Monday, September 24, 2007

INDONESIA: Female condom programme falters

Photo: Hera Diani/IRIN
Some women are intimidated by the large size of female condoms, but their relatively high cost and problems with distribution and supply have also hampered the government's attempts to promote them.
JAKARTA, 28 August 2007 (PlusNews) - Ningsih [not her real name], 22, was taken aback when she was handed a pack of two female condoms in Jakarta, capital of Indonesia, but was even more surprised when she opened one. Measuring 17cm long and 7cm in diameter with a sponge attached inside, the female condom is indeed large compared to a male condom.

"My, it's so huge. Will it be painful using it?" asked the self-professed freelance sex worker, who was hanging out at a sidewalk stall in the Pramuka area of East Jakarta, a well known pick-up spot.

She told IRIN/PlusNews she was not willing to try the female condom; she was fine with a tri-monthly contraceptive injection, which kept her from getting pregnant.

What about sexually transmitted infections (STIs)? "I heard condoms might prevent that, but most of the clients don't want to use them, and I don't dare to insist, although I sometimes provide them," she said. "If a client ejaculates inside me I wash with Betadine," she added, referring to a popular feminine hygiene product.

INDONESIA: Cheap sex, high risk - the challenge of AIDS prevention

Photo: IRIN
Safer sex message needs ears to listen
JAKARTA, 24 September 2007 (PlusNews) - We were kerb-crawling for sex workers near the railway station in the grimy Cipinang district of Jakarta, Indonesia's sprawling capital, with Endang Supriyati providing a running commentary from the back seat of the car.

"There, do you see those women there, sitting next to the drink vendors?" said Supriyati, project manager for Yayasan Bandung Wangi, a local association that provides HIV/AIDS information and condoms to women working the streets in the eastern suburbs of Jakarta.

"They're sex workers? They look like they're selling drinks."

"No, they're sex workers," said Supriyati, pointing to women dressed in nondescript jeans and t-shirts; waiting, bored, among the night-time pavement traders along the traffic-choked main road.

"Can we get out and talk to them?"

"No," responded Supriyati, 22, who was having second thoughts about the evening's plan. "They'll ask, 'Who are you bringing, what do you want?'." Her concern was that if our voyeurism was spotted and perceived as snooping, it would ruin the relationship she has built with the women.

Selling sex is technically not a crime in the world's most populous Muslim country, but soliciting, pimping and procuring are. Indonesia's sex industry, although smaller that that of other South East Asian nations, still reportedly rakes in the equivalent of somewhere between 0.8 percent and 2.4 percent of the gross domestic product.

The previous authoritarian regime had encouraged designated "brothel complexes" in an attempt to regulate the sex trade. In the last 10 years, the rise of populist Islamic parties under Indonesia's new democratic order has brought the closure of established red-light areas by conservative local councils, wary of being seen as encouraging prostitution.

A booming sex industry

In spite of the new piety, swarms of massage parlours, karaoke bars and nightclubs have opened, cashing in on Indonesia's economic boom. They discreetly offer sex to better-healed punters, but in areas like Cipinang there is no façade. From the kerbside to a nearby alleyway, or shacks by the railway line - the only privacy an industrial rate of intercourse can afford - a streetwalker would be hard-pressed to charge more than US$1.50 for a quick round.

That sad fact undermines the advocacy efforts of activists like Supriyati: in a country where condoms are not popular and sex is cheap, market forces mean men "get sex the way they want it".

"The problem on the streets is that you have to compete [for clients]," said Supriyati. Insisting on condoms would not only be bad for business, but would "suggest the sex worker is HIV-positive". The harsh reality is that 23 percent of sex workers are living with the virus, according to the National AIDS Commission (NAC).

By the standards of the region, Indonesia has a serious HIV problem. In the eastern province of Papua it has become a generalised epidemic, with prevalence at 2.4 percent. In the rest of the country it is yet to break out of the sub-populations of injecting drug users (IDUs), prisoners and sex workers; but these subcultures are expanding as a result of lopsided economic growth.

