oversight

Defense Health Care: Effects of AIDS in the Military

Published by the Government Accountability Office on 1990-02-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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                                                                      DEFENSE HEALTH
lJ14,1w;r1-y           1 !)!)O




                                                                      CARE
                                                                      Effeets of AIDS
                                                                      in the Military
        United States
GA!!0   General Accounting Office
        Washington, D.C. 20648

        Human Resources Division

        B-238687

        February 26, 1990

        The Honorable Beverly B. Byron
        Chairman, Subcommittee on Military
          Personnel and Compensation
        Committee on Armed Services
        House of Representatives

        The Honorable Ron Wyden
        Chairman, Subcommittee on Regulation,
          Business Opportunities and Energy
        Committee on Small Business
        House of Representatives

        In response to your request, this report discusses the effects of AIDS in the military.
        Specifically, it provides information on (1) what the Department of Defense (DOD) is doing to
        assess and monitor the prevalence of the disease, (2) what action DOD has taken to prevent
        and control the spread of AIDS in the military, (3) how AIDS has affected DOD'S operations and
        medical treatment facilities, and (4) what plans DOD has for dealing with an increased
        incidence of ~\IDS.We are making several recommendations to the Secretary of Defense aimed
        at improving DOD'S AIDS education program and its plans for dealing with the disease in the
        future.

        As arranged with your office, unless you publicly announce its contents earlier, we plan no
        further distribution of this report until 30 days after its issue date. At that time copies of
        this report will be sent to the Secretary of Defense, appropriate congressional committees,
        and other interested parties.

        This report was prepared under the direction of David P. Baine, Director, Federal Health
        Care Delivery Issues, who may be reached on (202) 275-6207 if you or your staffs have any
        questions. Other major contributors are listed in appendix III.



          Anucek.
        LAU  \ tF3TCLh-r
            --c
        Lawrence H. Thompson
        Assistant Comptroller General
Executive Summary


-P
                       the human immunodeficiency virus (HIV). As of December 1989, nearly
                       118,000 AIDS cases had been reported in the United States, and approxi-
                       mately 1 million additional individuals are estimated to be infected with
                       the virus. AIDS affects every segment of the population, including the
                       military. The Chairmen of two House Subcommittees requested that GAO
                       review the effects of AIDS in the military. Specifically, they asked:

                   . What the Department of Defense (DOD) is doing to assess and monitor
                     the prevalence of the disease.
                   . What action DOD is taking to prevent and control the spread of AIDS in
                     the military.
                   l How AIDS has affected DOD’S operations and medical treatment facilities.
                   l How DOD plans to deal with an increased incidence of AIDS.



                       consistent approach for dealing with the disease. DOD’S policy includes
                       (1) testing all active duty and reserve personnel and civilian applicants
                       for military service, (2) educating personnel about HIV/AIDS, (3) retaining
                       on active duty HIV positive members who are capable of performing
                       their duties, and (4) providing necessary health care to infected
                       personnel.


                       DOD has done a good job of assessing and monitoring the prevalence         of
Results in Brief       HIV infection among military personnel. As of August 1989, DOD had
                       tested over 90 percent of its active duty personnel at least once, and it
                       plans to retest them periodically.

                       Besides testing, DOD has offered varied education programs for the gen-
                       eral military population and has provided counseling for HIV-infected
                       members to help control the spread of AIDS. These education programs,
                       however, do not focus on modifying high-risk behaviors that place indi-
                       viduals at greater risk of infection. DOD has not attempted systematically
                       to judge the effectiveness of its HIV/AIDS education program.

                       Thus far, AIDS has had a minimal impact on overall DOD operations; its
                       impact is unlikely to increase because a very small percentage of active
                       duty members are likely to be infected by HIV.

                       AIDS has had a significant impact on military hospitals, however, primar-
                       ily because of the strain placed on resources during mass testing. The


                       Page 2                                        GAO/HRD-90-39 AIDS in the Military
                           Executive Summary




                           hospitals responsible for evaluating and providing care to HIV-infected
                           members experienced an even greater strain on resources, The impact
                           on these hospitals is likely to increase as the size of the HIV-infected pop-
                           ulation grows.

                           DODhas collected data on HIV/AIDSand recognizes the disease’s potential
                           impact. However, it is unclear how DODplans to provide the resources
                           needed to deal with the expected increase in demand for HIV/AIDS-related
                           health care services.



Principal Findings

Testing                    As of August 1989, DODhad tested about 2.1 million of its almost 2.3
                           million active duty members for HIV. In addition, as of June 1989, DOD
                           had tested over 2.1 million applicants for military service. DODrequires
                           that at minimum, active duty members be retested for HIV in conjunction
                           with their periodic physical examinations. It also requires HIV testing for
                           service members who are assigned overseas, or seek treatment at alco-
                           hol, drug, prenatal, or sexually transmitted disease clinics. The services’
                           HIV testing programs generally exceed the minimum DODrequirements.
                           (See pp. 12-14.)


Education and Counseling   DODdesigned its education program for general audiences, which is one
                           element of AIDSintervention recommended by HIV/AIDSprevention
                           experts. The programs covered the definition of HIV a,nd AIDS,modes of
                           transmission, and service policies related to HIV. They did not, however,
                           focus on modification of high-risk behavior, a topic that experts have
                           suggested be presented. (See pp. 18-19.)

                           DODemphasized disseminating information quickly and did not include
                           an evaluation component in the education programs. A DODsurvey
                           showed that most service members know about HIV/AIDS,but some still
                           have misconceptions about HIV transmission. (See pp. 19-20.)

                           Medical personnel counsel HIV-infected members on such matters as
                           stress management and safe sex. They also instruct HIV-infected mem-
                           bers not to give blood and to inform potential sex partners and medical
                           personnel of their HIV status. (See p. 20.)



                           Page 3                                         GAO/HRB90-39 AIDS in the Military
                                                                                                                                            I
_   . .._ ~~-‘---


                                 Executive   Summary




E ffects o n O p e r a tio n s   A s o f A u g u s t 1 9 8 9 , 6 ,2 6 9 o f a b o u t 2 .3 m illion active d u ty m e m b e r s h a d
                                 b e e n reported a s IIIV infected. F e w e r th a n 2 ,1 0 0 o f th e 6 ,2 6 9 infected
                                 m e m b e r s w e r e still o n active d u ty. T h e r e m a i n d e r h a d retired, s e p a -
                                 rated, or d i e d . T h e r e h a s b e e n m inimal e ffect o n units’ ability to perform
                                 their m issions. ( S e ep p . 1 3 a n d 2 8 .)

                                 F r o m th e inception o f D O D ’S preinduction s c r e e n i n g in O c to b e r 1 9 8 5
                                 th r o u g h J u n e 1 9 8 9 , D O D i d e n tifie d a n d d e n i e d e n try to 2 ,7 5 2 mv-infected
                                 applicants for m ilitary service. P reinduction s c r e e n i n g a n d th e retire-
                                 m e n t o f service m e m b e r s u n a b l e to perform their d u tie s s h o u l d c o n tin u e
                                 to m inimize th e i m p a c t o f HIV/AIDS o n m ilitary o p e r a tio n s in th e n e a r
                                 fu ture. ( S e ep p . 1 3 a n d 2 8 .)


M ’i’ects o n Hospita ls         M ilitary hospitals initially d i d n o t receive a d d i tio n a l resources to imple-
                                 m e n t IIIV testing a n d evaluation. Hospitals s o m e tim e s b o r r o w e d staff
                                 from o th e r a r e a s o f th e hospital, c o n tracted o u t laboratory work, a n d /or
                                 d e fe r r e d s o m e e q u i p m e n t p u r c h a s e s to redirect fu n d s to HIV e fforts. ( S e e
                                 p . 2 3 .)

                                 B a s e d o n i n c i d e n c e rates calculated b y th e services to d a te , a n d th e cur-
                                 rent active d u ty p o p u l a tio n , D O D m a y i d e n tify a b o u t 1 ,5 0 0 to 1 ,7 0 0 n e w
                                 HIV infections a n n u a l l y a m o n g active d u ty service m e m b e r s .M o s t cases
                                 a r e i d e n tifie d in th e early stages o f infection, w h e n th e y require primar-
                                 ily o u tp a tie n t treatment. D O D reevaluates mv-infected active d u ty m e m -
                                 bers annually. T h e y a r e e x p e c te d to progress to th e latter stages o f th e
                                 disease,requiring m o r e a c u te a n d chronic care. ( S e ep p . 2 4 - 2 6 .)

                                 Early treatment with th e a n ti-A IDSd r u g A Z T will p r o l o n g life b u t n o t cure
                                 th e disease.It will also increase treatment costs a n d th e u s e o f m e d i c a l
                                 staff resources. ( S e ep p . 2 5 - 2 8 .)


I’l(m n ing                      DOD    a n d th e services h a v e collected information o n th e i n c i d e n c e a n d
                                 p r o g r e s s i o n o f HIV in th e m ilitary. B a s e d o n th e d a ta collected to d a te ,
                                 D O D e x p e c ts a n increase in th e d e m a n d for rrlv-related h e a l th care,
                                 including th e n e e d for m o r e o u tp a tie n t services, i n p a tie n t a c u te care,
                                 chronic care, a n d prescription drugs. It h a s n o t, h o w e v e r , m a d e deci-
                                 sions a n d p l a n s to a c c o m m o d a teth e s e g r o w i n g h e a l th care n e e d s ,partic-
                                 ularly a s th e y relate to m e d i c a l personnel, facilities, a n d b u d g e ts. ( S e e
                                 p p . 2 6 - 2 8 .)




                                 Page 4                                                         G A O / H R D - 9 0 - 3 9A IDS in the Militwy
                       Executive Summary




                       GAO   recommends that the Secretary of Defense:
Recofnmendations
                   l Modify DOD’S HIV/AIDS education programs to focus on changing high-risk
                     behaviors associated with HIV transmission.
                   . Evaluate the effectiveness of the education efforts.
                   l Develop financial, staffing, and facility resources plans for handling the
                     projected increases in (1) outpatient and inpatient work load and
                     (2) demand for prescription drugs and chronic care services.

   I
                           agreed with GAO’s findings, conclusions, and recommendations and
Agerky Comments        DOD
                       has initiated actions in response to the recommendations. (See pp, 2 1,
                       22, 29, and 30.)




                       Page 5                                      GAO/HRD-90-39 AIDS in the Military
C@ntents


Ebecutive Sun-u-nary                                                                                        2

                                                                                                         8
                          DOD’s HIV Program                                                              9
                          Objectives, Scope, and Methodology                                            10

                                                                                                        12
                          Development of a Comprehensive Testing Policy and                             12

                          Methods Used to Accomplish Testing                                            13
Pbogram                   Systems Used to Track Testing of Personnel                                    14
                          Other HIV Testing                                                             14
                          DOD’s Quality Control Testing Requirements                                    14
                          Conclusions                                                                   15

Chapter 3                                                                                               17
Methods Used to           Policies on Education
                          Various HIV/AIDS Education and Information Provided
                                                                                                        17
                                                                                                        I8
Control the Spread of          at Service Installations
HIV/AIDS                  Counseling Provided to HIV-Infected Members                                  20
    ,                     Other Prevention Efforts                                                     20
                          Conclusions                                                                  21
                          Recommendations                                                              21
                          Agency Comments                                                              21

Chapter 4                                                                                              23
HIV/AIDS                  Hospitals Have Been Affected Significantly
                          HIV/AIDS Effects Likely to Increase
                                                                                                       23
                                                                                                       25
Significantly Affects     Little Impact on Military Operations                                         28
Hospitals, but Military   Conclusions                                                                  29
                          Recommendation                                                               29
operations Are            Agency Comments                                                              29
Minimally Affected
Appendixes                Appendix I: Organizations and Facilities Visited by GAO                      32
                          Appendix II: Comments From the Department of Defense                         34
           I              Appendix III: Major Contributors to This Report                              49




                          Page 6                                       GAO/HRD-90-39 AIDS in the Military
                      Contents




RelabedGAO Products                                                                               52
   I


Tab@                  Table 2.1: HIV Testing of Active Duty Members as of                          13
                          August 1989
                      Table 4.1: Hospitals Designated to Evaluate HIV-Infected                     24
                          Service Members




                      Abbreviations

                      AIDS       acquired immunodeficiency syndrome
                      AZT        azidothymidine or zidovudine
                      CDC        Centers for Disease Control
                      DOD        Department of Defense
                      ELISA      Enzyme-Linked Immunosorbent Assay
                      GAO        General Accounting Office
           Y
                      HIV        human immunodeficiency virus
                      IV         intravenous
                      RDDR       Reportable Disease Data Base
                      USAF       United States Air Force


                      Page 7                                      GAO/HRD-90-39 AIDS in the Military
Cdapter 1

Introduction


               Acquired immunodeficiency syndrome (AIDS) is a relatively new disease
               that impairs the body’s immune system and leaves infected individuals
               susceptible to infections. There is no known cure for AIDS;nor is there a
               vaccine to prevent the spread of the human immunodeficiency virus
               (1-11~)
                     that causes AIDS.However, at least one drug, azidothymidine or
               zidovudine (AZT), prolongs the lives of people with HIV infection and
               AIDS.

