IRIN focus on the battle against HIV

His arms riddled with needle marks, twenty-five-year old Azamat Dshymagulov appeared dazed and confused. Outside the only drug rehabilitation centre in Kyrgyzstan's western city of Osh, the unemployed university graduate, could barely stand unassisted. "I want help," he tells IRIN. "I don't want to die." But with the increasing threat of AIDS among intravenous drug users in this impoverished Central Asian country growing, his future looks more uncertain than ever. There are some 50,000 drug users like Dshymagulov in Kyrgyzstan today, 70 percent of whom are intravenous drug users, the largest and fastest growing high risk group for HIV. Given the speed in which HIV, the virus that leads to AIDS, transmits among drug users, UN agencies and NGOs have raised the alarm. But in Kyrgyzstan, where a hit of heroin costs little more than US $1, the fight against HIV and AIDS is proving an uphill battle. Official figures reveal there are only 103 officially registered cases of HIV infection, a small amount when compared to the pandemic in Africa and other parts of the world. Indeed, it is these figures that give many a false sense of security in this country of 4.5 million. If the warning is unheeded, such apathy could prove deadly. While the number of HIV positive cases is small now, almost half of them were recorded since January this year. "This is only the beginning in terms of AIDS in Kyrgyzstan," national manager for the UNDP AIDS project in Kyrgyzstan, Larisa Bashmakova, told IRIN in the capital, Bishkek. "We don't have a very high incidence of AIDS in this country, but given the current rise in intravenous drug usage, an HIV outbreak could happen any minute," she warned. While official figures remain low, UNAIDS recommends they be multiplied by 10. Bashmakova, however, is even more pessimistic. She maintains they be multiplied by 15 or 20 to elicit a more realistic amount. If her calculations are correct, there are over 2000 cases of HIV infection today. How serious the implications of the problem are, is best explained by the dramatic upsurge in drug usage in Osh, the country's second largest city. Located at the crossroads of a major drug smuggling route for Afghanistan and Tajikistan, Osh for some has become a "second Columbia" of sorts. A 23-year old addict, Aziz told IRIN: "It's everywhere and it's cheap." Describing the progression of his four year addiction, the former law student explained: "In the beginning I smoked heroin, but found that a bit expensive so I began shooting up instead." It is precisely that type of comment which concerns the experts most. The fact is, in Kyrgyzstan, the highest probability of an HIV infection comes from a needle. "Intravenous drug users and needles are the biggest threat to HIV infection," Bashmakova said. Of all the HIV-infection cases registered in 2000-2001, all but one were intravenous drug users, she added. Commenting on the increase in narcotic usage there, "I'm afraid we could possibly have an explosion in the number of HIV cases in Osh," Chief doctor of the Osh oblast Centre on AIDS Prevention, Tugelbay Mamaev told IRIN. Each week, some 180 AIDS tests are conducted at this facility. In the first four months of this year, 4,013 tests were carried out, resulting in 24 positive cases. Out of 50 new cases of confirmed HIV in the country, most are in the Osh province. This in a country which diagnosed it's first HIV case in 1998. While officially there are 578 intravenous drug users in the Osh province alone, Mamaev maintains the figure to be 6,000 and growing. More disturbing, however, is the fact that between three to four users are sharing one needle, a staggering amount given the ramifications. Currently there are two needle exchange points in Osh. Established two years ago, Mamaev said some 110,000 needles have been exchanged to date. "Each day we exchange 300 needles," he said. He warned, however: "These 300 needles represent only four to five percent of the total number of needles out there." Funded by UNAIDS, the Soros Foundation and the local Osh municipality, the centre aims exhange 1000 needles per day and 1,500 the year after. Mamaev admitted, however, that limited funds may make such a goal impossible. "We are doing the best we can with limited resources," he explained. "But unfortunately we have many problems in Kyrgyzstan today - increasing poverty, social, economic and cultural issues." Compounding the problem further is the increase in prostitution throughout Kyrgyzstan, particularly in the urban areas. "In addition to the increase in narcotic usage, we also have had a dramatic rise in prostitution involving unprotected sex," Mamanev said. He added that intravenous drug usage among this group has also increased. One organisation working to counter this threat is the Bishkek-based NGO Tais-Plus. Named after Tais, a mythological prostitute of ancient Greece and lover of Alexander the Great, the NGO established in 1998 counts 2,500 commercial sex workers (CSWs) in the capital as its members. Originally established as a trade union of sorts for prostitutes, it has evolved today into a progressive, innovative and respected entity with some interesting supporters including UNDP, UNAIDS and WHO. One of Tais-Plus's more interesting programmes is a UNDP sponsored project for the prevention