HIV & AIDS Supplement for Ethics in Peacekeeping Course

ETHICS IN PEACEKEEPING Supplement: HIV/AIDS

I N A S S O C I AT I O N W I T H

Accordia Foundation

Peace Operations Training Institute

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I.

HIV AND AIDS AWARENESS Lesson Objectives By the end of this section the student will be able to:

• Demonstrate detailed understanding of the basic facts of HIV and AIDS;

• Explain HIV prevention strategies in detail; • Explain the concept of positive prevention; • Explain issues peacekeepers need to consider when planning to set up and maintain an HIV and AIDS prevention programme in their communities; and

• Discuss ethics and HIV in peacekeeping.

Introduction

In this lesson, we will discuss prevention of HIV and AIDS specifically regarding peacekeepers. In order to protect themselves, peacekeepers must understand and consider the peculiar risk factors that make them more vulnerable to acquiring HIV. As duty calls, peacekeepers must often be away from their loved ones for long stretches of time, and this can predispose them to practices that increase their susceptibility to HIV infection. Indeed, studies have shown military officers to be at a higher risk of acquiring HIV and other sexually transmitted diseases. This is due to a combination of their age range and mobility, their uniforms which represent force and influence, their easy access to water and food compared to the local population, and their generally pervasive risk-taking attitudes.

Furthermore, there often exists a power imbalance that favours peacekeepers over a local population that tends to be overwhelmingly submissive.

Female combatants, women associated with armed forces, and abductees are frequently at high risk as sexual violence and abuse are often widespread in these settings.

National and multi-national military personnel are among the most susceptible populations to sexually transmitted infections (STIs), particularly HIV. HIV is five to 20 times more likely to occur in the presence of other STIs. In some countries, STIs amongst military personnel may be two to five times higher than STIs amongst the civilian population. In foreign deployment situations, military STIs may quickly equal or exceed those of disrupted local populations whose infection rates may already be high. In the growing number of post-Cold War conflicts to which UN and other peacekeeping contingents are deployed, HIV poses a deadly threat, not only to those directly involved, but also to future peace and security.

Seen in this light, the development of effective HIV prevention and control programmes for multi-national peacekeepers and civilian police is of vital and immediate importance.

It is important that peacekeepers familiarize themselves with the facts about HIV infection and how it can be prevented. This lesson presents basic facts about HIV and HIV prevention and

addresses how HIV prevention can be integrated into the activities and mandates of peacekeepers on all levels.

II.

Basic Facts About HIV and AIDS

What is HIV and AIDS? HIV (human immunodeficiency virus) is a microscopic virus that can infect a person’s body and cause a syndrome known as AIDS, which is an acronym for:

• Acquired means that HIV is passed from an infected person to another person;

• Immune refers to the body’s immune system.

The immune system is made up of cells that protect the body from disease. HIV is a problem because, once it gets into a person’s body, it attacks and kills cells of the immune system;

• Deficiency means not having enough of

something. In this case, the body does not have enough of a certain type of cell, called immune cells, that it needs to protect against infections. HIV enters the body and acts like a patient sniper, hidden for as long as it takes to do its job to weaken the immune system. Over time, HIV kills more and more immune cells, the body’s immune system becomes too weak to do its job, and the person living with HIV becomes sick; and

• Syndrome refers to a group of signs and

symptoms that occur together and are associated with a particular disease. AIDS is a syndrome because people with AIDS have a combination of symptoms and diseases specific to AIDS.

It is important to understand the difference between HIV infection and AIDS. A person may have the HIV virus within their body (infection) but show no signs of AIDS. Once the person begins to show signs and symptoms of HIV (commonly seen as opportunistic infections like cryptococcal meningitis, severe wasting disease, and widespread/ disseminated tuberculosis), they are said to have AIDS. All patients with AIDS have the HIV infection.

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• Oral sex – HIV can enter the body through

How is HIV spread?

Body fluids that can spread HIV include semen, vaginal fluid, blood, and breast milk. Almost all transmission of HIV is through sexual intercourse between two people who do not correctly use condoms, either in heterosexual or homosexual relations. Mothers who are infected with HIV can pass the virus to their babies while pregnant, during labour and delivery, or after birth through breast milk. There are some cases when blood taken from a person infected with HIV is transfused to another person, although this is highly unlikely in the current era due to proper testing and screening of all donors.