               The United States Surgeon General has reported that the virus is not
               spread by casual contact, but primarily through intimate sexual contact
               and the use of shared hypodermic needles and syringes by intravenous
               (IV) drug users. In addition, infected pregnant women can transmit the
               disease to their unborn children. AIDScan also be spread via contami-
               nated blood to persons receiving blood transfusions.

               Although AIDS was initially discovered in the homosexual community,
               AIDSis not a disease that affects only homosexuals. AIDSis increasingly
               found in heterosexual people as well. The percentage of heterosexual
               contact cases increased from 1 to over 4 percent of the total cases
               between 1982-83 and 1988-89. The AIDSvirus generally infects persons
               who expose themselves to high-risk behaviors, such as certain types of
               sexual activities or sharing IV drug needles. In the United States, the
               groups with the highest likelihood of HIV infection are male homosexuals
               and IV drug abusers.

               As of December 1989, 117,781 cases of AIDSand 70,313 known deaths
               have been reported by the Centers for Disease Control (CDC).CDCesti-
               mates that 1 million Americans are infected with HIV. Epidemiological
               research, as of June 1989, indicates that more than half of those who
               carry the virus will develop AIDS within 10 years of their initial infec-
               tion. Some scientists, however, believe that all individuals infected with
               IIIV will eventually develop AIDSor AIDS-related complex, a condition that
               can also be debilitating or fatal. CDC projects that by the end of 1992,
               365,000 Americans will have developed AIDSand 263,000 will have died
               from the disease.’

               The costs of treating AIDSvary across the nation. Most studies that esti-
               mate treatment costs have focused on the direct costs associated with
               hospitalization. Estimates of average hospital costs over the lifetime of

               ‘GAO in its report, AIDS Forecasting: Undercount of Cases and Lack of Key Data Weaken Existing
               Estimates (GAO/PI%ID-89-13,     June 1, 1989), estimated that only about two-thirds of all cases of
               AIDS and other fatal HIV-related illnesses were captured in CDC’s data. As such, AIDS surveillance
               data should be adjusted upwards by an estimated 50 percent.



               Page 8                                                        GAO/HRD-90-39 AIDS in the Military
:.


                 Chapter 1
                 Introduction




                 an AIDS patient have ranged from $25,000 to $147,000.2 A 1988 review
                 of several studies of the costs associated with AIDS treatment suggests
                 that the lifetime per-patient costs of medical care will not exceed
                 $80,000 and will be comparable to the costs of treating other serious
                 illnesses.:’

                 Because of the potential impact on military operations and hospitals, the
                 Chairmen of the Subcommittee on Military Personnel and Compensation,
                 House Committee on Armed Services, and the Subcommittee on Regula-
                 tion, Business Opportunities and Energy, House Committee on Small
                 Business, requested that we examine the effects of AIDS in the military.


 s HIV Program   among other things, required all applicants for military service and all
                 active duty, reserve, and National Guard personnel to undergo blood
                 tests for HIV infection, In 1987, the policy was revised to include periodic
                 retesting of all personnel. The HIV policy is designed to protect both
                 infected and healthy service members. The policy provides that person-
                 nel infected with HIV cannot be deployed overseas. It also limits the use
                 of information obtained from individuals who are HIV infected.

                 DOD policy also requires each service to develop an education program
                 that includes information about the prevention and transmission of HIV
                 for its active duty population. DOD has adopted other preventive meas-
                 ures, such as counseling individuals who test positive for HIV infection.
                 DOD also conducts research on the disease and provides treatment.

                 Within DOD, responsibility for administering and implementing HIV policy
                 is shared by medical and personnel offices, The Office of the Assistant
                 Secretary of Defense (Health Affairs) is primarily responsible for devel-
                 oping and coordinating health policy for the program. The Office of the
                 Assistant Secretary of Defense (Force Management and Personnel) is
                 responsible for developing and coordinating personnel policy issues. The
                 military services are responsible for implementing WD policies.




                 ‘J. E. Sisk, “The Costs of AIDS: A Review of the Estimates,” Health Affairs, Vol. 6, No. 2 (Summer
                 19S7), pp. 5-2 1.
                 :‘D. Bloom and G. Carliner, “The Economic Impact of AIDS in the United States,” Science, Vol. 239,
                 No. 4840 (Feb. 5, 1988), pp. 604-10.



                 Page 9                                                        GAO/HRD-90-39 AIDS in the Military
                             Chapter 1
                             Introduction




                             The Chairmen asked us to determine:
O$jectives, Scope, and
M /%hodology             . what DOD is doing to assess and monitor the impact of AIDS in the
                           military,
                         l what action DOD is taking to prevent and control the spread of AIDS,
                         . how AIDS has affected DOD’S operations and medical treatment facilities,
                           and
                         . whether DOD has developed plans for dealing with an increased inci-
                           dence of AIDS.

                             We addressed these issues at DOD and military h.eadquarters offices and
                             at eight installations and 11 hospitals. Appendix I contains a list of the
                             DOD organizations, hospitals, and installations we visited and our ratio-
                             nale for selecting them. We limited our review to the active duty force.

                             To determine what DOD is doing to assess, monitor, and control the
                             impact of AIDS, we reviewed DOD’S HIV policies and each service’s HIV
                             instructions on screening procedures, controls, and actions taken con-
                             cerning personnel identified as HIV infected. We also obtained data on
                             testing costs, the number of active duty members and civilian applicants
                             for military service tested, and the number that tested positive for HIV
                             infection. (We did not independently verify the number of individuals
                             tested or the number that tested positive.) We also discussed AIDS educa-
                             tion, attended AIDS education briefings, and reviewed samples of educa-
                             tional materials provided to service members.

                             To determine how AIDS has affected DOD’S operations, we obtained docu-
                             mentation and interviewed commanders who had HIV-infected active
                             duty personnel assigned to them. Our discussions focused on the effects
                             that such personnel have on the ability of units to accomplish their mis-
                             sions, including the flexibility of assigning or deploying personnel. We
                             also discussed the impact of testing and education on operations.

                             To determine how AIDS has affected the military hospitals we visited, we
                             obtained information on each hospital’s HIV/AIDS work load and on costs
                             associated with the program that could be readily identified. Our discus-
                             sions focused on the ability of the hospitals to meet the requirements of
                             the HIV program and the program’s impact on each hospital.

                             At each organizational level, we discussed the potential effect of     HIV on
                             hospitals and operations and whether plans for dealing with an
                             increased incidence of AIDS in the military were being developed.



                             Page 10                                       GAO/HRD-90-39 AIDS in the Military
    Chapter 1
    Introduction




    We conducted our review from January 1988 to July 1989 in accordance
    with generally accepted government auditing standards.




*




    Page 11                                  GAO/HRD-90-39 AIDS in the Military
Chapter 2

I)OD Has Effectively Implemented a
Testing Program

                     DOD’S HIV testing program has succeeded in screening applicants for mili-
                     tary service and the vast majority of active duty military personnel to
                     detect and monitor HIV infection. The program includes initial testing,
                     retesting, and testing for other reasons, such as overseas deployment.
                     As of August 1989, the services had screened over 2 million active duty
                     personnel and reported over 6,200 members infected with IIIV.~ Each of
                     the services follows similar procedures to identify personnel for testing
                     and uses a central information system to monitor testing. Also, DOD has
                     established rigorous quality control standards to produce highly accu-
                     rate test results.

  1

                     Recognizing that HIV could significantly affect military personnel and
Dkvelopment of a     potentially affect military operations, DOD established a comprehensive
Cbmprehensive        testing program to assess and monitor the prevalence of HIV infection.
Tksting Policy and   DOD based its IIIV testing policy on a number of factors designed to pro-
                     tect HIV infected and uninfected members. Through mandatory HIV test-
Program              ing, DOD can (1) protect mv-infected service members from being
                     assigned to areas where they might be at risk to endemic disease,
                     (2) help assure that mv-infected members will not receive live vaccine
                     inoculations that could be hazardous to their health, (3) help ensure the
                     safety of the blood supply and decrease the potential transmission of
                     the virus to other individuals under battlefield or contingency condi-
                     tions, and (4) respond to the requirement of some foreign countries that
                     the military certify that its personnel are free of HIV infection before
                     entry into those countries.

                     The testing program consists of three components. First, all civilian
                     applicants for military service are tested to prevent nrv-infected individ-
                     uals from appointment or enlistment into the military. Second, all active
                     duty, reserve, and National Guard members undergo both initial HIV
                     tests and periodic retests in conjunction with periodic physical cxamina-
                     tions. Third, DODalso requires testing of active duty personnel who seek
                     prenatal care, seek services for sexually transmitted diseases, or are
                     enrolled in drug and alcohol programs.

                     Retesting policies of the services differ and are designed to meet the
                     individual needs of each service. Also, according to service officials, the
                     retesting policies were based on cost and rate of incidence of HIV infec-
                     tion. The Army and Air Force plan to retest all personnel every 2 years.

                     ’I~csc~rvt:and National Guard personnel who serve 30 or more days on active duty are includrd in this
                     group.



                     Page 12                                                      GAO/HRD90-39 AIDS in the Military
                                        Chapter 2
                                        DOD Hao Effectively   Implemented a
        ,                               Testing Program




            -“-
       I                                The Navy plans to retest all personnel serving in overseas and deploy-
                                        able units annually and will retest the remainder of its personnel in con-
                                        junction with their routinely scheduled physical examinations, which
                                        vary according to rank, age, and occupation, If the Air Force’s rate of
       I                                incidence remains low, it may adopt the Navy’s retesting policy.

                                        Since October 1985, the Army has conducted applicant screening for all
                                        branches of military service and tests about 750,000 recruit applicants
                                        annually. From October 1985 to June 1989, over 2.1 million applicants
                                        were tested under this program and 2,752 individuals were diagnosed as
                                        HIV infected and declared ineligible for military service.

                                        The services also began HIV screening of active duty members in October
                                        1985. As of August 1989, the services had screened over 2.1 million of
                                        their approximately 2.3 million active duty members at an average cost
                                        of $4 per HIV test. They reported 6,269 HIV infections among members;
                                        2,000 of the infected members were still on active duty, as shown in
                                        table 2.1. The remainder had retired, separated, or died,
--
Table 2.1: HIV Testing of Active Duty
Membgrs as of August 1989                                                                                               Number of
                                                                                                 Cumulative           HIV infected
                                                                         Eligible                 number of              on active
                                        Service                       population
                                                                            _-       N,u,msPeed’HIV infected                  duty
                                        Army                           866,426        792,072                2,390              575
                                                     -   ~~ ~~~~..
                                        Navy                           831,027
                                                               _-~~ ~.___             792,496          -.__. 2,942            1,160
                                        Air Fo&                        583,711         537,625                              334
                                                                                                              937 _~~.____ .~~~-
                                        Total                          2,281,164    2,122,193               6,269         2,069



                                        Service officials responsible for implementing the testing program devel-
Methods Used to                         opcd similar methods to carry out testing requirements. At each location
Acdomplish Testing                      we visited, service officials responsible for testing used a personnel ros-
                                        ter to schedule IIIV testing. Active duty personnel reported to designated
                                        locations to have blood drawn by medical staff. Personnel on ships and
                                        submarines usually had their blood drawn by medical personnel on
                                        board. Alternate test dates were available for personnel who could not
                                        report on their scheduled date. In each service, the member presented a
                                        military identification card to the medical personnel who drew the blood
                                        sample and recorded each member’s identifying information (such as
                                        name, rank, social security number, and unit) on the required forms and
                                        sample containers.




                                        Page 13                                                 GAO/HRD-90-39 AIDS in the Military
                        Chapter 2
                        DOD Haa Effectively   Implemented a
                        Testing Program




                        In 1985, the Assistant Secretary of Defense for Health Affairs estab-
S$stems Used to Track   lished a central management information system-the Reportable Dis-
Tetstingof Personnel    ease Data Base (RDDB) to provide DOD and service management with
                        information on infectious diseases. In addition to providing information
                        on other communicable diseases, each service supplies HIV test data on
                        all military personnel to the RDDB.

                        The services also use their personnel information system to monitor
                        testing coverage. A Naval Medical Command official informed us that in
                        December 1988, the office of the Chief of Navy Personnel compared the
                        master personnel files with the RDDB HIV data to determine which Navy
                        personnel had not been tested. Navy commands were notified of person-
                        nel without a recorded HIV test date and requested to either furnish
                        information documenting members’ test dates or have the individuals
                        tested, The Air Force plans to cross-check the RDDB'S HIV data against
                        other Air Force-wide data systems.

  1
  I
                              policy requires that all members have a current mv test before
Otther HIV Testing      DOD'S
                        assignment to overseas locations. All military members seeking services
                        at sexually transmitted disease, prenatal, and drug and alcohol clinics
                        must also undergo IIIV tests. Further, the services screen blood donors
                        before accepting blood and offer HIV testing to dependents of military
                        personnel on a voluntary basis.

                        DOD  policy does not preclude the services from imposing additional test-
                        ing requirements. For example, the Army requires active duty members
                        admitted to Army hospitals to undergo an HIV test if the latest HIV test
                        occurred more than 12 months before admission, The other services do
                        not require hospital admission testing.


