U.N. Peacekeeping: United Nations Faces Challenges in Responding to the Impact of HIV/AIDS on Peacekeeping Operations
Published: 2001-12-12T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Last year, the U.N. Security Council passed a resolution expressing concern that the conflicts and instability associated with peacekeeping operations produce condition that could increase the spread of the human immunodeficiency virus (HIV). The resolution encouraged member states to educate peacekeeping personnel--including those who are HIV positive--on peacekeeping missions. The policies and guidance of the U.N. Department of Peacekeeping Operations discourage, but do not preclude, countries from sending individuals who are HIV positive on peacekeeping missions. This is consistent with the U.N. peacekeeper's code of conduct to do no harm. This is also consistent with the U.N.'s stated opposition to discrimination against those who are HIV positive. The number of HIV-positive peacekeepers is unknown because (1) the U.N. opposes mandatory HIV testing and collects no information on infection rates and (2) countries that contribute peacekeepers either do not test or do not share test results with the U.N. The U.N. has tried to reduce the spread of HIV during peacekeeping operations, but it faces immediate and long-term challenges. U.N. officials said that the U.N. has not given this effort enough priority and that it has been difficult to obtain funding for HIV prevention efforts. Moreover, little has been done to help civilian populations at risk of HIV infection from U.N. peacekeepers.

section_title: Letter
paragraphs: In July 2000, the United Nations Security Council passed a resolution  expressing serious concern that the increased risk of Human  Immunodeficiency Virus/Acquired Immunodeficiency Syndrome  (HIV/AIDS) in conflict situations could adversely affect peacekeeping  missions.  The Security Council resolution noted that an environment of  conflict and instability produces large movements of people and reduced  access to medical care, which increases the risk of HIV transmission.  The  resolution expressly encouraged member states to provide HIV prevention  training to peacekeeping personnel, including those troops who may be  HIV positive.  In January 2001, the U.S. Ambassador to the United Nations  expressed concern that the United Nations had not yet initiated an  adequate response to the Security Council’s concerns and, in particular, the  risk of transmission between peacekeepers and civilian populations.
Given the importance of U.N. peacekeeping efforts to U.S. foreign policy  goals and the approximately $700 million contributed to the United Nations  by the United States for these efforts in fiscal year 2001, you expressed  concern that HIV/AIDS infection could undermine the effectiveness of U.N.  peacekeeping operations. This report responds to your request that we  examine U.N. efforts to mitigate the potential impact of HIV/AIDS on its  peacekeeping missions. In this report, we (1) analyze U.N. policies and  guidance on the use and deployment of peacekeepers with HIV, (2)  examine the data available on HIV/AIDS prevalence rates among  peacekeepers, (3) assess actions the United Nations is taking to limit the  spread of HIV/AIDS among peacekeepers, and (4) examine the actions the  United Nations is taking to limit the impact of HIV/AIDS on civilians  affected by armed conflict, including groups who may come into contact  with peacekeepers.
As part of our review, we analyzed documents and interviewed key officials  from the U.N. Department of Peacekeeping Operations, the Joint United  Nations Programme on HIV/AIDS, the World Health Organization, the  United Nations Children’s Fund, the U.N. Population Fund, and other U.N.  agencies.  We also obtained perspectives on U.N. policies and activities  from officials of the State Department and the Department of Defense. In  addition, we researched and reviewed the limited data available on HIV  prevalence rates for the uniformed services. Appendix I provides a more  detailed description of our scope and methodology.
subsections: section_title: Background
paragraphs: The U.N. Department of Peacekeeping Operations (DPKO) serves as the  operational arm of the U.N. Secretary General for all U.N. peacekeeping  operations and is responsible for conducting, managing, directing,  planning, and preparing those operations. DPKO is currently operating 15  peacekeeping missions, as shown in figure 1, at a budgeted cost of  approximately $2.7 billion for 2001.  As of September 2001, 88 countries  were contributing 46,957 military and civilian police personnel, and  countries are reimbursed about $1,000 per peacekeeper per month for  contributing to these missions. (See app. II for a list of the countries  contributing U.N. peacekeepers as of September 2001.)  The United States  currently contributes 732 peacekeepers and pays for 25 percent of the total  cost of peacekeeping operations. Three U.N. peacekeeping missions are in  sub-Saharan Africa, where more than 25.3 million people have HIV/AIDS.
We recently reported that several challenges hinder the ability of the  international community to address the growing HIV/AIDS pandemic,  including limited funding for programs, cultural impediments to program  effectiveness, and weak national health care systems.  Conflicts  exacerbate these challenges because the organizations that deliver  HIV/AIDS prevention and awareness programs are unable to function  normally.  In these situations, vulnerable populations–including refugees,  internally displaced persons, orphans, ex-combatants, commercial sex  workers, and war-affected local civilians–face increased risk of exposure to  HIV.  Refugees, internally displaced persons, and orphans are particularly  vulnerable to HIV infection because they are at high risk of sexual violence  and exploitation and because they may use sex as a commodity to survive.  Peacekeeping missions bring peacekeepers in close proximity to these  populations.
