Cultural taboos, changing sexual norms spur HIV surge in Iran

Iran is facing a surge in HIV infection, according to its Health Minister Hassan Hashemi, who on Sunday announced a ninefold increase in diagnoses of the disease over the past decade. His announcement suggests a dramatic reversal in the Islamic Republic's efforts to stem the rate of HIV infection, which the country was believed to have effectively contained in 2006.

Hashemi said the greatest rise in infections was through sexual contact, shifting the trend in Iran away from infection through intravenous drug use. Speaking during a national AIDS-awareness week, he said HIV was growing at an annual rate of 80 percent and warned that social stigmas deter many Iranians from getting tested and admitting they are infected. "Unfortunately in our country, awareness is poor among patients, as is social support and education about prevention," he told state media. "As the government, we blame ourselves for this neglect."

The surge in HIV infection has been spurred by a dangerous confluence of factors that include former President Mahmoud Ahmadinejad's knocking AIDS prevention off the government's public-health agenda, a massive increase in cheap heroin coming from neighboring Afghanistan and a shift in young Iranians' sexual behavior that the state has failed to acknowledge or respond to. “This new occurrence is an outgrowth of a decade of economic degradation that has purportedly increased high-risk sexual activities such as prostitution in Iran’s cities,” says Amir Afkhami, assistant professor of psychiatry and global health at George Washington University, who has expertise on HIV in Iran. “Young couples have found marriage to be unaffordable, leading to increased high-risk, multi-partner sexual relationships among unmarried young urbanites which has fanned the flames of heterosexual HIV transmission in Iran.”

Young Iranians are having sex earlier than ever before and delaying marriage, thus engaging in premarital sex over more years, according to Shirzad Abdollahi, an education expert in Tehran. And many increasingly see drinking and drug use as a means of enhancing their sexual experience. "Substance abuse and risky sexual behavior are related, but there is little or no discussion in schools about life skills or safe sexual relations," he said. With frank discussions about sex still difficult for both educational authorities and families, young people are forced to rely on their peers or satellite TV for information about sexual risk. Abdollahi added, "Officials don't like to talk about or give any statistics for such social dangers in relation to adolescents and high school students. It's taboo."

A survey conducted two years ago by Allameh Tabatabei University professor Mahmoud Golzari — which was released inadvertently and generated great controversy — found that 80 percent of female students in Tehran had boyfriends, with contact ranging from phone calls to full sexual relations. "In big cities, having a boyfriend or a girlfriend has now become normal for high school students and even younger," Abdollahi said. "Because of taboos, the behavior stays underground and away from adult eyes."

The social stigma around AIDS can be seen most strikingly in the gender gap in reported cases, according to Arash Alaei, a physician who helped draft Iran's national strategic plan for AIDS control and harm reduction of drugs from 2003 to 2008 and is now a professor at SUNY Albany. Women account for only 11 percent of reported cases, up from 5 to 6 percent a decade ago but clearly still well below actual numbers.

"What's also a huge problem in Iran is that we don't know about 75 percent of cases. Those people don't know they're infected," Alaei said. "They're not getting treatment, they're spreading (HIV), and we can't help them."

About 27,000 people are known to be infected in Iran, but the real number of sufferers is estimated at 100,000.

Sexual mores have been changing for years, but a profound shift occurred in the past decade, experts say, coinciding with the onset of the Ahmadinejad era and resulting in a catastrophic impact on HIV transmission. Iran had managed to flatten out its rate of HIV growth in the mid-2000s through harm-reduction policies that won international acclaim, according to Afkhami. But the Ahmadinejad government viewed nongovernmental organizations as agents of regime change and rolled back programs around the country while cutting budgets for the state's harm-reduction programs.

"It became such a contentious space to work that many (NGOs) closed shop, went quiet or got sidelined because the government really put the fear of God into all these people," Afkhami said.

Iranian public-health experts who were on the ground at the time say they expected little else.

"What we're hearing today is not shocking for us. This was predictable for the Ahmadinejad era," said Alaei, who, despite pioneering AIDS treatment across Iran with world-renowned clinics, spent three years in prison on charges of seeking to overthrow the regime.

Under Ahmadinejad, who famously told the world in 2007 that Iran did not have gay people, the ministry of health lost approximately 75 percent of its budget, Alaei said, after the president failed to seek funding from parliament. Authorities took World AIDS Day off the national calendar, put into storage more than a million educational booklets printed for high school biology classes and disrupted the street coordination that had been established between police and social workers handing out condoms to sex workers and sterile needles to intravenous drug users.

"The quality of care came down. The programs couldn't work nationally," he said.

While Hashemi's remarks seemed pitched to ring a national alarm, Gary Lewis, the United Nations' resident coordinator in Iran, said that Iran is not, in fact, experiencing a sharp rise.

"What we are witnessing is a gradual increase (in sexual transmission of HIV)," he said, cautioning that it would be too speculative to attribute the reported increase to any specific social factor. "In fact, sexual transmission has always been there. It has become more visible because we have become better able to detect it."

But Lewis does urge more research to map the sexual component of Iran's HIV epidemic. "This will help to better guide the response accordingly," he said.

The government's ability to provide an effective response, though, is up for debate.

"Unfortunately they're not equipped to deal with that," Afkhami said. "It will require them first and foremost to admit that there is non-Islamic-sanctioned sex going on in the country. Without admitting that, it will be challenging to put the right public-health measures in place."

Hashemi's remarks have raised hopes that President Hassan Rouhani's government will redirect resources and political will to HIV prevention.

"The government coming forward like this breaks the stigma. It means they are ringing the alarm bell and don't want to ignore it anymore, which is good news," Alaei said.

But he cautions that the government's intentions will be easier to read in six months, after it releases its budget and has a chance to set forward its drug-control approach. That the state has put aside a national week for AIDS, engaged national personalities to participate and, according to Abdollahi, has sent the educational pamphlet back into high schools, is all cause for optimism.

What matters now, Alaei says, is for the international community to step forward and help Iran import anti-retroviral medications once again. While medicines are formally exempt from international sanctions imposed in response to Iran's nuclear program, banking restrictions have in practice restricted Iranian patients' access to these vital drugs. Iran offers routine counseling before and after HIV tests and free comprehensive medical care to those with HIV.