DoD's Global Arsenal
                                            by Marisa Cole

Combating HIV/AIDS: DOD’s Global Arsenal                     MHS Profiles
DoD's Global Arsenal
Testing for HIV/AIDS:
A member of the military
administers an HIV rapid
                                     Mozambique’s civil war ended
test in Kenya. DHAPP
encourages military and
                               almost 20 years ago, but soldiers
civilian populations to be
tested for HIV. Prevention,
                               continue to die. However, this time the
care, and treatment are
the keys to combating
                               enemy is more difficult to fight against
HIV/AIDS. (Photo Courtesy
                               because it is invisible, silent and deadly.
                               That new enemy is HIV/AIDS.

                              These are the words of Antonio        militaries to decrease the impact
                              Langa, the U.S. Department            of the disease, benefiting not only
                              of Defense HIV/AIDS Program           foreign militaries but also their
                              Manager in Mozambique – one of        surrounding civilian populations.
                              75 countries the DoD assists in       MHRP focuses on developing a
                              the global fight against HIV/AIDS.    safe, globally effective HIV vaccine
                                                                    to protect U.S. and foreign military
                              High HIV infection rates are both     members from infection and reduce
                              a national security issue for         the global impact of the disease.
                              disease-burdened countries and
                              a potentially destabilizing issue     DoD HIV/AIDS Prevention Program
                              globally. Worldwide, AIDS directly
                              impacts military readiness and               ,
                                                                    DHAPP based at the Naval Health
                              kills many more people than any       Research Center in San Diego, Calif.,
                              ongoing conflict.                     is the DoD Executive Agent for the
                                                                    technical assistance, management
                              The United States Department          and administrative support of the
                              of Defense recognizes the global      global HIV/AIDS prevention, care and
                              threat HIV/AIDS poses to U.S.         treatment for foreign militaries. DHAPP
                              national security – as well as that   administers funding, directly conducts
                              of the rest of the world – and is     training and provides technical
                              combating it through the efforts      assistance for focus countries and
                              of the DoD HIV/AIDS Prevention        other bilateral countries. DHAPP
                              Program and the U.S. Military HIV     oversees the contributions to PEPFAR
                              Research Program. Both programs       of a range of DoD organizations, which
                              receive funding from the U.S.         fall under the various regional military
                              President’s Emergency Plan for AIDS   commands, as well as specialized
                              Relief, and MHRP also receives        DoD institutions whose primary
                              a significant amount of funding       mission falls within the continental
                              from the Army and other federal       United States.
                              agencies, such as the National
                              Institutes of Health. DHAPP efforts   DHAPP’s efforts grew out of the
                              focus on working with foreign         U.S. Leadership and Investment

                                                                                    MHS Profiles
Radio Broadcast: Antonio Langa        for Fighting an Epidemic initiative,     are special systems and they need
(Left), Department of Defense HIV/    established in 2001 to combat HIV/       a special approach. These soldiers
AIDS Program program manager for      AIDS in Africa and India. It now has     are the protectors of nations, trained
Mozambique pictured here in the       implemented programs in 75 nations       to believe that they are invincible.
Mozambique Armed Forces Local         across Europe, Africa, Asia and          Helping them to deal with HIV really
Radio Station. The radio program is   Latin America – collaborating with       does take a special focus to help
driven by the Mozambican military.    a country’s military to support HIV      them support their unique risk
(Photo Courtesy DHAPP)                prevention programs that address         perceptions and behaviors.”
                                      the special risk factors of military
                                      personnel, as well as treatment          To provide for the unique needs
Education: DHAPP-funded Testing       and care programs for HIV-infected       of the military population, DoD
and Counseling event in Rwanda,
                                      individuals and their families.          hires partner country nationals to
                                                                               facilitate interactions between the
March 2008. (Photo Courtesy
                                      “There can be a tendency to feel that    DHAPP technical experts located at
                                      the military might not need special      its headquarters at the Naval Health
                                      attention,” says Dr. Anne Thomas, the    Research Center in Point Loma,
                                      DHAPP Director of Epidemiology and       San Diego, and the partner country
                                      Surveillance. “The fact is that these    military HIV/AIDS program leaders.

           I would describe my role as one of an actor in
   action/thriller movie. If I don’t fight for money to fund
   [military] activities, then the program does not exist.

