HIV spread in Afghanistan
KABUL, Afghanistan, March 13 — Sitting and eating quietly on his
father’s lap, the 18-month-old was oblivious to the infection in
But his father, a burly farmer, knew only too well. It was the
same one that killed his wife four months ago, leaving him alone
with four children. The man started to cry.
“When my wife died, I thought, well, it is from God, but at
least I have him,” he said. “Then I learned he is sick, too. I
asked if there is medicine and the doctors said no. They said,
‘Just trust in God.’ ”
Cloistered by two decades of war and then the strict Islamic
rule of the Taliban, Afghanistan was long shielded from the
ravages of the AIDS pandemic. Not anymore.
H.I.V. and AIDS have quietly arrived in this land of a thousand
calamities. They remain almost completely underground, shrouded
in ignorance and stigma as the government struggles with the
help of American and NATO forces to rebuild the country in the
face of a new offensive by Taliban insurgents.
The father of this boy, the youngest Afghan known to have H.I.V.,
agreed to speak to a reporter only if their names and other
details were omitted. He has not even told his family what his
He said he believed that his wife contracted it through blood
transfusions in Pakistan years ago.
The few surveys that exist suggest that Afghanistan has a low
prevalence of H.I.V. — only 69 recorded cases, and just three
deaths. Yet health officials warn that the incidence is
certainly much higher.
“That figure is absolutely unreliable, even dangerous,” said
Nilufar Egamberdi, a World Bank consultant on H.I.V./AIDS. The
World Health Organization has estimated that 1,000 to 2,000
Afghans are infected, but Ms. Egamberdi said even that was “not
even close to reality.”
Dr. Saifur Rehman, director of the National AIDS Control program
in the Ministry of Health, agreed. Afghanistan, a deeply
religious and conservative country — sex outside marriage is
against the law — may still be less at risk of the spread of the
virus than other places.
But international and Afghan health experts warn that it faces
the additional vulnerabilities of countries emerging from
conflict — lack of education and government services, mass
movements of people and a sudden influx of aid money, commerce
Geography and migration make Afghanistan particularly
susceptible. It is surrounded by countries with the
fastest-growing incidence of AIDS in the world — Russia, China
and India. Other neighbors, Pakistan and Iran, have high levels
of drug addiction and a growing number of H.I.V. infections, as
does Central Asia to the north, experts say. AIDS can easily
cross borders, carried by migrants or refugees who pick up drug
habits or have sex with infected people in those countries and
return home. Rates of drug addiction are rising in Afghanistan,
with its booming opium and heroin trade.
Though the Afghan government and senior religious leaders have
won praise for making H.I.V. a national priority, they are
struggling with many problems.
“In Afghanistan, all the traditional risk factors for rapid
spread of H.I.V. exist concurrently,” said Dr. Fred Hartman of
Management Sciences for Health, a Boston-based group working in
Afghanistan. He has worked as technical director of Reach, an
American-financed program to expand health care to Afghanistan’s
rural communities for three years, and has advised the
government on H.I.V./AIDS.
Afghanistan experienced a trade boom in the last five years, and
hundreds of thousands of Afghans go abroad, especially to Arab
countries in search of work.
A European doctor, who asked not to be identified because his
work was confidential, worked in a hospital in the United Arab
Emirates where foreign workers went for mandatory testing and
said that in 2001 and 2002, 23 Afghans were deported after
testing H.I.V.-positive. “There were only 30 known cases in
Afghanistan then, and I knew of 23 more,” he said.
The return home of more than two million refugees is another way
the disease is likely to spread, said Renu Chahil-Graf, regional
coordinator for Unaids, the United Nations program, who was
visiting Pul-i-Charkhi prison in Kabul, where a voluntary
testing clinic has opened. Some of those returning to
Afghanistan have drug habits, and they spread AIDS by sexual
contact with spouses, prostitutes and street children.
Afghanistan, the biggest opium- and heroin-producing country in
the world, has nearly one million drug users, according to
United Nations estimates. Most users still smoke the drug, but
five years ago, injectable heroin hit the streets of Kabul, the
capital. Now there are an estimated 19,000 intravenous drug
users here, according to the World Bank. Addicts are not
difficult to find, living in bombed-out buildings in the old
part of the city and in Kota-e-Sangi, a neighborhood on the
city’s south side.
They are homeless or returned refugees, mostly young men,
according to Miodrag Atanasijevic, a coordinator for Doctors of
the World, a French aid group that runs a clean needles program
in Kabul. “It will become a huge thing,” he said. “In this
country you have a lot of drugs.”
