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Can We Stop AIDS in Afghanistan?

Can We Stop AIDS in Afghanistan?. Wassay Niazi Former Associate Professor of Infectious Diseases Kabul Medical Institute (now Kabul Medical University) & Richard Gordon Radiology, UM January 14, 2005. Terrain of Afghanistan. http://www.nationbynation.com/Afghanistan/Map.gif.

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Can We Stop AIDS in Afghanistan?

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  1. Can We Stop AIDSin Afghanistan? Wassay Niazi Former Associate Professor of Infectious Diseases Kabul Medical Institute (now Kabul Medical University) & Richard Gordon Radiology, UM January 14, 2005

  2. Terrain of Afghanistan http://www.nationbynation.com/Afghanistan/Map.gif

  3. Afghanistan vs Canada Two official languages Pashtu/Dari English/French Adapted from atlases and: World Health Organization (2002). Core Health Indicators: http://www3.who.int/whosis/core/core_glance_process.cfm?strISO3=AFG. http://www3.who.int/whosis/core/core_glance_process.cfm?strISO3=CAN.

  4. http://www.aeronautics.ru/map/economic_activity.jpg

  5. http://www.aims.org.af/

  6. Others: Kazaks Qizilbash Wakhis Sikhs Hindus Jews Christians (NGOs) http://www.nationalgeographic.com/landincrisis/images/ethnic_enlarge.jpg

  7. http://www.afghan-network.net/Ethnic-Groups/ 52% 10% 25% 12-15%

  8. Religion • Muslim: 98% • Sunni 84% • Shi’i 14% • Hindu, Sikh, Jews 2%

  9. Costumes & Jewelry http://www.tribalmax.com/clickforafghancoins.jpg&imgrefurl=http://www.tribalmax.com/&h=287&w=288&sz=45&tbnid=zCtWl0V3LNoJ:&tbnh=109&tbnw=109&start=2&prev=/images%3Fq%3DAfghanistan%2Bcostumes%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DG

  10. http://www.mazeltovjewelry.com/ trade.html

  11. Politics: 7 Neighboring Countries, and Landlocked Political Map http://www.globalsecurity.org/military/world/afghanistan/images/afghan-provinces-map.gif

  12. Transportationhttp://www.times.kg/i/m/afmap_big.jpg

  13. Recent History: Past 3 Decades • invasion by the Soviet Union • war of liberation • fighting between many factions • takeover by the Taliban • routing of the Taliban and Al Queda by Coalition Forces and NATO • a free election • continuing skirmishes with remnants of the Taliban and warlords

  14. Consequences • Worst land mine problem in the world • 2 million deaths • 200,000 widows • 6 million refugees • Long hiatus in education • Destruction of economic and health infrastructure • Increased opium poppy cultivation • People lived well before this period, but now most are in an environment of poverty • Country appropriated for terrorist activity

  15. George, M. (2002). Afghanistan's landmine legacy [BBC News Online], http//news.bbc.co.uk/2/hi/south_asia/2153371.stm. Most due to Russia

  16. Afghan refugees wait along the fence to cross [into Pakistan at] the border at Torkham, Pakistan-Afghanistan border post, 31 miles (50 kilometers) west of Peshawar, Sunday, Jan. 21, 2001. AP Photo http://www.afghan-network.net/News/Archives/2001/Refugees/refugees3.jpg&imgrefurl=http://www.afghan-network.net/News/Archives/2001/Refugees/photoreport-10-01.html&h=300&w=450&sz=25&tbnid=v-Hwj5mIclMJ:&tbnh=82&tbnw=123&start=117&prev=/images%3Fq%3DAfghan%2Brefugee%2BIran%2BOR%2BPakistan%26start%3D100%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN

  17. Afghan refugees prepare food at Jalozai camp in Pakistan's northwestern frontier province on Tuesday, Jan. 9, 2001. http://www.afghan-network.net/News/Archives/2001/Refugees/refugees3.jpg&imgrefurl=http://www.afghan-network.net/News/Archives/2001/Refugees/photoreport-10-01.html&h=300&w=450&sz=25&tbnid=v-Hwj5mIclMJ:&tbnh=82&tbnw=123&start=117&prev=/images%3Fq%3DAfghan%2Brefugee%2BIran%2BOR%2BPakistan%26start%3D100%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN AP Photo