In resolution 1308, passed in July 2000, the U.N. Security Council  recognized that in conditions of conflict, violence, and instability there is  increased risk of exposure to HIV. Resolution 1308 encouraged U.N.  agencies to take action with member states to develop strategies to  mitigate the spread of HIV/AIDS in peacekeeping missions. In addition, the  resolution directed the Secretary General to take additional steps to  develop and provide training to peacekeepers on HIV/AIDS awareness.
section_title: Department of Peacekeeping’s Policy Discourages but Does Not Preclude Deployment of HIV- Positive Peacekeepers
paragraphs: DPKO recommends that countries contributing to U.N. peacekeeping  operations should not send HIV-positive individuals on peacekeeping  missions for three reasons. First, medical treatment available during the  peacekeeping mission may not be adequate to meet the special  requirements of peacekeepers with HIV.  Second, peacekeepers may have  to undergo predeployment vaccinations and may be exposed to diseases  during deployment, both of which pose additional risks to their health.  Third, the presence of HIV-positive peacekeepers poses the risk of  transmission to medical personnel, fellow peacekeepers, and the civilian  population.
DPKO officials point to the third factor as weighing heavily in their  recommendation not to deploy HIV-positive individuals.  The U.N. Code of  Conduct for Peacekeepers, although it does not address specific sexual  conduct, states that peacekeepers should do no physical, sexual, or  psychological harm.  To minimize the risk of spreading HIV to the local  population in the peacekeeping zone, DPKO officials recommend that  individuals with HIV not be sent on peacekeeping missions.
While DPKO policy recommends against deploying individuals with HIV, its  policy also states that those who do not show clinical manifestations of  AIDS are not precluded from peacekeeping service. Therefore, DPKO  policy is consistent with the overall policy of the United Nations, which has  gone on record in several documents expressing its concern for the human  rights of individuals with HIV/AIDS and taking a stand against  discrimination against such individuals.  Specifically, the General Assembly  in a December 1991 resolution (Res. A/RES/46/203) urged U.N. member  states to avoid taking discriminatory action against individuals with HIV in  employment.  In addition, the United Nations has stated that, in general, a  public health exception to the principle of nondiscrimination, even in the  case of HIV/AIDS, is seldom a legitimate basis for restrictions on human  rights. U.N. guidelines state that mandatory testing or registration for HIV  status is not justified on public health grounds.  Finally, the U.N.’s  personnel policy states that (1) the only medical criterion for recruitment is  fitness to work; (2) HIV infection does not, in itself, constitute a lack of  fitness to work; (3) there will be no HIV screening of candidates for  recruitment; and (4) there should be no obligation on the part of the  employee to inform the employer about his or her HIV/AIDS status.
section_title: The United Nations Does Not Know How Many Peacekeepers Have HIV
paragraphs: The United Nations does not know how many peacekeepers have HIV/AIDS  because it opposes mandatory HIV testing before, during, or after  deployment to a peacekeeping mission and because contributing countries  either do not test or do not share test results with the United Nations.  Officials remain concerned that peacekeepers with the infection may be  deployed on peacekeeping operations, especially the approximately 14  percent of peacekeepers that come from countries with high HIV/AIDS  prevalence rates, such as Nigeria and Kenya. Even if they are not infected  before deployment, peacekeepers—like other military personnel—are  likely to engage in behaviors such as unsafe sexual practices that increase  the risk of contracting and spreading HIV.
subsections: section_title: The United Nations Does Not Collect Data on the HIV Status of Peacekeepers
paragraphs: The United Nations opposes mandatory testing of peacekeepers for HIV  before, during, or after deployment to a peacekeeping operation. It  therefore does not know whether countries are sending HIV-positive  individuals to peacekeeping operations or how many individuals with HIV  or AIDS make up its peacekeeping forces. As a result, while the media have  reported a handful of cases of peacekeepers spreading or contracting HIV,  there is little direct information on the extent of HIV transmission in  peacekeeping operations.  (See app. III for a description of the information  available.) Furthermore, because the United Nations opposes mandatory  testing and because contributing countries retain control over their own  forces, DPKO cannot direct countries to test or keep data on HIV  prevalence among their peacekeeping forces.
HIV testing policies vary widely among contributing countries. Some  contributing countries do not test their personnel for HIV and have no data  to share with the United Nations. For example, according to DPKO and the  Department of Defense (DOD), the United Kingdom, the Netherlands, and  Nigeria, among other countries, do not screen military personnel for HIV.  Also, Zambia’s military, which at one time conducted testing and screening  for HIV, is no longer financially able to do so. Together, these four countries  account for about 11 percent of current peacekeeping forces.
