HIV/AIDS IN SAARC COUNTRIES....

COUNTRY PROFILE:Afghanistan



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State of the Epidemic

Reliable data on HIV prevalence in Afghanistan is sparse. To date, 478 HIV cases have been reported, however, UNAIDS and WHO estimate that there could be between 1,000 and 2,000 Afghans living with HIV. The HIV epidemic is at an early stage in Afghanistan, and is concentrated among high risk groups, mainly injecting drug users (IDUs) and their partners. Afghanistan’s emerging epidemic likely hinges on a combination of injecting drug use and unsafe paid sex. According to a 2006 study, percent of IDUs in Kabul were HIV positive. Almost one third of the IDUs participating in the study said they used contaminated injecting equipment. In addition, large proportions of these (male) drug users also engaged in other high-risk behavior. For example, 32 percent had sex with men or boys, and 69 percent bought sex. Only about half of the IDUs knew that using unclean syringes carries a high risk of HIV transmission or that condoms can prevent infection.



Risk Factors

Knowledge is increasing about the factors that influence the spread of HIV in Afghanistan. Risks and vulnerabilities that play a role and which require further investigation include:

Injecting Drug Use: Afghanistan is the world’s largest producer of opium, which is used to make heroin. A 2005 survey estimated that Afghanistan had almost one million drug users including 200,000 opium users and 19,000 drug injectors of whom 12,000 inject prescription drugs and 7,000 inject heroin. A 2006 survey in Kabul estimated that several categories of drug use had increased by more than 200 percent in 12 months. The intensification of the war on drugs, by reducing the availability of heroin, can cause drug users to turn to injecting drugs as a more cost-effective option. These factors, combined with poverty and the lack of information, can lead to widespread injecting drug use and the sharing of needles. The use of non-sterile injecting equipment can jumpstart an epidemic and lead to rapid increase in HIV prevalence.
Large Numbers of Refugees and Displaced People: Approximately eight million Afghans spent some time living abroad as refugees, in Pakistan (5 million) and Iran (3 million). Today, about one million widows and 1.6 million orphans, four million returnees and 500,000 internally displaced people live in Afghanistan, while almost four million Afghan refugees still live in Pakistan and Iran. These countries have rapidly growing IDU driven HIV epidemics. Although little is known about the HIV risk behaviors of Afghan refugees and displaced people, such groups generally have little access to information about HIV. They are also at risk due to isolation from their families and lack of means to support themselves.
High Levels of Illiteracy: Illiteracy presents a barrier to HIV awareness and prevention. The literacy rate in the general population is very low (36 percent) and lowest among women (13 percent) with little awareness about HIV and AIDS and almost no condom use.
Competing Health Priorities: Afghanistan has one of the worst maternal mortality rates in the world, with an estimated 15,000 Afghan women dying every year from pregnancy-related causes. One in four children dies before its fifth birthday; more than half the deaths are due to acute respiratory tract infections, diarrhea, and vaccine-preventable diseases. Early attention and response to HIV and AIDS risks getting lost amid the focus on these other urgent health issues.
Low Status of Women: Women in Afghanistan experience one of the lowest social positions in the world. Denied access to education and jobs and often not allowed to leave their homes without a male relative, they lack access to information on how to protect themselves.
Issues and Challenges: Priority Areas

Universal access to health care services for most at risk groups. The Ministry of Public Health is committed to universal access to health services. However, due to stigma, discrimination and other socio-economic factors access to services for most at risk groups is limited.
Gather data for planning and action. Behavioral surveillance data and knowledge, attitude and practice (KAP) surveys are urgently needed to develop a coherent plan which can be translated into effective action. Mapping of high-risk groups such as injecting drug users and sex workers was conducted in 2007 in Kabul, Jalalabad and Mazar, and different HIV prevalence studies have been conducted among IDUs. However, the information about IDUs, MSM and sex workers networks remain limited.
Implement a multi-sector response. Coordination among ministries is crucial to guarantee health services to IDUs, sex workers and prisoners, who are currently facing barriers to access. It is also important to increase HIV awareness, and reduce stigma. It is especially important that, in addition to the health sector, the counter narcotics, transport, justice, interior, religious, women’s affairs and education sectors are involved.
Expansion of primary health care services to remote underserved areas. The primary health care system is the backbone of any HIV/AIDS program. An effective, community-oriented primary health care system will improve reproductive health. This includes providing access to condoms, treating STIs, and increasing public awareness of HIV/AIDS and methods to prevent the spread of HIV. It is critical that the primary health care services be expanded to remote underserved areas
National Response to HIV/AIDS