                             has established several quality control measures to help assure the
DOD’s Quality Control   DOD
                        accuracy of its AIDS testing program. DOD uses two different tests to
Testing Requirements    detect HIV. The first is called the Enzyme-Linked Immunosorbent Assay
                        (ELISA) test, a Food and Drug Administration-approved        screening test.
                        The ELISA test is simple to perform and interpret but produces a rela-
                        tively high rate of false positive results; that is, positive test results for
                        individuals who have not actually been infected with the virus. There-
                        fore, a positive ELBA test must be confirmed by a more specific test, the
                        Western Blot.




                        Page 14                                         GAO/HRD-9039 AIDS in the Military
    .


              Chapter 2
              DOD Has Effectively   Implemented a
              Testing Program




              DOD  requires two positive ELBA test results and one positive Western Blot
              test result on two different blood samples before an individual is consid-
              ered to be HIV positive. The initial HIV-positive test result is confirmed by
              performing ELISA and Western Blot tests on a new blood sample. Com-
              mercial laboratories perform ELBA and Western Blot tests for the
              servicesz

              Because of the possibility of errors in interpreting HIV tests, DOD requires
              the services’ laboratories and their contract laboratories to meet certain
              standards. The contract includes stiff penalties for poor performance;
              failure to meet a 95-percent accuracy rate on tests obligates the contrac-
              tor to repeat every Western Blot test performed during the preceding
              month free of charge. One laboratory within each service monitors the
              accuracy of HIV test results.

              In 1987, DOD’S Inspector General conducted an audit of HIV testing in
              each service to determine compliance with the quality assurance
              requirements.:’ The report concluded that the services followed proce-
              dures that adequately ensured conformity with DOD standards for pro-
              ducing reliable test results.


                    HIV testing program, which incorporates quality control standards
Conclusions   WD’S
              to ensure accurate test results, has enabled DOD to effectively assess and
              monitor the prevalence of HIV infection within the military.

              Through its initial force testing, periodic retesting, and other HIV testing
              programs, DOD has screened the vast majority of its personnel. DOD’S HIV
              testing program includes provisions that help ensure that service mem-
              bers who may have engaged in activities that place them at a higher risk
              for exposure to HIV infection (such as those requiring services at drug
              and alcohol and sexually transmitted disease clinics) are tested.

              The mandatory testing program helps DOD to identify HIV-infected mem-
              bers, enabling DOD to protect them from (1) assignments to areas with
              high endemic disease and minimal medical care and (2) live virus inocu-
              lations, which could be life threatening.



              %efore June 1989,27 Navy laboratories performed the Navy’s ELISA analyses.
              %OD, Office of the Inspector General, Report on the Audit of Testing for Acquired Immune Defi-
              ciency Syndrome (Oct. 2,1987).



              Page 16                                                     GAO/HRD-90.39 AIDS in the Military
    Chapter 2
    DOD Has Effectively   Implemented a
    Testing Program




    The testing program has also enabled DODto (1) identify HIV-infected
    applicants for the military and deny them entry into the services and
    (2) help ensure the safety of the blood supply in battlefield situations by
    requiring that military personnel deploying overseas have a recent HIV
I   test with a negative result.




    Page 16                                      GAO/HRD-90-39 AIDS in the Military
Methods Used to Control the Spread of
HIk/AIDS

                        In addition to its testing program, DODhas instituted an HIV education
                        program intended to control the spread of HIV/AIDS in the military. A
                        variety of methods are used for educating the active duty force, includ-
                        ing briefings, printed materials, and counseling. As in the civilian sector,
                        the effectiveness of these educational efforts in changing behavior has
                        not been evaluated. A DOD survey indicates, however, that most military
                        personnel understand the basic facts about the transmission and preven-
                        tion of IIIV, but they still have misconceptions1


                             policy requires that an HIV/AIDS education program be offered to all
Policies on Education   DOD
                        beneficiaries of the military health care system. Each of the services
                        included provisions in its HIV policy to implement DOD’S HIV/AIDS educa-
                        tion policy. While each service’s policy requires that education be pro-
                        vided, those policies vary with respect to the amount and frequency of
    /                   the education required.

                        Between October 1985 and August 1988, DOD policy guidance on HIV/AIDS
                        education instructed the services to implement an “appropriate AIDS
                        education program.” In addition, DOD developed a list of approved films
                        and materials for use by the services. DOD issued additional guidance
                        based upon the results of the 1988 survey of health behaviors of mili-
                        tary personnel. DOD instructed the services in an October 1988 memoran-
                        dum to ensure that commanders receive general educational information
                        about mv. Further, in November 1988, DOD provided the services with an
                        HIV/AIDS information and education program framework that (1) speci-
                        fied groups that should receive HIV/AIDS education, (2) identified meth-
                        ods or mediums to provide education, and (3) established time frames
                        for educating the selected groups.

                        Each service’s mv policy has slightly different HIV/AIDS education
                        requirements. The Army stipulates that commanders are responsible for
                        assuring that at least 4 hours annually of unit-level instruction on the
                        Army’s HIV/AIDS testing and education program be provided, The Air
                        Force requires that HIV/AIDS prevention education be provided to all
                        active duty personnel and civilian supervisors. The Navy’s HIV policy
                        does not require mandatory AIDS education for its active duty personnel,
                        but the policy requires that informational programs be conducted to
                        inform service members of ways to prevent the disease and the risks of
                        uiv infection. Further, the Navy has included HIV/AIDS in certain other


                        ‘DOD, 1988 Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel.



                        Page 17                                                  GAO/HRD-90-39 AIDS in the Military
                           Chapter 3
                           Methads  Wed to Control the Spread of
                           mv/AIDB




                           mandatory training programs. For example, new recruits are to receive
                           HIV/AIDS information during orientation.



                           The methods used by the installations we visited to provide HIV/AIDS
V rious HIV/AIDS           education varied although they provided similar information. Education
E 1 ucation and            programs generally did not focus on modifying high-risk behaviors, such
In ormation Provided       as IV drug use and homosexuality. Rather, they were designed for the
                           general military population. The education sessions covered the defini-
at Service Installations   tions of HIV and AIDS, the modes of transmission of HIV, measures for
                           preventing transmission, and the service’s policy as it relates to HIV. The
  1                        services did not centrally monitor education. Accordingly, information
                           on the number of individuals who received education and the types of
  ,                        education was not available.
  I
                           At the Army installations we visited, health care workers or command-
                           ing officers trained by preventive medicine service personnel provided
                           HIV/AIDS education. The length of the education sessions and the method
                           used to deliver them varied from a 15- to 20-minute briefing when blood
                           samples were collected for testing, to 60- to go-minute sessions that were
                           provided semiannually. Army officials advised us that their education
                           requirement is being reviewed and will be revised once they determine
                           the appropriate type and amount of education that should be provided.

                           The Air Force’s policy on AIDS education was not uniformly interpreted
                           as a mandatory requirement. Some Air Force personnel interpreted the
                           policy to mean that it was mandatory that HIV/AIDS education be pro-
                           vided to all active duty members, and others believed it was mandatory
                           to offer it. At Air Force bases we visited, the Environmental Health and
                           the Infectious Disease Services provided AIDS education. The education
                           was provided using a 35-minute training session that included a lecture,
                           film , and question-and-answer period or briefings during a commander’s
                           call (meeting) and by distributing HIV/AIDS information pamphlets.

                           At the Navy installations we visited, Navy physicians, upon request,
                           provided HIV/AIDS education to active duty members when available to
                           do so. The methods used included (1) providing education to certain
                           enlisted personnel reporting to a facility, (2) showing films, (3) distrib-
                           uting pamphlets, and (4) providing 2-hour sessions, including lectures
                           and slides.




                           Page 18                                        GAO/HRD-90-39 AIDS in the Military
                              Chnpter3
                              Methods    Used to Control the Spread of
                              HIV/AIDS




Exp&ts’ Suggestions           The United States Surgeon General and the National Academy of Sci-
Regafrding Education          ences’Institute of Medicine advocate that education is the most effective
                              way to significantly reduce the spread of HIV infection. Both suggest pro-
                              viding general educational information about the disease, as well as spe-
                              cifically focused information on modifying high-risk behaviors, such as
                              IV drug use and homosexual or bisexual activity. They advocate educat-
                              ing individuals on ways to protect themselves and others from infection.
                              Also the Institute warned that it is important to communicate broadly
                              the message that specific, high-risk sexual practices increase the
                              probability of AIDS transmission. Further, because the virus can be
                              spread through unprotected heterosexual intercourse, clear and direct
                              messages about transmission routes and safer sexual practices are
                              important in preventing the spread of HIV infection.


Effetitiveness of Education   Research on AIDS education is inconclusive because the disease is rela-
Unkhown                       tively new and there has not been sufficient time to establish research
                              plans and measure the effectiveness of educational campaign efforts.
                              Neither DOD’S program nor many public AIDS education programs include
                              an evaluation component that would facilitate assessment of the pro-
                              gram’s effectiveness.

                              Experts have suggested that an evaluation component be integrated into
                              education programs to assess the effect of efforts on controlling the
                              spread of HIV infection. These experts suggest that if assessments of the
                              impact of education on the spread of the epidemic show that it is not
                              sufficiently slowed, determinations of the need for additional or redi-
                              rected funding for prevention measures could be made. In a September
                              1988 report, GAO also stressed the need to evaluate education programs.”

                              Although the effectiveness of DOD’S HIV/AIDS education programs has not
                              been evaluated, to obtain information on the knowledge military person-
                              nel have of AIDS, DOD conducted a 1988 survey of health behaviors that
                              included questions on HIV/AIDS. The survey indicated that military per-
                              sonnel are aware of the major means of transmission and prevention but
                              still have some misconceptions. The survey showed that a-bout 95 per-
                              cent of the personnel knew that HIV/AIDS could be transmitted by needle
                              sharing or having sex with someone who has AIDS. About 35 percent
                              realized that HIV could be transmitted through blood transfusions.
                              Approximately 20 percent believed HIV could be transmitted by donating
                              blood, and 25 percent believed it could be transmitted by dining in a

                              ‘AIDS Education: Reaching Populations at Higher Risk (GAO/PEMD-88-36, Sept. 16, 1988).



                              Page 19                                                   GAO/HRD-90-39 AIDS in the Military
                      Chapter 3
                      Methods Used to Control the Spread of
                      HIV/AIDS




                      facility where a cook has AIDS.About 90 percent of the military person-
                      nel believed abstinence and monogamous sex are effective means of pre-
                      vention; however, 25 percent believed asking sexual partners if they
                      had the disease was effective.


                      To contain the spread of HIV, DODrequires preventive medicine counsel-
Cdunseling Provided   ing for active duty personnel who test positive for the infection, Individ-
to SHIV-Infected      uals identified as HIV infected receive in-depth counseling during the
M                     initial evaluation. For example at two locations we visited, counseling
                      included discussions concerning such matters as interpretation of labo-
                      ratory test results, low-risk and safe sex, diet, and stress management.
                      In addition, HIV-infected personnel receive orders to follow preventive
                      measures, including informing potential sex partners and medical per-
                      sonnel of their HIV status. They are also directed not to donate blood.
                      Each HIV-infected individual is required to sign a statement acknowledg-
                      ing counseling and an understanding of the information and the safe-
                      guards to follow to prevent transmission of the virus. Failure to comply
                      with these orders is grounds for disciplinary action, including discharge.


                      DODoffers HIV/AIDSeducation to dependents and other DODbeneficiaries.
Other Prevention      In addition to classroom educational instruction, DODand the services
Efforts               distribute pamphlets and other literature on AIDS, print articles in mili-
                      tary publications, and display AIDSinformational posters.

                      Health care workers receive education on prevention of transmission
                      and caring for HIV-infected patients. Military hospital officials told us
                      they also follow the Centers for Disease Control’s universal precautions
                      to prevent transmission in health care settings by treating all patients as
                      if they have a transmittable disease. Health care workers use rubber
                      gloves when handling certain body fluids and excretions and do not
                      reuse needles. DODhospitals also closely monitor needlestick injuries in
                      health care workers caring for HIV-infected patients by periodically test-
                      ing the workers for HIV.

                      DODpolicy also requires that Food and Drug Administration guidelines,
                      Armed Services Blood Program Office policies, and accreditation
                      requirements of the American Association of Blood Banks be followed to
                      ensure the safety of the blood supply. In addition, DODhospitals are to
                      review blood donations to determine whether HIV-infected individuals
                      had received or donated blood. The military bases we visited make con-
                      doms readily available for sale and some provided them free of charge.


                      Page 20                                       GAO/HRD-90-39 AIDS in the Military
                      Chapter 3
                      Methods Used to Control the Spread of
                      HIV/AIDS




                           has taken several steps to control the spread of HIV within the mili-
Conblusions
   /
                      DOD
                      tary. The preventive measures taken by DUD, including HIV/AIDS educa-
   I                  tion, will undoubtedly help control the spread of HIV infection.

                      DOD’S education programs have been designed for a general audience,
                      which is one element of HIV/AIDS prevention recommended by experts.
                      DOD’S programs, however, do not focus on modifying high-risk behaviors
                      that place individuals at greater risk of infection--Iv drug use, homo-
                      sexuality, and bisexuality-an    element that is also recommended by
                      experts.

