In Iran, A New Fight Against AIDS
In Iran, A New Fight Against AIDS
New York, October 3, 2003
Kaveh Khosnood, Assistant Professor, Division of Epidemiology, Yale University School of Public Health
Dr. Aresh Alaei and Dr. Kamiar Alaei, advisors to the Ministry of Health in IranRobert Newman, President Emeritus of Continuum Health Partners and Director of the Baron Edmond de Rothschild Chemical Dependency Institute of Beth Israel Medical Center
Joanne Csete, Director of the HIV/AIDS and Human Rights Program at Human Rights Watch
Welcoming Remarks by Ambassador Nicholas Platt, President of the Asia Society
In this, the first program of the AIDS in Asia Initiative at the Asia Society, Dr. Kamiar Alaei, speaking for himself and his brother Aresh, described the extent to which drug use has ravaged Iran and propelled the country into the world of HIV/AIDS. Long a country known for its gentle custom of smoking opium, Iran has descended into a nation where opium, heroin and morphine are increasingly infiltrating most parts of society. The growth of HIV/AIDS is directly linked with the growth of injected drug use.
Drs. Aresh and Kamiar Alaei show there is hope. Their program, which began in their hometown of Kermanshah, grew slowly from a prison population study to a program that treats the high-risk group of injection-drug users, sex workers and HIV positive clients. By use of peer counseling and peer referral, the doctors have succeeded in capturing the clients that were often too illiterate to be able to read government help pamphlets. By indirectly approaching the family through the user-participants, the doctors hope to educate the women of Iran, who will be transmitters of the deadly HIV virus soon. By inviting key religious leaders onto national drug and HIV awareness committees, the brothers have swayed their votes, prompting them to ask for the kinds of treatments that they would ordinarily find abhorrent to their beliefs. Their story is compellingly simple but heroic under the circumstances.
Doctor Alaei's remarks are followed by a glimpse into the United State's limited and failed approach at drug abuse by Dr. Robert Newman, a world- renowned advocate for methadone treatment and harm reduction. And finally Joanne Csete, Human Rights Watch, discusses the trials and tribulations of drug users in Central Asia.
Nick Platt: This is a wonderful turnout, particularly for a Friday night in New York. But I know the program and the issue is a compelling one and I share your interest. We are very pleased to host tonight's program on AIDS in Iran. And we are grateful to the Starr Foundation and the Bill & Melinda Gates Foundation for their generous support. And also to AIC for helping us make this happen.
Tonight's program is particularly important to the Asia Society because it is the first event of the new initiative on AIDS in Asia. The Asia Society will officially launch the AIDS in Asia initiative next Tuesday morning with a live interactive discussion with our chairman of the Board, Ambassador Richard Holbrooke, who will be in India, along with other leaders and experts in the global fight against AIDS. And I encourage you to join us on the 14th at 8 o'clock in the morning, which is not too early and is about right for India as well. We will have interactive arrangements here and I look forward to it.
Let me encourage you all to join this institution, which has every facet that could interest you, whether it is arts, culture, business, politics, children's education, the whole works. We are trying to expand our membership; we have brochures outside. I encourage you to join me.
We are honored to welcome some of the leading authorities and advocates for HIV/AIDS in Central Asia and authorities on the disease's close relationship with drug use. We are particularly honored and grateful to have Dr. Aresh Alaei and Dr. Kamiar Alaei, and we will learn shortly about their remarkable story. On behalf of the Asia Society let me say welcome and thank you. Now let me introduce Hooshang Amirahmadi and thank him for his cooperation in making this event happen.
Hooshang Armirahmadi: Thank you, Nick. I am very honored to have this gathering here. AIC has been a part of this from the beginning. I want to say that as Nick said, this is a distinguished group of people, not just distinguished but also dedicated, extremely dedicated. They are people who are working in the field -- both Alaei brothers, Dr. Khoshnood and Dr. Newman--they have all been in Iran, either living in Iran or visiting Iran. We are very honored. This is the fourth panel that AIC has organized on the subject. We will publish proceedings from this and the other ones soon. All the others were at Capital Hill and the last one was sponsored by Senator Chuck Hagel.
I want to emphasize that there is no politics in today's panel and there has never been any politics in any of the previous humanitarian AIC panels. There is a mistake about the AIC. Most people think the AIC is out there just to establish US-Iran relations. But we are there to contribute to a better understanding between the two peoples. And the AIC does other things: we work on all kinds of humanitarian matters in Iran. So I want to emphasize very clearly that this is a humanitarian panel and there are no politics here.
I am very grateful again to our colleagues here for participating in this and I want to thank Nick and his colleagues for organizing this very important event. Thank you very much.
Nick Platt: Thanks very much, Hooshang. And now let me introduce Kaveh Khoshnood, the Assistant Professor of Epidemiology at the Center for Interdisciplinary Research on AIDS at Yale, who will introduce the other panelists and moderate tonight's program.
Kaveh Khoshnood: Thank you very much to the organizers and all the hard work you did to putting this panel together and to all of you for being here.
I am going to have a short presentation of 15 minutes and then I will turn it over to the real speakers who will tell us what is going on in Iran today.
As was mentioned, I am a faculty member at Yale school of Public Health. I was born in Iran but have been living in the United States for over 20 years. I had the good fortune of meeting the two Alaei brothers at a harm reduction conference in Thailand last year and subsequently went to Iran and made some contacts. I am grateful that they were able to come here.
Let me give you some background as to why this topic today is important. And I want to apologize to people who have a background in HIV/AIDS. For them this is sort of an old problem.
There are three take-home messages I have for you. First, HIV/AIDS and illicit drugs are both threats to global security. That I will go over very quickly because I know Joanne is also going to talk about that. And I am hoping that most of you came here with an appreciation for that. So I won't dwell on that much.
The second point is that Iran is strategically important to the global community because of its geography and its politics and because of the epidemiology of both drug addiction and HIV/AIDS. I will just touch on those.
Third, and I think this is quite significant and perhaps why we are all here, that there are new and progressive responses to the drug-use driven HIV epidemic in Iran that deserves our support and attention and could serve as a model for the region and beyond. So these are the take-home messages I want to leave you with.