        MHS Profiles                                                          Combating HIV/AIDS: DOD’s Global Arsenal
These country nationals provide   Mozambican minister of defense,         for money to fund activities, then the
invaluable support because they   the chief of the army and the           program does not exist,” Langa says.
are most familiar with the cultural
                                  director of national military health.   One program that Langa has
and political backdrop of their   His tasks range from discussing         worked tirelessly to support is
individual nations and therefore  annual plans with the Mozambican        the Mozambique Armed Forces
provide a unique perspective and  military,   to    overseeing     the    Local Radio Station Broadcast.
dedication to the programs.       training of military doctors and        The radio program informs soldiers
                                  nurses, to implementing military        about all aspects related to HIV/
One such individual is Antonio prevalence and behavioral studies.         AIDS, such as prevention and
Langa, a Mozambican national                                              risk reduction (male circumcision,
working for the U.S. DoD. He is “I would describe my role as one          condom use, partner reduction),
the main point of contact for DoD of an actor in an action/thriller       diagnosis (counseling and testing),
and PEPFAR activities directed movie. I’m the beginning and end of        care (opportunistic infections,
to the Mozambican military – whatever happens in benefit of the           tuberculosis, sexually transmitted
coordinating frequently with the Mozambican military. If I don’t fight    diseases),      and        treatment

Combating HIV/AIDS: DOD’s Global Arsenal                                                  MHS Profiles
 DoD HIV/AIDS                                                                             Community Education:
 Programs                                                                                 Community mobilization
                                                                                          event in Uganda. Integrating
 DoD is an implementing agency, along with seven                                          host nation militaries and
 other U.S. government agencies, supporting the                                           civilian populations is
                                                                                          crucial in providing HIV/AIDS
 PEPFAR mission.
                                                                                          education. (Photo Courtesy
 •	 DHAPP, located at the Naval Health Research Center in Point                           DHAPP)
    Loma, San Diego, is the DoD executive agent for HIV/AIDS
    Prevention Support to Foreign Militaries.

 •	 DHAPP engages in the international military cooperation of HIV/
    AIDS prevention, education, care, and treatment.

 •	 MHRP is centered at the Division of Retrovirology, Walter Reed
    Army Institute of Research in Silver Spring, MD.

 •	 MHRP is an international vaccine research program that
    successfully integrates HIV/AIDS prevention, care and treatment
    directly funded by PEPFAR.

(prevention    of    mother-to-child    equipment. The U.S. DoD brought
transmission, prevention with           in a team to train the Mozambicans
positives, anti-retroviral therapy).    on operating a military radio station
It includes live discussions with       – from gathering and processing
doctors and other relevant people       information, to broadcasting, to
with a telephone number that            monitoring and evaluation,” Langa
listeners can call to ask questions     says. “We found great acceptance of
on the air.                             the project since it is operated by the
                                        Mozambican military themselves.”
“The idea for the radio program was
inspired by the movie ‘Good Morning     The initial idea was to use a
Vietnam,’ and I just used the same      closed circuit radio (a DJ station
approach and converted it to focus      and speakers installed in selected
on health issues, with an emphasis      areas of the military base), but
on HIV/AIDS,” Langa says.               ultimately the project ended up
                                        as an FM radio station covering a
According to Langa, the project         much wider area around the military
presented logistical challenges,        base, therefore reaching more
but because the Mozambican              people. Because the radio program
military took ownership of the          also broadcasts to non-military
station, it became a success. “The      areas, it covers other public health
Mozambican       military accepted      issues as well. “The surrounding
the challenge and provided the          community benefits from the radio
space to install the station. They      program because they are able to
also identified young soldiers to       discuss health issues of interest to
be trained and operate the radio        them,” Langa says.

       MHS Profiles                                                               Combating HIV/AIDS: DOD’s Global Arsenal
Langa      describes     his     job       as the Seroprevalence and Behavioral       which in turn help the militaries to
as     “challenging,      rewarding,       Epidemiology Risk Survey, or SABERS.       fine tune their prevention programs.
impacting people’s lives, requiring        According to Thomas, who oversees          For example: Do they need to
imagination and critical thinking to       the survey effort, “The purpose is two-    promote condom use? Are condoms
find solutions to problems.”               fold: to determine HIV prevalence in       not available? Do they have to make
                                           foreign militaries and understand the      them more available? Or is there lack
Understanding the Burden of Disease        behavioral risk factors.”                  of education about different topics
                                                                                      like basic transmission or treatment?
Understanding the burden of                “The surveys support the militaries        Answering these questions leads to
disease is critical in formulating         in determining the level of infection in   more tailored education programs.”
the appropriate disease response.          their respective military populations,”
To accomplish that, over the years         Thomas says. “It gives them a better       DHAPP is supporting survey work in
DHAPP has deployed a series of HIV         idea of their clinical needs and           Mozambique, Botswana, Swaziland,
prevalence and risk surveys in many        allows more informed planning. They        Ethiopia, Rwanda, Southern Sudan,
active duty foreign militaries – known     also help define the behavioral risks,     Lesotho and Belize.

