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Drs. Aresh and Kamiar Alaei show there is hope. Their
program, which began in their hometown of Kermanshah,
grew slowly from a prison population study to a program
that treats the high-risk group of injection-drug users,
sex workers and HIV positive clients. By use of peer
counseling and peer referral, the doctors have succeeded
in capturing the clients that were often too illiterate
to be able to read government help pamphlets. By
indirectly approaching the family through the
user-participants, the doctors hope to educate the women
of Iran, who will be transmitters of the deadly HIV
virus soon. By inviting key religious leaders onto
national drug and HIV awareness committees, the brothers
have swayed their votes, prompting them to ask for the
kinds of treatments that they would ordinarily find
abhorrent to their beliefs. Their story is compellingly
simple but heroic under the circumstances.
Doctors Alaei remarks are followed by a glimpse into the
United State's limited and failed approach at drug abuse
by Dr. Robert Newman, a world- renowned advocate for
methadone treatment and harm reduction. And finally
Joanne Csete, Human Rights Watch, discusses the trials
and tribulations of drug users in Central Asia.
Nick Platt:
This is a wonderful turnout, particularly for a Friday
night in New York. But I know the program and the issue
is a compelling one and I share your interest. We are
very pleased to host tonight's program on AIDS in Iran.
And we are grateful to the Starr Foundation and the Bill
& Melinda Gates Foundation for their generous support.
And also to AIC for helping us make this happen.
Tonight's program is particularly important to the Asia
Society because it is the first event of the new
initiative on AIDS in Asia. The Asia Society will
officially launch the AIDS in Asia initiative next
Tuesday morning with a live interactive discussion with
our chairman of the Board, Ambassador Richard Holbrooke,
who will be in India, along with other leaders and
experts in the global fight against AIDS. And I
encourage you to join us on the 14th at 8 o'clock in the
morning, which is not too early and is about right for
India as well. We will have interactive arrangements
here and I look forward to it.
Let me encourage you all to join this institution, which
has every facet that could interest you, whether it is
arts, culture, business, politics, children's education,
the whole works. We are trying to expand our membership;
we have brochures outside. I encourage you to join me.
We are honored to welcome some of the leading
authorities and advocates for HIV/AIDS in Central Asia
and authorities on the disease's close relationship with
drug use. We are particularly honored and grateful to
have Dr. Aresh Alaei and Dr. Kamiar Alaei, and we will
learn shortly about their remarkable story. On behalf of
the Asia Society let me say welcome and thank you. Now
let me introduce Hooshang Amirahmadi and thank him for
his cooperation in making this event happen.
Hooshang Armirahmadi:
Thank you, Nick. I am very honored to have this
gathering here. AIC has been a part of this from the
beginning. I want to say that as Nick said, this is a
distinguished group of people, not just distinguished
but also dedicated, extremely dedicated. They are people
who are working in the field -- both Alaei brothers, Dr.
Khoshnood and Dr. Newman--they have all been in Iran,
either living in Iran or visiting Iran. We are very
honored. This is the fourth panel that AIC has organized
on the subject. We will publish proceedings from this
and the other ones soon. All the others were at Capital
Hill and the last one was sponsored by Senator Chuck
Hagel.
I want to emphasize that there is no politics in today's
panel and there has never been any politics in any of
the previous humanitarian AIC panels. There is a mistake
about the AIC. Most people think the AIC is out there
just to establish US-Iran relations. But we are there to
contribute to a better understanding between the two
peoples. And the AIC does other things: we work on all
kinds of humanitarian matters in Iran. So I want to
emphasize very clearly that this is a humanitarian panel
and there are no politics here.
I am very grateful again to our colleagues here for
participating in this and I want to thank Nick and his
colleagues for organizing this very important event.
Thank you very much.
Nick Platt:
Thanks very much, Hooshang. And now let me introduce
Kaveh Khoshnood, the Assistant Professor of Epidemiology
at the Center for Interdisciplinary Research on AIDS at
Yale, who will introduce the other panelists and
moderate tonight's program.
Kaveh Khoshnood:
Thank you very much to the organizers and all the hard
work you did to putting this panel together and to all
of you for being here.
I am going to have a short presentation of 15 minutes
and then I will turn it over to the real speakers who
will tell us what is going on in Iran today.
As was mentioned, I am a faculty member at Yale school
of Public Health. I was born in Iran but have been
living in the United States for over 20 years. I had the
good fortune of meeting the two Alaei brothers at a harm
reduction conference in Thailand last year and
subsequently went to Iran and made some contacts. I am
grateful that they were able to come here.
Let me give you some background as to why this topic
today is important. And I want to apologize to people
who have a background in HIV/AIDS. For them this is sort
of an old problem.
There are three take-home messages I have for you.
First, HIV/AIDS and illicit drugs are both threats to
global security. That I will go over very quickly
because I know Joanne is also going to talk about that.
And I am hoping that most of you came here with an
appreciation for that. So I won't dwell on that much.
The second point is that Iran is strategically important
to the global community because of its geography and its
politics and because of the epidemiology of both drug
addiction and HIV/AIDS. I will just touch on those.
Third, and I think this is quite significant and perhaps
why we are all here, that there are new and progressive
responses to the drug-use driven HIV epidemic in Iran
that deserves our support and attention and could serve
as a model for the region and beyond. So these are the
take-home messages I want to leave you with.
Very quickly, the UN Security Council in 2001 said AIDS
is a threat to global security. But a couple of years
before that the General Assembly had already identified
another threat to global security and that is drug
trafficking and consumption of elicit drugs. The
estimates back in 2002 were that there were over 185
million illicit drug users - clearly a major global
problem. And why is it a global problem and a security
issue? I have listed some of the reasons. But this slide
to me illustrates all of this. And this basically shows
the life expectancy in several countries, and most of
them happen to be in Africa but not all. And it shows
what happens to life expectancy due to AIDS. And you can
see how life expectancy in some countries has dipped
below 40. That is why HIV/AIDS, in a nutshell, is a
global security (issue). Unfortunately sometimes we have
to say how HIV is impacting the military before we get
the attention of certain sectors of the government. And
these are some of the numbers that have been coded. I am
saying "unfortunately" because there have been millions
of millions of people infected and dying of HIV/AIDS but
unfortunately governments sometimes only pay attention
to these kinds of numbers so we have to use them in our
presentations.
Most of you who know about the field of HIV/AIDS know
about the CIA report that came out a few months ago
(LINK to CIA Report) that came out a few months ago that
projected that Russia, China, India, Nigeria and
Ethiopia are going to collectively have the largest
number of HIV/AIDS cases by 2010. And there was a
mention of Central Asia as one of the areas where
HIV/AIDS is rapidly expanding. I know I am going fast. I
am going to make the presentation available to the Asia
Society so there will be a way to distribute it to all
of you. These are some of the numbers that I know Joanne
will go over also, the global look at the pandemic.