"Two things force girls into this industry: poverty and lack of opportunity," said Supriyati. Although she must have told the story many times before, she cried when she remembered how her father had sold her, at the age of 12, to settle his debts to an aunty who was running a brothel in east Jakarta. "If he wasn't poor, he wouldn't have done it," she insisted.

Photo: Obinna Anyadike/IRIN
Recovering heroin addict - drug addiction adds to the risk
But working the upmarket bars and clubs can also be lucrative, and there's a chance of finding a husband among the expatriate workers that hang out at the pubs of the big hotels. "It is often assumed that all sex workers join the industry under duress because they lack other employment opportunities ... But the data suggests that many women in the booming economies of East and South East Asia choose sex work because it can pay comparatively well," said a report by the Monitoring AIDS Pandemic Network (MAP), a group of internationally recognised experts.

NAC deputy secretary Kemal Siregar told IRIN/PlusNews that regular condom use among sex workers was between 30 percent and 40 percent. Three-year-old surveillance data among brothel-based workers suggested condom use of around 15 percent (compared to almost 98 percent in the Thai capital, Bangkok). Worse still, just under half of all clients buying sex in Indonesia were deemed "high-risk": truck drivers, sailors and port workers.

If safer sex has been a hard sell among female sex workers, male and transgender prostitutes are in a neglected league of their own. "Almost everywhere it has been measured, condom use in commercial sex between men and women is consistently higher than condom use in commercial sex between men, even though sex between men carries a far higher risk of HIV transmission," the MAP study noted.

Sex and drugs

The use of putau - low-grade heroin - has exploded over the last 10 years, adding a further dimension of risk. It is typically injected, often with needles shared by many addicts, speeding the potential rate of HIV transmission. The medical technician in charge at a small government-run methadone programme in east Jakarta told IRIN/PlusNews that 86 percent of the former IDUs who were tested this year were HIV-positive.

Addicts sell and buy sex, and the barrier between those sexual networks and the rest of society is highly permeable. "I've noticed that a lot of parents of young men who are drug users are encouraging them to marry early, to change them. But the fact is that they infect their wives and children," said NAC secretary Nafsiah Mboi.

Islamic leaders are wrestling with the issue of condom use. "We agree condoms should be in red-light areas, but it should be sex workers that buy them; they should not be for everyone, like students for example," was the less than ringing endorsement of Aelhi Laksono, an outreach officer at the Angung Sunda Kelepa mosque in Jakarta.

"The figures show that [HIV prevalence] has nothing to do with good or bad people; a certain percentage of the population will engage in high-risk behaviour, and from them it will enter into the general population," Mboi responded. "The people that don't care about abstinence or being faithful need condoms."

Supriyati acknowledged that even her group, Indonesia's only advocacy organisation made up of former sex workers, has struggled to get its message across. In her depressing assessment, "Until they get infected, Indonesian people will not realise how important safe sex is."

Saturday, September 22, 2007

AIDS Vaccine Fails, So Merck Is Ending Study

Associated Press
Saturday, September 22, 2007; A08

TRENTON, N.J., Sept. 21 -- A promising experimental AIDS vaccine failed to work in a large international test, leading the developer to halt the study.

Merck & Co. said Friday that it is ending the enrollment and vaccination of volunteers in the study, which was partly funded by the National Institutes of Health.

It was a high-profile failure in the daunting quest to develop a vaccine against AIDS. Merck's vaccine was the furthest along and was closely watched by experts in the field.

Officials at the company said 24 of 741 volunteers who got the vaccine in one segment of the experiment later became infected with HIV, the virus that causes AIDS. In a comparison group of volunteers who got dummy shots, 21 of 762 participants also became infected.

Michael Zwick, an HIV researcher at Scripps Research Institute, said it is too soon to know whether other vaccines using the same strategy would also fail. "It's par for the course in the HIV field," he said of the Merck result.