Combating HIV/AIDS: DOD’s Global Arsenal                                                             MHS Profiles
            Understanding the burden of
      disease is critical in formulating the
      appropriate disease response.

 Because every military is different,        She emphasizes that the work is not
 with varying internal capacities,           done alone. “Some countries have
 DHAPP supports and works with               a lot of internal capacity and others
 the partner militaries to design the        don’t. Some can do the data entry
 surveys and collect, enter and analyze      and analysis and some countries we
 the data. Thomas generally travels to       support with training and technical
 each of the countries to “get the ball      assistance. Implementing partners
 rolling.” She oversees and facilitates      are usually brought in to help, as our
 the work being done on the ground           staff is not big enough to support all
 along with the DHAPP Epidemiology           of the ongoing surveys.”
 and Surveillance team and also                                                                       Procession: MHRP
 helps form collaborative teams in           DoD and other PEPFAR-funded U.S.                         programs in Africa are
 each of the countries with the partner      government agencies support efforts                      very involved with the
 militaries, local U.S. Embassy, PEPFAR      such as SABERS as well as other types                    local community. For
 agencies and implementing partners.         of capacity development to achieve and                   HIV Vaccine Awareness
                                                                                                      Day they sponsored a
                                                                                                      marathon to increase
                                                                                                      community awareness
                                                                                                      and involvement. (Photo
                                                                                                      Courtesy MHRP)
DoD Global Fight Against AIDS
                                                                                                      Global Coverage:
DoD supports the fight against HIV/AIDS in host militaries                                            DHAPP and MHRP provide
and civilian communities in 75 countries around the                                                   HIV/AIDS prevention, care
world through strategic communication, human capacity                                                 and treatment programs
                                                                                                      and services in over 75
development, and program and policy development.                                                      countries worldwide.

These activities are accomplished through:    DoD and their in-country partners support:
•	 military-to-military assistance            •	 a wide range of HIV
                                                 prevention programs
•	 military-to-civilian assistance
                                              •	 infrastructure development and
•	 support to non-governmental                   support (including laboratory, clinic
   organizations and universities                and hospital facility renovation,
•	 collaboration with other U.S.                 equipment, and training)
   government agencies in country             •	 treatment and care activities

         MHS Profiles                                                               Combating HIV/AIDS: DOD’s Global Arsenal
sustain success for years to come          of a broader prevention effort to       ”This       extensive         network,
in the battle against HIV/AIDS. In         help control the epidemic,” notes       which includes state-of-the-art
doing so, they leverage each agency’s      Col. Nelson Michael, M.D., Ph.D.,       laboratories and clinical trial
technical expertise and strengths.         Director, Division of Retrovirology,    capabilities, allows MHRP to
                                           WRAIR and Director, MHRP The   .        conduct targeted research in parts
“We all try and use the best of what       integration    of    PEPFAR-funded      of the world hit hardest by the
everyone is doing. Each country is         prevention, care and treatment          epidemic.” Michael says.
unique in terms of what is available       services has helped MHRP build          Michael notes that PEPFAR has had a
on the ground — at the U.S.                strong and trusting relationships       tremendous impact in the last five years
government agency level and with           with the communities in which           in Kenya, Tanzania, Uganda, Nigeria
the partner military,” says Thomas.        research is conducted, while            and Thailand, where MHRP operates.
                                           providing an ethical framework for      “When I first visited Uganda in 1999,
MHRP HIV Research                          the conduct of HIV clinical research.   every other stall at the roadside

In 1986, Congress authorized
the U.S. Military HIV Research
Program at the Walter Reed Army
Institute of Research to protect
service personnel and serve the
global community by reducing
the risk of HIV. More than 20
years later, MHRP has become a
leader in international HIV vaccine
development efforts, with five
research sites in Africa and Asia.