Some militaries test their troops intermittently and may test peacekeepers  before, during, or after a peacekeeping operation. However, data from  these tests are not always shared with the United Nations. For example,  according to DOD, South Africa has conducted HIV testing of its rapid  deployment force used for peacekeeping operations, although it is  unknown if any of these individuals were precluded from peacekeeping  service. According to a member of the UNAIDS Steering Committee on  HIV/AIDS and Security, countries may consider this information vital to  national security because it could be considered a strategic weakness. In  addition, countries might not release this information because doing so  may jeopardize both their standing as peacekeeping contributors and the  revenue they receive in return for their participation. On the other hand, an  HIV/AIDS expert at DOD, who works closely with militaries, stated that  even those countries that test may not know the HIV/AIDS prevalence rates  of their militaries because they do not capture, store, or analyze the data  that result from the tests.
section_title: Some Peacekeepers Come From Countries With High HIV Prevalence Rates
paragraphs: Although the United Nations does not know how many peacekeepers have  HIV, many come from countries with relatively high HIV prevalence among  the general population, leading to expectations of high prevalence among  the military, including peacekeepers. UNAIDS estimates that military  personnel are two to five times more likely than civilians to contract a  sexually transmitted infection, including HIV. In addition, according to the  National Intelligence Council, HIV prevalence in African militaries is  considerably higher than that of the general population. For example, the  Council estimates that between 10 and 20 percent of Nigeria’s military is  HIV-positive, compared to a 5-percent prevalence rate for the general  population. Nigeria is the largest African contributor to U.N. peacekeeping  operations.
More than 14 percent of peacekeepers come from countries where the  adult HIV prevalence rate is greater than 5 percent (see table 1).  According  to public health experts, prevalence levels this high make it significantly  more likely that uninfected persons in the population will be exposed to the  infection.  The higher the prevalence rate in a population, the more rapidly  the infection will spread.  The situation is most pronounced in Sierra  Leone, where 32 percent of peacekeepers originate from countries with  HIV prevalence rates greater than 5 percent.
section_title: Conditions Are Conducive to the Spread of HIV/AIDS in Peacekeeping Operations
paragraphs: Peacekeepers operate in an environment where exposure to HIV is more  likely. Because peacekeepers often have money to spend, commercial sex  workers, known to have high rates of HIV infection, migrate to areas where  peacekeepers are deployed.  For example, in Ethiopia, where a U.N.  peacekeeping operation is ongoing, sex workers were found to have HIV  prevalence rates exceeding 70 percent. In addition to the presence of  commercial sex workers, peacekeeping operations are surrounded by  populations of orphans, internally displaced persons, and refugees.   According to UNAIDS, these populations may have sold sex to survive and  may have been the victims of rape or sexual violence during the conflict  preceding the peacekeeping operation.
According to DPKO, there has been only one confirmed case of a member  of a peacekeeping mission transmitting the HIV infection.  At the same  time, there have been a number of media reports of peacekeepers  contracting HIV while on a peacekeeping mission.  However, very few have  been confirmed. According to DPKO, two Bangladeshi peacekeepers  contracted the infection in Cambodia in 1993 and one in Mozambique in  1994. In addition, a medical study in 1995 found that 10 Uruguayan  peacekeepers had contracted HIV while on a U.N. peacekeeping mission in  Cambodia.
Despite the absence of data, U.N. and U.S. government officials have  expressed concern that peacekeepers may be transmitting or contracting  the virus during peacekeeping operations.  Surveys of military personnel  indicate that many do not practice safe sex. For example, according to the  U.N. Population Fund, a study of the Ukrainian military showed that only  10 percent of the officers surveyed practiced safe sexual behavior—that is,  consistent condom use and one faithful partner—while 28 percent of the  officers surveyed reported having multiple sexual partners.  In addition,  according to DOD, on a 2000 training operation in South America, about 30  percent of U.S. sailors reported having sexual contact while in ports of call,  with about 15 percent of this group saying they did not always use a  condom.  In addition, according to UNAIDS, 45 percent of Dutch  peacekeepers in Cambodia had sexual relations with commercial sex  workers or members of the local population over a 5-month period in 1993,  with approximately 11 percent of that group saying they did not always use  condoms.
section_title: U.N. Efforts to Address the Impact of HIV/AIDS on Peacekeepers Face Challenges
paragraphs: The United Nations has initiated a number of activities to address the  impact of HIV/AIDS on the health of peacekeepers. However, these  prevention efforts face immediate obstacles that may impact their  implementation. In addition, the long-term success of U.N. efforts will be  difficult to ascertain due to the lack of baseline data on the knowledge and  awareness of HIV/AIDS or on the sexual behavior of the contingents that  make up its uniformed forces.
subsections: section_title: Implementation of U.N. Efforts Faces Immediate Obstacles
paragraphs: DPKO has focused its HIV/AIDS efforts on three interventions: (1)  development and distribution of an HIV/AIDS awareness card, (2) training  in HIV/AIDS prevention, and (3) the distribution of condoms. However, it is  unclear if all contingents are implementing DPKO’s interventions, there are  gaps in DPKO’s HIV/AIDS training curriculum, and not all contingents may  make condoms readily available to peacekeepers under their command.
