Assessment of sexual behavior and risk perception about HIV/AIDS of male military peacekeepers returned from peacekeeping mission at 14 th Division of North Command, around Aduwa, North Ethiopia. Across-sectional study. By: Fasil kenea Advisor: Dr.Mitike Molla Dec Addis Ababa, Ethiopia 1

Presentation outlines 2  Introduction  Objectives  Methodology  Results and Discussions  Conclusion and Recommendations  References  Acknowledgements

Introduction 3  Globally, HIV/ AIDS epidemic remains a major Public Health, social, economic and development challenges.  The prevalence is most pronounced in some groups of the population where the military shares the largest proportion to HIV acquisition and transmissions. The possible reason given for this includes:  lengthy periods spent away from home,  Age group at greatest risk for HIV infection the sexually active 15–24 year age group  Military's ethos and masculine tends to excuse or even encourage risk-taking

Introduction cont’d 4  soldiers experience sense of invulnerability, low self esteem, boredom and extreme loneliness.  Outlook on life, attitudes to sex and their partners, influence their risk of contracting HIV or other diseases.

Introduction cont’d 5 Generally Risk for HIV may increase many times during peacekeeping mission the most possible identified reason  Mostly deployed soldiers are young population  Duty schedules and periods of deployment resulting in separation from families  Opportunity of additional income during military operations  Host population dependent on military for food and other  Civilian perception of for the military peacekeepers  Handling injured and dead bodies at the mission.  Peacekeepers stationed in Africa, which is home to 70% of people living with HIV.  Conflict and post conflict environment where the survival area of CSW as a result Peacekeepers are universally identified as the main clients of commercial sex workers

Introduction cont’d 6  So the findings of this study believed to strengthen the prevention and control of HIV/AIDS in peacekeeping environment especially for Ethiopian army and hence decrease the transmission of HIV.

Objective of the study 7 General objective  To assess sexual behaviour and risk perception about HIV and AIDS among Ethiopian army peacekeepers returned from UN mission in 14 th Division of North Command. Specific objective  To assess attitude and risk perception about HIV/ AIDS  To assess sexual behavior of army peacekeepers during UN mission  To identify predisposing factors to HIV / AIDS in generally and particularly during UN mission

Methodology 8 Study area and period  14 th Division of North Command, around Aduwa in February Study design  cross-sectional descriptive study design which was complimented by qualitative study

Methodology…….cont’d 9 Source and study population  Source population constitutes all Ethiopian army because peacekeepers they were recruited from every corner of Ethiopia army for UN mission in every round.  Study population constitutes all peacekeepers that come back from UN mission at 14 th Division of North Command from 2006–2010.

Methodology……….cont’d 10 Sample size determination  Taking assumption of Proportion of military personnel (ground force) who reported having had sex with CWs and those who reported consistent condom use with CSW in the last 30 days were 80.4%(BSS I)  d= degree of precision = marginal error = 5%  CI= 95%  Design effect =2 n = (Z α /2) 2 p (1-p) _________ = 242 d 2

Methodology……….cont’d 11  Since the population in the study less than 10,000 the following formula were used. n=n÷1+n\N = 163  Finally 10% none response rate considered and that made the total sample size to be 358 because of multistage sampling. Sampling procedure  Participant were selected by lottery method from sampling frame (payroll)

Data collection procedures and instrument 12 Quantitative  Using a questionnaire adapted from FHI guideline for repeated Behavioral survey in population at risk of HIV, BSS round two(2005), VCT up take on army(2006), KAP survey in the army(2001), report on peacekeeping.  The questionnaire was prepared originally in English and then translated to Amharic language and finally back translated to English to improve the accuracy/exactness.  Questionnaires were pretested for clarity, repetition, and flow and time requirement.  The pre-test were carried out in randomly selected 25 peacekeepers in the armed force hospital.

Methodology……….cont’d 13  Ten civilian data collectors, with a minimum qualification of diploma or experience in survey & trained for two days  Two military supervisors were recruited to facilitate the data collection process. Qualitative study  U sing semi-structured topic guide.  The total of three FGD, which consisted of eight individuals in each group.  Two moderator, assistant note taker and tape recorder provided for every discussion not to miss issues discussed, and finally transcribed then analyzed.  This was takes places by grouping similar idea in the same category then the event summarized sequentially by describing consequence for HIV/AIDS.

Data quality management 14  First careful preparation and clarity of the questionnaire were maintained.  Research assistance was selected and trained for two days.  The questionnaire was pre-tested.  The questionnaire was anonymous and privacy and confidentiality was maintained  Respective data collectors, supervisor and investigator was checked all questionnaires at the spot.

Data processing and analysis 15  Data was coded, entered and cleaned using Epi info version and exported to SPSS 16 for analysis.  Frequencies and percentages was calculated  Then bi-variate analysis with COR was used to test possible association of the independent variables with the dependent variables.  Finally multiple logistic regression was used to see independent effects of variables on outcome variables.

Ethical consideration 16  Ethical clearance was obtained from Research ethics committee  Then permission was obtained from Head of Health department of Federal Ministry of Defense, Head of Ethiopia Army UN peacekeeping commands and head of North Command of different Division before started the study.  Informed consent was obtained from each study participants.

