mobile groups, and pregnant women attending antenatal clinics. For the prevalence rate to be determined, an estimate of the size of each of these groups also needs to be provided.

Generalized HIV/AIDS epidemic prevalence rates, however, are based primarily on surveillance data collected from pregnant women attending antenatal clinics. This data is then assumed to be broadly similar to HIV/AIDS prevalence among men and women aged between 15 and 49 in the community. What these estimates do not consider, however, is the probability that HIV-positive women are less likely to attend antenatal clinics. They also make certain distinct assumptions on the number of sexual partners of men and women. It is important to note that risk behaviour never occurs in a vacuum, but always in a risk environment, and this environment can aggravate or alleviate risk behaviour to various degrees. Indeed, this point is quite vital, for Barnett stressed the degree to which the vulnerability of at-risk populations is closely linked to the scope of their life choices; and the poorer people are, the more restricted these choices become. Poverty puts people at risk from HIV/AIDS, especially from cruelly vulnerable constructions of sexuality: male machismo as a means of coping with danger and powerlessness; young women driven to sell unprotected sex for mere survival.

There has been much heated debate, especially in South Africa, on the reliability of the statistics underpinning key policy choices. Much of the criticism is misinformed, Barnett maintained, and he therefore spent some time explaining how the estimates are constructed. Nothing was secret, he explained. The models utilised and the assumptions incorporated in the estimation of national HIV/AIDS prevalence rates are peer reviewed, in the public domain and widely debated in various journals and media. Once national HIV/AIDS prevalence estimates have been determined, they are compared with community and population surveys. The data is then incorporated into the UNAIDS database and, in conjunction with UN Population Division data, is then utilised to compile global epidemic estimates of new infections, mortality and prevalence rates using the Spectrum model. The US Bureau of Census is an especially important global resource. It maintains an online HIV/AIDS surveillance database, which forms the basis for the UN country sheets and global report.

Contrary to the suggestions of conspiracies by Rian Malan (who had agreed to attend the first workshop but then, without prior explanation, failed to appear to defend his take on the issue), all HIV/AIDS statistics are peer reviewed and are progressively being refined. As with all data, however, “accuracy” is within a range, and as with all models, the outputs vary according to the assumptions that are incorporated. A key question to probe, however, is whether the prevalence rates are showing upward or downward trends.

HIV/AIDS is a long-wave disaster because it has such a long “incubation” period (i.e. invisible) in which the major shaping influences are rooted and growing before the magnitude of the crisis becomes clear and before any significant response can be launched. It is therefore of crucial importance to establish these trends by using the available statistics.

To understand the implications of HIV/AIDS statistics, it has to be recognized that a conventional economic approach to the assessment of impact has distinct limitations. These limitations have security implications because they affect how resources are distributed and they impact the assessments of urgency and of timescale. In the 1990s, environmental issues suffered a similar fate, when conventional economics systematically excluded from view the “externalities” of costs. Here, as there, the need is to make the “externalities” visible “internally”. As participants noted, this is similar to what Green Economics seeks to do (in the successive volumes of theBlueprint for Sustainable Economics edited by David Pearce and colleagues during the 1990s). In large measure, the issue is also similar to that which has plagued development economics, which fail to take account of the nature and role of the “informal sector”.

As an example of the partial picture given by a conventional economic assessment, a book entitled The impact of HIV/AIDS on labour productivity in Kenya (by Fox et al) was used as illustration. The book delineates the corporate bottom line, and does not adequately concern itself with “external costs”. It illustrates how Kenyan workers often bring unrecorded “helpers” along, as decreased attendance and output may put sick workers in jeopardy of losing their jobs, and also imposes financial burdens on employers. With “only” a 6% national HIV/AIDS prevalence rate in Kenya (a more robust figure calculated from national sero-survey data than the previous UNAIDS estimate of 15% extrapolated from those attending antenatal clinics), HIV/AIDS is taking its toll on commercial agriculture in Kenya and affecting the income of workers and the foreign exchange earnings of the country.

This implies a serious impact on economic costs. But who really carries those costs? Kenyan tea pickers, for instance, are eligible for paid sick leave and annual leave and receive a service gratuity upon reaching ten years of service for the same company. Yet, they are not entitled to receive retirement, death or disability benefits. Moreover, in the commercial sector in 2003, the monthly income of a Kenyan tea picker was US $48. The reality is people working for low incomes with little in the way of social support beyond their own households and communities until they have worked for ten years for the same company. This may be a very difficult threshold for most people to achieve. In addition, workers on Kenyan tea plantations support their dependants and are supported by them in turn. In other words, their presence in the tea estate is intertwined with complex processes of social and economic reproduction elsewhere.

What of excluded “external” costs? When the non-wage sector is unable to function effectively because of a disease, a whole series of costs accrue to Kenyan society, as indeed to any society under threat from this epidemic. These costs are impossible or very difficult to calculate and may include the costs of dying and of subsequent orphan care. Losses of social infrastructure also carry in steep price. In the longer term, costs also accrue to communities and to the country as a result of large numbers of poorly socialized people who have grown up as orphans.

Another example of excluded costs refers to so-called “hedonic losses”. This describes costs incurred as a result of the emotional trauma and the loss of happiness associated with HIV/AIDS. The inclusion of hedonic losses in economic calculations will inevitably alter the benefit-to-cost ratio of standards of care. In addition, the hedonic effects of large numbers of orphans on the future of any region are bound to be severe. Apart from hedonic losses, the loss of relational goods (i.e. relationships viewed as “goods” and thus lost relationships as a consequence of HIV/AIDS viewed as “costs”) also needs to be considered. In this regard, the variables of cost against return, value measured against benefit, the time period, and the unit of analysis all need to be weighed up.

