Transcript The history of HIV/AIDS in Iran from a long time denial to the breaking the silence. Best practice of WHO/EMRO Dec.17th 2005 Kamiar Alaei MD,MPH ;

The history of HIV/AIDS in Iran
from a long time denial to
the breaking the
silence.
Best practice of WHO/EMRO
Dec.17th 2005
Kamiar Alaei MD,MPH ; Arash Alaei MD
PCRI & NRITLD
Country Profile
• Iran is located in southwest region of Asia .
• The 70 million population of the country is
quite young with half being under 25 years.
70% are under 29 with different religions.
11/6/2015
Introduction:
• Iran is in a region close to Afghanistan
(with 1300 km border) that is the largest
producer of opium in the world.
• This characteristic has affected on the
total amount of opium that is coming to
Iran on their way to other regions such as
Central Asia and Europe. It is estimated
that there are 270,000 injection drug users
(IDUs) in Iran and this has increased
during the recent years along with the
increase in opium production in
Afghanistan.
• HIV infection is concentrated among
IDUs, representing approximately 80% of
all known HIV/AIDS cases in Iran. In
addition, explosive HIV epidemics have
been reported among IDUs in a number
of prisons.
• From the beginning, when HIV/AIDS
appeared to be confined to groups perceived as
socially deviant, the AIDS epidemic has been
shrouded by ignorance, fear, and denial. This
has led to stigmatization (social ostracism) and
discrimination against people with HIV/AIDS.
Many people with HIV/AIDS have lost their
jobs and have been denied medical care,
housing, and opportunities to travel because of
their HIV status. In many settings, individuals
with HIV have been exiled from their families
and communities.
• As a result of fear of stigma and discrimination, there was a
•
high incidence of suicide among IDUs within their first year
of their HIV+ diagnosis. “Drug use is acceptable to some
but there is still a lot of stigma attached to HIV.
Women are more stigmatized with HIV. Stigma is a major
obstacle to combating HIV/AIDS because it leads women to
avoid being tested for HIV and disclosing their HIV status if
they are tested. Furthermore, stigma and discrimination
force those at highest risk of contracting and spreading HIVincluding commercial sex workers, injecting drug users,-to
conceal their lifestyles, making it difficult to reach them
through HIV-prevention programs. Thus, in Iran stigma has
created more opportunities for HIV to spread to the general
population.
History and Policy of Addiction during
1980-2004 in IRAN
1980-2000 at the beginning;
• Policy was:
- Short and long term prison sentence for drug users
- Execution of drug dealers
• Situation of addication at the beginning,
-100/000 – 150/000 drug user non official (1980)
-Most of the cases were non injection drug users
-Intensive border control ( Construe of sement walls
and border control with 3000 army solders)
Results:
- Increseing rate of addicts;
from 100/000-150/000 ) Non official 1980)
- 2/1 millions (1999 UNODC)
- 3/2 millions (2000 MOH)
About 4000 of patriot solders have given up their lives.
-Incising member of prisoners by %150of capacity
(the member of the prisoners became twice that of
capacity of prisons)
-Increasing number of judicial files(%60 of total)
-Loss of family stractuer due to imprisonment or death
of head of the family as a result of drug users.
-Lowring of age of drug users.
- Increasing prevalence of diseases such as TB
and HIV/AIDS in prison and drug users
comunitee and their family.
11/6/2015
Review of the relation of HIV/AIDS and
Injecting drug users in IRAN;
-Ditection of first HIV/AIDS case in 1989 in
a hemophilic patient
-Considering HIV and modes of
transmission, policy makers ignored the other
modes of transmission (such as IV Addiction
and sexual and only paidattention to blood
products problem.
-Policy makers denyed existence of any drug
users and sexual contacts ) sex workers).
-Challenge between experts and policy makers
for conducting HIV surveillance and changing
the method of care for drug users, 1986-1995.
-Performing the initial pilot study in at risk
group such as to design a survey in prisons to
know about situation of HIV/AIDS in Iran,1996.
-To find high rate of HIV/AIDS infected cases
among prisoner drug users (One of them was
kermanshah prison(,1995.
-One of the kermanshah parliament member
applied to establish a big comprehensive
hospital, he raised its budget.
-However, due to lack of community's
knowledge and presence of challenge between
different policy parties, the plan faced resistance
from the society,1997.
-In such a way that nobody reelected that
parliament member,1997.
