The Chicago Tribune, August 5, 2008

AIDS adds sting to Afghanistan misery

In a nation already suffering from plagues both natural and man-made, the rising prevalence of HIV—exacerbated by ignorance and drug addiction—threatens to become an epidemic

By Kim Barker, Tribune correspondent

KABUL, Afghanistan — The man, thin as a coat rack, said he started shooting heroin because a friend told him it was easier to quit the needle than to stop smoking the drug. His friend died, and now the young man is dying too.

The bombed-out grounds of the Russian cultural center in Kabul is now home to as many as 1,000 itinerant drug addicts.

The addict is 28, but sharp cheekbones and tiny wrinkles around his lips make him look much older. This is the face of AIDS in Afghanistan, a conservative Islamic country that has been reluctant to acknowledge the problem the disease poses.

A former refugee in Iran, he said he tested positive in March and already has full-blown AIDS. His fate is fairly certain. There is no treatment for AIDS in Afghanistan yet.

"Life is just passing, one day starving, one day a full stomach," he said, crying and wiping his eyes where he sleeps on the floor of the bombed-out grounds of the Russian cultural center, now home to as many as 1,000 itinerant drug addicts. He did not want to be identified because of the shame associated with the disease here.

In a country plagued by war and Islamic militants, by one of the highest rates of maternal mortality in the world, by malnutrition and starvation and even by locusts, AIDS has arrived. So far the Afghan government has officially identified only 435 cases of HIV — a small number, considering how many there are in neighboring countries—but international and Afghan health experts say there are likely thousands in Afghanistan.

1 scourge falls, 2nd rises

The rising number of cases is the unexpected fallout of the end of the strict Taliban regime in 2001, the rise in Afghan-grown heroin use and the intrusion of the world into this once-isolated, war-torn country that is now a focus of U.S. and Western efforts to contain the terrorist threat in South Asia.

AIDS now is a test for the government of President Hamid Karzai, caught between Western backers and conservative clerics, many of whom believe AIDS victims deserve their fate.

"You see where Afghanistan is going," said Dr. Saif-ur-Rehman, director of the National HIV/AIDS Control Program in the Health Ministry. "How do we tackle this problem before it turns into a major fire, an epidemic?"

Although there were cases of HIV before in Afghanistan — the first was registered in 1989 — only a handful were identified. The Taliban health minister insisted in 1998 that there was no AIDS in Afghanistan, because it was against Islam.

But after the Taliban fled, refugees addicted to heroin and opium returned from Iran and Pakistan, some bringing HIV with them. More and more Afghans who never left the country are now using drugs and injecting them as the heroin trade booms in the post-Taliban era.

More long-distance truck drivers are carrying goods to this landlocked country and using Afghan prostitutes. Sex between men, never acknowledged, is common, health workers say.

The conditions could be ripe for many more cases, especially given the average Afghan's ignorance of the disease. Nationwide, the medical infrastructure is rudimentary at best, and many doctors know nothing about AIDS. Most people are illiterate, and women have such a low status that they cannot insist on condoms.

Several parliament members at a budget debate in March described people living with the disease as "criminals and adulterers who deserve death."

Hiring Afghan doctors for HIV-prevention programs can be difficult. Hospitals often refuse to treat addicts.

"To recruit a doctor willing to work with drug users is a nightmare," said Carole Berrih, general coordinator with Doctors of the World, a French aid group that runs a clean-needle and education program for addicts.

Last year, the government's HIV testing center in Kabul conducted 6,700 tests, but mostly for people going abroad for work or school. That's a tiny amount, considering that about 4 million people live in the capital.

Some gains in fight

But some Afghans and many international donors are waking up to the problem. The amount of money devoted to the government AIDS program has increased from $100,000 in 2003 to a total of more than $23 million as of this year, officials said. Six centers in Afghanistan now test for HIV and hand out condoms. Another program tests drug addicts in the field. Other programs target sex workers.

The UN and international aid groups soon will pay for anti-retroviral drugs to start treating patients.

UNAIDS is supposed to set up a program here soon. Clean-needle programs will be expanded throughout the country, including to jails in eight cities. Education campaigns are planned. Doctors of the World is hoping to bring methadone to Afghanistan to wean addicts off heroin; with methadone, HIV-positive addicts could be stable enough for treatment.

There is some evidence that the message is working, in Kabul at least.

At the Russian cultural center, where anti-American films were shown in the 1980s and addicts now shoot up and smoke heroin amid piles of trash and human waste, there are also plenty of wrappers from disposable needles. The addicts know about AIDS and that they should not share needles—although some do.

Last week, one man known for sharing needles was lying on the floor on his side, breathing fast, unable to talk. When other addicts lifted his blanket, sores could be seen over his entire body. The next day, his friends tried to get him help, but no hospital would take him. Friends and aid workers later said he had died.

Abdul Hamid, 36, squatted as a friend shot heroin into his arm with a new needle. Hamid said he has been addicted since a rocket killed his wife and two children in the civil war. He started using needles 1 1/2 years ago and recently tested negative for HIV.

"I know nothing about AIDS," he said. "But I have heard it's a dangerous sickness and can kill you. I've heard from some people that it's even more dangerous than cancer."

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