Government: The Ministry of Public Health has developed a national strategic plan (2006-2010), with goals to maintain low HIV prevalence (less than 0.5 percent) and to reduce the mortality and morbidity associated with HIV and AIDS. This strategic framework has been translated into a program operational plan (POP). Reversing the spread of HIV has also been included as a goal of the Afghanistan National Development Strategy (ANDS)

According to the Afghanistan National HIV/AIDS Strategic Framework, the six objectives are to:

Strengthen strategic information to guide policy formation, program planning and implementation;
Gain political commitment and mobilize resources necessary to implement the national HIV/AIDS/STI strategy;
Ensure development and coordination of a multi-sector HIV/AIDS response and develop institutional capacity of all sectors involved;
Raise public awareness on HIV/AIDS and STI prevention and control, ensure universal access to behavior change communication on HIV, especially targeting vulnerable and at risk groups;
Ensure access to prevention, treatment and care services for high-risk and vulnerable populations;
Strengthen the health sector capacity to implement an 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.
To address the multi-sectoral issues attached to the HIV epidemic, the Afghanistan HIV/AIDS Coordination Committee (HACCA) was established in 2007. The HACCA acts as a policy forum for different ministries, NGOs, and civil society involved in the fight against HIV and AIDS.

An international conference on Opioid Substitution Therapy (OST) was held in Kabul in November 2007 with participation of experts from Afghanistan, Uzbekistan, India, Europe and the United States. This conference was an important step towards the establishment of OST in Afghanistan and a sign of the growing organizational capacity of the National AIDS Control Program.



Non-Governmental Organizations (NGOs): Afghanistan has both international and national NGOs involved in the provision of health services. Eighty percent of existing health facilities are either operated or supported by NGOs. The support of NGOs by the health care system is critical, including drug supplies, supervision, training, and incentives. NGOs play a key role in reaching most at risk and vulnerable groups (injecting drug users and their partners, sex workers and their clients; prisoners and others). Several NGOs are involved in targeted interventions to prevent HIV among high risk groups, though still on a small scale.



Donors: UNICEF (through PMTCT, training, and MSM study), UNFPA (through VCCTs), and WHO (through ART and TB/HIV projects) are supporting Afghanistan’s efforts to combat HIV/AIDS. The total budget of these UN agencies is around $500,000 per year. UNODC is also very active in the country, though primarily focused on demand reduction interventions. The Global Fund to Fight AIDS, Tuberculosis, and Malaria has approved a proposal for US$ 11 million that will finance harm reduction activities in 8 provinces of the country: activities are expected to start in September 2008. Other partners include the Asian Development Bank and USAID. USAID is expected to provide US$ 1 million to explore MSM networks, to support laboratories and to finance the HACCA Secretariat.



World Bank Response



In 2007, the World Bank signed a three year, US$10 million grant with the Government of the Islamic Republic of Afghanistan to enhance the national response to HIV/AIDS through the Afghanistan HIV/AIDS Prevention Project.



The project will provide harm reduction services to at risk groups (IDUs, sex workers, prisoners, and truckers) in different cities (Kabul, Mazar, Jalalabad, Herat). Services will be provided by NGOs selected through a competitive process. The project also aims at strengthening surveillance through integrated biological and behavioral surveys and knowledge, attitudes and practice studies to be conducted among high risk groups by Johns Hopkins University. The project aims to increase awareness of HIV prevention and reduce stigma and discrimination through communications and advocacy activities to be implemented by Constella Futures.



The project is funding capacity building activities to strengthen the National AIDS Control Program in areas such as program management, monitoring and evaluation, communication etc. Funding for multi-sector innovative activities will also be made available to NGOs and ministries other than public health, to enhance the multi-sector response to HIV.



As mentioned above, project activities will be carried out by agencies (national NGOs and international institutions) to be contracted by the National AIDS Control Program. The contracts for HIV surveillance and advocacy and communication were signed in July 2008, while nine other contracts are expected to be signed by August 2008.