What can be said then of the responsibilities of conventional economists? Their problem is familiar. Science asks strictly delimited questions, and hence many economists strive to maintain the “scientific” status of their answers. In offering policy advice, economists and politicians either forget the strict limitations of their arguments or extend them inappropriately, or they exclude variables as external to their necessary dataset, which are then ignored, may lapse into denial by allocating variables to certain “externalities” that remain unanalysed.

In conclusion, it can be said that HIV/AIDS statistics reflect the normal problems of sampling and representivity, but that the urgency and severity of the subject make it especially important to clarify any issues. This must be done in a way that will deny those who seek to avoid confronting the pandemic the opportunity to hide behind supposedly confusing data. It was put forward that HIV/AIDS projections depend on model assumptions, and that these, the data and the models are peer reviewed. If prevalence rates are high and/or curves are rising, the impact must be fully analysed: both the “internalities” and the “externalities” must be in view. Conventional economic techniques, however, tend to underestimate costs and to exclude many vital but non-quantifiable effects of the impact of the epidemic. This, in turn, will by implication limit understanding of the impact of HIV/AIDS and may therefore dull or delay an urgent awakening to its security implications.

HIV/AIDS and the military

The third session of the workshop was introduced by SANDF Colonel Andre Loubser who stressed, as is made clear in his paper accompanying this report, that he expressed personal opinions and only employed data already in the public domain. Loubser indicated that the correct starting point was to match capacity to need. He thus maintained that it was imperative for the military to ensure that it possessed the capacity to fulfil its mandate. The military’s mandate in South Africa is closely tied to the state’s intentions of establishing South Africa as a regional power, and expectations have been raised regionally and internationally for South Africa – with its perceived legitimacy and economic capacity – to fulfil this role. Yet, the military also has an HIV/AIDS epidemic to contend with, and for this reason the SANDF does health assessments of all new recruits to ensure a healthy deployable force. An HIV test is one of the criteria, as are all other medical conditions that can incapacitate an individual to deploy. This policy is not entirely consistent with the human rights-based approach currently employed in South Africa. However, once an existing member of the SANDF tests positive for HIV, this is managed like any other chronic disease.

The challenges facing the Southern African Development Community (SADC) include the development of effective governance and the creation of a collective security management system in Southern Africa. The creation of the African Union (AU) has underscored various positive opportunities and challenges, but the African continent remains hampered by instability, food insecurity and a poor health capacity, with most governments having neither the will nor the physical capacity effectively to address the HIV/AIDS epidemic.

However, the internal security situation in South Africa is relatively stable, even though the persistence of corruption, crime, right-wing extremism, unemployment, HIV/AIDS, and perceived problems with transformation, land redistribution, border control and service delivery remain causes for concern.

With South Africa committed to strengthening regional peace and security, the South African government dedicated itself to the planning and execution of peace missions. In this regard, the SANDF would be involved in security projection and intervention in order to facilitate regional conflict resolution. Yet reports in the media (including that subsequent to the workshop, which reported the findings of the Engelbrecht Commission, reproduced below) have projected an HIV infection rate in the SANDF of between 40% and 90%, although a Comprehensive Health Assessment exercise in SANDF units placed the HIV infection rate in the region of 17 to 20%. The assessment also revealed, ominously, that the greatest rate of infection was prevalent among those members aged 25 to 33, thus comprising the rank groups Lieutenant to Lieutenant-Colonel in the officer’s grouping and Sergeant to Warrant Officer in the NCO grouping. According to the British All Party Parliamentary Group, approximately 25% of middle management in the SANDF is infected.[1]

The implications for deployment and budgetary considerations are painfully obvious and, unless a new approach to the policy for manning force levels in the SANDF is adopted, the financial burden needed to address the HIV/AIDS epidemic in the military is simply unsustainable. In discussion it was argued that if the SANDF will only be capable of deploying one brigade within five years – a calculation made by analysts by combining the profile of HIV/AIDS infections with the reductions in the overall scale of the military establishment – this will have many implications outside the country, including in regional contexts where South African forces might be expected to take a leading role; for the ambitions of the AU to take on greater responsibilities, for example in the way that it is seeking to address the Darfur crisis in Sudan; for non-regional states that may otherwise have to pick up the short-fall; and hence for the ambitions of the UN to broaden the base of international crisis prevention, peace enforcement and peacekeeping. Moreover, Loubser observed, the implications of exposing HIV-infected individuals to health threats during operational deployment abroad and the resultant strain on logistical services are grave.

The current SANDF policy for the management of HIV/AIDS is principally focused on education and prevention, measures against the discrimination and victimisation of people living with HIV/AIDS, the care and support of those affected and infected, as well as monitoring, surveillance, research and coordination, and intersectoral cooperation. Thus the SANDF disseminates information in HIV/AIDS workplace programmes and mass awareness programmes. As a preventive approach, the SANDF is also engaged in the Masibambisane (Beyond Awareness) campaign to inform, encourage and educate members of the SANDF on HIV/AIDS. It draws on the assistance and expertise of external partners in intervention programmes in the SANDF, and has included HIV/AIDS education and training in the military as part of its mainstream curriculum. Complete sexual abstinence is considered to be an unachievable goal, and hence the most effective intervention method that the SANDF could employ would be to advocate sober, safe sexual practices. The frank speaking of President Museveni of Uganda with his officers was mentioned and commended in discussion. Abstinence should be seen as a bonus – and this is also the focus of another intervention programme implemented by the Chaplaincy. The SANDF is currently also engaged in Project Phidisa, a clinical research project focused on the management and treatment of HIV infection among uniformed members of the SANDF and their dependants. Although it is important to keep soldiers healthy, it is essential to the national mission to guarantee that the competence of the security function of the state is conducted reliably by healthy soldiers. This forces a confrontation with the difficult issues of prioritisation, but Loubser was clear in his mind what the priority should be, uncomfortable though this may be. Although the human rights of individuals should be considered, the needs of the state must be given the appropriate weight in this instance.