Very quickly, the UN Security Council in 2001 said AIDS is a threat to global security. But a couple of years before that the General Assembly had already identified another threat to global security and that is drug trafficking and consumption of elicit drugs. The estimates back in 2002 were that there were over 185 million illicit drug users - clearly a major global problem. And why is it a global problem and a security issue? I have listed some of the reasons. But this slide to me illustrates all of this. And this basically shows the life expectancy in several countries, and most of them happen to be in Africa but not all. And it shows what happens to life expectancy due to AIDS. And you can see how life expectancy in some countries has dipped below 40. That is why HIV/AIDS, in a nutshell, is a global security (issue). Unfortunately sometimes we have to say how HIV is impacting the military before we get the attention of certain sectors of the government. And these are some of the numbers that have been coded. I am saying "unfortunately" because there have been millions of millions of people infected and dying of HIV/AIDS but unfortunately governments sometimes only pay attention to these kinds of numbers so we have to use them in our presentations.
Most of you who know about the field of HIV/AIDS know about the CIA report that came out a few months ago (LINK to CIA Report) that came out a few months ago that projected that Russia, China, India, Nigeria and Ethiopia are going to collectively have the largest number of HIV/AIDS cases by 2010. And there was a mention of Central Asia as one of the areas where HIV/AIDS is rapidly expanding. I know I am going fast. I am going to make the presentation available to the Asia Society so there will be a way to distribute it to all of you. These are some of the numbers that I know Joanne will go over also, the global look at the pandemic.
And these are the growth areas. You can see this is Russia, where we have seen incredible increases. And we are seeing Iran, Central Asia is right there, and this is a major drug trafficking route and with that comes HIV/AIDS.
This slide shows the proportion of HIV infections in various parts of the world, including some parts in Asia, where 50% of AIDS cases are attributed to injection drug use.
Moving on to my second point, why Iran is strategically important geographically, politically and epidemiologically. I think that geographically it is quite simple: Iran borders Afghanistan, the largest producer of opium in the world. And we will talk about this fact. Drugs do come through Iran on their way to lucrative markets in Europe and other parts of the world. Politically, Iran has the largest population in the area. It clearly has influence in what happens in Central Asia and in the Muslim world in general. Epidemiologically, if you look at what's going on in Central Asia and the neighboring countries of Iran, you see similar patterns and they are not by accident. If you look at drug trafficking routes, basically HIV follows that route.
This is a slide showing the map of Iran and this is Afghanistan and you can see this large border and drugs coming inside Iran on their way to the Persian Gulf, Europe and Central Aisa. I don't believe the opium produced there makes it to the United States but it does make it to Europe. Estimates are that half or as high as 90% of all the heroin and opium seizures in the whole world occurs in Iran. This is quite a significant number.
Now what is the impact of that, of this large drug trafficking on Iran and beyond? According to official statistics, more than 3,000 Iranian border patrol police have lost their lives. This is an ongoing, daily battle. The Iranian government estimates that only about 20% of all the opium that is smuggled into Iran is actually confiscated. The rest of it is shipped out to the destinations I have mentioned and unfortunately we are seeing a large number that are even more frightening than these numbers. Remember the estimates of the number of opiate addicted individuals in the United States is about one million, with a population of 270 million. Iran, population about 70 million, has this number of people addicted to opium and heroin (data from slide: 1 to 2 million people). It is somewhere around 5 times the prevalence of drug addiction compared to the United States. So it's a major, major problem and in some geographic areas, including Kermanshah, where the Doctors Alaei come from, the prevalence is even higher.
Just a quick look at Iran at the present: I put the title young and vulnerable population of 66 million because a large percentage of the population is under the age of 30. This is a very, very young population and they are vulnerable. There are (high) unemployment rates, opportunities for higher education are limited, recreational opportunities are limited and there has been growing rates of depression among the youths. These are all the ingredients, if you will, that give rise to drug addiction. And unfortunately, HIV/AIDS follows often.
Here are some more estimates about the status of the epidemic of drug addiction in Iran. Iran has dealt with opium use for hundreds of years. It was somewhat of a social phenomena in Iran, where my grandfather, I remember, after dinner, would go to a back room and just sort of smoke his opium and he was completely functional, had a family and was a school principal and so on. But there is a new phenomenon and this is the phenomenon of people injecting heroin. We don't have the time to go into the reasons for this but needless to say the price of opium has skyrocketed in Iran but heroin is extremely cheap and many of the younger generation are starting with heroin use and the injection of heroin. And this is a major problem because this is how hepatitis B, hepatitis C and HIV are spreading in the population. This is sort of the typical opium addict that we used to see in Iran and unfortunately this is what we are seeing now.
A quick look at HIV/AIDS in Iran: it started late. The first case of HIV in this country started back in 1981. Another 6 years passed before Iran identified its first case of AIDS. These are official estimates: as of 2002, there were a little over 3,000 HIV positive cases, and 400 AIDS cases. However UNAIDS estimates that there are over 20,000 people who are infected and living with HIV/AIDS. I think the Alaeis have some updated numbers for us.
We don't really know. The surveillance system is there but it is not up to date so the numbers could be manifold higher. Unfortunately in that area, it is not unexpected to see these numbers rise manifold over a short period of time. So although the epidemic of HIV/AIDS is relatively new, all the ingredients are there for it to take off very rapidly because of the drug injection that I mentioned.
A very quick look at drug policy in Iran, concentrating on since the revolution of 1979. There used to be opium production and cultivation in Iran. After the Islamic Revolution it was banned completely. Also, drug treatment centers were banned. Drug use and drug addiction basically became a crime and there were very harsh penalties against people who used drugs: mandatory detention, execution if you had possession of certain amounts of opium and so on. Then something happened in the mid-1990s and don't ask me why and I cannot really explain it. It is a deep question of social, political factors. But in the mid 1990s, there was what I consider a paradigm shift in drug policy and the way the Iranian government responded to the drug addiction problem. It started where it should always start, by the government coming out and saying, we have a problem, we have a major problem, we have an epidemic of drug use and drug addiction on our hands. And what we have been doing, which is basically incarcerating people, has not worked. So we start there. Those reports came out of government, they were published in newspapers, and they were discussed openly. That was the first step.
Then things started happening soon after that. In 1995-96, treatment of drug addiction became legalized. Up to that point, you couldn't treat a drug user. And then things kind of took off from there. Outpatient clinics, nationwide, methadone clinics started up again. Methadone had a history in Iran before the revolution. It came back again. We are now hearing about syringe exchange programs where injection drug users can actually exchange syringes for new ones, which is still controversial in this country and as some of you may know there continues to be a federal ban on using federal dollars on needle exchange programs. There is one starting very soon. I have talked to prison officials who are talking about having syringe exchange programs in the prison, which is a very radical concept for the US and Western Europe. And successful application to the Global Fund for HIV/AIDS, TB and Malaria, which the two brothers had a major role in. Iran was successful in receiving something in the order of $14 million from the Global Fund.
