Like other Muslim cultures with strictures against
promiscuity and drug use, Egyptians have been slow to admit to a
Sunday, March 13, 2005
By Anita Srikameswaran, Pittsburgh
CAIRO, Egypt -- A quarter-century after the AIDS virus began
its grim march across the world and nearly 20 years after
discovering its first AIDS patient, the Egyptian government has
begun to offer anonymous HIV testing.
It's not doing so because of an alarming rise in the number
of people infected with HIV, the virus that causes AIDS. Egypt
and other Middle Eastern nations have some of the lowest
recorded HIV rates in the world, which political and religious
leaders attribute to their traditional condemnation of
promiscuity, drug use and other practices that help spread
blood-borne infections like HIV.
Instead, Cairo's first voluntary HIV counseling and testing
center is a tentative step toward acknowledging that Egypt and
the rest of the Middle East may not remain safe from AIDS for
long, and that their conservative culture could make matters
worse if HIV begins to spread.
To prevent an HIV epidemic, international public health
experts say, Middle Eastern nations have to stop stigmatizing or
ignoring those who are at the greatest risk of infection:
homosexuals, prostitutes and drug users.
They suspect the recorded number of HIV cases is artificially
low, partly because there is no anonymous testing in many parts
of the region. And they worry that the Middle East, like other
regions, will do too little too late, and experience an
explosion of AIDS that might have been prevented.
"This is sort of the situation that occurred in [sub-Saharan]
Africa, where people didn't pay attention to it and then, all of
a sudden, you have this huge epidemic," said Sandy Sufian, a
University of Illinois professor who founded the Global Network
of Researchers on HIV/AIDS in the Middle East and North Africa
last year. "And that potential is there in the Middle East."
Even now, the virus could be simmering in the margins of
society, ready to spill over into the mainstream. And as other
nations have learned firsthand, dismissing AIDS as a disease of
licentious foreigners doesn't stop the virus from crossing
borders and cultural boundaries.
Indonesia, the largest Muslim country in the world, appeared
to have little HIV at the end of 1998, according to the World
Health Organization. During the next two years, infection rates
jumped, particularly among intravenous drug users. Indonesia now
has one of the fastest growing HIV epidemics in the world, with
an estimated 130,000 people infected in 2004 alone.
In a World Bank study, "HIV/AIDS in the Middle East and North
Africa: The Costs of Inaction," authors Carol Jenkins and David
Robalino reported two years ago that only a few Muslim countries
in the region were developing large-scale HIV prevention
Among that handful, Tunisia is reaching out to young people
with education, counseling, testing and condoms. Iran is
tackling intravenous drug addiction and providing HIV diagnosis
and treatment, and Morocco is upgrading its sexually transmitted
But other predominantly Muslim Middle Eastern nations see
AIDS as someone else's problem, and resist aggressive AIDS
programs that might force them to be more open about sensitive
The same attitude has occurred in non-Muslim cultures, too,
such as in China, where officials dismissed HIV as a scourge
afflicting its neighbors in Southeast Asia, until China's own
infection rates soared and they could no longer ignore them.
Of course, it's difficult for leaders in any society to admit
that their citizens don't always conform to cultural or
Some Middle Eastern officials worry that if they start to
promote the use of condoms or clean needles, they will not only
condone but might even encourage such sinful practices as
illicit sex or drug use.
Dr. Nasr El-Sayed, who leads the AIDS program for Egypt's
Ministry of Health, cautioned that "you can't say on the TV,
'OK, do whatever you want and use a condom,' You should respect
the culture and the religion of the community when dealing with
Yet public health experts say that it's crucial to address
such topics publicly.
As Jenkins and Robalino wrote in their report, "Societies
cope with HIV and prevent its spread best where governments are
open about the issues, provide information and services, and
partner with organizations representing affected communities.
The highest levels of political commitment are needed to ensure
And a few voices in Egypt agree with that.
"The numbers of those carrying the infection should not be
treated as a shameful secret to be hidden from the public," said
a December editorial in Al-Ahram, an influential
English-language weekly. "We need to be frank and open if we are
to halt the spread of the disease."
HIV gets low
Home to the Nile River, the pyramids and 73 million people,
Egypt has several pressing health issues, including a soaring
hepatitis C rate, tuberculosis and even a case or two of polio
But AIDS has been a hidden menace.
The Muslim majority and Coptic Christian minority both
condemn sex outside of marriage, homosexuality and the use of
recreational drugs, which has probably slowed the spread of HIV.
As a result, Egypt's leaders have seen little reason to put
HIV/AIDS at the top of their priority list.
Since 1986, fewer than 0.01 percent of Egypt's population, or
about 1,800 people, have been officially diagnosed with HIV. But
most of the country's cases probably go unreported or
"How would one know? Without surveillance, the Middle East
countries don't really know what they've got," said Jenkins, the
World Bank consultant. "So you can happily say you have nothing,
but that's just putting your head in the sand."
