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					United Nations Peacekeeping Operations and Mandatory HIV Testing

August 1996 (Revised August 2001)

Eric A. Feldman, J.D., Ph.D. Robert Wood Johnson Foundation Health Policy Research Scholar Institution for Social and Policy Studies, Yale University Associate Director, Institute for Law and Society, New York University (from 9/96)

Gerald H. Friedland, M.D. Professor of Medicine Director, AIDS Program Yale University School of Medicine

TABLE OF CONTENTS I. EXECUTIVE SUMMARY ........................................................................................................... 3 II. INTRODUCTION ........................................................................................................................ 3 III. CAN HIV-POSITIVE INDIVIDUALS PERFORM THE DUTIES REQUIRED OF UNITED NATIONS PEACEKEEPERS? ....................................................................................... 7 A. The Duties of Peacekeepers ............................................................................................................. 7 B. HIV-Positive Peacekeepers: Potential Barriers to Fitness for Work ............................................... 8 1. Medical Issues ............................................................................................................................... 8 a. Live Vaccines............................................................................................................................. 8 b. Killed Vaccines ........................................................................................................................ 10 c. Viral Load ................................................................................................................................ 12 C. Harsh Conditions in Host Countries .............................................................................................. 13 1. Psychological Risks .................................................................................................................... 13 2. Medical Risks.............................................................................................................................. 14 a. Enteric infections ..................................................................................................................... 15 b. Vector-borne infections............................................................................................................ 16 c. Endemic fungal infections........................................................................................................ 16 d. Respiratory infections .............................................................................................................. 16 D. Special Duties of Peacekeepers ..................................................................................................... 18 Cognitive impairment....................................................................................................................... 18 E. Beyond Peacekeeping: Implications for UN-Affiliated International Workers ............................ 20 1. Public Health Issues .................................................................................................................... 21 a. Potential Impact of HIV-positive Peacekeepers on Other Peacekeepers.................................... 21 b. Potential Impact of HIV-positive Peacekeepers on Residents of Host Countries ...................... 22 c. Implications for UN-Affiliated International Workers ............................................................... 23 IV. ARE THERE FINANCIAL ISSUES THAT SUPPORT A POLICY OF MANDATORY TESTING? ......................................................................................................................................... 23 A. Cost of Medical Care ..................................................................................................................... 23 B. Liability for Vaccine-Related Injuries ........................................................................................... 25 C. Cost of Testing ............................................................................................................................... 26 V. ARE THERE POLITICAL ISSUES THAT SUPPORT A POLICY OF MANDATORY TESTING? ......................................................................................................................................... 26 A. Peacekeeping has a Symbolic Role in International Relations ..................................................... 26 B. Peacekeeping Missions are Subject to the Acceptance of Host Nations ....................................... 27 VI. CONCLUSION .......................................................................................................................... 28 REFERENCES .................................................................................................................................. 30

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I. Executive Summary This report presents an evaluation of the medical, public health, financial, and socio-political issues relevant to the establishment of an HIV testing policy for UN peacekeeping forces. Medical topics considered include the consequences of administering live and killed vaccinations to those infected with HIV; the potential health repercussions for HIV-positive individuals of harsh peacekeeping conditions, the impact of HIV-positive peacekeepers on the safety of the blood supply; and the potential cognitive impairment of those HIV-positive who are engaged in high-performance, high-stress duties. In addition, in the era of highly active antiretroviral therapy (HAART), the responsibility of provision of treatment for peacekeepers found to be HIV positive is raised and discussed. Among the public health issues discussed is the risk that HIV-positive peacekeepers will infect third parties, such as other peacekeepers, or residents of host countries. Central financial concerns are the cost of medical care for HIV-infected peacekeepers, including the cost of testing, the cost of assessment, antiretrovirals and monitoring of treatment, and possible liability claims brought by peacekeepers with HIV. Sociopolitical issues, such as accusations against the UN that it is responsible for the spread of AIDS in nations that host peacekeepers, are also discussed. The medical and public health literature on many of these subjects is extensive, but incomplete and does not provide a clear or full guide to policy makers. Ought there be a mandatory HIV test for all peacekeepers? Should testing be voluntary and consensual? Would mandatory testing violate the rights of peacekeepers? What are the boundaries of a fitness-to-work standard in the context of peacekeeping? In considering these questions, the authors used numerous on-line databases to identify the relevant scholarly literature. Questions about national military policy were discussed with military officials and other experts in the US, Canada, and Belgium. United Nations representatives from the Department of Peacekeeping Operations and the Medical Service were interviewed. Representatives of international aviation organizations were contacted. There was extensive contact with officials of the World Health Organization‟s Global Programme on AIDS and UNAIDS. Input was received from experts in infectious diseases, immunology, tropical medicine, public policy, ethics, and law. The HIV testing policy raises an array of complex issues. The incomplete nature of much of the scientific and medical literature has been exploited by advocates of particular policy positions. We recognize that policy must often be based on incomplete data. This report attempts a balanced review and exploration of the issues, and seeks to avoid imposing a non-existent consensus on a body of work that continues to evolve. After review, recognizing the real and potential consequences of HIV infection in peacekeepers, and the utility of knowledge of HIV status for care and prevention, as well as the array of associated public health, financial and social issues, it is the judgment of the authors that current knowledge as reflected in the literature and experience reviewed for this report does not justify a UN policy of mandatory HIV testing of peacekeepers and that voluntary confidential counseling and testing for HIV remains the policy of choice. The scientific, medical and public health literature is continually evolving. New facts about HIV will be reported in the future. As knowledge of HIV develops, the issues raised in this report may require further examination. II. Introduction Troops in United Nations peacekeeping missions are drawn from developed, industrialized nations and developing countries; from nations with conscription and those with voluntary military service; from nations that provide health insurance to all citizens and those that do not. There are many other differences between countries that contribute to peacekeeping forces. An ethical, appropriate, and enforceable UN medical policy for peacekeepers must take into account the many differences between
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member nations while addressing the common medical issues faced by all peacekeepers. (One shared medical fact is that individuals who become peacekeepers -primarily young, male, single, and sexually active - are at greater risk for sexually transmitted and drug related diseases such as HIV infection than the general population. In peacetime, sexually transmitted disease infection rates among armed forces are generally 2 to 5 times greater than in comparable civilian populations. In times of conflict, the difference can even be greater. Soldiers from the US and UK and France have higher rates of HIV infection than comparable civilian populations. Studies from Zimbabwe and Cameroon in the mid 1990s indicate that military HIV infection rates are 3 to 4 times higher than those in the civilian population (UNAIDS 1998). The UN has already addressed aspects of HIV/AIDS policy for peacekeeping troops. For example, the document “Protect Yourself Against HIV/AIDS! A Briefing Document for Police and Armed Forces Personnel” represents the collaborative work of the UN Department of Peacekeeping Operations and UNAIDS in producing a State-of-the-Art document on HIV prevention and education for peacekeepers. But the most difficult question about HIV policy and peacekeeping has not yet been answered; should the UN adopt a policy of accepting only those peacekeepers who have tested negative for HIV? Or, put another way, should countries contributing troops to UN peacekeeping missions be required to test them for HIV? National military policies vary considerably in the area of HIV. However, as of 1995, in a survey carried out by UNAIDS and the Civilian Military Alliance to Combat HIV and AIDS, HIV testing was carried out in some form by 58 of 62 (93%) of responding countries. (UNAIDS 1998). Of these, 43 stated that they had imposed mandatory testing in certain situations: pre-recruitment (25 countries); before foreign deployment (24 countries); before active separation from active duty (12 countries); periodically (9 countries); and before a new assignment (8 countries). Rejection of candidates for recruitment based on a positive test is carried out by 45 of 54 respondents, while 44 out of 56 impose restriction of duties for those who are known positive (for example banning from piloting aircraft or combat). Of those responding, 37 of 41 exclude HIV positive personnel from overseas deployment. The history of this policy can be traced back to decisions made in the previous decade. The US military has since 1985 required all recruits to be tested for HIV; those with a positive test result cannot serve. The policy was adopted after a contentious public debate in which a civilian advisory panel, the Armed Forces Epidemiological Board, made recommendations that were in part ignored by the Secretary of Defense (Bayer, 1991). An authoritative account of the military‟s decision to implement a mandatory HIV testing policy writes that “in response to a serious and almost fatal illness in a recruit subsequent to receiving smallpox immunization at basic training...the Department [of Defense] initiated HTLV-III/LAV antibody testing as a routine part of the medical assessment of all applicants for military service” (Herbold, 1986). In addition, the safety of the blood supply in situations of “buddy transfusions” in the field, the danger of acquisition of „exotic‟ infectious diseases in areas where the military may be deployed, the lack of available health care, the risk of HIV transmission to those uninfected, and the medical costs incurred by the military because of infected recruits, were cited as justifying the policy of mandatory testing (Tramont, 1987). Implemented during the Reagan presidency and at a time when information about HIV infection was extremely limited, many critics viewed mandatory HIV testing in the military as a smokescreen for a policy that they believed was aimed at eliminating homosexual men from military service (Rivera, 1987). From the perspective of military officials, however, their duty was to evaluate the limited available evidence and take every precaution necessary to safeguard military readiness. Knowing that the courts regarded the military as a regulated community and were unlikely to interfere with military judgment in the matter of HIV testing, mandatory testing was implemented. Mandatory testing was accompanied by policies of rejecting recruits for military service who were HIV positive, retaining HIV positive active duty personnel in the military and providing for their HIV and other health care but