-Complete silence was prevailed not only in
Kermanshah but also all over Iran about
HIV/AIDS and drug users care programs(1997-1999).
- Starting the project in a situation which HIV
was stigmatized ,Drug Use and sex working
were illegal in Kermanshah, 1999 .
Setting:
• Kermanshah province is
located in West of Iran with
two million inhabitants and
different religions. The rate
of drug use is 5 percent
highest rate in Iran and one
percent are Injecting Drug
users.
• The HIV problem was
ignored by the society and
psychosocial supports for
drug users were rare.
The status of drug use and mortality in
HIV/AIDS cases
Age of beginning
addiction
HIV
Neg.
number
percent
<15
69
9.3
9
35
20
15-20
288
39.2
27
135
16.6
20-30
294
40.2
20
124
13.8
30-40
44
6
0
13
0
40-50
8
1.08
0
3
0
>50
5
0.67
0
5
0
Unknown
23
3.1
6
12
33.3
total
731
100
62
327
15.7
Kind of death
Suicide due to IDU
Suicide due to
other way
Other infection
diseases
AIDS related
diseases
Hit
total
Single
Pos.
Relation
Married
Total
number
percent
number
percent
number
percent
10
29.4
3
8.8
13
38.2
5
14.7
2
5.9
7
18.5
6
17.6
4
11.8
3
8.8
3
8.8
0
10
29.4
1
2.9
0
0
1
2.9
25
73.5
9
26.5
34
100
First step :Local policy
Started in Kermanshah :
• Accepting HIV cases, DUs and STIs (in Triangular
clinic) .
• Starting the project voluntarily without propaganda
and challenging the key persons and society .
• Creating link among NGO ,GO, religious and key
persons.
• Establishing an unlabeled center in a public poly
clinic in a high drug users area .
• The main principle was a friendship relation instead
of medical relation.
• Integration of prevention and care services.
Our project;
We started our project at the end of 1999 in that
situation in kermanshah, in one of the national
health care system clinic.
-Absorbing patients by giving syringes and medical
care, most important of all was consultation and
having good and friendly communication with drug
users that had been away from the community and
family.
-In a study, it was observed that 176 of drug user
that knew they were infected had suicide.
-Our referrals increased from 1-2 patients/week to
50-60 patients/day.
• Include partners, families, networks, and the
boarder communities.
• Develop activities in users’ natural environment
• Personalize prevention for each person at risk .
• Giving attention to sensitivity of cultural,
racial/ethic, and gender
• Confidentiality and not registering the ID of the
clients
Triangular clinics
The center provide free of charge:
• Education
• consultation
• HIV testing (VCT)
• Care :
vaccination
post exposure prophylaxis
Prevention of mother to child transmit ion
TB and OIs Diagnosis, care, and Prophylaxis.
Anti retroviral treatment.
Cont ‘
Sexual Transmitted Infection care.
• Drug users care:
Harm reduction in the center and outreach :
1.Needle exchange program,
2.Condom Promotion
3.MMT
4.Bleach
5.Detoxification
6.Rehablitation
The rate of HIV infection in drug users by
education level
• The majority of drug users are illiterate or at a primary
education level, but the routine HIV information was in
newspapers, pamphlets and posters that this group could not
read.
Cont’
• Peer education programs
• Psychosocial supports for infected and
•
•
•
affected people
Referral services to specialist centers
Outreach programs (recently)
Follow up of clients at home (limited home
care)
• PLWHA and Drug users committee
self help group
•
information sharing
•
collection of syringes
•
prevention with high risk groups
•
music group
•
sports
•
providing seminars
Student committee
•
volunteering in prevention work
Part of outcomes:
•
•
•
•
•
•
•
•
•
Increasing patients from 1-2/week to 50-60/day.
1700 HIV infected registered cases.
20-30 cases receive Harm reduction box daily.
40-50 cases receive counseling & care services.
70 couples that one of them has infected, have continue
their relation.
25 AIDS cases receive HAART.
50% Reduction in active TB in HIV cases .
Changing from suicide to cooperation in implementation of
IEC and HR programs.
Mach making for PLWHA.
Observing the results/outcome;
-The community and policy makers accepted that
drug users can return to the society and their
families, in the system designers design a programs
based on target group needs.
-One of the important programs that decreased the
problems of program expansion was visit and
acceptance of our program by international experts
(approved by WHO members from EMRO and HQ
(Dr. Mohit and his friends visit), and to have training
course by Dr. Newman and Dr. Wodak on Methadone
treatment.