The SANDF is the state organ used by the government of South Africa to conduct its internal and external security operations. Hence the first priority of the SANDF is to maintain its ability to fulfil this task. HIV/AIDS impacts significantly on this primary responsibility of the SANDF, and thus it is imperative that a strategic approach should be adopted to address HIV/AIDS in a holistic manner in order to ensure that the self-supporting combat-readiness of the military is safeguarded. The emphasis in the management of HIV/AIDS should be geared towards prevention, and the young officer and NCO (new recruits) should be the primary targets for a mandatory informal and formal preventive training programme. Moreover, life skills training should also be incorporated into this training programme, which in itself should be of a continuous nature and geared to changing attitudes and not only to education. While recognizing the sensitivity of the suggestion (which was extensively and soberly debated by workshop participants) this long-term policy might also be supplemented by a short-term policy in which skilled persons could be drawn into – or most likely be drawn back into – the SANDF. This policy should be geared towards the primary operational needs of the organization and might force a delay in the process of making the organisation more representative of South African society. Pragmatism in addressing the security functions of the state is essential. In short, the unprecedented challenge to manage HIV/AIDS in the military requires a bold and unique approach.

In the face of the debilitating effects of HIV/AIDS in the military, the workshop reviewed all options. In particular, it debated the value of making more comprehensive use of private military companies. Yet, the use of these companies was rejected partly due to the fact that there is no legal basis for using them. Maintaining centralised command and control was considered to be operationally very difficult in such a scenario. The more extensive use of retrenched personnel would be a better and more cost-effective option and could best be achieved through temporary or reserve re-enlistments.

The workshop extensively debated the question of the human rights of serving soldiers. It was observed that all soldiers, when joining up for military service, agree to forego certain liberties, but that in return they expect adequate protection from the authorities that owe them and their families a special duty of care, as signing up for military service does not entail the abrogation of all civil liberties. A specific contract, however, could be signed for specific occasions, because the maintenance of command and control remains essential.

The question of the speed with which the SANDF can match the “colours” of the “rainbow nation” in contrast with simply having the personnel who can “do the job” is a difficult one. Overall, workshop participants declined to see these as mutually exclusive choices. Either end of the spectrum, exclusively, is in fact unacceptable. Other parts of the SANDF are far less involved in HIV/AIDS issues, especially the navy and the air force. The obvious question that needs to be asked is therefore the one with which Loubser began: “what exactly is the SANDF needed for?” Regional tasks will definitely feature prominently in any answer to this question. This triggers a further question: “what type of a country is South Africa?” It is in fact geopolitically and culturally a Western country, but one that has a moral and geopolitical leadership role in its region by virtue both of its transformation into a genuinely multicultural society and because of its unquestioned economic predominance.

Some new environmental medical and virological aspects of HIV/AIDS

The fourth session of the workshop was introduced by Linda McCourt-Scott, from the Department of Biological Sciences, University of Surrey, and the Department of Community Health, University of Stellenbosch. The presentation was entitled: “Is a deficiency of selenium exacerbating the HIV epidemic in South Africa?” McCourt-Scott introduced the workshop to new and potentially encouraging dimensions in research on the medical aspects of prevention, focusing on the role of one key micronutrient.

Selenium is an essential trace mineral required for immune function, antioxidant protection and thyroid hormone metabolism. The South African recommended daily allowance (RDA) for selenium is 55 mcg for adults, although there is some dispute over the sufficiency of this value. Dietary selenium intakes across the world range from high to low, depending on the levels and bioavailability of soil selenium in different geographical areas. Current intakes in the UK and much of Europe, for instance, are well below recommended levels, primarily because of low soil selenium bioavailability due to acid rain and other factors. In addition, many people rarely eat foods that are high in selenium (i.e. brazil nuts, kidney, liver, shellfish and fish) and are therefore mainly dependent on cereal crops as a source of selenium. However, selenium levels in plant foods vary widely depending on the amount and bioavailability of selenium in the soils in which they are grown. While animals require selenium to grow and reproduce, plants do not require this trace element and can therefore thrive in selenium-deficient soils.

There is a dearth of data on selenium levels in plants, animals and humans throughout Africa. The few studies that have been done, suggest that selenium deficiency in Africa appears in areas with higher rainfall and where the soils are predominantly acid and/or high in iron – all factors that reduce selenium bioavailability. These also represent the main areas in which crops will be grown. With regard to South Africa, extensive areas of selenium deficiency in grazing animals have been identified in kwaZulu-Natal, Gauteng, Mpumalanga and the Western Cape. One small study found that selenium deficiency appeared to be a problem among people living in the former Transkei and Ciskei. An analysis of cereal crops grown in South Africa has shown low selenium content and suggests that dietary intakes may therefore be generally low, especially among populations primarily dependent on plant foods.

Selenium is a critical nutrient in determining the course of HIV/AIDS because of its role in immune function and antioxidant protection. Research suggests that the HI-virus hijacks the host’s supply of selenium for its own antioxidant protection, thereby inducing or exacerbating a selenium deficiency with increasing disease progression. This has dire consequences as it has been conclusively demonstrated that selenium deficiency is associated with much faster disease progression in HIV-infected adults. In addition, selenium-deficient HIV-positive adults are 20 times more likely to die from HIV-related complications than those with adequate selenium status. Moreover, selenium deficiency confers a much greater mortality risk than deficiency of any other nutrient investigated. Recent research also suggests that selenium deficiency may increase the infectiousness of HIV-positive women. Selenium supplementation dramatically improves T-cell function and reduces apoptosis (cell death), and could therefore prove a valuable treatment adjunct in HIV/AIDS.

Selenium is required for the antioxidant enzyme glutathione peroxidase, a major protective enzyme against oxidative stress. Evidence suggests that HIV-1 infected patients are under chronic oxidative stress, which contributes to several aspects of HIV pathogenesis. A recent study demonstrated that selenium blood levels below 135mcg/L in HIV-infected drug users on antiretroviral therapy were associated with a three times increased risk of mycobacterial (tuberculosis) disease. Levels above 100mcg/L are considered adequate under normal conditions suggesting an increased need for selenium in HIV disease.

