Enhanced risk of illness during the 1918 influenza pandemic after previous influenza-like illnesses in three military populations.

The reasons for the unprecedented mortality during the 1918 influenza pandemic remain poorly understood. We examined morbidity records from three military cohorts from years prior to and during the 1918 pandemic period to assess the effects of previous respiratory illnesses on experiences during the pandemic. Clinical registers and morbidity lists were examined to identify all medical encounters for acute respiratory illnesses in students at two U.S. military officer training academies and Australian soldiers deployed in Europe. Influenza-like illness prior to the major pandemic wave of 1918 predisposed Australian soldiers [relative risk (RR) 1·37, 95% confidence interval (CI) 1·18-1·60, P < 0·0001] and US officer trainees at West Point (RR 3·10, 95% CI 2·13-4·52, P < 0·0001) and Annapolis (RR 2·03, 95% CI 1·65-2·50, P < 0·0001) to increased risks of medically treated illnesses in late 1918. The findings suggest that susceptibility to and/or clinical expressions of the 1918 pandemic influenza virus depended on previous experiences with respiratory infectious agents. The findings are consistent with observations during the 2009 pandemic in Canada and may reflect antibody-dependent enhancement of influenza infection.

Pacific islands which escaped the 1918-1919 influenza pandemic and their subsequent mortality experiences.

Very few Pacific islands escaped the 1918-1919 influenza pandemic. Subsequent influenza epidemics in the established colonial outposts of American Samoa and New Caledonia infected many but killed very few persons whereas the extraordinarily isolated Niue, Rotuma, Jaliut and Yule islands experienced high mortality influenza epidemics (>3% of population) following 1918. These dichotomous outcomes indicate that previous influenza exposure and degree of epidemiological isolation were important mortality risk factors during influenza epidemics on Pacific islands.

The incidence of HIV infection among men in the United States Army Reserve Components, 1985-1991.

OBJECTIVE: To evaluate the incidence of HIV infection among men in the Army Reserve Components (RC) in the United States. METHODS: A prospective follow-up evaluating HIV seroconversions among men in the RC. Men who were initially seronegative were followed over time and periodically retested. The duration of follow-up was measured for each individual. Date of seroconversion was estimated to be the mid-point between last negative and first positive test. Demographic characteristics were evaluated for association with seroconversion, and incidence density between 1985 and 1991 was examined. RESULTS: We followed 733,622 RC men for 1,988,622 person-years between 1985 and 1991, and identified 534 seroconversions. Demographic correlates of risk included racial/ethnic minorities, age between 20 and 34 years, never having married, residence in an area with a low median income, and residence in metropolitan areas with high incidence of AIDS. Among most of these groups, the incidence density did not change substantially or significantly from the period 1985-1987 to 1991. CONCLUSIONS: The patterns of HIV infection are generally similar to those for reported AIDS cases. The incidence density over time is consistent with projections that AIDS incidence will plateau in the United States in the mid- to late-1990s.

HIV infection among women in the Army Reserve Components.

There is little information regarding the extent of HIV infection among women. Since late 1985, members of the Army Reserve Components have been routinely tested for HIV, providing an opportunity to measure directly the prevalence and incidence density of infection in a military-associated population with limited military contact. We evaluated the prevalence among 122,195 women, and directly measured the incidence density among 96,001 women followed for 247,872 person-years. The overall prevalence was 0.65 (per 1000), and the incidence density was 0.12 (per 1000 person years follow-up). Several demographically defined groups, including minority women, had elevated levels of infection. The incidence densities of infection between early and late in the testing program were compared, and no evidence of acceleration or deceleration was observed.

The dynamics of CD4+ T-lymphocyte decline in HIV-infected individuals: a Markov modeling approach.