Other ways of HIV transmission include sharing sex toys between people without cleaning or sanitizing them; using blood-contaminated needles, syringes, water, cotton filters, straws, or pipes that contain HIV to inject drugs or other substances; and using needles or ink contaminated with HIV-infected blood for tattooing, skin piercing, scarification rituals, or acupuncture. Often blood contamination is not visible to the naked eye.

any cuts or tears inside the mouth due to injury or gum disease. The person taking semen into his/her mouth is more vulnerable than the person who is ejaculating. Oral sex has a much lower risk for infection than vaginal or anal sex, especially if semen is not taken into the mouth.

• Infected needles – Those who share needles can transfer infected blood to each other.

This is particularly the case with those who inject drugs such as heroin.

• Mother-to-child – During pregnancy, HIV

can be passed from mother to baby through the placenta. At birth, HIV can be transmitted through blood from the birthing process. In addition, HIV is present in breast milk and can be transmitted to a baby during breastfeeding.

Without preventative measures, there is a one in three chance an infected mother can transmit HIV to her baby.

What factors are associated with HIV infection?

High viral load A high viral load increases the risk of HIV transmission. The viral load is the number of HIV virus copies that the infected person has per millilitre of blood. A high viral load is likely to occur during the window period and when HIV infection has progressed to the AIDS stage. When infected by the HIV virus, it takes time before the virus concentration is high enough to convert your test from negative to positive. The time before this happens is called the window period. The window period may last up to six weeks. During this time, a person may be infected and have the ability to transmit the disease, even though the test may be negative. Medications called antiretrovirals (ARVs) decrease viral load thus decreasing the risk of HIV transmission, as we shall see later on.

It only takes one unsafe sexual act or drug injection for someone – anyone – to become infected with HIV. Eighty per cent of all HIV infections are caused by having unprotected intercourse with an HIV-infected partner. It‘s important to note that some sexual practices, like penetrative anal sex, have a greater HIV transmission risk than either vaginal or oral sex.

• Vaginal sex – HIV can enter the body through

Sex without a condom

any cuts or tears inside the vagina or the penis.

When the penis is erect it stretches and when a woman is aroused the vagina stretches.

This stretching makes both these organs more susceptible to injuries that increase the risk of infection.

• Anal sex – HIV can enter the body through

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Drinking alcohol or using illegal drugs will reduce a person’s judgment, ability, and desire to act within the bounds of safe behaviour. In addition, when people are under the influence of alcohol and/ or drugs, they are more likely to indulge in risky sexual contacts. Consumption of alcohol also tends to increase the libido and make people feel like having sex. Sex workers can often be found at places where alcohol is served. Peacekeepers who serve in uniformed services may look forward to their monthly salaries, getting leave, getting drunk, and having unprotected sex with women. Though their intention may be to have protected sex by using condoms, they are often less concerned with HIV infection when they are drunk.

Increased length and frequency of exposure Increased length and frequency of exposure can also increase the risk of HIV transmission. People who have multiple sexual partners have a higher risk of acquiring HIV. Having unprotected sex with a sex worker will further increase the risk of transmission.

Sex workers have multiple partners increasing their chances of being infected. Additionally, frequent unprotected sexual acts with the same partner who is HIV-positive also increases the risk of transmission.

cuts or tears in the rectum or anus. Because the rectum does not stretch readily (unlike the vagina), it tears and bleeds more easily. A person can contract HIV through semen when a man ejaculates in his/her rectum. A penis can irritate and cut the anal lining, increasing the opportunity for the virus to enter the body.

