Special report by Update contributor Andrew Hoffman
*An asterisk denotes names that were changed to protect the identity of the person quoted.
When Brian*, 25, came home after a year as part of the 2003 U.S. invasion of Iraq, he was diagnosed by VA doctors as having post-traumatic stress disorder, or PTSD. During his tour of duty, Brian had survived mortar attacks and the horrific death of a fellow platoon member. He turned to alcohol to numb the pain. "Half a year after I got out of the Army, I was in the liquor store purchasing a case of Jack Daniels. It struck me that I had just purchased a case of Jack a week prior. I generally match my friends two shots to one, so that means I was drinking eight fifths of Jack per week," he said.
Unable to find work that he could handle while contending with PTSD, Brian couldn't afford a place to live. He began couch-surfing and sleeping on subways and benches. After a year of homelessness, Brian landed a job as an editor, enabling him to pay rent on a modest apartment in a not-so-nice neighborhood. He's cut back on the alcohol but has "flirted" with turning to heroin and relies on marijuana to help manage his sleep troubles, anxiety, fits of rage, cold sweats and "suicidal ideations."
Brian is anything but unique. Homelessness and mental illness are widespread among veterans, as is substance abuse. So far 1.6 million service members have been deployed to Iraq or Afghanistan, and the New York Times and the Associated Press have both reported that a "tsunami" of homeless veterans may be in the offing. In 2006, nearly 200,000 veterans were homeless on a given night, representing 26 percent of the homeless population overall.
Around 45 percent of homeless vets are affected by mental illness and slightly more than 75 percent struggle with drugs and alcohol, according to the Department of Veteran's Affairs (VA). A recent five-month CBS News investigation showed that suicide among veterans has reached "epidemic" proportions accounting for an average of 120 veteran deaths per week in 2005 -- twice that of suicides among non-vets. Service members with the highest suicide rate? Veterans aged 20 through 24 who have served in Iraq and Afghanistan.
While much has been said about vets' battles with homelessness, mental illness and drug use, comparatively little has been said about the connection between those battles and veterans' risk for HIV. A growing body of research and the experience of those who work with veterans indicate that the link ought to be taken seriously.
Recipe for Transmission
The biggest threat for veterans is that homelessness and PTSD often both lead to intravenous drug use, one of the primary ways that HIV is transmitted.
"We know that homelessness and intravenous drug use go hand in hand with HIV/AIDS," John Keaveney told the Update . Keveaney fought in Vietnam and founded New Directions, www.newdirectionsinc.org, an organization that helps veterans obtain substance abuse treatment, job training, and other services. "When you're shooting dope and you need a fix, and somebody says, 'I've got a needle, let me give you a taste,' you're liable to do anything."
"Common sense should tell you we're looking at a potential HIV problem down the line," said Johnny Baskerville, director of health and human services at the Swords to Plowshares' Iraq Veteran Project, www.swords-to-plowshares.org/iraq-veteran-project, a San Francisco-based agency that provides health, housing, and other services for vets. "The vector for this new group of veterans will be through the drug culture. Combat is a drug and it's addictive. Many of these men and women get hooked on the rush, and when they're done, the next best thing is methamphetamine. Intravenous methamphetamine use is especially dangerous, because even if you don't get infected from the needle, there's an increased chance you'll engage in risky sexual behaviors."
The data on homelessness and IV drug use backs up Keaveney and Baskerville's concerns. In November 2007, the journal AIDS and Behavior published a special issue on the link between homelessness and HIV transmission. One study showed that homeless or unstably housed people are two to six times more likely to "have recently used hard drugs, shared needles or exchanged sex" than similar low-income persons who were stably housed. The same special issue contained preliminary data from a study by Centers for Disease Control and Prevention (CDC) researchers that showed a demonstrable correlation between a person's housing status and his likelihood of transmitting or getting HIV.