And these are the growth areas. You can see this is
Russia, where we have seen incredible increases. And we
are seeing Iran, Central Asia is right there, and this
is a major drug trafficking route and with that comes
HIV/AIDS.
This slide shows the proportion of HIV infections in
various parts of the world, including some parts in
Asia, where 50% of AIDS cases are attributed to
injection drug use.
Moving on to my second point, why Iran is strategically
important geographically, politically and
epidemiologically. I think that geographically it is
quite simple: Iran borders Afghanistan, the largest
producer of opium in the world. And we will talk about
this fact. Drugs do come through Iran on their way to
lucrative markets in Europe and other parts of the
world. Politically, Iran has the largest population in
the area. It clearly has influence in what happens in
Central Asia and in the Muslim world in general.
Epidemiologically, if you look at what's going on in
Central Asia and the neighboring countries of Iran, you
see similar patterns and they are not by accident. If
you look at drug trafficking routes, basically HIV
follows that route.
This is a slide showing the map of Iran and this is
Afghanistan and you can see this large border and drugs
coming inside Iran on their way to the Persian Gulf,
Europe and Central Aisa. I don't believe the opium
produced there makes it to the United States but it does
make it to Europe. Estimates are that half or as high as
90% of all the heroin and opium seizures in the whole
world occurs in Iran. This is quite a significant
number.
Now what is the impact of that, of this large drug
trafficking on Iran and beyond? According to official
statistics, more than 3,000 Iranian border patrol police
have lost their lives. This is an ongoing, daily battle.
The Iranian government estimates that only about 20% of
all the opium that is smuggled into Iran is actually
confiscated. The rest of it is shipped out to the
destinations I have mentioned and unfortunately we are
seeing a large number that are even more frightening
than these numbers. Remember the estimates of the number
of opiate addicted individuals in the United States is
about one million, with a population of 270 million.
Iran, population about 70 million, has this number of
people addicted to opium and heroin (data from slide: 1
to 2 million people). It is somewhere around 5 times the
prevalence of drug addiction compared to the United
States. So it's a major, major problem and in some
geographic areas, including Kermanshah, where the
Doctors Alaei come from, the prevalence is even higher.
Just a quick look at Iran at the present: I put the
title young and vulnerable population of 66 million
because a large percentage of the population is under
the age of 30. This is a very, very young population and
they are vulnerable. There are (high) unemployment
rates, opportunities for higher education are limited,
recreational opportunities are limited and there has
been growing rates of depression among the youths. These
are all the ingredients, if you will, that give rise to
drug addiction. And unfortunately, HIV/AIDS follows
often.
Here are some more estimates about the status of the
epidemic of drug addiction in Iran. Iran has dealt with
opium use for hundreds of years. It was somewhat of a
social phenomena in Iran, where my grandfather, I
remember, after dinner, would go to a back room and just
sort of smoke his opium and he was completely
functional, had a family and was a school principal and
so on. But there is a new phenomenon and this is the
phenomenon of people injecting heroin. We don't have the
time to go into the reasons for this but needless to say
the price of opium has skyrocketed in Iran but heroin is
extremely cheap and many of the younger generation are
starting with heroin use and the injection of heroin.
And this is a major problem because this is how
hepatitis B, hepatitis C and HIV are spreading in the
population. This is sort of the typical opium addict
that we used to see in Iran and unfortunately this is
what we are seeing now.
A quick look at HIV/AIDS in Iran: it started late. The
first case of HIV in this country started back in 1981.
Another 6 years passed before Iran identified its first
case of AIDS. These are official estimates: as of 2002,
there were a little over 3,000 HIV positive cases, and
400 AIDS cases. However UNAIDS estimates that there are
over 20,000 people who are infected and living with
HIV/AIDS. I think the Alaeis have some updated numbers
for us.
We don't really know. The surveillance system is there
but it is not up to date so the numbers could be
manifold higher. Unfortunately in that area, it is not
unexpected to see these numbers rise manifold over a
short period of time. So although the epidemic of
HIV/AIDS is relatively new, all the ingredients are
there for it to take off very rapidly because of the
drug injection that I mentioned.
A very quick look at drug policy in Iran, concentrating
on since the revolution of 1979. There used to be opium
production and cultivation in Iran. After the Islamic
Revolution it was banned completely. Also, drug
treatment centers were banned. Drug use and drug
addiction basically became a crime and there were very
harsh penalties against people who used drugs: mandatory
detention, execution if you had possession of certain
amounts of opium and so on. Then something happened in
the mid-1990s and don't ask me why and I cannot really
explain it. It is a deep question of social, political
factors. But in the mid 1990s, there was what I consider
a paradigm shift in drug policy and the way the Iranian
government responded to the drug addiction problem. It
started where it should always start, by the government
coming out and saying, we have a problem, we have a
major problem, we have an epidemic of drug use and drug
addiction on our hands. And what we have been doing,
which is basically incarcerating people, has not worked.
So we start there. Those reports came out of government,
they were published in newspapers, and they were
discussed openly. That was the first step.
Then things started happening soon after that. In
1995-96, treatment of drug addiction became legalized.
Up to that point, you couldn't treat a drug user. And
then things kind of took off from there. Outpatient
clinics, nationwide, methadone clinics started up again.
Methadone had a history in Iran before the revolution.
It came back again. We are now hearing about syringe
exchange programs where injection drug users can
actually exchange syringes for new ones, which is still
controversial in this country and as some of you may
know there continues to be a federal ban on using
federal dollars on needle exchange programs. There is
one starting very soon. I have talked to prison
officials who are talking about having syringe exchange
programs in the prison, which is a very radical concept
for the US and Western Europe. And successful
application to the Global Fund for HIV/AIDS, TB and
Malaria, which the two brothers had a major role in.
Iran was successful in receiving something in the order
of $14 million from the Global Fund.
The last point, and this is my observation as an
outsider, I do believe that this shift that has taken
place is fragile. I don't think this is a permanent
shift. I worry that for political reasons and other
reasons, things can reverse and go back to where they
were a few years ago, which makes it even more urgent
for us to stay vigilant, watch what is going on, be
engaged, support people like the Alaei brothers, all the
NGO movements and make sure we don't go back to the old
policies of incarceration and criminal approaches to
drug use and addiction.
To sum up my main points: we have a major problem of
dual epidemics of drug addiction and HIV/AIDS -- drug
addiction being much more of a severe epidemic but on
the tail of it, HIV/AIDS is rising. And it can
destabilize Iran and it can destabilize the region.
There has been a recent change in government policies.