Drinking alcohol or using illegal drugs

In some cities in Africa, up to 25% of pregnant women tested in antenatal clinics are found to be infected with HIV. A young woman breast-feeding her baby in the Kagera Region of the United Republic of Tanzania. (UN Photo #19997 by Louise Gubb, January 2001)

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Damage to the mucous membranes or different coverings of the body increases the risk of transmission. This is more likely to occur in the presence of other sexually transmitted diseases, rough sex, and anal sex where a penis can irritate and cut the anal lining, increasing the opportunity for the virus to enter the body. The presence of an untreated STI like syphilis or gonorrhoea facilitates the transmission of HIV. Open sores and blisters provide an easy entrance into the body for STIs, including HIV. Using a condom greatly lessens the chances of HIV transmission by these means. Also, using petroleum jelly or oil-based products can weaken a condom and cause it to break.

Be aware that the consumption of alcohol can impair your judgement, which could result in risky sexual contact. (UNAIDS, Peer Education Kit for Uniformed Services, September 2003)

Low-risk behaviour

• Sex with condoms; • Oral sex (even without a condom), unless the person has cuts in his/her mouth;

• Touching the blood of an infected person; and • Sharing razors.

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Behaviours that CANNOT Transmit HIV (No risk!)

• It is important to appreciate that HIV cannot be transmitted through the following ways:

• Casual, non-sexual, social contact like shaking hands, touching, or hugging;

• Toilet seats; • Eating food prepared by someone living with HIV and AIDS;

• Sharing eating and cooking utensils like cups, plates, pots, or forks and spoons;

• Kissing. Though HIV has been found in saliva, the amount of HIV in saliva is extremely small that there is minimal risk of contracting HIV by kissing;

• Mosquitoes. Mosquitoes transmit other diseases like malaria, but not HIV;

• Abstinence; • Sex between mutually faithful and uninfected partners;

• Donating blood; • Sharing a bathroom or latrine; and • Caring for a person who has HIV – Those who are caring for women with HIV should be extra careful handling menstrual blood.

The stages of HIV infection Window Period

Asymptomatic Period After a person is infected with HIV, there is usually no change in that person’s health for quite a few years. The person feels well, is able to work as before, and shows no signs or symptoms of being sick. In other words, they are asymptomatic. This asymptomatic period varies from a few years to up to as many as 12 years.

Symptomatic Period The symptomatic period begins when the infected person begins experiencing illnesses related to their suppressed immune system. Most of the conditions that start to appear are called “opportunistic infections.” Opportunistic infections are caused by bacteria or viruses that normally do not cause illness in a person with a strong immune system, but they do cause illness in a person with a weakened immune system. Opportunistic infections include infections such as diarrhoea, tuberculosis, and pneumonia, and they repeatedly make the person sick. Remember, AIDS is a “syndrome,” or a collection of conditions that, taken together, allows us to make a diagnosis of AIDS. When a person is diagnosed with AIDS, the length of time until death can vary among individuals depending on the number and type of opportunistic infections and the availability of treatment and drugs. Individuals can live for one to two years or much longer (if receiving treatment with drugs).

Is there a Cure for AIDS?

Once a person becomes infected with HIV, he or she will not immediately test positive for the infection. There is a period of usually three to six weeks (sometimes as long as three to six months) before the body reacts to the presence of the virus and produces antibodies that can be detected during blood testing in the laboratory. The detection of these antibodies results in a positive test. The period of time between the actual infection and when the test can detect the infection is referred to as the window period. It is important to understand that in this time an infected person has the ability to transmit the disease even though they test negative.

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There is no cure for AIDS at present. A combination of drugs called antiretroviral drugs (ARVs) can result in controlling the virus so it does not weaken the immune system, which would make it vulnerable to AIDS-related illnesses.

In some places, however, the high cost of ARVs makes them unaffordable for people. Progress has been made in reducing the cost of the drugs, which has increased their availability. Many countries are now able to offer free antiretroviral drugs for people who have tested positive for HIV. Traditional healers, or “folk healers”, around the world are selling herbs reported to cure HIV and

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AIDS. Many of these have been examined by scientists but none so far has proved to eliminate HIV. There would be great joy in the world if traditional healers did come up with something that cured AIDS. Traditional healers can ease some of the symptoms of AIDS-related illnesses and opportunistic infections.

Unfortunately, many with HIV and AIDS turn to traditional healers with false hope and waste their money.

III.

