OUTBREAK, CAUSES AND INTERVENTIONS FOR PREVENTION 
 

Dr. Hameed Shuja
University of Essex
Colchester, U.K
Shuja41@hotmail.com

1. 
   

   Introduction and background history:

The World Health Organization (WHO) reported in December 2007 that more than 30 million people were living with HIV worldwide. Compared to the rest of the world, the situation regarding HIV in central Asian countries is slightly better. But recent studies in the past decade indicate that behaviours related to the spread of HIV exist in the region, especially in the former Soviet Union countries (Hammers and Downs, 2003).

Afghanistan is a nation devastated by decades of war and bloodshed. To add to the miseries, there is a new enemy emerging in the form of HIV/AIDS. In 2002, 8 cases of HIV infection were reported by officials, which reached 15 in 2003. One year later, the first registered HIV/AIDS deaths in Afghanistan were reported when a father and his two children died due to the infection. In December 2007 the figure reached 266 ( The Body, 2007) Unfortunately this figure kept rising every year and latest reports from the country do not show any fall or even stability in the number of people being infected with HIV/AIDS. The tragedy is Afghanistan has other more important issues to tackle first.

“In post- conflict and humanitarian situations, HIV prevention is frequently overlooked because of other priorities.”(Bergenstrom, 2003 p215-224)

Afghanistan is a typical example of such a situation, with the highest maternal mortality rate and ever growing opium trade putting lives of millions and risk. However that does not mean that the issue of HIV/AIDS has not been addressed at all. Things are starting to improve and both national and international health officials and policy makers are planning and implementing projects to tackle the issue. In 2007 the first HIV/AIDS diagnostics centre was established in the country. This was the first centre of its kind and paved the way for the introduction of more such centres all over the country to keep an eye on the infection and its prevalence. 
 
 

2. 
   

   Risk factors and causes:

There are many high risk factors for the spread of HIV/AIDS in Afghanistan. Among them, war, poverty, migration, drug addiction and lack of education and awareness are the most serious.

1. 
   

   Drug addiction

There are estimated 13 million IDUs worldwide (Carmen et al, 2004). Injected drug users (IDUs) are considered to be the major carriers of the infection in Afghanistan, which is the largest opium producing country in the world. The World Bank’s estimate in 2007 shows that there are 92,000 drug users in Afghanistan. Multiple usage of infected syringes for the purpose of drug use is the most common and dangerous cause of direct infection. This direct link between HIV and drug use is also evident from studies about other countries like Burma, India, China and Vietnam. (Beyrer et al, 2000)

2. 
   

   Prostitution and unsafe sex

Prostitution together with the lack of awareness about HIV infection among Afghan women is another major cause of the disease in Afghanistan. Although this lack of awareness is almost the same among men, yet sex workers are a major factor since they can easily spread the infection due to sexual contact with more than one client. Most of the women who are involved in the sex trade in the country do not have any education about the use of condoms. They do not have any kind of awareness about HIV/AIDS and its modes of spread and mortality. This lack of literacy and awareness makes the situation ever worse. ( Zafar et al 2003) But there is a general lack of awareness about safe sex in the country, even among the educated class. A study in 2008 by Abdul Basir Mansoor for his M.Sc thesis showed that even university students were not regularly using condoms.

3. 
   

   Lack of awareness:

In 2008, InterMedia revealed that there was general lack of knowledge about HIV/AIDS among the Afghan population.  The study said that level of formal education, especially among women, is the single most important factor linked to HIV/AIDS awareness. It said that low literacy rate among women posed a challenge to public health campaigns in the country. The study also pointed to religious, social and cultural barriers to sex education and awareness about HIV/AIDS in the conservative Afghan society.  
 
 

4. 
   

   Unsafe healthcare practice:

The World Bank report published in 2007 says that unclean needles are syringes from hospitals are not always properly disposed but rather thrown out in the rubbish. They easily become available to IDUs and become an easy and direct cause of HIV infection spread. Lack of blood screening before transfusion in hospitals makes the situation even more horrible. Only 30% transfused blood is tested for HIV. There is also no anti retroviral therapy available for HIV patients. Due to poverty, sometimes people are paid to give blood to other patients in emergency situation without being screened for HIV.

3. 
   