It has also been shown that relatively harmless RNA viruses quickly become virulent in a selenium-deficient host. The first crossing over of the HI-virus to humans occurred in the selenium-deficient population of Zaire/DRC, and other dangerous viruses have also emerged from this selenium-deficient area.

Human selenium deficiencies can be corrected through the addition of selenium to fertilisers, through food fortification, and by taking selenium supplements.

Nutrition as a whole, McCourt-Scott maintained, is a Cinderella aspect of medicine, but it represents an important treatment modality to help support immune function and delay the progress of HIV disease. This is especially relevant to the huge numbers of HIV-infected people living in sub-Saharan Africa who will never have access to antiretroviral therapy.

Selenium is important in prolonging the clinical latency stage of HIV/AIDS. Selenium deficiency can be both a cause and effect of disease progression. HIV-positive people with selenium deficiency encounter faster HIV progression and greater mortality, morbidity and infectiousness. It is therefore essential that the selenium status of populations throughout Africa, especially where the HIV/AIDS epidemic is raging, is urgently assessed and dealt with appropriately. Indeed, if the present indications of the research reported by McCourt-Scott are confirmed, selenium supplementation may be a highly cost-effective intervention, because it would strengthen the underpinnings of more general human security in circumstances where they are stressed already. The mechanism for this would be quite familiar in public health interventions. Improved resistance to initial infection abates the progression of the epidemic, longer clinical latency abates the socially destructive effects of premature deaths, and both these repair damage to the fabric of civil society. Furthermore, the net reduction in demand on the health budget alleviates the pressure to ignore or to downgrade other public health threats. Finally, a cheap and generalized intervention like selenium supplementation of fertilizers is the most equitable way to support the health status of even the very poorest individuals, since the action is not dependent upon treatment of individuals. Thus there can be a powerful reinforcement of social security. Together these actions relieve the pressures driving towards a traditional security crisis.

The workshop was excited by this work, and plans for accelerated field research in South Africa through collaboration by some participants was one of the practical outcomes arising from the meeting.

Dr Lynne Webber, Clinical Virologist for Lancet Laboratories and associate lecturer at the University of Pretoria and Medunsa, added a different but essential dimension in a riveting presentation that introduced the HI-virus as a (female) personality as a way of dramatising its remarkable ingenuity. This led to a discussion on immuno-biological genetics at the workshop.

This presentation served to raise one of the thorniest of the moral dilemmas about current medical responses to the virus. Because the demands of compliance with a treatment regime of antiretrovirals (ARV) are so severe, and the likelihood of patients being able to meet these unforgiving standards, so open to question, it must be frankly understood that “she” (the virus) might employ exposure to ARV like athletes use a training session: to familiarise “herself” with obstacles and to become stronger. Concerns were raised that the impending government antiretroviral treatment (ART) programme might most predictably produce a more drug-resistant virus. Nevertheless, this treatment rollout is currently the best that can be done about HIV/AIDS.

Once a person is on ART, the viral load does indeed recede, but in order to escape the ARVs, the virus already hiding in the genital tracts could follow the career of syphilis and retreat further to the eyes and brain. Recent studies have shown that, within days of HIV infection, “she” (the very capable and superbly designed virus) has already penetrated into the peripheral nervous system. What does this really mean? HIV “hides” away in the nervous system and uses this anatomical region as a “sanctuary site”. It also gives “her” easy and immediate access to the central nervous system (the spinal cord, brain and eyes) where she can lie virologically dormant or evoke physiological and immunological mischief. In short, the ARV rollout programme has both self-evident short-term benefits and potential long-term adverse consequences. Epidemiologically, the best single medical intervention in South Africa is the prevention of mother-to-child transmission. The second most effective medical intervention would be one that empowered women to protect themselves from infection during sex without the man’s knowledge and in the absence of (or refusal to use) barrier contraception. Viricidal pessaries and creams – even, from some recent Australian research, as simple as the presence of lemon juice in the vagina – could be beneficial in combating a disease which, for mechanical reasons, is one that infects women more often than men.

The development of a vaccine capable of entering and destroying the “power house” of the virus remains a tremendous challenge. The problem lies in the sophistication of the virus’s chameleon-like ability to change its protein coatings with extraordinary frequency, thereby frustrating the ability of vaccines to recognize the target. It is doubtful whether even a concept for the design of a core vaccine is yet identified. However, French advances in developing vaccines that can activate the guardian functions of mucosa were more promising.

These observations led to a vigorous discussion of the social construction of sexuality. It was evident that the employment of the various pharmacological female defence options were predicated upon an assumption of failure to control or curb male sexual demands for unprotected sex (demands painfully documented in Campbell’s field work from Summertown, Letting them Die). It all raised a bleak picture of the state of war between the sexes if it was so difficult – even impossible – for the terms of sexual intercourse to be negotiated. Yet, this appears to be the state of affairs in many places. The exceptions thus become vitally important cases for close study – an issue that was returned to in the final session.

Webber made it perfectly clear that, in the human timescale, the HI-virus will never go away. The virus comes from an ancient (millions of years old) viral family: those retroviruses that have actually evolved along with the development of the cell itself. Retroviruses are thus ubiquitous and humans even have endogenous retroviral “footprints” integrated into their own DNA genome. Does HIV understand mankind’s own immune response and the only defence against viral destruction superbly and will she always have the “upper hand” in her attempts to evade the immune response? Treatment is currently the best option against the virus, and potent new drugs and technologies are constantly becoming available. Yet, intervention cannot stop at treatment alone: the preventive message has to be stronger.

