Like other Muslim cultures with strictures against promiscuity and drug use, Egyptians have been slow to admit to a problem

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 programs.

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 disease services.

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 subjects.

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 religious ideals.

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 sensitive issues."

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 success."

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 priority

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 every year.

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 undiagnosed.

"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."

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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 to UNAIDS.

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 testing

That's where the new Voluntary Counseling and Testing centers come in.

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 operations.

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 government medicine.

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 resistance develops.

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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 many.

"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.

Modernizing blood donations

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 infected.

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 anitas@post-gazette.com or 412-263-3858.)