   Importance

It’s important to address the issue of HIV/AIDS in Afghanistan because it’s still in the early stages and therefore easier to handle. Afghanistan has the chance to gain from this window of opportunity. (Bergenstrom, 2003). Although the prevalence of HIV infection in the country is low at present, but its high potential for rapid growth is a sign of danger for the future. There is also a direct link between HIV infection and drug addiction. Afghanistan has a very large number of IDUs and in 2006 WHO stated that 3% of the IDUs in Kabul were HIV positive. It is therefore important to come up with plans and projects to irradiate HIV/AIDS in Afghanistan and hence stop the spread of the infection to neighbouring courtiers. Recent studies have shown that there are direct effects of Afghan war on the use of shared needles for drug use in neighbouring Pakistan. This indicates that the issue has its roots beyond the boundaries of just Afghanistan. (Stefanie et al 2003).  
 

4. 
   

   Transmission

In our discussion above we have already pointed to some common ways in which HIV infection is spreading in Afghanistan. Among them, drug use through injection is the most common cause which is directly related to the opium trade in the country. Apart from this, unsafe safe among life partners and formal sex workers also cause a danger. There is a very low degree of self protection among healthcare workers in hospitals. As such, the infection can spread easily due to cuts and bruises due to medical procedures. The lack of blood screening before transfusion is also a direct cause for the transmission of the virus from person to person.  
 
 

5. 
   

   High risk groups

IDUs and their partners are at highest risk. Formal sex workers and their clients are also in danger. This rate is higher among formal sex workers in Kabul. (Todd et al, 2010 a). Poverty has forced many street children into sex trade, making them vulnerable. An HIV test among 108 prisoners in Herat City prison indicated that there was a 10% HIV prevalence. (Ministry Of Public Health, 2008). There is also lack of awareness about HIV infection among healthcare workers in Afghanistan, making them easy target of infection due to direct exposure to infected blood. (Todd et al, 2009 b). The high influx of returning refugees is also said to be a factor, with many cases of refugees returning from Pakistan and Iran bringing the virus with them ( The Christian Science Monitor, 2003) 
 

6. 
   

   Detection

Unfortunately there are no planed procedures in place for the detection of HIV infection in Afghan setup. Most cases are detected by chance and accidentally. They are usually at later stage so the infection. So far almost all the cases that have been detected have appeared after the onset of symptoms and health deterioration. Afghanistan is a conservative Islamic society and therefore stigma is always related to such diseases. This makes the detection and registration of infected people even more difficult because in many cases infected people hesitate to come forward and register themselves due to social and religious barriers. There is also lack of surveillance and data collection and protection about HIV cases in Afghanistan.  
 

7. 
   

   Impact

As mentioned earlier, HIV infection may have a low prevalence but a high potential for rapid growth in Afghanistan. Afghanistan’s neighboring countries are also showing a rapid growth in IDU driven HIV epidemic. This again points towards the ever lavishing opium trade and drug problem in the region. It therefore affects not only Afghanistan but its neighbor countries as well and poses a serious public health challenge for the concerned governments. All these countries are conservative Islamic societies. Such diseases are not acceptable due cultural and religious issues. Therefore people are discriminated against due to their health issues and are situated at the lowest level of the society. It cannot be ignored though that lack of awareness about the causes and spread of HIV infection is a major cause of such discrimination. HIV also has a huge economic impact on Afghanistan. It is one of the world’s poorest countries and tackling such a problem is a huge financial burden. Currently Afghanistan is receiving more than 50% of its annual budget from foreign aid.  
 

8. 
   

   Interventions for prevention

The Afghan government with the help of international agencies has come into action and has developed and implemented a national HIV/AIDS prevention project which aims to keep the prevalence to less the 0.5% among the general population and below 5% among the high risk groups. Apart from the Afghan government, the World Bank and the WHO are important players in the fight against HIV in Afghanistan. The World Bank provides funds and expert advice while the WHO is carrying the mission ahead on the ground. As a result of these joint efforts the Afghanistan HIV/AIDS Prevention Project (AHAPP) has been established, which has the following major objectives. 
 

1. 
   

   Communication and Advocacy:
    

This component is about increasing knowledge, changing attitudes and reducing stigma and discrimination among vulnerable groups.  
 

2. 
   

   Strengthening Surveillance of HIV:
    

This component is about mapping and estimating the size of groups engaged in high risk. Biological and behavioural surveys will be conducted every 2 years in 4 major cities and more data becomes available these surveys will be extended to other cities too.  
 

3. 
   

