CAIRO: It was 1986 when the first case of HIV was reported in Egypt. The patient, a man in his 20s, was quarantined against his will at one of Egypt's local fever hospitals. Reluctant to stay, the infected patient attempted to escape. A hospital security guard shot him down in cold blood. Another case surfaced at the same hospital some months later. A woman diagnosed with HIV had gone into labor and was taken there to give birth. Terrified by the consequences of attending to her, doctors and nurses abandoned the mother-to-be.The baby was born with the help of one of the hospital janitors. Nearly a decade has passed and HIV/AIDS awareness in the region has made noticeable advancements. Disposable syringes have, at many places, replaced traditional glass needles, and health care workers are better equipped to respond to patients diagnosed with the syndrome. Taboos have been abated through educational campaigns and the Arab world has managed to steer clear of the pandemic that has swept sub-Saharan Africa,due in large part to the reinforcement of religious ideologies surrounding abstinence before marriage. Conservatism in the Middle East and North Africa region (MENA) has been challenged in recent years as economic hardships force delayed marriage, and premarital sex, while discouraged, is practiced with greater frequency. According to the Egyptian Ministry of Health and Population, there are approximately 1,800 cases of AIDS and asymptomatic HIV in Egypt today. The World Health Organization (WHO) challenges these statistics, reporting an estimated 8,000 cases of HIV/AIDS in Egypt. Furthermore, UNAIDS reports in 2004, 540,000 cases of HIV/AIDS were documented in MENA, with an estimated 28,000 deaths due to AIDS last year. Experts admit the numbers may be even higher, citing the inability to track and monitor infected patients as a major fallback. "We have a low number of cases now, but we have all the potential for rapid spread, says Ahmed Ragab, professor of reproductive health at Al-Azhar University and author of the study "Gender and HIV/AIDS in Egypt: Challenges and Solutions. "We have to guard against it. It is a minor threat now, but it has the potential to be a major threat in the future. In his research, Ragab interviewed a number of community members, health professionals and religious leaders in several of Egypt's governorates, from metropolitan Cairo and Alexandria to the rural governorate of Minia. In one interview, a laboratory technician spoke of one case where infected prostitutes were left to roam the streets without surveillance. "Police captured a prostitute who was working in Minia . A blood test for her found that she is carrying the virus, the technician reported. "Once she was released she escaped to another governorate. We could not trace her. The problem is that she is young, beautiful, apparently healthy, and she has no source of income except prostitution - this is very dangerous. "The problem with commercial sex workers in Egypt is they are available, accessible and affordable, but commercial sex itself is illegal in the country, Ragab explains, noting he does not condone prostitution. "So, with this illegality, there is no way to supervise them,to counsel them, to promote condom use, to screen them for HIV. Promoting condom use,however, strikes discord among religious leaders who in many cases believe that promoting safe sex is promoting safe adultery. While family planning programs have adopted condom use as one of many methods for protection, condom promotion via HIV/AIDS programs continues to be a subject of contention. "I had a Gonorrhea case and he was cured, then he went and had sex with the same girl and got Gonorrhea again, recalls Hisham Issa, a lecturer of laboratory medicine at Cairo University. "The concept of safe sex is not there.When someone talks about sexual education in schools, people say 'it's not ethical, it's bad to talk to children about these things and it should come by nature.' Egypt's National AIDS Program reports the majority of HIV/AIDS cases last year were transmitted through heterosexual relations, making up an estimated 30 percent of all cases. Blood transfusions account for the second highest mode of proliferation at 20 percent, and homosexual transmission makes up 10 percent of HIV/AIDS cases in Egypt. Experts say it is impossible to survey mode of transmission given the current surveillance systems in place. Egypt's street children are a major point of apprehension among health professionals. Their testimonies show the vast majority of them are repeatedly raped or bribed for sex, and many report having been drugged - all of these factors exposing them to infection and ultimately, the spread of infection. "People cheat young street