subsections: section_title: DPKO Begins Distribution of HIV/AIDS Awareness Card
paragraphs: Figure 2 displays the HIV/AIDS awareness card for peacekeepers.   Developed jointly with UNAIDS, as of September 1, 2001, the card was  available in English, French, and Russian.  The awareness card includes  facts about the disease and contains a pocket for a condom.  The card  states that AIDS is a deadly disease caused by the HIV virus and describes  methods of protection against the disease.  The back of the card provides a  code of conduct calling for pride, respect, and consideration for law,  customs, and traditions. The card also states that peacekeepers should  limit alcohol use and avoid illegal drugs because they impair judgment and  can lead people to take risks they may not otherwise take.
By September 2001, DPKO had distributed 15,000 HIV/AIDS awareness  cards to peacekeeping contingents in Sierra Leone.  According to DPKO,  the official responsible for HIV/AIDS activities in Sierra Leone gave the  contingents a lecture on HIV awareness when the cards were delivered to  each contingent. DPKO leaves it up to contingents to include a condom  with the card. DPKO plans to distribute the HIV/AIDS awareness card to  U.N. peacekeeping operations in Ethiopia/Eritrea, Congo, East Timor, and  Kosovo.  In addition to being written in English, French, and Russian, the  card is expected to be produced in Kiswahili, Arabic, Hindi, Bengali, Urdu,  Spanish, and Portuguese.  These represent the primary languages of 90  percent of the nationalities serving in peacekeeping operations worldwide.   Since the contributing countries are responsible for the conduct of their  forces, DPKO officials stated they are not certain if all peacekeepers will  carry the card.
As part of its train-the-trainer program, DPKO provides senior officers from  contributing countries with an intensive 2- to 3-week peacekeeper training  program. The HIV/AIDS training is comprised of several modules on the  impact of HIV on the military; the link between HIV, other sexually  transmitted infections, and substance abuse; HIV risk assessment;  prevention strategies; and behavior change. The contributing countries are  responsible for ensuring that peacekeepers receive training before and  after deployment.
Effective implementation of DPKO’s HIV/AIDS training faces some  immediate obstacles.  First, the curriculum was developed in the United  States and does not address issues specific to some cultures. For example,  cultural practices in some parts of sub-Saharan Africa, such as social  acceptance of multiple sex partners for males and females, increase the  rates of sexually transmitted infections, including HIV/AIDS.  Therefore,  according to the U.S. Agency for International Development (USAID),  training should be adopted to specifically address the risky behaviors  unique to peacekeepers in question.  Second, although gender issues are  broadly addressed in the train-the-trainer program, according to the U.N.  Development Fund for Women, the current HIV/AIDS training curriculum  does not adequately address gender issues necessary to sensitize  peacekeepers to respect girls and women rather than viewing them as  sexual commodities.  Third, according to UNAIDS, the training is too  technical and requires trainers to have a medical background. In addition,  HIV training competes with other training priorities, such as land mine  awareness. Finally, because DPKO does not routinely monitor whether the  contingents provide the training, it does not know whether peacekeepers  received the training before and after being sent to the mission.
section_title: Unclear Whether All Contingents Make Condoms Readily Available to Peacekeepers
paragraphs: DPKO provides contingents with five condoms per troop per week. DPKO  procures condoms for peacekeepers primarily from the U.N. Population  Fund, delivers them to the commanders of each contingent, and makes  them available in bathrooms, nightclubs, and other venues frequented by  peacekeepers. DPKO relies on the commanders of each contingent to  distribute the condoms to their contingents.
However, universal distribution of condoms to all peacekeepers faces  religious and cultural obstacles. According to DPKO, commanders from  south Asia and the Middle East object to making condoms readily available  to their uniformed forces because sex with prostitutes outside of marriage  is against their religious beliefs and would indicate tacit approval of such  behavior.  In addition, because DPKO does not routinely monitor condom  distribution, it does not know whether peacekeepers have access to  condoms.
section_title: Success of U.N. Efforts Will Be Difficult to Determine
paragraphs: The long-term effectiveness of the awareness card, HIV prevention training,  and condom distribution will be difficult to determine. UNAIDS and DPKO  have not collected baseline data on troop knowledge and awareness of  HIV/AIDS or sexual behavior. Baseline data are essential to evaluating the  impact of interventions such as the HIV/AIDS awareness cards and training  on peacekeeper knowledge and behavior. For example, U.N. officials  recognized that the awareness card has not been tested or proven to be an  effective HIV/AIDS intervention. In spite of this, U.N. officials agreed to get  the cards to the field as soon as possible in Sierra Leone, recognizing that  the time spent pretesting and gathering data would delay the rollout.  According to USAID, surveys of sexual behavior are needed for measuring  condom use, which is expected to increase as a result of successful HIV  awareness and training and serves as a proxy for estimating HIV  transmission. Officials at DPKO stated that they are in discussions with the  U.S. Centers for Disease Control and DOD on the development of a data  collection instrument to gather baseline data on HIV/AIDS knowledge and  sexual behavior of peacekeepers.