The participants were all free of HIV at the start and at high risk for contracting the virus: Most were homosexual men or female sex-workers. Merck said all were repeatedly counseled about how to reduce their risk of HIV infections, including condom use.

In a statement, the NIH said a data safety monitoring board, reviewing interim results, found that the vaccine did not prevent infection or limit the severity of the disease "in those who become infected with HIV as a result of their own behaviors that exposed them to the virus" -- another goal of the study.

Wednesday, September 19, 2007

Pakistan: Roadside Dentists Pose HIV, Hepatitis Threat

PAKISTAN: Roadside dentists pose HIV, hepatitis threat

Photo: Kamila Hyat/IRIN
Roadside dentists heighten the risk of spreading HIV
LAHORE, 18 September 2007 (PlusNews) - Holding a chunk of ice wrapped in a handkerchief firmly to his right cheek, Saleem Jawad, 34, looks rather pleased with himself. From time to time he turns away to spit out a stream of red blood, before sipping from a glass of cold water beside him.

Saleem, a car mechanic, has just had a molar removed in Lahore, capital of Pakistan’s eastern Punjab Province. The roadside dentist, Siraj Saeed, who performed the task, has the extracted tooth in a steel bowl next to an array of instruments spread out on a small, stained mat where he receives and treats his patients.

"The problem has gone now. I will be able to sleep properly and eat again in a few hours," Jawad told IRIN/PlusNews.

But while the roadside tooth removal - carried out without anesthetic and with only the most primitive, unsterilised tools - was obviously painful, there could be dire consequences for those who use the services of roadside dentists.

Recent studies in Pakistan have shown that roadside barbers, dentists and doctors are responsible for the rapid spread of diseases such as hepatitis, as well as HIV/AIDS.

"When the same instruments are used on one patient after another, and only dipped in a pail of water to clean them, there is an immense danger of passing on all kinds of disease, including HIV," said Fahd Anwar, a Pakistani dentist based in the USA.

Dr Anwar, who is considering moving back to Pakistan, cited an acute shortage of qualified practitioners - effectively encouraging such practices to thrive.

Shortage of qualified dentists

According to Pakistan government figures for 2006, there were 6,761 dentists in the country for a population of at least 155 million - roughly one dentist for every 23,000 patients.

This ratio had improved somewhat over the past decade, but the number of qualified practitioners remained dismally low.

This also means fees charged by trained dentists at private clinics tend to be high, while government medical facilities are often poor and involve long waiting periods.

"I know people say one can get sick by visiting roadside dentists. I have seen a programme on TV about this, and something about boiling instruments," said Jawad.

''When the same instruments are used on one patient after another, and only dipped in a pail of water to clean them, there is an immense danger of passing on all kinds of disease, including HIV.''
But he, and Siraj Saeed's next patient, Umar Gul, from Pakistan's North West Frontier Province, both agree: "People like us cannot afford to go to the fancy clinics where qualified doctors work”.

Roadside dentists charge between eight US cents and $3 for their services, while a visit to a private dentist will cost more than $8. Even treatment at public sector facilities often incurs larger costs.

Such costs are beyond the means of many people in Pakistan who earn less than $100 a month.

As a result, thousands of people each year visit roadside practitioners, who usually depend on lessons passed on from elders or simply first-hand experience, for their expertise. Moreover, most have little or no awareness about the need for hygiene, let alone sterilisation or the dangers of HIV/AIDS.

"These things are in Allah's hands; we do what we can," says Saeed. "I wash my tools with soap each evening."

Hepatitis, HIV/AIDS

But with the prevalence rates for hepatitis stated by the Pakistan Medical Association to be at least 11 percent and rising, such practices also play an inevitable role in the spread of the disease, which claims hundreds of lives each year, as well as HIV, say specialists.

Pakistan is now ranked in the “concentrated epidemic” stage of HIV/AIDS, according to the World Health Organization (WHO). Pakistan's National AIDS Control Programme (NACP) officially confirms only 3,198 HIV/AIDS cases across the country, but NACP experts concede the "number of sufferers could be higher".