  18. http://www.gospelcom.net/glia/2001/wv/images/121701a.jpg 3 million refugees are living in Pakistan and 2 million in Iran 1/2 million in Western countries

  19. http://images.encarta.msn.com/xrefmedia/sharemed/targets/images/pho/000a4/000a4f72.jpghttp://images.encarta.msn.com/xrefmedia/sharemed/targets/images/pho/000a4/000a4f72.jpg

  20. Return of the Refugees Return of the Refugees http://www.humansecuritybulletin.info/archive/en_v1i3/_assets/_images/_afghan/idpmap_big.pdf http://www.humansecuritybulletin.info/archive/en_v1i3/_assets/_images/_afghan/idpmap_big.pdf

  21. Narcotics: Opium Banks, P. (2004). Bitter-sweet harvest Afghanistan's new war [http//www.irinnews.org/webspecials/Opium/default.asp], IRINnews.org. Gannon, K. (2001). Taliban stop enforcing anti-opium laws; Afghan farmers prepare fields for poppies [Associated Press], http//opioids.com/afghanistan/opiumcrop.html. http://www.poppies.org/news/103820335171660.shtml Foreign fighters from Pakistan, Saudi Arabia, Egypt, Jordan, Somalia, Sudan, Iran, Chechen, etc. used Afghan land for their activities, establishing terrorist camps and were involved in drug trafficking. They used the farmers’ economic weakness for their own benefit and induced them to plant poppies on their land, making Afghanistan one of the world’s largest producers of opium.

  22. Opium Statistics • Poppy sales worth US$2.3 billion/yr • US linked aid of $2.3 billion to opium reduction • Generates 50-67% gross domestic product • Employs 2.3 million farmers (15% of farm population) • Farmers earn up to 10-25x other cash crops • Per capita income to opium families US$260-600 • Afghanistan’s GDP per capita US$207 • 87% of the world's supply, most sold to Europe • Results in 20,000 heroine addicts in Kabul alone Costa, A.M. (2004). Afghanistan Opium Survey 2004, Vienna Office on Drugs and Crime, United Nations. http//www.unodc.org/afg/en/reports_surveys.html

  23. North, A. (2004). Afghanistan's home-grown drug problem [BBC], http//news.bbc.co.uk/2/hi/south_asia/3469469.stm.

  24. Refugee habit • Processing used to be done outside the country, so it wasn’t a local problem • Refugees from Pakistan and Iran became regular heroin users there and they have brought the practice and the demand home with them • 10 beds for treatment in Kabul for 20,000 addicts • Heroine intake shifting from smoking to (often shared) needles North, A. (2004). Afghanistan's home-grown drug problem [BBC], http//news.bbc.co.uk/2/hi/south_asia/3469469.stm.

  25. Tensions in Afghan Society • Ethnic groups: Pashtun dominance • University of Kabul as “troublemakers” • In 1960s and 1970s was a source of Marxism, who saw themselves as the vanguard of a nonexistant proletariat • Taliban as “troublemakers” • orphans raised in Pakistan madrasas • Warlords vs central government • Urban vs rural: Kabul as “the” place to be • Islam unification vs ethnic rivalries • Sunni Islam vs Shi’i Islam • Modernization vs tradition • Literate (36%) vs illiterate (64%) • Male dominance vs female aspirations • No access to basic health care, especially rural/female

  26. WHO Health Regions Political Map N Kabul W E Central SW http://www.globalsecurity.org/military/world/afghanistan/images/afghan-provinces-map.gif

  27. Risk Factors for AIDS in Afghanistan High levels of intravenous drug use Unsafe blood transfusion Afghanistan health system needs to be rebuilt Medical equipment used by doctors is not clean Dentists, surgeons and people who work in laboratories do not properly sterilize the equipment Sexual abuse Violence Lack of information and education

  28. More Risk Factors for AIDS in Afghanistan Illiteracy (51% of men, 80% of women) High numbers of refugees High numbers of people displaced within Afghanistan 50% of the country’s 44 hospitals that perform surgery do not systematically test blood for HIV before transfusion Low status of women Many widows are forced into sex work to support their families