Good work can be done now, harm reduction, science-based
prevention can be done and that is positive. Government
is allowing that to happen and is supporting it in
different ways. There are capable, accountable and
willing groups of individuals within the academic
community, within the civil society and within certain
government sectors, particularly the Ministry of Health
that I know of, that are very knowledgeable, willing to
respond to this growing epidemic. The reason I am
excited that Asia Society has taken this issue up is
that policy makers, academic folks, foundations here, we
could have a tremendous impact supporting what has
started in Iran only the last few years, to make it
grow.
With that I will end and ask Dr. (Kamiar) Alaei to talk
about what is actually going on in Iran today. Thank
you.
Dr. Alaei:
Ladies and gentlemen. Thank you and welcome for coming
to this session and thanks for the organizers and thank
you to my friend, Dr. Kaveh Khoshnood, who helped me in
my presentation.
As Dr. Khoshnood mentioned, the main problem in Iran is
that we have huge numbers of users in our country, that
the majority of them are less than 19 years old. And the
means: trafficking of opium addiction and opium
transport from Afghanistan to Iran and to Europe.
Unfortunately we had a good history of opium maintenance
traffic before the revolution and the first year after
the revolution but unfortunately the majority of the
experience is closed. More than two decades. Based on
our history, we had a limited experience of methadone
maintenance and methadone treatment before the
revolution and unfortunately after the revolution, for
more than 15 years, the majority of activity stopped.
During these 20 years, the most common users are opium
addicts and heroin addicts. Some of the drug users
inside the prisons inject opium. This way, we see that
the main problem in our addicts group is in the age
between 20 to 30. We have different estimation that the
majority of them show that the rate of drug use is
between 2 million to 4 million, from 65 million
inhabitants. So all the studies show that the main
problem in Iran is opium and some opium users have a
history of injections. So in the future we will have a
problem of HIV and hepatitis and several blood-born
diseases.
We started our project in Kermanshah, which is in the
west of Iran, with 2 million inhabitants. It is at the
border of Iraq and we had a problem of addiction and
HIV/AIDS in this city. To start our project, we studied
what the opium addiction and drug use status in
Kermanshah and which group of drug users is more at risk
for HIV/AIDS. We saw that the majority of HIV/AIDS cases
have infected HIV from prison. The majority of the
prisoners who had a history of imprisonment between 5 to
10 years were more infected for HIV/AIDS. In another
study we saw that unfortunately the majority of the drug
users who start their addiction before they are 15 years
old are more at risk for HIV/AIDS compared to other drug
users who started their addiction after 30. So this
group is more vulnerable for HIV/AIDS and unfortunately
before they know more information about addiction, they
are infected by HIV/AIDS.
We also saw that unfortunately the majority of drug
users who have a low level of education, for example are
illiterate or at a primary education level, are more at
risk for HIV/AIDS. But at that time the majority method
of information for this highest group was in newspapers,
pamphlets and posters that this group could not read. So
we saw that we must change our approach for the control
of HIV/AIDS based on the needs assessment of our
clients.
As you see in these three pictures, the rate of HIV/AIDS
in drug users during two years increased from 16% to
20%. And the main way of HIV infection in Kermanshah was
injecting drug use.
We wanted to know what is the main reason of mortality
in HIV-infected people before we started our activities.
Unfortunately we saw that the main reason of mortality
in HIV cases at that time was (suicide) - it was more
than 60%. And the majority of them had suicide during
the first year after they were proved positive. And the
majority was due to the isolation from the community,
from their friends, partners, children and so on. So we
saw that they need counseling. Not only counseling for
themselves but also for the family, the friend and so
on.
I want to show the history of our project. Before our
project, the limited cases of HIV-infected were related
to blood transfusion. But for nearly two decades we had
huge silence from our government. The first sign started
in 1996 in a prison in Kermanshah. They saw that the
rate of HIV/AIDS in prisoners was very high. So in 1997
one of the members of Parliament, who was in Kermanshah,
offered to establish a national case center for HIV/AIDS
cases. He found $10 million for the first year. But
because there was not a good advocacy from the citizens
of Kermanshah, the majority of the citizens of
Kermanshah opposed this issue. For example the next year
nobody selected this Member of Parliament for the next
election. For nearly two years nobody could speak
anything about HIV/AIDS. For example, when Kermanshah
University in 1998 invited a national manager of AIDS to
Kermanshah and he wrote Welcome AIDS Manager. Some of
the government in Kermanshah said why are you writing
this? It was a huge stigma. When we wanted to do this
activity, we had no support from the government and from
the community. We wanted to offer an established HIV
case center but without any label and without any
stigma.
We started our project in early 1999. We wanted to show
to the community and the government, step by step what
we need and what we should do.
We had 3 main target groups at that time: 1) drug users;
2) STI cases, sex workers; 3)HIV cases. We wanted to put
all of this highest group together so we wanted to offer
a comprehensive service. And we wanted to integrate
prevention and care together. Because we started our
project very late so we wanted to do all the prevention
and care activities together. And we believed that even
HIV cases need care and management but their partners
and children need prevention.
By this way we had the full step in our project. The
first step started in Kermanshah as a local policy. We
started our activity voluntary and non-profit because
there is a difference between developing and developed
countries. In developed countries you write an excellent
proposal and you find the funds and after that you do
your activity. But in the majority of the developing
countries, such as Iran, you must show your activity and
its result to the government and then they believe your
activity and give money to you. So it is very different.
So we had to start our activity on a voluntary basis.
And all our staff worked voluntarily.
We wanted to show that these three main target groups
believed us and trusted us and came to our centers.
The early cases, the majority of them were infected in
the prison. Only a limited number of cases of those who
had been released came to our centers. So we had limited
cases, one case per week. But when we gave them
comprehensive services, and they believed us and they
brought their friends and partners, our clients rapidly
increased during the first six months from one case per
week to 60 cases per day. So it showed that the need is
very high. So we want to continue giving our services
and expanding our activities.
Our approach was: to include partners, form networks and
border communities in our activities; and develop
activities in the users' natural environment; and to
personalize prevention for each person at risk; and to
have dignity and respect with sensitivity to cultural,
racial, ethics and gender; and without any propaganda
and stigma.
Step by step we wanted to give information to the
society-- not go to the television and welcome all AIDS
cases. That is not a good approach. This way we wanted
to overcome some of our barriers. One of them is to
involve people living with HIV/AIDS in our activities
because we believe that when we give our comprehensive
services to HIV cases and they believe us, they bring
their friends. Our target group was not only HIV cases;
our target group was the highest (risk) group. So our
HIV cases went to the community and they knew where the
places that have needle sharing and sexuality contact
and (they) motivated them to come to our centers. After
that we wanted to change the attitude of the family of
the HIV cases because the majority of the families of
the HIV cases accepted the (drug) addiction for more
than 10 years but when they found that he or she is HIV
infected, they rejected them. So we went to the homes
and spoke to the families and encouraged them to come to
our centers and step-by-step changed the attitude so
they accepted these HIV cases. And instead of them being
homeless and going to the places that may increase the
rate of needle sharing, they go to the home and find
social support and psychological support and this way
solve their problem step by step.