HIV and AIDS Prevention Strategies

Over the past 20 years, several strategies have been developed to prevent HIV transmission. No single solution has proven effective on its own.

Combining multiple strategies has proven to have the most impact. The following are descriptions of the major strategies that, when used in combination, are effective for preventing sexual, blood-borne, and mother-to-child HIV transmission.

Strategies for Prevention of Sexual Transmission The majority of new HIV infections around the world are sexually transmitted. The prevention strategies for sexual transmission are: Behaviour Change Programmes Behaviour change programmes aim to have people change their sexual behaviours, thus reducing the risk of both acquiring and transmitting HIV. Safer sex1 is a means of preventing the sexual transmission of HIV. The easiest form of safer sex for those who are sexually active is the use of latex condoms every time they engage in vaginal, oral, or anal sex. Safer sex also includes abstinence, fidelity between uninfected partners, and practicing non-penetrative sex, such as hugging, kissing, masturbation, mutual masturbation, and simulating sex between a partner’s thighs or breasts.

1 “Safer sex” is the preferred term over “safe sex” because these prevention methods only reduce the chances of transmission, but does not eliminate them.

In other words, following these prevention methods will make a person safer than he or she otherwise would be, but not completely safe from HIV.

Additionally, people are encouraged to:

• Limit number of sexual partners; • Practice less risky sexual activities; • Recognize STI symptoms and need for prompt treatment; and

• Avoid risky social behaviour like consuming too much alcohol.

Peacekeepers are often away from their families for a long periods of time. This often predisposes them to temptations of adopting other methods of sexual gratification like getting involved with commercial sex workers. This vulnerability can also be increased by use of alcohol and other drugs. Use of these substances impairs judgement and may lead to unprotected and unintended sexual encounters which will increase the risk of HIV transmission. It is therefore important for peacekeepers to drink alcohol responsibly or abstain from its use if at all possible.

Promoting Condom Use Condoms are highly effective in preventing sexual transmission of HIV and other STIs. The U.S. National Institutes of Health (NIH) issued a report in 2001 showing that consistent and correct condom use can reduce the risk of HIV transmission by 85 per cent. In order for condoms to work they should be used all the time during sex.

The challenge with condom use is that most often people use them in the early phases of their sexual relationship but abandon them as the relationship matures. This is often done without knowing the partner’s status. It is advisable to use condoms in all sexual contacts until the HIV status of your partner is confirmed.

The effective and consistent use of condoms remains the most powerful weapon in the global struggle against HIV and AIDS, even though condom use varies widely within and among societies. As highly structured, formal organizations with well-developed command and control mechanisms, the military is virtually unique in their capacity for achieving and maintaining standardized patterns of behaviour. Most of the world’s military recognize these advantages in

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promoting and providing condoms amongst their troops, but fewer are fully prepared to maximize condom use – and, thus, HIV prevention – in their ranks. Absent in some national militaries are specific plans through which condoms are routinely promoted and provided. This lack of commitment is often paralleled by passive, group-informational approaches to condom promotion, as well as inadequate instruction on effective condom use and “on-request” distribution methods that are equally indifferent to soldiers’ possible disregard of and/or aversion to condoms.

for people who are in relationships that involve unprotected sexual contact. This includes married couples. HIV testing should be offered routinely and all officers should be encouraged to have their tests done on a regular basis.

Diagnosis and Treatment of Other STIs Concurrent infection with other sexually transmitted infections (STIs) increases the risk of HIV acquisition and transmission. Common STIs include gonorrhoea, syphilis, genital ulcers, and herpes simplex. The risk of HIV transmission is reduced by timely diagnosis and treatment of STIs. Programmes for the prevention and treatment of STIs, especially among populations at higher risk for sexual transmission of HIV, remain important elements of HIV prevention.

The main symptoms and signs of common STIs are:

• Discharge from the penis; • Ulcers/wounds in the genital area; • Abnormal vaginal discharge; and • Scrotal swellings.

To protect yourself from STIs and HIV, always insist on using a condom.

(UNAIDS, Peer Education Kit for Uniformed Services, September 2003)

Social and cultural factors can heavily influence predispositions towards or against condoms; therefore, the knowledge, attitudes, beliefs, and practices (KABP) of individual military units should be taken into consideration for successful HIV prevention amongst UN peacekeeping forces, which draw from many societies and cultures around the world.