  29. And More Risk Factors High incidence of STDs such as gonorrhea, trichomoniasis and syphilis Injected drug use Child kidnapping and slave trafficking (taken to Middle East countries) HIV infection in neighboring countries 80,000 people in Pakistan, most injected drug users 30,000 in Iran, with 136,000 drug users

  30. The Question of Cultural “Sensitivity”: (Some) Muslims can Freely Discuss HIV and AIDS Francesca, E. (2002). AIDS in contemporary Islamic ethical literature. Med Law21(2), 381-394. Ghalib, K. & L. Peralta (2002). AIDS and Islam in America. J Assoc Acad Minor Phys13(2), 48-52. Gibney, L., P. Choudhury, Z. Khawaja, M. Sarker & S.H. Vermund (1999). Behavioural risk factors for HIV/AIDS in a low-HIV prevalence Muslim nation: Bangladesh. Int J Std AIDS10(3), 186-194. Milder, J.E. & V.M. Novelli (1992). Clinical, social and ethical aspects of HIV-1 infections in an Arab Gulf State. J Trop Med Hyg95(2), 128-131. Sheikh, N.S., A.S. Sheikh, Rafi-u-Shan & A.A. Sheikh (2003). Awareness of HIV and AIDS among fishermen in coastal areas of Balochistan. J Coll Physicians Surg Pak13(4), 192-194. Literature on Islam & AIDS

  31. Ahmed, M.A., T. Zafar, H. Brahmbhatt, G. Imam, S. Ul Hassan, J.C. Bareta & S.A. Strathdee (2003). HIV/AIDS risk behaviors and correlates of injection drug use among drug users in Pakistan. J Urban Health80(2), 321-329. Gray, P.B. (2004). HIV and Islam: is HIV prevalence lower among Muslims?Soc Sci Med58(9), 1751-1756. Haque, N., T. Zafar, H. Brahmbhatt, G. Imam, S. ul Hassan & S.A. Strathdee (2004). High-risk sexual behaviours among drug users in Pakistan: implications for prevention of STDs and HIV/AIDS. Int J Std AIDS 15(9), 601-607. Kurbanov, F., M. Kondo, Y. Tanaka, M. Zalalieva, G. Giasova, T. Shima, N. Jounai, N. Yuldasheva, R. Ruzibakiev, M. Mizokami & M. Imai (2003). Human immunodeficiency virus in Uzbekistan: epidemiological and genetic analyses. AIDS Res Hum Retroviruses19(9), 731-738. Tavoosi, A., A. Zaferani, A. Enzevaei, P. Tajik & Z. Ahmadinezhad (2004). Knowledge and attitude towards HIV/AIDS among Iranian students. Bmc Public Health4(1), 17. Zafar, T., H. Brahmbhatt, G. Imam, S. ul Hassan & S.A. Strathdee (2003). HIV knowledge and risk behaviors among Pakistani and Afghani drug users in Quetta, Pakistan. J Acquir Immune Defic Syndr32(4), 394-398.

  32. Agha, A., S. Parviz, M. Younus & Z. Fatmi (2003). Socio-economic and demographic factors associated with injecting drug use among drug users in Karachi, Pakistan. J Pak Med Assoc53(11), 511-516.Buckley, C., J. Barrett & Y.P. Asminkin (2004). Reproductive and sexual health among young adults in Uzbekistan. Stud Fam Plann35(1), 1-14.Kagimu, M., E. Marum & D. Serwadda (1995). Planning and evaluating strategies for AIDS health education interventions in the Muslim community in Uganda. AIDS Educ Prev7(1), 10-21.Khattak, M.F., N. Salamat, F.A. Bhatti & T.Z. Qureshi (2002). Seroprevalence of hepatitis B, C and HIV in blood donors in northern Pakistan. J Pak Med Assoc52(9), 398-402.Rehan, N. (2003). Profile of men suffering from sexually transmitted infections in Pakistan. J Ayub Med Coll Abbottabad15(2), 15-19.Strathdee, S.A., T. Zafar, H. Brahmbhatt, A. Baksh & S. ul Hassan (2003). Rise in needle sharing among injection drug users in Pakistan during the Afghanistan war. Drug Alcohol Depend71(1), 17-24.