More on HIV in Pakistan
HIV/AIDS will not go away if you ignore it
Lonely drivers face HIV/AIDS threat
Taboo heightens risk for male sex workers
Drug injecting refugees vulnerable to HIV infection
Speaking to IRIN/PlusNews, Naveeda Shabbir at the NACP said prevalence among the general population was below 0.1 percent, but added there was a higher prevalence among specific populations, most prominently injecting drug users (IDUs).

According to WHO, the number of HIV-positive people in Pakistan could be as high as 85,000.

Epidemics have been reported among IDUs in the town of Larkana in Sindh Province and also in other major cities. The high prevalence of sexually transmitted infections, the large number of female and male sex workers, inadequate checks on blood transfusions and high levels of illiteracy and lack of awareness about AIDS also place Pakistan at high risk.

Following a month-long anti-AIDS campaign, the NACP country director, Asma Bokhari, said that in several Punjab districts, the re-use of syringes was found to be a major cause of the spread of the virus, and that "unsafe medical practices" posed a grave risk.

Yet despite this, across Lahore, and other major cities in Pakistan, dentists - as well as barbers who traditionally also lance boils, ear doctors and other quacks - continue to carry on their unsafe practices.

Their numbers are unknown but it is estimated to be in the tens of thousands. To date, campaigns to tackle such unsafe practices have failed to achieve any results, despite the obvious risks.

Monday, September 17, 2007

Kenya: Muslim Opposition to Condoms Limits Distribution

Photo: IRIN
Muslim leaders say promoting condoms is tantamount to promoting adultery
MANDERA, 17 September 2007 (PlusNews) - The strong anti-condom stance of religious leaders in northern Kenya means few people there are using them and traders are refusing to stock them, which AIDS activists warn is jeopardising the fight against the pandemic.

"I will never sell condoms in my shop; it is like promoting adultery and operating a brothel," Sharrif Mohamed, who owns a shop in Isiolo, Eastern Province, told IRIN/PlusNews.

Most traders in the mainly Muslim northeastern part of the country have refused to stock condoms, which are usually only available at government health centres.

Zamzam, a single mother of three in Garissa, a town North Eastern Province, dismissed condoms as "a thing for the prostitutes", saying, "I use my brain and intelligence when I want to sleep with a man, and can tell who is sick [with HIV/AIDS]; I am not a prostitute to use it." This level of ignorance is common across the region, where literacy levels are the lowest in the country.

"The HIV/AIDS pandemic is a curse and punishment because people have engaged in immoral acts and offended Allah [God]," Maalim Hussein Mohamud, a teacher at a 'madrassa', or Islamic school, in Mandera, near the Somali border, told IRIN/PlusNews. "They have to repent, observe religious teaching and not use condoms."

Mohamud said the only way to prevent the viral infection was to observe religious teachings, abstain from 'illegal' sexual acts and avoid the use of condoms.

"Our position is very clear: we shall never support the use of condoms; Muslims must shun acts that will endanger their lives. To be safe [from HIV], youths must pray five times daily, fast, and refrain from looking at women; extramarital affairs must be avoided and women must dress decently," he insisted.

Noor sheikh, who works at the government's HIV/AIDS and sexually transmitted infection control programme in North Eastern Province, said stiff opposition to the use of condoms was proving to be a hindrance to HIV prevention. "Our region has the lowest use of condoms in the country," he said. "Of course it is a factor responsible for many cases of infections."

Some activists have complained that the government has not done enough to educate the local population about condom use, particularly in rural areas, and it was also often very difficult to obtain condoms.

"Many youths are informed about the use of condoms, but have said they are not available in remote parts of the region," said Margaret Leshore, of the Samburu Women's Empowerment Programme, a non-governmental organisation advocating women's rights.

The condom is one of the main HIV prevention strategies employed by the government, and free condoms are available at most health centres around the country.

Although northern Kenya has some of the country's lowest prevalence rates, concerns have been raised about low awareness of the pandemic and the region's continued resistance to condom use.