of HIV, AIDS and STDs among sex workers in Bishkek, putting prostitutes on the frontline in terms of peer prevention. Asked to comment on the threat of intravenous drug usage among this group, Olga Yun, the 30-year-old Tais-Plus chairman told IRIN: "At least 10 percent of sex workers in Bishkek are intravenous drug users and it's growing." She warned: "This is a real danger." "We are a very little and poor country with no job prospects - prostitution for many is just a means to an end," Yun maintained. "It's not a way to live, it's a way to survive," she explained. According to the former Russian teacher, who claims to know 80 percent of the capital's prostitutes personally, if the average monthly salary per month for a civil servant is US $12 and one sex act costs US $2 to US $3, pure economics forces the decision for many of these women. Referring to their life as Russian roulette, Yun claimed when business was brisk, many of the women she interviewed had as many as six customers per night, with one woman claiming to have had 12 clients in one night. However, with 50 percent of their income going to local pimps and corrupt officials, made worse by the fear of violence and STDs, there was a genuine need to help them and defend their rights, she added. Today the NGO's mandate is includes medical, social and legal rights for Kyrgyzstan's 3,500 prostitutes. Nonetheless, HIV and AIDS prevention and awareness remains its mainstay. Using a peer education approach, Yun, along with a staff of four, organises weekly workshops for prostitutes to discuss various health issues and AIDS awareness issues. Further workshops are provided to taxi drivers, traders, soldiers and lorry drivers - groups which often have direct contact with CSWs. By nightfall, backed by a team of some 50 volunteers, many of them prostitutes themselves, as well as students, doctors and one lawyer, Yun hits the streets distributing condoms and pamphlets to where prostitutes traditionally work. One such location is the intersection of Pravda Bokonbaeva, one of the capital's busiest thoroughfares and an area notorious for prostitution. There on a darkened bridge, some 170 women solicit their wares to the hundreds of men that pass over it. While they haggle over prices, most are indifferent to the issue of prevention. Shaha, a prostitute, who is also a Tais-Plus volunteer, explained life at the 'piatak', the Kyrgyz word for where prostitutes work. For her AIDS is a real fear. Armed with a UNDP card, identifying her as a participant of the programme, the 27-year-old told IRIN: "I used to work in a shop, but I couldn't live on it, nor feed my two children," she said. "Of course I'm afraid - everyone is afraid, but I need money to live." Today she is one of the many Tais-Plus volunteers that while soliciting their bodies, also solicit their clients and peers about safe sex and prevention. "I try to get my clients to use condoms," Shaha said. "If they refuse, I don't go with them." She said many men offer more money to women not to use condoms adding: "It's my job to let them know the risks." For those who frown on this unconventional approach, results from the UNDP sponsored project speaks volumes. In 1998, only 13 percent of prostitutes used condoms, while in 2000, more than 60 percent did. One other risk group now taking action to thwart the spread of HIV is Kyrgyzstan's gay community, a task particularly challenging given the sensitivity of homosexuality. Prior to 1998, homosexuality in Kyrgyzstan was illegal and people faced two years imprisonment if caught. However, things are changing. One group trying to break the silence and raise the issue of AIDS awareness and prevention is the Bishkek-based NGO Oasis. Established in 1995 and working out of Kyrgyzstan's only gay club (claiming some 5,000 members in Kyrgyzstan and neighbouring Central Asian countries), the group is actively working to raise awareness by distributing condoms and pamphlets on safe sex to club visitors. The club was never thought of as a business, but rather an opportunity to establish a venue for gays to gather and discuss issues, Oasis founder and club owner, Vladimir Tupin told IRIN. "We wanted to raise the issue of safe sex among high risk group and so far the response has been positive," he added. While in neighbouring Uzbekistan where homosexual activity remains illegal and those caught face imprisonment of up to five years, Tupin maintains: "Things are better here." He noted, however, in their efforts to distribute safe sex material, condoms or promote counseling activities, neither the government nor any UN agency are providing them with any sort of assistance. "They never come here so I guess we are on our own," he said. Quick to remain optimistic, however: "No members of Kyrgyzstan's gay community is infected and we're working to keep it that way," he added. Indeed it is Tupin's self determination with regard to AIDS prevention which is paramount. HIV today is an emerging issue in Central Asia. Despite limited resources, Kyrgyzstan is one of the few countries in the region meeting the challenge head on. But while the country battles the issue of HIV and AIDS, the war has yet to be won. Prevention according to Bashmakova is the absolute key. "If we are going to win this war, critical funding is needed now - otherwise it will be too late."