The last point, and this is my observation as an outsider, I do believe that this shift that has taken place is fragile. I don't think this is a permanent shift. I worry that for political reasons and other reasons, things can reverse and go back to where they were a few years ago, which makes it even more urgent for us to stay vigilant, watch what is going on, be engaged, support people like the Alaei brothers, all the NGO movements and make sure we don't go back to the old policies of incarceration and criminal approaches to drug use and addiction.
To sum up my main points: we have a major problem of dual epidemics of drug addiction and HIV/AIDS -- drug addiction being much more of a severe epidemic but on the tail of it, HIV/AIDS is rising. And it can destabilize Iran and it can destabilize the region. There has been a recent change in government policies. Good work can be done now, harm reduction, science-based prevention can be done and that is positive. Government is allowing that to happen and is supporting it in different ways. There are capable, accountable and willing groups of individuals within the academic community, within the civil society and within certain government sectors, particularly the Ministry of Health that I know of, that are very knowledgeable, willing to respond to this growing epidemic. The reason I am excited that Asia Society has taken this issue up is that policy makers, academic folks, foundations here, we could have a tremendous impact supporting what has started in Iran only the last few years, to make it grow.
With that I will end and ask Dr. (Kamiar) Alaei to talk about what is actually going on in Iran today. Thank you.
Dr. Alaei: Ladies and gentlemen. Thank you and welcome for coming to this session and thanks for the organizers and thank you to my friend, Dr. Kaveh Khoshnood, who helped me in my presentation.
As Dr. Khoshnood mentioned, the main problem in Iran is that we have huge numbers of users in our country, that the majority of them are less than 19 years old. And the means: trafficking of opium addiction and opium transport from Afghanistan to Iran and to Europe. Unfortunately we had a good history of opium maintenance traffic before the revolution and the first year after the revolution but unfortunately the majority of the experience is closed. More than two decades. Based on our history, we had a limited experience of methadone maintenance and methadone treatment before the revolution and unfortunately after the revolution, for more than 15 years, the majority of activity stopped. During these 20 years, the most common users are opium addicts and heroin addicts. Some of the drug users inside the prisons inject opium. This way, we see that the main problem in our addicts group is in the age between 20 to 30. We have different estimation that the majority of them show that the rate of drug use is between 2 million to 4 million, from 65 million inhabitants. So all the studies show that the main problem in Iran is opium and some opium users have a history of injections. So in the future we will have a problem of HIV and hepatitis and several blood-born diseases.
We started our project in Kermanshah, which is in the west of Iran, with 2 million inhabitants. It is at the border of Iraq and we had a problem of addiction and HIV/AIDS in this city. To start our project, we studied what the opium addiction and drug use status in Kermanshah and which group of drug users is more at risk for HIV/AIDS. We saw that the majority of HIV/AIDS cases have infected HIV from prison. The majority of the prisoners who had a history of imprisonment between 5 to 10 years were more infected for HIV/AIDS. In another study we saw that unfortunately the majority of the drug users who start their addiction before they are 15 years old are more at risk for HIV/AIDS compared to other drug users who started their addiction after 30. So this group is more vulnerable for HIV/AIDS and unfortunately before they know more information about addiction, they are infected by HIV/AIDS.
We also saw that unfortunately the majority of drug users who have a low level of education, for example are illiterate or at a primary education level, are more at risk for HIV/AIDS. But at that time the majority method of information for this highest group was in newspapers, pamphlets and posters that this group could not read. So we saw that we must change our approach for the control of HIV/AIDS based on the needs assessment of our clients.
As you see in these three pictures, the rate of HIV/AIDS in drug users during two years increased from 16% to 20%. And the main way of HIV infection in Kermanshah was injecting drug use.
We wanted to know what is the main reason of mortality in HIV-infected people before we started our activities. Unfortunately we saw that the main reason of mortality in HIV cases at that time was (suicide) - it was more than 60%. And the majority of them had suicide during the first year after they were proved positive. And the majority was due to the isolation from the community, from their friends, partners, children and so on. So we saw that they need counseling. Not only counseling for themselves but also for the family, the friend and so on.
I want to show the history of our project. Before our project, the limited cases of HIV-infected were related to blood transfusion. But for nearly two decades we had huge silence from our government. The first sign started in 1996 in a prison in Kermanshah. They saw that the rate of HIV/AIDS in prisoners was very high. So in 1997 one of the members of Parliament, who was in Kermanshah, offered to establish a national case center for HIV/AIDS cases. He found $10 million for the first year. But because there was not a good advocacy from the citizens of Kermanshah, the majority of the citizens of Kermanshah opposed this issue. For example the next year nobody selected this Member of Parliament for the next election. For nearly two years nobody could speak anything about HIV/AIDS. For example, when Kermanshah University in 1998 invited a national manager of AIDS to Kermanshah and he wrote Welcome AIDS Manager. Some of the government in Kermanshah said why are you writing this? It was a huge stigma. When we wanted to do this activity, we had no support from the government and from the community. We wanted to offer an established HIV case center but without any label and without any stigma.
We started our project in early 1999. We wanted to show to the community and the government, step by step what we need and what we should do.
We had 3 main target groups at that time: 1) drug users; 2) STI cases, sex workers; 3)HIV cases. We wanted to put all of this highest group together so we wanted to offer a comprehensive service. And we wanted to integrate prevention and care together. Because we started our project very late so we wanted to do all the prevention and care activities together. And we believed that even HIV cases need care and management but their partners and children need prevention.
By this way we had the full step in our project. The first step started in Kermanshah as a local policy. We started our activity voluntary and non-profit because there is a difference between developing and developed countries. In developed countries you write an excellent proposal and you find the funds and after that you do your activity. But in the majority of the developing countries, such as Iran, you must show your activity and its result to the government and then they believe your activity and give money to you. So it is very different. So we had to start our activity on a voluntary basis. And all our staff worked voluntarily.
We wanted to show that these three main target groups believed us and trusted us and came to our centers.
The early cases, the majority of them were infected in the prison. Only a limited number of cases of those who had been released came to our centers. So we had limited cases, one case per week. But when we gave them comprehensive services, and they believed us and they brought their friends and partners, our clients rapidly increased during the first six months from one case per week to 60 cases per day. So it showed that the need is very high. So we want to continue giving our services and expanding our activities.