Homelessness isn't the only struggle that may put vets at risk for HIV transmission: PTSD, which accounted for more than half of all mental health problems among Iraq and Afghanistan war veterans, doubles the chance that a person will have an alcohol disorder, and triples the chance that a person will have a drug problem. As far back as 1997, Yale researchers showed that the combination of PTSD and substance abuse increases the risk of HIV by almost 12 times.
Brian, who also spent six months on a tour of duty in Afghanistan in 2002, believes an epidemic of HIV among veterans of Afghanistan and Iraq is a real possibility. He cites the high number of homeless vets, the temptation of intravenous drugs for veterans suffering from PTSD, "and the propensity of an individual who has spent 15 months in Iraq masturbating in a Port a Potty to just want to get laid, condom or no condom."
Brian spoke candidly about AIDS, but most vets the Update approached on the Internet or at soup kitchens and shelters would not. If homelessness, mental illness and drug use put veterans at risk for HIV, the stigma around AIDS in military culture could also be a powerful factor. According to one veterans' services insider, the ex-soldiers he knew didn't want to talk about AIDS because they "didn't want to be associated with homosexuality." The Update was briefly banned from a popular military-themed discussion board after asking a question about a possible connection between AIDS and veterans. When the ban was lifted, the responses to the question were uniformly hostile. Wrote one discussion board participant, "Go peddle your horse pucky to the insurgents."
Whether or not stigma is to blame, it is clear that veterans aren't aware that they're at risk for HIV -- or aren't facing up to the risk. A March 2007 study published in the Journal of General Internal Medicine found that only about one-third to one-half of VA patients identified as being at-risk for HIV had been tested within the five-year period of the study. The study emphasized that "early identification is critical for patients to receive life-prolonging treatment and risk reduction counseling" and recommended "substantially more ambitious programs for testing" of at-risk patients.
Despite the concerns of veterans' advocates and the close link of homelessness, mental illness and HIV transmission, the U.S. Department of Veteran affairs says it's not taking any special steps to ensure that HIV rates among returning vets from Iraq and Afghanistan don't rise. "We of course monitor the incidence [of HIV/AIDS] and will continue to monitor it, so that if, for some unexpected reason there's an increase, we certainly want to be prepared and have enough resources to handle it," said Jane Burgess, Deputy Chief Consultant for the VA's Public Health Strategic Health Care Group. But "we've no reason to expect that [the veteran] population is any different from the regular population."
According to the VA, as of 2006, 23,000 vets had been treated for HIV at VA facilities across the nation. That was an increase of 3,000 vets from 2003, when the Iraq War began. When the Update asked what portion of that 15 percent increase had served in Iraq or Afghanistan, VA spokesperson Jim Benson said the VA doesn't collect such data, but he found it "highly unlikely" that the increase was from that population, given that "military members are tested before deployment and monitored while in theater as operations permit." However, he did concede that adjustment difficulties after returning home "might" predispose those veterans to risk-taking behavior.
Paul Sullivan, a Gulf War vet who worked as a data analyst at the VA from 2000 to 2006 producing statistical and analytical reports relating to PTSD , says that he finds it hard to believe that the VA doesn't know what portion of new HIV infections are among Iraq and Afghan war vets. "I am absolutely certain they have those numbers. And it's shameful and inappropriate for VA to refuse to release them. The people have a right to know and Congress has a right to know so that the right policies can be implemented to help all of our citizens," Sullivan said. He added, "Every single social indicator of a crisis for veterans is flashing red," and that we can expect a "huge tidal wave of veteran casualties," including a possible surge in HIV.
Is No News Good News?
The VA doesn't just deny that it might have an HIV problem on its hands. It also says that a massive homelessness epidemic is simply not happening. Pete Dougherty, the VA's director of homeless veterans programs, said he's seen no sign that a surge in homelessness is underway, much less a surge in HIV. "We've only seen a little over 400 [Iraq/Afghanistan] vets in homeless specific programs," he said. "Given the fact that 850,000 or more men and women who served in Iraq have come home and been home, in some cases for a number of years, that's not an alarming number."