Webber posed a further problem: “why has HIV-infection, in all its aspects, become different from any other viral infection?” She illustrated this dilemma by using examples of other viral infections to illustrate that HIV, in the discipline of Medical Virology, is really not unique and shares many of “her” features with other viral infections. A few examples were given to drive home the message. No human herpes viral infections can be “cured” and these infections stay with the host for life. Certain slow acting neurodegenerative viral infections also have long incubation periods, possibly taking years to kill or damage the host. The hepatitis B virus (HBV) is a sexually transmitted, as well as a bloodborne infection and 10% of individuals become permanent viral disease carriers. Interestingly, HBV also has the reverse transcriptase enzyme, which indicates that this enzyme is not a unique strategy of HIV alone.

One of the participants in the workshop reflected on the reasons why HIV/AIDS has come to be treated in a different way from any other disease. HIV, the participant maintained, first appeared in homosexual communities in the 1980s, and thus from the very outset the disease was politicized. In effect, with HIV/AIDS, the period of death is deferred long enough to permit considerable further transmission, but short enough to impact significantly on the social structures of a society and a household. It is the length of time from incubation to morbidity to death that is decisive with HIV/AIDS. It is a disease that hits two reproductive and one generational group, and there is thus resonance between the natural cycle of the virus and the natural cycle of society.

HIV/AIDS modelling and analysis

The fifth session of the workshop was presented by Professors Gwyn Prins and Tony Barnett, and was entitled “Operational Analysis and Strategic Analysis techniques: what can they bring?” The session included a presentation in absentia of a sequel paper to that presented at the February Pugwash workshop by Dr Lorraine Dodd, Senior Operational Analysis modeller and mathematician in QinetiQ, a company in the British Defence Science Community.

The underlying basic requirement for analytical methods is to track and explain reliably the relationship between social and political coherence and the experience of pandemic disease. Hence four integral questions need to be addressed in all cases: What has happened? What might happen? What could happen? What should happen? The main question, then, for analytical methods is as follows: What are the appropriate modes of analysis to grip this diverse data and make it tractable for effective policy response?

Firstly, the context must be characterised for the purposes of bounding the primary system dynamics and defining the dimensions of the situation space so that effects of interventions can be formally modelled in terms of situation attributes (i.e. number of HIV-positive individuals, HIV incidence rate, HIV prevalence rate, etc.).

The situation attributes must be amenable to quantification (so that they can be used as inputs to secondary dynamic simulations to calculate knock-on effects or impacts), and must also be qualified. Qualification is highly subjective and consists of cost evaluation, which must then produce acceptability assessments (i.e. being OK or not-OK depending on who you are). This process can now be overlaid across the situation space to produce a “cost landscape” (with for example certain regions of the landscape space demarcated as “no-go” regions). The analysis can be based on benefits or utility rather than cost: then the desired end-states would be hilltops rather than valleys.

The knock-on impacts will include such effects as a reduction in the strength of the workforce: these are among the invisible “external costs” that Barnett had earlier suggested must be brought into any realistic cost/benefit calculation. Knock-on effects will be more difficult both to quantify (as they are based on complex models of projection) and to qualify. Knock-on effects can be estimated using influence dynamics via “softer” analysis methods that may also include, for example, effects on social morale, community spirit and national pride.

The landscape across which intervention paths can be explored is now charted formally. The landscape is not static and will be subject to changes. In some cases it might be easier to change perceptions of costs and belief systems than it would be to change the situation attributes themselves. Such interventions often create conditions rather than establish end-states whose effects are naturally enduring because they lie in a “real” low-cost region. There is a fundamental assumption that in designing intervention actions, the attempt is at all times to move toward regions of lower cost than the current position.

There may also be firm boundaries such as budget limitations or policy constraints. These can be imagined as forming “brick walls” or out-of-bounds regions on the landscape. Other structural constraints could form easy-going, low-cost “roads” across the landscape. All of these features of the landscape can themselves be the focus for intervention actions. Actions must be formally translated through the medium of a programme of controlled and coordinated activities into targeted changes in situation attributes, and the control space must be fully understood. Intervention actions can then be represented and laid-out formally as routes across the landscape. In this way, actions are literally charted as changes in situation attributes. Put differently, these mapped options are ingredients in forming a plan of campaign to achieve particular effects.

The generating of options for intervention should initially be an unconstrained creative exercise, but should be done after the situation appraisal, in the full and rational knowledge of the landscape over which any novel paths are being charted. It is vital that the knock-on effects are formally explored because these are the meta-attributes that could form sudden catastrophic cliff-edges in the landscape.

It is because of its capacity for surprising effects – and the AIDS/security nexus explored earlier is a challenging example – that as ill-understood, as socially explosive a phenomenon as this long-wave pandemic demands both dynamic trend analysis and the “snap shot” arresting and problem-posing that scenario methods provide. Such scenario methods were the subject of the final session.

Thinking like a fox (and not a hedgehog)

The sixth and final session of the workshop was presented by Clem Sunter, Chairman of the Anglo American Chairman’s Fund, and was entitled “AIDS modelling and options for action”. In it he outlined the Anglo American Corporation’s analysis of the HIV/AIDS epidemic in South Africa and discussed the ways in which the mining conglomerate had reacted to its understanding of the threat. Taking the title of his recent book from Isaiah Berlin’s famous distinction between the hedgehog (who knows One Big Thing) and the more flexibly minded fox (who can think laterally and creatively), Sunter advocated the virtues of using scenario planning to think like a fox around and beyond the obvious.

Sunter explained that, in common with dynamic trend analysis, scenario planning had a prime information requirement: knowing what you do NOT control. This is what should therefore be considered first. He plotted the situation space thus:

From this he proceeded to define the scope of the HIV game thus, in terms of agents:

And added to this its rules:

  1. That HIV leads to AIDS (whatever maverick opinion may say)
  2. That it is mainly heterosexually transmitted: so young women are most at risk – the Botswana survey data now finds 50.1% in the 23-29 age cohort to be HIV+
  3. That it has a delayed impact
  4. That local action counts

These remarks scoped one of the three biggest challenges (unemployment, the HIV epidemic and the issue of land redistribution) presently facing South Africa. When considering the HIV pandemic on its own, South Africa is faced with several certainties and uncertainties. It is these uncertainties that present the biggest challenge: the two key uncertainties are the rate of infection and the response to the epidemic, with a third wild card thrown in, that of a possible cure and/or vaccine in the future.