Our approach was: to include partners, form networks and border communities in our activities; and develop activities in the users' natural environment; and to personalize prevention for each person at risk; and to have dignity and respect with sensitivity to cultural, racial, ethics and gender; and without any propaganda and stigma.
Step by step we wanted to give information to the society-- not go to the television and welcome all AIDS cases. That is not a good approach. This way we wanted to overcome some of our barriers. One of them is to involve people living with HIV/AIDS in our activities because we believe that when we give our comprehensive services to HIV cases and they believe us, they bring their friends. Our target group was not only HIV cases; our target group was the highest (risk) group. So our HIV cases went to the community and they knew where the places that have needle sharing and sexuality contact and (they) motivated them to come to our centers. After that we wanted to change the attitude of the family of the HIV cases because the majority of the families of the HIV cases accepted the (drug) addiction for more than 10 years but when they found that he or she is HIV infected, they rejected them. So we went to the homes and spoke to the families and encouraged them to come to our centers and step-by-step changed the attitude so they accepted these HIV cases. And instead of them being homeless and going to the places that may increase the rate of needle sharing, they go to the home and find social support and psychological support and this way solve their problem step by step.
One of our main target groups was women because women are more stigmatized with HIV. Men will say they are infected by injections but women could not speak about the infection, even in their families. We wanted to involve this group as one of our main target groups in our activity. We wanted to speak about our activity indirectly to the places that have higher rate of drug use and HIV/AIDS. We trained students in the school and youths in these places. They trained themselves at first and indirectly they trained their families and friends. They offered our services indirectly to their family. So step-by-step their families believed in the activity and why we must have harm reduction approaches, why we should have a social support for infected cases and step-by-step we involved a larger percent of the community.
One of our main target groups was religious key persons because they have a main role of not only decision-making but also in the society. Our approach was to design some national committees and provincial committees, with some of the members from the religious key persons. So when we showed them the results of the facts and the status of the HIV/AIDS and drug use, step-by-step their attitude changed. In some of the committees, the majority is from the scientific group. They speak with each other and they have different ideas and issues. After that they said to the religious group or the government, you should do this. And they said, 'we will not'. So we must involve them indirectly and we don't order them. So this way they say, 'why don't you do this?' We invited the more flexible key religious persons and they went to the society and spoke to the rigid key religious person, as a peer approach. And after two years, the majority of them accept our activities.
One of the main places we wanted to start our project was in prison because some part of the prisoners are drug users who inject inside the prison and the rate of HIV/AIDS inside is high, similar to the society. Some part of the members of this (national) committee are from the prison organization. One year after meetings they offered to us, 'why don't you do harm reduction activities inside the prison?' Before that we feared to ask them. But when they said that to us, we said 'ok'.
This is our approach for condoms inside the prison: each prisoner has a meeting with his or her partner inside the prison every month or three months, for one day. Before that we give information to the partner and to the prisoner and we give condoms to them. But we give many more condoms than they need and they bring condoms (back to the prison population) indirectly and prison organization says 'no problem'. So based on our cultures, we want to be flexible. Our request is that the government must be flexible and so on but the majority of us are rigid, we say we must do this; we must start by a needle exchange program. No, we started by pleas and after that we say, which one do you want, methadone or needle? And they say methadone and step-by-step they change.
We have had a link between the prison and our centers because some of the highest (at risk) group go to the prison and after release come to our centers. And we motivated some of the NGOs, such as Red Crescent in Iran and some charity that support HIV infected cases. When we spoke at the first meeting nearly 3 years ago, they went from our meeting out to say that we support women who are HIV infected who have sex with several partners. But for example in Kermanshah, we have 36 females that don't have any support, a husband, but they have several children and all of them are supported by these NGOs. Last year they bought a home for all of them which is very important.
This is our program, known as Triangular Clinic, with these three target groups. We have different activities, such as need assessment, information, education, communication, risk reduction counseling, HIV counseling and testing, HIV care and management and post-exposure profilaction, and preventing of mother to child transmission and social support for the infected and affected cases to live together. For example in Kermanshah, we have 76 couples where one of them is HIV positive and the other is negative and they live with each other more than 3 years.
Regarding harm reduction, we have needle exchange program, condom promotion, methadone maintenance therapy and bleach. We have peer education programs because some of the highest group are not interested to come to our centers so we go to the community by these peer educators. And we have psycho-social support for infected and affected cases and referral services and we follow up some of them in their homes.
What is the role of HIV cases in these activities? They have designed a committee, male and female together, and they have self-help groups and information sharing and collection of syringes and prevention with highest groups and they have music and sports groups and marriage program.
What is the role of the users? We trained the students and they have a committee, not only in high school but also in university and the army because after high school males either go to the university or they go to the army. So we cover all of them by this program. We have workshop for them and they have workshops for other friends because often the students are not interested in talking about their problems with teachers. But they will speak with other students as peer educators and they refer them to our center.
The activities: some are HIV infected, some are family of HIV infected, some are students, every week they go to the mountains and they say, even if we are HIV positive, what we want is to be positive for the society. In the mountains, they have music programs and they invite all the youths in the city to come to the mountains and encourage them to stop drugs, if they are users, and if not drug users, prevent to be drug users. It is very nice. In this picture, one of them is from the judiciary system. The relation between prison staff and prisoner for several years was fighting against each other but now they go together to the mountains and for both of them, the attitude changed, prison staff and drug users.
After the first step, fortunately our activities are approved as a best practice, so the president of the country said to the Ministry of Health and the committee to write a national strategy plan for the control of HIV/AIDS. So we have shared in writing this national strategy plan and after that we wrote the Global Fund because we wanted to involve international support for our activities. And after that we established different national committees of AIDS and harm reduction, which is the main coordinator of our activity. We have a superior committee, which the head of them are the head of the country and ministers of various organizations. They meet once per six months. The majority of our activities are done in national committees, which have different sub committees: information, education, research and evaluation, harm reduction, social support, care and treatment. And we have provincial committees because in Iran we have different languages, different cultures and different religions and we want to involve different groups together. And based on the provinces they have their own approaches, because the transmission of HIV may be different in the west than in the east.
Up to now we have established more than 21 Triangular Clinics in the country and more than 20 Triangular clinics inside the prisons. And we have a curriculum for educating school children.
This is the status of HIV/AIDS in Iran. Even though we have had limited HIV cases, based on activity, it is rapidly increasing and case finding will show that the rate of HIV/AIDS is increasing and even though the majority of HIV infected are male, the transmission will change to the female and from drug use to sexuality.