HIV Counselling and Testing HIV counselling and testing play an important role in prevention efforts. People who know their status are more likely to practice safer sex, protecting themselves and others from infection. It is important that peacekeepers know their status and take every opportunity to be tested for HIV. HIV testing should be done on a regular basis

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Common STIs include gonorrhoea, syphilis, genital ulcers, and herpes simplex.

refrain from any sexual activity until the penis is completely healed – usually at least six weeks.

The World Health Organization (WHO) recommends that all men who are seeking circumcision should be offered voluntary HIV testing and counselling. Additionally, circumcision should only be undertaken by trained health providers in a safe medical setting.

Blood-borne HIV Transmission Blood Supply Safety Routine screening of blood supply has nearly eliminated the risk of HIV transmission through donated blood, especially in developed countries.

No patient should be transfused with blood that has not been screened properly for HIV. UNAIDS recommends three essential elements of an effective blood safety program:

• National blood transfusion service runs on a not-for-profit basis;

• Policy of excluding paid donors and relying on voluntary, low-risk donors; and

• Screening all donated blood for HIV. Infection control in emergency operation settings

Male circumcision

Infection control at the health facility

Several studies have shown that male circumcision reduces the risk of sexual HIV transmission by about 60 per cent. There is no definitive evidence that male circumcision reduces the risk of HIV transmission from men to women, or from men to men. However, it does reduce the risk of the circumcised male from acquiring HIV. Male circumcision undertaken by appropriately trained health providers is considered to be part of a comprehensive HIV prevention package.

The requirements of some countries for health workers to use “universal precautions” has nearly eliminated HIV transmission in health care settings.

The concept of universal precautions assumes that every patient has the potential to be infectious, thus protective gear and procedures are used with everyone. Additionally, workers use approved protective protocols for equipment, syringes, and sterilization processes. In addition, PEP (post exposure prophylaxis) must be readily available for care providers who become accidentally exposed to HIV infection.

Male circumcision does not completely protect a man against HIV, so circumcised men should continue to engage in safer sexual practices.

These include reducing the number of sexual partners as well as correct and consistent condom use. Men who undergo circumcision should

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An HIV/AIDS test is conducted in one of Jordan’s Ministry of Health labs, Amman. (UN Photo #20019 by G Pirozzi, January 2001)

Exposure to the blood of those receiving care occurs most often via accidental injuries from sharp objects such as syringe needles, scalpels, lancets, broken glass, or other objects contaminated with blood. Poor patient care practices by HIV-infected medical staff may also expose the patient to infection. Also, when injecting using poorly sterilized equipment, HIV may be passed from an HIV-infected individual to an uninfected patient. Protecting service providers and ensuring that they know their status and receive HIV treatment as appropriate are important priorities for the health sector. A good occupational health programme aims to identify, eliminate, and control exposure to hazards in the workplace.

WHO recommends that an occupational health programme do the following:

• Designate a person to be responsible for the occupational health programme;

• Allocate a sufficient budget to the programme and procure the necessary supplies for the personal protection of health workers;

• Provide training to service providers and

involve them in identifying and controlling hazards;

• Promote health workers’ knowledge of their own HIV, hepatitis, and TB status through:

--

Employment/pre-placement screening;

--

Providing immunization against hepatitis B;

and

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• Implement standard infection control precautions;

• Promote reporting of incidents and quality

Cases where PEP should not be given

• If individual is already HIV positive (a test

should be administered at the beginning of PEP);

control of services provided; and

• Provide free access to post exposure

• If a person has been chronically exposed to

Infection control in the field

• If the exposure does not pose a risk of

the source;

antiretroviral prophylaxis for HIV.

The same universal principles of infection control should be applied in the field as much as the circumstances allow. However, in the field there may be limited access to the equipment and expertise available in health care settings. In such circumstances, peacekeepers should ensure that they always use protective gear like gloves when resuscitating victims of injuries. Changing gloves between victims is also necessary, as infections can be transferred from one patient to another.

