Iran enjoys a low prevalence of HIV/AIDS, but as the number of injecting drug users increases, so too will the government's need to enhance prevention efforts. The country is a major transit route for narcotics coming from neighbouring Afghanistan and Pakistan, destined for Europe, Central Asia, as well as the Gulf region.
"Intravenous drug usage remains the key challenge to combating the spread of HIV/AIDS in Iran today," Dr Mitra Motamedi, the director of Iran's department of AIDS and hepatitis in the Ministry of Health, told IRIN in the capital, Tehran. The vast majority of Iran's AIDS sufferers - 65 percent - were men who contracted the disease through contaminated needles, she said.
According to official estimates, infection was 12 percent through sexual contact, nine percent through blood transfusion, one percent mother-to-child transmission and 13 percent unknown.
The first reported AIDS case in Iran dates back to 1987, when a six-year-old haemophiliac child was diagnosed to have been infected, resulting in the establishment of the National Committee to fight AIDS and its executive and technical committees. Since then, there have been 4,237 reported cases of HIV/AIDS. Of this number, 626 have developed full-blown AIDS and 585 have died.
But health officials, most notably in the government, acknowledge that the real numbers are much higher. "These are only reported cases. A more accurate estimate would be around 20,000," Motamedi said.
Sharing her concern was head of infectious diseases at the Ayatollah Khomeini Hospital and one of the leading experts on AIDS in Iran, Dr Minoo Mohraz. "The threat is increasing. We have not stopped it," she told IRIN. "It's not under control."
Her warning is not new. Just two years ago, former Health Minister Mohammad Farhadi described HIV/AIDS at a conference ahead of World AIDS Day in Tehran as a "time bomb" waiting to go off. "There is a time bomb ticking in Iran and we have to take it seriously," he reportedly said.
But what concerns experts most in this staunchly Islamic state of 70 million is the increasing number of intravenous drug users. Of the two million addicts estimated to be in the country, according to a recent government study, some 136,000 were injecting drug users. Others fear the number could be far higher.
In many ways, the rise in intravenous drug usage is a product of the Taliban ban on the cultivation of opium in Afghanistan in 2000. This in turn has also resulted in a change in the categorisation of drug users.
"Most of the drug abusers here use opium, and the method of use is through smoking/inhalation," Fariba Soltani, an expert on drug demand reduction at the United Nations International Drug Control Programme (UNDCP) in Tehran, told IRIN. "However, as a result of that opium ban, there was a reduction in the opium supply, so the prices increased dramatically. This in turn resulted in the drug users either going into treatment - wherever possible - or they switched to heroin, and injecting drug abuse increased." she explained.
According to the expert, drug usage had a long history in Iran, but what had changed were the categorisation of users. "Before it was elderly people, men using drugs, smoking opium in a traditional sort of setting - a social sort of activity," she said. "Now it's moving to the younger generations."
The tendency towards heroin abuse also grew stronger. "This is the worrying factor and why all these harm-reduction committees have been formed," she said, noting that about 70 percent of the country's population was below the age of 30.
In short, drug usage is increasing far faster than earlier expected, and officials are alarmed.
In October, Reza Sarami, who heads the anti-addiction programme of the national anti-narcotics trafficking body, reportedly said drug use was rising by eight percent annually. Given the existing numbers, Iran could be counting nine million addicts, or some one-seventh of the total population, and undoubtedly even more injecting drug users, within the next 20 years unless drastic action was taken.
However, it is addiction problem within the prisons system that remains the main source of concern seven years after a major HIV outbreak was reported in the western Kermanshahan Province in 1995. One former government official told IRIN that of the 400 inmates tested for AIDS, a startling 146 of them tested HIV-positive. Due to a rise in crime and addiction and deteriorating economic conditions, Iran has a large and growing prison population.
"Prisons are the main source of HIV," Mohraz said. As the population increased, so too would addiction and the number of men who have sex with men, she explained. Turning to the size of the facilities, she noted that a prison which might have a capacity of 2,000, could have as many as 10,000 or more inmates. Moreover, until recently, new prisoners were often mixed with inmates who were addicted and potentially HIV infected, only to have those prisoners become HIV infected as well. She observed that many of her patients, most of whom were addicts, had left prisons HIV positive.
"Sharing of needles is very popular within the prison system. The way to prevent that is through harm-reduction programmes such as methadone treatment," she said. But given conservative attitudes, that is easier said than done. Although the government has recently accepted methadone-maintenance therapy, which has started as a pilot project, the situation inside the prisons remains the same.
According to Pejman, a former inmate and intravenous drug user at the Gezel Hesar prison near Tehran, home to some 10,000 prisoners, getting heroin inside was easy. "If you want it, you can find it," the 45-year-old told IRIN.
He recalled how after 28 years of addiction, using up to five grammes of heroin a day, he found himself in jail under Iran's strict laws on drug abuse. During his incarceration, things went from bad to worse and, like many other addicts, he too became HIV positive.
"This was something I did to myself, so it was easier for me to accept," he said. "However, the situation for haemophiliacs or people who received it through sexual transmission by accident is something different."
Currently undergoing anti-retroviral therapy, he heads a peer-support group for six other HIV infected individuals, meeting biweekly, at the Shemiranat health centre in the north of Tehran, one of seven so-called triangular clinics in the capital, supported by the government, where needle exchange and condom distribution take place.
"It's a small number, but it's a start. I'm a positive person and I want other people to be positive as well," he said. Dedicated now to helping others, he nevertheless feels the government should be doing more on awareness and support. "Of course I think more needs to be done. That's why I'm here."
Mohraz couldn't agree more. Experts have called for a more moderate approach to the growing number of addicts in order to curb the spread of drug-related AIDS, most notably by way of the free distribution of syringes to avoid contamination.
But according to the health expert, existing bureaucracy remains a major hurdle to the HIV campaign. "As addiction is a crime, they cannot provide methadone as a treatment, but we have the acceptance of the justice ministry that treating addicted people is not a crime or against the law - as it was before," she said, noting the importance of harm reduction efforts. "There needs to be a change of rules and policies in order to start using methadone in the prisons. The attitude towards AIDS is not very positive and there are some who view methadone like heroin," she explained.
However, officials in Iran are far from complacent. The government has established a national harm-reduction committee meeting biweekly, and has also accepted the National AIDS Prevention Committee's comprehensive strategic plan.
"Acceptance of this is a solid step towards implementation," Motamedi said, recalling the government's recent acceptance of methadone therapy as a pilot project. Moreover, the ministry of education has recently accepted the inclusion of education material on sexually transmitted diseases and HIV in the national curriculum, as well as the education of soldiers and those serving in the armed forces, she added.
While admitting there was much work ahead, she stressed that "the political commitment towards this challenge is excellent".
Fariba added that Iran had demonstrated some very progressive efforts in containing the disease's spread. She noted that anti-retroviral treatment had been paid for by the Ministry of Health and that just recently the government had called for the protection of HIV-infected people's rights in the workplace.
Although once a taboo subject, given the past few years of growing awareness, she maintained that "things are changing. It's gradual. You can't expect things to change overnight, but it is happening."