We modeled the decline of CD4+ T-lymphocytes (T4 cells) in HIV-infected individuals with a continuous-time Markov process. The model partitions the HIV infection period into six progressive T4-cell count intervals (states), followed by a seventh state: a definitive HIV-infection end point, i.e., AIDS diagnosis or Walter Reed stage 6 (opportunistic infections). The Markov model was used to estimate the state-specific progression rates from data as functions of important progression cofactors. We applied the model to data on 1,796 HIV-positive individuals in the U.S. Army. The estimated mean waiting time from seroconversion to when the T4-cell count persistently drops below 500/mm3, but is greater than 349/mm3, is 4.1 years, and the waiting time to a T4-cell count of less than 200/mm3 is estimated at 8.0 years. The estimated rate of T4-cell decline was higher for HIV-infected individuals with initially high numbers of T4 cells, but the estimated rate of decline remains relatively uniform when the T4-cell count dropped persistently below 500/mm3. The opportunistic infection incubation period, i.e., the time from seroconversion to opportunistic infection diagnosis, is estimated at 9.6 years. Age is found to be an important cofactor. The estimated mean opportunistic infection incubation periods are 11.1, 10.0, and 8.9 years for the youngest (less than or equal to 25 years old), the middle (26-30 years old), and the oldest (greater than 30 years old) age groups, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for prevalent human immunodeficiency virus (HIV) infection in active duty Army men who initially report no identified risk: a case-control study.

A large proportion of human immunodeficiency virus antibody (HIV-Ab) positive male soldiers are considered to be at no identified risk (NIR) because they do not disclose histories of sexual activity with other men, intravenous drug use, blood transfusions, or sexual activity with persons at known high risk for HIV infection. A case-control study involving personal interviews with 26 NIR cases and 74 controls was conducted to determine if lifestyle information that might jeopardize a soldier's military career could be obtained from an Army population and to evaluate risk factors for prevalent HIV infection. Subjects consented to a voluntary, anonymous, and confidential interview containing information on demographic characteristics, medical history, drug use, and sexual behavior. Of 26 cases interviewed, 20 (76.9%) reported behaviors defined by the Centers for Disease Control (CDC) as risk factors for HIV infection, while 11 of 74 (14.9%) controls also reported such behaviors. This proportion of reclassified NIR cases was similar to that reported from the NIR case series study conducted by the CDC. Of the six (23.1%) cases who remained at NIR, all reported at least one of the following risks: a history of sexually transmitted diseases, sexual contact with prostitutes, or sexual activity with female partners which caused bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety and immunogenicity of multiple conventional immunizations administered during early HIV infection.

Twenty-one asymptomatic adults who had recently received multiple polysaccharide, live viral, and protein-derived vaccines were identified as being infected with human immunodeficiency virus (HIV). The mean subject age was 24 years (range 18-33); 20 of 21 (95%) were male. The mean T4 count was 523/mm3 with a mean T4/T8 ratio of 0.6. Serologic responses to immunization with meningococcus group C, adenovirus types 4 and 7, tetanus, and diphtheria were evaluated for the HIV seropositive subjects and were compared with the responses of similarly vaccinated age-, sex-, and race-matched HIV-seronegative controls. Significantly fewer (p less than 0.03) HIV subjects responded to meningococcus C (bactericidal antibody) and adenovirus 4 (neutralizing antibody) vaccines than did normals; the HIV-infected subjects who did respond produced functional antibody comparable to that of normals. Booster responses of HIV subjects to tetanus and diphtheria were comparable to those of normals. HIV-infected vaccine nonresponders did not differ from HIV-infected responders in total white blood cell, T4, T4/T8, total serum IgG, or delayed-type hypersensitivity skin test reactivity. All HIV subjects had negative cultures for live vaccine viruses (rubella, measles, adenovirus, and poliovirus). Postimmunization, no clinically apparent adverse reactions to vaccination were detected.

Tracking the spread of the HIV infection epidemic among young adults in the United States: results of the first four years of screening among civilian applicants for U.S. military service.

Because the period from infection to clinically apparent disease is long, variable, and changing as new therapies are developed and applied, AIDS data are inadequate for tracking current values of critical parameters of HIV infection epidemics: prevalence of infection, rate of acquisition of new infections (incidence rate), and direction and rate of change of infection incidence over time (acceleration). These "vital signs" of infection epidemics can be tracked using serial cross-sectional seroprevalence data, however. From October 1985 through September 1989, more than 2.3 million applicants for U.S. military service were screened for antibody to HIV. The overall seroprevalence was 1.31 per 1,000 (3,014/2,300,675). Seroprevalences were highest near urban centers of the AIDS epidemic and were independently associated with age, race/ethnicity, and gender. Based on age seroprevalence trends, it was crudely estimated that at least one of 2,000 young men and one of 7,000 young women are infected with HIV annually in the U.S. Infection incidence rates, estimated from age and temporal trends, were estimated to be highest among black males (1.40/1,000/year) and lowest among white females (0.03/1,000/year). Poisson regression analysis of seroprevalence trends suggested that infection incidence rates accelerated among black females during the first 3 years of screening. Since selection factors undoubtedly changed over the period, estimates based on these data probably underestimate actual values in the general population, particularly near urban AIDS epicenters. Nonetheless, even crude estimates of these critical values, particularly among adolescents and young adults, are useful to guide policy development, to allocate resources, and to monitor program effects.