                      We recognize that because of the seriousness of HIV/AIDS, it was impor-
                      tant that DOD disseminate information quickly to the general military
                      population, W ithout an evaluation component, however, DOD does not
                      know if it is (1) effectively communicating the message to those individ-
                      uals at greater risk of becoming infected and (2) spending prevention
                      funds in the most effective manner.

                      Since experts believe that education and appropriate behavior modifica-
                      tion are currently the only tools to prevent the spread of HIV infection,
                      DOD should provide an HIV/AIDS education program that clearly addresses
                      high-risk behavior modification. DOD should also incorporate an evalua-
                      tion component that will provide valid information on the effectiveness
                      of its programs.


                      We recommend that the Secretary of Defense
Recommendations
                  l   modify the Department’s HIV/AIDS education programs to focus on
                      changing high-risk behaviors and
                  l   evaluate the effectiveness of the HIV/AIDS education efforts.


                      In a letter dated February 16, 1990, the Principal Deputy Assistant Sec-
Aghcy Comments        retary of Defense (Health Affairs) stated that DOD concurred with our
                      conclusions and recommendations (see app. II). However, DOD cautioned
                      that even with the additional efforts we recommended, the HIV incidence
                      rates may have reached an irreducible minimum without the availability
                      of further interventions, such as vaccines,

                      LX)D stated that it is in the process of finalizing a directive consolidating
                      urv-related DOD policies that it expects to issue in April 1990. DOD will
                      direct the services to implement an information and education program


                      Page 21                                         GAO/HRD-99-39 AIDS in the Military
Chapter 3
Methods Used to Control the Spread of
HIV/AIDS




that focuses more specifically on sexual practices and needle sharing.
DOD stated that this type of targeted education, which presumably will
require strategies involving one-to-one counseling and small group
instruction, is expected to require more resources. DOD stated that inher-
ent in the proposed DOD directive is the expectation that the services will
budget specifically for HIV education in their Defense budget
submissions.

DOD  also stated it will direct the services to add an evaluation component
to their educational programs to determine their effectiveness. DOD
noted that the correlation between effective education and behavior
change is unknown. DOD officials told us, however, during a meeting to
discuss their response to this report, that evaluating the HIV/AIDS educa-
tion program is, in their judgment, the best means available for judging
how to tailor a program to fit the audience.




Page 22                                       GAO/HRD9039   AIDS in the Military
      .




Chapter 4

HIV/AIDS Significantly Affects Hospitals, but
M ilitary Operations Are I!hnimally Affected

                         The impact of HIV/AIDS on hospitals has been significant. DODhealth care
                         officials, however, do not believe the disease has impaired tv quality of
                         health care delivery to other patient populations. Implementing the
                         HIV/AIDS program strained hospital resources to varying degrees, and
                         tradeoffs had to be made to accomplish HIV testing, conduct medical
                         evaluations, and provide treatment. The demands for and costs of
                         health care services are expected to increase in the future as (1) more
                         people are identified as HIV positive, (2) those infected begin to exhibit
                         symptoms requiring treatment, and (3) emerging drug treatments pro-
                         long the lives of HIV-infected patients. It is unclear how M )D and the ser-
                         vices will accommodate the future demand for AIDS-related care.

                         In contrast, HIV/AIDShas not had a significant effect on m ilitary opera-
                         tions and has not prevented m ilitary units from accomplishing their m is-
                         sions. If, as DODbelieves will be the case, the rate of HIV infection does
                         not increase, the future impact on m ilitary operations should continue to
                         be m inimal.


                         Implementing DOD’S HIV program affected m ilitary hospitals because the
Hos’pitals Have Been     program was a major undertaking that involved testing, medical evalua-
Affected Significantly   t’
                          ion, and treatment. In most instances, the added duties were performed
                         without additional staff or funds. While all hospitals were affected,
                         those with responsibilities for evaluating HIV-infected patients generally
                         experienced the greatest impact.


Test;ing Program         The HIV testing program constituted a major challenge and placed a
                         strain on m ilitary hospital resources. Hospitals had to redirect personnel
                         from other areas of the hospital to conduct HIV testing and to perform
                         medical evaluations. Staff worked long hours over extended periods of
                         time; hospitals contracted out laboratory work previously performed in
                         house and deferred equipment and supply purchases because funds
                         were diverted to the HIV program .

                         Hospital laboratories coordinated HIV testing, drew blood specimens,
                         prepared specimens for shipment to contractors for analysis, and per-
                         formed a variety of administrative tasks associated with the program .
                         In addition, one hospital laboratory in each service served as a quality
                         control monitor (e.g., checking the accuracy of HIV test results). Navy
                         laboratories experienced greater impact because they performed the ini-
                         tial HIV test in house and, for the most part, absorbed the work load with
                         existing resources.


                         Page 23                                       GAO/HRb90-39   AIDS in the Military




                                                                                                      .I
    ,
                                        Chapter 4
                                        HIV/AIDS Significantly Affects Hospitals,
                                        but Military Operations Are
                                        Minimally AfYected




Medical Evaluations and                 Medical evaluations and outpatient treatment accounted for most of the
Trdatment                               services that hospitals provided to HIV-infected members. The medical
                                        condition of each HIV-infected member is assessed and periodically
    I                                   reevaluated at 1 of 10 designated DODhospitals, as shown in table 4.1.

Tab1 4.1: Hospitals Designated to
Eva1 ate HIV-Infected Service Members   Servlce                            Hospitals
    t                                   Army                               Brooke, Madigan, Fitzsimons, Walter Reed, and Eisenhower
                                        Navy                               Bethesda, Oakland, Portsmouth, and San Diego      ___-
                                        Air Force                          Kilford Hall
                                        Note: Before November 1988, Beaumont, Letterman, and Tripler Army Medical Centers also performed
                                        medical evaluations.


                                        From 1985 through July 1989, the services had conducted about 13,000
                                        medical evaluations, including initial and subsequent reevaluations of
                                        HIV-infected members. Army hospitals conducted 6,645 evaluations of
                                        HIV-infected service members, while the Navy and Air Force hospitals
                                        conducted 5,307 and 830, respectively. Conducting evaluations placed a
                                        strain on staff resources in the evaluation hospitals we visited, as they
                                        had to reassign physicians from other areas of the hospital to the HIV
                                        program, use graduate medical students, or delay evaluations.

                                        DOD  requires annual evaluations of HIV-infected active duty members.
                                        Individuals who are placed on temporary disability retirement are
                                        required to be evaluated every 18 months. Any patient, however, may
                                        be evaluated more frequently if a physician believes such evaluations
                                        are necessary.

                                        The initial evaluation consists of examinations, extensive tests, orienta-
                                        tion, and preventive health counseling that includes (1) a complete medi-
                                        cal history and thorough physical examination; (2) extensive laboratory
                                        tests, such as urinalysis, total lymphocyte count, hepatitis screen, skin
                                        tests, chest X-rays, and additional tests as needed, based on the results
                                        of initial tests; and (3) numerous consultations with health care provid-
                                        ers from departments and services throughout the hospital, such as der-
                                        matology, ophthalmology, psychosocial, epidemiology, dental, and
                                        preventive medicine. An Air Force laboratory official commented that
                                        the average HIV-infected patient requires about 70 laboratory tests for
                                        each evaluation. At the six hospitals with evaluation responsibilities we
                                        visited, the length of time to conduct initial evaluations ranged from 1 to
                                        3 weeks.




                                        Page 24                                                     GAO/HRD-90-39 AIDS in the Military
                     Chapter 4
                     HIV/AIDS SlgniRcantIy Affects HOEPitalS,
                     but Military Operations Are
                     IklhhaUy Affected




                     During the evaluation, patients are categorized by the stage of infection
                     according to a classification system developed at the Walter Reed Army
                     Institute of Research. The classification system consists of six stages
                     ranging from stage one, identifying only exposure to the virus and
                     denoting no physical symptoms or signs of illness, to stage six, denoting
                     the most serious stage of the disease. Individuals found fit for duty are
                     returned to active duty. HIV-infected personnel who are determined to be
                     unfit for duty are either temporarily or permanently retired on disabil-
                     ity and are eligible for medical care in any military hospital. Individuals
                     who are permanently retired (as well as other service members who are
                     discharged) also have the option of obtaining care at Department of Vet-
                     erans Affairs hospitals.

                     In addition to performing evaluations, hospitals provided inpatient and
                     outpatient treatment. Since the majority of HIV-infected members are in
                     the early stages of infection, most of the treatment provided has been on
                     an outpatient basis, relying heavily on services provided by such depart-
                     ments as infectious disease, laboratory, social services, and
                     dermatology.


                     It seems inevitable that the demand for patient services and the costs of
HIV/AIDS Effects     providing these services will increase for several reasons, First, the size
Likely to Increase   of DOD'S HIV-infected population who are eligible to obtain care from DOD
                     hospitals will probably increase. As of August 1989, about 3,700
                     HIV-infected service members were eligible for care in the DOD health
                     care system. Based on a constant active duty population of 2.3 million,
                     and incidence rates of 0.67/1,000 and 0.76/1,000, developed by the
                     Navy and Army respectively, about 1,500 to 1,700 new HIV infections
                     are expected to be identified annually. An unknown number of depen-
                     dents for whom HIV testing is voluntary is also expected to be identified.
                     (Testing of the active duty force will continue to be mandatory.)

                     Secondly, MT, which increases the life expectancy of HIV/AIDS patients,
                     will result in patients obtaining services for a longer period.

                     Third, service medical officials stated that most of W D ’S HIV-infected
                     population who are eligible to receive care from a DODhospital are
                     expected to continue seeking care in DOD'S system rather than the
                     Department of Veterans Affairs system. In the Army and Navy, officials
                     stated that at least 60 percent of HIV/AIDSpatients who are no longer on
                     active duty return to designated DOD evaluation hospitals for treatment.



                     Page 26                                       GAO/HRD-90-39 AIDS in the Military
Chapter 4
HIV/AIDS Signifkantly     Affect8 Hospitals,
but Military Operations   Are
Minimally   Affected




Lastly, HIV-infected patients will become sicker, requiring more inpatient
care. Research indicates that at least 60 percent and perhaps all
HIV-infected individuals will eventually develop AIDSor AIDS-related ill-
nesses. Physicians at the medical centers we visited maintain that the
future treatment work load will greatly increase as HIV-infected person-
nel progress through the stages of the disease and become AIDGpatients.

HIV program and infectious disease physicians at Bethesda Naval Hospi-
tal told us in January 1989, that experience has shown that (1) 15 per-
cent of their HIV-infected patients develop AIDSwithin 2 years of being
identified as HIV infected, (2) 85 percent will develop AIDSwithin about 8
years, and (3) 10 percent of the symptomatic or AIDSpopulation will die
annually. Infectious disease physicians also estimated that patients with
AIDS-related complex may be admitted to a hospital about once a year,
whereas AIDSpatients may require hospitalization as frequently as once
a month.

Two HIV program physicians at W ilford Hall Medical Center believe that
the work load created by individuals progressing to the later stages of
the disease over the next 3 to 5 years will necessitate significant
increases in hospital personnel to provide care for these patients. W il-
ford Hall is the only Air Force hospital designated to perform evalua-
tions of HIV-infected service members.

The HIV program coordinator at Walter Reed advised us that HIV/AIDS
patients comprised about 90 percent of the infectious disease clinic’s
outpatient work load at Walter Reed. In July 1989 about 85 percent of
the Army’s HIV-infected patients were in one of the first three stages of
infection. The HIV program coordinator advised us that within 5 to 6
years, he expects most of these patients will likely need inpatient care.

Hospital officials also expressed concern about increasing expenditures
for drugs, such as AZT and pentamidine, commonly used in HIV/AIDS
treatment. AZT, which has been proven to prolong the life of an
HIV-infected individual and is now recommended for individuals in the
early stages of the disease, costs about $6,400 annually per patient. The
services estimate that 60 percent of their HIV-infected populations qual-
ify for early treatment with AZT. The Army’s estimated fiscal year 1990
AZT budget is $13.1 million compared to $1 .l million in fiscal year 1989.
We estimate the cost of providing AZT to Air Force and Navy personnel
will be about $10 million.




Page 26                                        GAO/HRD-99-39 AIDS in the Military
j .


      Chapter 4
      HIv/AIDsf3gnJflcantlyAPPectsHosPitals,
      but Military Operations Are
      MinimaRy Affected




      Pentamidine, a drug used to treat the pneumonia prevalent among AIDS
      patients, costs about $2,000 per treatment, Individuals may require mul-
      tiple treatments of pentamidine. Interferon, a relatively new drug some-
      times used to treat an AIDSpatient with Kaposi’s sarcoma, a cancer, is
      also expensive. It costs $1,000 per week and a patient can be treated
      with interferon from a few weeks to a few months.

      Military hospitals do not budget or account for costs by specific illness
      or diagnosis. Therefore, the total costs of HIV/AIDS treatment are not
      known but are absorbed in hospitals’ operating budgets.

