New York Times, March 19, 2007

A New Sorrow for Afghanistan: AIDS Joins List

Only 30 percent of blood used in transfusions in hospitals is screened for HIV

By CARLOTTA GALL

KABUL, Afghanistan — Sitting and eating quietly on his father's lap, the 18-month-old was oblivious to the infection in his veins.

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 son has.

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 and outsiders.

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 socially unacceptable.

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 the child."

When he was told he could indeed kiss his son, he burst into tears.

"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 medical care."

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.

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