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limiting overseas assignment. During the ensuing decade 4,421,792 sera were tested for HIV-1 antibodies (Brown, 1996). Active duty personnel in the US Army were tested at a rate of 380,000 to 460,000 per year at a recommended frequency of once every 6 months. More than 99.5% of active duty soldiers in the HIV testing program were negative for antibodies for HIV. The overall case detection rate was 5.4 cases per 10,000 sera screened at an overall cost of a minimum of $12.6 million and an average cost per case detected of $5,290. This extensive and expensive program has been recently assessed after a decade of implementation (Brown, 1996). The assessment concludes that the program has been successful and cost effective largely because of the money saved by prevention of additional HIV infections. Although this may well be the case, data is not presented in support of this view. Indeed, about half of respondents of an anonymous survey of HIV infected military beneficiaries indicated that they did not use condoms during sex with HIV-negative partners. Other benefits of this extensive program have been excellent documentation of HIV incidence trends and acquisition of other epidemiologic and natural history data but these are not relevant to the discussion at hand nor do they address other justifications for implementing the program. A question to which we will return throughout this report is whether now, over a decade later, there is additional data to further provide a sound scientific basis for US military policy. The recent review of HIV testing notes that “the US military sets an example for other militaries around the globe” (Brown, 1996). US policy regarding HIV testing has indeed been adopted by many nations. As noted above, the majority of nations contributing peacekeeping forces employ mandatory testing, although the testing circumstances vary. There are many nations that have not implemented a US-style testing policy. In Canada, for example, recruits are accepted for military service without an HIV test. Those known to be HIV-positive can be immunized and posted overseas if they pass a medical evaluation and are judged to be asymptomatic. Thereafter, they will be subject to a medical examination every six months. For all known HIV-infected members of the Canadian Forces there are limitations on piloting, justified by what are considered to be subtle neuropsychological deficits related to HIV (Canadian Forces, 1995). Canadian policy was to some extent influenced by a decision of the Canadian Human Rights Tribunal, which held that the Canadian Forces acted inappropriately when it failed to reasonably and practically accommodate an HIV-positive recruit posted on a ship and instead issued a discharge (Simon Thwaites, 1994). Rather than discharging him because he was HIV-positive, the Tribunal ruled that the CF was required by law to assess the individuals‟ potential risk to himself and others, and weigh it against his capabilities. This case served to emphasize the duty of the military to evaluate HIV-infected persons individually rather than exclude them as a class. Through 1993, all applicants to the Belgian military were HIV tested, and those with a positive test result were not admitted for service. Currently, military personnel in Belgium are not required to be tested for HIV. According to the Medical Service of the Belgian Armed Forces, mandatory HIV testing is not required because it is expensive and ineffective, and would violate articles 8 and 14 (right to privacy and discrimination) of the European Convention on Human Rights (Debaker, 1996). Those with known HIV infection can perform all military duties, including foreign deployment. HIV-positive individuals can remain in service until they are physically unfit to carry out their duties. The Medical Service advises against live polio and measles vaccines for those with HIV infection, and recommends yellow fever vaccination for those with a T4 count above 200 cells/mm3 (Directives, 1995), and the government admits both medical and financial liability for vaccine-related injuries. In the judgment of a Belgian military official, overseas deployment of HIV-infected personnel has not, in comparison to seronegative personnel, resulted in the increased transmission of endemic diseases (Debaker, 1996). Pilots and others in high-stress, high-performance jobs are tested regularly for physical fitness, but HIV is not considered to be prima facie evidence of neurological impairment, so an HIV test is not required for such individuals. Limiting HIV transmission from members of the

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military is addressed through prevention programs, not testing. Throughout the militaries of Europe, Africa, South America, and elsewhere, there is a wide range of HIV testing policies, and conflicting justifications provided for those policies. In addition, in areas of high HIV seroprevalence, the HIV prevalence rate is of such magnitude, that wholesale exclusion of peacekeepers from such areas might be a resultant policy option.

HIV Prevalence in Selected Militaries in Sub-Saharan Africa*

Country

Estimated HIV prevalence

Angola 40-60 Congo ( Brazzaville) 10-25 Cote d‟Ivoire 10-20 Democratic Republic of the Congo 40-60 Eritrea 10 Nigeria 10-20 Tanzania 15-30 (DIA/AFMIC 1999 quoted in National Intelligence Council 2000)

Current UN policy with regard to HIV testing of peacekeepers, outlined in the Medical Support Manual (Medical Support Manual), is to "highly recommend that military or police personnel should be tested and that personnel with known positive HIV status should not be sent to UN peacekeeping missionsThis recommendation appears to be based on four claims made in the same section of the Manual: that many countries contributing peacekeepers are already testing for HIV; that treatment for sexually transmitted diseases may be inadequate in the locations where peacekeepers are deployed; that immunizations required for HIV-positive peacekeepers may be harmful to their health; and that endemic diseases in areas where peacekeepers are deployed may pose a health risk. The Manual emphasizes that "testing is not a mandatory requirement yet," implying that such a policy may be forthcoming. Before a more restrictive policy is implemented, it is critical to step back and analyze the numerous claims for and against mandatory testing of peacekeepers, assess current UN policy, and consider alternative strategies. Determining whether the mandatory HIV testing of peacekeepers is desirable requires consideration of several questions: 1. Can HIV-positive individuals perform the duties required of United Nations peacekeepers? 2. Are there health risks to individual HIV-positive peacekeepers and to others associated with deploying peacekeepers who are living with HIV? 3. What are the political and financial costs to the United Nations of requiring (or not requiring) that all peacekeepers be tested, and permitting (or prohibiting) the deployment of HIV-positive peacekeepers? These will be discussed in detail below.

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III. Can HIV-Positive Individuals Perform the Duties Required of United Nations Peacekeepers? A. The Duties of Peacekeepers The designation "HIV-positive" is not a precise description of an individual's physical health. HIV is now recognized as a chronic viral infection with a prolonged asymptomatic period of lack of clinical disease, good health and completely normal functional capacity. In most individuals, this period may last for a decade or more past the point of infection with HIV. However, some asymptomatic individuals who test positive may have seriously compromised immune systems whereas others may have relatively intact immune function. Similarly, like work environments of all kinds, there is a range of tasks and activities presented by peacekeeping missions to deployed individuals (Daniel and Hayes, 1995; Diehl, 1993; Durch, 1993). At one end of the spectrum are duties in every way analogous to the duties faced by a typical military recruit (although peacekeeping duties are generally of lesser duration, averaging 6-12 months). This is why peacekeepers are drawn from the military of member nations. They may be called upon to patrol in hostile environments, to engage in possible combat, to live in tents in wet tropical conditions without the most rudimentary of comforts. Such conditions are physically and psychologically demanding for even the most capable individuals. But not all peacekeeping activities are similar to military duty. Indeed, many peacekeepers perform "civilian" duties. Under United Nations guidelines, peacekeeping forces are not constituted to have offensive military capability. They may only use force when necessary defensively. They are only lightly armed. To a large extent, the cluster of issues related to HIV, testing, and civilian peacekeeping activities are applicable to UN staff, those in the diplomatic service, and others posted overseas. The standard of fitness for work is endorsed by the UN, the World Health Organization, and the International Labor Organization as a guiding principle for making appropriate hiring and personnel decisions. Fitness for work is also the standard articulated by the militaries of the US, Canada, Belgium, Australia, and many others as determining the suitability of individuals for military service. The considerable controversy over fitness for work is not directed at the general usefulness of the principle, but rather at its precise application. Ought it be limited to a medical determination of one‟s immediate fitness or include determinations of future fitness? How far into the future can those making judgments on fitness permissibly speculate? How ought the risks to others created by an individual be weighed in determining that individual‟s fitness for work? Is danger to self an appropriate criterion, or should individuals be allowed to put themselves at risk? To what extent, if any, can factors external to an individual‟s health, such as financial or political concerns, be factored into a fitness for work determination? In evaluating the literature bearing on the issue of mandatory testing of peacekeepers and HIV, we adhere to the following standard. Because peacekeeping forces may be deployed with little advance notice, and it is difficult to predict in advance what duties will be assigned to an individual peacekeeper, we will assume that all peacekeepers should be fit to perform civilian and military peacekeeping duties. The central question we consider is whether there are characteristics of being HIV-infected that limits the physical or mental abilities needed for peacekeeping duties, or creates untoward risks to self or others, that makes individuals unfit for the work of peacekeeping, now or in the 6-12 months during which one may serve as a peacekeeper. If HIV infection does not make peacekeepers unfit to fulfill peacekeeping functions, there should emerge a strong presumption against mandatory HIV testing. Even if HIV were found to have an impact on fitness for work, it would not necessarily follow that mandatory HIV testing would be required or that all HIV-positive peacekeepers should be excluded from peacekeeping duties.

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B. HIV-Positive Peacekeepers: Potential Barriers to Fitness for Work 1. Medical Issues Current medical guidelines strongly recommend that HIV infected asymptomatic persons continue their employment and normal life activities. There is no reason for restriction of activity (Hecht and Soloway, 1992; Sande and Volberding, 1996). Indeed, in the era of effective treatment for HIV disease, most persons with HIV disease, even if previously symptomatic, can be restored to a state of good health and functioning. (NIH, 2001, Carpenter 2000, Bozette 1998, Pallela 1998, Montaner 2001, Knobel 2000). Five medical justifications for the mandatory HIV testing of UN peacekeeping forces have been offered: 1. the potential danger of live attenuated vaccines; 2. the possible failure and dangers of killed vaccines; 3. the psychological and physical stress brought on by the harsh living conditions in host countries; 4. the lack of adequate medical facilities in host countries to care for sick HIV-positive peacekeepers; and 5. the possible deterioration of particular physiological abilities, notably cognitive function, necessary for the performance of special peacekeeping duties. The evidence which we have explored which provides support or lack of support for each of these justifications is presented below. In addition, we have added comment and discussion of the issue of HIV care and antiretroviral therapy and its implications for a testing policy. a. Live Vaccines Concern that live attenuated vaccines pose a danger to people with HIV have been expressed since the mid-1980s. This concern was seen as compelling by the US Department of State - and was the primary stated reason provided by the government for requiring that all military recruits in the US be tested for HIV (Rivera, 1987; Alexander, 1988). This decision appears to have been based upon a single reported and highly publicized case of disseminated vaccinia in a military recruit with undetected HIV disease who received smallpox vaccination (Redfield, 1988). In particular, “after a case of disseminated vaccinia occurred in an HIV seropositive military recruit, it became apparent [to US military officials] that the potential for these attenuated viruses to cause significant disease was real” (Alexander, 1988). The logic of mandating that all potential peacekeepers be tested for HIV because of the danger of live vaccines is: 1. The administration of live vaccines is essential for the deployment of peacekeepers; 2. Administering live vaccines to those HIV-positive may fail to offer the needed protection, and can induce illness; 3. Therefore, it is necessary to determine who is HIV-positive, and eliminate such individuals from the pool of peacekeepers. The extent to which this logic is compelling depends largely upon the current status of adequate medical evidence. It has been noted that medical evidence concerning HIV and live vaccines demonstrates two dangers. First, that such vaccines may not provide adequate protection against disease, because the response to vaccines will be blunted as a result of the damaged immune systems of those who are HIVpositive. Second, and of apparent greater concern, that in HIV infected individuals, live vaccines may themselves cause disease, indeed even the very disease against which protection is sought. Both parts of this claim are relevant to peacekeeping. For every peacekeeping mission, the UN makes recommendations for pre-deployment vaccinations. Due to the varying immune status of individuals in different countries, each nation that contributes peacekeeping forces makes the final decision on which vaccines to administer. Failure to follow UN recommendations, however, "could result in denial of medical claims and compensation" (Medical Support Manual). In addition, UN recommendations carry significant persuasive force; member countries do not simply disregard UN policy. It appears that in most cases where UN recommendations are not completely followed, it is a consequence of the high expense of vaccinations, not deliberately ignoring the UN's authority. Thus, while the UN lacks the formal authority to require pre-deployment vaccination, its recommendations

