IRIN Focus on the battle against HIV/AIDS

Mohammad looks healthy, but following a seizure and a sudden fever in June, the 38-year-old father of two received a devastating blow when his doctor told him he was HIV-positive, infected with the virus that leads to AIDS.

"I went into immediate shock," he told IRIN. "Sometimes I forget I have HIV, but every day when I wake up, that reality returns, and I'm angry with myself," he said. Unsure how he contacted the disease, doctors decided to test him after learning he had lived abroad for three years. Today, Mohammad has AIDS, one of only 35 officially registered cases in the Islamic Republic of Iran, but the prognosis is grim.

A major problem in this staunchly religious society is the stigma attached to HIV. "If people know I have AIDS, I become a bad person, I will be shunned," he asserted. Mohammad, like 10 other registered AIDS sufferers, has not even told his wife. It is this kind of stigma that most hampers the battle against the disease in Iran.

Although the country currently has a low HIV prevalence, the constraint on public discussion is increasingly rendering it vulnerable to the pandemic. "HIV/AIDS is a top priority now in Iran," Bahram Yeganeh, faculty member of Tehran University and member of the national AIDS committee, told IRIN. "It's definitely increasing," he said.

From 1987 until now, there have been 3,109 reported cases of HIV in Iran. Of these, 369 had developed AIDS and of these, 334 had died, he added. While low compared to many countries, Yeganeh estimates the true number of HIV cases to be 15,000 with 1,500 actual AIDS cases.

Last year, a former minister of health, Mohammad Farhadi, said HIV was a "time bomb" waiting to rip through Iranian society, and needed to be taken seriously. How seriously that threat is being taken remains open to debate.

"The main problem in Iran is our culture," said Dr Alireza Sadra'i, general practitioner and manager of the Eslamshahr health centre, located in a poor district 80 km southwest of Tehran. He said open discussion and acceptance of such issues was not easy, because of the sexual connotations. "Talking about AIDS in Iran is a taboo subject, and our main challenge is how to change this perception," he said. Only until very recently did the government allow open discussion of the disease in the media, he added.

The disease was first detected in Iran in 1987 when a six year-old haemophiliac boy was diagnosed as HIV-positive after receiving contaminated blood imported into the country. This led to the establishment of a national committee to fight AIDS.

Yeganeh said that before 1996, the country had a very low prevalence of the disease, but then a major outbreak occurred within the Iranian prison system. Of 400 prisoners tested for HIV at the Kerman prison, a staggering 146 inmates tested positive, most of them intravenous drug users (IDUs), he said. Indeed, it is this group which presents the greatest challenge in Iran. In 1996, the number of AIDS cases jumped from 16 to 35, followed by 40 cases in 1997.

According to Iran's AIDS Prevention Committee, the main mode of transmission is among IDUs, accounting for 64 percent of all cases of HIV/AIDS from 1987 to now. The country lies along a major transit route for narcotics coming from neighbouring Afghanistan and Pakistan and onward through Turkey and into Europe. Of the estimated two million addicts in the country, over 300,000 are IDUs, many of them sharing needles, according to Yeganeh. He added that heroin remained easily obtainable, and a single hit cost as little as 50 US cents.

Asked what steps the government had taken to curb the problem, he said needle-exchange centres had been established in the cities of Mashhad, Shiraz and Kermanshah, which also provided methadone. About 3,000 people a month visit these centres free of charge and also receive information on sexually transmitted diseases (STDs). The centres have proved to be a success and, according to Yeganeh, their number is set to increase to 30.

He said the Supreme Leader, Ayatollah Seyyed Ali Khamene'i, had taken the threat of AIDS seriously and a national strategic plan had been approved last year.

Meanwhile, it is the situation in prisons which is most worrying. "Drug usage is quite prevalent in the prison system, and it's not difficult to get it if you want to," Yeganeh said. He added that access to those infected remained inadequate, and there was a genuine lack of treatment facilities in the nation's prisons.