A third step is a regional strategy for promotion of collaboration with Iran. Based on the WHO, we are in the Middle East but we believe we have similar culture and language to the north countries such as Tajikistan and Afghanistan. So we want to design a program not only regional, but inter-regional. So we started to have a similar program to involve all the countries in Central Asia because we have several transmission of infection between Iran and north of Iran and west of Iran.
The fourth step is globalization because we believe there are different religions and different cultures and not only just in the Middle East or Central Asia. So we are going to design an international consultation for religious key persons from different languages and we have started in our country and our region the International Muslim Leaders for Control of HIV/AIDS and Harm Reduction, which will be held in June 2004 in Teheran. And after that we want to involve the women to share in our activity. There is no difference between women and men. This way we want to show and highlight the important role of women because we believe the main access group, the main vulnerable group is women. If they are infected they are more stigmatized and so we want to prevent and to reduce the stigma of HIV/AIDS and even drug use. We have to change the attitude of the policy makers about drug use, to believe it is a disease and not a crime and to use flexible roles and intervention about drug use. And we need to collaborate with other countries and international agencies for control of HIV/AIDS and doing harm reduction programs. And we want community-based services and outreach together.
We appreciate the organization of this program, the president of the Asia Society and the American consul and everyone who helped us in arranging this presentation. And we welcome everyone to come to our centers.
Kaveh Khoshnood: Thank you Dr. Alaei. I am going to ask Bob Newman to come up next. The bios are in your program.
Robert Newman: I also want to extend my congratulations to Betsy Williams on putting together an extraordinary program in a very, very short period of time. But I am very mindful of the limitation on time and I grudgingly speak, knowing that every minute I speak is that much less time for questions and answers and comments directed at our guests Dr. Alaei and Dr. Alaei. So let me be very brief and explain to you what to me was so impressive the first time I had contact with my Iranian colleagues. It was about a year and a half ago and a friend here in New York said there are some speakers talking about drugs and AIDS and Iran up at Yale, would you like to go? And I had absolutely no idea what was going on in this field in Iran and it wasn't high on my list of curiosity, I must admit. But I had a granddaughter who was four months old, who was up at Yale at the time and so as soon as I heard Yale I said I'm going, I'm going. And I am extremely glad that I did go because I was enormously impressed by the presentation by two colleagues, Dr. Mokri from Teheran was one.
What impressed me was the extraordinary pragmatism with which they approached the problems they face with regard to HIV/AIDS and drug abuse. And they explained how the government and the academic world and the clinical world in Iran had decided that they had this huge problem and they absolutely must approach it with a substantial effort at treatment, making treatment available and that they realized without treatment availability there was no way they would ever be able to come to grips with this problem. They had also come to the conclusion that part of the treatment that was offered had to include methadone treatment or again, they simply would not be able to reach more than a tiny proportion of the population.
But that treatment was the key and after the presentation I got up and expressed my amazement and said I am sure this is a reflection of my own stereotype of thinking and my lack of knowledge but I said I am just amazed to hear colleagues from Iran put so much emphasis on treatment and helping and services and so on. And the response was exactly as Kaveh just said in his remarks, it was so self-evident and so logical that it almost made me feel embarrassed that I asked the question because the response was, well, we have tried every other approach and God knows, we have tried to deal with this through supply reduction. And they cited figures how they do interdict more contraband opium and heroin than any other country in the world and Dr. Mokri said, it just doesn't work. We know that that's not the way to deal with this problem. So this pragmatic orientation, which sadly is lacking in most counties of the world, including unfortunately my own here in America, is very, very impressive.
The other part, and it is related, of what has impressed me so much with regard to the attitude in Iran is the willingness to accept the scale on which this problem exists. And I have been privileged to work in the region and outside the region and in many countries that are beginning to address the problem of addiction. And I always, as a methadone advocate, almost a pathological methadone advocate, welcome the news that Uzbekistan has OK'd methadone and will start methadone and the Ukraine has started to provide methadone treatment and other countries. And it is a major breakthrough. But when you get down to what exactly is being done, it turns out that there is a very nice little pilot program and they are going to have 80 patients, and two psychiatrists and an internist and 6 nurses and social workers and counselors and after two years they are going to evaluate that 80 person pilot program and if its successful then maybe they will have 3 more pilot programs. And you hear this and you say and how many estimated intravenous heroin addicts are there in their country? Well, they say, the estimates around 125,000. It's this lack of ability to address the problem on the appropriate scale that is so strikingly different in Iran.
Usually we say action speaks louder than words, but in this particular case I think it's the concept, the commitment that is brought to the problem that is much more important than the actual action with regard to a very small number of people. I have experienced New York in the early 1970s and Hong Kong in the mid-1970s, particularly those two places, where the government has said our commitment is make treatment available to every single narcotic-dependent person who is willing to accept it. When that commitment exists, there is no other resource required to fulfill that commitment. Its not money, its not professional people, it's the commitment. And I am convinced that that commitment does exist in Iran and I am hopeful that as they proceed to fulfill that commitment, as they try to replicate what has been done in Hong Kong, what had been done briefly in New York, making treatment available to everyone who wants it, that as they succeed in pursuing that goal they will become a model for other countries in the region-Tajikistan - that face this huge problem.
But also it is my hope that they will become a model for America to consider as well. Because we have God knows a lot of action in the last 30 years. We have spent hundreds of billions of dollars to try to get rid of the growth of opium and other drugs, to try to deal with the problem through law enforcement. We have the distinction of having a greater proportion of our population in America in prison than any other country in the entire world. I mean Russia used to be ahead of us, but we beat them. And now we're number one! And yet we do not think of changing our fundamental approach to this problem. It is simply more of the same. And I am hoping that a country with such a staggering problem of opium and heroin addiction as you've heard described in Iran, as they begin to deal with this problem in a different, more pragmatic, more realistic and ultimately more productive way, that that will indeed be a lesson for other countries in the world, including for very selfish reasons, I hope, my own. Thank you very much.
And now I can introduce the next speaker, Joanne Csete.
Joanne Csete: Thank you. I am pleased to be part of this distinguished and heroic panel. One among many of the amazing things about the work from Iran that you have been told so much about tonight is that it comes in the midst not only of a relatively hostile environment within the borders of Iran but in the middle of a region where none of these positive and courageous achievements flow naturally from history or from the current circumstances. Iran's neighbors, as you know, include Afghanistan and Pakistan where almost literally drug users are being run into the ground. And also the former Soviet republics of Central Asia about which I will say a few words tonight where the standard of public policy for so long has been that the only good drug user is a heavily-policed and preferably incarcerated drug user. So I hope very sincerely we will find ways as Bob said to share the experience of Iran because it is so desperately needed in the region.