Even after five years of international assistance to the health
sector, only 30 percent of blood used in transfusions in
hospitals is screened for H.I.V., according to a recent World
Bank report. Dr. Rehman said that 80 percent of government
hospitals screened blood, but he acknowledged that many other
institutions did not. Health workers remain ill-informed and
careless, often reusing needles even when they know it risks
spreading the disease, he said.
While several organizations are working to provide needle
exchanges and to increase H.I.V. awareness, a far wider program
is needed, according to the World Bank, which is providing $10
million to fight H.I.V./AIDS in Afghanistan.
A recent study of 461 intravenous drug users in Kabul showed
that 3 percent were infected, Dr. Rehman said.
Stigma is perhaps the most difficult challenge in dealing with
H.I.V./AIDS in Afghanistan. The Taliban government, with its
stoning and execution of adulterers and homosexuals, may be
gone, but sex outside marriage and homosexual sex are still
Doctors and health workers here warn that AIDS patients will
face ostracism, even death, if their communities learn they are
infected. The Ministry of Health closely guards the identity of
the few people who have tested H.I.V.-positive.
Dr. Muhammad Farid Bazger, H.I.V./AIDS coordinator of the German
aid organization ORA International, has seen firsthand the
cruelty communities are capable of.
During his work in villages and refugee camps in Pakistan, he
came across an unmarried man who had returned from the Arabian
Peninsula infected with H.I.V. The man told his father, who, not
understanding the consequences, told others.
Soon, villagers told the father he should kill his son. The son
ended up locked in a brick cell in the family yard, with only a
small opening where food was thrown in.
Dr. Bazger and his colleagues eventually rescued him and made a
film about him, which has been shown on Afghan television.
ORA has also worked among women in the sex trade in Kabul. In a
2003 survey of 126 of the women by ORA, only one was familiar
with condoms and only one had knowledge of H.I.V./AIDS.
Seventy-eight percent of those surveyed were married.
Eighty-four percent were illiterate.
Scores of foreign prostitutes have arrived in Kabul in recent
years, along with the influx of foreigners and foreign
assistance. Afghans are using their services as well,
particularly the well-paid young men employed by foreign
organizations, health officials say.
Sex between men is an even worse taboo in Afghanistan, but
health officials say it does occur. Ms. Egamberdi, who is from
neighboring Uzbekistan, said sex between men was a reality in
much of Central Asia, including Afghanistan.
Afghanistan’s efforts to combat AIDS have been stymied by the
lack of urgency among donors who believe Afghanistan has a low
prevalence of H.I.V., Dr. Hartman and others said. Even United
Nations agencies have been slow to develop H.I.V./AIDS
education, Ms. Egamberdi said. “At least do awareness
campaigns,” she said in frustration.
Until this year, the members of the government AIDS team worked
out of a shipping container on the grounds of the Health
Ministry. They have graduated to a drafty unheated hall inside
the main building. While the World Bank granted Afghanistan
money to gather data and work with high-risk groups, Dr.
Rehman’s hopes for an AIDS treatment ward in Kabul, country-wide
testing and antiretroviral drugs remain unfulfilled.
The Health Ministry has enlisted the Ministry of Hajj and
Religious Affairs to educate mullahs, often the most influential
people in villages, to help promote basic health education and
mitigate the stigma of AIDS.
Yet they have barely reached the population beyond the capital.
The father of the infected 18-month-old said his village mullah
had never talked about AIDS. Nearly a year of tests on the
father have found no H.I.V., and the older children are clear,
but his smallest child tested positive at 10 months. “The doctor
asked me a lot of questions — did you have an operation, did you
have illegal sex?” he said. “But I knew I was a Muslim, and I
don’t have illegal sex, and I trusted my wife, too. So then he
said it was from her operation.”
Six years earlier, his wife lost a baby and had several
transfusions in Pakistan. After she became sick and was found to
be infected, “I told the family her blood was not good and to
avoid eating with her,” he said. “And I tell them not to kiss
When he was told he could indeed kiss his son, he burst into
“I don’t know what to do,” he said. “I have sacrificed so much
since my marriage. I mortgaged half my land to pay for her
The father can do little for his son but keep his secret. There
are no AIDS treatment centers in Afghanistan, only a single
confidential clinic in the capital that just monitors the
disease, and no antiretroviral drugs are available.
Source: New York Times