One of our main target groups was women because women
are more stigmatized with HIV. Men will say they are
infected by injections but women could not speak about
the infection, even in their families. We wanted to
involve this group as one of our main target groups in
our activity. We wanted to speak about our activity
indirectly to the places that have higher rate of drug
use and HIV/AIDS. We trained students in the school and
youths in these places. They trained themselves at first
and indirectly they trained their families and friends.
They offered our services indirectly to their family. So
step-by-step their families believed in the activity and
why we must have harm reduction approaches, why we
should have a social support for infected cases and
step-by-step we involved a larger percent of the
community.
One of our main target groups was religious key persons
because they have a main role of not only
decision-making but also in the society. Our approach
was to design some national committees and provincial
committees, with some of the members from the religious
key persons. So when we showed them the results of the
facts and the status of the HIV/AIDS and drug use,
step-by-step their attitude changed. In some of the
committees, the majority is from the scientific group.
They speak with each other and they have different ideas
and issues. After that they said to the religious group
or the government, you should do this. And they said,
'we will not'. So we must involve them indirectly and we
don't order them. So this way they say, 'why don't you
do this?' We invited the more flexible key religious
persons and they went to the society and spoke to the
rigid key religious person, as a peer approach. And
after two years, the majority of them accept our
activities.
One of the main places we wanted to start our project
was in prison because some part of the prisoners are
drug users who inject inside the prison and the rate of
HIV/AIDS inside is high, similar to the society. Some
part of the members of this (national) committee are
from the prison organization. One year after meetings
they offered to us, 'why don't you do harm reduction
activities inside the prison?' Before that we feared to
ask them. But when they said that to us, we said 'ok'.
This is our approach for condoms inside the prison: each
prisoner has a meeting with his or her partner inside
the prison every month or three months, for one day.
Before that we give information to the partner and to
the prisoner and we give condoms to them. But we give
many more condoms than they need and they bring condoms
(back to the prison population) indirectly and prison
organization says 'no problem'. So based on our
cultures, we want to be flexible. Our request is that
the government must be flexible and so on but the
majority of us are rigid, we say we must do this; we
must start by a needle exchange program. No, we started
by pleas and after that we say, which one do you want,
methadone or needle? And they say methadone and
step-by-step they change.
We have had a link between the prison and our centers
because some of the highest (at risk) group go to the
prison and after release come to our centers. And we
motivated some of the NGOs, such as Red Crescent in Iran
and some charity that support HIV infected cases. When
we spoke at the first meeting nearly 3 years ago, they
went from our meeting out to say that we support women
who are HIV infected who have sex with several partners.
But for example in Kermanshah, we have 36 females that
don't have any support, a husband, but they have several
children and all of them are supported by these NGOs.
Last year they bought a home for all of them which is
very important.
This is our program, known as Triangular Clinic, with
these three target groups. We have different activities,
such as need assessment, information, education,
communication, risk reduction counseling, HIV counseling
and testing, HIV care and management and post-exposure
profilaction, and preventing of mother to child
transmission and social support for the infected and
affected cases to live together. For example in
Kermanshah, we have 76 couples where one of them is HIV
positive and the other is negative and they live with
each other more than 3 years.
Regarding harm reduction, we have needle exchange
program, condom promotion, methadone maintenance therapy
and bleach. We have peer education programs because some
of the highest group are not interested to come to our
centers so we go to the community by these peer
educators. And we have psycho-social support for
infected and affected cases and referral services and we
follow up some of them in their homes.
What is the role of HIV cases in these activities? They
have designed a committee, male and female together, and
they have self-help groups and information sharing and
collection of syringes and prevention with highest
groups and they have music and sports groups and
marriage program.
What is the role of the users? We trained the students
and they have a committee, not only in high school but
also in university and the army because after high
school males either go to the university or they go to
the army. So we cover all of them by this program. We
have workshop for them and they have workshops for other
friends because often the students are not interested in
talking about their problems with teachers. But they
will speak with other students as peer educators and
they refer them to our center.
The activities: some are HIV infected, some are family
of HIV infected, some are students, every week they go
to the mountains and they say, even if we are HIV
positive, what we want is to be positive for the
society. In the mountains, they have music programs and
they invite all the youths in the city to come to the
mountains and encourage them to stop drugs, if they are
users, and if not drug users, prevent to be drug users.
It is very nice. In this picture, one of them is from
the judiciary system. The relation between prison staff
and prisoner for several years was fighting against each
other but now they go together to the mountains and for
both of them, the attitude changed, prison staff and
drug users.
After the first step, fortunately our activities are
approved as a best practice, so the president of the
country said to the Ministry of Health and the committee
to write a national strategy plan for the control of
HIV/AIDS. So we have shared in writing this national
strategy plan and after that we wrote the Global Fund
because we wanted to involve international support for
our activities. And after that we established different
national committees of AIDS and harm reduction, which is
the main coordinator of our activity. We have a superior
committee, which the head of them are the head of the
country and ministers of various organizations. They
meet once per six months. The majority of our activities
are done in national committees, which have different
sub committees: information, education, research and
evaluation, harm reduction, social support, care and
treatment. And we have provincial committees because in
Iran we have different languages, different cultures and
different religions and we want to involve different
groups together. And based on the provinces they have
their own approaches, because the transmission of HIV
may be different in the west than in the east.
Up to now we have established more than 21 Triangular
Clinics in the country and more than 20 Triangular
clinics inside the prisons. And we have a curriculum for
educating school children.
This is the status of HIV/AIDS in Iran. Even though we
have had limited HIV cases, based on activity, it is
rapidly increasing and case finding will show that the
rate of HIV/AIDS is increasing and even though the
majority of HIV infected are male, the transmission will
change to the female and from drug use to sexuality.
A third step is a regional strategy for promotion of
collaboration with Iran. Based on the WHO, we are in the
Middle East but we believe we have similar culture and
language to the north countries such as Tajikistan and
Afghanistan. So we want to design a program not only
regional, but inter-regional. So we started to have a
similar program to involve all the countries in Central
Asia because we have several transmission of infection
between Iran and north of Iran and west of Iran.