  33. Recommendations • Public awareness campaign regarding HIV/AIDS via radio, TV, newspapers, schools, universities, mosques • Explain condoms for birth spacing vs condoms for AIDS prevention • Establish a national strategy based on the modelling of the epidemic in Afghanistan and policies appropriate to traditions and culture • Conduct a wide survey of HIV prevalence and modes of transmission • Train staff in use of diagnostic kits • Identification of risk groups • Include HIV/AIDS in curriculum of universities • Set up preventive measures based on the survey and modelling

  34. Switch to R.G.

  35. Some Books and a Movie • Seierstad, Å. (2003). The Bookseller of Kabul, London Little, Brown. [Tradition vs modernity: sort of notes for an Afghan version of Fiddler on the Roof] • Armstrong, S. (2002). Veiled Threat, The Hidden Power of Afghan Women, Penguin. • Magnus, R.H. & E. Naby (2002). Afghanistan Mullah, Marx, and Mujahid, Cambridge, MA Westview Press. • Medley, D. & J. Barrand (2003). The Survival Guide to Kabul, Guilford, Connecticut Globe Pequot Press. • Barmak, S. (2003). Osama [DVD], Kabul United Artists Films. • Let’s avoid an Afghan version of: • Shilts, R. (1987). And the Band Played On Politics, People, and the AIDS Epidemic, New York St. Martin's Press.

  36. Goal of Modelling • Rapidly formulate alternate policies to predict their impact versus rapidity of response • Estimate the range of uncertainty in each prediction • Stop the epidemic before it gets rolling Model now, not later! Gordon, J. (2004). Architecting Response in the Health Sector [Presentation]. In: Rohne, J., TRLabs Winnipeg, Information & Communications Technology Symposium, Health Sector Challenges and Solutions, November 9, 2004, Winnipeg: TDV Global, http://www.win.trlabs.ca/icts/slides.

  37. Let’s start with AIDS & Condoms • Gordon, R. (1989). A critical review of the physics and statistics of condoms and their role in individual versus societal survival of the AIDS epidemic. J Sex Marital Ther15(1), 5-30. • Conclusions: • Condoms inadequate to protect an individual from an infected partner • If everyone used condoms, the epidemic would stop

  38. Moghadas, S.M., A.B. Gumel, R.G. McLeod & R. Gordon (2004). Could condoms stop the AIDS epidemic?Journal of Theoretical Medicine5(3-4), 171-181. • Conclusions: • Yes: if product of compliance and efficacy > 75% • Can monitor whether staying above this threshold • Could adjust campaigns and strategies on the fly

  39. The Thailand Experience • Course of the AIDS epidemic in Thailand, believed to have been brought about by a campaign to use condoms. • Thailand Ministry of Public Health (2001). The Success of the 100% Condom Programme in Thailand Policy Implications and Recommendations [http//www.cdcnet.moph.go.th/cdcdept/Aids/aids-en.htm], Thailand Ministry of Public Health. Success in Thailand

  40. Analogous to an individual not continuing a full course of antibiotics Effects of failure to sustain high levels of condom use in sex work - rapid epidemic regrowth from 85% Thai Working Group on HIV/AIDS (2001). HIV/AIDS Projections for Thailand 2000-2020. Executive Summary. Thai Working Group on HIV/AIDS Projection, Feb 10, 2001, Thailand Ministry of Public Health.

  41. Susceptibles Infected AIDS • This model has no spatial components, and therefore might best be used for Kabul only • The major modifications needed to the model are in: • Refugee influx (∏ most come to Kabul: 1.5  3 million 2002-2004) • Include more categories of people and relationships (as drug users, male-male encounters, widows in sex trade, NGOs, etc.) • Inclusion of the drug trade, needle transmission and its relationship to sexual transmission • Effect of quarantining people for some duration • Need to calculate transients, whereas most modelling has been of steady states, as dS/dt = 0