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carry a great deal of force. Once peacekeepers are under UN command, responsibility for immunization vests in the UN. While theoretical dangers have been emphasized by researchers, medical evidence demonstrating an adverse impact of live vaccines on HIV-positive individuals remains anecdotal and limited. Reports of adverse events following the inadvertent administration of live vaccines to HIV-infected persons have been infrequent. The most pertinent examples are the one involving vaccinia vaccination and disease cited above (Redfield, 1987), several reported case of BCG disease in vaccinated individuals with HIV disease (Boudes, 1989; CDC, 1985; Smith, 1992; Marks, 1993; CDC, 1996; O‟Brien KL et al., 1995), and rare instance of a measles vaccine complication (CDC, 1996). Population based studies of complications of live vaccination in HIV infected individuals are lacking. This is not to say that risks do not exist, but rather, that without sufficient data, it is not possible to measure actual risk of complications of live vaccination. Live vaccines of greatest concern are vaccinia, measles, polio, and yellow fever. Although vaccinia vaccination is of concern, smallpox has been eradicated and the necessity for this vaccination is questionable, at best. Measles antibodies appear to persist in HIV infected adults, even with low CD4 counts (Sha, 1991; Zolopa, 1994; Wallace, 1994). After years of experience with measles vaccine and disease in HIV-infected persons, and assessing risk and benefits, the recommendation falls in favor of giving measles vaccine to HIV-infected persons who are nonimmune to measles because of the increased risk for severe complications associated with measles infection and the absence of serious adverse events after measles vaccination (Wilson, 1991; Von Reyn, 1987; Embree, 1992; Kaplan, 1992; CDC, 1994; CDC, 1996). Response rates range from 60%-100% in asymptomatic HIV infected individuals (Brena, 1993; Arpadi, 1996), although antibody levels are lower than those achieved in HIV seronegatives. Although there is a risk for measles-vaccine-associated encephalopathy in immunosuppresssed subjects, severe complications have not been noted after measles immunization of more than 300 HIV-1 infected children as of the end of 1990 (Wilson, 1991). Although the largest experience with measles vaccine in HIV-infected persons comes from the pediatric experience, a few small studies have examined adults. Sprauer et al. administered measles-mumpsrubella vaccine (MMR) to 39 HIV seropositive adults with CD4 counts > 200 cells/mm3 and 17 seronegative adults (Sprauer, 1993). There was no difference in clinical adverse reactions between the two groups. Response to vaccines was similar in HIV and non-HIV infected individuals. Lutwick et al. gave measles vaccine to 6 measles-seronegative, HIV-infected adults, 5 of whom had CD4 counts <200 (Lutwick, 1993). Four of the six developed detectable measles antibody post vaccination and no adverse effects of the vaccine were noted. Similar responses to mumps and rubella vaccine have been noted, without adverse effect. However, a case of measles vaccine induced measles pneumonia in a young adult with HIV infection and severe immunodeficiency, has recently been reported (CDC, 1996). This represents the first such reported instance of this complication in individuals with HIV infection. Changes in recommendations for measles vaccination have, at this writing, not been made. On the basis of this evidence, it appears that asymptomatic non-immune HIV-infected individuals can be safely immunized with live measles vaccine and with mumps and rubella vaccine. Oral live poliomyelitis vaccine has been considered of danger in immunocompromised children because of risk for disease and potential transmission to family members. Cases of active disease have been reported following immunization, but not in HIV infected individuals (Nkownade, 1987). Nevertheless, a theoretical risk exists. We were unable to locate information about effectiveness and adverse experience with live attenuated polio vaccine among HIV seropositives. Yellow fever vaccination is usually considered most problematic. Anecdotal cases of encephalitis following vaccination have occurred in infants but have not been documented in HIV infected adults (Bia and Barry, 1992). Postvaccination encephalitis has been a rare complication (18

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cases reported since 1945, mainly in children less than 1 year of age) with this live vaccine, occurring primarily in children less than 4 months of age (Joint statement 1966; Wilson, 1991). More than 250 million doses of the 17D vaccine, the one used in the US, have been administered since 1966. Data from the US military indicate that approximately 100 asymptomatic HIV-infected personnel received yellow fever vaccine before mandatory HIV screening was instituted and that no adverse reactions were noted (Redfield R.; personal communication, quoted in Wilson et al.). The limited data available on HIV-infected persons given the YF vaccine suggest the vaccine is generally safe though small numbers do not support complete confidence in this conclusion. Because of continuing concern, yellow fever vaccination is not recommended to HIV infected individuals who are symptomatic or have CD4 cell counts below 200 cells/mm3 (Wilson, 1991, Bia, 1992). Among bacterial vaccines, BCG and typhoid vaccine are of particular interest. As noted above, the former has been reported to cause active disease in HIV infected individuals in several instances. The safety of BCG vaccination in HIV-infected adults has not been determined by large scale or controlled studies (CDC, 1996). It is likely that tens to hundreds of thousands of HIV infected individuals have received BCG worldwide, and therefore this risk, though real, must be quite low, particularly in asymptomatic individuals. Recent review of this issue as it pertains to vaccination of newborns in high prevalence areas for HIV concludes that the available data indicates that routine vaccination of newborns, including those infected with HIV is safe and should be carried out (Felten and Leichsenring, 1995). Others, after review of existing literature and experience, have come to similar more general conclusions (Weltman and Rose, 1993). Nevertheless, persons with HIV infection are possibly at greater risk for lymphadenitis and disseminated BCG infection following vaccination than those not infected with HIV. Increased rates of local reactions were seen in Haitian infants born to mothers with HIV infection when larger-than-recommended doses of BCG were administered (O‟Brien, 1995). However, studies in Congo and Zaire using standard doses did not demonstrate increased rates of adverse reactions (CDC, 1996; Colebunders et al., 1988; Lallemant-Le Cour S et al., 1991). Typhoid vaccine may represent a significant problem. There is an increased risk for salmonellosis among those infected with HIV and concerns about vaccine complications are legitimate. The risk of vaccination at this point is unknown and likely to be greatest among those with substantial levels of immunodeficiency. However, because of the risk and seriousness of S. typhi infection, the potential benefit of vaccination likely outweighs the risk. In sum, anecdotal cases of disease as a result of live virus vaccination have been reported albeit, infrequently. These instances raise legitimate concerns about vaccine danger. This danger is likely directly related to degree of immunosuppression and clinical status. There is no population based data upon which to base an estimation of actual risk, however. b. Killed Vaccines

In addition to the potential danger of live attenuated vaccines, killed vaccines have also been presented as detrimental to the health of HIV-positive individuals, including peacekeepers. While such vaccines do not present a risk of causing disease, there is concern about their efficacy in providing adequate protection to peacekeepers as well as the risk of vaccination induced antigenic stimulation resulting in acceleration of HIV disease. Recommendations about killed vaccines, generally favor their use in HIV infected individuals (USPHS, 1995; CDC, 1993; CDC, 1994; Von Reyn, 1987). In HIV-infected persons the immune response to vaccines may be less robust and less durable (Singer and Sax, 1996; Tasker, 1995; Nelson, 1988; Bia, 1991; Rodriguez-Barradas, 1992; Collier, 1988; Kroon, 1994; Sprauer, 1993; Steinhoff,

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1991), but the response may be within expected levels. Diminished response to vaccines reflects the degree of HIV-associated immunodeficiency. Routine killed vaccines of relevance to peacekeepers include Diphtheria-tetanus booster (every 10 years), annual influenza vaccination, pneumococcal and Haemophilus influenza b vaccines, Hepatitis B series if not immune by antibody status, killed typhoid vaccine, and in special circumstances, cholera vaccine, rabies vaccine, meningococcal vaccine, Japanese encephalitis vaccine and plague vaccine. The extent and frequency of use of these various vaccine preparations may vary by geographic area, nationality of peacekeepers, and site of deployment. Most information about vaccine responsiveness in HIV infection has been derived from studies of pneumococcal, influenza and haemophilus vaccines. With pneumococcal vaccine, as with others, antibody response may be suboptimal and appears to correlate with absolute CD4 cell counts (Rodriguez-Barradas, 1992; Muscarat-Lemone, 1995). In one study, antibody non-response occurred in only 17% of patients and was not associated with CD4 count level (Vandenbruaene, 1995). Although the level of antibody correlating with clinical protection is unknown, HIV-infected individuals clearly may have a normal antibody response to immunization with the polyvalent pneumococcal vaccine, suggesting that the vaccine will be protective. The actual clinical efficacy of the pneumococcal vaccine in HIV infection, however, is not known, but routine immunization with polyvalent vaccine is universally recommended. Several case reports have described severe influenza infections in AIDS patients. However, there is no definite evidence demonstrating an increased incidence or severity of influenza infection in HIV infected individuals. Although influenza vaccination has been shown to be efficacious and costeffective in healthy immunocompetent adults, similar prospective studies have not been done in adults or children with HIV infection. Antibody response to the influenza vaccine is suboptimal in HIV patients, particularly in those with absolute CD4 counts under 100/mm3. HIV-infected individuals experience less direct morbidity and mortality from influenza than from pneumococcal infection, and because the vaccine must be administered annually, yearly influenza vaccination may not be cost-effective (Singer and Sax, 1996). Given the similar modes of transmission of hepatitis B virus (HBV) and HIV, populations at risk for HIV are also at high risk for hepatitis B. Depending on the group studied, from 35% to 80% of HIV-infected persons are already immune to or are chronic carriers of HBV and consequently are not candidates for vaccination. Acute hepatitis B infection may be less severe in people infected with HIV than in HIV-negative individuals, but the risk of chronic HBV carriage is greater in those with HIV infection. From a public health standpoint, vaccination may prevent further transmission. For those found to be HBV seronegative or not a chronic carrier, vaccination with three intramuscular doses of the hepatitis vaccine is recommended. In both children and adults with HIV infection, and as with other vaccines, the antibody response to hepatitis B immunization is suboptimal in HIV-infected individuals, with less than 60% developing a protective antibody response, compared with more than 90% of HIV seronegative controls (Zuin,1992; Rodrigo, 1992; Keet, 1992; Bruguera, 1992). There are no clinical trials of the efficacy of the hepatitis vaccine in preventing hepatitis B in people with and without concomitant HIV infection, but it is likely to be less protective in HIV-infected people based on antibody levels. Unlike the diseases prevented by the other routinely recommended vaccines, however, behavioral interventions to prevent HIV and other disease transmission (e.g., condom use, avoidance of needle-sharing, etc.) may also prevent HBV transmission. The incidence of H. influenza infections is higher in HIV-infected adults than in age-matched controls, but only third of such infections are caused by type-B strains. Although antibody response to the Hib polysaccharide vaccine in HIV-infected adults is lower than in noninfected controls, immunization with a conjugated polysaccharide vaccine results in an improved antibody response,