section_title: U.N.’s Effort to Provide HIV/AIDS Assistance to Civilians Affected by Conflict Faces Difficulties
paragraphs: The United Nations has begun to address the spread of HIV/AIDS among  civilians affected by armed conflict; however, according to U.N. officials, it  does not give adequate priority to this effort and faces challenges obtaining  funding.  Furthermore, the United Nations has taken little action to target  populations specifically at risk of HIV transmission from peacekeepers.
subsections: section_title: U.N.’s Effort to Address HIV/AIDS in Emergencies Is Inconsistent and Faces Funding Obstacles
paragraphs: Although U.N. agencies are implementing programs to provide HIV/AIDS  education and care to populations affected by armed conflict, according to  U.N. officials, the United Nations has not consistently given these programs  priority and faces challenges in funding them.  For example, the U.N.  Children’s Fund’s (UNICEF) has trained young people in post-conflict  situations to be peer educators on HIV/AIDS, and the U.N. Population Fund  has provided condoms and reproductive health kits in emergency  situations (see app. IV for other efforts).  According to U.N. officials, U.N.  agencies that supply emergency assistance have not traditionally focused  on HIV/AIDS and have been reluctant to address HIV/AIDS because they  have not always viewed it as part of their mandate. U.N. officials also  report that U.N. agencies have not consistently included HIV/AIDS  programs in their appeals for funding in complex emergencies.  In addition,  U.N. officials report that due to a lack of cooperation, different U.N.  agencies work on small-scale, ad hoc projects that tend to cover similar  areas while leaving program gaps in other areas.  In regard to funding,  participants at the 2001 Inter-Agency Task Team on HIV/AIDS and Children  in Conflict noted that HIV/AIDS programs have been underfunded because  of a lack of response from U.N. member states.
section_title: The United Nations Has Taken Little Action to Assist Populations at Risk of Contracting HIV From Peacekeepers
paragraphs: Efforts to assist civilian populations at risk of contracting HIV from  peacekeepers are a subset of the U.N.’s overall effort to address  populations affected by armed conflict.  While the United Nations has  recognized the importance of assisting groups that might be at risk of HIV  transmission from peacekeepers, to date it has taken little action. At the  Expert Strategy Meeting on HIV/AIDS and peacekeeping in December  2000, delegates noted an urgent need to provide appropriate information  and services to populations affected by peacekeeping operations.   In  response, DPKO now participates in some country-level HIV/AIDS theme  groups even though there is no written policy requiring this participation.
UNAIDS has agreed to help fund personnel to serve as HIV/AIDS policy  officers in each of the five largest peacekeeping operations.  However,  DPKO has only appointed a focal point in Sierra Leone, and DPKO and  UNAIDS are still discussing whether this focal point will become the HIV  officer for that operation.
section_title: Conclusions
paragraphs: The United Nations recognizes that HIV/AIDS is a security issue that  threatens the effectiveness of U.N. peacekeeping missions. DPKO policy,  which discourages but does not preclude countries from sending  individuals with HIV on peacekeeping missions, underscores the tension  between the U.N.’s peacekeeping policy and increased concern about the  threat of HIV/AIDS.  Legitimate concerns have been raised regarding both  the stigmatization of peacekeepers who may have HIV/AIDS and the  potential risk that they could transmit the disease to local populations.   Because of the U.N’s opposition to mandatory HIV-testing and contributing  countries’ wide variance in testing potential peacekeepers for HIV, DPKO  has no knowledge of the HIV/AIDS prevalence rates among its contingents.   Without this information, DPKO will find it difficult to focus interventions  on the peacekeepers at highest risk of transmitting HIV.  In fact, without  routine monitoring of how the contingents implement DPKO’s efforts,  DPKO does not know if peacekeepers receive training or have access to  condoms.
section_title: Recommendations for Executive Action
paragraphs: To improve the United Nation’s ability to (1) measure the effectiveness of  activities aimed at reducing risky behaviors among peacekeepers and (2)  identify which contingents are at highest risk of transmitting or contracting  sexually transmitted infections, including HIV, at each mission, we  recommend to the Secretary of State and the U.S. Permanent  Representative to the United Nations that they request the U.N. Secretary  General and the Executive Director of UNAIDS to  develop and conduct behavior surveys of U.N. peacekeeping  contingents to gather baseline and follow-up data on peacekeepers’  knowledge and awareness of HIV/AIDS and their sexual behavior; and  analyze information gathered from these surveys to measure the  effectiveness of their efforts and to identify which contingents are at  highest risk of transmitting or contracting sexually transmitted  infections, including HIV, at each mission to better target resources.
section_title: Agency Comments
paragraphs: We received oral comments from DOD and written comments from the  Department of State and UNAIDS.   The written comments from the  Department of State and UNAIDS are reprinted in appendixes V and VI.   In  addition, the Department of State and UNAIDS provided technical  comments to update or clarify key information.  We incorporated these  comments where appropriate.