  42. Policy Alternatives to be Modelled:Presently No National Strategy for AIDS • Quarantine versus voluntary “exceptional” approach of Western societies • Duration of quarantine • Appeal to non-Islamic nature of heroine use • Condoms for birth control (non-Islamic) vs condoms for preventing AIDS (acceptable) • Prohibition of poppy growth vs legalization or taxation • van der Veen, H. (2003). Taxing the drug trade: coercive exploitation and the financing of rule. Crime, Law and Social Change40(4), 349-390. • Effective clean needle program

  43. Need for Data So far there are no data about the rate of infection or the actual number of HIV/AIDS cases among refugees. "We are running a basic HIV/AIDS awareness raising programme for Afghan refugees through our health units - set to cater for the refugee population in camps.” UN joint programme on HIV/AIDS (UNAIDS) Wassay Niazi: ineffective, based on his clinic in a refugee camp IRIN (2004b). UN agencies implement HIV/AIDS programme for Afghan refugees, http//www.afghanistan.org/news_detail.asp?17465. Urgency to gather data: 1 million refugees told to leave Iran for Afghanistan by May, 2006 Leggat, A. (2004). Afghanistan A Window of Opportunity, http//www.ockenden.org.uk/index.asp?id=1099.

  44. NGOs & Health “Afghanistan has more than 80 international NGOs and about 25 national NGOs involved in the area of health. Eighty percent of existing health facilities are either operated or supported by NGOs. The support of NGOs to the health care system, including drug supplies, supervision, training, and incentives, is critical.” http://www.worldbank.org.af/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/AFGHANISTANEXTN/0,,contentMDK:20153500~pagePK:141137~piPK:217854~theSitePK:305985,00.html

  45. Sex Education Policy Alternatives in Afghanistan • Education of women and job creation for women • Canadian Women for Women in Afghanistan http://www.w4wafghan.ca/ • Sex education via gender groups and nonpictorial media (as radio): "Afghans' ignorance about sexuality is abysmal, and the work of educating them is immense” • Heath, D. (2004). Afghan condoms a hard sell [NEWS24.com], http//www.news24.com/News24/World/News/0,,2-10-1462_1521000,00.html. • Non-Islamic to use birth control • Bisexual and gay behavior contradicts but co-exists with Islamic precepts • But 1 million condoms have now been sold for “birth spacing” via “sensitive marketing” • Miller, A. (2004). Afghanistan Sensitive Marketing Leads to Sales Milestone [Population Services International/Afghanistan], http//www.psi.org/news/1004b.html.

  46. Voluntary vs Coercive Is Cuba’s success based on initial mandatory quarantining? Are we imposing Western values with “Voluntary Counseling and Testing (VCT)”? UNFPA [United Nations Population Fund] support for establishment of the first HIV/AIDS Voluntary Counseling and Testing Centre in Kabul http://afghanistan.unfpa.org/latestnews.html

  47. Three Stages for Each Country!? • “pattern of three stages: • denial followed by • recognition followed by • mobilization, was observed in nearly all jurisdictions examined” • Zeegers Paget, D. (1998). HIV/AIDS and the legislature: an international comparison. AIDS Care10(Suppl. 1), S65-S73. • Can we ever learn from others’ experiences? • Does cultural “sensitivity” have to lead to needless disease and death, or can we accelerate the 3 stages? • ACT FAST: can we mobilize to stop AIDS now in Afghanistan? • “there is no specific HIV/AIDS component [to health care] due to more immediate priorities” • http://www.worldbank.org.af/WBSITE/EXTERNAL/COUNTRIES/SOUTHASIAEXT/AFGHANISTANEXTN/0,,contentMDK:20153500~pagePK:141137~piPK:217854~theSitePK:305985,00.html

  48. Safi, N. (2003). Ministry of Health, Afghanistan HIV/AIDS/STI Control Program [PowerPoint]. In Anon., Thirteenth Inter-Country Meeting of National AIDS Programme Managers, 6 -7 July 2003, Abu Dhabi, United Arab Emirates, Kabul Ministry of Health, Government of Afghanistan, http//www.emro.who.int/asd/digitallibrary/ uae03/nap/posters/Afghanistan-Poster.ppt Ministry of Health, AfghanistanHIV/AIDS/STI Control Program By: Naqibullah Safi MD, MPH NACP Manager, MoH

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