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directly correlated with the CD4 count (Steinhoff, 1991). However, whether this response protects against invasive disease specifically secondary to H. influenza disease is unknown. Limited data is available with regard to other killed vaccines. Varon et al. studied a group of HIV seropositive and seronegative hemophilic patients vaccinated during an outbreak of poliomyelitis in Israel using enhanced inactivated poliovirus (eIPV). Similar rates of response to the three vaccine viral types were observed in the two groups, although higher levels of antibody were achieved among the seronegatives. Interestingly, in this study, vaccine responsiveness was not associated with CD4 count. Killed polio vaccine responsiveness was similar in a group of HIV infected and uninfected infants in another study (Barbi, 1992). In a study in adults with HIV infection, 83-100% responded to tetanus vaccine and 78-100% to inactivated trivalent poliovirus vaccine, although those with CD4 cell counts below 300 cells/mm3 had significantly lower titers (Kroon, 1995). In summary, HIV infected persons respond to vaccines but at a frequency and level below that of HIV negative persons. Although it is established that antibody responses are lower in the HIV-infected than in noninfected controls, we do not know all the correlates of clinical protection, and certainly some individuals with HIV do respond adequately. The response, for all vaccines investigated, appears to be related to the degree of immune damage as measured by CD4 count and/or clinical status. Individuals who are without HIV related symptoms and with higher CD4 counts tend to respond more vigorously and durably than those who are ill. Data on clinical effectiveness of routine vaccination of HIV infected adults are not available. With the available information, routine immunizations for persons with HIV disease should continue to be administered, particularly in those who are asymptomatic and in situations where there is an increased risk of disease acquisition. c. Viral Load To the controversy and uncertainty in the area of live and killed vaccine efficacy and live vaccine danger has now been added another concern - that of the effect of vaccination on the progression of HIV disease itself. Evidence is emerging that vaccination may stimulate HIV replication, at least temporarily; this could theoretically accelerate the progression of HIV disease. Concern about this has prompted discussion and consideration of reevaluation of routine immunization of HIV-infected people. However, at this writing, the data is inconsistent and definitive data are not available on the possible clinical harm of vaccines on HIV disease. Theoretical concerns about the effect of vaccination on HIV replication were first raised when in vitro studies showed that stimulation of HIV-infected T-cells by mitogens or cytokines resulted in increased HIV replication (Zagury, 1986). A similar phenomenon has been reported in HIV-infected persons during acute infections, including influenza, HSV-1, HSV-2, and opportunistic infection (Singer and Sax, 1996). Several studies have evaluated the effect of influenza immunization on virologic markers in HIV-infected persons. HIV viral load, measured by quantitative PCR of peripheral blood mononuclear cell (PBMC) HIV RNA, increased an average of 11.6-fold in the first one to two weeks after immunization in 10 of 20 patients receiving influenza vaccine, compared with a 2.4-fold increase in the 14 nonvaccinated controls (O‟Brien, 1995). Transient rises in plasma HIV RNA in 30 HIV-positive patients immunized for influenza have been reported by Hamilton and colleagues (Hamilton, 1995). In a large double-blind, placebo-controlled trial involving 47 HIV-infected subjects, immunization with influenza vaccine resulted in increases in HIV viral load as measured by plasma viral RNA. Preliminary analyses showed a plasma HIV RNA increase from a mean of 24,000 to over 130,000 copies/ml in the vaccinated group, while in the placebo group mean plasma HIV RNA levels decreased slightly, from 26,000 to 18,000 copies/ml at one month post-vaccination. At three months post-

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immunization, the mean percentage of CD4 cells dropped by 1.8% in the vaccinated group and increased by 0.2% in the control group (Tasker, 1995). Other studies have not shown influenza immunization to have an adverse effect on viral load. In a published study using p24 antigen measurements (a relatively insensitive marker for viral load), influenza vaccine did not boost HIV levels (Nelson, 1988). Recent studies with newer techniques have similarly shown no change in plasma HIV RNA at one to two weeks after vaccination (Chapman, 1995); or in HIV RNA, PBMC HIV DNA, and CD4 cell counts one month after vaccination (Yerly, 1995). Several studies presented at the recent International AIDS meetings addressed the issue of effect of influenza immunization on viral load. Fuller et al. studied 33 subjects and were only able to demonstrate an increase in plasma RNA levels following immunization in one patient. Also levels of CD4 counts did not appear to have an effect on viral load changes. Studies by Nelson et al. gave similar results and those reported by Ward, Salvato, and Thompson in 86 patients showed a transient increase in viral load at 1 month which was not sustained at 2 months. In this study, CD4 counts surprisingly showed an increase at 2 months in vaccinated subjects (Fuller et al., 1996; Nelson et al., 1996; Ward, Salvato, and Thompson, 1996). Preliminary evidence has shown that immunization with the pneumococcal vaccine also results in transient increases in HIV replication (Janoff, 1995). In a recently published study by Stanley et al. observations on viral load effects of immunization have been carried further (Stanley, 1996). Thirteen HIV-1 infected patients with CD4 cell counts ranging from 8 to 1102 cells/mm3 received immunization with tetanus toxoid. Studies evaluated changes from baseline in plasma viremia, proviral burden, isolation of HIV-1 from peripheral lymphocytes, and the susceptibility of PBMCs to acute infection in vitro. All 13 had transient increases in plasma viremia after immunization; peak viremia occurred 3 to 28 days after immunization, with a mean of 13 days. Level of response did not correlate with CD4 count, although those with higher counts showed earliest responses. Other parameters showed similar changes but not in all subjects. These results are of substantial concern. However, the demonstrated changes were transient and thus, as discussed by the authors, still of questionable pathogenic relevance. These data, although inconsistent and preliminary, and at most presently, transient in effect, do raise questions regarding the safety and advisability on immunizations in HIV-1 infected individuals and it is clear that further studies are warranted. There are clearly both benefits and dangers as a result of vaccination in HIV infected individuals. Further studies to assess the efficacy and toxicity of vaccines in HIV, and to determine the short- and long-term effects of immunization on viral load, immunologic markers, HIV disease progression, and survival, will be needed before definitive recommendations can be made. The weight of the literature in tropical medicine and infectious diseases, embodied in current immunization practice for international travelers, and by analogy, peacekeepers, is that the potential benefit of most vaccines outweighs the theoretical risk. It is the general conclusion, at this writing, that it remains preferable to prevent or reduce the likelihood of acquiring the diseases for which immunization is directed than to not give warranted immunizations. Thus, no changes in immunization practices have been recommended and those deemed to be of benefit to peacekeepers should be administered, regardless of HIV status. C. Harsh Conditions in Host Countries 1. Psychological Risks Some individuals sent on peacekeeping missions may experience a radical shift in their living conditions. They may be taken from affluent, industrialized nations where they enjoy what are considered to be the basic comforts of life, and thrust into a situation where all such comforts are

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lacking. Regardless of country of origin and previous living conditions, they may witness starvation, illness, death, and intense despair on a daily basis. They may be subject to verbal and physical attack, and feel unwelcome by citizens of the host country. The psychological stress of such events can be significant. One justification that has been offered for requiring all peacekeepers to be tested for HIV is that the stress associated with deployment as a peacekeeper can accelerate progression of HIV disease. Evidence that acceleration of HIV disease occurs as a consequence of psychological or physical stress is limited. Many individuals with HIV have substantial personal and environmental stressors, including loss, substance abuse, depression, etc. In longitudinal cohort studies, these do not appear to have a definable impact upon the rate of progression of HIV disease. Some support for the link between psychological health and HIV progression has been provided (Burack, 1993). However, in subsequent personal discussion with the author, and review of other literature, we conclude that psychological factors per se do not have a measurable or observable impact on HIV progression. Indeed, more recent literature suggests that the negative influence of depression on HIV disease progression is a result of poor access to care and/or adherence to therapy. (Ickovics 2001) In the context of peacekeeping, the question is not whether psychological and physiological conditions exist and are interdependent. More importantly, the question is whether there are particularly unique characteristics about the stress of peacekeeping that will have an unusually profound impact on the health of those with HIV. There is currently insufficient evidence available to support such a position. Concern is frequently expressed about the potential risk for suicide among those who are infected with or at risk for HIV. There is anecdotal evidence of occasional suicides soon after learning of HIV infection. However, most individuals are able to handle information about HIV infection and eventually continue with their usual function. Most studies do not demonstrate increased rates of suicide during the course of HIV infection until the final stages of disease (Starace, 1993). At this point of symptomatic disease, suicide increases, but not necessarily with more frequency than with other chronic terminal diseases. From the perspective of danger to the peacekeeper force as a result of HIV related suicide, concerns appear to be unwarranted and certainly not sufficient to require mandatory testing for HIV. 2. Medical Risks While the psychological strain sometimes associated with peacekeeping may not justify mandatory HIV testing, perhaps the physical conditions of peacekeeping offer such a justification. Deployed in substandard conditions, in areas with unfamiliar and potentially hazardous endemic diseases, some peacekeepers will be at particular risk for acquisition of exogenous pathogens and illness. Are HIV-positive peacekeepers at identifiably greater risk of serious illness than other peacekeepers? Peacekeepers from developed nations assigned to developing countries, for example, may be at increased risk for tuberculosis and enteric diseases by virtue of that assignment. This risk may differ from peacekeepers from nations where conditions are similar to or even less healthy than those where peacekeepers are deployed and prior exposure to such pathogens is likely to have occurred. Evidence does suggest that certain infectious diseases are more prevalent, more easily acquired, and/or more severe in HIV infected individuals and therefore represent a health hazard. In addition, there is the concern that illnesses that threaten peacekeepers and could accelerate HIV. For purposes of this discussion, infectious disease risks can be placed in two main categories: those with a worldwide distribution and those with a geographically focal distribution. Many infections with a worldwide distribution, such as salmonella, cryptosporidia, typhoid fever, tuberculosis, and hepatitis A, are predictably more common in the areas where levels of hygiene and sanitation are poor and high rates of such diseases exist. Knowledge of the general standard of sanitation can be helpful in