The Joint United Nations Programme on HIV/AIDS, known as
UNAIDS, estimates that from 5,000 to 31,000 Egyptians were
living with HIV in 2003. Still, even the higher estimate would
represent an infection rate far below that of the United States,
where as many as 950,000 people are thought to be infected.
At 31,000, Egypt's rate would be one HIV infection for every
2,355 people. The U.S. rate is one for every 311 people, nearly
eight times as high.
Every year, Egypt tests about 150,000 people, mostly young
men, who must show they aren't infected with HIV to get visas to
work in Persian Gulf countries. In 2000, 700,000 units of blood
for donation also were checked and 45 were positive, according
While those screening measures provide some reassurance that
HIV is not rampaging through the general population, Egypt
hasn't been looking for the virus among those who take part in
high-risk activities -- men who have sex with men, commercial
sex workers and intravenous drug users.
First step toward
That's where the new Voluntary Counseling and Testing centers
Until recently, Egyptians could not find out whether they
were infected with HIV without giving their names to a doctor or
the government's central lab. Health experts argue that many
people at high risk will not seek testing if it isn't anonymous,
fearing public exposure and social ostracism.
The new centers promise to protect people's identities, and
are being developed with the help of Family Health
International, an organization funded in Egypt by the U.S.
Agency for International Development.
"We don't know anything about high-risk groups," acknowledged
Dr. Cherif Soliman, FHI country director. "Here is the problem:
When you start these things, there is no base to start with."
Egypt's first test center is in a walled compound just south
of downtown Cairo's Liberation Square, within walking distance
of many government buildings, including El-Sayed's office at the
Ministry of Health. It's a several-flight climb to the testing
office, which sits above the government's central lab.
The testing center consists of four plain rooms, including
two where staffers and clients "can talk together like family,"
said Seftab Jabi, the motherly coordinator of day-to-day
Anyone who wants an anonymous test must sit down with her
first. A unique "client code" is created to track tests, and no
name is required.
In its first six weeks of unofficial operation, Cairo's first
center tested about 40 people. Three were positive for HIV,
including a mother and child. The mother probably contracted the
virus from a blood transfusion eight years earlier.
Jabi hopes that once the center is officially opened, a
steady stream of people will come to get tested and learn more
about HIV in the process.
"To spread awareness between people, it will help a lot, I
think," she said. "But if they disregard HIV ... it will spread.
From one person it could be spread to millions."
Maha Aon, who works in the Cairo office of UNAIDS, welcomes
the long-awaited anonymous testing service. But she is concerned
that greater access to testing will have little impact if
treatment with antiretroviral medicines is not made affordable
and easily available.
She recalled talking to a young intravenous drug user who was
terrified that he might be infected but was reluctant to get
tested because of the stigma of AIDS.
"As he sees it, he's got everything to lose and nothing to
gain," Aon said. "First, if the word leaks out, it's going to be
a social problem. Second, there are no [drugs], so what's the
point? I even question if it's ethical to try to promote
[voluntary counseling and testing] without having something to
tell the people who test positive."
El-Sayed said about 50 people who have developed AIDS
symptoms had received free medications from the Ministry of
Health and that another 50 soon would receive them. Limited
supplies and high cost, however, mean people whose HIV
infections haven't progressed to AIDS don't have access to
Only a few kinds of drugs are available in Egypt. In the
West, medications are started as soon as an HIV infection is
confirmed, and different types of drugs can be tried if
In Egypt, it costs the government the equivalent of $400 a
month for each person's treatment, and black market drugs are
even more expensive, putting medications out of the reach of
"Every day, we are negotiating with drug companies to reduce
the price," El-Sayed said. In November, he said, Egyptian
companies began working to manufacture AIDS drugs locally.
Soliman, of Family Health International, has been working
with Egyptian officials to improve the safety of the nation's
blood supply, too, another front in the effort to prevent the
spread of HIV.
There are more than 250 blood banks in state-run and
university hospitals in Egypt. In 1997, 17 people were infected
with HIV from tainted blood transfusions at one hospital. In
1993, more than 60 kidney dialysis patients at two centers were
Family Health International discovered blood bank workers
didn't routinely wear gloves or follow other practices to handle
blood and body fluids safely, so it started a training program.
To assist people with HIV, the organization also has developed
self-care guides in Arabic.
Because Egypt has so few known AIDS cases, doctors have
little experience with HIV-infected patients. Sometimes, they
refuse to offer care in general hospitals, fearing other
patients won't use a facility that is treating people with AIDS.
HIV patients typically are treated at government-run centers
known as fever hospitals. Each of Egypt's 27 governing districts
has two. Family Health International is training fever hospital
staff to manage HIV cases and is developing curricula for
doctors and nurses.
Experts say it is important for health care staff not to
avoid HIV or remain ignorant of the facts about it.
"In countries where people are not suspicious of HIV, doctors
don't test," Jenkins said. "And no one dies of HIV. They die of
TB or they die of cancer, diarrhea or pneumonia."
Not identifying HIV as the underlying cause of death, the
experts warn, can allow the disease to fester in the shadows.
(Anita Srikameswaran can be reached at
email@example.com or 412-263-3858.)