      In response to a growing concern over AIDS, in 1986 the Army began
      allocating and tracking some HIV/AIDS expenditures. Using these data, it
      has estimated that the lifetime cost (10 years) to DODto provide medical
      care to each HIV-infected service member will range from $157,000 to
      $208,000. This estimate assumes that the incidence rate for personnel
      testing HIV positive will remain constant and that 60 percent of the
      patients will seek health care within the DOD health care system. Using
      the same assumptions the Army projects that HIV/AIDSwill cost DOD
      $3 billion over the next 10 years.’ The Army also projected HIV/AIDS
      costs using alternative assumptions for incidence rates. For example,
      over a lo-year period, a 20-percent increase in HIV infections would cost
      DODabout $10 billion, while a 20-percent decrease would bring the cost
      down to about $1 billion.

      Medical officials at the hospitals we visited expressed concern about
      their ability to handle the increased work load and costs. They said it is
      unclear how the expected demands for HIV-related health care will be
      met, from a personnel, facility, or budgetary perspective. For example,
      medical officials stated that military hospitals are generally designed to
      handle acute care patients rather than chronic, long-term care patients.
      However, in addition to acute care, AIDSpatients in the later stages often
      require chronic or long-term care facilities. Medical officials said that
      treating AIDS patients in an acute care setting when acute care is not
      required increases costs and reduces the number of acute care beds for
      those who need them.



      ‘Civilian sector cost estimates have generally been lower. One reason for the difference may be attrib-
      uted to the exclusion of certain services, such as outpatient care. Another factor is that the care and
      treatment of IIIV-infected military members begins sooner than in the civilian sector because of early
      detection in the military. Further, the civilian sector also offers alternative methods of care, such as
      home health care, hospices, and nursing homes, that are not available in the DOD health care system.



      Page 27                                                        GAO/HRD90-39 AIDS in the Military
                       Chapter 4
                       Hxv/AIDs Slgniflcantly Affects Hospitals,
                       but Military Operations Are
                       Mhimally Affected




-
                       Also, medical officials expressed concern over whether there would be
                       sufficient health care personnel to care for the increased hospital load
                       that will occur as the number of HIV-infected patients grows and as the
                       number progressing to the later stages increases (requiring more care).
                       According to these military hospital officials, personnel resources for
                       treating the current number of HIV patients are already stretched.

                       The Office of the Assistant Secretary of Defense (Health Affairs) moni-
                       tors the number of active duty personnel that have tested positive for
                       HIV infection to assess the potential impact on military operations. DOD
                       also monitors the number of service members on the temporary disabil-
                       ity retirement list, the number that have separated, and the number that
                       have permanently retired. It also collects information on the HIV/AIDS
                       disease and recognizes that increased treatment demands will be placed
                       on hospitals as infected individuals become sicker and as the number of
                       infected individuals increases. DOD officials stated that the increased
                       demand for health care will have to be met because health care in DOD is
                       an entitlement, It is unclear to them, however, how to address the need
                       for additional budgetary and personnel resources or the impact that the
                       increased demand will have on DOD facilities.


                       The impact of HIV/AIDS on military operations has been minimal because
Little Impact on       only about 2,000 HIV-infected personnel were on active duty as of
M ilitary Operations   August 1989, less than 0.1 percent of the active duty force. Those who
                       are HIV infected and who are found to be unfit for active duty are medi-
                       cally retired. Denying individuals entry into the military who test posi-
                       tive for HIV infection and retiring personnel unfit for duty should
                       continue to minimize the future impact on operations.

                       Unit commanders expressed differing views about the impact that HIV-
                       infected members have on their unit’s operations, but none believed that
                       these individuals affected the unit’s ability to perform its mission. Some
                       commanders indicated that HIV-infected personnel were good perform-
                       ers. A few commanding officers expressed concern about potential acci-
                       dents and administering first aid to HIV-infected persons. This was of
                       particular concern to commanding officers overseeing industrial opera-
                       tions Others expressed concern about duty restrictions and the poten-
                       tial adverse impact on unit cohesiveness in the event the unit was
                       deployed. Some also expressed concern about HIV-infected personnel
                       being absent from duty for medical evaluations, while others expressed
                       concern about all personnel being absent from duty for HIV testing and
                       education.


                       Page 28                                      GAO/HRD-90-39 AIDS in the Military
                      Chapter 4
                      HIV/AIDS Significantly Affect8 Hospitals,
                      but Military Operations Are
                      MinImally Affected




   /
                      There are several indications that the impact of HIV/AIDS on DOD’Shealth
Conklusions           care system will increase, especially in those hospitals designated as
                      evaluation hospitals. DODHealth Affairs and the services have collected
                      a great deal of data on HIV/AIDS. While DODrecognizes the disease’s
                      potential effect, it is unclear how DODplans to accommodate the
                      increased demand for health care services as a result of HIV/AIDS from a
                      budgetary, personnel, or facility perspective.

                      Even though DODdoes not normally plan or budget by specific disease or
                      diagnosis, the complexity of this disease and the potential effect it could
                      have on DOD’Shealth care system may warrant an exception to this prac-
                      tice. AIDS is an expensive disease to treat and treatment is labor inten-
                      sive. Both the financial and staffing resources that may be required of
                      DODto provide care to its HIV-infected beneficiaries may adversely affect
                      DOD’Shealth care system if plans are not made to accommodate these
                      increased demands for resources.

                      The impact of HIV/AIDS on military operations has not been severe since
                      the number of personnel infected is relatively small compared to the
                      total active duty population. The impact on operations during the next
                      few years will likely be minimal as well. DODwould have to experience a
                      large increase in the number of active duty members testing HIV positive
                      and remaining on active duty to pose a significant problem for military
                      operations. W ith preinduction screening and other preventive efforts,
                      this occurrence is unlikely.


                      We recommend that the Secretary of Defense develop plans for dealing
Recbmmendation        with the increased demand for HIV-related care. Such plans should
                      address the need for financial, staffing, and facility resources, including:

                  l budgeting for treatment costs, especially prescription drugs;
                  . assessing which hospitals, based on staffing and bed capacity, could
                    accommodate the projected work load; and
                  l determining how DODwill meet needs for chronic care since its hospitals
                    are currently better suited to provide acute care.


                      DODconcurred with our conclusions and recommendation. In April 1990,
Agency Comments       the Assistant Secretary of Defense for Health Affairs will task the ser-
              Y
                      vices with developing financial, staffing, and facility resources plans for
                      dealing with the increased demand for HIV-related services. DODstated



                      Page 29                                        GAO/HRD90-39 AIDS in the Military
Chapter 4
HIV/AIDS Significantly AfYects Hospitals,
but Military Operations Are
Mhlmally Affected




that long-range planning may be complicated by uncertainty surround-
ing what percentage of infected military health care beneficiaries will
continue to seek care from the military system rather than the Depart-
ment of Veterans Affairs. They said they would continue to monitor the
extent to which HIV/AIDS-infectedpatients use DODfacilities.




Page 30                                     GAO/HRD-90-39 AIDS in the Military
--




     Page 31   GAO/HRD99-39 AIDS in   the Military
ppendix I

hganizatims   and Facilities Visited by GAO


                   We conducted our work at DOD and service headquarters, eight installa-
                   tions, and 11 hospitals, At DOD, we obtained information from officials of
                   the Offices of the Assistant Secretaries of Defense for Health Affairs
                   and Force Management.

                   At the service headquarters level, we obtained information from offi-
                   cials responsible for HIV medical and personnel issues. We met with offi-
                   cials from each service’s Office of the Surgeon General. In the Army, we
                   met with officials from the Health Services Command, Fort Sam Hous-
                   ton, Texas, and the Office of the Deputy Chief of Staff for Personnel,
                   Washington, D.C. In the Navy, we met with representatives of the Naval
                   Medical Command, Washington, D.C., and the Office of the Chief of
                   Naval Operations, Arlington, Virginia. In the Air Force, we met with
                   officials from the Office of the Deputy Chief of Staff for Personnel,
                   Washington, D.C.; the Air Force Military Personnel Center, Randolph Air
                   Force Base, Texas; and the Air Force School of Aerospace Medicine and
                   the Air Force Human Systems Division, Brooks Air Force Base, Texas.

                   At the installations, we obtained information from commanders and unit
                   commanders. At the hospitals, we obtained information from the hospi-
                   tal commanders or their representatives in the following or comparable
                   departments or divisions:

               .   Community and Mental Health.
               s   Dentistry.
               .   Financial/Resource Management.
               .   Infection Control.
               .   Infectious Disease.
               .   Internal Medicine.
               .   Medicine.
               .   Nursing.
               .   Pathology.
               .   Patient Administration.
               .   Pharmacy.
               .   Preventive Medicine.
               .   Psychiatry.
               .   Psychology.
               .   Radiology.
               .   Social Work.

                   The hospitals and installations we visited represented a range of size,
                   mission, number of IiIv-infected personnel, involvement in the HIV pro-
                   gram, and geographic location. Six of the 11 hospitals play a significant


                   Page 32                                       GAO/HRD-90-39 AIDS in the Military
                                 Appendix I
                                 Organizations and Facilities Visited by GAO




                                 role in the HIV program because they conduct medical evaluations and
                                 provide medical care to HIV/AIDS patients. Other hospitals selected had
                                 limited involvement in the program, but were collocated with installa-
                                 tions that have large active duty populations and high priority for mili-
                                 tary deployment or both. We visited the hospitals and installations listed
                                 below.


Department   0f   the Army   l   Brooke Army Medical Center, San Antonio, Texas.
                             l   Walter Reed Army Medical Center, Washington, D.C.
                             l   Darnall Army Community Hospital and Fort Hood, Kileen, Texas.
                             l   Kimbrough Army Community Hospital and Fort Meade, Fort Meade,
                                 Maryland.
                             l   Womack Army Community Hospital and Fort Bragg, Fort Bragg, North
                                 Carolina.


Depgrtment of the Navy       l National Naval Medical Center, Bethesda, Maryland.
                             . San Diego Naval Hospital, San Diego, California.
                             l San Diego Naval Station, San Diego, California.
                             . Portsmouth Naval Hospital, Portsmouth, Virginia, and Norfolk Naval
                               Base and Shipyard, Norfolk, Virginia.


Department of the            . Langley USAF Hospital and Langley Air Force Base, Hampton, Virginia.
                             . Malcolm Grow IJSAF Medical Center and Andrews Air Force Base,
Air Eyorce                     Andrews Air Force Base, Maryland.
                             . W ilford Hall USAF Medical Center, Lackland Air Force Base, Texas.
                             . Air Force Military Personnel Center, Randolph Air Force Base, Texas.




                                 Page 33                                       GAO/HRD-SO-39 AIDS in the Military
Cbmments From the Department of Defense


-



                                      OFFICE   OF THE ASSISTANT   SECRETARY       OF DEFENSE
                                                    WASHINGTON.    D.C.   20301




           HEALTH   AFFAIRS


                                                                                    16 ff.9 I690
                    Mr. David P. Baine
                    Director,   Federal Health Care
                       Delivery  Issues
                    Human Resources Division
                    U.S. General Accounting Office
                    Washington, D.C. 20548
                    Dear      Mr. Baine:
                         This is the Department of Defense (DOD) response to the
                    General Accounting Office   (GAO) draft report,   "DEFENSE HEALTH
                    CARE: Effects of AIDS in the Military,"     dated December 19,
                    1989  (GAO Code 101327/0SD  Case 8208).  The DOD concurs with the
                    GAO findings   and the recommendations.
                            Guidance on the identification,            surveillance,    and
                    administration          of personnel infected       with the Human
                    Immunodeficiency           Virus (HIV) is contained in an August 4, 1988,
                    Deputy Secretary of Defense memorandum. The memorandum
                    recognizes that current scientific                knowledge about this disease
                    is essential         to the formulation      of sound DOD policy.
                    HIV-infected         individuals     are denied appointment or enlistment
                    for military         service and periodically        evaluated for medical
                    fitness      for duty for continued service in the same manner as
                    personnel with other progressive              illnesses.       The policy ensures
                    the safety of the blood supply and establishes                   aggressive
                    disease surveillance             and health education programs.          The DOD is
                    in the process of issuing this policy in Directive                    format.  The
                    Directive       will    be forwarded to the Secretary of Defense within
                    60 days.
                           The DOD is pleased that the GAO found the Services
                    implementing an appropriate        and comprehensive testing        program
                    with a quality     control   program that ensures the accuracy of its
                    HIV testing.      The GAO further     noted that HIV/AIDS has had
                    little    impact on military     operations.      The GAO specifically
                    recommended that the DOD modify current education programs to
                    focus on changing high risk behaviors and discussing              safe sex
                    practices,    while evaluating     these education efforts.         The DOD
                    concurs with these recommendations and will direct             their
                    implementation     in April 1990, in a memorandum from the
                    Assistant    Secretary of Defense for Health Affairs         to the
                    Services.     However, the successful        implementation  of these




                    Page 34                                                       GAO/~SO-39       MDFii in the MilitrvY
         Appendix~
         CemmentsFremtheDepartment ofDefense




-c




                                                                               2


     recommendations may be impeded, because some behaviors
     associated with transmission   of the virus are currently
     considered illegal  or incompatible  with military   service.   In
     April 1990, the DOD will also direct    the Services to develop
     plans for the perceived increased demand for HIV-related
     medical care.
          The detailed   DOD comments on the report findings   and
     recommendations are provided in the enclosure.       The Department
     appreciates    the opportunity to comment on the GAO draft report.




