The first time the Human Immune Virus (HIV) affected someone I knew was during my college sophomore year. I had just finished class for the day when I received a frantic phone call from my friend telling me he had just been diagnosed with HIV. After a few seconds of silence, he started sobbing uncontrollably and told me that he “didn’t want to die.” He said this several times during our call. I would spend the next three hours reassuring him that everything was going to be alright. Once we got off the phone, I started to learn everything I needed to know about HIV and what I could do to help my friend during this difficult time.
Looking back six years later, it amazes me how little we both knew about HIV. Neither of us were informed about the preventative measures that existed, nor did we know how far medical treatment had come in the past two decades. Unfortunately, this is a common problem in American society. In 2019, a survey found that 27% of Americans were aware that antiretroviral therapy (ART) is highly effective in improving the health of HIV-positive individuals. Additionally, in this same survey only 42% of Americans knew about preventative medications for HIV-negative individuals. These results indicate that a lot of work remains to be done to reduce the stigma surrounding HIV and improve public awareness about the medical and preventative methods that are available.
If American society wants to mitigate the negative impacts of HIV, then it needs all stakeholders to participate and facilitate an open dialogue about how to address HIV — and that includes the US military.
This lack of understanding plays out in outdated laws and policies. Specifically, the US military’s HIV ban institutionalizes stigma and ignorance toward HIV-positive people. Institutions that keep these policies are doing a disservice to Americans because it ostracizes those who are HIV-positive and prevents broader discussion about an illness that impacts everyone. Within the US military, a survey from 2006 found that 53% of servicemembers felt the current HIV educational measures were inadequate to tackle the problem.
If American society wants to mitigate the negative impacts of HIV, then it needs all stakeholders to participate and facilitate an open dialogue about how to address HIV — and that includes the US military. Therefore, the US military needs to update these policies so that they have a positive influence on all Americans, especially those who are willing, ready, and able to serve. In other words, the time has come for the US military to decide whether it wants to reflect society or lead it.
THE US MILITARY’S BIGOTRY TOWARD THE HIV-POSITIVE
The US military began screening all recruits for HIV in 1985 and has denied anyone who tests positive from entering the US armed forces. This policy made sense 36 years ago when little was known about the virus and no medical treatment existed. At that time, most individuals who were diagnosed with HIV would later develop Acquired Immune Deficiency Syndrome (AIDS), which led to the immune system shutting down, resulting in death. Since the 1980s, health professionals have made tremendous strides in developing treatment and prevention medications that reduce the risk of transmission and enable HIV-positive individuals to live healthy lives.
In 2012, the US Food and Drug Administration approved the use of Truvada, a pre-exposure prophylaxis (PrEP), which is a once a day prescription pill for HIV-negative individuals. PrEP is 99% effective at reducing the risk of acquiring HIV through sexual intercourse if taken as prescribed. For HIV-positive individuals, ART is a once or twice a day medication that prevents HIV from replicating rapidly, restores white blood cell count to normal levels, and minimizes transmission of HIV through sexual contact. ART makes it possible for HIV-positive individuals who take their treatment regularly to live just as long as people who don’t have HIV and continue their lives with little inconvenience. Despite all this, the US military still believes that HIV-positive individuals are unfit to serve solely based on their HIV status. This policy ignores significant advances in medical treatment and applies a different standard to HIV than other chronic conditions.
Overall, the US military has a robust set of medical standards that recruits must meet in order to qualify for military service across all branches. Individuals are eligible to apply for waivers depending on the type of medical condition. Recruits who are HIV-positive, however, are ineligible to receive a medical waiver regardless of whether they are already receiving treatment and are undetectable. This policy is inconsistent with policies for other chronic illnesses. For instance, in the case of diabetes, diabetic recruits are evaluated on a case-by-case basis. Furthermore, active-duty personnel with diabetes have received medical waivers for deployment in combat zones. While HIV-positive servicemembers are eligible to submit waivers for deployment into combat zones, none have ever been granted to date.
Another example of how the US military’s health policy has adapted to meet new information and treatment of medical conditions can be seen in the evolution of the response to COVID-19. At the start of the pandemic, the US military banned all individuals who had tested positive from military recruitment because little was known about coronavirus. This policy would eventually be overturned as more information came available. Now recruits who had COVID-19 are evaluated case by case. It took the US military roughly one month to change these policies based on the scientific evidence they acquired over time, while the US military’s HIV policies have remained the same after nearly 40 years of research.