Evidence for spread of the human immunodeficiency virus epidemic into low prevalence areas of the United States.

Reports of an increased proportion of AIDS cases occurring in small and medium-sized cities suggest that the HIV epidemic may be spreading into locations that were previously characterized by their low HIV antibody prevalences. Studying the question of the geographic spread of the HIV infection epidemic (rather than the AIDS epidemic) has been difficult largely because most serial seroprevalence data have been gathered from cohorts of high risk individuals (e.g., homosexual/bisexual cohorts) in New York City, San Francisco, and other geographically circumscribed areas. The U.S. military applicant HIV screening data were used in the current report to examine rates and 24 month temporal trends in geographic areas characterized by their HIV endemicities. The data examined concern the seven most populous states and four hyperendemic metropolitan areas located within those states (New York City, Miami, Houston, and San Francisco). In the nonepidemic regions, seroprevalence rates increased among black and white applicants. In the four epidemic urban areas, only young black applicants had higher HIV seroprevalence rates during the second 12 month period. Six of the seven nonepidemic regions had positive HIV seroprevalence trends, and these trends were significant in Florida, California, Texas, Illinois, and Ohio. The increases in these regions were greater for young blacks (30% excess for year 2 vs. year 1) compared to young whites (12% excess for year 2 vs. year 1). These data provide evidence of birth year specific increases in seroprevalence over time occurring in presumed low HIV prevalence areas. These increases cannot be due to, but are observed in spite of, biases associated with increasing self-selection over time.

The prognostic utility of delayed-type hypersensitivity skin testing in the evaluation of HIV-infected patients. Military Medical Consortium for Applied Retroviral Research.

Many reagents and techniques have been used for delayed-type hypersensitivity (DTH) skin testing in the evaluation of HIV-infected patients, resulting in varied interpretation of the utility of DTH skin testing in this population. We report the development of a simple algorithm for selection of DTH antigens and the clinical relevance of DTH skin testing in HIV disease. Antigens and concentrations for testing were first evaluated in a demographically matched, HIV-negative, immunologically healthy population. The testing scheme was then applied to the HIV population of interest for 5 years at several clinical sites. The antigens and concentrations selected resulted in 100% reactivity to two or more antigens in the HIV-negative cohort. Anergy is thus a distinct immunologic abnormality. Although some correlation (r2 = 0.6) of skin test reactivity and CD4 cell count was found in a cohort of HIV-infected individuals, anergy was found to be independently predictive of the development of symptomatic late-stage disease (Walter Reed Stage 6), AIDS, or death. This stepwise evaluation of skin testing and reagents has led to the modification of the skin testing protocol by defining the minimum number of antigens required and establishing the independent prognostic role of DTH skin testing in the evaluation of HIV-infected patients. The addition of mumps (40 CFU/ml), tetanus (1:10), and candida (1:10) to the purified protein derivative (PPD) skin test provides the critical controls to evaluate the status of PPD skin test in HIV-infected individuals as well as to provide a useful and prognostic clinical immunology evaluation.

Predictors of HIV-1 disease progression in early- and late-stage patients: the U.S. Army Natural History Cohort. Military Medical Consortium for Applied Retrovirology.

