HIV escalates geopolitical hotspots and undermines US military strength---low drug prices are key to treatment.

HIV is a threat to U.S. military interests for two principal reasons: the direct biomedical threat of, and the costs and consequences incurred by, infection to warfighters and the destabilizing effects that HIV may have on the sociopolitical systems of our strategic allies. MHRP has a multipronged strategy to counter these biomedical and sociopolitical threats posed by HIV.

Effective prevention of HIV infection is the cornerstone of the strategy, and MHRP has emerged as a leader in HIV vaccine research. Areas of research include both the development of effective vaccines and “passive vaccination” approaches with monoclonal antibodies to directly neutralize HIV before infection is established. MHRP also conducts research in acute HIV infection to deepen understanding of the early events of infection. Intervening in acute infection allows for the evaluation of strategies to vastly simplify treatment or even present the possibility of a functional cure, or treatment that effectively suppresses viral replication and blocks immune decline and forward transmission without the requirement for ongoing therapy. In addition to these product development initiatives, MHRP collects and analyzes data on HIV epidemiology and threat patterns, using domestic and international observational studies of both military and civilian populations to identify opportunities to mitigate the risk of HIV and other sexually transmitted infections.

MHRP is also part of a broader Department of Defense (DOD) initiative to provide direct HIV-service delivery across the globe. DOD receives funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) to support HIV services in the military health systems of countries hardest hit by the global HIV pandemic (military-to-military programs, supported principally by the DOD HIV/AIDS Prevention Program). Some of that funding goes to MHRP to provide an array of HIV services to civilian communities that participate in MHRP research (military-to-civilian programs). These activities represent a broad collaboration across the U.S. military and are a critical DOD tool to foster stability, promote goodwill, and enable strategic alliances and safer deployments.

HIV Threats to the Warfighter and Military Services

In the United States, HIV rates vary widely among groups, with the virus disproportionately affecting African Americans, Latinos, people who live in the American South, and, increasingly, those who are 25 to 34 years old—all groups highly represented in the U.S. military. These elevated infection rates have a negative impact on accessions; HIV remains a bar to enlistment because of restrictions on deployment and concerns about the ability to maintain consistent treatment in battlefield conditions.

Similarly, the incidence of HIV varies widely across the globe, with particularly elevated rates of infection in many African and some Asian nations, and increasing incidence in Russia, Ukraine, China, Pakistan, the Philippines, Afghanistan, the Middle East, and North Africa, all of which are potential theaters of future military activity or strategic locations for U.S. military presence (figure 1). Of particular note, because of increasing potential for U.S. military presence, Ukraine has the second highest HIV incidence in Europe, behind only Russia, and HIV incidence in the Philippines has increased by an alarming 237 percent since 2010. In such countries, the increasing incidence of HIV and low coverage of treatment poses risks to U.S. Servicemembers through either sexual contact or exposure to blood, blood products, or sharps, which could occur on the battlefield or in forward surgical and medical units. The availability of sufficient and safe blood products during times of conflict is a growing concern. A model run using the Medical Planners’ Toolkit (and the Casualty Rate Estimation Tool) estimated that in a near-peer conflict with over 50,000 casualties in the first 4 days and 2,000 to 3,000 casualties per day after that, more than 70,000 units of red blood cells would be needed over the first 90 days.4 That need would rapidly deplete stocks of available blood products and overwhelm prescreened walking blood bank strategies and therefore pose risks to the supply and to effective treatment. If such a conflict were to happen in an area of rising HIV incidence, such as Russia, where an estimated 1.1 percent of the adult population is HIV-infected, breakthrough contamination to the blood supply employed in the emergent treatment of mass casualties would be likely.

Figure 1. HIV Prevalence and Incidence in Selected Countries

There are approximately 350 new HIV infections among Active Servicemembers each year, almost all acquired through unprotected sexual activity, and it has been estimated that there are currently over 2,000 Active Servicemembers with HIV.5 These Servicemembers are typically not deployable given the potential for treatment interruption, which could compromise performance. At a lifetime treatment cost of over $420,000 per HIV-infected Servicemember, HIV imposes a heavy financial burden on the U.S. Military Health System, a burden that could be alleviated by preventing infection and the long-term consequences of HIV disease.6 Preventing and treating HIV is not only a professional obligation for military clinicians, but it is also a tactical measure. Identifying and utilizing the most optimal biomedical tools yield a tactical advantage in medical readiness when facing adversaries that do not mitigate their own HIV threats.

Geopolitical Threats of HIV

In many ways, the more pervasive threat of HIV is not clinical but social and geopolitical. Like many infectious diseases, HIV is both a cause and a consequence of war and social unrest. In the 1990s and early 2000s, entire communities in certain countries were altered by the loss of their most active and productive members, which left them with unsupported orphans, a dwindling socioeconomic base, and increasing social disorder. Economic desperation and social disorder, either because of HIV itself or as a consequence of civil unrest or war, contributed to forced and commercial sex, illicit drug trafficking, internal migration, and limited access to health care—thus creating environments even more conducive to the spread of HIV. The United Nations Security Council (UNSC) recognized HIV as an international security issue; it passed Resolution 1308 in July 2000, the first time that a health issue was acknowledged as a threat to peace and security. In June 2011, the UNSC passed Resolution 1983, recognizing the impact of HIV in conflict and postconflict environments.7

Health is a security imperative, central to the success of the combatant command missions. HIV threatens health security and if left unaddressed can undermine efforts to secure and stabilize volatile regions. As mentioned, military personnel may be at greater risk for acquiring and then transmitting HIV, and if those personnel do not have reliable access to affordable medications and quality health care, there is a real risk of amplifying transmission and compromising force readiness. In addition, in regions where U.S. forces serve alongside those of allies, high rates of infection can compromise the allied militaries, thus impeding U.S. strategic interests.