children telling them they will provide them with working opportunities, then rape them, one street youth, age 18, was quoted in the study. "The young children are more vulnerable, another youth, age 17, was reported to have said. "Once they get used to having sex, they like it and even demand it. Levels of infection among antenatal women or blood donors can be contained; the study reports,but concerns surround high risk groups, such as sex workers, homosexuals, frequent travelers, and intravenous drug users. Drug use is attributed to the majority of HIV infections in Algeria, Bahrain, Kuwait and Oman. In Iran, 15 percent of HIV cases reported since the rise of the epidemic were in 2003 alone, according to UNAIDS. Experts say the sudden escalation is mainly due to increased drug use. "One of the magazines published an article about a queue in a graveyard, the City of the Dead in Cairo, where drug addicts had - for one needle - a queue waiting to have this fix, tells Ragab. "In my research, there was evidence that the same happens in Alexandria, so drug use is important. In Libya, excessive drug use has caused heightened concerns over the spread of HIV. According to UNAIDS, some 90 percent of the total reported cases are attributed to intravenous drug use. Additionally, 90 percent of the 5,160 cases reported by the end of 2002 had occurred between the years 2000 and 2002 alone. Currently, the courts in Libya are considering an appeal filed by five Bulgarian nurses and a Palestinian doctor sentenced to death after they were convicted of transferring HIV to 426 Libyan children in 1999. Some health experts have rallied for the medical team, saying the outbreak began before the nurses arrived and was probably caused by poor hygiene. Ragab's study finds that concerns surrounding the sanitation of hospitals and clinics when dealing with HIV/AIDS patients are in some cases legitimate. In 2003, the Ministry of Health and Population, the World Health Organization (WHO), the Ford Foundation and the United States Naval Medical Research Unit launched the Infection Control Program, making disposable needles and instruments widely available. Not widely enough, however, as a shortage of medical supplies complicated matters, and reusable and glass syringes are still used by many health workers today. "In my laboratories, sexually transmitted HIV is minimal, says Issa. "Most of the cases I've seen have gotten it through blood transfusions. But testing for HIV has definitely increased, because to travel to the Gulf, you have to be HIV negative. It's the same thing at many embassies if you are applying for immigration. Increased awareness has certainly eased taboos to a degree. Until five years ago, all those who were tested for HIV/AIDS in Egypt had to be reported to the Ministry of Health and Population. Prior to ten years ago, those who tested positive were quarantined in special hospitals and left to die. Many people interviewed by Ragab were quoted as saying AIDS is a foreign disease and does not exist in the Arab world. While the culture has evolved to a certain degree, treatment and education are lagging behind most of the world. According to UNAIDS, MENA saw 55,000 new cases of HIV in 2003,while Central and Western Europe saw an estimated 35,000 new cases. However, it is AIDS-related deaths in those regions that reveal the shocking realities. In 2003, 45,000 AIDSrelated deaths were reported in MENA, whereas only 3,000 people were said to have died from the disease in Central and Western Europe. "This shows the relative containment of the epidemic in the Western Europe,while the same epidemic is rapidly expanding in the region, insists Ragab. "There, treatment is better, behavior especially toward those living with HIV/AIDS, personal habits and counseling is better; people living with HIV/AIDS there have better chances. Here, since there is no real treatment, they died of neglect. Health professionals such as Ragab and his colleagues insist that there are immediate steps that can be taken to alleviate this growing threat. The struggle to have the study of HIV/AIDS added to the standard curriculum of many schools in the region continues to this day.Meanwhile, activists believe the only way to abolish false stereotypes is through educational campaigns. Since it is impossible to control people's actions, awareness campaigns are the only route for reaching them and ultimately, for preventing an epidemic. "The high stigma that surrounds HIV/AIDS prevents people from going for testing, admits Ragab. "Poverty leads to prostitution, leads to street children, leads to desperation; the lack of enforcement and education regarding drug use - all of these things, if we work on them, can really make a difference.