HIV-infected individuals in both early and late stages of HIV disease were evaluated over 2 years to assess temporal trends and determinants of disease progression. The Walter Reed (WR) staging system was used to categorize patients into an early-stage cohort (WR Stages 1 and 2, N = 1183) and a late-stage cohort (WR Stage 5, N = 260) based on the initial clinical evaluation. Progression was defined as the occurrence of Stage 5 disease or beyond for the early cohort and Stage 6 disease or beyond for the late cohort. The cumulative incidence of progression was 15.7% (137 events) for the early-stage cohort, and 53.7% (85 events) for the late-stage cohort. Baseline CD4+ T lymphocyte (T4) count was the most significant marker of progression: 26% of WR Stage 1 or 2 patients with T4 lymphocytes below 500/mm3 progressed, compared with 12% with T4 lymphocytes at or above 500/mm3. In late-stage individuals, 83% with T4 lymphocytes under 200/mm3 progressed, compared with 27% with T4 lymphocytes at or above 200/mm3. Older age was associated with progression in both early- and late-stage groups. Differences in the rates of disease progression were not significant between blacks and whites or between men and women. Two-year rates of progression among the late-stage patients dropped from 78 to 47% between 1986 and 1988. This contrasted with progression rates in the early-stage cohort, which remained stable: 18% for those entering follow-up in 1986 and 17% for those entering follow-up in 1988. These data indicate a significant slowing of HIV disease progression rates and mortality rates among individuals with late-stage disease that is temporally associated with the increased availability and use of therapies. With control of T4 lymphocyte count, age, and calendar time, neither gender nor race was significantly associated with progression in either early- or late-stage patients.

Epidemiology and control of acute respiratory diseases with emphasis on group A beta-hemolytic streptococcus: a decade of U.S. Army experience.

OBJECTIVE: To summarize the experiences of the U.S. Army regarding prevention and control, and frequencies, rates, trends, and determinants of febrile acute respiratory diseases (ARDs), particularly Group A beta-hemolytic streptococcus (GABHS). METHODOLOGY: Since 1966, the U.S. Army has conducted routine surveillance of ARDs among basic trainees. Since 1985, all trainees with fever and respiratory tract symptoms have been cultured for GABHS: Field investigations were conducted when outbreaks of acute respiratory or GABHS-associated illnesses were detected. Mass plus tandem benzathine penicillin prophylaxis were used to interdict and control training center GABHS outbreaks. RESULTS: During the period 1985 to 1994, there were 65,184 hospitalizations for acute febrile respiratory illnesses among Army trainees. The crude hospitalization rate was 0.45 per 100 trainees per week. The rate consistently declined over the period. Incremental declines were temporally associated with increased use of adenovirus immunizations and broader use of benzathine penicillin prophylaxis. During the period, 10,789 of 59,818 (18%) pharyngeal cultures were positive for GABHS: GABHS outbreaks were associated with diverse clinical manifestations including streptococcal toxic shock, acute rheumatic fever, and pneumonia. The emergence of mucoid colony morphology in clinical isolates was a consistent indicator of circulating virulent strains with epidemic potential. Outbreak-associated M types were M1, M3, M5, and M18. In response to six GABHS outbreaks, mass plus tandem benzathine penicillin chemoprophylaxis produced rapid and sustained GABHS control. ARD and GABHS recovery rates were lowest when benzathine penicillin prophylaxis was widely used. CONCLUSIONS: ARD rates among Army trainees have consistently declined to unprecedented levels. GABHS has reemerged as an important threat to military trainees. Benzathine penicillin chemoprophylaxis is safe and effective for interdicting and preventing GABHS outbreaks in closed, healthy young adult populations.

The nature, incidence, and impact of eye injuries among US military personnel: implications for prevention.

OBJECTIVES: To assess incidence rates of eye injuries in the US Armed Forces and to identify demographic and occupational correlates of risk. DESIGN: Retrospective population-based study. SETTING: US military medical facilities worldwide. PARTICIPANTS: All individuals in the US Armed Forces during 1998. MAIN OUTCOME MEASURES: Incidence rates of hospitalizations and ambulatory visits for eye injuries. RESULTS: The incidence rate of ambulatory visits (983 per 100 000 person-years) for eye injuries was 58 times higher than the incidence rate of hospitalizations (17 per 100 000 person-years) for eye injuries. Orbital floor fractures, contusions, and open wounds to the ocular adnexa and orbit accounted for 85% of eye injuries resulting in hospitalization, while 80% of ambulatory visits were for superficial wounds and foreign bodies. Hospitalization rates varied widely across demographic subgroups. Men had twice the incidence rate as women, and the youngest age group (17-24 years) had 6 times the incidence rate of the oldest age group (35-65 years). Together, motor vehicle crashes and fights caused nearly half of the hospitalizations. Ambulatory rates varied significantly in relation to occupation but not to demography. Tradespeople (eg, metal body machinist, welder, and metalworker) had incidence rates 3 to 4 times higher than the overall population rate. CONCLUSIONS: Hospitalization and ambulatory data provide different views of the morbidity associated with eye injuries. General safety precautions and behavior modification, rather than eye-specific interventions, are indicated to prevent the most serious eye injuries. However, the consistent use of eye protection during known hazardous occupational activities could prevent much of the morbidity associated with the less serious, yet more common, eye injuries.