Also, peacekeepers should always (whenever possible) carry safety boxes for disposal of used needles as well as other sharp objects.

Principles of Post-Exposure Prophylaxis (PEP)

• Immediately care for the exposed skin. Wash cuts and skin with soap and water. Flush mucus membranes with water.

• Seek medical attention. Note that it’s important for the source of contamination to be tested for HIV and the affected person to know their HIV status. There is a risk of transmission if the source is positive and affected person is negative.

• Health worker will give PEP to persons

whose exposure puts them at risk of infection transmission. For individuals who qualify for PEP, they should start it as soon as possible and preferably within 24 hours. PEP drugs should never be given later than 72 hours!

The prophylaxis should be taken for at least 28 days with routine regular visits to health workers to assess the effects of the drugs.

• PEP can be used among peacekeepers in

situations of accidents where there is mixing of blood amongst casualties, in cases of rape, or accidental splashing of infected fluids into one’s eyes.

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transmission, e.g. any exposure to noninfectious body fluids (such as faeces, saliva, urine, and sweat), or if infectious fluids came into contact with intact skin;

• If exposed to body fluids from a person

known to be HIV-negative, unless this person is identified as being at high risk for recent infection and thus likely to be within the window period; and

• If the exposure occurred more than 72 hours previously.

IV.

Programmes for Injection Drug Users

Use of drugs by UN peacekeepers should be strongly discouraged. It is equally important that those identified to be victims of this habit be rehabilitated and supported to overcome and abandon the addiction. UN peacekeepers should support implementation of programmes that discourage drug abuse in their areas of operation.

V.

Strategies for Prevention of Mother-To-Child Transmission

Mother-to-child transmission (MTCT) of HIV, also referred to as “vertical transmission”, occurs when HIV is passed from an HIV-positive mother to her infant. The majority of children infected with HIV acquire the virus through MTCT. MTCT attaches no blame or stigma to the woman who gives birth to a child infected with HIV and it should not obscure the fact that HIV is often introduced into a family through the woman’s sexual partner. MTCT can occur during pregnancy, labour and delivery, as well as through breastfeeding. The highest risk of transmission occurs during labour and delivery.

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There is a four-pronged strategy for the prevention of MTCT: Strategy One: Primary prevention The focus is on prevention of HIV infection amongst women and men of child-bearing age, as well as the general population using the ABC strategy (Abstinence, Being faithful, and Condom use). This is the most ideal and effective strategy for reducing MTCT and encompasses all the HIV prevention strategies.

Strategy Two: Prevention of unintended pregnancy among HIV positive women The focus is on counselling and supporting HIV positive women and their partners to avoid unintended pregnancy through:

• Abstinence; and

Strategy Four: Provision of treatment, care, and support to women infected with HIV, their infants, and families The PMTCT programme routinely identifies women infected with HIV who need medical care and social support to address concerns about their own health and that of their families.

• If a woman is assured that she will receive

adequate treatment and care for herself, her partner, and her children, she is more likely to accept HIV testing and counselling and, if HIVpositive, accept interventions to reduce MTCT.

• It is important to develop and reinforce linkages with programmes for treatment, care, and support services to promote long-term care of women living with HIV and their families.

• Promote community and family support, especially spousal support.

• Dual protection methods (effective

contraceptives in addition to condoms).

Strategy Three: Reduction of MTCT among HIV-positive pregnant women Recommendations for PMTCT (preventing MTCT) when the first two strategies fail include:

• Adoption of safer sexual practices during pregnancy and lactation;

• Modified care during prenatal, delivery, and postnatal periods;

• Provision of antiretroviral drugs for reduction of MTCT; and

• Counselling on optimal infant-feeding practices.

How the interventions work:

• Identify women infected with HIV; • Reduce maternal HIV viral load; • Reduce infant exposure to the virus during labour and delivery; and

• Reduce infant exposure to the virus by using safer feeding options.

Positive Prevention These are strategies aimed at supporting people living with HIV. Positive prevention strategies seek to protects one’s sexual health, including prevention of new STIs. They also work to delay the progression of HIV and AIDS and to prevent the transmission of HIV to others. Strategies for positive prevention are not stand-alone programmes, but work in combination with each another.