Wednesday, September 12, 2007

Molding the Ideal Islamic Citizen


CULTURE BLEND Islamic strictures met Persian love of pleasure in a Tehran shop in 2005 when a head scarf was pulled back to show some hair.

Eric Grigorian / Polaris

PUBLIC DISPLAY Sexual pleasure is encouraged for newlyweds; when fingers touch in public, wedding rings can avert disapproval.

From the New York Times
By Michael Slackman"
September 9, 2007


THE instructor held up an unfurled green condom as she lectured a dozen brides-to-be on details of family planning. But birth control was only one aspect of the class, provided by the government and mandatory for all couples before marriage. The other was about sex, and the message from the state was that women should enjoy themselves as much as men and that men needed to be patient, because women need more time to become aroused.

Full article...

Tuesday, September 4, 2007

Mozambique: Islamic Leaders Try to Come to Terms with AIDS

Photo: Mercedes Sayagues/PlusNews
Islam is part of the fabric of society in Pemba
PEMBA, 3 September 2007 (PlusNews) - Sheik Muhamade Aboulai Cheba's call to prayer wafts over the thatch-and-coral houses behind their four-metre high bamboo fences. The Indian Ocean shimmers between the tall slender trunks of palm trees at the turns and ends of the narrow, sandy alleys they shade. This is Paquitequete, the oldest neighbourhood in Pemba, capital of Cabo Delgado, Mozambique's northernmost province.

The bustling neighbourhood quiets down on Fridays after 11, when the green-and-white mosque set between the hill and the beach, fills up. Often the sermon is about AIDS. "We teach people how to protect themselves and how to deal with the disease if they have it," Cheba told IRIN/PlusNews.

Seroprevalence in Cabo Delgado, which borders Tanzania, is 8.6 percent, the lowest in the country; the national average is 16.2 percent.

Arab traders brought the Muslim faith to Africa's eastern coast around the eighth century. Around 80 percent of Cabo Delgado's 2.5 million people are Muslim, as are about a quarter of Mozambique's nearly 20 million people.

Word power

Cheba knows the power of his words: "In a place of worship people pay more attention," and also in a place of learning. He is the provincial director of 139 registered madrassas (Islamic schools), where pupils start learning about AIDS as early as six years of age, "in an appropriate way, using metaphors, not showing a condom."

Following Islamic teachings, Cheba insists on faithfulness among couples and postponing sex until marriage. Condoms are not recommended.

Many mosques have organised teams who visit the sick and orphans at home, and the Portuguese medical charity, Medicos do Mundo, has trained about a dozen women, including Cheba's wife, to administer home-based care. Orphans are exempt from paying the madrassa school fee of 5 contos (US$0.20) a month, and are given food and clothing.

HIV-positive Muslims are encouraged to join support groups, says Nassurulahe Dula, President of the Islamic Congress of Cabo Delgado, the province's largest Muslim congregation.

All this is helpful, but some AIDS activists in Pemba have often bristled at Cheba's statements: "This disease is a divine punishment; the Prophet said that a disease without cure and sudden death is the punishment for adultery."

He hastens to explain that "like the tsunami in Indonesia, AIDS is a punishment that affects those who do good, and those who do evil. People must repent and return to God."

A good Muslim

Maria de Fatima Bacar, 44, a large, friendly woman who lives in a hamlet 20km inland from Pemba, has one son alive, three dead, and two grandchildren whom she dotes on.

''AIDS does not target Muslims, Christians or pagans; AIDS is like malaria, we are all equal in front of it''
In June 2003, her husband, a policeman, became sick after his first wife had died some time before. Bacar and her husband both tested positive for HIV and soon started antiretroviral treatment, among the first in the province to do so. She had worked as an assistant at the local health post for many years, and her experience helped them cope with the virus.

The couple organised a support group, the Association to Help your Neighbour, which now has 22 members and cares for 12 HIV-positive children. They visit the sick, help with burials, make sure that orphans go to school and encourage people to test for HIV at the local health post. "Fifty-seven last month," she says proudly.