Moreover, providing education about the threat of AIDS to convicts has yet to be realised, rendering the Iranian prison system particularly vulnerable to another outbreak. How the drugs are getting in is unclear, but one health official told IRIN he was sure that prison guards were involved in smuggling them in.

Drug abuse is strictly illegal, and IDUs are sent to rehabilitation centres or prisons on the basis of the quantity of drugs possessed, and their past records. About 16 percent of drug addicts are in prison or a have a past record of being imprisoned.

In Iran, 10 percent of reported HIV cases are attributed to sexual relations, but asked to comment on this statistic in the context of commercial sex, Yeganeh asserted: "We don't have any commercial sex workers. It is extremely illegal. If these things happen, we don't have access to any information about it." He went on to say that women constituted only 4 percent of the 3,109 confirmed cases of HIV/AIDS. Similarly, the issue of homosexuality is not openly discussed. "That type of behaviour isn't found here," he said.

One challenge unique to Iran is the culture of temporary marriages. Known as sigheh, these temporary marriages are found only in Iran or countries practising the Shi'ite form of Islam. Such marriages are permitted; they can last for several days or months, or even just a few hours. "The time is determined by the [verbal] contract," Yeganeh said. Sigheh marriages were "officially recognised, but not officially registered", he said.

The potential spouse generally receives a cash payment depending on the duration of the agreement. Thousands of women every year are married in this way in Iran, a situation which undoubtedly presents a host of challenges to the prevention of HIV in Iran. However, Yeganeh dismissed the threat, saying action was being taken to heighten awareness among the women involved in the practice. "When our doctors speak to these women, they emphasise the importance of condom usage," he said.

What is accepted, however, is the need for more public education. Of the 65 million people living in Iran today, 60 percent are under the age of 25. Moreover, the marriage age is rising, and although not culturally accepted, premarital sex is expected to increase over time.

Currently, in all 39 of Iran's medical universities, there are hotlines for people wishing to inquire about AIDS, STDs and hepatitis. At the Iranian Centre for Disease Control in Tehran, there are two dedicated hotlines for AIDS and STDs.

Manning one of them, Dr Mitra Motamedi, a 37 year-old specialist in infectious diseases, told IRIN that most questions concerned modes of transmission, or the caller was worried after having engaged in some form of high-risk behaviour. "There is a definite need for better information," she said. "Most of these people seem quite young, and these are precisely the people we need to reach with information."

One local NGO targeting this group is Ofagh or Horizon. Established last year in Eslamshahr, this independently funded group of 30 men and women volunteers has been visiting universities, high schools and other public venues in an attempt to sensitise people to the threat of HIV.

"People are afraid of talking about HIV as there is a lack of public information out there," 25 year-old group member, Asam Rasuli, told IRIN. She explained that when people in Iran first heard about AIDS, they immediately concluded that homosexuality was the only mode of transmission. "Talking about such things is simply not done," she said. Others simply did not believe the risk applied to them.

Asked how people responded to her group's workshops, she said most of those attending were between 14 and 29 years of age and wanted additional information. Rasuli maintained that people tended to remain prejudiced against talking about AIDS. "It's getting better, but there is a lot of work to do," she added.

While Iran is taking some steps in the right direction, a far more rigorous campaign is needed in the realm of public discussion. Experts agree that ignorance is one of the principle reasons for the pandemic's spread to about 40 million people worldwide.

For people like Mohammad, keeping the secret is more important now. To acknowledge AIDS in yourself is to be branded sinful. He agreed there was insufficient awareness, but said he was beginning to witness the issue being discussed on television. Today, he takes a daily regimen of three different drugs to contain the disease. With a monthly income of only US $200, he considers himself fortunate that the US $800 a month cost of the drugs is met by the Iranian government.

Asked if he regrets not telling his wife, Mohammad said: "I don't want to scare her. Many people don't know how the disease is transmitted, and besides - now I practise safe sex. In Iran it's better not to say."