“Given the significant threat of HIV
infection worldwide, an efficacious
vaccine is urgently needed as part

Combating HIV/AIDS: DOD’s Global Arsenal                                                           MHS Profiles
Left to Right: Dr. Fred Sawe,
Partner. Col. Nelson Michael,
M.D., Ph.D., Director, Division of
Retrovirology, WRAIR and Director
MHRP. (Photos Courtesy DMHRP)
. Dr. Anne Thomas, DHAPP Direc-
tor of Epidemiology and Surveil-
lance. Antonio Langa, DHAPP Pro-
gram Manager in Mozambique.
(Photos Courtesy DHAPP).

           An efficacious HIV vaccine is urgently needed given the
   significant threat of HIV infection worldwide.

                                                                                         markets had coffins for sale. They
Major Accomplishments of MHRP:                                                           virtually lined the road. In contrast, on
                                                                                         a recent trip I saw that only a few stalls
MHRP has made great strides forward toward finding                                       were selling coffins. I’m convinced this
an HIV vaccine.*                                                                         is due to effective HIV prevention and
                                                                                         treatment programs, which are funded
                                                                                         through PEPFAR,” he says.
•	 Led first HIV vaccine trial to show that an investigational HIV vaccine
   regimen was safe and modestly effective at reducing the rate of HIV
                                                                                         HIV Vaccine Progress
   infection (RV144 in Thailand)

•	 First to identify heterosexual transmission of HIV-1                                  MHRP led an Army-sponsored HIV
                                                                                         vaccine trial that, for the first time,
•	 Developed the initial HIV disease staging system                                      demonstrated modest effectiveness
                                                                                         in preventing HIV infection, reducing
•	 Supported early diagnosis, comprehensive care and prevention and                      the potential to contract HIV by about
   DoD policy development to retain Active Duty Soldiers                                 31 percent. The study, RV 144, was
•	 Characterized more than half of the known HIV genetic subtypes
                                                                                         conducted in Thailand and involved
                                                                                         more than 16,000 Thai men and
•	 Developed extensive clinical research infrastructure in East Africa and S.E. Asia     women. It was sponsored by the
                                                                                         U.S. Army Surgeon General and
•	 Successfully implemented HIV Care and Treatment Programs in Africa                    conducted by the Thailand Ministry
   (PEPFAR). In the four African countries MHRP has supported since 2004:                of Public Health. MHRP at the Walter
      •	 72,000 have been enrolled on anti-retroviral therapy (ART)
                                                                                         Reed Army Institute of Research,
                                                                                         U.S. Army Medical Research and
      •	 1.16 million have received voluntary counseling and testing, and                Materiel Command, provided overall
         received their results                                                          project leadership, and the U.S.
      •	 390,000 women have been helped through prevention of mother                     Army Medical Component – Armed
         to child transmission efforts
*as of March 30, 2009

             MHS Profiles                                                              Combating HIV/AIDS: DOD’s Global Arsenal
Forces Research Institute of Medical
Sciences executed the trial in Thailand
on behalf of the sponsor.

“This is the first evidence that a
prime-boost HIV vaccine regimen
may prevent infection and represents
a significant step forward for vaccine
research,” Michael says.

Michael has been with MHRP since
1989 and took over as director in
2006. He and his colleagues have
been battling this evasive disease         Looking ahead, Michael and his team      Research: Laboratories at the
for more than 20 years together. “We       are hopeful. “This is the end of the     Armed Forces Research Institute
were both humbled and gratified by         beginning for HIV vaccine research.      of Medical Sciences in Thailand,
this discovery that it was possible        We have now shown that the 26            where a recent clinical trial of a
for an HIV vaccine to prevent HIV          year global effort into developing HIV   HIV vaccine combination showed
infection, albeit only modestly. We all    vaccines has not been in vain.”          modest success. MHRP has
have much more work to do, but the                                                  five state-of-the-art research
door is now open,” Michael says.           Integrating Prevention, Care             laboratories on three continents
                                           and Treatment                            that support international vaccine
RV 144 was the largest HIV vaccine                                                  development efforts. (Photo
trial ever conducted, and trial            To    accomplish     the     research
                                                                                    Courtesy DHAPP)
volunteers were from a population at       mission at its sites in Africa, MHRP
“community” risk for infection. “This      integrates HIV prevention, care and
was the first HIV vaccine efficacy study   treatment, and vaccine development
to be done in people at moderate risk      into one comprehensive initiative.
for HIV infection largely as a result      Its philosophy is that a credible
of heterosexual exposures,” notes          prevention program must accompany
Michael. “Much more research will be       any vaccine research study and that,
needed to understand how it protected      in resource-poor settings, medical
some people from infection.”               benefits including comprehensive

Combating HIV/AIDS: DOD’s Global Arsenal                                                      MHS Profiles
       This is the end of the beginning for
HIV vaccine research. We have now shown
that the 26 year global effort into developing
HIV vaccines has not been in vain.

