High-risk Behaviors Could Lead To HIV Epidemic In Afghanistan

"Our findings suggest that interventions to reduce high-risk behaviors among injection drug users are urgently needed in Afghanistan," said Catherine S. Todd, M.D., MPH, assistant professor in UCSD's Division of International Health and Cross-cultural Medicine, who is currently working in Kabul, Afghanistan.

Although HIV prevalence is currently low among injection drug users in Kabul, Todd and colleagues with the National HIV/AIDS Control Program of the Afghan Ministry of Public Health found that risky injecting and sexual behaviors were alarmingly high. The incidence of Hepatitis C infection was also high, which could foreshadow an increase in HIV rates.

"It is important to educate the public about this looming problem in Afghanistan," said Dr. Saifur Rehman, manager of the HIV/AIDS Control Program of the Afghan Ministry of Public Health, who added that one of the biggest obstacles to intervention programs is lack of funding. Afghanistan has received a $10 million grant from the HIV/AIDS programs of the World Bank for three years and has a pending proposal to the Global Fund. Programming for drug users, directed towards reducing or containing adverse health, social, and economic consequences, is a major component of these plans. The country continues to seek other support to help deal with the potential increase in HIV -- a problem which, Rehman says, is of unknown proportions. "It is not clear how many cases we have, but there are probably many more than are reflected by available test results," he said.

The research team conducted a study of 464 injection drug users in Kabul, age 18 and older, which was administered between June 2005 and June 2006. The study was conducted through the Voluntary Counseling and Testing Center at the Central Polyclinic in Kabul, an Afghan Ministry of Public Health facility. Pre- and post-test counseling and rapid antibody testing for HIV and HCV were performed, and all participants received risk reduction counseling, condoms and sterile syringes.

Among this group of Afghan males, high-risk behaviors were common, including sharing syringes (50%), paid sex with a women (76%), and sex with men or boys (28%.) More than half had been incarcerated in prison, 21 percent of them, more than once.

The prevalence of infection with HIV was calculated at about three percent while 38% of the respondents tested positive for Hepatitis C (HCV) infection. HCV was associated with the sharing of needles or syringes, duration of injecting, and having received injections from a non-medical provider. The relatively high prevalence of HCV may potentially foreshadow an HIV epidemic, as these infections share common risk factors.

"The window of opportunity is rapidly closing to avert an HIV epidemic among Afghan injection drug users. The low prevalence of HIV infection is unlikely to continue in the presence of high-risk behavior," said Todd, adding that the higher prevalence of hepatitis C may be a harbinger of trends with HIV.

Central Asia is experiencing a rapid increase in HIV cases, largely driven by injection drug use. Afghanistan is the largest global producer of opium; recent UNODC reports estimate there are 50,000 heroin users in the country. While opium has been used for centuries in Afghanistan, the researchers' data suggests that injection drug use in Kabul is a relatively new behavior.

A combination of outreach, HIV testing and counseling, access to sterile syringes and drug substitution therapies have been credited with stabilizing HIV rates in other international settings, the study noted. The researchers conclude that a scale-up of needle exchange and other harm-reduction programs, particularly in prisons, is necessary to prevent an HIV epidemic in Afghanistan.

The findings are published in the September issue of the journal Emerging Infectious Diseases.

Collaborating researchers include Abdullah M.S. Abed and Naqibullah Safi, formerly of the National HIV/AIDS Control Program, Ministry of Public Health, Islamic Republic of Afghanistan in Kabul; Steffanie A. Strathdee, UCSD Division of International Health and Cross-Cultural Medicine; Paul T. Scott, U.S. Military HIV Research Program at Walter Reed Army Institute of Research, Rockville, Maryland; and Boulos A. Botros and Kenneth C. Earhart, U.S. Naval Medical Research Unit 3, Cairo.