Responding to HIV in Afghanistan

Impoverished and war-torn Afghanistan is now facing an epidemic of HIV infection owing to its increasing numbers of injecting drug users, many of whom have returned from refugee settings in Pakistan and Iran. Other vulnerable groups are also at high risk of HIV infection. As a low-prevalence but high-risk country, Afghanistan's national authorities recognise HIV control as a major priority. The country is adopting a public-health approach that includes harm reduction to reduce the spread of HIV among injecting drug users. Although the financial costs of HIV prevention will be substantial, the costs of failing to control HIV and AIDS will be far greater. Early and decisive action is crucial for containing HIV infection.

Afghanistan is one of the poorest countries in the world, with a yearly income per head estimated at $US300 in 2005.1 After nearly three decades of war and 5 years of drought, the population's health, social, and economic conditions have declined greatly. Life expectancy at birth is only 43 years, and maternal and child mortality remains among the highest in the world. The literacy rate in the general population is very low (28%), especially for women (13%).[2] and [3] The government, installed after the military intervention that began in 2001, now controls most of the country, with continuing major US and NATO military support. However, anti-government forces have made some advances in recent years, especially in the southern provinces bordering Pakistan, where 70% of the country's opium is cultivated.

Only recently has Afghanistan had to face the problem of HIV and AIDS. The Ministry of Public Heath reported a total of 69 cases of HIV infection in Afghanistan in late January, 2007, based on data from the Kabul blood bank and an HIV seroprevalence survey of injecting drug users in Kabul. Only a few months later (August, 2007), the government reported 245 cases of HIV infection in Afghanistan, although the actual number is likely to be much higher. Injecting drug use has ignited HIV epidemics in many central, east, and south Asian countries. As seen in these neighbouring countries,4 the epidemic in Afghanistan has the potential to grow quickly from a small base of injecting drug users and their partners. In countries with a concentrated HIV epidemic dominated by injecting drug users, a previous modelling study5 indicated a substantial risk of extensive spread to heterosexual men and women unless effective, vigorous, and sustained action is started early.

Almost all the known cases of HIV infection in Afghanistan today are due to injecting drug use. The sharing of contaminated injecting equipment is thought to confer the greatest risk of contracting HIV compared with other risk factors. Although the dominant routes of drug use in Afghanistan have previously been oral and inhalation, injecting practices are becoming increasingly prevalent. About 8 million Afghans fled to neighbouring countries, especially Pakistan and Iran, during the recent decades of conflict. Some began using, and injecting, heroin during their difficult years as refugees. HIV has spread rapidly among injecting drug users in Pakistan and Iran. In Quetta, a town in Pakistan bordering Afghanistan, for example, a 24% prevalence of HIV infection has been reported in a cluster of injecting drug users.[6] and [7] These data have increased the fears of an epidemic in Afghanistan, since an estimated 5·7 million Afghans have returned home in the past few years.

A recent study of 464 injecting drug users in Kabul showed an HIV prevalence rate of 3% and highlighted the extremely high risk of the spread of the disease among injecting drug users and their partners, and to the general population.8 An earlier study of the same population showed that high-risk behaviours were very common: 35% had ever shared syringes; 76% had ever paid for sex with a woman; 27% of men had ever had sex with men; 23% had received so-called therapeutic injections in the previous 6 months; 4% had ever been paid for donating blood; and 35% had injected drugs in prison.9 The four viral samples assessed in the study had the same genome sequences previously identified in injecting drug users in Iran, where HIV prevalence is known to be much higher than Afghanistan. Moreover, the prevalence of hepatitis C—also predominantly spread by the sharing of injecting equipment—was already 37%, which indicates the very high risk of spread of blood-borne viruses in this population.

Production of opium in Afghanistan has reached record levels in 2007, with the estimated amount produced reaching 8200 metric tonnes, an increase from the previous year of 34%, and amounting to 93% of the world's supply.[10], [11] and [12] The 2006 opium crop was estimated to have provided $3·1 billion to Afghanistan, representing 46% of the licit economy (excluding opium cultivation and drug trafficking) or 32% of the entire national economy.11 Whereas almost all of the opium and heroin produced in the country was previously exported, 2% of the output is now believed to be consumed locally. Since production is now believed to exceed worldwide demand by a vast margin, large quantities are probably being stockpiled.10
A 2005 survey estimated that Afghanistan has almost 1 million drug users including 200 000 opium users and 19 000 injecting users, of whom 12 000 inject prescription drugs and 7000 inject heroin.13 A 2006 survey in Kabul estimated that several categories of drug use had increased by more than 200% in 12 months. Most drug users were men but the proportion of women using prescription drugs was high, probably indicating the very difficult living conditions for many Afghan women. As the overall drug problem in Afghanistan continues to receive international attention, aggressive counter-narcotic efforts focus largely on supply reduction. A proposal to eradicate opium poppy cultivation by use of aerial herbicides and other chemicals is being debated. However, there is a real danger that more vigorous counter-narcotics policies are not without risk of exacerbating a transition from smoking or eating opium to injecting heroin, with subsequent risk of increased HIV infection associated with injecting drug use. The complexity of the problem is also highlighted by the risk that more vigorous counter-narcotics policies could undermine counter-insurgency efforts, which might also weaken efforts to control HIV infection. Opium eradication might predominantly affect poorer farmers. Opium cultivation generates an estimated 36 million days of farm labour and is deeply entrenched in the rural economy.