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assessing the risk for these kinds of infection. In addition, the risk is not uniform within a given country or duty assignment. Among the infections that are geographically focal, only some present an incremental risk to HIV infected persons. Most importantly, for both HIV infected and not infected individuals, peacekeepers and non-peacekeepers alike, standard infection control practices such as insuring the safety and source of food and water, reducing exposure to insect vectors, and adherence to prophylactic medication regimens can substantially reduce risk of infection. In reviewing major infectious disease risks for HIV-infected peacekeepers, it is useful to group pathogens by modes of transmission: enteric, respiratory, vector-borne, sexually transmitted, and other. Sexually transmitted diseases are discussed in a separate section related to public health significance. Generally accepted prevention education, advice and provision of barrier protection should be the same for all, regardless of HIV status. From the standpoint of the individual‟s health universally recommended barrier precautions that prevent an HIV-infected person from transmitting HIV to others should also protect him or her from most sexually transmitted infections. Frequent occurrence of sexually transmitted diseases among those who are HIV infected is more likely a function of more frequent unprotected sexual exposure, rather than enhanced susceptibility. a. Enteric infections Enteric infections probably present the greatest threat to HIV-infected individuals, although the rate of risk is not known (Hoge, 1993). Even without travel, enteric infections are common among persons with HIV infection, but occur at increased frequency and severity as immunodeficiency increases (Bartlett, 1992). The incremental risk related to peacekeeping duty assignment is not known. Caused by fecal contamination of food and drink, they are preventable by avoidance of such exposures. During travel to developing countries, 20 to 50 percent of travelers develop so-called traveler‟s diarrhea, which is usually mild, self limited, and preventable and/or easily treated with antibiotics (DuPont, 1993). However, several of the pathogens commonly causing diarrhea in travelers may cause infection in HIV-infected persons that can be severe, chronic, or relapsing or associated with extraintestinal spread. Bacterial infections such as salmonellosis are of particular concern (Gotuzzo, 1991). These are partially preventable by vaccination and avoidance of contaminated food and water, and are treatable. Rotaviruses and other viruses (e.g., Norwalk, caliciviruses, astroviruses, among others) have been found in travelers with diarrhea (Gilger, 1992). Studies of the association of rotavirus and HIV infection have produced conflicting results. Some studies have found evidence that the rotavirus infection is more frequent and more likely to be associated with chronic diarrhea and extra intestinal spread in HIV-infected more than in HIV-uninfected persons (Wilson, 1991). Although the older studies of traveler‟s diarrhea did not include tests for cryptosporidiosis, reports from small groups of travelers and data from studies in developing countries document that cryptosporidiosis is common in developing countries in areas where poor hygiene prevails. Specific increased risk to HIV-infected persons in this environment is probable at stages of marked immunosuppression. The best documentation of risk of cryptosporidiosis to HIV infected individuals, paradoxically, comes from a large outbreak in the United States as a result of sewage contamination of drinking water. Severity of illness is related to underlying immunocompromise. Giardiasis has been a common cause of diarrhea in travelers to the former Soviet Union and other destinations. HIV-infected persons appear to respond well to conventional treatment for this infection. Another protozoan parasite that causes diarrhea in travelers that probably is more severe in HIV-infected persons is the recently identified cyclospora species (tentatively named Cyclospora cayetanensis). The organism is probably spread via contaminated water and food. Sporadic cases and outbreaks have been reported from many geographic locations including the Americas, Caribbean, Asia,

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and Eastern Europe. Entamoeba histolytica is an important cause of colitis in some geographic regions and occasionally causes liver abscesses and other extra intestinal infections. Amebiasis has not appeared to be more common in HIV-infected persons. Strongyloidiasis, a helminthic infection, was included in early discussions of expected serious infections in AIDS patients. Given the experience with disseminated strongyloidiasis in patients on steroids and with other immunocompromising conditions, it was predicted that disseminated infection would likely be a frequent problem in HIV-infected persons. Although reported, disseminated strongyloidiasis has not been common, even in regions where infection with strongyloides is endemic. In sum, there is likely increased risk for acquisition of certain enteric pathogens among persons with HIV. As with all individuals, this risk can be substantially reduced be adherence to excellent food and water hygiene, which should be the universal standard for peacekeeping operations. b. Vector-borne infections Visceral leishmaniasis, a protozoan infection transmitted by the bite of an infective sandfly, appears to more common in HIV-infected persons than in uninfected persons (Berenguer, 1989; Montalban, 1989). No controlled studies have assessed frequency and severity of disease HIV-infected persons relative to uninfected persons. Other vector-borne infections, such as dengue fever, malaria, and rickettsial infections, that may be encountered by UN peacekeepers have not been reported to cause increased morbidity or mortality in HIV-infected persons. The evidence is particularly strong for malaria in this regard (Nguyen-Dinh, 1987) and of significance since concern about increased risk for malaria among HIV infected individuals was part of the initial justification for the US Department of Defense mandatory testing policy. c. Endemic fungal infections Several focally endemic fungal infections can cause severe and disseminated infection in HIVinfected persons. Penicillium marneffei, a dimorphic fungus found in soil and in bamboo rats in Southeast Asia, can infect apparently normal hosts but is much more likely to cause symptomatic, disseminated infection in immunocompromised hosts, especially HIV-infected persons (Supparatpinyo, 1993; Hilmarsdottir, 1993). There are currently no vaccines or prophylactic medications that can prevent these fungal infections. All, however, respond to antifungal therapy, if infection is recognized and treatment begun early enough in the course of infection. d. Respiratory infections HIV-infected persons experience an excess of respiratory tract infections, frequently with pathogens that are common in the general population. People with HIV are at high risk for invasive and recurrent pneumococcal disease, with rates of pneumococcal bacteremia 150- to 300-fold higher in HIV-patients than in age-matched controls. In a prospective study which included 1130 HIV-infected persons, over an 18-month period, 4.8% developed bacterial pneumonia (in contrast to <1% of HIVnegative persons), a rate of 5.5 per 100 person years. Rates significantly increased as CD4 counts dropped. (Hirschtiek, 1995). Streptococcus pneumoniae and Haemophilus influenzae are the most common causes of bacterial pneumonia. Each responds well to conventional antibiotic treatment. As noted above, the capacity to respond to both pneumococcal and H. influenza vaccination may be at normal levels but declines with HIV disease progression. HIV infection increases the risk for reactivation and acquisition of infection with Mycobacterium tuberculosis (Chaisson, 1987; Barnes, 1991; Hopewell, 1992). This risk has been demonstrated to be in the range of 8%/year for those who are dually infected (Selwyn, 1987). It is also known that HIV infected individuals are at higher risk for acquisition of tuberculosis, if exposed, and

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not previously infected. Even endogenous re-infection has been noted in HIV infected individuals with low CD4 counts. Risk of infection is highest for persons spending long periods in crowded indoor areas with poor ventilation. Many geographic areas of the world where peacekeepers may be sent have high prevalences of both tuberculosis and HIV (Bulletin of the World Health Organization, 1992; Naraine, 1992). Despite these concerns, the risk of new acquisition of tuberculosis is low for most, especially short-term stays, and will be dependent upon circumstances of exposure not just presence in a country of high prevalence of tuberculosis. For peacekeepers from developing countries, the risk is not likely to be higher than that experienced in the countries from which the peacekeepers themselves come and reactivation of undetected latent M. tuberculosis infection is more likely for this population. Isoniazid prophylaxis has been shown to significantly reduce this risk and should be standard practice for PPD positive peacekeepers. Consideration might appropriately be given to universal INH prophylaxis to those from high prevalence countries. The risk for M. tuberculosis reactivation and infection raises a legitimate concern about the risk to HIV-positive peacekeepers of tuberculosis disease. However, it is reasonable to ask if the magnitude of risk greater for peacekeepers is any greater than that of other UN personnel? Assignment to a geographic area with increased prevalence of tuberculosis per se need not disqualify individuals for services. Information on the actual risk could not be acquired and would be important to document in order to develop appropriate policy. According to the UN Medical Service (personal communication, Dr. Laux visit in 1996) there have been no reports of TB among peacekeeping forces, even though there have undoubtedly been many HIV-positive peacekeepers deployed in areas where TB is endemic and likely opportunity for exposure to active tuberculosis. The Medical Service collects reports made by peacekeepers in the field. However, there is no active surveillance system and many cases could have been undetected in the field or have occurred after peacekeeper deployment. Whether this risk exceeds that of other UN personnel is not known but unlikely. That is, there is no special and unique risk to peacekeepers which exceeds that of other overseas stationed UN personnel? We have had access to only a limited amount of information about the health of peacekeepers in the field, and we have been unable to ascertain that such individuals have had major health problems or infections more frequently, with different or more severe diseases, than other peacekeepers or other UN personnel. More research and data is necessary to better evaluate this issue. The general conclusion relating to this issue is that peacekeepers are likely to be exposed to a variety of diseases, and that some of these represent increased risk for peacekeepers with HIV infection, particularly for those with immunocompromise who have low CD4 cells. Many of these agents are avoidable by adherence to generally recommended infection prevention measures, such as clean food and water, avoidance of insect bites, and preventive therapy for tuberculosis. These measures, if applied properly, should afford protection for asymptomatic HIV infected peacekeepers as well as those who are not HIV infected. The ability to apply these measures, in turn, is likely to be a function of the specific circumstances of peacekeeper assignment. More information related to the actual rates of risk among peacekeepers would help guide policy decisions. Similarly, the availability of medical care for peacekeepers who become ill during service is likely to be variable. Development of clinical illness has apparently been infrequent and most medical evacuations have been the result of trauma (DelPonte, personal communication). Serious illness may be handled on site if facilities are available and by medical evacuation if necessary. Where resources exist, those with known HIV infection may benefit from prophylactic and antiretroviral therapies, but these are not universally available for most peacekeepers from diverse national backgrounds. In addition, provision of therapeutic health care is not among the justifications for the establishment of mandatory HIV testing, but now has to be considered because of health and policy issues raised by availability of

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antiretroviral therapy. Voluntary identification of HIV infection may be sufficient to identify those for whom these benefits can be applied and accepted. Mandatory testing is not employed to provide these benefits in other settings. Further, unless such therapeutic strategies are to be made available, the benefits of testing, particularly mandatory testing, are questionable. If available, education and explanation of their benefit and assurance of their availability would likely result in acceptance of voluntary confidential testing, if restriction of work was not a requirement. If unavailable, mandatory testing will both restrict employment for those who are fit for duty and not offer any therapeutic benefit to those who are found to be HIV seropositive. Finally, it is argued quite reasonably that mandatory testing and identification of HIV seropositives and their restriction from overseas service will protect them from dangers of vaccination and exposure to exotic diseases. These risks, although not known quantitatively, are likely low and appear to increase with symptomatic HIV disease and at CD4 counts below 200/mm3. They quite likely decrease as counts increase above this level. It would follow that HIV testing should be accompanied by clinical and immunologic laboratory assessment to more fully assess risk for individuals who are otherwise fit for work. Only those demonstrating significant immunocompromise and lack of fitness for work would be kept from overseas peacekeeping service. An alternative strategy would be to make antiretroviral therapy and opportunistic infection prophylaxis available to those who fit within the guidelines of recommended institution of therapy (NIH, 2001, Carpenter 2000). The question then arises as to who should provide these life-prolonging therapies? For developed countries, the infrastructure and expertise as well as resources have been available to enable this, however, for many countries in the developing world, even with lowered antiretroviral therapy prices, treatment may not be available. In this case, should the UN be responsible for provision of care or just referral back to the country of origin? D. Special Duties of Peacekeepers There are high-performance, high-stress jobs in every military that call for particular skills and intensive training. Flying a fighter plane, for example, requires that one undergo lengthy and expensive education before being certified as a pilot. The financial cost of such training is a central factor in the decision of some national militaries to require HIV testing of all recruits. From the perspective of such nations, it is unjustifiable to pay for the training of an individual who may not live long enough for the financial investment in such training to bear fruit. Whatever one's views of the logic behind such policies - an analysis of the economic justification for HIV testing forwarded by the military of certain nations is beyond the scope of this report - they are not relevant to the peacekeeping context. Members of contributing country military forces come to peacekeeping operations fully trained, and the additional training provided by the UN, if any, is trivial. Cognitive impairment Of more relevance is the abundant literature devoted to exploring the potential cognitive impairment of HIV-positive individuals. This is of particular relevance to peacekeepers who perform special duties. These duties may include piloting, commanding tanks, decoding sensitive messages, and operating particular weapons, among others. If HIV infection resulted in cognitive impairment, and that impairment caused individuals to perform particular activities poorly, and poor performance could endanger the lives of others, there would be a strong argument for a policy that mandated HIV testing for such individuals and prohibited them from engaging in certain activities. This logic has been used to restrict HIV infected pilots from flying in both civilian and military settings.