                                - Enrigue   Mended, Jr.,     M.D.
                             Principal   Deputy Assistant     Secretary
     Enclosure
     as stated




        Page36                                              GAO/HRD-90-39AIDSintheMilitary
                           Appendix II
                           CommentsFrom the Department of Defense




                                      GAO DRAFT REPORT- DATED DECEMBER19, 1989
                                           (GAO CODE 101327) OSD CASE 8198
                             "DEFENSE HEALTH CARE: EFFECTS OF AIDS IN THE MILITARY"
                                            DEPARTMENTOF DEFENSECOMMENTS
                                                        ******
                                                          FINDINGS
                        UNDINGa:         Acouired Immunodeficiencv        Svndrome . The GAO
                        explained that acquired immunodeficiency               syndrome (AIDS) is a
                        relatively      new disease that impairs the body's immune system
                        and leaves infected         individuals    susceptible    to infections.    The
                        GAO observed that there is currently             no known cure for
                        AIDS--nor is there a vaccine to prevent the spread of the human
                        immunodeficiency       virus (HIV) that causes AIDS. The GAO
                        observed, however, there is at least one drug, azidothymidine
                        or AZT, that prolongs the lives of people with the HIV
                        infection     and AIDS. The GAO noted that the U.S. Surgeon
                        General stated that the virus is not spread by casual
                        contact--rather,       it is primarily      spread through intimate      sexual
                        contact and the use of shared hypodermic needles and syringes
                        by intravenous      drug users.        The GAO further    noted that AIDS can
                        also be spread via contaminated blood to persons receiving
                        blood transfusions        and by infected     pregnant women transmitting
                        the disease to their unborn children.               The GAO emphasized that
                        the disease affects         every segment of the U. S. population--
                        including     the military.
                        According to the GAO, by July 1989, 102,621 cases of AIDS and
                        over 59,000 known deaths had been reported by the U.S. Centers
                        for Disease Control.        The GAO indicated    that the Centers for
                        Disease Control estimates that from 1 to 1.5 million            Americans
                        are infected    with HIV--and epidemiological        research indicates
                        that more than half of those who carry the virus will develop
                        AIDS within 10 years of their initial         infection.     (The GAO
                        observed that medical experts believe that, eventually,            almost
                        all individuals     infected with HIV will develop AIDS or AIDS-
                        related complex--a disease that can also be debilitating             or
                        fatal.)
                        The GAO indicated    that reports of hospital    costs over the
                        lifetime   of an AIDS patient    have ranged from $25,000 to
                        $147,000--although     a 1988 review of overall   studies of the
                        costs associated with AIDS treatment suggests that the lifetime
                        per patient    costs of medical care will not exceed $80,000 and
                        will be comparable to the costs of treating       other serious
No3 on pp. 2 and 8-9.   illnesses.     (p. 2, pp. 13-15/GAO Draft Report)
                        POD Remonse  : Concur.     The DOD recognized the potential    impact
                        of HIV/AIDS in the military    in late 1985 and early 1986, when
                        it began a program of screening applicants      for military service
                        and active duty personnel,    provided counseling and physical

                                                                                 Enclosure




                          Page 36                                               GAO/HRWHl-39AIDSintheMilitary
        Appendix II
        Cwnmente From the Department of Defense




    examinations  for its infected members, and mandated an
    education program directed    at preventing transmission of the
    virus.
    FIWDING:         Q!iwUmmt         Qf a ComrJrehensise DOD Te%bu
    Policv-                       The GAO found that, recognizing          the
    significant      affect HIV could have on military             personnel and the
    potential     for impacting military         operations,     the DOD
    established      a comprehensive testing          program to assess and
    monitor the prevalence of HIV infection.                 The GAO observed that
    the DOD based its HIV testing            policy on a number of
    factors--designed          to protect HIV-infected       and uninfected
    members. The GAO observed that, through mandatory HIV testing,
    the DOD can (1) protect HIV-infected               Service Members from being
    aesigned to areas where they might be at risk to endemic
    disease,     (2) help assure that HIV-infected            members will not
    receive live vaccine inoculations              that could be hazardous to
    their health,        (3) help ensure the safety of the blood eupply
    and decrease the potential           transmission      of the virus to other
    individuals      under battlefield       or contingency conditions,        and
     (4) respond     to the requirement of some foreign countries              that
    the military       certify    that its personnel are free of HIV
    infection     before entry into those countries.
    The GAO described      the DOD testing      program as consisting       of
    three components,      as follows:
    -    first,   all civilian    applicants     for Military      Service are
         tested to prevent HIV-infected          individuals     from appointment
         or enlistment     into the Military:
    -    second, all Active Duty, Reserve, and National Guard
         members undergo both initial HIV tests and periodic
         retesting;  and
    -    third,  the DOD also requires testing   of active duty
         personnel who (1) seek prenatal care, (2) obtain services
         for sexually transmitted    disease, or (3) are enrolled in
         drug and alcohol programs.
    The GAO found that the retesting    policies   of the Military
    Services differ   and are designed to meet the individual      needs
    of each service--based    on cost and the rate of incidence of HIV
    infection.    The GAO reported that the Army and Air Force plan
    to retest personnel every 2 years --while    the Navy plans to
    retest personnel serving in overseas and deployable units
    annually and the remainder of its personnel in conjunction        with
    their routinely   scheduled physical examinations     (which vary
    according to rate, age, and occupation).
    The GAO reported that, since October 1985, the Army has
    conducted applicant    screening for all branches of Military
    Service--testing    about 750,000 recruits  annually. The GAO

                                           Page 2


Y




        Page 37                                                 GAO/HRD-99-39 AIDS in the Military
                                                                                                                                                      ,




                                               A p p e n d i x II
                                               C o m m e n t s F r o m the D e p a r t m e n t of D e f e n s e




                                          o b s e r v e d that, from October 1 9 8 5 to J u n e 1 9 8 9 , over 2.1 million
                                          applicants w e r e tested u n d e r this p r o g r a m a n d 2 , 7 5 2 individuals
                                          w e r e d i a g n o s e d as HIV-infected       a n d declared ineligible    for
                                          Military        Service.       T h e G A O further reported that, in October
                                          1 9 8 5 , the Military         Services also b e g a n HIV screening of Active
                                          Duty m e m b e r s : as of October 1 9 8 9 , the Services h a d s c r e e n e d
                                          over 2.1 million of their approximately 2.3 million Active                         Duty
                                          m e m b e r s at a n a v e r a g e cost of $ 4 p e r HIV test--identifying
                                          6 , 2 6 9 HIV-infected m e m b e r s (2,390 Army; 2 , 9 4 2 Navy; 9 3 7 Air
                                          Force) . T h e G A O c o n c l u d e d that the D O Dh a s d o n e a g o o d job of
                                          assessing a n d monitoring the prevalence of HIV infection                       among
Noti   on   pp, 2 , 9 , a n d 1 2 - 1 3   military        personnel.         (p. 3, p. 5, p. 15, pp. 1 9 - 2 1 / G A O Draft
                                          Report)
                                          m:                          Concur. T h e applicant a n d active duty screening
                                          programs         continue to b e integral parts of the D O D effort                        to
                                          monitor the status of HIV infection                       a m o n g applicants for
                                          military         service a n d active duty personnel.                   A s of D e c e m b e r
                                          1 9 8 9 , the rates of infection                in both populations r e m a i n
                                          constant.            T h e D O Dwill continue to monitor the infection                       among
                                          its applicant a n d military                 populations.         T h e Navy a n d M a r i n e
                                          C o r p s will initiate            a third all force screening in F Y 1 9 9 0 .
                                                            .c            s U s e d to Accomvlish Testing.              T h e G A Of o u n d
                                          that Service officials                  responsible for implementing the testing
                                          p r o g r a m d e v e l o p e d similar m e thods to carry out testing
                                          requirements.               A t e a c h location it visited,           the G A O f o u n d that
                                          those Service officials                  responsible for testing u s e d a
                                          p e r s o n n e l roster to schedule HIV testing--with                     alternate test
                                          dates available for p e r s o n n e l w h o could not report o n their
                                          s c h e d u l e d dates.        T h e G A O reported that in e a c h Military
                                          Service the m e m b e r presented a military                    identification         card to
                                          the medical p e r s o n n e l d r a w i n g the b l o o d s a m p l e - - w h o r e c o r d e d
                                          e a c h m e m b e r ' s identifying         information,      such as n a m e , rank,
                                          social security n u m b e r , a n d unit, o n the required forms a n d
Nowon       pp, 1 2 - 1 3 .               s a m p l e containers.           (p.15, p . 2 2 / G A O Draft Report)
                                          m~es~onse:       Concur. T h e D O D continues                          to u s e this      same
                                          m e thod to accomplish testing.
                                          FINDING:        w            UsgeL                                             . The
                                          G A O reported that,       in 1 9 8 5 , the Assistant Secretary of Defense
                                          for Health A ffairs        established a central m a n a g e m e n t information
                                          system--the Reportable Disease Data Base--in o r d e r to provide
                                          D O D a n d Service m a n a g e m e n twith information in infectious
                                          diseases.      T h e G A O o b s e r v e d that, in addition to providing
                                          information o n other c o m m u n i c a b l e diseases, e a c h Military
                                          Service also supplies HIV test data o n all military                       personnel
                                          to the Reportable Disease Data Base. T h e G A On o t e d that the
                                          Services also u s e d their p e r s o n n e l information system to
N o w o n p. 14.                          monitor testing coverage.                 (pp. 2 2 - 2 3 / G A O Draft Report)
                                          P p p Resow:       Concur. T h e Reportable Disease Data B a s e
                                          provides m a n a g e m e n t information o n HIV to e a c h Service a n d
                                          prevalence data to the O ffice of the Assistant Secretary of
                                          Defense (Health A ffairs).           It is b e i n g e x p a n d e d to include
                                          other diseases of military           importance.

                                                                                                      Page 3




                                               Page 38                                                                G A O / H R D - 9 0 - 3 9A IDS in the Military
                   Appendix II
                   Comments   FromtheDepartmentofDefense




              FINDING:       Qther.                 The GAO found that the DOD
              policy requires that all members have a current HIV test before
              assignment to overseas locations.        The GAO further     found that
              all military     members seeking services for sexually transmitted
              diseases, prenatal care, and drug and alcohol abuse must also
              undergo HIV tests.       The GAO found that, in addition,      the
              Military    Services screen blood donors before accepting blood
              and offer HIV testing      to dependents of military    personnel on a
              voluntary    basis.   The GAO observed that the DOD policy does not
              preclude the Services from imposing additional        testing
Now on   14   requirements,     as determined to be appropriate.       (pp. 23-24/GAO
              Draft Report)
              r:                  concur.     A draft Directive      consolidating     the
                            1988, Deputy Secretary of Defense memorandum and
              other l&related        DOD policies       proposes to continue to mandate
              testing    for individuals      potentially     at greatest    risk of
              infection,      and monitoring    of the blood supply.         The draft
              Directive     is currently     out for comment and will be forwarded
              for Secretary of Defense signature within 60 days.
              FINDING:        a                                                  . The GAO
              found that the DOD has established          several quality      control
              measures to help assure the accuracy of its AIDS program. The
              GAO observed that the DOD uses two different             tests to detect
              HIV--the first      is called the Enzyme-Linked Immunosorbent Assay
               (or ELISA) test --a Food and Drug Administration-approved
              screening test. The GAO described the ELISA test as simple to
              perform and interpret,        but producing a relatively        high rate of
              false positive      results --that   is, positive   test results      for
              individuals     who have not actually      been infected with the
              virus.     The GAO observed that a positive        ELISA test must,
              therefore,    be confirmed by a more specific         test--the     Western
              Blot.     The GAO found that the DOD requires two positive               ELISA
              test results      and one positive     Western Blot test result on two
              different    blood samples before an individual          is considered to
              be HIV positive.
              The GAO reported both Military           Service and commercial
              laboratories      perform the ELISA and Western Blot tests for the
              Services.      Because of the possibility         of errors in interpreting
              HIV tests,     the GAO observed that the DOD requires the Service
              laboratories,      as well as those with whom they contract,            to meet
              certain    standards.       The GAO observed that the contract        includes
              stiff   penalties     for poor performance--failure         to meet a 95
              percent accuracy rate on tests obligates             the contractor     to
              repeat every Western Blot test performed during the preceding
              month free of charge.           The GAO noted that one laboratory         within
              each Service monitors the accuracy of HIV test results.                   The
              GAO also reported        that, in 1987, the DOD Inspector        General
              conducted an audit of HIV testing           in each Military     Service to
              determine compliance with the quality             assurance
              requirements --and concluded the Services followed procedures
              that adequately ensured conformity            with DOD standards for
              producing reliable         test results.    The GAO concluded that the
              DOD HIV testing       program, which incorporates        quality  control
              standards to ensure accurate test results,              has enabled the DOD

                                                     Page 4




                   Page 39                                              GAO/HRD-90-39 AIDS in the Military
                         Appendix II
                         Comments From the Department of Defense