The US military’s reasons for continuing the HIV ban have evolved over time, with concerns about the potential for transmission on the battlefield being a top priority. This battlefield concern is tied to an inability to maintain a supply of necessary medications and risk of contamination of the US military’s blood supply in a combat zone. These arguments may seem logical at first glance but are disproportionate to the treatment of other chronic diseases. While there is a possibility of transmission through open wounds, the risk is low because ART is extremely effective at reducing the viral load and would require exposure to a large amount of blood. With respect to the medical supply issue, HIV medications are easy to transport and require no special storage, akin to other medications made readily available to servicemembers with other underlying conditions. When it comes to blood donations, the US military must follow FDA regulations, which prohibit HIV-positive individuals from donating blood. Additionally, the US military only permits the collection of fresh whole blood if no tested blood products are available. These rules limit the use of blood transfusions, which reduces the instances where HIV transmissions are most likely to occur.
HIV is a global epidemic that impacts millions of people around the world. HIV-positive individuals, therefore, could include non-combatants and enemy combatants that US troops may encounter. Simply removing HIV-positive soldiers from your ranks does not eliminate the possibility of HIV transmission on the battlefield. Instead, it perpetuates stigma and allows for unsound policies that exclude HIV-positive Americans who are fit for service.
Disclosing HIV status
Another major flaw is the US military’s safe sex orders, which requires HIV-positive servicemembers to always disclose their status to sexual partners. If HIV-positive individuals are receiving medical care and are unable to transmit HIV to their sexual partners, they should not be required to disclose their status. Requiring HIV-positive servicemembers to disclose their status in every situation could also put them at greater risk of being physically harmed by their sexual partner. The US military’s safe sex orders place too much responsibility on HIV-positive military personnel and enables the vast majority of servicemembers to remain ignorant about HIV. By removing the safe sex orders, the US military would be able to develop a more holistic approach that relies on everyone to play a part in reducing the spread of HIV, rather than forcing only those who are positive to prevent further infections.
The US military maintains that the sole purpose of this policy is to safeguard military readiness, but this is not entirely accurate. When the HIV ban was implemented, the HIV/AIDS epidemic was perceived by many to only affect men who had sex with men. At that time, the US military blanketly prohibited queer individuals from entering the armed forces. By implementing this policy, the US military was able to identify gay and bisexual servicemembers and court-martial them for homosexual acts. The HIV ban, therefore, was not just about keeping the US military prepared; it was intended to criminalize queer servicemembers and force them out of the US military. This is something that the US military still neglects to publicly recognize when openly advocating for the HIV ban.
IT’S TIME TO CHANGE — AND LEAD
The US military should adopt the following three policy recommendations to address its internal biases toward HIV-positive servicemembers.
First, the US military should allow HIV-positive recruits to apply for medical waivers. Recruits who have other chronic illnesses are allowed to submit medical waivers for those conditions, so should HIV-positive individuals. Additionally, HIV is no longer terminal and HIV-positive individuals can live healthy lives as a result of ART. Having HIV alone should not count for immediate disqualification from service and each HIV-positive recruit should be considered case by case.
Second, the US military should allow HIV-positive servicemembers to deploy to combat zones. Although HIV-positive servicemembers are allowed to submit waivers to be able to deploy, there is no evidence that any have ever been granted. Current research suggests that if HIV-positive servicemembers receive medication, they pose minimal risk of transmission on the battlefield.
Finally, the US military should eliminate its safe sex order policy. Forcing HIV-positive military personnel to be solely responsible for disclosing their status even when they are undetectable and not able to transmit the virus is not fair to HIV-positive servicemembers. If the US military wants to prevent further HIV infections, then start educating all servicemembers about safe sex practices.
Currently, the scientific data that is available does not support the US military’s position. By keeping this outdated policy, the US military is denying all the advancements that have been made to help treat and prevent HIV. Furthermore, the HIV ban institutionalizes prejudice and furthers public ignorance about HIV. With simple policy changes, however, the US military can reposition itself as an institution that cares about its servicemembers and American society. Whether or not the military leadership has the political will to do so is another issue.
Cody Kennedy is a research intern in the Military, Veterans, and Society Program at the Center for New American Security.