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Cognitive deficits in individuals with HIV infection are associated with the AIDS dementia complex or HIV encephalopathy. This is the most common direct CNS complication of HIV infection. This entity has been the subject of great interest and an extensive literature exists. Essential points are that patients‟ earliest symptoms usually consist of difficulties with concentration and memory and there is a characteristic progressive slowing of motor and mental responses ( Price, 1988; Navia, 1986). After an AIDS diagnosis has occurred to the point of death, more than one third of individuals may have the syndrome in various degrees of severity (Price, 1988). The existence of this syndrome in individuals with AIDS was recognized early in the HIV/AIDS epidemic and quickly raised the issue of whether subclinical decline in cognitive function and performance occurs early in the asymptomatic stage of HIV infection. This also resulted in concern about health and employment practices, an issue which has received different policy interpretations by different national, international civilian and military bodies and remains controversial. An early study (Grant, 1987) suggested that subtle detectable neurologic impairment was frequently present early in HIV seropositive asymptomatic subjects and was of importance in the US military policy to remove asymptomatic seropositive personnel from technically “complex” positions, such as flight duty, because of the possible risk of cognitive impairment (Harrison and McArthur, 1995). However, characteristically, and of importance to this discussion, in most instances, neurologic impairment manifests itself after patients develop HIV related symptoms and the major opportunistic infections and neoplasms which define AIDS (Portegies, 1994; Siditis, 1990, Nelson,1995; Harrison and McArthur, 1995). That is, in the vast majority of individuals, measurable and clinically significant cognitive defects occur late in HIV disease usually after constitutional symptoms have already occurred. Patients have been described who present with forms of this syndrome before major systemic complications occur but this is unusual. In 1988, the World Health Organization reviewed the available literature on cognitive impairment and concluded that there was no evidence for an increase in neurologic abnormalities of clinical significance in asymptomatic HIV (World Health Organization, 1988). A wide array of studies have since been performed addressing this issue. Some have demonstrated significant cognitive impairment early in HIV. Studies performed at Walter Reed Army Medical Center have indicated frequent slowing of information processing among asymptomatic HIV infected individuals (Mapou, 1993), and others have found early defects (Wilkie, 1990; Martin, 1993; Peavy, 1994). However, the most rigorously performed and largest studies have not found early defects (Harrison and McArthur, 1995; Newman, 1995). Results of many large cohort studies performed in HIV infected individuals, indicate that the syndrome is rare in those who are otherwise asymptomatic (Selnes, 1990; McArthur, 1993; Portegies, 1994). Most notable are the results of repetitive carefully performed tests of cognitive function in men enrolled in the Multicenter AIDS Cohort Study (Selnes, 1995) and other cross sectional and longitudinal studies from this cohort. For example, in one report, only one in 279 asymptomatic seropositive patients (3.7 per 1000) was mild dementia detected (McArthur, 1989). Additional information of relevance is the consistent finding that cognitive impairment is not only infrequent but also decline is not apparent in long term follow-up in asymptomatics. The controversy and discrepant results in the literature are most likely explained by methodological differences in patient selection, testing parameters, and, most importantly, study size (Harrison and McArthur, 1995). Concerns about neurological impairment in HIV disease are not unique to peacekeepers. For example, physicians, surgeons and others who perform functions requiring high degrees of cognition are not required to be tested for HIV (AMA). Decisions about driving, and other technically complex jobs do not routinely require HIV testing. If the legitimate military concern is that of the dangers of cognitive impairment, then a more logical approach would be to screen for cognitive impairment itself rather than for HIV, since many behavioral and substance abuse practices and other neurologic diseases may also impair cognition.

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There is every reason to subject all individuals charged with high-performance, stressful jobs to frequent formal examination and tests for cognitive and functional impairment, as well as tests that identify individuals who are substance abusers, are emotionally unstable, or are otherwise unfit to perform particular duties. However, since asymptomatic HIV infection per se is unlikely to result in such impairment, its presence alone should not disqualify an individual who otherwise meets standards of performance. In our opinion, a policy of mandatory HIV testing is not warranted based upon fears of cognitive impairment. Screening for cognitive impairment should be the primary detection strategy. E. Beyond Peacekeeping: Implications for UN-Affiliated International Workers In none of the areas that we have considered - live and killed vaccines, harsh conditions and poor medical facilities in host countries, special duties - is peacekeeping unique. We can identify no principle by which peacekeeping is distinguishable from non-peacekeeping in the international arena, with regard to the medical issues presented. In fact, many of the medical issues discussed above are relevant to travelers and tourists, to civilian surgeons and train drivers, volunteer and relief workers, to those transferred by corporations to work in developing countries, and to others. Mandatory testing of peacekeepers would therefore have implications far beyond the context of peacekeeping. Those who believe that there is a medical justification for the mandatory HIV testing of UN peacekeepers face a dual challenge. First, they must offer more complete evidence that HIV-infected peacekeepers are not fit to serve in peacekeeping forces. Second, they bear the burden of demonstrating either that peacekeeping is a distinctive work setting, or accepting that the logic of mandatory testing of peacekeepers requires the testing of others working in the international arena - UN staff, members of the diplomatic service, those affiliated with NGOs, and others. To the extent that there is disagreement over the analysis and interpretation of the medical evidence discussed above, that disagreement cannot be confined to the realm of peacekeeping. A mandatory testing policy for peacekeepers will inexorably lead to the conclusion that others must also be tested. If there existed conclusive medical evidence that being HIV-positive created increased health risks for individual peacekeepers, but not for third parties, mandatory testing and exclusion from peacekeeping contingents would be one possible policy. Some analysts would claim that in such circumstances a paternalistic policy of testing and exclusion was in the best interests of the infected individual. Not doing so would put the individual at increased risk of medical complications, illness, and death. However, the extension of this argument would be that those individuals tested and found to be positive would be required to be offered and receive therapy for HIV disease if indicated. It is likely that the availability of treatment either by referral or through the UN would further increase the desirability of voluntary counseling and testing and weaken the case for mandatory testing. There is a perhaps stronger argument, however, that such a paternalistic approach unnecessarily limits individual autonomy. From the perspective of respecting autonomy, a better policy would be to describe to all peacekeepers the potential risks of peacekeeping for those who are HIV-positive, provide the opportunity for all peacekeepers to be tested, and allow each individual to decide whether or not to be tested. Such a policy would be consistent with the choice accorded to individuals in the civilian population of most countries. Even among populations at high risk of HIV infections, individuals are counseled to be tested and to protect their own health and that of others. But they are not required to be tested and to confront information about their HIV status. For other health conditions as well, public health policy seeks to provide opportunities for individuals to obtain information about their health, but rarely forces individuals to confront medical information they do not want. The UN, by providing an assessment of the risks and offering an HIV test and counseling to all peacekeepers, can honor its ethical responsibility to peacekeepers without infringing on individual autonomy.

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1. Public Health Issues Protecting the health of peacekeepers, respecting the rights of HIV-positive individuals, and avoiding discrimination against those infected by HIV are of primary concern in determining whether mandatory HIV testing is an appropriate policy in the peacekeeping forces. But they are not the only relevant criteria by which to evaluate HIV testing policy. In peacekeeping, as in all other workplaces and social settings, it is necessary to take measures to protect the health and safety of third parties who come into contact with individuals with infectious diseases. The history of infectious disease control internationally is rife with examples where government officials have had to balance the possible infringement of individual rights with the protection of the public health. Such balancing is difficult; sometimes it has been performed adequately, other times inappropriately. Even today in some areas of the US, individuals with TB who do not take their medication can technically be deprived of their liberty in the name of the public health. In the context of HIV and peacekeeping, the question is whether there are public health concerns of such significance that mandatory HIV testing should be considered. From this perspective, evaluation of the fitness to work as a peacekeeper includes an estimation of the potential danger to others created by the presence of HIV-positive peacekeepers in the peacekeeping workplace. If the potential danger is high, and its impact widespread, then mandatory testing may be an appropriate policy. A number of issues have been raised that relate to the potential health impact of HIV-positive peacekeepers on others. They fall into two major groups: issues concerning the potential impact of HIV-positive peacekeepers on other peacekeepers; and those relevant to their impact on residents of countries hosting peacekeepers. a. Potential Impact of HIV-positive Peacekeepers on Other Peacekeepers The most significant issues have to do with the possible transmission of HIV from HIV-positive peacekeepers to peacekeepers who have not tested HIV-positive, particularly through blood. Among the potential dangers of HIV transmission through the blood supply are the possible necessity of emergency blood transfusions, the requirement that every peacekeeper be a "walking blood bank," concern about direct contact with blood through blood spills during battle, and problems that might arise in the provision of medical care, such as infection by, or of, peacekeeper medics. Ensuring a safe blood supply in the context of peacekeeping is more difficult than in a civilian setting. Standards for blood safely vary widely between nations, and blood is considered a separate function from general medical logistics during peacekeeping operations. Once standards for managing blood are determined, peacekeepers from all nations must comply. Those nations that prefer to have a national supply of blood and blood products may do so, but at their own expense. The added complexity of a common blood supply for a peacekeeping force, while not insignificant, does not appear to present a unique or intractable problem. With regard to the general blood supply, emergency transfusions, and the idea of a "walking blood bank," blood screening precautions that are recommended by the WHO for civilian blood banks are adequate in most cases. In many instances, improvements in blood technology have significantly reduced the danger of disease transmission through blood. The possibility of direct contact with blood through blood spills in battle, while of possible concern in certain military situations, is relatively small in peacekeeping. The issue of trauma and inadvertent blood contact is reassuringly addressed by the information that even a needle stick injury from known HIV positive individuals carries a risk of approximately 3 per 1000 (CDC, 1994) The risk of HIV infection after and skin and mucous membrane exposure to HIV contaminated blood and other fluids is too low to be detected in population based studies.