-


                     to assess and monitor the prevalence of HIV infection               within
Nf   on pp. 14-15.   the Military.  (pp. 24-25/GAO Draft Report)
                     QoD R-:            Concur.     The DOD will continue to monitor
                     quality   control aspects      of the.testing    program.  The draft
                     Directive   referred   to in    the DOD response to Finding E further
                     mandates quality     control    efforts    in the area of CD-4 cell
                     counts.
                     &DING G: DOD Policies           on HIUS        Ed-        . The GAO
                     observed that DOD policies        require that an HIV/AIDS education
                     program    be offered to all beneficiaries         of the military     health
                     care system.      The GAO found, however, that while the regulation
                     for each Military      Service requires the education be provided,
                     the Military     Service policies     vary with respect to the amount
                     and frequency of the education required.             The GAO noted that,
                     between October 1985 and August 1988, DoD policy guidance on
                     HIV-AIDS education instructed         the Services to implement an
                     “appropriate     AIDS education    program."     In an October 1988
                     memorandum, the DOD further        instructed    the Military     Services to
                     ensure that commanders receive general educational              information
                     about HIV. In November 1908, the DOD provided the Military
                     Services with additional        HIV-AIDS information      and an education
                     program framework (1) specifying          groups that should receive the
                     HIV-AIDS education,      (2) identifying      methods or mediums to
                     provide the education,       and (3) establishing      time frames for
Now on pp. 17-18     educating the selected groups.           (p. 4, pp. 27-29/GAO Draft
                     Report)
                     DOD Rem:       Concur.     The DOD has placed the responsibility
                     to educate its members with each Service.     The framework,
                     developed by a Tri-Service    working group, provides goals for
                     the Services.
                     FINDING:         Various-     v-                                               d
                     gt Service Inst&(&tions              The GAO found that, at the
                     installations      it visited]     the methods used to provide HIV/AIDS
                     education varied--although           similar   information  was provided.
                     The GAO concluded, however, that the education programs
                     generally     did not focus on high risk behaviors--rather,             they
                     were primarily       designed for the general military         population.
                     The GAO noted that, because the Services do not centrally
                     monitor education,        information     on the number of individuals       who
                     received education and the types of education              received    was not
                     available.
                         unerts'    Suaaestions Reaardina Education--The       GAO noted
                         that the U. S. Surgeon General and the National Academy of
                         Sciences Institute    of Medicine   advocate  education   as the
                         most effective    way to reduce significantly     the spread of
                         HIV infection.     The GAO pointed out that both suggest
                         providing   general educational   information   about the
                         disease-- as well as specifically     focused information     on
                         modifying high risk behaviors,      such as IV drug use and
                         homosexual or bisexual activity.

                                                            Page 5




                        Page 40                                                GAO/HRD-90-39 AIDS in the Military
         I
                              Appendix II
                              Comments From the Department of Defense




                                             8 of EQ&ation Unknoyn--The GAO reported that
                               research on AIDS education is inconclusive        because the
                               disease is relatively      new and there has not been sufficient
                               time to establish     research plans and measure the
                               effectiveness   of educational    campaign efforts.    The GAO
                               noted that neither the DOD education programs nor many
                               public AIDS education programs include an evaluation
                               component-- which would facilitate      assessment of the
                               program's effectiveness.
                               POD 1988 Health Behaviors a.n-vev . The GAO did note,
                               however, that although the effectiveness       of the DOD
                               education programs    has not been evaluated, the DOD
                               conducted a 1988 survey of health behaviors--which           included
                               questions on HIV-AIDS.      The GAO reported that the survey
                               indicated military    personnel are generally     aware of the
                               major   means of transmission   and prevention--but    still     have
                               some misconceptions.     The GAO noted, for example, that
                               about   25 percent wrongly believed the infection      could be
                               transmitted   by dining in a facility    where a cook has AIDS.
                          The GAO concluded that the DOD education program will
                          undoubtedly assist in controlling       the spread of the disease.
                          The GAO further concluded, however, that in addition to the
                          general information      program, the education efforts   should focus
                          on the high risk      groups.   The GAO also concluded that, without
                          an evaluation      component, the DOD does not know if it is (1)
                          effectively      communicating the message to those individuals    at
                          greater     risk of becoming infected and (2) spending prevention
Nowon   pp.   3and18-21   funds in th: most effective       manner.   (P. 6, P. 32, P. 34,
                          p. 35/GAO Draft Report)
                          s:              Concur. The DOD agrees that education is the
                          only method currently   available   to reduce the spread of HIV
                          infection.  In November 1988, the DOD provided the Services
                          with an educational   and informational      framework that specified
                          which groups should receive education.          This framework is an
                          enclosure to the draft Directive      referred to in the DOD
                          response to Finding E. In April 1990, the DOD will direct the
                          Services to budget for and to add an HIV evaluation         component
                          to their educational   programs to determine their effectiveness.
                          Several factors regarding the GAO's findings must be
                          considered.     First, the DOD agrees that educational          efforts    are
                          best addressed toward behaviors that put individuals             at risk
                          rather than solely at groups.         Second, certain high risk
                          behaviors are incompatible     with military    service and/or are
                          illegal,   thus educational   efforts    may be more difficult.
                          Third, the correlation     between effective    educational      efforts,
                          as measured by evaluation     efforts,    and changes in attitude         and
                          behavior are unknown. The evaluation         program will strive to
                          identify   those messages that are most effective.         Fourth, even




                                                                Page 6




                              Page 41                                              GAO/HRD-90-39 AIDS in the Military
                                                                                                                                  I




                              A p p e n d i x II
                              C o m m e n t s F r o m the D e p a r t m e n t of D e f e n s e




                           with the additional    efforts      r e c o m m e n d e dby the G A O , the
                           incidence rates m a y h a v e r e a c h e d a n irreducible      m i n i m u m without
                           further interventions,      i.e.,     vaccines.
                           D D I N G I:         $Zounselins P r o v i d e d to HIVfected                 M e m b e r s. T h e
                           G A O f o u n d that, to contain the s p r e a d of HIV, the D O D requires
                           preventive medicine counseling for active duty p e r s o n n e l w h o
                           test positive             for the infection.           T h e G A Oo b s e r v e d that, in
                           addition,         HIV-infected p e r s o n n e l receive orders to follow
                           preventive measures--including                    informing potential             sex partners
                           a n d medical p e r s o n n e l of their HIV status--and they a r e
                           directed not to d o n a t e blood.                T h e G A O further o b s e r v e d that
                           e a c h HIV-infected           individual     is required to sign a statement
                            (1) a c k n o w l e d g i n g the counseling w a s received a n d (2)
                           confirming a n understanding of the information a n d safeguards
                           to follow to prevent transmission of the virus.                                 The G A O
                           reported that failure to comply with these orders is g r o u n d s
                           for disciplinary              action, including discharge.                  The G A O
                           c o n c l u d e d that the D O Dh a s taken several steps to control the
                           s p r e a d of HIV within the military.                   T h e G A O further c o n c l u d e d
                           that the preventive m e a s u r e s taken by the D O Dwill u n d o u b t e d l y
N o w o n p. 20.           assist in controlling               the s p r e a d of HIV infection.               (P. 33,
                           p. 3 4 / G A O Draft Report)
                           D O D Response: Concur. C o u n s e l i n g m e a s u r e s a r e e m p h a s i z e d in
                           the August 4, 1 9 8 8 , Deputy Secretary of Defense m e m o r a n d u ma n d
                           a r e e m p h a s i z e d in the p r o p o s e d D O D draft Directive referred to
                           in the D O D r e s p o n s e to Finding E .
                           FINDING J: O ther D O D Prevention E fforts.            T h e G A O f o u n d that,
                           in addition,     the D O D offers HIV/AIDS education to d e p e n d e n t s
                           a n d other D o D beneficiaries.     T h e G A Oalso f o u n d that health
                           care workers receive education o n prevention of transmission
                           a n d caring for HIV-infected patients.          T h e G A O reported that,
                           according to military       hospital officials,       they follow the
                           Centers for Disease Control universal precautions to prevent
                           transmission in health care settings by treating all patients
                           as if they h a v e a transmissable disease.           T h e G A O further f o u n d
                           that D O Dhospitals closely monitor needlestick injuries                     in
                           health care workers caring for HIV-infected patients by
                           periodically     testing the worker for HIV a n d offering AZT.
                           T h e G A O also f o u n d that D O D policy requires that F o o d a n d D r u g
                           Administration         guidelines,     A r m e d Services B l o o d P r o g r a m O ffice
                           policies,      a n d accreditation        requirements of the A m e r i c a n
                           Association of B l o o d B a n k s b e followed to e n s u r e the safety of
                           the b l o o d supply.      T h e G A O n o t e d the D O Dhospitals also review
                           b l o o d donations to determine whether HIV-infected                   individuals
                           h a d received or d o n a t e d blood.          T h e G A O further n o t e d that s o m e
                           military     b a s e s also m a k e c o n d o m s readily available for sale or
                           provide t h e m free of charge.
                           T h e G A O c o n c l u d e d that the D O D h a s taken n u m e r o u s steps to
                           control the s p r e a d of HIV within the military                  a n d that the
                           preventive m e a s u r e s will u n d o u b t e d l y assist in controlling        the
Now   on   pp. 2 0 - 2 1   s p r e a d of HIV infection.          (pp. 3 3 - 3 4 / G A O Draft Report)

                                                                                     Page 7




                              Page 42                                                             G A O / H R D 9 0 - 3 9 A IDS in the Military
        Appendix11
        CommentzFromtheDepartmentofDefense




    I)oD:            Concur.   The DOD will continue to develop
    applicable  preventive   medicine strategies,   in cooperation       with
    the U.S. public Health Service and other federal and
    non-federal  agencies.
    FINDIWG:     DoDe                     Been Affected Sianificantlv
    HIV*            The GAO found that implementing the DOD HIV
    program has affected military        hospitals  because the program was
    a major undertaking--involving        testing,  medical evaluation     and
    treatment.   The GAO noted that, in most instances,          the added
    duties were performed without additional          staff or funds.     The
    GAO found that hospitals       had to redirect    personnel from other
    areas of the hospital     to conduct HIV testing       and to perform
    medical evaluations.
    -    !&&&o      Proargm--The GAO observed that the HIV testing
         program constituted        a major challenge and placed a strain
         on military     hospital     resources.    According to the GAO, to
         implement the testing         program, staff worked long hours over
         extended periods of time, hospitals           contracted   out
         laboratory    work previously       performed in-house,    and
         purchases of equipment and supplies were deferred because
         funds were diverted        to the HIV program.      The GAO noted that
         Navy laboratories        experienced the greatest      impact because
         they performed the initial          HIV test in-house and, for the
         most part, absorbed the workload with existing             resources.
         d--Treatment--The                            GAO observed that
         medical evaluations      and outpatient treatment accounted for
         most of the services that hospitals       provide to HIV-infected
         members. The GAO noted that the medical condition         of each
         HIV-infected    member is assessed and periodically
         re-evaluated    at one of the ten designated DOD hospitals,
         currently    as follows:
         m..     AMY                     Brooke, Madigan, Fitzsimmons,
                                         Walter Reed, and Eisenhower;
         --      Navy                    Bethesda, Oakland, Portsmouth,
                                         and San Diego: and
         wm      Air    Force            Wilford   Hall.
         The GAO indicated       that, from 1985 through July 1989, the
         Military    Services conducted about 13,000 medical
         evaluations,     including    initial    and subsequent re-
         evaluations    of HIV-infected        members--Army hospitals
         conducted 6,533 evaluations,           while the Navy and Air Force
         conducted 5,307 and 830, respectively.
         The GAO concluded that the impact of HIV-AIDS on military
         hospitals   has been significant,     primarily  because of the
         mass testing--  straining    hospital  resources to varying

                                         Page 8


w




        Page43                                             GAO/HRD-90.39AIDSintheMihtary
                               Appendix II
                               Comments From the Department of Defense




-


                          degrees and requiring    tradeoffs.     The GAO observed, however,
                          that according to DOD health care officials,        the HIV-AIDS
                          program has not impaired the quality       of health care delivery   to
NC   XI pp. 3 and 23-25   other patient  populations.       (p: 4, pp. 37-41/GAO Draft Report)
                          DOD Reaoom:          Concur.
                                               DS Effects on t$i$itarV Hoswi~elv           to
                                       The GAO observed it seems inevitable    that the demand
                          for patients   services and the costs of providing     the services
                          for HIV-AIDS patients    will increase--for  several reasons:
                          --    first,   the size of the DOD HIV-infected     population,   who are
                                eligible    to obtain care from DOD hospitals,     will probably
                                increase (as of August 1989, about 4,000 HIV-infected
                                Service Members were eligible     for care in the DOD health
                                care system-- with about 1,400 new cases of HIV infection
                                expected to be identified     annually,  along with an unknown
                                number of dependents:
                          --    second, AZT, which increase6   the life expectancy of
                                HIV/AIDS patients,  will result in patients   obtaining
                                medical services for longer periods of time;
                          --    third,   Military  Service medical officials     expect that most
                                of the DOD HIV-infected    population,    who are eligible   to
                                receive care from a DOD hospital,      will continue seeking
                                care in the DOD system rather than in the Veterans
                                Administration    medical care system; and
                          --    lastly,  HIV-infected        patients     will become sicker, requiring
                                more inpatient     care (medical         experts believe that almost
                                all HIV-infected       individuals       will develop AIDS or AIDS
                                -related   illnesses).
                          The GAO reported that DOD hospital         officials     also expressed
                          concern about increasing      expenditures      for drugs commonly used
                          in HIV-AIDS treatment,     such as AZT, pentamidine,          and
                          interferon.      The GAO pointed out that AZT, which has been
                          proven to prolong the life of an HIV-infected             individual   and is
                          now recommended for individuals        in the early stages of the
                          disease, costs about $6,000 annually per patient.                The GAO
                          reported the Military     Services estimate that about 69 percent
                          of their HIV-infected     populations    qualify     for early treatment
                          with AZT. The GAO noted, for example, that the Army FY 1990
                          estimated budget for AZT is $13.1 million            compared to $1.1
                          million     for CY 1989. The GAO pointed out that, in addition,
                          pentamidine costs about $100 per dose ($2,100 for a Il-day