Bacar is unhappy about what she hears at mosques. "AIDS is not a divine punishment; whoever says AIDS is a punishment, says it out of ignorance," she says firmly.

"I am a good Muslim woman. I never did anything outside my faith. I was an honest and faithful wife, and I got HIV through my husband. Instead of embracing people, they reject us."

The link between AIDS and sex has long been a thorny issue for faith organisations that promote strict sexual guidelines and behaviour. "We are encouraging AIDS with the way we dress, showing bellies and tempting men," says Awash Ingles, a prominent Muslim woman leader who worships at the Paquitequete mosque.

Like malaria

Islam has "immense problems" in dealing with AIDS in Cabo Delgado, says Diquessone Rodrigues, provincial coordinator of MONASO, the national umbrella for AIDS service organisations.

Photo: Mercedes Sayagues/PlusNews
Fatima Bacar: "I'm a good Muslim woman"
"We must try to change this belief that AIDS is a divine punishment because girls wear tchuna-babes [tight jeans] and have sex before marriage."

MONASO is meeting with groups of mosque-associated women to try to change their perceptions and enlist them to bring about change. "They can speak [about AIDS] at mosques and madrassas," says Rodrigues.

Another potential ally is the Provincial Council against AIDS, which plans to meet with Islamic authorities. "We want to work with Islamic leaders to change this discourse, because it hurts HIV-positive people to hear AIDS is a punishment from God," says Council director Teles Manuel Jemuce.

The idea is to gently nudge Muslim thinking in Cabo Delgado towards common ground with Bacar, who says: "AIDS does not target Muslims, Christians or pagans; AIDS is like malaria, we are all equal in front of it."

Monday, September 3, 2007

First Association for People Living With HIV in Pakistan

From UNAIDS - 24 August 2007

A new national initiative from UNAIDS in Pakistan aims to ensure that communities and the government listen to the experts - people living with HIV - when making decisions about treatment, care, support and prevention.

The association was launched on World AIDS Day
2006 with the support of UNAIDS and its UN
co-sponsors, and the Pakistan government.
Photo credit: UNAIDS / J. Moore

Twenty-four year old Masood is the newest recruit to one of UNAIDS’ latest initiatives: the“Association of People Living with HIV and AIDS in Pakistan”.

The association was launched on World AIDS Day 2006 with the support of UNAIDS and its UN co-sponsors, and the Pakistan government. The aim is to make sure that people living with HIV are consulted when decisions about prevention, treatment, care and support are taken at federal and provincial level.

In keeping with the principle of greater involvement of people living with HIV, all the executive board members of the association are HIV positive. Now, it is establishing the first network among people living with HIV in Pakistan to provide a platform for them to speak in unison.

“In my experience, most HIV positive people here have difficulty conveying their needs, often because of poverty and because the literacy rate is low and information provided is limited,” says Masood.

“Here in Pakistan HIV is not seen as a priority and people have many issues surrounding their treatment, care and support, stigma and discrimination and society’s attitudes.” Stigma and discrimination is specifically associated with children and women from rural areas of Pakistan. These women have been infected by their husbands; most of them were migrant workers who have been deported by certain countries without being told about their HIV positive status.

The objective is to provide training in leadership
skills and health information, including adherence
to anti-retroviral treatment.
Photo credit: UNAIDS / J. Moore

The Association has already begun to bring the small number of NGOs and self-help groups together. The objective is to provide training in leadership skills and health information, including adherence to anti-retroviral treatment.

With a Masters in Business Administration from University in Lahore, Masood is working with them to organize themselves strategically, to develop policies and to raise funds.

There has been a three-day workshop on capacity building already, focusing on the issues for people living with HIV in Pakistan and how to operate an effective positive self-help group. Another two-day workshop focused on HIV literacy helped pre-testing and collecting feed back on the newly developed booklets and other information materials produced in Urdu and English for people living with HIV (PLHIV).