The fourth step is globalization because we believe
there are different religions and different cultures and
not only just in the Middle East or Central Asia. So we
are going to design an international consultation for
religious key persons from different languages and we
have started in our country and our region the
International Muslim Leaders for Control of HIV/AIDS and
Harm Reduction, which will be held in June 2004 in
Teheran. And after that we want to involve the women to
share in our activity. There is no difference between
women and men. This way we want to show and highlight
the important role of women because we believe the main
access group, the main vulnerable group is women. If
they are infected they are more stigmatized and so we
want to prevent and to reduce the stigma of HIV/AIDS and
even drug use. We have to change the attitude of the
policy makers about drug use, to believe it is a disease
and not a crime and to use flexible roles and
intervention about drug use. And we need to collaborate
with other countries and international agencies for
control of HIV/AIDS and doing harm reduction programs.
And we want community-based services and outreach
together.
We appreciate the organization of this program, the
president of the Asia Society and the American consul
and everyone who helped us in arranging this
presentation. And we welcome everyone to come to our
centers.
Kaveh Khoshnood:
Thank you Dr. Alaei. I am going to ask Bob Newman to
come up next. The bios are in your program.
Robert Newman:
I also want to extend my congratulations to Betsy
Williams on putting together an extraordinary program in
a very, very short period of time. But I am very mindful
of the limitation on time and I grudgingly speak,
knowing that every minute I speak is that much less time
for questions and answers and comments directed at our
guests Dr. Alaei and Dr. Alaei. So let me be very brief
and explain to you what to me was so impressive the
first time I had contact with my Iranian colleagues. It
was about a year and a half ago and a friend here in New
York said there are some speakers talking about drugs
and AIDS and Iran up at Yale, would you like to go? And
I had absolutely no idea what was going on in this field
in Iran and it wasn't high on my list of curiosity, I
must admit. But I had a granddaughter who was four
months old, who was up at Yale at the time and so as
soon as I heard Yale I said I'm going, I'm going. And I
am extremely glad that I did go because I was enormously
impressed by the presentation by two colleagues, Dr.
Mokri from Teheran was one.
What impressed me was the extraordinary pragmatism with
which they approached the problems they face with regard
to HIV/AIDS and drug abuse. And they explained how the
government and the academic world and the clinical world
in Iran had decided that they had this huge problem and
they absolutely must approach it with a substantial
effort at treatment, making treatment available and that
they realized without treatment availability there was
no way they would ever be able to come to grips with
this problem. They had also come to the conclusion that
part of the treatment that was offered had to include
methadone treatment or again, they simply would not be
able to reach more than a tiny proportion of the
population.
But that treatment was the key and after the
presentation I got up and expressed my amazement and
said I am sure this is a reflection of my own stereotype
of thinking and my lack of knowledge but I said I am
just amazed to hear colleagues from Iran put so much
emphasis on treatment and helping and services and so
on. And the response was exactly as Kaveh just said in
his remarks, it was so self-evident and so logical that
it almost made me feel embarrassed that I asked the
question because the response was, well, we have tried
every other approach and God knows, we have tried to
deal with this through supply reduction. And they cited
figures how they do interdict more contraband opium and
heroin than any other country in the world and Dr. Mokri
said, it just doesn't work. We know that that's not the
way to deal with this problem. So this pragmatic
orientation, which sadly is lacking in most counties of
the world, including unfortunately my own here in
America, is very, very impressive.
The other part, and it is related, of what has impressed
me so much with regard to the attitude in Iran is the
willingness to accept the scale on which this problem
exists. And I have been privileged to work in the region
and outside the region and in many countries that are
beginning to address the problem of addiction. And I
always, as a methadone advocate, almost a pathological
methadone advocate, welcome the news that Uzbekistan has
OK'd methadone and will start methadone and the Ukraine
has started to provide methadone treatment and other
countries. And it is a major breakthrough. But when you
get down to what exactly is being done, it turns out
that there is a very nice little pilot program and they
are going to have 80 patients, and two psychiatrists and
an internist and 6 nurses and social workers and
counselors and after two years they are going to
evaluate that 80 person pilot program and if its
successful then maybe they will have 3 more pilot
programs. And you hear this and you say and how many
estimated intravenous heroin addicts are there in their
country? Well, they say, the estimates around 125,000.
It's this lack of ability to address the problem on the
appropriate scale that is so strikingly different in
Iran.
Usually we say action speaks louder than words, but in
this particular case I think it's the concept, the
commitment that is brought to the problem that is much
more important than the actual action with regard to a
very small number of people. I have experienced New York
in the early 1970s and Hong Kong in the mid-1970s,
particularly those two places, where the government has
said our commitment is make treatment available to every
single narcotic-dependent person who is willing to
accept it. When that commitment exists, there is no
other resource required to fulfill that commitment. Its
not money, its not professional people, it's the
commitment. And I am convinced that that commitment does
exist in Iran and I am hopeful that as they proceed to
fulfill that commitment, as they try to replicate what
has been done in Hong Kong, what had been done briefly
in New York, making treatment available to everyone who
wants it, that as they succeed in pursuing that goal
they will become a model for other countries in the
region-Tajikistan - that face this huge problem.
But also it is my hope that they will become a model for
America to consider as well. Because we have God knows a
lot of action in the last 30 years. We have spent
hundreds of billions of dollars to try to get rid of the
growth of opium and other drugs, to try to deal with the
problem through law enforcement. We have the distinction
of having a greater proportion of our population in
America in prison than any other country in the entire
world. I mean Russia used to be ahead of us, but we beat
them. And now we're number one! And yet we do not think
of changing our fundamental approach to this problem. It
is simply more of the same. And I am hoping that a
country with such a staggering problem of opium and
heroin addiction as you've heard described in Iran, as
they begin to deal with this problem in a different,
more pragmatic, more realistic and ultimately more
productive way, that that will indeed be a lesson for
other countries in the world, including for very selfish
reasons, I hope, my own. Thank you very much.
And now I can introduce the next speaker, Joanne Csete.
Joanne Csete:
Thank you. I am pleased to be part of this distinguished
and heroic panel. One among many of the amazing things
about the work from Iran that you have been told so much
about tonight is that it comes in the midst not only of
a relatively hostile environment within the borders of
Iran but in the middle of a region where none of these
positive and courageous achievements flow naturally from
history or from the current circumstances. Iran's
neighbors, as you know, include Afghanistan and Pakistan
where almost literally drug users are being run into the
ground. And also the former Soviet republics of Central
Asia about which I will say a few words tonight where
the standard of public policy for so long has been that
the only good drug user is a heavily-policed and
preferably incarcerated drug user. So I hope very
sincerely we will find ways as Bob said to share the
experience of Iran because it is so desperately needed
in the region.
