By Don Duncan
KABUL // The checkpoints on Kabul's streets and concrete barricades around its key buildings are a reminder of the war Afghanistan has been in since 2001. But beneath some of its bridges are signs of another war - the battle against HIV.
Afghan drug addicts cover their heads with scarves as they use drugs under a bridge inhabited by drug addicts in Kabul. (Ahmad Masood / Reuters)
During a recent afternoon, aid workers weaved in and out among the hundreds of drug addicts who gather daily under a bridge in the Pul-e Sought-a neighbourhood of the city to smoke and inject heroin.
Men of all ages huddle in corners, amid rubbish and discarded needles. The smell of boiling heroin combines with the stench of rotting food in the thick air.
"I began to inject because of police disturbance," said Mohammed, 22, a heroin addict for almost seven years. "Injecting doesn't take much time whereas smoking takes longer, so with injecting there is less risk of the police catching you."
The aid workers help dress wounds caused by injections. They monitor the condition of addicts in bad health and provide information on how injecting drug users can avoid some of the harmful health consequences of their habit, including how to avoid contracting HIV, the virus that can cause Aids.
Afghanistan produces about 70 per cent of the world's opium, an annual trade worth an estimated US$65 billion (Dh238bn).
At just a few dollars a gram on the streets of Kabul, many people - often to deal with hardship and poverty - are becoming addicted.
According to the United Nations, Afghanistan has an estimated one million drug users, a 140 per cent increase since 2005. Of the 120,000 who use heroin, an increasing number are choosing to inject it instead of smoking it, and this is where an HIV epidemic is being born.
The Ministry of Public Health estimates that the maximum number of HIV cases in the country is 3,000, although only 700 of those are documented. But what has epidemiologists concerned are recent infection trends developing among the country's injecting drug users.
A 2009 Ministry of Health study, conducted by Johns Hopkins University in the United States, found that the percentage of injecting drug users who are HIV positive is at 7 per cent nationally, making it a "concentrated epidemic". Infection rates among injecting drug users rise to as high as 18 per cent in Herat city.
"General society is at risk by virtue of specific groups being at risk, because history dictates that at some point it transcends that group; it always does," said Peter Graaff, Afghanistan country director for the World Health Organisation (WHO).
Afghanistan is surrounded by countries - Iran, Pakistan, Russia - that for a long time ignored the HIV risk posed to injecting drug users and now have HIV epidemics.
"What is clear is that it's going to happen [here] unless we take care of our IDUs [injecting drug users]," said Mr Graaff.
"We have to make sure that they don't get HIV and if they do, that they are taken care of properly, and that they don't pass it on. Are all the elements in place to create the barriers to transmission? The answer is no."
About 30 residential and out-patient clinics across Afghanistan treat about 7,000 people per year. Since 2005, needle exchanges, HIV testing and anti-retroviral drugs for the treatment of HIV have been available in some of these facilities. But health advocates said that more needed to be done.
"People have got to understand that being addicted to heroin is not a question of will. You need real treatment, not just people telling you that you should stop," said Olivier Vandecasteele, Afghanistan general co-ordinator for NGO Médecins du Monde.
He cited statistics from detox treatment centres around the world that show relapse rates as high as 80 per cent, and argued that Afghanistan needs more opiate substitution therapy, such as methadone, as another core pillar of its response to heroin addiction.
Last year, Afghanistan's first methadone clinic opened, on a trial basis, treating 70 addicts. Its retention rate is at the 80 per cent mark and the former heroin addicts on the programme continue to come to the clinic daily for their dose of methadone. Next page
"I tried and failed to detox eight times," said Mohammed Moussa, 42.
He has been on methadone, and off heroin, for 14 months.
"Methadone is completely different from detox, which is routine in Afghanistan. Methadone is very good for me and one of the main advantages is the reintegration into society and the normal life I have now," Mr Moussa said.
Once stabilised, and off heroin, many of the trial participants are hired by Médicins du Monde as outreach workers.
They go out to the drug dens of Kabul and educate drug users about the risks of their habit and about safer drug-taking practices.
"Many of our staff are from the community," said Dr Vandecasteele, "so they spread the message."
But increasing the use of methadone to help curb heroin addiction comes with its own set of problems.
"We know that methadone works, but what is the system of importing methadone into the country? What is the system of supply chain, of getting it from Kabul to Herat? Who is responsible for it not being diverted? These are conversations that still need to take place," said Harsheth Virk, an HIV/Aids specialist at the Kabul branch of the UN Office on Drugs and Crime.
"But we want to move faster and we want to do more. Resources are not the issue."
While government and international stakeholders may differ on how exactly to confront Afghanistan's HIV problem, they all agree on one thing: an effective response needs to happen as soon as possible.
"The real issue is do we really understand that this is our chance to get it right," said Mr Graaff of the WHO, "before it becomes the problem that is really going to overwhelm us and is going to be a very costly and very painful and very sad affair."