AIDS in Yemen: A silent bomb [Archives:2006/1004/Health]
December 4 2006
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The most recent estimate of AIDS and HIV patients in Yemen said there are at least 11,600 cases. However, many experts doubt this number, as many patients don't report their disease. “The situation is very bad. There's a huge silence surrounding AIDS in Yemen,” says the director of the Central Public Health Laboratory's virus department, Dr. Abdullah Al-Hababi.
He points out that Yemen's conservative cultural and social context, aggressive attitudes toward AIDS patients and widespread stigmatization about the disease among both health care workers and the general population have led to significant underreporting of cases. He suggested that a hidden HIV/AIDS epidemic is developing in Yemen.
According to the World Health Organization (WHO), HIV surveillance systems are very weak in Yemen. Reporting HIV cases is based on laboratory data available at the Central Public Health Laboratory and its governorate branches, as well as in private hospitals and labs.
Ad hoc screening (opportunistic screening) of vulnerable groups has been conducted, but long-term trends are difficult to interpret due to a lack of standard methods. WHO has established an action plan to strengthen second-generation surveillance in collaboration with the National AIDS Program, including routine surveillance of blood donors and screening in all blood banks, as well as repeated surveys of knowledge, attitudes, practices and behavior among vulnerable groups.
“Evidence has shown that there's a high level of stigmatization and discrimination within health facilities ranging from isolation to total denial of health care services. Access to testing is very limited. Infection control and blood safety measures are weak – no more than about 20 percent of blood donors in the country are screened. Legislation on and regulation of blood services urgently are required to ensure complete blood safety,” the WHO report stated.
Shame, ignorance and poverty
Many Yemenis still think of AIDS or HIV as sexual diseases, that is, transmitted only via extramarital sexual relations (considered “illegal”), Al-Hababi says, which causes citizens to judge AIDS patients like criminals and refuse to deal with them. Furthermore, people are scared of AIDS patients because they think the disease is contagious, which is why patients are abandoned by their friends and families.
“An AIDS patient told me he entered a clinic and he was honest with the doctor, informing him that he had AIDS. The doctor immediately kicked him out, refusing to treat him,” said Al-Hababi, who explained that AIDS patients prefer to hide their sickness rather than face the community.
Ministry of Health Deputy Minister Dr. Abbas Al-Mutawakil says AIDS is considered a taboo subject in many Arabic countries, including Yemen, because it was always linked to homosexual relationships “But we can't ignore the fact that this widespread epidemic exists, therefore, we established the National AIDS Program and the National Strategic Framework for the Control and Prevention of HIV/AIDS. This start is considered the first steps toward recognizing and knowing about this disease,” he said.
Al-Mutawakil reviewed the three ways HIV is spread: sexual contact with an infected individual, contact with contaminated blood (for example, transfusions using infected blood or wounds from contaminated sharp instruments) and transmission from an infected mother to her child, either before or during childbirth or through breastfeeding.
“All of us are subject to infection if we aren't careful or if we don't know what this disease is and its causes,” Al-Mutawakil noted.
In this regard and according to WHO, the availability of voluntary testing and counseling services in Yemen is very limited, although the National AIDS Program initiated a pilot testing and counseling service in July 2004. Expanded testing and counseling services are planned and a training program for counselors already has begun.
Policies and guidelines for testing and counseling services in public and private facilities are needed urgently and currently being developed. AIDS treatment guidelines as well as nursing care guidelines are being developed in accordance with international standards along with WHO support.
Dr. Mohammed Taqialdeen, former director of the National AIDS Program, says poverty and ignorance are other contributing factors in AIDS spreading in Yemeni society. “When I was working in the AIDS program, I met many Yemeni girls younger than 20 years old who were practicing prostitution.
When I warned them that they may be infected with HIV, their replies were, 'We want to give up this type of work, but do you have another job for us in order to live?' At that point, I shut up,” said Taqialdeen, who confirmed that commercial sex and sexual tourism has become common in Yemeni regions, but it's rare to find anyone who wants or dares to speak about this issue publicly. He also stressed that most who practice these types of jobs suffer poverty and illiteracy.
Taqialdeen also mentioned “unhealthy sexual relationships in marriage,” referring to the lack of condom usage among Yemenis. “We saw many cases where men, particularly those who were abroad and had sexual relations, then transmitted the disease to their wives,” he commented.
According to UNAIDS, the primary reported mode of HIV transmission in Yemen is through heterosexual contact. However, apparently, difficulties remain in achieving universal HIV screening of donated blood and adequate blood donor selection. Additionally, unsafe practices in handling skin piercing instruments is common, whether in health care settings or by traditional healers, while intravenous drug use is rare.
Travel history commonly is linked to risk of infection, but in more than half of reported AIDS cases, infection occurred among Yemenis without a travel history. Women face increasing vulnerability to HIV, as the gender gap among reported AIDS cases was closing from 4:1 in 1995 to 2:1 in 1996 and 1:1 in 1999.
It's unclear whether sexual work or homosexuality are influencing the epidemic. Among a small group of prostitutes identified by police, the HIV rate was reported at 4.5 percent in 1998 and 2.7 percent in 1999, but a 2001 report found a 7 percent infection rate.
Patients seeking rights or revenge
Feeling shame, rejection and pain, AIDS patients often choose to isolate themselves from the community. “I left my home, my work and my friends when I discovered my HIV infection,” said K.M., who was infected while working as a nurse in a public hospital, “No one knows about my infection except my brother.”
However, not all patients take this same attitude, as some confessed that they choose to “take revenge” in their own way. Sa'eed (not his real name) recounted that when people learned he had HIV, he lost his job, he was forced to divorce his wife and the owner of the house he rented threw him out.
“Once, I was upset. I had just come from a center where I met a doctor who taught me how to deal with my sickness, what I must do not to infect others, etc. I left the center and was walking on the street when I saw a barbershop. I then made up my mind. I entered the shop and asked the barber to cut and shave my hair, which the doctor advised me against doing, unless I inform the barber about my condition because there's a risk that another customer could get AIDS/HIV if the barber drew some blood from me and then used the same instruments. I don't know what I was thinking I don't know,” Sa'eed said.
He confessed that he realized that such reckless behavior would expose others to danger. He also confessed that many times, he considered donating his blood to blood banks, but confirmed that he didn't.
Sa'eed's attitude reflects the frustration, loss, blame and pain AIDS patients suffer and such emotions become stronger in a community that treats them like criminals. “We in the Human Rights Ministry receive complaints from AIDS patients. For example, a month ago, we received a complaint from an AIDS patient who was fired because of his infection. We contacted involved authorities at his work and we managed to allow him to return to his work,” said the director of the information sector at the Ministry of Human Rights, Nusiba Al-Ghashmi.
She added, “However, the Ministry of Human Rights sometimes lacks the means and the executive power to defend these people's rights because there's no law defining their rights or their duty toward society.”
The National Strategic Framework for the Control and Prevention of HIV/AIDS reveals that most HIV-infected Yemenis are married with children and their needs and rights haven't been addressed.
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