Iran tackles AIDS head-on

2 young doctors lead establishment of clinics

Fellows Fall 2004

By Anita Srikameswaran

June 03, 2009

It's hard not to be startled when you hear the name of the Middle Eastern nation that has been doing some of the most progressive HIV work in the region.

Iran.

Yes, Iran.

Characterized as part of an "axis of evil" by the Bush administration, haughty in its disdain of American culture, and known for its repressive theocracy, the Islamic Republic of Iran has astounded the international public health community with its willingness to tackle AIDS.

"Everybody has the same reaction. It just doesn't make sense," said Kaveh Khoshnood, an HIV expert at Yale University School of Public Health. "You expect it to come from Holland or Australia. Not Iran."

Spearheaded by the efforts of two young doctor brothers, Iran is planning to establish 60 centers across the country to diagnose and treat HIV-infected intravenous drug users, and add 45 more centers in prisons. The government will provide, for free, needle exchanges, methadone treatment, condom promotion and distribution and antiretroviral drugs.

Dr. Arash Alaei, one of the architects of the national program, said that few officials paid attention after the first Iranian, a hemophiliac, developed AIDS in 1987.

Then in the mid-1990s, the Ministry of Health established HIV surveillance sites in some prisons, including one in Alaei's hometown of Kermanshah, in western Iran.

The high number of HIV infections found in the prisons prompted a politician to suggest building an AIDS hospital. The notion was quickly quelled for fears that Kermanshah would develop a sordid reputation that would ruin its residents' marriage prospects.

But in 1998, two years after completing medical training, Arash Alaei and his brother, Kamiar, quietly launched an HIV program for intravenous drug users who had recently left prison. With support from their literature professor father and the head of Kermanshah's university, they and two other volunteers invited addicts to get help at a couple of rooms in a primary care clinic.

At first, the former prisoners "had worries because nobody wants to have a relationship with this group," Alaei explained. "They are isolated and families reject this group."

Accustomed to pariah status, they cried the first time the doctors reached out to shake their hands.

Relationships work, judgments don't, Alaei said. As trust built, patients began telling other addicts about the service.

"We started with one patient per week. After six months, we had 40 patients per day," the doctor said.

As two rooms grew into an entire clinic, the doctors were careful to maintain a respectful relationship with community leaders to keep the program going.

After 18 months, they had found 1,300 people living with HIV infections.

Iran's leaders noticed their success and, worried about increases in IV drug use and HIV cases, they invited the Alaei brothers to develop a national strategic plan for AIDS.

"We want to show if we have good [community] connections and we have good programs, we can stop the rate of HIV/AIDS" from increasing, Alaei said. After six years of rising HIV infections in Kermanshah, the rate has leveled.

Still, according to a United Nations fact sheet, Iran's HIV epidemic "appears to be accelerating at an alarming trend."

The government, relying on its improved surveillance methods, said last month that about 9,800 Iranians had tested positive for HIV and half were infected through intravenous drug use. Another 30,000 people could be infected and not know it.

Iran now has more than 150 sites for voluntary HIV testing and counseling, and more than 600 sites that are solely for counseling, according to the U.N. Development Program. Medicines are distributed free of charge.

Yet there is still a long way to go, Yale's Khoshnood said.

For example, very little is known about Iran's gay community, which is highly stigmatized.

"Some people would be able to talk about their own drug addiction or their family member's, but they find it incredibly difficult to talk about homosexuality in any way," Khoshnood said. "If you're not acknowledging its existence, you're certainly not going to be developing any programs" for gays.

Still, he hopes other Middle Eastern nations pay close attention to the strides Iran is making.

Alaei would like to share what he's learned with counterparts who have similar cultural and religious environments, and he's trying to organize a conference this year for people from other Muslim nations.

"It's good to know about other countries," he said. "Maybe other countries have other programs they can show to us."