                                                                        Page 9




                               Page 44                                                 GAO/HRB99-39 AIDS in the iMIlitary
                            Appendix II
                            Comments From the Department of Defense




                         period) --with some patients     requiring  multiple    treatments.   The
                         GAO estimated that interferon      costs $1,000 per week--and
                         treatment can last from a few weeks to a few months.            The GAO
                         noted that, because military      hospitals  do not budget or account
                         for costs by specific    illness   or diagnosis,     the total costs of
                         HIV-AIDS treatment are not known--they are simply absorbed in
                         the hospital   operating budgets.
                         The GAO reported that medical officials                at the hospitals      it
                         visited   expressed concern about their ability                 to handle the
                         increased workload and costs--indicating                that it is unclear how
                         the expected demands for HIV-related              health care will be met
                         from a personnel,      facility      or budget perspective.          The GAO also
                         reported there is concern over whether there will be sufficient
                         health care personnel to care for the increased hospital                     case
                         load--which    will occur as the number of HIV-infected                patients
                         grow and the number progressing            into the later stages of the
                         disease   process increase--thus          requiring     more care.     The GAO
                         observed that, at the DOD headquarters               level,    there is
                         considerable     monitoring     of the number of Active Duty personnel
                         who have been tested positive           for the HIV infection--in          order
                         to assess the potential         impact.     The GAO reported that,
                         according to DOD officials,           notwithstanding       the impact, the
                         increased demand for health care will have to be met because
                         health care in the DOD is an entitlement.                  The GAO concluded
                         that there are several indications             that the impact of HIV-AIDS
                         on the DOD health care system will increase--especially                    in
                         those hospitals     designated as evaluation            hospitals.     The GAO
                         further   concluded, however, that although the Office of the
                         Assistant    Secretary of Defense for Health Affairs                and the
                         Military    Services have collected          a great deal of data on
                         HIV-AIDS and recognize the potential              effect of the disease, it
                         is unclear how the DOD plans to accommodate the increased
                         demand for health care services as a result of HIV-AIDS--from                     a
Now on pp. 4 and 25-28   budget, personnel,       or facility     perspective.        (p. 4, pp. 41-47,
                         p. 48/GAO Draft Report)
                         Q$Q~swonse:         Concur.     In April 1990, the Assistant      Secretary
                         of Defense for Health Affairs            will task the Military   Services
                         to develop plans for dealing with the increased demand for
                         HIV-related     services.     The plans will include the need for
                         financial,    staffing,     and facility      resources.    The GAO cites an
                         increased demand for patient            services and increased costs
                          (patients,   therefore,     will seek care from the DOD system rather
                         than the Veterans Administration),              and implies that, as
                         patients    become sicker they will require more inpatient             care
                         from the DOD system, rather than the Veterans Administration.
                         Although these GAO findings           are based on data currently
                         available,    this situation      may change over time, thus making
                         long-range planning difficult.              The DOD will continue to
                         monitor the situation        carefully.


                                                                 Page 10




                             Page 46                                                 GAO/HRD-90-39 AIDS in the Military
                         Appendix II
                         Commentskomthe DepartmentofDefense




                                                Has w     Little   Illlpact on m
                                       The GAO found that, because only about 2,000
                      HIV-infected     personnel were on active duty as of August 1989
                       (i.e.,  less than one-tenth of 1 percent of the Active Duty
                      Force), the impact of HIV-AIDS on military            operation8    has been
                      minimal.     The GAO reported that those who are HIV-infected             and
                      who are found to be unfit for active duty, are medically
                      retired.     The GAO concluded that denying entry into the
                      Military    Services of those individuals         who test positive    for
                      the HIV infection      and retiring    personnel unfit     for duty should
                      continue to minimize the future impact on operations.
                      The GAO noted that individual           unit commanders expressed
                      differing      views about the impact that HIV-infected        membere have
                      on their unit operations--but           none believed these individuals
                      affected     the unit's   ability     to perform ite missions.    The GAO
                      found that a few commanding officers            expressed concern about
                      potential      accidents and administering       first  aid to HIV-infected
                      persons--this       was of particular     concern to commanding officers
                      overseeing industrial        operations.      The GAO reported that eome
                      commanding officers       also expressed concern about duty
                      restrictions       and the potential     adverse impact on unit
                      cohesiveness in the event the unit was deployed--some also
                      expreseed concern about HIV-infected            personnel being absent
                      from duty.
                      The GAO concluded that the impact of HIV-AIDS on military
                      operations     has not been severe because the number of personnel
                      infected     is relatively      small compared to the total Active Duty
                      population.        The GAO further     concluded that the impact on
                      operations      during the next few years will likely          continue to be
                      minimal as well.         The GAO observed that the DOD would have to
                      experience a large increase in the number of Active                Duty
                      Members    testing    HIV-positive     and remaining on active duty to
                      pose a significant         problem for military    operations--a     situation
                      unlikely     to occur with current pre-induction         screening and the
Now on pp. 4 and 28   other preventive       efforts.      (pp 7, pp. 47-48, p. 49/GAO Draft
                      Report)
                      DOD Rem:        Concur.    The percentage of personnel on active
                      duty who are HIV-infected    has remained at less than one-tenth
                      of one percent for eighteen months.       The DOD effort  in the area
                      of education,  attitude   change, and behavior modification     with
                      regard to the prevention    of HIV infection   may eventually   aid in
                      the reduction  of the current incidence rate.




                                                            Page 11




                          Page46                                               GAO/HRD-9039AIDSintheMilitary
                              Appendix11
                              Comments FromtheDepartmentofDefense




         --c




                                                          RECOMMENDATIONS

                           RECOMMENDATION:          The GAO recommended that the Secretary of
                           Defense modify the       DOD HIV-AIDS education programs to focus on
                           (1) changing high      risk behaviors and (2) discussing   safe sex
Now on         .5 and 21   practices.   (p. 9,      p. 36/ GAO Draft Report)
                           s:               Concur.   The DOD agrees that education is the
                           only method currently    available  to reduce the spread of HIV
                           infection.   In November 1988, the DOD provided the Services
                           with an educational   and informational    framework that specified
                           which groups should receive education.        This framework is also
                           readdressed in the draft Directive      on HIV referred   to in the
                           DOD response to Finding E. The Directive        is expected to be
                           forwarded for Secretary of Defense signature       within 60 days.
                           Implementing an information      and education program that focuses
                           more specifically    on sexual practices     and needle sharing
                           presumably will require strategies       involving  behavioral
                           medicine interventions     for one-to-one counseling and small
                           group instruction.     This type of targeted education is expected
                           to require more resources.       Inherent in the proposed Directive
                           on HIV is that the Services will budget specifically           for HIV
                           education and evaluation      in the Defense Budget.
                           Several factors exist that may decrease the effectiveness                  of
                           the GAO recommendations when they are implemented.               First,     the
                           DOD agrees that educational          efforts    are best addressed toward
                           behaviors that put individuals           at risk, rather than solely
                           toward groups.       Second, certain high risk behaviors are
                           incompatible     with military      service and/or are illegal,      thus
                           hampering educational       efforts.       Third, even with the additional
                           efforts   recommended by the GAO, the incidence rates may have
                           reached an irreducible        minimum without the availability          of
                           further   interventions,      i.e.,   vaccines.
                           Although the above may be potentially limiting factors, the DOD
                           will direct the Services in April 1990, to make their education
                           more specific.
                           -2:                 The GAO recommended that the Secretary                of
                           Defense evaluate the effectiveness  of the DOD HIV-AIDS
Now on pp. 5 and 21        education efforts.   (p. 9, p. 36/GAO Draft Report)
                           DOD Reswonse: Concur.       In April 1990, the DOD will direct      the
                           Services to add an evaluation      component to their educational
                           programs to determine their effectiveness.        However, the
                           correlation   between effective    educational efforts,    as measured
                           by evaluation   efforts,  and changes in attitude      and behavior are
                           unknown.

                                                                  Page 12




                              Page47                                                  GAO/HRD-9039AIDSintheMilitary
                                                                                                          ,
                                                                                                              l


                           Appendix II
                           CommentsFromtheDepartmentofDefense




-


                       The DOD will        also continue to monitor knowledge about HIV/AIDS
                       through its       survey of health behaviors.     While not a measure of
                       attitude  or      behavior,   the 1988 survey results   indicated that
                       many Service        personnel still  had factual misconceptions   about
                       HIV and how       it is transmitted.
                       -3:                   The GAO recommended that the Secretary of
                       Defense develop plans for dealing with the increased demand for
                       HIV-related  medical care.     The GAO suggested that such plans
                       should address the need for financial,     staffing,  and facility
                       resources,  including   the following:
                       -     budgeting     for   treatment   costs,   especially   prescription
                             drugs;
                       -     assessing which hospitals   could accommodate the projected
                             workload--based on staffing   and bed capacity:  and
                       -     determining  how the DOD will meet needs for chronic
                             care--since  its hospitals   are currently better suited             to
No+ on pp. 5 and 29.         provide acute care.     (p. 9, p. 49/GAO Draft Report)
                       pnD ResOpnaQ: Concur.         In April 1990, the Assistant            Secretary
                       of Defense for Health Affairs         will task the Military
                       Departments to develop plans for dealing with the increased
                       demand for HIV-related      services.      The plans will include the
                       need for financial,     staffing,     and facility      resources.      Although
                       the GAO cites data that may allow initial             planning,     long-range
                       planning may be complicated by uncertainty              surrounding     what
                       percentage of infected military          health care beneficiaries          will
                       continue to seek care from the military             system (rather than the
                       Veterans Administration)        as treatments      and costs change.




                                                                 Page 13




                           Page48                                                  GAO/HRD-90-39AIDSintheMilitary
Appendix III

Majbr Contributors to This Report


                         Stephen P. Backhus, Assistant Director
Hum@ Resources           Dr. Murray Grant, Medical Advisor
                         Edward M. Morahan, Assignment Manager
                         Shelia D. Drake, Evaluator-in-Charge
                         David W. Bieritz, Evaluator
                         Donna M. Bulvin, Evaluator


                         James G. Cooksey, Site Supervisor
Dallal Regional Office   Sandra Ham, Evaluator


                         Lynn C. Johnson, Site Supervisor
Norfdk Regional          Linda M. Herron, Evaluator
office                   Kellie 0. Schachle, Evaluator




                         Page 49                                  GAO/HRD-90-39 AIDS in the Military
a
B
ca
0
Page 61   GAO/HRD-99-39 AIDS in the Military
@ated GAO Products


             AIDS: Delivering and      Financing Health Services in Five Communities
             (GAO/HRD89-120,Sept.       13, 1989).

             AIDS Education:    Staffing and Funding Problems Impair Progress
             (GAO/HRD-89-124,   July 28, 1989).

             AIDS Forecasting: Undercount of Cases and Lack of Key Data Weaken
             Existing Estimates (GAO/PEMD-89-13, June 1, 1989).

             Pediatric AIDS:    Health and Social Service Needs of Infants and Children
             (GAO/HRD-89-96,    May 5, 1989).

             Public Health: Centers for Disease Control Staffing for        AIDS   and Other
             Programs (GAOjHRD-89-66, Apr. 27, 1989).

             AIDS Education: Issues Affecting        Counseling and Testing Programs
             (GAO/HRD-89-39, Feb. 3, 1989).

             AIDSResearch: NIH Review of Process and Outcome of Applications for
             Grants and Contracts (GAO/HRD-89-17, Feb. 3, 1989).

             AIDSEducation: Activities Aimed at the General Public Implemented
             Slowly (GAOpIRD-89.21, Dec. 16, 1988).

             Federal Advisory Committee Act: Presidential Commission on              AIDS-
             Compliance With the Act (GAOjGGD-89-17, Oct. 19, 1988).

             AIDS Education: Reaching Populations at Higher Risk          (GAO/PEMD-88-36,
             Sept. 16, 1988).

             AIDS:Views on the Administration’s Fiscal Year 1989 Public Health
             Service Budget (GAO/HRD-88-104BR, June 2, 1988).

             Issues Concerning     CDC'S AIDS    Education Programs   (GAO/T-HRD-~~-~~,
             June 8,1988).

             AIDSEducation: Printing and Distribution of the Surgeon General’s
             Report
             --     (GAO/HRD-88-gOI%, Apr. 27, 1988).

             AIDS: Information on      Global Dimensions and Possible Impacts
             (GAO/NSIAD-88-SlFS,OCt.     28, 1987).




(101827)     Page 62                                            GAO/HRD-9039 AIDS in the Military
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