DOD officials stated that the report was well written and that it accurately  assessed the current situation with regard to HIV prevalence among U.N.  peacekeepers.  DOD agreed with our recommendations.
The Department of State stated that it will continue to consult with U.N.  agencies involved in HIV/AIDS programs and peacekeeping operations to  encourage programs to raise the level of HIV/AIDS awareness and reduce  risky behaviors among U.N. peacekeepers, as well as efforts to measure the  effectiveness of programs.  The Department of State also said it would  continue to encourage U.N. efforts to address the spread of HIV/AIDS  among target populations in situations of violence and instability.  The  Department of State did not comment on our recommendations.
UNAIDS agreed with our recommendation that behavioral surveys should  be carried out to gather baseline and follow-up data on U.N. peacekeepers’  knowledge and awareness of HIV/AIDS and their sexual behavior.  UNAIDS  disagreed with our characterization that the U.N.’s overall effort to address  HIV/AIDS in emergencies is inconsistent.  In their letter, UNAIDS lists a  number of meetings in which concerns for vulnerable populations and  peacekeeping are addressed.  According to UNAIDS, these collaborative  efforts demonstrate a consistency of approach that is contrary to our  finding.  While collaborative meetings are an important first step in efforts  to assist vulnerable populations, U.N. agencies have undertaken few  concrete actions to address this emerging problem.  We found that that  there has been a lack of consistency in U.N. actions to help vulnerable  populations because emergency assistance agencies have tended not to  include HIV/AIDS programs in their requests for funds and generally do not  view HIV/AIDS prevention as part of their mandates.
We are sending copies of this report to interested congressional  committees, the Secretary of State, the Secretary of Defense, the Secretary  General of the United Nations, the Executive Director of UNAIDS, and  other interested parties.  We will also make copies available to other parties  upon request.
If you or your staff have any questions concerning this report, please call  me at (202) 512-8979.  Other GAO contacts and staff acknowledgments are  listed in appendix VIII.
section_title: Objectives, Scope, and Methodology
paragraphs: At the request of the Chairman of the House Committee on International  Relations, we (1) analyzed U.N. policies and guidance on the use and  deployment of peacekeepers with HIV; (2) examined the data available on  HIV prevalence rates among peacekeepers; (3) assessed actions the United  Nations is taking to limit the spread of HIV/AIDS among peacekeepers; and  (4) examined the actions the United Nations is taking to limit the impact of  HIV/AIDS on civilians affected by armed conflict, including groups who  may come in contact with peacekeepers.
In analyzing U.N. policies and guidance on the use and deployment of  peacekeepers with HIV, we interviewed officials from the U.N. Department  of Peacekeeping Operations (DPKO), the Joint United Nations Programme  on HIV/AIDS (UNAIDS), the Department of State, and the Department of  Defense (DOD).  We also questioned these officials concerning the context  in which the policies were formulated and DPKO’s intent in issuing the  policies.  Additionally, we examined U.N. documents such as DPKO’s  medical manual to determine the precise wording of the policies and  guidance, as well as U.N. Security Council Resolutions and U.N. General  Assembly Resolutions regarding the U.N.’s general policies on the rights of  HIV-positive individuals in employment situations.
In examining the data available on HIV prevalence among U.N.  peacekeepers, we interviewed officials from DPKO, UNAIDS, USAID, DOD,  and other officials to identify whether data collection is being conducted  among peacekeepers. We also asked these officials to identify and discuss  any other data sources, including medical research and academic studies.  We conducted searches for reports of HIV transmission to and from  peacekeepers, and we attempted to verify the validity of these reports  through discussions with U.N. officials. To determine HIV/AIDS prevalence  among populations that may be chosen for U.N. peacekeeping duty, we  examined the data available on HIV/AIDS prevalence among uniformed  forces and civilian adult populations for countries that contribute  peacekeepers. This included collecting and analyzing information in the  U.S. Census Bureau’s HIV/AIDS Surveillance Data Base, June 2000;  UNAIDS’ report on the global HIV/AIDS epidemic, June 2000; and DPKO’s  monthly summary of troop contributors. For our review of the risk factors  that peacekeepers face during peacekeeping operations, we examined  documents from UNAIDS, the Civil-Military Alliance to Combat HIV/AIDS,  the International Crisis Group, and the National Intelligence Council.  We  also asked officials at DPKO, UNAIDS, DOD, Family Health International,  and others to identify and discuss these risk factors.