VI.

Ethics and Prevention of HIV in Peacekeeping

Ethics is a very important component of HIV prevention for peacekeepers. The ethical principles guiding the peacekeepers include impartiality, integrity, respect, and loyalty.

These principles can be applied to the context of HIV prevention as well. Peacekeepers should be impartial in offering the services to all the community members. There should be equity in offering the HIV counselling and testing services.

People with HIV should not be denied services because of their HIV status. This will not only encourage members to get tested but they

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will also be able to access treatment and offer better services to the community in need. While peacekeepers are assured of access to health care, including treatment of STIs and HIV Voluntary Counselling and Testing (VCT), there should be an effort to ensure their sexual partners have access to these same resources.

Peacekeepers should have integrity which is the ability to know what is morally right and should refrain from all acts that may degrade their status, such as sexual harassment. In addition, they should respect the community they are serving, especially women and children. If this principle is adhered to, cases of rape and defilement, sexual exploitation and abuse, all of which increase the risk of HIV, would be minimized. A peacekeeper’s uniform represents power and force and can also be a source of respect and fear. This therefore creates an imbalance between the officers and the community, especially in areas of conflict. It is therefore the responsibility of the peacekeepers to be aware of the potential for abuse of this power.

Officers should neither indulge in alcohol abuse nor get involved in any acts of sex-for-money activities.

On-the-job sexual harassment of women should be addressed and there should be a clear mechanism through which complaints of this nature can be handled. Peacekeepers implicated should not be protected. Loyalty does not mean pardoning bad behaviour. It is the duty of peacekeepers to ensure that their colleagues adhere to the stipulated code of conduct and to discipline those who deviate from it. Sexual harassment is not acceptable at any time and having sex with minors (below 18 years of age) is punishable by law, even if it is consensual.

Degrading the Uniform There are specific actions that degrade the image of uniformed personnel and professional conduct.

These actions reinforce the avoidance of practices that place uniformed service personnel at risk of infection with HIV and STIs.

children, which spreads HIV and AIDS. Additionally, they may unknowingly encourage organized crime involving prostitution and the trafficking of women.

Peacekeepers can also degrade themselves by abandoning children they have fathered and by abandoning women who have been promised marriage or other benefits in exchange for a sexual relationship. This compounds the difficulties these communities face. Such behaviour is illegal and morally unacceptable. Acting responsibly can greatly reduce the spread of HIV. Professionalism and respect for diversity are core values of ethics in peacekeeping. Due to the nature of their work, peacekeepers are often away from their homes and must learn to adapt to the different cultures. For example, in some cultures, women do not cover their breasts when breast-feeding.

In other cultures, it may be common for women to wear scant attire in public. None of this should be misinterpreted as an invitation or an enticement to have sex. It is the responsibility of peacekeepers to learn about cultural norms and to adapt to the places that they are working in.

Discretion and Respect It is expected of peacekeepers to not consume excessive amounts of alcohol or indulge in sexual relations. Involvement in these activities, however, is an undeniable reality and peacekeepers, along with the community they serve, are exposed to HIV. Peacekeepers have a responsibility to uphold the high standards expected of them when they joined and swore allegiance to their service. Officers, because of their power and influence over other personnel, must become positive role models and must not breach the code of conduct themselves, lest their subordinates follow their example.

Off-duty misconduct is also not acceptable.

Peacekeepers are held in high esteem whether in uniform or not.

Unfortunately, some peacekeepers have used their powerful position to abuse vulnerable populations.

They do this by hiring prostitutes, often including

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51, Suppl. 3 (July 2009), pp. S111–8.

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6. Nancy B. Mock, Sambe Duale, Lisanne F. Brown, Ellen Mathys, Heather C. O’Maonaigh, Nina K.L. Abul-Husn, and Sterling Elliott, “Conflict and HIV: A Framework for Risk Assessment to Prevent HIV in Conflict-affected Settings in Africa”, Emerging Themes in Epidemiology, vol. 1, No. 6 (October 2004).