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Concern remains about transmission of HIV infection by close contact that does not involve sexual relations or blood. Abundant evidence from studies of household contacts of persons with HIV infection and AIDS makes it clear that despite such concerns, the risk of transmission as a result of close interpersonal contact is too small to be measured (Friedland, 1990; Friedland, 1987). Further, although an isolated transmission from an HIV-infected health care worker to six patients has been documented, this case remains an anomaly in which no specific procedure or practice was implicated and the reason for transmission of infection remains unexplained. Indeed, retrospective evaluation, including HIV testing of more than 22,000 patients who were treated or had a procedure or surgery performed by one of 51 HIV-infected health care workers did not demonstrate any case in which the epidemiologic or laboratory data suggest an HIV-infected health care worker was a source of infection to a patient. Furthermore, surveillance of AIDS and HIV infection since the beginning of the epidemic in the United States more than 15 years ago (with more than 650,000 reported AIDS cases) has not identified any cases of HIV transmission from an infected physician to a patient, even during an invasive procedure. Hence, transmission, if it occurred, has been so rare (only the cases associated with the Florida dentist) that it presents no real risk in the peacekeeping setting. The problems that have been identified with regard to HIV transmission in peacekeeping medical settings are similar to those in civilian health care institutions. The WHO, the CDC in the US, and other public health agencies throughout the world have developed guidelines for universal precautions, as well as other safeguards for health care workers and patients, that adequately address these issues. The most common routes of HIV infection, sex and drugs, apply in the military as well as civilian population. The responsibility to reduce transmission within the military by these routes lies with both individuals and the military itself. The appropriate response is not mandatory testing but targeted and effective education and risk reduction strategies. b. Potential Impact of HIV-positive Peacekeepers on Residents of Host Countries From the perspective of public health, most residents of host countries will be unaffected by the presence of HIV-positive peacekeepers. The only individuals at immediate risk of HIV infection from peacekeeping forces are those who are in close contact with peacekeepers, generally as a result of sexual relations. Whether as a consequence of an intimate personal relationship or commercial sexual services, it is a well-established principle of international public health that prevention through education is the best way to reduce HIV transmission resulting from sexual intercourse. A collaborative effort of UNAIDS and the Department of Peacekeeping Operations has made significant progress in preparing educational material for peacekeepers and convening special sessions for HIV education, both pre-deployment and once peacekeepers are in the field. Refining and increasing these activities should be a high priority of the UN‟s HIV policy for peacekeepers. A successful policy will limit HIV transmission both from peacekeepers to host country residents, from one resident to another, and from residents to peacekeepers. To every extent possible, an effort should also be made to initiate HIV education and prevention activities in host countries. Even the best prevention program will not eliminate all high-risk behavior, and it is likely that there will be some level of HIV transmission from peacekeepers to local populations, and vice versa. Mandatory testing would not eliminate such transmission, since the risk is likely to be ongoing and testing would have to be unrealistically frequent and there will always be some HIV-infected peacekeepers who, because they are in the window period or for other reasons, will not be detected by an HIV test. While the ultimate goal should be to eliminate all HIV transmission in peacekeeping operations, a more realistic objective is to select a strategy that will minimize transmission.

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Is mandatory testing the best way to minimize transmission between peacekeepers and local populations? Surely a mandatory HIV test will identify some infected peacekeepers and exclude them from deployment, ensuring that they will not spread their infection to others. But there may be unintended consequences of testing and exclusion. Those who test negative, for example, may experience increased feelings of invulnerability that lead them to engage in behavior more likely to put them or others at risk of HIV infection. They may be more likely to ignore prevention message. There is some evidence that this concern may be warranted. Moreover, testing and exclusion implies that individual, HIV-infected peacekeepers bear the entire burden of limiting HIV transmission, and neglects to address the corresponding duty of the local population to act responsibly. Further research is needed to disentangle the public health from the political motivation for asserting that peacekeepers will spread AIDS in host countries, to document through epidemiological studies the extent to which HIV has been transmitted by peacekeeping forces, and to analyze the most effective mechanisms for limiting such transmission. c. Implications for UN-Affiliated International Workers Similar to the discussion in Section III above, the public health concerns that have been suggested as possible support for mandatory HIV testing of peacekeepers are not limited to the peacekeeping context. The one exception is the potential contact with blood spilled in combat, which appears to be an extraordinarily unlikely source of HIV infection and one for which there is currently no evidence. Otherwise, issues of the blood supply, and of sexual contact with those living in host countries, are of equal concern to all who are living or traveling overseas. There are clearly an array of important precautions that must be taken by every individual to avoid becoming infected with HIV, and to avoid infecting others, through sexual relations, injection drug use, the blood supply, and in health care institutions. If mandatory HIV testing is believed to be the most effective and appropriate policy for peacekeepers, imposing an HIV test on other UN employees under the banner of public health will be a logical next step. IV. Are There Financial Issues that Support a Policy of Mandatory Testing? Medical and public health concerns are not the only bases on which pre-deployment mandatory HIV testing of peacekeepers has been advocated. Foremost among additional justifications is the potential financial cost to the UN of permitting the deployment of HIV-positive peacekeepers. That cost may allegedly include the cost of medical care, the cost of caring for individuals in host and contributing nations infected by peacekeepers, and liability for injuries of HIV-positive peacekeepers as a consequence of vaccinations. Of particular relevance in the era of antiretroviral therapy is the cost of treatment and responsibility for treatment. A. Cost of Medical Care Certain pre-deployment costs such as general medical examinations and the cost of vaccinations are a national responsibility. Once deployed, however, almost all costs associated with the provision of health-related services are borne by the United Nations. Historically, it appears that the UN has provided care for most health needs during mission, even pre-existing conditions and other ailments unrelated to the performance of one's peacekeeping duties. The most likely reason for this generous policy is that the marginal cost of providing such care is small. Health care facilities and providers are already in place. Distinguishing between medical conditions that are and are not related to peacekeeping duties is difficult. And peacekeepers, primarily young men in good health who have

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undergone the rigors of military training, are relatively healthy individuals who are less likely that the general population to present with complex or expensive medical problems. With regard to HIV-positive peacekeepers, those who are symptomatic or who have AIDS will have been screened out during routine pre-deployment medical examinations on the basis of the symptoms they present. For asymptomatic HIV-positive peacekeepers who are deployed, there are a number of possible scenarios. The most likely is that they will continue to be asymptomatic, and the UN will incur no expense in providing them with medical care. Another possibility is that an HIV-positive peacekeeper will develop an HIV-related health complication that the UN will have to treat. Such a scenario is analogous to other unforeseen health problems that arise in the course of a person's life. There is no data to suggest that HIV-related health care is consuming a disproportionate share of medical resources during peacekeeping missions. A more extreme scenario is that a peacekeeper's CD4 count will undergo a significant decline, and the peacekeeper will develop AIDS during the peacekeeping mission. UN policy dictates that peacekeepers with AIDS will be repatriated. In such a cases, the UN will bear the cost of providing medical care and of repatriation. Such a policy is justifiable on the grounds that having AIDS makes one unfit to perform peacekeeping duties. Like all other conditions that make individuals unfit for duty, it is therefore grounds for repatriation at UN expense. Finally, the cost of care for those who are HIV infected, asymptomatic and able to perform their duties yet requiring treatment must be considered. Present guidelines for institution of therapy and opportunistic infection prophylaxis provide a general standard of care that should be applied to military as well as civilian persons. The cost of this care includes drugs, expertise, clinical and laboratory monitoring for efficacy and toxicity. Again, this issue is compounded by the unequal availability of such care among countries contributing to UN Peacekeeper forces. HIV positive persons in the military and in peacekeeping forces should be given the opportunity to perform the tasks for which they have been trained and for which they are fit to perform. For some, this may require the use of these treatment and prophylactic medications and it is our belief that these should be provided as needed and recommended for those living with HIV and AIDS. It must be recalled that the average length of time spent on a peacekeeping mission is 6-12 months. It is highly unusual for someone to spend more than one year on duty. Experience to date does not indicate that a large number of asymptomatic HIV-positive peacekeepers will require special health care services, although available information is limited. This may change as the HIV epidemic matures and spreads. Until recently, such therapies were available only to developed countries or individuals with substantial financial resources in developing countries. The cost of therapy, previously out of reach, has recently declined to a level that would allow for broader use both by the UN and developing country militaries. Surely, in certain cases the cost of health care for HIV-positive peacekeepers will be high, just as there are other unanticipated health problems that will consume a disproportionate share of resources. Until there is data to clearly demonstrate that HIV-positive peacekeepers are consuming too large a share of health care resources, it is inappropriate to use the hypothetical cost of health care as a basis on which to eliminate HIV-positive individuals from peacekeeping duties. If such data were available, mandatory testing would not be the only appropriate solution to avoiding untoward financial costs. Explicitly limiting UN liability for bearing the cost of such care, and providing individuals with the opportunity to be tested, would also be a policy option. In addition to the possible financial costs incurred by care provided during peacekeeping missions, the cost of post-mission care may also present certain dilemmas. Assume, for example, that the UN continues to have no mandate that all peacekeepers be tested for HIV before deployment. Some peacekeepers, after returning to their home countries, will be HIV-positive, and they are all likely to develop medical complications. Of those peacekeepers, a portion would have been HIV-positive prior to