Using the two key uncertainties, as well as the actors, scope and rules displayed above, an HIV game board can be constructed to illustrate different scenarios that could occur in South Africa as a result of the present HIV/Aids epidemic.

Presently, with the high rate of infection and the overall weak response of the country’s government, South Africa finds itself in the upper left quadrant of the game board, aptly named the “graveyard shift”, as the death phase of the epidemic is entered. A strong response by government, like mass medication, as in the present ART rollout programme, should shift the scenario over into the right upper quadrant. The cost of such medication has been calculated at US $1 500 per person per year, and the government plan is to treat 5 million HIV-infected people in this way (R60 billion rand in total). The pitfalls of high cost and compliance with the programme are just some of the inherent risks in relying too heavily on this scenario on its own to curb infection rates. This leads to a third scenario of a strong response of mass medication coupled to other even stronger responses, that could actually drive the infection rate down, thus moving the epidemic into the lower, right sector of the HIV game board. Such a strong response will rely heavily on the so-called ABC approach to prevention. With the Ugandan experience in mind, the emphasis should largely be on “abstaining” (A), with lesser emphasis on “be faithful” (B) and “use condoms” (C) – unlike the present situation in South Africa, where this prevention drive to date has highlighted C, the use of condoms, only. It is only with a combined strong treatment response and an enormous, effective prevention drive that South Africa will move from the graveyard shift, with all its dire consequences, into a better position and in so doing get a meaningful handle on this epidemic. Sunter described HIV as a miniature weapon of mass destruction. It leaves everyone with tragic choices.

Sunter had earlier emphasized in his discussion of the available agents the special importance of churches. They were, he suggested, greatly underestimated in importance if the key requirement was to achieve modifications in the socialization of young people. The point resonated with other participants who noted that the role of churches in bringing about a change in sexual politics in Uganda seems to have been pivotal. The age of first intercourse has now risen for young women and their ability to control both sexual debut and the terms of subsequent sex, have improved. None of this is the result of conventional medico-social information. The implication for South Africa, it was suggested, was that the role of the African Zionist churches as agents of socialization, for example, needed to be better understood and valued.

The fourth scenario, so-called “early days”, of a low infection rate and weak response can best be demonstrated in a remote town like Upington in the Northern Cape province of South Africa, which is off the beaten track and, more importantly, off a main trucking route.

As for Anglo American, the corporation had done nothing about HIV/AIDS during the 1980s. During the 1990s, the corporation launched prevention programmes. It was only in 2002, however, that the corporation launched comprehensive prevention and treatment programmes for its employees. In 2004, it added to this response by engaging in corporate social investment programmes. Some participants expressed surprise that even with Sunter’s warnings at hand, it had taken the board so long to act.

Some of the key findings of the HIV/AIDS intervention at Anglo American could be instructive on a larger scale. To be most effective, any HIV/AIDS response programme must be driven personally by the most senior officer, e.g. the CEO, of a company. Key performance indicators should measure HIV/AIDS intervention programmes. It can be effective, furthermore, to tie the attainment of these indicators to the remuneration of project leaders. The Voluntary Counselling and Testing programme at Anglo American has seen only 7 to 8% of the staff coming forward to make use of it. In short, such programmes need a proactive champion and a steering committee. Of the entire Anglo American workforce of 134 000 employees, it is estimated that 34 000 employees are currently HIV positive. Yet, only 1 300 employees are on treatment, while 5 000 are actually supposed to be on treatment.

In 1986, Sunter maintained, Anglo American had only four HIV-positive employees. This was the first year that HIV/AIDS was talked about at Anglo American. The reason that there was such belated action was that people at first did not see any discernible effects of HIV/AIDS (i.e. increased absenteeism). The hardest thing in business is to convince people to spend money on preventing something invisible and intangible. One participant observed that this, in a nutshell, is the way in which a long wave and stealthy solvent of social cohesion, with apparent suddenness, can precipitate destructive trends that can in turn produce threats to international peace and security. But the suddenness is only apparent, not real. Foresight is required; and with foresight and appropriate strategic analysis techniques, warnings and indicators can be fashioned that will work.

Themes, actions, implications

The past two and a half decades have sprung upon the Southern African region – already heavily under stress – the cruel, unexpected and undeserved burden of HIV/AIDS. However, these are exciting times. The workshop heard of cutting-edge possibilities in immuno-nutrition and of viral research that enables everyone to know the enemy better. It learned of new antiretroviral drug development and (as important) innovation in delivery and compliance: the initiation of creative yet functional intervention programmes has also arrived. So – as is the mark of revolutionary moments in history: “It was the worst of times. It was the best of times”. In this regard, South Africans deploy great resources of social resilience, forged in the long hard years of apartheid and tempered by the healing qualities of reconciliation that underpin the achievements of the last decade. The leading edge of this first wave is thus occurring within a social experiment with significant implications for the global community. At the same time, South Africa is called to exercise regional leadership in the context of a deepening crisis of governance as the post-colonial state settlement unravels in many parts of tropical Africa. At this very moment, its own military instrument is fractured by the impact of HIV/AIDS, and thereby weakened. The pandemic therefore has both a formal, narrow security dimension and a broader, social security dimension – together they compose a truly formidable threat to global security for the foreseeable future.

The Mabula workshop sought to bring to bear the widely multidisciplinary expertise of those gathered within the spirit of the Pugwash Movement: to think in a new way in the face of new dangers to humanity. This report has sought to summarise the principal features of the way in which this new security agenda is unfolding. It ends with a summary account of main points, and a list of steps that workshop participants believe the Pugwash Movement should now take.