Result: 17  A total of 342 uniformed peacekeepers participated in the study obtaining a response rate of 95%.  The mean age of the respondents was 34.69(SD±5.1).  Half of the respondents 188(55%) were ever-married and the mean age at marriage was (SD±4.01).  Amongst the ever-married respondents, 29(8.5%) had had extra marital sex while in peacekeeping.  Knowledge about HIV and AIDS was 62%.  Out of the total participants, 54 (15.7%) had sex at mission, where 28(51.85%) had reported to have more than one sexual partner. 39(72.2%) used condoms consistently while in peace keeping.

Result: 18  The majority of 204(59.6%) respondent were between years of age  The dominant religion 236(68.2%) were followers of Orthodox.  The majority of the participant 173(50.6%) and 128(37.4%) stayed for 10 and 9 months respectively.  The median service year of the participants in the army was 13 years.  The majority of the participant 191(55.8%) belong to other (lower) rank category.  The major responsibility of the participant in peacekeeping environment was gate keeping 162(47.7%)  286(69%) of them reside in cities in area where they deployed.  318(97%) of them earn dollars in month additional to their salary in the mission area.

Result 19  40(11.7%) participants had reported STI in the last 12 months before the study.  Only 5.8% of the respondents perceived themselves to be at risk of HIV during peacekeeping mission.  Regression analysis indicated that, those who believe peacekeeping environment predispose them to unsafe sex [AOR and (95% CI) 5.86, (1.47, 23.50)],  Those who believe that they will be at risk of HIV/AIDS if they continue with the behavior they had during peacekeeping mission [AOR=4.00, 95%CI=1.01, 15.70],  Those who had sex while in peacekeeping mission [AOR=8.23, 95%CI=1.01, 67.45] were more likely to perceive themselves at risk of HIV.  Service duration of months [AOR with 95%CI=24.85(6.85, 90.20)] were more likely to engage in extra marital sexual partnership than their counterparts

Result 20  Peacekeepers who had limited knowledge about HIV/AIDS [AOR with 95%CI=3.14(1.01, 11.49)] were more likely to engage in extra marital sexual partnership than their counterparts  The large variations in knowledge levels and the misconceptions across groups may be that come from very different background, cultures and perception of peacekeepers.  There was no significant statistical relation between comprehensive knowledge and training for HIV/AIDS before deployment but those trained in mission area had 4 times more compressive knowledge with[AOR of 95% CI=4.04(1.01, 16.07)]. Military ethos/ masculinity  On the question of “Military is expected to have more than one sexual partner,” 217(63.5%) respondents did not agree  In the FGD Majority of the group state masculinity and sexual activity were strongly linked in peacekeeping environment; the dominant military culture equates visiting sex workers and having multiple sexual partners with being a real, strong man.

Mobility 21  The group widely recognized that mobility can increase risk behavior when men separated from regular sexual partners, they were more likely to engage in casual or paid recreational sex specially like peacekeeping environment stayed for 9-17 months. VCT UPTAKE  The VCT uptake during returnee were (17.3%), these test rates were achieved by offering VCT following an orientation session in which the importance of “knowing your status” is advocated according to FGD result

Peer pressure 22  Of all, 239(69.9%) agreed peer pressure is determinant factor to did sex with multiple partner.  This may be the army mostly lived together both in the mission and after returnees.  FGD result indicate the group widely recognized that peer pressure was particularly strong during drinking games when pressure to drink was intense.  Not drinking when the rest of the group was yelling to drink were considered rude and other members of the group may insult the slow drinker's masculinity or even become angry.

Condom use 23  About 275(80.4%) of participant agreed permanent condom use can protect from HIV/AIDS  But condom use in the last 12 months before the study was poor that, out of 188 ever married men, 30(15.96%) did not use it consistently while having sex with casual partners  In FGD most respondent state sex was done in the peacekeeping mission behind somebody's back (in secret) so they had no opportunity to use condom consistently.

Risk perception toward HIV/AIDS 24  Only 5.8% of the respondents perceived themselves to be at risk of HIV during peacekeeping mission  FGD result stated that uniformed servicemen are trained, required and expected to face risks in their employment and indeed may be punished if they refuse.  It is therefore not surprising that this attitude to danger can carry over to civilian. They believed that this risk was no greater and far less apparent than the risks inherent in advancing under enemy fire or confronting an armed thief.  This attitude to danger means that educating uniformed servicemen about the personal dangers of HIV/AIDS alone is unlikely to be sufficient to motivate sexual behavior change.

Strength and Limitation 25 Strength  This study has tried to see the risky sexual behavior, and risk perception among peacekeepers may be used as base line for the futures.  This study was complimented by qualitative data i.e. focus group discussions in order to insight more the complex sexual behavior.

Strength and limitation 26 Limitation  Understatement of sexual behavior among the peacekeepers while in peacekeeping.  May be recall bias because peacekeepers returned to Ethiopia between two to five years before the study.  There was lack of reference nationally and international related to peacekeeping in order to compare obtained result with other findings in the discussion parts.

Recommendation and conclusion 27  Despite their high knowledge about HIV/AIDS, the uniformed peacekeepers were engaged in risky sexual behaviors and also perceived themselves to be at lower risk of contracting HIV and AIDS.  This low perception predisposes themselves and the community both at the host country and back home.  HIV prevention programs should target uniformed population in general and UN peacekeepers in particular.  In addition health promotion messages should consider the unique context of peacekeeping environment

Acknowledgment 28  First and foremost, I would like to extend my sincere thanks to my advisor Dr. Mitike Molla, for unreserved guidance and timely comments from the research proposal up to thesis write up.  I would also like to extend my heartfelt thanks to all that support me to did this study.  ICASA for inviting me to present our finding

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