But even the presence of a small number of veterans from Iraq and Afghanistan at shelters may be an ominous sign for the future. "We are already beginning to see these folks showing up in shelters around the country," said Phil Landis, a Vietnam veteran and chairman of Veterans Village of San Diego. "With my generation of warrior, it took years and years for us to start showing up."
Baskerville concurred. "With Gulf War I, it took between six and eight years before we started seeing those men and women. But as this war has progressed, and they started doing multiple tours, we're seeing them a lot quicker," he said.
Dougherty argues that the appearance of veterans from Iraq and Afghanistan testifies to how well the VA and "community and faith-based service providers" are doing their jobs. "The fact that three to four times as many veterans are coming to us right after their military service ends than they did during Vietnam would indicate to me that those health needs and health issues are getting addressed on the front end," he said.
If Dougherty is wrong, it's not at all clear that the VA is equipped to deal with health problems that can lead to HIV infection or health problems caused by HIV. Amy Fairweather, director of the Swords to Plowshares' Iraq Veteran Project, said the VA can't handle the number of mental health cases already on its plate. "I have vets all the time who call me and say they're trying to get help for mental health through the VA. But they only get an appointment once a month, they are given pharmaceuticals, and their symptoms are downplayed," she said.
Joe*, an Army recruiter who was diagnosed with HIV four years ago, told the Update that the Army's and VA's medical services were excellent but severely lacking when it comes to offering emotional support people with HIV depend on. "We don't have the resources to help us deal with the overnight life change of being diagnosed with HIV. You find out, 'I'm HIV positive,' and the panic factor sets in, but there aren't enough resources that help you go home and deal with it." Joe, who has never seen combat, is nonetheless concerned about an epidemic among vets of Afghanistan and Iraq. "If they can't get the care they need from the VA, they'll substitute street drugs for the real treatment they need," he said.
Brian is in the midst of a two-year battle with the VA over whether his PTSD was service-related. "The general attitude of the VA with regards to any disability claim that's filed is delay and deny until the day they die," said Brian. "They're not looking to treat you, they're essentially looking to medicate, to give the individual a grab bag of pills."
Harvard professor and Clinton administration member Linda Bilmes told Newsweek that "the VA doesn't have the capacity to process large numbers of disability claims at the same time." Last January, Bilmes released a study on the long-term cost of caring for veterans from Iraq and Afghanistan, projecting that at least 700,000 new veterans will flood the system in the coming years. According to the report, the Veterans Benefits Administration already has a backlog of some 400,000 claims.
Where Do We Go From Here?
Like AIDS advocates, veterans' advocates--who stress that their criticisms of the VA are aimed at its administration and not its excellent frontline medical staff--are focused on the importance of housing in order to address a range of problems, including HIV risk. "Increasing access to affordable housing and services for vets who need them is the most important policy change that needs to be made," said Mary Cunningham, director of the Homelessness Research Institute at the National Alliance to End Homelessness (NAEH). Among the proposals contained in a recent study co-authored by Cunningham: the creation 5,000 new housing units per year for the next five years that are linked to veterans' support systems, many of which are directly related to the prevention of HIV.
Keaveney, who says veterans are routinely tested for HIV when they utilize services from New Directions, sees Cunningham's recommendation as a good start, but he worries that the NAEH is setting the bar too low. To really address the issue of HIV and other health threats to veterans, he said, there needs to be legislation that makes disabled veterans a protected class. "This legislation," he said, "would allow us to get HUD money to build affordable housing for all disabled veterans."
Sullivan says the VA and state and local agencies should work together to determine the scope of the HIV problem among vets, then take steps to address it.
According to Brian, addressing the negative stigma associated with receiving treatment for the psychological wounds of war "would definitely go a long way toward preventing HIV. Those who "actually bother to put on the uniform, a pair of boots, pick up a rifle, and go sit in the sandbox for a year, deserve every bit of care that this country can give them and then some," he said.