UNAIDS will be supporting more workshops across the country and is planning to do this activity in collaboration with Association of PLHIV, provincial and federal Government and civil society organizations working on AIDS issues.

“We aim to contribute to improving people’s lives, give them a sense of belonging, political empowerment and strength of spirit,” says Masood.

At the same time the Association aims to contribute to the national goal – to “prevent a generalized epidemic in Pakistan by containing the spread of HIV and AIDS and elimination of stigma and discrimination against those infected and affected” .

Twenty-four year old Masood is the newest recruit
to one of UNAIDS’ latest initiatives: the“Association
of People Living with HIV and AIDS in Pakistan”.
Photo credit: UNAIDS

*The country's epidemic is concentrated and intensifying. Pakistan has one of the highest rates of injection drug use in the world (4.5 per capita per annum), and 64% of injecting drug users report use of non-sterile needles. Frequent use and reuse of unsterilized and contaminated needles contributes to a high transmission rate of HIV among injecting drug users (10%). The World Health Organisation and UNAIDS estimate the actual prevalence may be as high as 85,000 (46 000- 210 000).

During the Launching ceremony of Association of PLHIV in 1 st December, 2006 Dr. Aldo Landi, UNAIDS Country Coordinator said:

“This is the first step as a breakthrough in the fight against stigma and discrimination”. He further expressed the need of involvement of PLHIV at both federal and provincial level. Most importantly PLHIV should be treated in full respect of human rights.

Masood is a hemophiliac who contracted HIV through infected blood. In Pakistan, about 50 per cent of blood products are screened for HIV before blood transfusion – and 1.5 million blood bags are transfused every year. About 18 per cent of people living with HIV in Pakistan were infected in this way.

“I have spent many years of my life for humanity,’” says Masood, who has campaigned for better treatment for hemophiliacs and as a volunteer, running a UNICEF funded project for a Lahore based PLHIV NGO, before joining UNAIDS.

“I am very ambitious because I am facing and feeling the pain,”says Masood. “I want to make a real difference by encouraging people living with HIV to realize how important it is for them to be involved at every level.

“They themselves will bring about change. I am happy to be the first drop of rain.”

HEALTH-PAKISTAN: Drug Addicts Routinely Denied Anti-HIV Medicines

By Zofeen Ebrahim

KARACHI, Aug 18 (IPS) - ''I’ve been running temperature for the past 25 days and lost about five kg in the last one month... just feel so weak every day,'' says Mohammad Sohail, 28, who tested HIV positive a little more than a year ago. His CD4 count is 152.

The strength or weakness of a person’s immune system is calculated on the basis of CD4 count. The normal range is between 600-1,500 cells per cu mm of blood. The count helps health providers decide when to put an HIV positive person on anti-retroviral therapy (ART).

HIV positive people are those found to have, in their blood, the human immunodeficiency virus (HIV) which affects the immune system and causes acquired immune deficiency syndrome (AIDS).

According to World Health Organisation (WHO) guidelines ART must be started when the CD4 count falls below 200.

Despite noting Sohail’s temperature chart and examining a report from his doctor, the government-run referral centre he visits has run no tests on him. But he is being administered antibiotics.

Sohail is among the 175 HIV positive cases currently registered at the Centre of Excellence at Service Hospital, where the Sindh AIDS Control Programme is running the Enhanced HIV/AIDS programme. Of these 60 are on ART.

For the last four months Sohail has been visiting the centre regularly, waiting in line for up to four hours. "The commuting takes another two hours. These visits are taking a toll on me, physically and financially.’’

Each trip to the centre means taking leave from work for a day. He has recently been employed by Dr Saleem Azam for an AIDS prevention project funded by the European Commission on a salary as there were no jobs available for former drug users like him.

But despite his low CD4 count, he is yet to be started on ART that may not cure, but makes the difference between living on the margins and leading a better quality of life. "They (doctors at the referral centre) tell me I look quite fit and don’t need the drug," says Sohail quietly.

