State of the Epidemic
Reliable data on HIV prevalence in Afghanistan is sparse. To date, 1,250 HIV cases have been reported. However, UNAIDS and WHO estimate that there could be between 2,000 and 3,000 Afghans living with HIV. The HIV epidemic is concentrated mainly among injecting drug users (IDUs). Afghanistan’s emerging epidemic likely hinges on a combination of injecting drug use and unsafe paid sex.
According to the 2009 IBBS (integrated biological-behavioral surveillance) conducted in three cities i.e. Kabul, Herat and Mazar-e-sharif, the HIV prevalence among IDUs was estimated to be between 1-18 percent. However, there are wide variations in HIV prevalence among the cities: 1 percent, 3 percent and 18 percent in Mazar-e-Sharif, Kabul and Herat respectively. Among prison inmates, the IBBS showed a HIV prevalence of 0.57 to 1.57 in Kabul and Herat respectively. The study indicated zero HIV prevalence among truckers and female sex workers. Some 94 percent of IDUs used sterile needles in their last injection, 86 percent Herat and 98 percent in Kabul. Knowledge levels of IDUs to HIV are still very low, only 29 percent of the IDUs could correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission. About 22 percent of the IDUs have ever tested and know their HIV status (in Kabul just 19 percent). About 9-12 percent of the IDUs had bought sex in the last six months. Of these, only 17-32 percent of IDUs used condom in their last sexual encounter (in the last six months).
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: In 2009, UNODC published the second survey on drug use in Afghanistan. It found that since 2005 at the time of the first survey, illicit drug use had increased across the country. The number of regular opium users in Afghanistan grew from 150,000 in 2005 to approximately 230,000 in 2009, a 54 percent increase. In 2005, the estimate of regular heroin users in the country was 50,000, compared to approximately 120,000 users in 2009, an increase of 140 percent. Overall, adult drug users are estimated to number close to one million (high estimate 940,000) people. That figure represents nearly 8 per cent of the population aged between 15 and 64.
Intensification of the War on Drugs: 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 8 million Afghans spent some time living abroad as refugees in Pakistan (5 million) and Iran (3 million). Today, about 1 million widows and 1.6 million orphans, 4 million returnees, and 500,000 internally displaced people live in Afghanistan, while almost 4 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 (26 percent) and lowest among women (12 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 South Asia, with an estimated 460 per 100,000 live births. Child mortality is also very high; and 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 are often 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 socioeconomic factors access to services for most at-risk groups is limited.
Gather data for planning and action: Comprehensive integrated biological-behavioral surveillance (IBBS 2009) has been completed among priority populations of injecting drug users, prisoners, female sex workers, and road transport workers. The results of the survey have important implications for Afghanistan’s AIDS program. Injecting drug use is the major source of new HIV infections, with transmission highest in Western Afghanistan. HIV prevalence is significant among prisoners and appears to be related to the proportion of injecting drug users in prison. HIV prevalence is zero among both sex workers and road transport workers, suggesting limited sexual transmission. The National AIDS Control Program has finalized the policy on Opioid Substitution Therapy which makes it possible to provide a more comprehensive set of harm reduction services to enable injecting drug users to minimize their risk from HIV/AIDS. The HIV/AIDS policy has been also finalized. 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: In order to maintain low HIV prevalence (less than 0.5 percent) and to reduce the mortality and morbidity associated with HIV and AIDS, the Ministry of Public Health has developed a strategic framework 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:
1. Strengthen strategic information to guide policy formation, program planning, and implementation;
2. Gain political commitment and mobilize resources necessary to implement the national HIV/AIDS/STI strategy;
3. Ensure development and coordination of a multi-sector HIV/AIDS response and develop institutional capacity of all sectors involved;
4. 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;
5. Ensure access to prevention, treatment, and care services for high-risk and vulnerable populations;
6. 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. Currently a pilot of OST is going on in Kabul city by an NGO contracted by the NACP.
Nongovernmental 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 $11 million that finances harm reduction activities in eight provinces of the country; and currently it is at its phase 2. Other partners include the Asian Development Bank and USAID. USAID has provided US$1 million to explore MSM networks, support laboratories, and finance the HACCA Secretariat.
World Bank Response to HIV/AIDS
In 2007, the World Bank signed a three-year, $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 provides harm reduction services to at risk groups (IDUs, sex workers, prisoners, and truckers) in different cities (Kabul, Mazar-e-Sharif, Jalalabad, Herat). Services are provided by NGOs selected through a competitive process. The project is strengthening surveillance through integrated biological and behavioral surveys and knowledge, attitudes, and practice studies 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. 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. Project activities will be carried out by agencies (national NGOs and international institutions) who are contracted by the National AIDS Control Program. Based on the recommendations of the mid-term review, the project was restructured in February 2010. The restructuring includes: (i) Modification of the project performance indicators; (ii) cancellation of part 4.2 in schedule 1 to the Financing Agreement (innovative initiatives sub-component); (iii) expansion of the project scope including possible extension of the provision of harm reduction services for injecting drug users (IDUs) to Farah and Nimroz provinces where the HIV epidemic is believed to be high (dependent on the results of the rapid IDU assessment in these provinces); and (iv) extension of the Project Closing Date from December 31, 2010 to June 30, 2012. Beyond June 30, 2012, the HIV/AIDS activities will be streamlined under a larger health project being financed by the World Bank in the health sector.