   Targeted Interventions:

 
 

These TIs will be for people engaged in high risk behaviours. These include injecting drug users, sex workers, drivers, and prisoner and healthcare workers.  
 

4. 
   

   Program Management and Coordination:

 
 

This component focuses on capacity development, monitoring and evaluation and innovation fund for multi sector activities.  
 

Apart from the above, the Ministry of Public health is committed to gain political commitment and mobilize resources necessary to implement the national HIV/AIDS/STI strategy. It also wants to ensure development and coordination of a multi-sector HIV/AIDS response and develop institutional capacity of all sectors involved. It is focussing on raising public awareness on HIV/AIDS and STI prevention and control, ensuring universal access to behaviour change communication on HIV, especially targeting vulnerable and at-risk groups, ensuring access to prevention, treatment, and care services for high-risk and vulnerable populations. It is also working to strengthen the health sector capacity to implement and essential package of HIV/AIDS prevention, treatment, and care services within the framework of Basic Package of Health Services and Essential Package of Hospital Services. (http://www.moph.gov.af/en/report.php?id=6, 2010) 
 

9. 
   

   STRENGTH OF INTERVENTIONS FOR PREVENTION OF HIV:
    
   

   
   
   1. 
      

      Funds

  Strong and continuous financial backing is crucial for any health intervention. Afghanistan has been lucky in this case. The international community has provided financial aid to run HIV/AIDS related projects in the country. In 2003 $100,000 were devoted to the Afghan HIV/AIDS prevention programme. This amount reached $23 in 2009. (The Chicago Tribune, 2008) 
 

2. 
   

   Awareness programs

  The most important and effective interventions have been those designed for spreading education and awareness about HIV/AIDS in the country. Health workers have managed to reach both male and female populations and started educating them about the causes and spread of the disease. 
 

3. 
   

   Human expertise

  Human expertise is vitally important for any project to kick off and achieve its goal. Afghanistan has a very limited number of highly trained/qualified experts on health issues. But the international community has not only given money, but also sent health experts from all over the globe. These health professionals are playing a major role in designing new policies, implementing new projects and most importantly training Afghans in infectious disease control. 
 

4. 
   

   Safe blood transfusion

  The WHO has stepped up efforts to ensure safe blood transfusion for patients undergoing surgery in various hospitals. It has sent blood screening kits to many hospitals and healthcare facilities in the country and has also trained specialized staff to carry out the screening test. This will help to prevent the spread of the infection due to unsafe and unscreened blood transfusion to a great extent.  
 

5. 
   

   Sustainability

 The national HIV/AIDS prevention project launched by the Afghan government is a well designed long term project and hence ensures that any intervention for eradicating the disease will be long term and well funded until the desired goals are achieved. The project is designed in a way which encourages collaboration from other health departments in the national set up, such as primary health care department, mental health department, drug demand reduction and education and communication. 
 

6. 
   

   Surveillance and mapping

  In 2007 the University of Manitoba completed a report on the mapping of IDUs and sex workers in some of the major cities in the country including Kabul, Mazzar Sharif and Jalalabad. This was a new start in regards to pin-pointing high risk targets and preventing the spread of the infection beyond the specified boundaries. 
 

7. 
   

   Small successful steps

  Interventions such as “one needle one syringe programme” have been very helpful and effective in providing safe needles to all patients during surgical procedures in hospital set ups. 
 
 

10. 
    

    Weaknesses of the interventions

 
 

1. 
   

   Security

  The presence of foreign health professionals and experts in Afghanistan depends on the security situation in the country. Unfortunately the security situation has worsened during the past few years which have resulted in the withdrawal of international aid workers from the country, including those working in the health sectors. This has halted the implementation of HIV/AIDS prevention project in many parts of the country. Even local health workers cannot move around safely. 
 

2. 
   

   Conservative society

  The most difficult issue to tackle is perhaps spreading education about HIV/AIDS in the country. This is because when talking about HIV/AIDS one has to discuss sex, prostitution, use of condoms for safe sex, drug use and many other such things which cannot be openly discussed in the conservative Afghan society. Although this trend is changing slowly, yet it will take a long time before these issues can be discuss in open. 
 
 

3. 
   

   Corruption

  Corruption and miss-management on the government level has affected the supply of funds to the intended project. This has affected the outreach of the project to different parts of the country. The money has not been spent properly and many stages of the project have been adversely affected. 
 

4. 
   