I am going also like Bob to abridge what I was going to
say because I do think Iran is the star of the show and
not the Central Asian republics. But let me convey a
little bit about the situation from the work that we
have done there in Human Rights Watch. All I was going
to say about these official numbers of the UN, of people
living with AIDS globally, are that for the region of
Eastern Europe and Central Asia, which you see in the
top right part of the map, this is a grossly un-useful
number because it is so badly underestimated. In Russia
alone, many people believe and some officials have even
allowed, there are over 2 million people living with
AIDS. So you can see how the understatement is and the
understatement continues in other regions, which I won't
talk about, but certainly there hasn't been enough done
in this region to get good numbers that we can work
with.
Now I realize that the region depicted here is not in
the Asia Society's mandate but I wanted to make a small
point about the spread of AIDS in Africa and what that
tells us for Central Asia. If we think about the change
in this map from 1987, which is the picture you are
looking at now, to 1997, we in the public health world
thought it was a pretty fast spread of AIDS. And so it
is. And you can see it in bar graph form for the country
of South Africa, it looks like that. But if you think
about an injection drug-driven epidemic, the picture
looks a little more like this, so you see that in a very
short time you could have very dramatic increases among
populations of injection-drug users. Now these are
scattered studies taken mostly from cities. But this
really has proven to be the pattern in much of Eastern
Europe and again numbers in both the region of Central
Asia and in Eastern Europe throughout the former Soviet
Union are sketchy.
It has turned out to be the pattern in Russia, which you
don't see as dramatically here because these are
officially registered cases but even so, look at that
rate of increase over a short time. It has proven to be
the case in the Baltic states, the very dramatic that
you see in this slide from Lithuania and it certainly
has proven to be the case where we can put numbers
together and again they are sketchy, in the Central
Asian republics of the former Soviet Union.
I will come back to this story of Kyrgyzstan because I
think it is an important one. I would like to focus
mostly on Kazakhstan but I want especially to come back
to the apparent reduction that the bar graph show in
Kyrgyzstan. As we've already heard, the percentage of
drug users in the population is very high in Iran. The
numbers that we've seen from the UN indicate that it's
highest in Iran and Pakistan but the Central Asian
republics are catching up fast. And all of you know a
lot about this and some of those factors have been
alluded to that with the fall of the Soviet Union we
have in the former Soviet republics, in addition to the
factors that you've already heard regarding Iran, we
have no more Red Army patrolling the borders to keep
drugs out in the way that was done before. We have a
complete collapse of economies and of livelihood
opportunities. We have as well the drug trade becoming
an important source of funding for wars in Afghanistan
and elsewhere. In any case what we have is a drug
problem overlaid on a police force already very well
practiced in repression. A drug trade that has provided
new opportunities for corruption for the police and for
public officials and we have a drug-using population
that a very high percentage of which spends some point
of its life in jail.
We have poverty fueling all this and very little being
done to address poverty either by the governments
concerned or by donors. I wanted to say that
particularly Tajikistan has a major challenge in that it
not only has the longest border with Afghanistan of any
of the five Central Asian republics but it is still in
many ways recovering from its own civil war in the
1990s, lots of war widows with no livelihood
opportunities and so on.
Again we are seeing in this region among the highest
rates of spread of HIV in the world. In the former
Soviet Union, amazingly enough, there were institutions
called AIDS centers in the 1980s, long before there was
any recognized AIDS epidemic. Unfortunately the main
mission of those centers was to engage in widespread
mandatory HIV testing so people who were considered high
risk in any way, which turned out to include pregnant
women and anyone who had traveled abroad, turned out to
include anyone detained by the state for any reason and
certainly high risk persons such as drug users and sex
workers and men who have sex with men and so on. And in
these centers, and there is a great tradition of this
that lingers today, people who tested positive for HIV
were registered as such and their status was not
necessarily kept confidential. It is not surprising that
all of this has resulted in a deep fear of official
services that stays with us today. To say nothing of the
fact that, as Bob has said on other occasions, there is
a special place in hell for drug users in these
countries. Drug users are severely demonized both in the
law and in the attitudes of the population.
I won't say much about this, you will notice. Any of you
who know anything about the Central Asian republics will
understand why the Turkmenistan bar there is blue. By
some miracle, Turkmenistan has no drug users. Would you
believe it? No, you shouldn't. In any case, these are
largely drug-use driven epidemics in the five republics.
Bob has already alluded to methadone. As far as we know,
Kyrgyzstan is the only place where methadone is actually
legal or tolerated as something quasi-legal. There is a
small methadone pilot program going on now in
Kazakhstan, which is actually very exciting but I am
afraid suffers from some of the pilot syndrome that Bob
talked about. Needle-exchange is legal or tolerated in
many places but access is indeed very low. And I will
talk a little bit in human rights terms about why that
is, but fear of police abuse has a lot to do with it.
And as I mentioned, prisons are an important part of the
picture with so many young drug users being in prison at
some time in their lives and prisons being a breeding
ground for HIV. You have a major public health concern
in prisons that's really not being dealt with.
This is the picture of the official numbers of
Kazakhstan. I am not sure you should read too much into
the dip in the middle there. It is definitely an
epidemic that is increasing by leaps and bounds. There
is a much higher number of people living with AIDS in
Kazakhstan than in the four other Central Asian
republics combined.
And Timertau, a city north of Qaraghandy, the bigger
city in central Kazakhstan and it is, to coin a phrase,
always referred to as ground zero of the Kazak epidemic.
A huge percentage of the population is injecting drug
users. It also happens to be a place that is well on the
drug-trafficking routes that go through Kazakhstan.
That, with the collapse of the Soviet Union, Timertau is
a company town, a town where coal mining and steel
refinement was done by almost everyone in the
population. When that all fell apart, so did jobs, so
did livelihood opportunities of all kinds, so did, in
many ways, social services as well. And with drugs
coming in at about the same time, it was a recipe
naturally for disaster. And now that experience has been
replicated as far as we know in many other parts of the
country but Timertau. Still is the place most closely
studied. Mandatory testing, as in the Soviet tradition,
is widely applied in Kazakhstan, and the AIDS centers do
register people with AIDS. We went there partly because
there seemed to be some openings. there seemed to be
some positive things that were being talked about. There
was a rule in Kazakhstan that by law that anyone in any
kind of state detention, pre-trial detention, awaiting
adjudication of their cases, would be tested mandatorily
for HIV. And a new director of the national AIDS program
came in and she said, no more of this. And yet the
Ministry of the Interior, which still regulates
procedures in pre-trial detention as far as we know, has
not completely implemented the new decision. There is
this methadone pilot which we hope will turn into more
than a pilot and the President himself has talked about
decriminalization of cannabis, which is a very
interesting thing. I think he made a visit to the
Netherlands. It is a very interesting thing to hear
about in this part of the world.