Summary of main points in each session

HIV/AIDS as a security issue

  • HIV/AIDS is acknowledged as a threat to international peace and security. It should be considered on the same level as conventional defence and security issues in those regions worst hit by the pandemic.
  • The difficulty of dealing with HIV/AIDS in political policy-making as a result of its impact over an exceptionally long timespan was underscored.
  • The rising second wave of the global epidemic will have a particular security impact in regions such as West Africa where the production of oil becomes lucrative at the time when the epidemic starts to reach crisis proportions.
  • The challenge to define thresholds for the epidemic that could activate policy makers requires thorough debate on political, social and microbiological levels.

HIV/AIDS statistics: thoughts about knowledge, complexity, cost and value

  • Most epidemiological statistics seek to represent the percentage of a susceptible population known or assumed to be infected with a disease agent (i.e. seroprevalence).
  • Statistical models and assumptions are consistently peer reviewed, in the public domain, widely debated and progressively refined. Prevalence estimates are also extensively compared with other surveys.
  • Because of the long incubation period of HIV/AIDS it is crucial to establish whether prevalence rates show upward or downward trends.
  • A conventional economic approach to assess the impact of HIV/AIDS has security implications if it is used to define the distribution of resources and the establishment of issues such as timescale and urgency. Because of the limitations of this approach, it is difficult to view the “externalities” of costs.
  • External costs are extremely difficult to calculate and include costs that accrue to communities and countries over time, such as those as a result of poorly socialized people who grew up as orphans as a result of HIV/AIDS.
  • It is crucial to analyze the impact of HIV/AIDS when prevalence rates are high and/or curves are rising. This should bring vital invisible and unquantifiable costs in view, on the same level that conventional economic issues are considered.

HIV/AIDS and the military

  • The SANDF is facing serious challenges as a result of the high rate of HIV infection among its soldiers. The state’s intention to establish South Africa as a regional power is inextricably intertwined with the military’s ability to fulfil its mandate. HIV/AIDS seriously undermines this ability.
  • The SANDF’s HIV/AIDS management policy currently focuses mainly on education, prevention, anti-discriminatory measures, monitoring, research, cooperation and coordination.
  • Long-term intervention should focus on changing attitudes and not only on education.
  • In the short term, skilled people could be (re)drawn into the SANDF to ensure that it can continue to fulfil its mandate nationally, regionally and internationally.
  • South Africa is geopolitically and culturally a Western country with a moral and geopolitical leadership role in the region. In this context, the SANDF will be crucial in fulfilling regional tasks as part of its raison d’être.

Some new environmental medical and virological aspects of HIV/AIDS

  • Selenium, an essential trace mineral, is a critical nutrient in determining the course of HIV/AIDS. Selenium deficiency is associated with much faster disease progression and greater mortality risk in HIV-infected adults. It may also increase the infectiousness of women. Nutrition, including selenium supplementation, can therefore have a positive impact on people living with HIV/AIDS.
  • In discussing immuno-biological genetics, the danger was emphasized that the severe demands of compliance with a treatment regime of ARVs may lead to people being unable to meet them, thus producing a more drug-resistant virus. Treatment, however, remains the best option against the virus, but without a stronger preventive message, the outlook remains bleak.

HIV/AIDS modelling and analysis

  • In HIV/AIDS modelling and analysis, the context must first be characterized so that the effects of interventions can be modelled in terms of the attributes of the situation. The latter must be quantifiable and qualified. It is then overlaid across the situation space to produce a “cost landscape”, with the analysis then based on benefit and utility rather than cost. Knock-on impacts are then estimated also by using “softer” analysis methods. This provides the landscape across which interventions can be explored.
  • The generation of interventions options should initially be an unconstrained creative exercise, but only after the situation is fully appraised. The formal exploration of knock-on effects is important as these could form sudden catastrophic cliff-edges in the landscape.
  • The nexus between HIV/AIDS and security demands a dynamic trend analysis precisely because of its capacity to produce surprising effects.

Thinking like a fox (and not a hedgehog)

  • Scenario planning is about knowing what you do NOT control.
  • The two key uncertainties about HIV/AIDS in South Africa are the rate of infection and the response to the epidemic.
  • South Africa is in the so-called “graveyard shift” where only a strong treatment response and an effective prevention drive will be able to shift it into a better position.
  • The role of the churches in modifying the socialization of young people is of crucial importance in addressing HIV/AIDS.
  • On corporate level, interventions benefit from being driven by top management, with programmes managed by proactive champions.

Issues requiring further exploration

  • The domestic and regional security consequences of an AIDS-weakened, or an AIDS-protected SANDF;
  • The further understanding of the potentials of immuno-nutrition to enhance social security.
  • The deeper examination of the ethical dilemmas that ARV treatments pose, especially for attempts to introduce enhancements of human rights.
  • The integration of dynamic and scenario-planning analyses to better understand potential AIDS futures, and
  • Beyond the AIDS/security nexus, using the Pugwash tradition of linking analysis to action to convene a longer “oblong table” of analysts and key agents in the AIDS campaign, particularly from among church leaders, carers and community groups.


[1] Subsequent to the Mabula workshop, the following article was published in the press, providing more up-to-date information that serves to underscore the point being made.


HIV/AIDS and the Military Environment – A Perspective, by Colonel Andre Loubser

Assessment of intervention actions for HIV/AIDS, by Lorraine Dodd and Mark Round

HIV/AIDS modelling and analysis

Some new environmental medical and virological aspects of HIV/AIDS

HIV/AIDS and the military

HIV/AIDS as a security issue

HIV/AIDS statistics: thoughts about knowledge, complexity, cost and value

Themes, actions, implications



“SANDF Unveils Shock Aids Data” by Jani Meyer. Sunday Independent, 1 August 2004, p. 1.

