" HIV/AIDS: An emerging health crisis in Afghanistan?"
In the wake of latest reports that point to alarming increase in the cases of HIV in Afghanistan, it has become important to treat the issue of HIV and AIDS not just as a health crisis but as a development issue that deserves attention of the government and all other stakeholders.
Thirty years of war and political unrest has taken heavy toll on institutions of governance in Afghanistan. It has destroyed the economy and made the country one of the poorest in the world, with Human Development Index as low as 0.346. It has also affected the capacity of the country to respond to an emerging health crisis – an epidemic that Africa and Asia have been battling with for the last three decades – HIV and AIDS.
Along with scourge of poverty, low literacy rate, lack of security, crime against women, human rights violations in various forms and manifestations, Afghanistan now has to think about how to look at the new risk, one that is growing in the high risk group of injecting drug users, female sex workers, men who have sex with men and prisoners, and threatens to overflow into the general population if immediate steps are not taken to curb it. It is not the ideal time to have to face an epidemic of this nature in a country like Afghanistan.
Alarming rise in HIV cases:
Fresh reports coming in have sent shockwaves across the world. Ministry of Public Health on December 1, which marks the World AIDS Day, announced that the cases of HIV in Afghanistan have shot up by 10 percent. It means Afghanistan has to fight a new monster now.
It is important to take stock of what new has occurred or what remains unchanged that has given rise to the number of people living with HIV in the country. It is high time that the accurate estimates of the most-at-risk-populations are etched out at the earliest so that policies, interventions, planning and implementation could be executed at quick speed to arrest the spread of HIV in Afghanistan.
According to officials from the Ministry of Public Health, a total of 1694 cases have been registered by the government monitoring systems, but the actual number is likely to be higher. It is important to remember that stigma of HIV and AIDS is so high globally that discrimination itself acts as a barrier to access of healthcare services and people most often do not come forward for treatment or go for counseling or diagnosis. More than 4500 people, according to Ministry officials, are infected with the virus in Afghanistan.
Acting Minister of Public Health, Ahmad Jan Naeem said the outbreak of HIV is primarily due to lack of awareness, use of drugs, poverty, illiteracy and immigration. He said the Ministry of Public Health has set up many prevention centers, consultancy centers and curative centers to check the outbreak of HIV in the country.
From treatment to prevention:
HIV, besides the health infrastructure, requires the development of ‘an enabling environment’ for those who are at risk of getting infected and those who are infected. Africa and Asia, with high HIV prevalence, have managed to move from ‘treatment’ to ‘prevention’ and uplifting of the high risk population, in a bid to provide an enabling environment in which they would choose safe practices, reducing their risk of infection to HIV, and access the health facilities.
In a country that continues to experience the consequences of war, where caste, gender and patriarchy decide privileges and benefits including life, justice, education, employment and even access to healthcare, it is going to be a difficult and arduous journey.
Human Immunodeficiency Virus (HIV) in an infection that renders an individual's immunity incapacitated in a fight against other diseases, lowering immune system to the extent that it opens the door to many other deadly infections.
What makes HIV/AIDS deadly and difficult to tackle, unlike other maladies, is the route of transmission that is intimate in nature, making it a topic not ‘discussed’ and the fact that there is no cure for AIDS. The treatment is limited to Ante Retroviral Therapy (ART), which boosts immune system of the person with HIV, prolonging his or her life.
Early detection of HIV important:
Africa and Asia have designed national HIV programmes that give priority to raising awareness on HIV among the general population and on the need to test for HIV and early treatment and counseling for the high risk population. But in a country where war and violence dominate the discourse, dialogue and advocacy on HIV remains limited.
According to the United Nations, the estimated number of people living with HIV in Afghanistan is around 5000 but what is of concern is that only 30 percent of them have been tested. The rise in HIV cases is due to the low number of people going for testing, making early detection of HIV impossible.
Data on all the high risk groups is scarce in Afghanistan, owing to social and cultural barriers to reach these populations, also due to displacement of thousands of people by conflict and natural disasters, with people staying in camps and cities across the country.
There is almost no data on men who have sex with men. In the absence of information of denominators, designing a comprehensive HIV prevention programme at the country level becomes difficult and complex.
HIV in India: Lessons for Afghanistan:
In India, the HIV programme design is ‘evidence based’ where data is used to assess the size estimate of the high risk groups, what efforts work, what don’t work, the resources provision and utility and the impact on the epidemic.
The Indian national programme lays emphasis in getting more and more people to test for HIV and systems have been put in place to ensure testing is not compromised. Besides Counselling and Testing Centres at government hospitals, Community Based Organizations (CBOs) also run community-led clinics that offer free HIV testing and HIV related services.
Non-governmental organizations are active in mobilizing individuals who are at risk to come for testing at the ICTC. This approach boosts testing to a level that the government machinery alone cannot hope to achieve.
The national HIV programme encompasses systems where community based organizations led by high risk groups run targeted interventions and address HIV and other issues of stigma, discrimination, livelihood and violence. Along with HIV prevention, care and treatment, creation of an enabling environment is the focus in India.
Making changes in HIV programme:
The HIV scenario in Afghanistan may be argued by public health professionals around the world to be not as grim as in African and Asian countries, but what is grim is the difficult task of making changes in the HIV programme in the absence of human rights for women, the high risk groups, the people living with HIV and in an environment of oppression.
To ensure scale up in testing, early detection, early treatment, adherence to ART, it is almost necessary to have these segments of the population to be empowered stake holders in the country's HIV programme.
It would be a good strategy to adopt the rapid scale up model adopted by countries like India to boost its coverage of HIV response from 8 provinces at present to all the 34. The ownership of HIV programme by legislators in India under the aegis of the Forum of Parliamentarians on HIV and AIDS (PFA) has gone a long way to bring the issue of HIV and AIDS not just as a health crisis but as a development issue that deserves attention of the government and other stakeholders.
In Uganda, for example, Mayors have taken the lead in mobilizing people to increase the service uptake at a national level.
December 1 is observed as the World AIDS Day every year to raise awareness globally on the AIDS pandemic caused by the spread of HIV infection. The 2014 theme for World AIDS day is ‘Focus, Partner, Achieve: An AIDS–free Generation’ and highlights the need for different stakeholders including government and health officials, NGOs, communities that are most-at-risk to address AIDS prevention, care and treatment.
In Afghanistan a new strategy will have to be put in place to be able to first understand the factors underlying the rise in HIV cases this year and then walk ahead to build structures and systems to contain the pandemic.
About the Author:
Urmila Chanam is an HIV/ AIDS and public health professional, a gender rights activist and a journalist based in India. A recipient of Laadli Media and Advertising Awards for Gender Sensitivity 2012-13, she began her career with UNAIDS, the Joint United Nations Programme on HIV/AIDS. She has been nominated for the global award ‘21 leaders in the 21st century’ to be held in USA in early 2015 for her contribution to women’s health rights.
** This story was originally published in the leading magazine in Afghanistan, Afghan Zariza, on World AIDS Day 1 December 2014