Laboratory evaluation of a dot-blot enzyme immunoassay for serologic confirmation of illness due to Rickettsia conorii.

Of the 169 United States Army soldiers who deployed on a field training exercise to a remote area of Botswana for two weeks in January 1992, more than 30% developed a febrile illness within five days of their return. A diagnosis of South African tick typhus was suggested by soldiers' exposure to ticks, as well as the presence of eschars and vesicles at the site of tick bites, and tender regional lymphadenopathies. This high attack rate, experienced during such a short exposure period, emphasizes the hazard of illness due to Rickettsia conorii to persons visiting endemic areas. A rapid, diagnostic, semiquantitative enzyme immunoassay (DS) for detection of IgG and IgM antibodies to R. conorii was performed on 209 acute and convalescent sera from soldiers in the outbreak and on 75 control sera. For the acute sera from soldiers meeting the probable case definition of having both regional lymphadenopathy and tick bite eschar, as judged by an IgG indirect fluorescent antibody (IFA) test, the resulting sensitivity and specificity of the DS test were 100% and 48%, respectively. In the analysis of the acute sera, the DS test identified as reactive more of the probable cases (62%) than either the IgG (16%) or IgM (55%) IFAs. This simple and rapid diagnostic test could be useful in establishing a preliminary diagnosis of R. conorii rickettsiosis in remote settings when immediate confirmation by IFA is impossible.

Injuries in the military: a review and commentary focused on prevention.

BACKGROUND: In November 1996, the Armed Forces Epidemiological Board (AFEB) Injury Prevention and Control Work Group issued a report that cited injuries as the leading cause of morbidity and mortality among military service members. This article reviews the types and categories of military morbidity and mortality data examined by the AFEB work group and the companion Department of Defense (DoD) Injury Surveillance and Prevention Work Group. This article further uses the injury data reviewed to illustrate the role of surveillance and research in injury prevention. The review provides the context for discussion of the implications of the AFEB work group's findings for the prevention of injuries in the military. METHODS: The AFEB work group consisted of 11 civilian injury epidemiologists, health professionals and scientists from academia, and other non-DoD government agencies, plus six military liaison officers. Injury data from medical databases were provided to the civilian experts on the AFEB work group by the all-military DoD Injury Surveillance and Prevention Work Group. The AFEB work group assessed the value of each database to the process of prevention and made recommendations for improvement and use of each data source. RESULTS: Both work groups found that injuries were the single leading cause of deaths, disabilities, hospitalizations, outpatient visits, and manpower losses among military service members. They also identified numerous data sources useful for determining the causes and risk factors for injuries. Those data sources indicate that training injuries, sports, falls, and motor vehicle crashes are among the most important causes of morbidity for military personnel. CONCLUSIONS: While the work group recommends ways to prevent injuries, they felt the top priority for injury prevention must be the formation of a comprehensive medical surveillance system. Data from this surveillance system must be used routinely to prioritize and monitor injury and disease prevention and research programs. The success of injury prevention will depend not just on use of surveillance but also partnerships among the medical, surveillance, and safety agencies of the military services as well as the military commanders, other decision makers, and service members whose direct actions can prevent injuries and disease.

Epidemiology of HIV infection and AIDS in the United States.

HIV-1 disease has been recognized as a distinct clinical entity for fewer than 10 years. Yet during that time, the virus has spread around the world and affects people of virtually all ages, genders, sexual behaviors, and geographic regions. In the United States, there have been more than 140,000 individuals diagnosed with AIDS, the clinical end stage of HIV-1 disease, and it is projected that AIDS incidence will accelerate through at least 1993. In the early years of the infection epidemic in the United States, the virus spread rapidly and insidiously, predominantly among homosexual men, intravenous drug users, people with hemophilia, and recipients of infected blood products. Since then, the epidemic has been propagated concurrently with epidemics of drug use (intravenous and noninjectable) and sexually transmitted diseases such as syphilis. Since its beginning, HIV-1 has disproportionately affected members of racial and ethnic minorities, particularly in large cities, where transmission takes place sexually, parenterally, and perinatally. The epidemic of HIV-1 has spread outside of traditional urban epicenters and is more significantly affecting adolescents, women, and heterosexuals. There is a great need for renewed and refocused infection-prevention efforts. Projections of resource and medical service needs should be based on up-to-date and accurate assessments of infection epidemic parameters, including infection prevalence, incidence, and acceleration (changes in epidemic velocity over time) rates.