The combat readiness of the South African National Defence Force (SANDF) is under threat, with the latest results of an Aids project showing that an overwhelming 89 percent of those soldiers who volunteered for testing were HIV-positive. The SANDF is also losing at least 400 000 working days a year because of the disease. This was disclosed at a five-day conference held in Richards Bay this week. Sixteen African countries attended the conference, which was a collaboration between the SANDF and the United States. The aim is to establish the rate of infection and the effects of anti-retroviral treatment on South Africa’s military forces. In the first six months of the project 1 089 soldiers volunteered to be tested, of whom 947 were found to be HIV-positive. The average age of the sample was 34, and 60 percent of volunteers were married. South Africa cannot test soldiers without their permission. Rear-Admiral JG Engelbrecht said infected soldiers in the early stages of the disease were absent for an average of 20 days a year. This increased to 45 days for soldiers displaying symptoms, and a minimum of 120 days for those with full-blown Aids. Conservatively, 18 940 days will be lost by the 947 soldiers identified on the programme. The SANDF’s official figure for HIV/Aids-infected soldiers stands at 23 percent, but Aids specialists have set a more realistic figure of 40 percent, or about 28 000, infected. With the figure of 23 percent infection, 338 000 days are lost. However, if the figure is closer to 40 percent then the number of working days lost each year rises to a staggering 560 000 days. With the SANDF in the process of downgrading its troop levels – the army has reduced its complement from 100 000 to 70 000 – its future looks bleak. Engelbrecht said the government had to decide whether to remove the infected soldiers from combat roles, or whether to remove them when they became too ill to function. South Africa cannot test soldiers without their permission, except those who accept postings to United Nations missions. The SANDF expects 50 000 soldiers to be tested for HIV during the next five years. Those who test positive will be able to enrol in a programme called Project Phidisa at six army sites around the country. The first tests were carried out on January 19 at No 1 Military Hospital, Pretoria, and at the military base in Mtubatuba. SANDF members infected with HIV/Aids received their ARV drugs for the first time on February 2. Four additional sites will be opened at No 2 and No 3 Military Hospitals, in Phalaborwa and Umtata, before the end of this year. The Phidisa project was partly prompted by the cabinet’s decision on August 8 last year to provide comprehensive health care for people with HIV and Aids. The project’s medication budget for this year alone is more than R2-million and it covers only members on the programme. According to Phidisa’s data management co-ordination and operations centre director, Colonel Jabulani Msimang, the project’s budget for the rest of the year is more than R4 million. While the Phidisa project will be used in researching the effects and effectiveness of anti-retroviral drugs, it also paints a clearer, if stark, picture of the extent of Aids in the armed forces. With South Africa increasingly becoming involved in peacekeeping efforts in the rest of Africa, the risk of exposure to the disease is also increasing. There are 3 000 South Africans doing duty in the Democratic Republic of Congo and other parts of Africa. The UN requires soldiers to be tested before they are deployed on UN missions, effectively sending only healthy soldiers out of the country. This week’s conference painted a very bleak picture of the fighting fitness of the SANDF and highlighted the urgent need for intervention before the army itself succumbs to the country’s greatest enemy – Aids.



Gwyn Prins, Alliance Professor, Columbia University and London School of Economics and Political Science (LSE), Room V912, Tower Two, Houghton Street, London WC2A 2AE, United Kingdom

M E Muller, Dean and Professor in the Department of Political Sciences, Chair of SA Pugwash Group, Chair of the Pugwash Council, Faculty of Humanities, University of Pretoria, Pretoria 0002, South Africa,

Nola Dippenaar, Professor and Deputy Chair of SA Pugwash Group, Department of Physiology Faculty of Medicine, University of Pretoria, Pretoria 0002, South Africa

Hussein Solomon, Professor and Director of CIPS, Department of Political Sciences and Centre for International Political Studies, University of Pretoria, Pretoria 0002, South Africa

Andy Mogotlane, Vice-Principal (Health Sciences) University of Pretoria, Pretoria 0002, South Africa

Chris Terrington, Colonel and Chief of Staff (COS) HQ D INT CORPS, Chicksands, Shefford, Beds, SG17 5PR, UK

Tony Barnett, Professor and ESRC Professorial Research Fellow, Development Studies Institute, London School of Economics, Houghton St, London WC2 2AE, LSE, UK

Linda McCourt-Scott, Department of Biological Sciences, University of Surrey, UK, Department of Community Health, University of Stellenbosch

Robert Mtonga, Doctor, University Teaching Hospital, PO Box 50001, Lusaka, Zambia

Lynne Webber, Clinical Virologist for Lancet Laboratories, associate lecturer, University of Pretoria and Medunsa, South Africa

Peet RautenbachMedunsa

A J Loubser, Colonel, South African Defence Force, Pretoria, South Africa

Xolani Currie, Colonel and Regulatory Oversight Manager, Project Phidisa, South African National Defence Force, South Africa

Clem Sunter, Anglo America Corporation, South Africa

Tshepo Dibe, President: BMF Student Chapter – Gauteng Province, Predident: BMF Student Chapter – University of Pretoria, President: T-DTYF, CEO: Unique Eyet-T, PO Box 2531, HALFWAY-HOUSE

Barry Van Wyk, Research Consultant, Centre for the Study of AIDS, University of Pretoria, Pretoria 0002
South Africa

Gina van Schalkwyk, Senior Researcher, SADC Programme, Institute for Security Studies (ISS), Block C, Brooklyn Court, Veale Street, New Muckleneuk, Pretoria, PO Box 1787, Brooklyn Square, 0075, Pretoria,South Africa

Anita Mason, Humanitarian Assistance Program Manager at the Office of Defense Cooperation of the American Embassy, Pretoria, South Africa

Elaine Harrison, Colonel and Senior Staff Officer (involved in Project Masibambisani HIV/AIDS Programme of Department of Defence) & Deputy Director:Social Work, Social Work Policy & Planning, SA Military Health Service, South African National Defence Force, Private Bag X102, Centurion, 0046