Findings at baseline show that Angolan soldiers engage in a number of high-risk behaviors that may put them at risk for HIV infection. A large proportion of them had multiple sexual partners in the preceding three months and few used condoms.
As predicted by the Information, Motivation, and Behavior (IMB) model, the HIV prevention intervention group, compared to the control group had significant improvements over time in HIV/AIDS knowledge, perceived vulnerability to HIV infection and some of the behavioral outcomes.
Compared to those in the control intervention, HIV prevention intervention participants had more knowledge of HIV/AIDS three and six months after baseline, perceived people similar to themselves and Angolan soldiers to be more vulnerable to HIV at three and six months, reduced unprotected anal sex with live-in partners at three and six months, and were more likely to have increased condom use during vaginal sex at three months. Significant between-groups differences were not found for the other parameters measured.
It is possible that the lack of significant between-group differences in some of the other outcomes may be due to the observed improvements in both the HIV prevention and control groups. Nevertheless, improvements were often larger for the HIV prevention intervention group than the control group. In fact, the HIV prevention group reduced the number of unprotected vaginal sex acts with girlfriends, occasional and commercial partners, reduced unprotected anal sex with girlfriends, as well as reduced the total number of occasional and commercial partners, compared to baseline.
While it is not clear exactly why the control group also showed improvement on some of the behavioral outcomes, two environmental factors may offer some explanation. Approximately halfway through the study, the Angolan National Institute for the Fight against AIDS initiated radio campaigns designed to promote mutual fidelity and the use of condoms, encourage HIV testing, and reduce stigma. Around the same time, the Angolan Armed Forces, with support from the Global Fund, expanded its HIV prevention activities in areas where several of study bases were located. In addition, the assessment itself may have had some impact on the control group. To be asked about one’s sexual behaviors in such a detailed and systematic format would have been a very unusual experience for these men (Gale, 2004
). The uniqueness of the interview experience, as well as the half-day of HIV education we provided in the control intervention, may have led control participants to become more attentive to the national HIV prevention campaign and may have stimulated them to reduce their risk behaviors (Dworkin et al, 2006
However, the fact that the HIV prevention intervention group showed more consistent improvements in knowledge, motivation, and behavior than the control group suggests that the HIV prevention intervention group may have received benefits above and beyond that which the control group received from the national HIV prevention activities.
Though the HIV prevention intervention also focused on reducing alcohol consumption before sex, neither the HIV prevention nor control conditions showed reductions on this outcome. The assessment of alcohol consumption before sex consisted of a single question and had a one-month time frame; thus, it may not have been sufficiently sensitive to detect changes in the frequency of alcohol consumption prior to sex.
Though a five-session group intervention may be challenging to implement in a civilian setting, where the demands of daily living compete for time, it is feasible to do so in a military setting, where soldiers can be relieved of other duties to participate. In addition, the group intervention is consistent with military culture, which encourages activities that strengthen group cohesion and camaraderie.
The group randomized design may have minimized contamination across HIV prevention and control conditions. Randomizing individuals to conditions would have led to HIV prevention and control participants being on the same base. However, because bases, not individuals, were randomized, there were some differences between HIV prevention and control groups at baseline. It is possible that these differences may have impacted the uptake of the intervention in each group. Importantly, though, there were no differences between the HIV prevention and control groups on their baseline knowledge, motivation, and risk behaviors.
Other limitations included a reliance on self-report data about sexual behaviors, and an overrepresentation of military bases in the capital city. Self-report data may have been biased by participants’ ability to recall their sexual behaviors in the past three months, as well as by the possibility that they gave socially desirable, rather than completely accurate, responses. That most of the bases were located in the capital city may have biased the sample towards soldiers who have more access to other sources of HIV/AIDS information, such as the national radio campaign.
The findings from this study suggest some future areas of research to improve HIV prevention interventions for military men. In the present study, the degree of HIV risk reduction differed across partner types. Reduction of HIV risk with occasional and commercial partners was found more frequently than with girlfriends and live-in partners. Future studies should explore the perception of sex and related to it, the perception of condom use among soldiers, with each of these types of partners (see Boyce et al., 2007
). Interventions then may be able to address the specific issues within male soldiers’ sexual relationships with regular and non-regular partners more effectively. Future interventions may also explore ways to involve women partners, thus opening up opportunities to discuss gender roles and its impact on the negotiation of sex, condom use, faithfulness, and other HIV-related risk behaviors (see Kurpius and Lucart, 2000
; Shefer and Mankayi, 2007
In sum, this study presents evidence that militaries, even in resource-limited post-conflict countries, can provide effective HIV prevention to their soldiers. Though the HIV intervention presented in this paper is intensive and spans multiple sessions, the structure of militaries allows for intensive prevention training, as well as repeated follow-up sessions – techniques that are not easily implemented in civilian or non-workforce sectors. In addition, military culture can be leveraged to facilitate HIV prevention: military hierarchy, following orders through the chain of command, perception of soldiers as protectors of family and nation, and respect of soldiers by the general population. Such military-focused interventions, when supported by military commanders in countries with high rates of HIV, may help transform soldiers into positive agents of change, spreading HIV prevention messages throughout the country.