7. Robert H. Remien, Jenifar Chowdhury, Jacques E. Mokhbat, Cherif Soliman, Maha El Adawy, and Wafaa El-Sadr, “Gender and Care: Access to HIV Testing, Care, and Treatment”, Journal of Acquired Immune Deficiency Syndrome, vol. 51, Suppl. 3 (July 2009), pp.

S106–10.

8. Simcha M. Russak, Daniel J. Ortiz, Frank H. Galvan, and Eric G. Bing, “Protecting Our Militaries: A Systematic Literature Review of Military Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome Prevention Programs Worldwide”, Military Medicine, vol. 170, No. 70 (October 2005), pp.

886–97.

9. Praneed Songwathana, “Women and AIDS Caregiving: Women’s Work?”, Health Care for Women International, vol. 22, No. 3 (April 2001), pp. 263–79.

10. Paul B. Spiegel, “HIV/AIDS among Conflictaffected and Displaced Populations: Dispelling Myths and Taking Action”, Disasters, vol. 28, No. 3 (September 2004), pp. 322–39.

11. Virginiea Supervie, Yasminb Halima, and Sallya Blower, “Assessing the Impact of Mass Rape on the Incidence of HIV in Conflictaffected Countries”, AIDS, vol. 24, No. 18 (November 2010), pp. 2841–7.

12. Paolo Tripodi and Preeti Patel, “HIV and AIDS, Peacekeeping and Conflict Crises in Africa”, Medicine, Conflict and Survival, vol. 20, No. 3 (July–September 2004), pp. 195–208.

13. J. Volmink, Nandi L. Siegfried, Lize van der Merwe, and Peter Brocklehurst, “Antiretrovirals for Reducing the Risk of Mother-to-hild Transmission of HIV Infection”, Cochrane Database of Systematic Reviews, No. 7, Art. No. CD003510, (2011).

14. T. Young, F.J. Arens, G.E. Kennedy, J.W. Laurie, and G.W. Rutherford, “Antiretroviral Post-Exposure Prophylaxis (PEP) for Occupational HIV Exposure”, Cochrane Database of Systematic Reviews, No. 1, Art. No. CD002835, (2007).

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End-of-Lesson Quiz 1. When a person has AIDS, their body lacks:

6. Antiretroviral drugs are:

a. Immune cells;

a. A cure for AIDS;

b. Blood vessels;

b. Used to control the virus so it does not weaken the immune system;

c. Necessary nutrients;

c. An inexpensive source of relief for people with AIDS;

d. Bone marrow.

2. Almost all transmissions of HIV occur through: a. Sexual intercourse; b. Casual contact;

d. Placebos to help people with AIDS.

7. The following are ways to prevent the spread of HIV EXCEPT: a. Effective and consistent condom use;

c. Sharing items;

b. Avoiding risky social behaviour like consuming too much alcohol;

d. Kissing.

3. Body fluids that can spread HIV include: a. Blood;

c. Blaming HIV positive people for spreading the virus; d. Promoting HIV counselling and testing.

b. Breast milk; c. Semen;

8. Whick of the following statements best describe positive prevention in the context of HIV and AIDS?

d. All of the above.

4. AIDS CANNOT be spread: a. By sharing needles with a person living with AIDS; b. During the pregnancy of a mother with AIDS; c. Through the bite of an infected mosquito; d. By receiving a blood transfusion contaminated with HIV.

a. Supporting HIV positive people from acquiring other STIs; b. Helping HIV positive people to accept their status; c. Empowering HIV positive people to avoid spreading HIV to other people;

“Stigma Fuels HIV”, projected onto the façade of the UN Headquarters General Assembly building, is one of the topics of discussion during the UN’s high-level summit on HIV/AIDS. (UN Photo #475333 by Mark Garten, June 2011)

d. All of the above.

5. The stage of HIV infection before the body reacts to the presence of this virus and produces antibodies is called the: a. Asymptomatic period; b. Symptomatic period; c. Window period; d. Testing period.

ANSWER KEY: 1a, 2a, 3d, 4c, 5c, 6b, 7c, 8d 14 |

P E A C E O P E R AT I O N S T R A I N I N G I N S T I T U T E

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