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Afghanistan: AIDS Statistics Unknown Due To Social Repression

There has never been a scientific survey on the number of Afghans infected with the HIV virus that causes AIDS. Researchers from the World Health Organization are now attempting to study the issue. But they say cultural taboos within Afghan society make it difficult for foreign aid workers to discuss with Afghans the types of behavior that put people at risk of contracting the deadly disease. From Kabul, RFE/RL correspondent Ron Synovitz reports on international efforts to gauge the extent of HIV infection in Afghanistan and joint plans with the Afghan government to set up health education programs to help prevent the spread of AIDS.

Kabul, 11 July 2002 (RFE/RL) -- Nobody knows exactly how many Afghans are infected with the HIV virus that causes AIDS. It was only about a month ago that the World Health Organization began the first scientific study on the extent of HIV and AIDS infections in Afghanistan.

WHO spokeswoman Loretta Hieber-Girardet told RFE/RL today that conducting such a study is an extremely difficult and sensitive task. She says cultural taboos make many Afghans wary about discussing their sexual behavior with foreign aid workers.

"Sexual contact is not an open subject in this society. And there is no statistical data on heterosexual multipartner activities or even homosexuality. So it is difficult to get a grasp of that now at this stage, although certainly health education will be focusing on those issues." In an Islamic country where drug abuse is considered a violation of the Holy Koran, it also is difficult for researchers to determine how many heroin addicts may be spreading the HIV/AIDS virus by sharing infected needles.

The UN's Drug Control Program reports that there is a significant risk of HIV/AIDS infection among intravenous heroin users in Iran and the former Soviet republics that neighbor Afghanistan.

But in Afghanistan itself, hypodermic needles can be hard to find. UNDCP studies conducted during the last three years near Afghan refugee camps in Pakistan show that the most common method of ingesting heroin is a technique that users call "chasing the dragon." Addicts place the powdered drug on a piece of tin foil and hold a flame underneath it while drawing the fumes into their mouths through a tube.

Since heroin smokers are not sharing potentially infected needles, they are not considered to be at such a great risk of contracting HIV/AIDS as intravenous drug abusers.

WHO data suggest there is a total of some 60,000 intravenous drug users in all of Pakistan. But the UNDCP estimates that only about 10 percent of Afghan street addicts in Quetta, and just over 3 percent in Peshawar, have injected heroin at some point in their lives. The UNDCP studies also suggest that most Afghans in Peshawar who have injected heroin did so in Iran rather than in Pakistan.

Still, Hieber-Girardet warns that there are intravenous drug users in Afghanistan who risk spreading HIV/AIDS.

"One of the big problems that we have in Afghanistan is that there has never been any real study or survey on the potential number of HIV cases and, actually, it is quite difficult to collect data on this. This initial [WHO] survey which is being carried out is trying to ascertain the high-risk groups here in Afghanistan where we could potentially see some cases of HIV and to look a bit at their behavior to determine whether or not there is a need for some risk-control programs."

For now, Hieber-Girardet says there is not thought to be a serious HIV/AIDS problem in Afghanistan. But she says there definitely is a need to begin education and prevention programs as soon as possible.

"We've been aware since the change in government of the need to implement prevention measures here. Now Afghanistan is a blank slate, really. We don't know and we are not aware of any threat at all of HIV/AIDS yet. But there are some factors here which lead us to believe that there could be a problem if prevention measures are not implemented."

Hieber-Girardet says what little data has been obtained by the World Health Organization so far suggests that a key threat that HIV/AIDS may eventually spread in Afghanistan lies in the cash-strapped and undersupplied emergency medical system.

"Our major concern is blood transfusions, because not all of the hospitals in the country which perform surgery -- and there are less than 50 -- have the ability yet to test blood for HIV. Now there are some -- like the blood bank of Kabul, which does have the means to do this. So subsequently, blood transfusion is a major concern -- and not only about the spread of HIV, but also the spread of hepatitis."

She also says that the present social conditions in Afghanistan create dangerous possibilities for the spread of HIV/AIDS.

"We've seen similar cases in post-conflict countries where there are high levels of poverty; large-scale movements of populations; to some degree, intravenous drug use; and unsafe blood supplies -- which are all factors in the potential spread of HIV. And those factors are all present in Afghanistan."

The cultural taboos that prevent Afghans from openly discussing their sexual behavior have forced the current WHO research to focus on secondary data from clinics in order to estimate the number of Afghans behaving in ways that put them at risk of contracting the deadly AIDS virus.

And Hieber-Girardet says the clinical data on other sexually transmitted diseases in Afghanistan suggests that it would be foolish for Afghans to pretend there is no risk of AIDS in their country.

"There are high levels, in certain clinics, of sexually transmitted diseases that we are aware of. So we do know that there definitely is some sort of transmission of what we call 'sexually transmitted diseases' or 'sexually transmitted infections' as well going on. Now whether it is related to poor hygiene [or to sexual activity], those are aspects that we have to look at. Our response is that we really need to be vigilant about health education -- [not only] for women but also for men."

In particular, the extent of homosexuality in Afghanistan is an issue that researchers must treat with great care. It is well known that homosexuality is common in parts of Afghanistan.

Kandahar is famous among Afghans for widespread homosexual behavior, much as San Francisco is the city most commonly associated with homosexuality in the United States.

Ahmed Rashid, in his best-selling book "Taliban," says that the first military victories in the Taliban's rise to power during the mid-1990s were retribution attacks against Kandahar mujahedin commanders who had sodomized scores of unwilling young boys.

And Western journalists who have spent enough time in the north and south of Afghanistan to develop strong contacts with local militia commanders tell stories of pageboys being offered proudly to them as sex slaves.

One correspondent from a prominent weekly American news magazine says that when he was interviewing a local commander earlier this year, he was invited to have sexual intercourse with whichever one of several boys that he found to be the most attractive. The reporter said the boys were as young as 14.

In a measure of the sensitivity of the issue, none of the nongovernmental health organizations operating in Afghanistan and questioned by RFE/RL would comment publicly about the HIV/AIDS threat posed by homosexual behavior.

Aware of this sensitivity, Hieber-Girardet told RFE/RL today that it is not the job of the World Health Organization to comment on sexual practices within Afghanistan. But she also confirmed that it is the sensitivity of the issue that is complicating the task of researching the rates of HIV/AIDS in Afghanistan.

"We don't really know, quite frankly, [much] on heterosexual or homosexual relations [in Afghanistan] which could potentially spread HIV. We're not aware of any indicators that could let us know which groups of the population may be engaging in sexual practices which could be a potential threat for HIV. Currently, we do not believe that sexual transmission of HIV is going to be the major cause of the spread of the disease." Hieber-Girardet says that the WHO is now developing a health-education program in cooperation with the Afghan Ministry of Public Health that she hopes will be implemented across the country. She says the input from Afghan officials is vital to designing an effective educational program that isn't offensive to ordinary Afghans -- and especially to the many conservative Islamic fundamentalist men in Afghanistan who still find it offensive for a women to be seen in public without being covered by a burqa.

In that kind of a social environment, the idea of teaching both men and women about pregnancy, abortion, and protection against sexually transmitted diseases is one that could cause outrage among the conservative religious factions of the transitional government.