In assessing the actions the United Nations is taking to limit the spread of  HIV/AIDS among peacekeepers, we reviewed DPKO program documents,  including the HIV/AIDS Awareness Card.  We also reviewed documentation  from UNAIDS, including best practice studies.  In addition, we spoke with  senior officials at DPKO and UNAIDS about the development and  implementation of the HIV/AIDS Awareness Card and other initiatives. In  our review of DPKO’s HIV prevention training, we examined the DPKO  training manual and held discussions with DPKO’s senior medical advisor  and the Director of the Civil Military Alliance who developed the HIV/AIDS  curriculum. We also discussed the current training with senior officials at  the U.N. Population Fund, the U.N. Development Fund for Women, and the  U.S. Naval Health Research Center responsible for HIV/AIDS prevention  training of foreign military personnel.  With USAID contractors from the  Measure Demographic and Health Survey and Family Health International  (FHI), we discussed the use of sexual behavior surveys for measuring the  progress of HIV/AIDS prevention efforts to reduce risky behaviors and how  information about condom use can be used as a proxy indicator for  estimating risk of HIV transmission.
In examining the actions the United Nations is taking to limit the impact of  HIV/AIDS on civilians affected by armed conflict, we interviewed officials  from DPKO, the U.N. Children’s Fund, the World Health Organization, the  U.N. Population Fund, the U.N. Coordinator for Humanitarian Affairs, the  World Food Programme, and several other U.N. agencies to assess the  effectiveness of U.N. efforts to provide HIV/AIDS assistance in conflict and  to determine the extent to which the United Nations has addressed groups  at risk of contracting HIV/AIDS from peacekeepers.  We also reviewed  documents from U.N. interagency meetings that analyzed U.N. efforts to  limit the impact of HIV/AIDS on civilians affected by conflict.  To obtain  information on U.N. agency programs and activities in combating  HIV/AIDS, we examined the U.N. System Strategic Plan for HIV/AIDS, 2001- 2005, and various U.N. Consolidated Interagency Appeals.
We conducted our fieldwork in Washington, D.C.; New York, N.Y.; and  Geneva, Switzerland.  We performed our work from April 2001 through  November 2001 in accordance with generally accepted government  auditing standards.
section_title: U.N. Peacekeepers by Country, September 2001
section_title: Information Available on U.N. Peacekeeping Forces and HIV/AIDS
paragraphs: Six HIV cases in East Timor and  six in Kosovo were confirmed; it  is  unclear if peacekeepers were  deployed with HIV or if they  contracted the infection while on  deployment.
Data on HIV prevalence for samples  of uniformed forces in three  contributing countries show HIV  prevalence above 5 percent.
Defense Intelligence Agency  estimates 10-20 percent prevalence  for the Nigerian military, 15-30  percent for the Tanzanian military,  and 10-20 percent for the military in  Côte d'Ivoire.
Contributing countries' HIV testing  policies vary for uniformed forces  being sent to peacekeeping  operations.
Sexually transmitted infection rates  are estimated to be two to five times  higher among military personnel than  in civilian populations, suggesting  higher HIV rates as well.
Fourteen percent of peacekeepers  come from countries with high  civilian prevalence.
DPKO confirmed that one  civilian member of a  peacekeeping mission spread  the infection while on  deployment.
The rapid spread of HIV/AIDS in  Cambodia coincided with the U.N.  peacekeeping mission.
Increased rates of HIV infection in  East Timor conincided with the  presence of U.N. peacekeepers.
Rates of sexually transmitted  infections, which increase the risk of  contracting HIV 5 to 20 times, are  thought to be high among war- affected populations.
Ten Uruguayan peacekeepers in  Cambodia tested negative prior  to deployment and positive upon  return to Uruguay.
Prevalence rates are high among  samples of prostitutes in three  countries where peacekeeping  operations are ongoing: 27 percent  in Sierra Leone; 29 percent in  Congo; 73 percent in Ethiopia.
DPKO confirmed that two  Bangladeshi peacekeepers  contracted HIV in Cambodia and  one in Mozambique.
HIV/AIDS prevalence among a  sample of war-affected local  populations in Sierra Leone was  found to be 16 percent in 1995,  although rates in the sample prior to  the conflict are not known.
section_title: HIV/AIDS Activities of U.N. Agencies
paragraphs: Leads and coordinates  international action for the  worldwide protection of  refugees and the resolution of  refugee problems.
Provides shelter, food,  water, medicine, and  other basic  necessities to  refugees and other  displaced persons.
Supports programs  to prevent and care  for HIV/AIDS and  sexually transmitted  infections in refugee  settings; provides  technical assistance  to partners.
UNHCR reports  facing budgetary  constraints that  may limit its  capacity to  address HIV/AIDS  among its  beneficiaries.
Disseminates  information on  HIV/AIDS.
Implemented an  HIV/AIDS education  program for young  refugees in southern  Africa, in cooperation  with other agencies.
Advocates for children’s rights  to help meet their basic needs  and to expand their  opportunities to reach their  full potential.
Provides  humanitarian  assistance and  protection to children  in emergencies.