-In the year 2002, we were invited to design national
strategic plan.
Second Step:
After presenting the results to overcome the
barriers to the policy makers
• Writing the national strategic plans for control
of HIV and Drug Use 2002-2007.
• Writing GF proposal to control of HIV 20032008
• Establishment the national committees of AIDS
and Harm Reduction which is main coordinator
of plans and activities .
National committee
Technical subcommittees
•Information&education
• Research&evaluation
•Harm reduction
•Social support
•Counseling,care & treatment
Provincial committees
Iran National Strategic plan 2003-2008
-To establish 40 TAC in Cities.
-To establish 40 TAC in Prisons.
-To accept Harm Reduction program as a main
strategy, so all clinics must give patients
-syringes,
-short term and long term methadone therapy,
-condom,
-medical and psychological care and all
medicines such as HIV/AIDS treatment (ARV).
Some of the Out Comes :
• Proposing a plan for establishment of VCT
centers and integration of these centers as
triangular clinics, in country health system.
• Establishing 55 TAC centers in 14 provinces
it will be continued .
• Establishing modified forms of above centers
in the high risk prisons: 45 centers till now.
HIV/AIDS CASES BY SEX IN I.R.IRAN
1987-MARCH 2005
FEMALE
%5
MALE
%95
HIV INFECTED BY SEX AND TRANSMITION WAY
10265
9751
10000
8000
5925 5968
6000
4000
3166
3350
2000
43
686
433 253
206 13 219
21 21 42
184
514
0
MALE
FEMALE
TOTAL
IDU
SEXTUAL
BLOOD T
MOTHER TO
CHILD
UNKNOW
TOTAL
5925
433
206
21
3166
9751
43
253
13
21
184
514
5968
686
219
42
3350
10265
HIV/AIDS CASES BY MODE OF TRANSMISSION IN
I.R.IRAN 1987-MARCH 2005
UNKNOWN
PERINATAL
%21
%0/4
HETERPSEXUAL
%8/1
BLOOD
TRANSFUSION
%4.1
I.D.U
% 66.4
HIV INFECTED BY AGE GROUPE
3000
2500
2000
Male
Female
1500
1000
500
0
0- 4
14- May 15- 24
25- 34
35- 44
45- 54
55- 64
>65
Barriers of the project until second half of 2004;
-Need to change low from “Use of drug is Crime” to “
Use of drug is disease”
-Need for expansion of programs by NGOs.
Solutions:
-Establishment of private/NGO Clinics in kermanshah
with methadone treatment (Pars Institute),and in other
cities by private and NGOs sectors.
-Letter from Head of Judiciary to support all of the
needle exchange program and methadone treatment by
all government sectors.
-To establish methadone maintenance program in
prisons by private/NGO sectors.
In Pars institute we have had :
-3000 patients under short term Methadone
treatment and
-300 patients in methadone maintenance
treatment in city clinic and
- 200 prisoners are in our MMT program in
prison.
(It is program of one private/NGO clinic in
Kermanshah after 14 months activities).
-The number of people inside prisons who are on MMT
are 1500 inmates in 15 prisons by NGO/private sectors
and free of charge .
-Approximately 70.000 patients were detoxified by 220
private and public clinics and 1500 patients are on MMT
in 15 clinics (supervised by MOH)
-Welfare organization has also more than 400 private and
public clinics.
-However, by the new regulation on treatment clinics by
MOH, now they are forced to have at least 90 percent of
their Methadone supplies on MMT.
-Iran expects to have at least 35000 patients on MMT by
next year.
Global Network needs:
Cultural and Geographical approach
•
•
•
Third Step :
Promotion of collaboration in MENA/EMRO and
center of Asia countries .
Meeting ,workshop and study tour between Iran, Afghan
and Tajik.
Training of Afghan and Tajik experts, Avicenna project
and establish TAC in Afghanistan (Two week courses on
Harm Reduction and TB/HIV/AIDS).
Fourth Step : (globalization)
- Implementation of International conference and
networks among common cultures countries on
Harm Reduction programs 2005-2006 .
- To have study tour with cooperation of Indonesia,
Malaysia, Lebanon, Egypt, and Sudan.
- To apply to include harm reduction of drug to be
as a MDG indicators.
Acknowledgements
• Iranian Studies Group
• MIT university members
• Mohamad Hafezi
• Dr. Farzan Parsinejad
• Dr. Ali naieri
Thank you for your attention