Coming clean on AIDS is key to preventing epidemic

Lebanon’s rate of infection may be low, but failing to deal openly with social stigmas could exact heavy toll in near future

By Rhonda Roumani From The Daily Star

BEIRUT: Once a week, at a small center in the suburbs of Beirut, 10 to 15 HIV infected patients sit in a semi-circle on plush burgundy sofas to talk freely and openly about their disease. HIV and AIDS posters adorn the walls and an extensive library provides visitors with books and magazines in English, French and Arabic on everything related to HIV and AIDS. A tinted sliding window can be pulled out to divide the room if privacy is needed. For many of these patients, the solitary room is a safe haven where personal problems are shared, treatment options discussed, and most importantly, their secret well kept.

Abboud, 30, is a regular visitor. When he found out that he had contracted the HIV virus from having sex with his partner about a year and a half ago, he tried to go to one of his closest friends.
“I thought he would support me,” said Abboud, an engineer. “He was shocked. He did not ask me how I got it. I thought he would understand.”

Abboud’s friend refused to provide him any support. Since then, the young man has kept the truth about his health confined within the walls of the center.

“This is the only place they can talk about AIDS in an open way without having the stigma put on them,” said Nadia Badran, a social worker who heads the support group run by Soins Infirmiers et Developpement Communautaire (Health Care and Community Development), a non governmental organization committed to helping patients with HIV and AIDS. The group received a small grant nearly two years ago from Sidaction, a French organization, to start the support group in Lebanon. A similar support group is currently operating in Morocco.

A recent report by the World Bank on HIV and AIDS in the Middle East found that although the rate of HIV and AIDS remains low ­ 0.3 percent of a population of nearly 300 million ­ the region is at risk of experiencing a sharp increase.

“We are all in a situation of low prevalence, but those numbers are continually increasing,” said Mustafa al-Nakib, the director of the National AIDS Control Program, which operates in conjunction with the Health Ministry and the World Health Organization. “We are all involved and concerned about the progress of the disease.”

According to statistics compiled by the National AIDS Control Program, there are today 765 reported cases of HIV and AIDS in Lebanon, a country of 3.8 million people. The program, run by the Health Ministry, depends on physicians and hospitals reporting cases. Thus, the real figure for HIV/AIDS is likely to be higher. In 2001, the program had registered 650 cases. This year, 47 cases have been reported. The number is expected to rise by the end of the year.

Of the 765 cases, 75.7 percent were transmitted sexually, with 53.8 percent of these transmitted through heterosexual sex and 10.6 percent through homosexual sex, with some 30 percent declining to specify how they contracted the disease.

Lebanon, according to Nakib, is among the most proactive countries in the Middle East, along with Morocco and Tunisia, in dealing with HIV/AIDS.

“If you compare Lebanon to Syria, Jordan or Saudi Arabia, we are more open and expressive,” said Nakib. “So it is easier to combat the disease.”

To that end, Lebanon has six HIV/AIDS hotlines and more than 15 NGOs offering educational outreach to schools and universities. The Health Ministry offers free medication to all HIV positive Lebanese citizens and they often distribute condoms in bars and clubs. Certain NGOs cater to high-risk groups, such as sex workers, IV drug users, and the gay community.

Early next year, the National AIDS Control Program, in conjunction with the United Nations Population Fund, plans to release a five-year national strategy for combating AIDS, providing guidelines and actions for NGOs and governments to implement. Morocco has already issued a national strategic plan, while Syria, Jordan and Egypt are in the process of elaborating theirs.

But religious and cultural stigma associated with the virus may help keep HIV/AIDS underground, making it more difficult to target. With the disease threatening the youth and gay populations, experts fear the spread of the virus is still in its early stages.

According to statistics from the National AIDS Control Program, 58.4 percent of those who contracted HIV/AIDS were between 31 and 50 years of age.

HIV/AIDS was first detected in Lebanon in the early 1990s with the return of migrant Lebanese, especially from sub-Saharan and West Africa, where AIDS had already reached critical levels. That population was older.
But the new at-risk population may in fact be the youth. According to statistics released by the National AIDS Control Program, the number of HIV positive cases between the ages of 15 and 24 has increased four fold ­ from 2.5 percent in 1995 to 10.6 percent in 2003.