I am going also like Bob to abridge what I was going to say because I do think Iran is the star of the show and not the Central Asian republics. But let me convey a little bit about the situation from the work that we have done there in Human Rights Watch. All I was going to say about these official numbers of the UN, of people living with AIDS globally, are that for the region of Eastern Europe and Central Asia, which you see in the top right part of the map, this is a grossly un-useful number because it is so badly underestimated. In Russia alone, many people believe and some officials have even allowed, there are over 2 million people living with AIDS. So you can see how the understatement is and the understatement continues in other regions, which I won't talk about, but certainly there hasn't been enough done in this region to get good numbers that we can work with.
Now I realize that the region depicted here is not in the Asia Society's mandate but I wanted to make a small point about the spread of AIDS in Africa and what that tells us for Central Asia. If we think about the change in this map from 1987, which is the picture you are looking at now, to 1997, we in the public health world thought it was a pretty fast spread of AIDS. And so it is. And you can see it in bar graph form for the country of South Africa, it looks like that. But if you think about an injection drug-driven epidemic, the picture looks a little more like this, so you see that in a very short time you could have very dramatic increases among populations of injection-drug users. Now these are scattered studies taken mostly from cities. But this really has proven to be the pattern in much of Eastern Europe and again numbers in both the region of Central Asia and in Eastern Europe throughout the former Soviet Union are sketchy.
It has turned out to be the pattern in Russia, which you don't see as dramatically here because these are officially registered cases but even so, look at that rate of increase over a short time. It has proven to be the case in the Baltic states, the very dramatic that you see in this slide from Lithuania and it certainly has proven to be the case where we can put numbers together and again they are sketchy, in the Central Asian republics of the former Soviet Union.
I will come back to this story of Kyrgyzstan because I think it is an important one. I would like to focus mostly on Kazakhstan but I want especially to come back to the apparent reduction that the bar graph show in Kyrgyzstan. As we've already heard, the percentage of drug users in the population is very high in Iran. The numbers that we've seen from the UN indicate that it's highest in Iran and Pakistan but the Central Asian republics are catching up fast. And all of you know a lot about this and some of those factors have been alluded to that with the fall of the Soviet Union we have in the former Soviet republics, in addition to the factors that you've already heard regarding Iran, we have no more Red Army patrolling the borders to keep drugs out in the way that was done before. We have a complete collapse of economies and of livelihood opportunities. We have as well the drug trade becoming an important source of funding for wars in Afghanistan and elsewhere. In any case what we have is a drug problem overlaid on a police force already very well practiced in repression. A drug trade that has provided new opportunities for corruption for the police and for public officials and we have a drug-using population that a very high percentage of which spends some point of its life in jail.
We have poverty fueling all this and very little being done to address poverty either by the governments concerned or by donors. I wanted to say that particularly Tajikistan has a major challenge in that it not only has the longest border with Afghanistan of any of the five Central Asian republics but it is still in many ways recovering from its own civil war in the 1990s, lots of war widows with no livelihood opportunities and so on.
Again we are seeing in this region among the highest rates of spread of HIV in the world. In the former Soviet Union, amazingly enough, there were institutions called AIDS centers in the 1980s, long before there was any recognized AIDS epidemic. Unfortunately the main mission of those centers was to engage in widespread mandatory HIV testing so people who were considered high risk in any way, which turned out to include pregnant women and anyone who had traveled abroad, turned out to include anyone detained by the state for any reason and certainly high risk persons such as drug users and sex workers and men who have sex with men and so on. And in these centers, and there is a great tradition of this that lingers today, people who tested positive for HIV were registered as such and their status was not necessarily kept confidential. It is not surprising that all of this has resulted in a deep fear of official services that stays with us today. To say nothing of the fact that, as Bob has said on other occasions, there is a special place in hell for drug users in these countries. Drug users are severely demonized both in the law and in the attitudes of the population.
I won't say much about this, you will notice. Any of you who know anything about the Central Asian republics will understand why the Turkmenistan bar there is blue. By some miracle, Turkmenistan has no drug users. Would you believe it? No, you shouldn't. In any case, these are largely drug-use driven epidemics in the five republics.
Bob has already alluded to methadone. As far as we know, Kyrgyzstan is the only place where methadone is actually legal or tolerated as something quasi-legal. There is a small methadone pilot program going on now in Kazakhstan, which is actually very exciting but I am afraid suffers from some of the pilot syndrome that Bob talked about. Needle-exchange is legal or tolerated in many places but access is indeed very low. And I will talk a little bit in human rights terms about why that is, but fear of police abuse has a lot to do with it. And as I mentioned, prisons are an important part of the picture with so many young drug users being in prison at some time in their lives and prisons being a breeding ground for HIV. You have a major public health concern in prisons that's really not being dealt with.
This is the picture of the official numbers of Kazakhstan. I am not sure you should read too much into the dip in the middle there. It is definitely an epidemic that is increasing by leaps and bounds. There is a much higher number of people living with AIDS in Kazakhstan than in the four other Central Asian republics combined.
And Timertau, a city north of Qaraghandy, the bigger city in central Kazakhstan and it is, to coin a phrase, always referred to as ground zero of the Kazak epidemic. A huge percentage of the population is injecting drug users. It also happens to be a place that is well on the drug-trafficking routes that go through Kazakhstan. That, with the collapse of the Soviet Union, Timertau is a company town, a town where coal mining and steel refinement was done by almost everyone in the population. When that all fell apart, so did jobs, so did livelihood opportunities of all kinds, so did, in many ways, social services as well. And with drugs coming in at about the same time, it was a recipe naturally for disaster. And now that experience has been replicated as far as we know in many other parts of the country but Timertau. Still is the place most closely studied. Mandatory testing, as in the Soviet tradition, is widely applied in Kazakhstan, and the AIDS centers do register people with AIDS. We went there partly because there seemed to be some openings. there seemed to be some positive things that were being talked about. There was a rule in Kazakhstan that by law that anyone in any kind of state detention, pre-trial detention, awaiting adjudication of their cases, would be tested mandatorily for HIV. And a new director of the national AIDS program came in and she said, no more of this. And yet the Ministry of the Interior, which still regulates procedures in pre-trial detention as far as we know, has not completely implemented the new decision. There is this methadone pilot which we hope will turn into more than a pilot and the President himself has talked about decriminalization of cannabis, which is a very interesting thing. I think he made a visit to the Netherlands. It is a very interesting thing to hear about in this part of the world.