As in many other traditional and deeply religious countries, estimation of the scale of HIV spread associated with sex workers or men who have sex with men is difficult in Afghanistan. Local opinion varies as to the importance of these factors. Ex-inmates report that a substantial amount of drug injection occurs in Afghan prisons, a situation also reported in many other countries. Vulnerable groups potentially at risk of HIV infection include long-distance truck drivers and their helpers, the many women who have lost husbands or provide care for severely disabled husbands or sons, and the many abandoned children. Only a small proportion of transfused blood or blood products is currently tested for HIV, which will be of increasing concern as HIV prevalence rises. There is much re-use of injecting equipment and other medical equipment in the formal and informal health-care sectors, although there is little documentation about the extent and distribution of this practice.

Averting large numbers of HIV infections through harm reduction programmes will not only save lives but also makes sound development policy, even for a resource-constrained country such as Afghanistan. Because much HIV-related mortality occurs in adults in their productive age, the short-term and medium-term economic consequences for infected individuals, partners, and households are severe.[14] and [15] Although application of estimates from other regions and countries to the Afghan context is difficult, prevailing urban wages and health-care expenditure patterns in Afghanistan,[16] and [17] combined with standard mortality estimates by duration since infection,18 suggest that even if Afghanistan and international donors spend up to $2000 per HIV infection averted, the total economic returns (both private and public) on such an investment would be large—possibly as high as 300% per infection averted. This estimated return takes into account only the costs of wages foregone and of health and home care. The economic benefits would presumably be even higher if the subsequent detrimental outcomes to children and others in a household that suffers an HIV-related death are also included.

Control of HIV infection is a development priority in Afghanistan, in view of the links between poverty, drugs, and HIV. One of the pillars of the Interim Afghanistan National Development Strategy is to improve the wellbeing of the poor through social protection, counter-narcotics initiatives, and keeping HIV prevalence in the general population below 0·5%. The Millennium Development Goals for Afghanistan include halting and reversing the spread of HIV infection by 2020 and increasing substantially the proportion of injecting drug users in treatment by 2015.19 A national plan of operation to achieve these objectives has been prepared through a broad consultative process. To ensure the protection and rights of vulnerable populations at greatest risk of HIV infection, the Ministry of Public Health has drafted a code of ethics to be widely endorsed.20 Additionally, a national policy of harm reduction jointly prepared by the Ministries of Counter Narcotics and Public Health has been adopted, providing a sound framework for effective interventions to break HIV transmission for injecting drug users and their partners. Most importantly, best practices in HIV prevention in injecting drug users, including harm reduction, are being implemented by local non-governmental organisations and community-based organisations, providing successful local models for scaling up.[21] and [22]
A comprehensive approach to HIV prevention for injecting drug users is required. It includes communication, such as peer education and counselling, provision of the means for behaviour change (sterile needles, syringes, and condoms), substitution treatment (such as methadone or buprenorphine), and provision of effective outreach through drop-in centres. Special subpopulations (such as prison inmates) have to be adequately reached by these interventions.
A national policy decision will have to be made soon on substitution treatment. Some believe that methadone and buprenorphine are inappropriate for resource-constrained settings such as Afghanistan. Certainly, these interventions are too expensive to offer the large proportion of the 200 000 opium smokers and eaters who seek help. Many decades ago, opium registration systems in countries in west and south Asia were an inexpensive response to a widely prevalent problem before falling into disfavour. Although probably difficult to reintroduce in the present international environment, some form of carefully regulated opium dispensing could still be an option in this context. Afghanistan will pilot options to assess the most feasible, cost effective, and locally appropriate way to provide substitution treatment to its large drug-dependent population, who are mostly young people.

Afghanistan has much in common with the culture, language, and religion of neighbouring Iran, where injecting drug use is also the major driver of the HIV epidemic. Pragmatic responses to the control of HIV transmission among injecting drug users have received strong support in Iran, and there are encouraging indications that the Afghan government and religious authorities might also support these interventions. For example, triangular clinics, which provide harm reduction services to injecting drug users, treatment of sexually transmitted diseases, and care and support for people living with HIV and AIDS, are being implemented in Iran.22

Although interventions targeting injecting drug users and their partners are the first priority in responding to the threat of HIV in Afghanistan, comprehensive packages of preventive interventions are also needed for other vulnerable groups at high risk. Selling and buying sex, unprotected sex between men, and migration are all risk factors, especially where they intersect with injecting drug use. Raising awareness and advocacy efforts to build stronger political commitment, communication activities aimed at reducing stigma and improving knowledge among the general population, and capacity-building to ensure sustained and effective implementation are other government priorities.

Afghanistan is now deciding on its national response to the HIV epidemic. HIV prevention and AIDS treatment are not affordable for the Afghans and will require substantial external financial support (currently over half of the Afghan national budget is financed by external donors). France has already committed support to secure a safer blood supply, and the United Nations Population Fund will support HIV prevention for sex workers. A national implementation plan has been agreed on for World Bank support for surveillance, targeted interventions for vulnerable groups at high risk, communications and advocacy, and building programme management capacity.23 An application to the seventh round of the Global Fund to fight AIDS, Tuberculosis and Malaria has been approved. However, money alone will not be enough. Afghanistan will also need substantial technical assistance to support its HIV prevention priorities because of serious capacity constraints. Despite the very difficult local conditions, Afghanistan has several dedicated national and international non-governmental organisations and community-based organisations in almost all the provinces and most districts, and substantial progress has been made in reaching remote areas with basic health services.24 The developed world has, in the past, failed to fulfil many generous promises to Afghanistan. This time, promises made will have to be kept.


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Saif-ur-Rehman, Mohammad Zafar Rasoul, Alex Wodak, Mariam Claeson , Jed Friedman and Ghulam Dastagir Sayed
The Lancet, Volume 370, Issue 9605, Pages 2167-2169

Correspondence to: Mariam Claeson, AIDS South Asia Region, World Bank, Washington, DC, USA