   Lack of foreign advisers

Staff turnover is a headache and halts the smooth running of the project. It has many reasons. In case of foreign advisors recruited for the HIV/AIDS project many have to be replaced after sometime since they are not willing to continue working in the country. This has a bad effect on running the project, especially if it’s a long term one.  
 

5. 
   

   Opium trade

In the case of Afghanistan, the prevalence of HIV/AIDS is directly related to the opium growth and trade in the country. This is where it becomes an international issue and not just a local problem because neighbouring countries are directly involved in Afghanistan’s drug trade. Therefore single country and HIV programs are unlikely to succeed unless the underlying factor, which is drug trade in this case, is addressed both on national and international platform. (Breyer, C et al 2000) 
 

6. 
   

   Lack of surveillance and data

 There is no proper up to date system and database in place for indentifying and registering confirmed cases of HIV/AIDS in the country and keeping an eye on them during the treatment stage. Sharp rises in number of infected people have reported in a very short period of time. For example in January of 2007 the health ministry figures showed a total of 69 confirmed cases in the country. But that figure suddenly rose to 245 in August the same year. But in reality the actual estimate is much higher than what is report on most occasions. (Rehman et al 2007) 
 

11. 
    

    Recommendations for improving prevention and control

 

1. 
   

   Awareness

Awareness about safe sex is still very rare in the country. Sexual transmission of HIV is can be prevented to a great deal by simply providing the population with affordable condoms. Also basic HIV information is should be given to the population in such a way which is acceptable to them, keeping in mind their cultural and religious beliefs. This can be best done by members of the local population. 
 

2. 
   

   Continued financial support

Financial support from the international community is vital to keep the specified projects running. Afghanistan is a poor country and cannot bear the burden by itself. 
 

3. 
   

   Security

Security should be provided to both Afghan and international health workers so that they can move around safely in the country in order to implement various stages of the project in both urban and rural set ups. Basic infrastructure should be improved and trained staff should be offered job on long term contacts. 
 

4. 
   

   The capital city of Kabul

Kabul, where most of the foreigners are situated and which is the centre of interaction between foreigners and the local population, need urgent action against HIV/AIDS. Lack of knowledge about HIV/AIDS, the presence of numerous prostitutes and unfamiliarity with condoms could start an epidemic. The priority right now should be on awareness rising on schools and to representatives of the various high risk groups. (Bezger, 2004)

5. 
   

   Healthcare providers

Healthcare providers lack in-depth and up to date knowledge on the causes and modes of transmission of the infection. (Todd et al 2009). This gap of knowledge should be seriously addressed by continuing education for health care providers and communication strategies should be formed.

6. 
   

   Opium trade

Opium trade is directly related to the prevalence of high number of HIV/AIDS cases in Afghanistan. Unfortunately the growth of this crop is on the rise in spite of all the efforts of the international community. There can be no direct solution to the HIV/AIDS problem in Afghanistan unless serious steps are taken to eradicate the growth of poppy in the country and stop its trade and trafficking through neighbouring countries. (Rehman et al, 2007)

7. 
   

   Proper and advanced blood screening facilities

Proper blood screening facilities should be provided to both the local population and foreigners, in order to indentify infected individuals and prevent spread of the infection to others.

8. 
   

   Interventions, such as “one needle and syringe programme”

Such interventions should be encouraged and extended throughout the country in order to reduce causative factors. Cultural and religious issues should be respected in such projects. 
 

9. 
   

   A proper system of identifying and registering confirmed cases of HIV/AIDS

Registration of HIV cases should be developed in the form of a national database. This database should provide up to date information on the number of infected cases in the courtiers, mapping of high risk populations, provision and stages of treatment. 
 

10. 
    

    Free treatment and vaccines
     

Free treatment and vaccines should be provided to the infected cases as soon as possible. Fortunately the international donor community is moving ahead in that direction. There are also reports that methadone could be introduced into Afghan setup to reduce other ways of drug abuse hence lower the spread of infectious diseases.  
 

11. 
    

    Political and social support
     

Political and social support is vital for the implementation and success of the project. There should be collaboration among the ministries of Health, Anti-narcotics and Religious Affairs regarding projects to tackle HIV/AIDS. 
 

The author is a 26 years old Afghan doctor/dentist living in London. He holds a bachelor’s degree in Dental Surgery from Pakistan, and is working on his master’s degree in Public Health from the University of Essex in Colchester, UK. 
 
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