 HIV care and treatment must be             which has been the foundation for HIV
 available to the entire community,         care and treatment activities in this
 not just to research volunteers.           region of Kenya. The PMTCT program
                                            now includes 260 clinics, and the
 “In Africa, you have either been           team has provided HIV counseling and
 infected or affected by the disease.       testing to more than 260,000 women.
 None of us have been left untouched
 by the epidemic,” says Dr. Fred Sawe,      Without intervention, up to 40 percent
 MBChB, MMED, who is one of MHRP’s          of HIV-infected pregnant women
 partners in Kenya. HIV prevention and      will infect their babies, and the
 testing are critical to stemming the       transmission rates in Africa are still
 spread of the disease, and Sawe notes      too high because of lack of access to
 that the availability of anti-retroviral   preventive services. According to Sawe,
 therapies has helped destigmatize          “We have the science, technology and              Group: DHAPP
 HIV. “Suddenly people are willing to be    resources to reduce MTCT of HIV to                Seroprevalence and
 tested because it is no longer a death     less than 2 percent; what is needed is            Behavioral Epidemiology
 sentence,” he says.                        the will to implement effective PMTCT             Risk Survey, or SABERS
                                            interventions.” He added that the                 Survey Team in 2006,
 By the nature of its design and            program has had a positive impact. “To            for HIV prevalence and
 extensive local collaborations, the        be able to tell a pregnant HIV-infected           behavioral risk study.
 program not only provides treatment        woman that with interventions she                 DHAPP supports and works
 for individuals, but also helps            can live to become a grandmother to               with the partner militaries
 develop a sustainable capacity             the children of her unborn baby was               to design the surveys and
 among the health care facilities           beyond our imaginations a few years               collect, enter and analyze
 and local partners to serve long           ago,” Sawe says.
                                                                                              the data.
 term community needs. In Kericho,
 Kenya, the program, known locally as       Moving Forward in the Global
 the Walter Reed Project, has more          Fight Against HIV/AIDS
 than 180 employees—all but two of
 whom are Kenyans—who support               While the programs and initiatives
 its research and PEPFAR activities.        profiled here merely scratch the
 “Our program is run by the sons and        surface of the impact DoD is having
 daughters of the community we are          in the countries where it is operating,
 working in,” Sawe says.                    they prove that DoD’s pursuit of HIV/
 Since 2001, Sawe has been                  AIDS prevention, care and treatment
 instrumental in building Kericho’s         activities with foreign militaries is
 Prevention of Mother to Child              critical in combating the disease
 Transmission of HIV infection program,     globally. The disease burden has

    MHS Profiles                                                            Combating HIV/AIDS: DOD’s Global Arsenal
clear ties to security interests, regional
stability,   humanitarian      concerns,       PEPFAR
counterterrorism and peacekeeping              In 2003 President Bush launched the U.S. President’s
efforts because of its destabilizing           Emergency Plan for AIDS Relief to combat global HIV/AIDS
effect in developing societies.
                                               with $15 billion in funding - the largest commitment by any
                                               nation to combat a single disease in history.
With     the     U.S.     government’s
commitment of additional PEPFAR
funding through 2013, combating HIV/           On July 30, 2008 President Bush expanded commitment to
AIDS remains a U.S. priority. DoD, as          PEPFAR for five additional years, from 2009 through 2013,
a key implementing agency of PEPFAR,           with $48 billion to address HIV/AIDS, TB and malaria.
is ensuring that enough people are
trained, the necessary research is             The PEPFAR mission is implemented through the unified
being done and the right systems are           efforts of seven U.S. Government agencies:
in place to guarantee strong human
and organizational capacity for future         •	 Department of State
generations. In the long run, the best         •	 U.S. Agency for International Development
programs are run by partner countries.
Working together, these programs can           •	 Department of Commerce
help contain the global HIV/AIDS threat        •	 Department of Labor
to public health and national security
                                               •	 Department of Health and Human Services
in the United States and worldwide.
                                               •	 Peace Corps
Lisa Reilly, MHRP Director of
                                               •	 Department of Defense
Communications, contributed to this article.

Combating HIV/AIDS: DOD’s Global Arsenal                                                 MHS Profiles
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