Only five years ago, HIV and Aids appeared as remote threats to Afghanistan. Now, infection rates are on the rise.
Afghanistan's new crisis: the spread of HIV/Aids
If you ask Ahmad how he became HIV-positive, he cannot tell you, although the clues are not hard to piece together. The death of his wife about 10 years ago set him on a course that would place him in virtually every possible high-risk group for infection: he was tattooed with a dirty needle, he injected heroin and had multiple sexual partners.
Now a gaunt, unemployed recovering drug addict, Ahmad (his real name has been withheld to protect his identity) lives in government housing and spends most of his days receiving treatment for HIV and taking methadone to help him stay off heroin.
His situation may seem atypical in this devout, Islamic country, but in recent years Afghanistan has seen a relative explosion in HIV/Aids infection rates. As little as five years ago the disease represented an obscure threat to the country, but conditions have since conspired to create an environment in which it can spread quickly. Now, doctors say that Afghanistan has arrived at a critical juncture where serious action is required to prevent an epidemic.
The first confirmed case of HIV/Aids appeared in Afghanistan in 1989. Instances of the disease remained negligible for the next 15 years, before a combination of circumstances - including a rise in poppy cultivation, drug trafficking and drug use; unscreened blood being used in transfusions and conflict scattering refugees around the world - began to push infection rates up.
Today the disease has grown from a few isolated cases to what epidemiologists call a "concentrated epidemic" among injecting drug users. Indeed, while there are less than 700 confirmed cases of HIV in Afghanistan, doctors estimate that the real number is more likely between two and three times that number. Perhaps much higher.
Accurately tracking the disease and compiling reliable statistics remains a significant challenge. Not only is it difficult for doctors to reach large swaths of the population due to security reasons, but the country also suffers from poorly-equipped medical facilities.
However, it is becoming clear that HIV/Aids is taking its toll on drug users. Just four years ago, only three per cent of injecting drug users in Kabul tested HIV-positive. Now that number is seven per cent.
Ahmad was vaguely aware of all this a decade ago when he was living as a refugee in Iran. He'd heard of HIV/Aids, but it didn't seem like it was something that would affect him, even as he began using opium after his wife died of an illness unrelated to HIV/Aids.
Soon he began having problems with the police and was arrested three times for drug use and once more for a violent altercation. Later in prison, Ahmad got a tattoo. The tattoo artist used a shared needle.
"It took me two or three years to realise that I wasn't normal anymore, that I was an addict," he says.
Iranian authorities subsequently deported Ahmad back to Afghanistan because of his continuing addiction to opium.
Back in Afghanistan, he found work as a police officer in Kandahar. It seemed like a good job at first; it was a regular salary and he could continue using opium. His outlook on the job changed, however, when Ahmad was in a vehicle that struck a roadside bomb. The blast killed six of his friends and left him with back injuries and 29 stitches in his head.
He later left the police force and moved to Kabul, but was unable to find work. With time on his hands, his drug use escalated and he began injecting heroin.
Rumours of HIV/Aids and other diseases kept him from sharing needles, but even the most disciplined drug user will admit that these issues can get a little fuzzy. Meanwhile, he'd also begun sleeping with strangers. Ahmad estimated he slept with 11 different women in the years after his wife died.
Without knowing it, Ahmad had followed the same path as many other Afghans. Doctors who treat addicts and HIV patients said that most Afghans who use drugs report that they started when they were refugees in Iran. When they returned to Afghanistan, many addicts started injecting because it is more cost-effective and easier to hide compared to smoking.
Today, Afghanistan has almost one million drug users, or roughly eight per cent of the adult population, and that number is increasing. Over the last four years opium use has grown by 53 per cent and heroin use by 140 per cent, according to a United Nations Office on Drugs and Crime report. To make matters worse, injected drug use is up by 21 per cent and 87 per cent of injecting users report having shared needles.
Recognising the growing problem, the Afghan government created the National HIV/Aids Control Programme as a subdivision of the Ministry of Public Health in 2003. However, most of the serious activity to combat HIV/Aids has only recently begun.
"Most of the high-level officials know that HIV is a big problem and if we don't prevent HIV then it will cause … a crisis for Afghanistan," said Dr. Fahim Paigham, the programme's manager.
These efforts came too late for Ahmad. Roughly three years ago, doctors from a French nongovernment organisation, Médecins du Monde (MDM), found him in Kabul's abandoned Russian Cultural Centre, at that time a notorious drug den. They encouraged him to come back to their office for testing and there, Ahmad discovered he was HIV- positive.
"When I got the news, I was so scared I blacked out," he remembered. Since then Ahmad has been on an HIV treatment programme and he has also recently started on a methadone programme to ease him off heroin and opium.
Curing drug addiction is critical to controlling the spread of the disease, according to Olivier Vandecasteele, general coordinator for MDM in Afghanistan. In conjunction with the Ministry of Public Health, MDM conducts methadone treatment for habitual drug users. Currently they are only able to provide this service for 70 people, but hope they'll soon be able to expand their reach.
The next two years may represent a crucial period to stop the disease before it reaches a tipping point and spreads too fast for doctors to control.
In addition to curbing drug use, one of the biggest challenges ahead remains increasing public awareness about HIV/Aids. As a conservative country, the general community has a difficult time accepting people with a disease that is widely known to be sexually transmitted. There are numerous stories of women who having been infected by their husband were later accused of prostitution when their families found out.
HIV patients have also reported experiencing discrimination by the medical community. It is not uncommon for them to be denied treatment for basic health issues (conditions unrelated to HIV) when they visit public hospitals.
"It will take a long time before we have reached a level where each member of our community has been made aware and the stigma and discrimination in this country has been decreased. We are still far away from that goal," said Dr. Mohammad Tariq, UNODC's national HIV project officer.
Ahmad tells few people that he is HIV-positive, but he has tried to increase awareness. At an HIV/Aids event, he appeared on stage, blindfolded to protect his identity, and received a hug from the Minister of Public Health to demonstrate that people with the virus cannot transmit their illness through routine interactions.
For Ahmad, the tattoo he received in prison - that may have infected him with the disease that will eventually claim his life - still holds a special meaning.
A tearful eye on his bicep has a Dari inscription scrawled beneath it that reads, "The eye of my mother who waits for me."
When he got the tattoo, he wanted it as a reminder of his mother. Now, Ahmad says he's waiting to be cured of HIV/Aids before he sees his mother again. He is not aware that he is infected with a disease that can be treated, but never fully cured.
Tom A Peter is a freelance journalist who covers Afghanistan and the Middle East.