I do want to spend a few minutes saying something about
the kinds of human rights abuses that Human Rights Watch
went there to look at and they are summarized here. A
wide range of due process violations that drug users
face on top of all the demonization and stigmatization
that we've already talked about. We asked many police
officers if there are arrest quotas in drug users in
Kazakhstan and we were told over and over again, "Nyet
Nyet Nyet." But in fact it seems as though from the
other evidence we were able to find that there are
arrest quotas and that these are particularly dangerous
times for drug users when quotas need to be filled.
Addiction is something that is used against drug users
in many of the countries of the former Soviet Union and
other places in the world to coerce confessions, to
heighten their vulnerability to all sorts of
mistreatment, to have false charges pinned on them. And
we have story after story of this. Drug users are easily
extorted as well, partly because of their addiction.
They suffer all sorts of illegal searches. They have no
legal representation. A lot of the ones we talked to,
even though that is a provision of the Kazakhstan
constitution, that it is a privilege all people should
enjoy. And then there was this general concern about
police targeting needle exchange points, especially at
times when arrest quotas seemed to be in force.
Among the challenges of doing anything about this is
that the police are heavily involved in the drug trade.
And indeed there are very few people in public life, let
alone police or politicians or anyone else, who would be
willing to speak about reforming the drug laws in any
way.
We have talked about what this does for the ability to
carry out public health programs, the needle exchange
programs that have such a good record of effectiveness
and cost effectiveness and are so difficult in this
environment to attract drug users to.
Drug users, in addition, have been disinclined until
very recently to organize themselves so that they might
have a voice of some kind. That's changing in some of
the Central Asian countries and it's a very interesting
development to watch.
I am not going to talk in detail about sex workers
except to say that, pimps -- in Human Rights Watch, even
though we are the palace of political correctness, we
have not found a politically correct word for pimp --
but pimps are an enormously important group to work with
in most of the Central Asian republics where sex
workers, sex trade workers are organized around the
supposed protection of pimps. And indeed we found a few
who were beginning to come to the realization that HIV
was a major economic threat to them. It was a major
factor in the deteriorization of their commodity, so it
was interesting to us to see that what I think was the
most progressive AIDS center in Kazakhstan was actually
reaching out to pimps and working with them.
In any case, the situation for women, economic
livelihoods for women, I think, even more than for men,
collapsed with the fall of the Soviet Union. So we have
a very severe situation of human rights abuse related to
HIV transmission among sex workers.
I would like to point out that there was this sense,
that we've heard alluded to, that drug users are not
worthy of anti-retroviral treatment, which if you have
an AIDS epidemic that has over 80% of the people living
with AIDS being injection drug-users, this is an
incredibly self-defeating policy. You can't really think
of a more self-defeating policy in public health terms.
One thing I want to say, and this is something that I
think would make an excellent session on its own for the
Asia Society's effort to bring out issues on AIDS that
are important for the Asian continent, in the background
of all of this, the situation of national drug laws that
are draconian, national drug laws that demonize, not
just criminalize, drug users, we have three UN
conventions, treaties, that have the status of
international law that were made in 1961 and 1971 and
1988 (which only) talk about drug abuse (not drug use),
about drug users as criminals and regard policing as the
main strategy for dealing with drug control. This is not
a helpful situation because even if they are not
directly used by countries as a basis for policy, they
are often pulled out as excuses when we try to move
forward on more pragmatic and human rights-friendly
policies. In addition, as Bob would tell you, easily, if
you will listen for 45 minutes, methadone is classified
as an illicit substance that has no good therapeutic
value in these conventions. And yet the UN agencies,
even those that have public health as their business,
have done very little to try to push member states of
the UN to look again at these conventions and their
impact.
Going back to Kyrgyzstan, that Kyrgyzstan may be the
only place where we can begin to speak of an emerging
paradigm shift of the kind that we heard about in Iran,
where there is a goal to bring almost universal coverage
of the drug using population to needle exchange
services, where methadone programs actually seem to be
growing, where there was the radically-wonderful step of
needle exchanges in prisons that we've begun to see now,
government AIDS centers actually encouraging people to
network. As I looked at the wonderful pictures of the
network on the mountains in Iran, I thought, well we
really need a mountain or two in Central Asia because
there is very little encouragement of people to talk
about their HIV/AIDS or to be with other people in any
sense as HIV positive people. Kyrgyzstan has also got a
Global Fund grant and I think we can be optimistic that
harm-reduction measures will see some support.
So there is this hope that what we see there in the last
bar graph is a real trend and we can hope that that will
continue. Bob and I were at a meeting earlier today
where a prominent AIDS doctor in the United States, I
won't name him because I didn't ask if I could, who has
also done a fair bit of work in the former Soviet Union,
made a statement that I think begins to capture the
challenge that we have in turning all of this around in
Central Asia and more widely in the former Soviet Union.
He said that the idea of AIDS and drug users is so
merged in the head of some public policy people in the
former Soviet Union that when you talk to them about the
dire predictions, about the rapid spread of AIDS, they
think maybe the silver lining there is that AIDS is a
good way to kill off a lot of drug users. And I am
afraid that that's as bad as it is in a lot of places.
Keramanshah is a very lucky place because not many
communities have the visionary and courageous people
like the brothers Alaei to help them through this.
What is needed clearly, to make progress, are three
things that are easy to say but extremely hard to
achieve. We need first of all, greater awareness of the
kinds of experiences that we've heard about tonight from
Iran, both among policy makers and among the general
public in Central Asia. These real public health
successes that come from working respectfully with drug
users and with people with AIDs, they are not well
understood, they are not well known. Secondly, we
clearly need courage at the national level on the part
of some politicians and also influential health
professionals like our courageous friends here tonight.
It is really the easiest thing in the world to demonize
drug users. We can only hope that some politicians
somewhere will eventually have the guts to talk about
drug users as human beings with human rights and with
all that that entails.
And finally we clearly need international leadership.
And I really do come back to the UN and also other
important players, the bilateral donors. The health
agencies of the UN have made speeches here and there and
made statements here and there and a few documents about
the importance of harm reduction services, but they have
not brought policy statements to their governing boards.
They have not worked with donor countries to see a more
abundant flow of money into those services and they have
especially not challenged the drug control arm of the
United Nations to back off the criminalization of drug
users. For people and for countries such as those in
Central Asia that have had so much repression thrust on
them over the course of history, the idea of public
policy that is not based on repressing drug users is
necessarily exceptionally difficult. And what we are
asking of these countries, as Bob said so well, is not
only to be more vigilant about HIV prevention than
sub-Saharan Africa was or than the world was on
sub-Saharan Africa's behalf, but even more of a
challenge, to be braver than the United States of
America has been in recognizing narcotic drug addiction
as a disease rather than always as a crime. It is
politically so easy to say that drug users and people
with AIDS deserve what they get. And political leaders
in Central Asia have no trouble finding examples of that
attitude, including from politicians in this country. A
lot of the work that we do in the human rights world I
think falls into the category of hopeless causes or
maybe, as we would say in basketball, low percentage
shots - efforts where it is just not clear that our
advocacy is going to succeed because so many powerful
forces conspire against the kind of change that we are
after. I sincerely pray that this is not one such issue.