I do want to spend a few minutes saying something about the kinds of human rights abuses that Human Rights Watch went there to look at and they are summarized here. A wide range of due process violations that drug users face on top of all the demonization and stigmatization that we've already talked about. We asked many police officers if there are arrest quotas in drug users in Kazakhstan and we were told over and over again, "Nyet Nyet Nyet." But in fact it seems as though from the other evidence we were able to find that there are arrest quotas and that these are particularly dangerous times for drug users when quotas need to be filled.
Addiction is something that is used against drug users in many of the countries of the former Soviet Union and other places in the world to coerce confessions, to heighten their vulnerability to all sorts of mistreatment, to have false charges pinned on them. And we have story after story of this. Drug users are easily extorted as well, partly because of their addiction. They suffer all sorts of illegal searches. They have no legal representation. A lot of the ones we talked to, even though that is a provision of the Kazakhstan constitution, that it is a privilege all people should enjoy. And then there was this general concern about police targeting needle exchange points, especially at times when arrest quotas seemed to be in force.
Among the challenges of doing anything about this is that the police are heavily involved in the drug trade. And indeed there are very few people in public life, let alone police or politicians or anyone else, who would be willing to speak about reforming the drug laws in any way.
We have talked about what this does for the ability to carry out public health programs, the needle exchange programs that have such a good record of effectiveness and cost effectiveness and are so difficult in this environment to attract drug users to.
Drug users, in addition, have been disinclined until very recently to organize themselves so that they might have a voice of some kind. That's changing in some of the Central Asian countries and it's a very interesting development to watch.
I am not going to talk in detail about sex workers except to say that, pimps -- in Human Rights Watch, even though we are the palace of political correctness, we have not found a politically correct word for pimp -- but pimps are an enormously important group to work with in most of the Central Asian republics where sex workers, sex trade workers are organized around the supposed protection of pimps. And indeed we found a few who were beginning to come to the realization that HIV was a major economic threat to them. It was a major factor in the deteriorization of their commodity, so it was interesting to us to see that what I think was the most progressive AIDS center in Kazakhstan was actually reaching out to pimps and working with them.
In any case, the situation for women, economic livelihoods for women, I think, even more than for men, collapsed with the fall of the Soviet Union. So we have a very severe situation of human rights abuse related to HIV transmission among sex workers.
I would like to point out that there was this sense, that we've heard alluded to, that drug users are not worthy of anti-retroviral treatment, which if you have an AIDS epidemic that has over 80% of the people living with AIDS being injection drug-users, this is an incredibly self-defeating policy. You can't really think of a more self-defeating policy in public health terms.
One thing I want to say, and this is something that I think would make an excellent session on its own for the Asia Society's effort to bring out issues on AIDS that are important for the Asian continent, in the background of all of this, the situation of national drug laws that are draconian, national drug laws that demonize, not just criminalize, drug users, we have three UN conventions, treaties, that have the status of international law that were made in 1961 and 1971 and 1988 (which only) talk about drug abuse (not drug use), about drug users as criminals and regard policing as the main strategy for dealing with drug control. This is not a helpful situation because even if they are not directly used by countries as a basis for policy, they are often pulled out as excuses when we try to move forward on more pragmatic and human rights-friendly policies. In addition, as Bob would tell you, easily, if you will listen for 45 minutes, methadone is classified as an illicit substance that has no good therapeutic value in these conventions. And yet the UN agencies, even those that have public health as their business, have done very little to try to push member states of the UN to look again at these conventions and their impact.
Going back to Kyrgyzstan, that Kyrgyzstan may be the only place where we can begin to speak of an emerging paradigm shift of the kind that we heard about in Iran, where there is a goal to bring almost universal coverage of the drug using population to needle exchange services, where methadone programs actually seem to be growing, where there was the radically-wonderful step of needle exchanges in prisons that we've begun to see now, government AIDS centers actually encouraging people to network. As I looked at the wonderful pictures of the network on the mountains in Iran, I thought, well we really need a mountain or two in Central Asia because there is very little encouragement of people to talk about their HIV/AIDS or to be with other people in any sense as HIV positive people. Kyrgyzstan has also got a Global Fund grant and I think we can be optimistic that harm-reduction measures will see some support.
So there is this hope that what we see there in the last bar graph is a real trend and we can hope that that will continue. Bob and I were at a meeting earlier today where a prominent AIDS doctor in the United States, I won't name him because I didn't ask if I could, who has also done a fair bit of work in the former Soviet Union, made a statement that I think begins to capture the challenge that we have in turning all of this around in Central Asia and more widely in the former Soviet Union. He said that the idea of AIDS and drug users is so merged in the head of some public policy people in the former Soviet Union that when you talk to them about the dire predictions, about the rapid spread of AIDS, they think maybe the silver lining there is that AIDS is a good way to kill off a lot of drug users. And I am afraid that that's as bad as it is in a lot of places. Keramanshah is a very lucky place because not many communities have the visionary and courageous people like the brothers Alaei to help them through this.
What is needed clearly, to make progress, are three things that are easy to say but extremely hard to achieve. We need first of all, greater awareness of the kinds of experiences that we've heard about tonight from Iran, both among policy makers and among the general public in Central Asia. These real public health successes that come from working respectfully with drug users and with people with AIDs, they are not well understood, they are not well known. Secondly, we clearly need courage at the national level on the part of some politicians and also influential health professionals like our courageous friends here tonight. It is really the easiest thing in the world to demonize drug users. We can only hope that some politicians somewhere will eventually have the guts to talk about drug users as human beings with human rights and with all that that entails.