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deployment, a portion would have become HIV-positive during deployment, and a portion would have become HIV-positive post-deployment. In accordance with UN guidelines, contributing countries may make claims for reimbursement to the UN for the cost of treating illnesses that were incurred while performing official duties with a peacekeeping force. If they demand payment from the UN for the cost of HIV-related medical care, will this create a significant expense? The answer clearly depends upon the guidelines followed by the UN in making compensation decisions. Were an HIV test required, and HIV-positive peacekeepers deployed, there would be some basis for refusing compensation in cases where HIV was clearly a preexisting condition, accepting that some infections in the window period would not be detected. Still, there would remain the problem of defining which illnesses are HIV-related. Without requiring an HIV test, it is impossible for the UN to know when someone was infected. It is therefore critical that clear liability rules be established. One possibility would be to break with past compensation patterns, under which even the care of sexually transmitted diseases has been covered. It is difficult to accept that STD's are "incurred while performing official duties with a peacekeeping force." Similarly, HIV is unlikely to result from official peacekeeping activities, and HIV-related medical complications can thus be explicitly defined as outside the scope of UN compensation. This makes irrelevant the question of when an individual was infected, although the difficulty of defining which medical complications are HIV-related remains. In short, it is not at all clear that the cost of medical care justifies a policy of mandatory testing. During mission, there is no present evidence demonstrating that significant costs will be incurred and were they to be incurred, they may be cost effective if the result is the maintenance of good health and performance. (Freedberg, 2001). After mission, clear liability rules could function to protect the UN from the potentially heavy burden of paying for the care of former peacekeepers with HIV-related disease. It is possible to anticipate two additional financial claims that may be presented by HIV-positive individuals to the UN. First, residents of host countries may assert that they have been infected by peacekeepers, and could demand that the UN cover the cost of medical care, or pay additional compensation. Second, residents of contributing country can claim that they have been infected by peacekeepers, who themselves were infected while on UN mission. These individuals may also press the UN to pay for the cost of HIV-related medical care, and possibly for more general damages for pain and suffering. Such third-party claims could appropriately be refused by the UN on the basis of clearly articulated liability rules. They are not justification for requiring that all peacekeepers be tested for HIV. B. Liability for Vaccine-Related Injuries In the US, a primary catalyst for the policy of mandatory HIV testing of military recruits was the case on an HIV-positive individual who developed disseminated vaccinia as a result of smallpox immunization received at basic training (Redfield, 1987; Herbold, 1986). It is reasonable to assure that other HIV-positive recruits did not at the time suffer similar injury. As discussed in section III above, while the literature is limited, there is theoretical but still (fifteen years after the US incident) limited additional empirical data to indicate that HIV-positive individuals will be endangered if they receive the live and killed vaccines recommended for other peacekeeping troops. Were convincing data available, and the UN had concerns about potential financial liability for adverse reactions, mandatory testing would be one possible way of reducing the pool of possible claimants. There are, however, other policy options. The UN could require that all peacekeepers receiving UN-administered vaccines be fully informed about the possibility of an adverse reaction in HIV-positive individuals, and offered the

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opportunity to take a voluntary HIV test. Those refusing to do so could be required to sign a waiver limiting UN liability for vaccine-related injuries resulting from an individuals HIV-positive status. At present, the medical data still does not warrant such a policy. C. Cost of Testing A final issue relevant to the financial justification of mandatory HIV testing of peacekeepers is the cost of implementing and sustaining a testing program. Most countries already have a policy of mandatory HIV testing of military recruits. Other countries lack adequate testing facilities and laboratories, and/or the necessary expertise to conduct pre-deployment HIV testing of peacekeepers. In such cases, the UN might be faced with a situation in which it will be called upon to provide testing facilities, provide lab technicians, or provide the funds to use other facilities. In countries that have the facilities and resources to test on their own, the UN would be required to establish a system by which the method, accuracy, and results of HIV tests administered by contributing countries were verified. Most peacekeepers are deployed for an average of 6 months, although some may remain in the field for as long as a year. Because of the six month window period (less with antigen testing) and the possibility of new infections, peacekeepers would have to be periodically retested. Every peacekeeper deployed to replace an existing peacekeeper would also require testing. The confidentiality of test results would have to be properly safeguarded. The costs of such a testing program are difficult to quantify. The actual cost of test kits, as well as administering and reporting the results of an HIV test, vary by nation and change periodically (Brown and Brundage, 1996; Brown and Burke, 1995). Balancing the potential financial cost to the UN of not requiring all peacekeepers to be HIV tested, with the cost of requiring such tests, yields an equation with two sums that remain uncertain. Our best estimate is that neither side of the financial equation is likely to be onerous if the UN articulates appropriate liability rules. Financial uncertainty does not provide adequate justification for imposing an HIV test on all peacekeepers. V. Are There Political Issues that Support a Policy of Mandatory Testing? Added to medical concern that HIV-seropositivity poses a danger to infected peacekeepers or others, and financial worries that HIV-positive peacekeepers are an inappropriate drain on the UN‟s finances, there is a final justification that has been offered for a mandatory testing policy for peacekeepers. It includes what we have termed political issues, though "ideological" would be an equally appropriate label. A. Peacekeeping has a Symbolic Role in International Relations A national military force is by definition partisan. It is constituted to protect the sovereignty and interests of a single country, and its allies, using force when necessary. Peacekeeping forces have a different mission. They are constituted from the troops of a spectrum of nations, and are not deployed to represent the interests of a single country or political system. Instead, they are sent to "trouble spots" so as to fulfill humanitarian functions. They are intended to be protective and beneficent. Above all they must avoid doing harm. From such a perspective, it is imperative that the UN do everything possible to protect the image and reputation of its peacekeeping operations, and to avoid the perception that peacekeepers are in some way infected, compromised, or dangerous. The question is whether deploying HIV-positive peacekeepers violates this norm of peacekeeping.

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An analogy to the deployment of HIV-positive peacekeepers is the employment of HIV-positive health care professionals. Like peacekeepers, health care providers are bound by a norm of beneficence, the Hippocratic injunction that they should do no harm. Like peacekeepers, they are responsible for taking care of unknown others who may fall under their care. Like peacekeepers, they must act in the best interests of those under their care. Health care providers are not required to be tested for HIV before undertaking their work. All health care workers are expected to take all necessary precautions to protect their patients, regardless of HIV status. Those who are aware that they are HIV-positive may continue to practice. Policy statements from major medical and public health bodies have opposed mandatory testing or disclosure of HIV status by health care workers, noting that the risk of transmission to patients is extremely low. Similarly, allowing peacekeepers to be deployed without requiring an HIV test does not violate the norms of peacekeeping operations. All peacekeepers, regardless of HIV infection, must act in a manner consistent with the goals of UN peacekeeping missions. Among the most important peacekeeping norms, and of particular relevance to HIV, is to respect the residents of host countries. This includes monitoring one's actions in order to avoid subjecting host country residents to undue risk. A comprehensive program of HIV education and prevention is one part of ensuring that peacekeepers who are in intimate contact with others take necessary precautions. Peacekeepers may inadvertently and in a variety of ways fall short of the norms that govern their mission. But there is nothing inherent in HIV-positive peacekeepers that makes them less worthy than those not infected with HIV of representing the UN as members of a peacekeeping force. B. Peacekeeping Missions are Subject to the Acceptance of Host Nations Although the special nature of peacekeeping operations does not require a policy of mandatory HIV testing of peacekeeping troops, it is critical to anticipate how particular host nations will react to the knowledge that HIV-positive peacekeepers may be deployed. It is possible that at some point the government of a host nation will predicate the acceptance of a peacekeeping mission on the mandatory HIV testing of all deployed peacekeepers. How the UN should react to such a demand is a political question beyond the scope of this document. From a medical perspective, however, the current state of HIV testing technology makes it impossible for the UN to certify that any group of peacekeepers is "HIV free." The possibility of false negatives, the existence of a window period, and the existence of new infections make such a claim untenable. Moreover, leaders of host countries may claim that by deploying HIV-positive peacekeepers the UN is "spreading AIDS." Peacekeepers from particular contributing countries may suffer discrimination and harassment from host country residents, who assume that every peacekeeper from country "X" or region "Y" is HIV-positive. In both of these cases, regional politics and local prejudice will have focused on the most ancient of nationalist symbols - infected foreigners - for domestic, narrowminded concerns. It is the role of the UN to set an example by overcoming such pressure and instead emphasizing the importance of educating the local population about HIV. In addition, the UN could demonstrate through its HIV/peacekeeping policy the importance of tolerance and respect for individuals that all peacekeepers deserve. To single out HIV-infected peacekeepers and exclude them from missions for political reasons could be taken as an indication that the UN will allow ignorance of medical and public health facts to frame international policy.

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VI. Conclusion The past decade has witnessed a tremendous dynamism in the quantity and visibility of peacekeeping missions. At its peak in the early 1990s there were almost 80,000 deployed peacekeepers; that figure has declined to some 48,000 military and international civilian personnel who were deployed in peacekeeping missions as of May 2001. (UN Department of Public Information) To some extent, variation in the number and intensity of peacekeeping missions is an important quality of the peacekeeping process. It is a sign that peacekeeping responds to international changes and needs. To retain the ability to rapidly deploy peacekeeping forces when necessary, the UN must apply consistent and credible medical standards for individual peacekeepers in contributing and host countries. One element of those standards is the articulation of a policy on HIV and testing that adheres to, or establishes a model for, the principle of fitness for work applied to other settings and medical conditions. In considering the numerous policy options, it is important to be cognizant of the current disparity in practice of member states, ranging from mandatory testing on financial grounds to voluntary testing justified on the basis of human rights. These differences reflect both a broad range of views on the appropriate criteria of a fitness for work standard, and disagreement on interpretation of medical and public health risk based on medical data which is of substantial concern but incomplete and limited. A fitness for work standard applied to HIV-infected peacekeepers can reasonably focus on three determinations; current fitness to perform all duties entailed by peacekeeping; the likelihood that one will remain fit for the 6-12 month duration of a peacekeeping mission; and risk to uninfected third parties. While future risk is a controversial aspect of the fitness for work standard, we believe that in the context of peacekeeping, where individuals will serve for a discrete and predictable length of time, fitness for the entire peacekeeping mission is a reasonable standard. If asymptomatic HIV infection does not preclude fitness for peacekeeping duties in any of those three ways, then most possible justifications for mandatory HIV testing are eliminated. HIV serologic status loses its effect as a measure of fitness for work in the peacekeeping arena. We interpret the evidence we have examined as consistent with a determination that asymptomatic HIV infection does not make an individual unfit for the work of peacekeeping. Three additional factors have regularly surfaced in discussions of fitness for work in the context of HIV testing and peacekeeping. One is the importance of safeguarding the health of individual peacekeepers. While the medical and public health data is incomplete, and open to different interpretations, we do recognize that HIV infection does likely result in an undefined but finite increase in health risk to an individual peacekeeper, which increases as HIV immunocompromise progresses in severity and in the presence of clinical symptomatology. We agree that protection of the health of peacekeepers is a laudable goal and responsibility, but it is not clear that mandatory testing is the most effective and least intrusive means to that goal. A program emphasizing education about HIV, discussion of the possible risks of peacekeeping to HIV-positive individuals, the availability of voluntary testing, and the provision for continued service and available standard of care treatment and support may be as good or better than required testing. Weighing these options necessitates that policy makers make a determination of the extent to which the individual autonomy of peacekeepers should be valued. The final two concerns, financial and political consequences to the UN of deploying HIVinfected peacekeepers, are distinct from determinations of fitness for work. While we do not intend to minimize the significance of such concerns, we do not think that they are appropriately considered in the context of the fitness to work as a peacekeeper. If a mandatory HIV testing policy were endorsed by the UN as appropriate for peacekeepers because of financial and political concerns, that justification should be clearly articulated and distinguished from exclusion based on individual fitness.

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As stated in the introduction, the medical literature bearing on HIV and peacekeeping is continually evolving. Future evidence could necessitate a reevaluation of the fitness of HIV-infected individuals to be deployed, and the appropriateness of a mandatory testing policy. Until new data is available, however, the weight of the evidence leads us to conclude that mandatory HIV testing of UN peacekeepers is not currently justified.

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