I pray that this issue of drug user's rights and HIV
prevention in Central Asia is in another category. The
costs that Africa is paying for the neglect of simple
HIV prevention, pragmatic measures to prevent HIV and
protection of the human rights of those most at risk of
HIV is truly unimaginable. I hope that it will be the
objective of all of our efforts that Central Asia not
pay the same price. Thanks.
Khoshnood:
We have 15 minutes for questions and answers.
Question:
I don't think you can solve the problem right away. But
as far as the women in Iran, what type of role are you
taking for intervention and prevention specifically with
that group?
Dr. Alaei:
As you may know, more than 65% of the students in
university in Iran are female. As Dr. Khoshnood
mentioned, more than 70% of the total population are
less than 29 years old. So we have more educated youth
females. So when we started our project training the
females in the university, and by peer approach in the
community, we involve them in our activity. So for
example, in HIV infected cases who are females, their
main role for some part of our counseling. They have
self-help groups and so on, not only for other HIV
infected females but also for high risk and for partners
of HIV infected. By these activities they are involved.
We have several NGOs especially for supporting women. So
this group are interested in supporting the HIV infected
women.
Question:
What are the expenses of treating AIDS in Iran, for each
patient, per year. Are they generic drugs, are
medications available? And have your high school and
college education programs started or not?
Dr. Alaei:
Yes, we have 3 years experience for the AIDS cases and
all of the treatment is free of charge for clients. And
all AIDS cases when they start treatment, they have at
least for one year another treatment. We bought drugs
from England the first year. But now some are produced
in Iran. And the other ones we buy every year.
As for the students, we started our project more than
three years ago. We started in Kermanshah, where we have
900,000 inhabitants. Since last year we went to
different provinces and are training all students, by
training the teachers and training the student together.
We have a curriculum for them, based on the religious
key persons, we can speak about safe sexuality for the
females after 9 years old. So it is more available to
the teachers.
Question:
Since drug abuse and hepatitis and AIDS are so
interrelated, have you considered developing centers
that jointly treat infectious disease related to
addiction and methadone treatment. We are starting one
program in the United States by introducing methadone
into a primary care center, which is long overdue and
only 15 patients. But I would imagine in a country with
limited financial resources, the integration of
methadone treatment with infectious disease would be
very cost effective.
Dr. Alaei:
In Iran, one of our main problems is injection. So the
rate of hepatitis C in injection drug users is more than
2 times compared to HIV/AIDS. So our main target group
is injection drug users. So it will cover HIV, hepatitis
and all blood-borne diseases. And we have several
national research centers that focus on hepatitis C and
all HIV infected who are related to injection. And we
have some hospitals and special centers for methadone
maintenance. But as our national committee, they
accepted to cover at least 400,000 injection drug users
for the next five years for methadone maintenance and
methadone production inside Iran because it is very low.
We have a curriculum for training the general physician
as the primary level. We train them about HIV/AIDS and
drug use. And as they have general practiconer activity,
part of it is based on counseling on HIV and drug use.
So in Iran, every primary center is linked to a
pharmacy, so they can refer them for methadone.
Question:
How amenable is the government to having condom
distribution to unmarried youths?
Dr. Alaie:
For 15 years we have had good experience of giving
information about condoms. So it was very easy for us to
speak about it. We have condoms not only in our centers,
but in all pharmacies, they are available.
Question:
Here in New York City, we waited until one out of every
two injectors was infected with HIV before the public
health officials saw fit to begin to initiate syringe
exchange programs. What I want to ask, how is methadone
provided? What is the dosing? Are there urine testing
restrictions or anything like that?
Dr. Alaei:
I have a program for methadone maintenance that one of
our colleagues, Dr. Mokri, ( Dr. Azarkhsh Mokri,
Assistant Professor of Psychiatry, Tehran University of
Medical Sciences, Roozbeh Hospital) is expert about
this. But on behalf of him, I will say that we do not
have a limitation for maintenance because our goal is
prevention. And we have no limitation for if their
urinary test is positive. We increase the dose of
methadone. Because the government accepted the fact we
must prevent. So when they accept a needle exchange
program, so it is better for him to use methadone. And
in our clinics up to now we have a protocol for all of
them, starting with for example with 30 milligrams but
increasing to 100, 150, 200,based on the need. There is
no limitation. And there is no limit to offering both of
them: methadone maintenance and needle exchange
together. Because some of them, the first month, may
have injections. But our goal is changing from needle
exchanging to maintenance of methadone.
Dr. Newman:
I was struck as I was invited with a colleague from
Australia and a colleague from Poland to go to Tehran
for a workshop on methadone treatment. And as was I
want, we began the first day, trying to sell people on
the concept that methadone treatment is something
important. And the leader of this workshop very
politely, in typical Iranian polite fashion, said we
love what you are saying, but it's irrelevant. We don't
need to be sold on the notion that we need methadone. We
want to know how to do it and how to do it well.
Question:
I would like to know whether you are able to receive
visits from colleagues from Afghanistan, from Iraq, from
the Gulf countries, that truly must have the same kinds
of problems and where they are not being dealt with in
the same way?
Dr. Alaei:
We have designed a workshop to involve those from
Afghanistan, from Tajikistan and it will expand to Iraq,
to Uzbekistan. We believe we have similar problems. For
example in January 2004 we have invited those from
Afghanistan and Tajikistan to come to Iran for a start,
because they have approval for the Global Fund. We want
to develop and expand activity together.
Question:
Do you see at all the bisexual males under this project
or are they still out on the fringe?
Dr. Alaei:
Our main problem is drug use but it will soon change to
sexuality transmission. Our goal is prevention, not
judgment. One part of our clients have unprotected sex.
We give them condoms. But we don't ask whether clients
use it for males or females. We don't ask whether it is
homosexuality or heterosexuality. And we don't request
Ids from our clients. We ask what name they want to be
called by and by this we call them. I might want to be
called K1, for instance. And some might come and say my
friend has this problem. I don't ask whether it is his
problem or his friend's, I say 'use this condom.'
Kaveh Khosnood:
At I guess we will we end the formal part of our
presentation and I believe there is opportunity to have
informal conversations afterward. Thanks again.
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