Deployed US Army soldiers' knowledge and use of personal protection measures to prevent arthropod-related casualties.

The recommendation to use personal protection measures (PPMs) to prevent arthropod-related diseases and nuisance bites is a common element of travel medicine consultation.1-3 Prevention of arthropod-related casualties is especially important to the military, given the often intense exposure of service members to biting arthropods and the threat of personnel losses to mission success. In the 1980s, 75% deet (N,N-diethyl-m-toluamide) was the US military-issue insect repellent for use on skin and clothing. Collaboration between military and civilian researchers led to the implementation in 1991 of the current US military system of PPMs which has three components: topical application of 33% extended-duration deet, treatment of field uniforms with permethrin, and proper wearing of field uniforms.4-6 Compared to military-issue 75% topical deet, 33% extended-duration deet prevents bites up to three times longer (as long as 12 hours), is less greasy, and has lower plasticizing properties. Field uniforms treated with the contact toxicant, permethrin, are also necessary to minimize bites from crawling arthropods such as ticks and chiggers. Implementation of all three components of this system is a safe and effective means of reducing the threat posed by biting arthropods.7 We conducted a questionnaire survey to assess the degree of deployed soldiers' knowledge of the US military's system of PPMs and use of PPMs in general. Survey results may promote the development of better ways to advise and teach military and civilian travelers about the proper use of PPMs given the multitude of available products and practices.

Military preventive medicine and medical surveillance in the post-cold war era.

In response to the end of the cold war, the United States developed new foreign policy and national security strategies. As a result, many medical support concepts that were operative during the cold war were invalidated. Recently, the Chairman of the Joint Chiefs of Staff provided direction and guidance for long-range strategic planning (Joint Vision 2010). Medical support doctrine that is being developed within the framework of Joint Vision 2010 relies on currently unavailable preventive medicine and medical surveillance capabilities. This report analyzes the relevance and roles of military preventive medicine and medical surveillance in the context of post-cold war resource constraints and military medical support needs, presents the rationale for and objectives of a demand-reduction medical support strategy, and outlines the roles, responsibilities, and characteristics of a defense medical surveillance system.

Hospitalizations for all causes of U.S. military service members in relation to participation in Operations Joint Endeavor and Joint Guard, Bosnia-Herzegovina, January 1995 to December 1997.

Since December 1995, the United States has deployed military forces to Bosnia-Herzegovina to participate for varying periods in peacekeeping operations. Throughout the operations, medical surveillance data have been routinely integrated in the Defense Medical Surveillance System. For this analysis, all individuals who served in the U.S. armed forces between January 1995 and December 1997 were characterized as participants or nonparticipants in the Bosnia-Herzegovina operations. Each participant's service was divided into predeployment, deployment, and postdeployment phases. End points for analyses were hospitalizations (all causes) in military hospitals. The crude hospitalization rate among nonparticipants (80.9 per 1,000 person-years [p-yrs]) exceeded the rate among participants (56.6 per 1,000 p-yrs). Among participants, the crude hospitalization rate during deployment (84.4 per 1,000 p-yrs) exceeded the rates before deployment (54.7 per 1,000 p-yrs) and after deployment (49.9 per 1,000 p-yrs). Proportional hazards regression procedures were used to control for confounding effects in comparisons of participants and nonparticipants, to account for transitions in deployment-phase exposures at appropriate calendar times, and to adjust for changes in hospitalization criteria that were implemented during the study. Although the crude hospitalization rate after deployment was lower than the rate before deployment, adjusted relative risks were elevated during and after deployment (relative to before deployment).

The U.S. Army HIV testing program: the first decade.

In response to the human immunodeficiency virus (HIV) epidemic, the U.S. military established comprehensive policies to protect individual and public health and to assure military readiness. Central to this effort was the creation of a total-force HIV screening program. As representative of these military programs, the U.S. Army's HIV testing program is described. The first decade of this program is assessed from financial, research, policy, and epidemic-control perspectives. We conclude that the government's investment has been a prudent one, leaving the U.S. military better positioned to counter the threats posed by the HIV pandemic.