Develops and  supports actions to  reduce the  vulnerability of  children at high risk  of HIV/AIDS,  including those  affected by conflict.   Ensures protection  and support for  orphans and children  in families vulnerable  due to HIV/AIDS. $600 million  projected for  2001-2005.
Training adolescent  refugees to be peer  HIV/AIDS educators.
Developing a training  module for  peacekeepers on  gender and child  protection.
Helps to eradicate poverty  through sustainable human  development activities.
Provides logistic,  communications, and  other support for  international relief  agencies and focuses  on the relief- to- development  transition.
Supports the U.N.  response to  HIV/AIDS through   advocacy, capacity  building, and  training. $600 million  projected for  2001-2005.
Leads the fight against global  hunger through food  distribution in emergencies  and helps support social and  economic development.
Meets the food needs  of vulnerable  populations.
Attempts to mitigate  HIV/AIDS’ impact on  food security by  improving the longer- term food security of  families and groups  affected by  HIV/AIDS.
No information  available.
Makes its logistics  services and food  distribution sites  available for  HIV/AIDS prevention  activities by other  U.N. agencies.
Requires its truck  drivers in Ethiopia to  take 2-month HIV-  prevention course.
Attempts to ensure that all  people obtain the highest  attainable level of health.
Mobilizes expertise  and resources for  rapid response. Gives  high priority to  assisting vulnerable  groups, such as  commercial sex  workers and persons  in emergency  situations.
Aims to strengthen  the health sector’s  response to  HIV/AIDS and to  provide technical  assistance to  countries to improve  their HIV/AIDS  prevention and care  interventions. $146 million  projected for  2002-2003.
Developing a project  for HIV/AIDS  assistance to  refugees, internally  displaced persons,  and returnees from  Angola, Democratic  Republic of Congo,  and Sierra Leone.
Producing a basic  supply package for  HIV/AIDS assistance  in emergencies.
Aims to ensure universal  access to high-quality  reproductive health services  to all couples and individuals  by 2015.
Provides reproductive  health kits, trains  service providers to  diagnose and treat  sexually transmitted  infections, and  conducts information  activities.
Advocates for HIV  prevention and the  integration of HIV  prevention into  national reproductive  health programs.  Aims to strengthen  its emergency  HIV/AIDS activities. $254 million  projected for  2001-2005.
Provided health kits  and technical  support in Bosnia,  East Timor, Eritrea,  Ethiopia, Kosovo.
Provided training on  HIV/AIDS prevention  and care for health  providers working  with Eritrean  refugees in Sudan.
Coordinates the international  humanitarian response in  complex emergencies,  supports the humanitarian  community in policy  development, and advocates  on humanitarian issues.
Monitoring/early  warning, contingency  planning, interagency  needs assessment,  field coordination, and  development of  interagency funding  appeals.
Advocates for the  inclusion of  HIV/AIDS programs  into U.N. emergency  appeals for funding.
No information  available.
Provided training for  other U.N. agencies  on incorporating  HIV/AIDS and other  factors into U.N.  emergency appeals.
Supports HIV/AIDS  prevention and care, helps  reduce the vulnerability of  individuals and communities,  and assists in alleviating the  pandemic’s impact.
Provides strategic  guidance to the U.N.  system on HIV/AIDS,  mobilizes partners  and resources, and  assists partners in  information activities.  UNAIDS’ 132  country-level “theme  groups” on HIV/AIDS  coordinate the U.N.  response to  HIV/AIDS at the  country level. $305 million  projected for  2001-2005.
Created a  humanitarian unit to  address HIV/AIDS  and security issues,  including  peacekeeping.
Funded a study to be  conducted by the  U.N. Children’s Fund  to improve HIV/AIDS  interventions for  children in conflict.
Together with DPKO,  plans to deploy five  high-level HIV/AIDS  officers to five  peacekeeping  operations.
Promotes women’s human  rights, economic security, and  political participation;   promotes U.N. efforts to  support women’s  empowerment and to  incorporate gender into U.N.  policies and programs.
Advocates for  increased gender  sensitivity in U.N.  programs operating in  complex  emergencies.
Attempts to increase  understanding of the  links between human  rights, gender, and  HIV/AIDS.  Advocates for a  revised code of  conduct for  peacekeepers and  for greater gender  awareness in  peacekeeper  HIV/AIDS training. $8 million  projected for  2001-2005.  Fifty  percent of  UNIFEM’s  HIV/AIDS  resources are  assigned to  programs in  Africa.
Produced a joint  manual on gender,  human rights, and  HIV/AIDS.
Plans to deploy a  gender adviser in  Sierra Leone, in  conjunction with  UNAIDS.
Developing a guide  for women on  negotiating safer  sex.
section_title: Comments From the Department of State
section_title: Comments From UNAIDS
section_title: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the person named above, key contributors to this report were  Richard Boudreau, Lynn Cothern, Andrew Von Ah, Eve Weisberg, and Tom  Zingale.
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section_title: Public Affairs