He is convinced the indifference is due to his being a former drug user. ''When I complain of discrimination doctors say they fear I may revert to drugs and do not want to waste time and the medication on.’’ Sohail has been drug-free now for over five months.

It is this discriminatory attitude that is making Azam’s work on harm reduction difficult.

Working with intravenous drug users (IDUs) for the last 25 years, he has, at the moment 5,000 IDUs registered with his organisation, the Pakistan Society (PS), which also runs two rehabilitation centres. Almost all of his clients are people from the streets.

"The government is excluding drug users from HIV treatment. This is really dangerous as this population is fuelling the epidemic," says a piqued Azam. In Sindh, 30 percent of all IDUs are HIV positive.

There are over 35,000 to 40,000 IDUs in Sindh and according to the last study conducted in 2000 by the United Nations Office on Drugs and Crime, there are over 60,000 IDUs all over Pakistan. "Careful estimates would now put the figure between 80,000 to 100,000," says Azam.

Officially, the total number of confirmed HIV/AIDS cases in Sindh has gone up to 1,841 and the number of such cases reported from across the country stands at 3,364. Authorities, however, say the unregistered number could well be over 80,000.

Azam’s words echo those of Prasada Rao, Asia Pacific regional director for UNAIDS, the U.N.-joint programme against AIDS. Rao says access to ART is unacceptably low among IDUs because of a "lack of information, exclusion and widespread stigma and discrimination".

For the HIV prevention programmes to be effective, says Azam, these should reach out to IDUs specially.

In the last one year, ten people under his treatment died after they were refused treatment at the state-run hospitals. "About eight months ago, I had to bribe a doctor in Civil Hospital by paying him Rs 4,000 (66 US dollars)) just to operate on one of my clients which should have been done free of charge. Recently, one client died because the Jinnah Post Graduate Medical Centre refused admission on one pretext or the other and, without informing us, shifted him to a shelter run by the Edhi Foundation charity, where his condition deteriorated and he slipped into coma. This is nothing new and happening all the time," Azam said.

The vice-president of the National Association of People Living with AIDS Farid Ahmed Memon faces the same discriminatory attitude. ‘’The Sindh AIDS Control Programme (SACP) told me I don’t need to get the CD4 test done. Imagine if it’s happening to me -- and I know most doctors there -- what the others must be going through."

But Dr Azra Ghias, director of the Centre of Excellence established and run by Enhanced HIV/AIDS Control Programme, says: "No, we don’t discriminate among the various people living with HIV/AIDS nor do we write them off. Everyone who comes to us is our responsibility and our priority. Anyone who needs an ART will get it. But it’s a drug that needs hundred percent compliance and adherence. We do treat IDUs who are drug free for at least four months and who come to us through an NGO. That way we can assure its compliance."

And yet of the 20 HIV positive people registered with PS who have been approved for getting ART by the SACP, only three are getting the drugs "There are almost 100 more who fit the bill," says Azam.

"If this is not discrimination what is? It’s the SACP that runs the tests and register these people, then why the delay? They even have their own standards of gauging who needs the ART and who doesn’t,'' complained Azam.

"CD4 count of less than 200 was the earlier benchmark; it has since been revised by the WHO to 300 and we follow their guidelines," said Ghias.

Azam argues: "Why wait till the person is really sick and on his deathbed to qualify for the drug, why not start earlier? With the formation of the Global Fund to Fight AIDS, TB and Malaria, and ready availability of cheaper generic drugs, why this discrimination against drug users?"

According to the Ghias, one missed dose may cause immense harm. "We spend Rs 30,000 (496 dollars) per month per patient and just one missed dosage would mean his/her resistance to the first line and we’d have to start the person on the second line which is very expensive. That is the reason for our reluctance to giving ART to a drug user who may not know night from day."

But while many await their turn to receive ARV, Azam says there is an urgency to scale up access to other care options. People like Sohail could be diagnosed and treated for opportunistic infections such as tuberculosis, to which people with HIV are especially susceptible.

Worlds AIDS Day in Muslim Countries