And finally we clearly need international leadership. And I really do come back to the UN and also other important players, the bilateral donors. The health agencies of the UN have made speeches here and there and made statements here and there and a few documents about the importance of harm reduction services, but they have not brought policy statements to their governing boards. They have not worked with donor countries to see a more abundant flow of money into those services and they have especially not challenged the drug control arm of the United Nations to back off the criminalization of drug users. For people and for countries such as those in Central Asia that have had so much repression thrust on them over the course of history, the idea of public policy that is not based on repressing drug users is necessarily exceptionally difficult. And what we are asking of these countries, as Bob said so well, is not only to be more vigilant about HIV prevention than sub-Saharan Africa was or than the world was on sub-Saharan Africa's behalf, but even more of a challenge, to be braver than the United States of America has been in recognizing narcotic drug addiction as a disease rather than always as a crime. It is politically so easy to say that drug users and people with AIDS deserve what they get. And political leaders in Central Asia have no trouble finding examples of that attitude, including from politicians in this country. A lot of the work that we do in the human rights world I think falls into the category of hopeless causes or maybe, as we would say in basketball, low percentage shots - efforts where it is just not clear that our advocacy is going to succeed because so many powerful forces conspire against the kind of change that we are after. I sincerely pray that this is not one such issue. I pray that this issue of drug user's rights and HIV prevention in Central Asia is in another category. The costs that Africa is paying for the neglect of simple HIV prevention, pragmatic measures to prevent HIV and protection of the human rights of those most at risk of HIV is truly unimaginable. I hope that it will be the objective of all of our efforts that Central Asia not pay the same price. Thanks.
Khoshnood: We have 15 minutes for questions and answers.
Question: I don't think you can solve the problem right away. But as far as the women in Iran, what type of role are you taking for intervention and prevention specifically with that group?
Dr. Alaei: As you may know, more than 65% of the students in university in Iran are female. As Dr. Khoshnood mentioned, more than 70% of the total population are less than 29 years old. So we have more educated youth females. So when we started our project training the females in the university, and by peer approach in the community, we involve them in our activity. So for example, in HIV infected cases who are females, their main role for some part of our counseling. They have self-help groups and so on, not only for other HIV infected females but also for high risk and for partners of HIV infected. By these activities they are involved. We have several NGOs especially for supporting women. So this group are interested in supporting the HIV infected women.
Question: What are the expenses of treating AIDS in Iran, for each patient, per year. Are they generic drugs, are medications available? And have your high school and college education programs started or not?
Dr. Alaei: Yes, we have 3 years experience for the AIDS cases and all of the treatment is free of charge for clients. And all AIDS cases when they start treatment, they have at least for one year another treatment. We bought drugs from England the first year. But now some are produced in Iran. And the other ones we buy every year.
As for the students, we started our project more than three years ago. We started in Kermanshah, where we have 900,000 inhabitants. Since last year we went to different provinces and are training all students, by training the teachers and training the student together. We have a curriculum for them, based on the religious key persons, we can speak about safe sexuality for the females after 9 years old. So it is more available to the teachers.
Question: Since drug abuse and hepatitis and AIDS are so interrelated, have you considered developing centers that jointly treat infectious disease related to addiction and methadone treatment. We are starting one program in the United States by introducing methadone into a primary care center, which is long overdue and only 15 patients. But I would imagine in a country with limited financial resources, the integration of methadone treatment with infectious disease would be very cost effective.
Dr. Alaei: In Iran, one of our main problems is injection. So the rate of hepatitis C in injection drug users is more than 2 times compared to HIV/AIDS. So our main target group is injection drug users. So it will cover HIV, hepatitis and all blood-borne diseases. And we have several national research centers that focus on hepatitis C and all HIV infected who are related to injection. And we have some hospitals and special centers for methadone maintenance. But as our national committee, they accepted to cover at least 400,000 injection drug users for the next five years for methadone maintenance and methadone production inside Iran because it is very low. We have a curriculum for training the general physician as the primary level. We train them about HIV/AIDS and drug use. And as they have general practiconer activity, part of it is based on counseling on HIV and drug use. So in Iran, every primary center is linked to a pharmacy, so they can refer them for methadone.
Question: How amenable is the government to having condom distribution to unmarried youths?
Dr. Alaie: For 15 years we have had good experience of giving information about condoms. So it was very easy for us to speak about it. We have condoms not only in our centers, but in all pharmacies, they are available.
Question: Here in New York City, we waited until one out of every two injectors was infected with HIV before the public health officials saw fit to begin to initiate syringe exchange programs. What I want to ask, how is methadone provided? What is the dosing? Are there urine testing restrictions or anything like that?
Dr. Alaei: I have a program for methadone maintenance that one of our colleagues, Dr. Mokri, ( Dr. Azarkhsh Mokri, Assistant Professor of Psychiatry, Tehran University of Medical Sciences, Roozbeh Hospital) is expert about this. But on behalf of him, I will say that we do not have a limitation for maintenance because our goal is prevention. And we have no limitation for if their urinary test is positive. We increase the dose of methadone. Because the government accepted the fact we must prevent. So when they accept a needle exchange program, so it is better for him to use methadone. And in our clinics up to now we have a protocol for all of them, starting with for example with 30 milligrams but increasing to 100, 150, 200,based on the need. There is no limitation. And there is no limit to offering both of them: methadone maintenance and needle exchange together. Because some of them, the first month, may have injections. But our goal is changing from needle exchanging to maintenance of methadone.
Dr. Newman: I was struck as I was invited with a colleague from Australia and a colleague from Poland to go to Tehran for a workshop on methadone treatment. And as was I want, we began the first day, trying to sell people on the concept that methadone treatment is something important. And the leader of this workshop very politely, in typical Iranian polite fashion, said we love what you are saying, but it's irrelevant. We don't need to be sold on the notion that we need methadone. We want to know how to do it and how to do it well.
Question: I would like to know whether you are able to receive visits from colleagues from Afghanistan, from Iraq, from the Gulf countries, that truly must have the same kinds of problems and where they are not being dealt with in the same way?
Dr. Alaei: We have designed a workshop to involve those from Afghanistan, from Tajikistan and it will expand to Iraq, to Uzbekistan. We believe we have similar problems. For example in January 2004 we have invited those from Afghanistan and Tajikistan to come to Iran for a start, because they have approval for the Global Fund. We want to develop and expand activity together.
Question: Do you see at all the bisexual males under this project or are they still out on the fringe?
Dr. Alaei: Our main problem is drug use but it will soon change to sexuality transmission. Our goal is prevention, not judgment. One part of our clients have unprotected sex. We give them condoms. But we don't ask whether clients use it for males or females. We don't ask whether it is homosexuality or heterosexuality. And we don't request Ids from our clients. We ask what name they want to be called by and by this we call them. I might want to be called K1, for instance. And some might come and say my friend has this problem. I don't ask whether it is his problem or his friend's, I say 'use this condom.'
Kaveh Khosnood: At I guess we will we end the formal part of our presentation and I believe there is opportunity to have informal conversations afterward. Thanks again.