Jack Moukhbat, a member of the Lebanese AIDS society and a physician who handles HIV-related cases, said he is concerned with two trends that have emerged over the last three or four years.

“One of them is the young heterosexual population of Beirut, of Lebanon,” said Moukhbat, in a small office at Rizk Hospital in Achrafieh.

“There is an increasing demand on sex and frequently what is interesting is that it is seldom acquired from local sex workers. It is either acquired from abroad, or it is acquired from sex between people who are not for commercial sex.”

However, the most frightening spread of the emerging epidemic, according to Moukhbat, is taking place in the young homosexual community.

“I think one of the major problems here is that the gay community has never been seriously targeted by educational campaigns over the years,” said Moukhbat. “For several reasons ­ for bigotry, discrimination, because of the law.” Lebanese law considers homosexuality a misdemeanor.

“A lot of people cannot come forth, cannot be tested, cannot be reached easily by educational campaigns,” said Moukhbat.

But some organizations are finding new, innovative ways to reach these hidden, often scared communities.
Fadi is a peer educator for MSM ­ or what educators call men having sex with men. Last year, for a period of one month, Fadi hit the pavement to educate the homosexual community and male sex workers about HIV/AIDS. He visited clubs and bars, talked to male sex workers on the streets, and distributed pamphlets and condoms.

He estimates that some 15 percent (out of approximately 250 gay men encountered) had sufficient knowledge of the disease. However, reaching out to sex workers and homosexuals was challenging due to the fear both groups had of being arrested, thereby making it difficult to gain their trust.
“The best way would be to stop the legal or state discrimination against the community,” said Fadi. “Everybody is so scared that there would be an undercover policeman talking to him or waiting around the corner. Once the gay population feels secure about living in this country, I think it won’t be a problem for them being contacted about HIV.”

According to Moukhbat, the intolerance extends to all people who have HIV/AIDS, even from within the health field itself.
A poll of 1,000 people released by the National AIDS Control Program found that 60.6 percent of those who responded favored publicly releasing the names of all HIV/AIDS patients, so that society could protect itself better.

According to Moukhbat and others dealing with HIV/AIDS, stories of ignorance are common. It took one of his patients three days before he found an emergency room that was willing to treat his broken shoulder.
“I referred him to a governmental hospital simply for shoulder surgery, but he was rejected because he has HIV,” said Moukhbat. “He entered a small hospital without telling people he has HIV, otherwise they would have rejected him.”

One of the biggest problems for HIV/AIDS patients in Lebanon is finding hospitals and doctors willing to treat them. Patients must also deal with the sudden shortages of medicine in Lebanon. The Health Ministry offers HIV/AIDS treatment free of charge to its registered patients. Most NGOs have committed some portion of their budgets to supplementing the ministry’s program, which often runs out of medicines because of budgetary problems. The drugs cost the ministry up to $1,500 per month per patient, although this cost could be reduced to $150 following a recent deal struck with a drug company.

Abboud said the issue of drugs has dominated the support group’s discussions lately. “Now we are talking a lot about medications because there are no medications in Lebanon,” said Abboud, who had to pay $700 for his medication last month because it was not available at the ministry. For four months, Abboud was without medication because it was not available anywhere in Lebanon. On Wednesday, he heard the ministry had finally received a shipment. But when he inquired, it was still unavailable.
William, another HIV patient, is trying not to think about the future. He doesn’t have to take medication yet, but once he does, he is not sure he’ll be able to afford it. Because of constant Health Ministry short-falls, William is registered to receive his medication from social security. However, regulations stipulate that someone at his workplace has to sign off on his medication.

“I don’t want anyone to know,” said William, 35, who discovered he had HIV a year ago. “If you want it to be hidden, you have to pay for your therapy … but it is over my salary. I’m not going to think about it because it is really scaring me ­ I can’t be depressed now. It’s too early to think about it.”

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