Iran: Brothers Change Face Of HIV, Drug-Addiction Treatment

WASHINGTON, October 3, 2006 (RFE/RL) -- Two Iranian siblings have revolutionized the way drug addicts and HIV/AIDS-infected people are treated in their country.

Doctors Arash and Kamiar Alaei were raised in a wealthy family but now devote their lives to helping the less fortunate on the streets, treating them, and counseling them on how to rejoin society and even find a spouse.

They now have clinics in 67 Iranian cities and 57 prisons and are a World Health Organization model for the Muslim world. The brothers were interviewed on September 28 in Washington after their visit to the U.S. National Institute of Health.

Arash is the director of the International Education and Research Cooperation of Iranian National Research Institute of Tuberculosis and Lung Disease (NRITLD) that collaborates with WHO-EMRO. His brother, Kamiar, is executive director of an Iranian nongovernmental group (Pars Institute) working on the prevention, care, and support of carriers of HIV and other sexually transmitted diseases, as well as intravenous drug users. He is currently a visiting fellow at Harvard University's School of Public Health.

RFE/RL: You call the clinics "triangular" because they treat three serious problems. What are these? And what does the World Health Organization [WHO] think of your model?

Arash Alaei: The triangular clinics are working in the field of [sexually transmitted infections (STI)], HIV/AIDS, and drug-addiction programs. These clinics offer clients harm-reduction boxes such as needles, methadone, condoms, treatment for sexually transmitted infections, antiretroviral therapy, and other medical services for people living with HIV/AIDS. Three years ago, an international adviser from the World Health Organization visited [our] clinics and accepted us as the "best practice" model for countries in the Middle East and North Africa.

RFE/RL: In 1996, a program similar to yours -- a national AIDS hospital -- was begun by a member of Iran's parliament. The program failed, and the lawmaker was not reelected. Why do you think he failed where you have succeeded?

Kamiar Alaei: This member of parliament was a physician, and he thought that all of the AIDS patients needed in-patient care. So he wanted to establish a national AIDS hospital. But he didn't have the acceptance of the citizens in his own city. He wanted to start from the top and push to the bottom, without any situational analysis -- what's the real need, what's the need assessment? He was not successful. So when we started our project, we started at the bottom and went step by step. We wanted to know: what is the main need of our target group? And based on that need, we expanded our project. And step by step, we involved different parts of the community.

RFE/RL: As a nongovernmental organization, you operate outside the auspices of the government. Where do you get your funding? Do you receive any government support or money from international donors?

Arash Alaei: The triangular program is under the observation of medical universities, [and] medical universities have a specific budget for different activities in the field of health. And three years ago, the universities, with the collaboration of the government, applied for a [United Nations] Global Fund [ UN Global Fund to Fund to Fight AIDS, Tuberculosis, and Malaria] budget. And [now], the total budget is coming from university budgets and the Global Fund.

RFE/RL: Now to a very sensitive topic: sex education for Muslim school-age girls. What kinds of skills are needed to talk to these girls about such matters? How did you even gain access to them in the first place, to begin to educate them?

Kamiar Alaei: I think this sensitive issue is not limited only to Muslim communities. Different communities in different countries have some concern regarding unsafe sex, education for their children. When we wanted to start our project we had some training courses for the teachers and the parents, to [tell them] what's going on, and which topics we wanted to [cover]. And we started with the family-planning issues, not only safe sex or unsafe sex. And we wanted to highlight what's true related to HIV/AIDS -- different transmission [methods]: blood transfusion, needle sharing. And one of [the transmission methods] was unsafe sex. So we didn't want to highlight a very sensitive issue, we wanted to put it in a curriculum. And in our curriculum, we had some training about it: If in the future you get married, or you have sex, you should have some devices such as condoms. So it's very important how you teach them. And if you want to have intervention in the schools, before that you involve the parents and the teachers.

RFE/RL: Was there any resistance to your plans to do this?

Kamiar Alaei: When we started, yes, [there] was resistance. It was related to the culture. It was related to the different cities' cultures and attitudes. But, step by step we started our pilot project. And we [found] success, and after that we could expand to other cities.

RFE/RL: That brings me to my next question, which concerns the involvement of religious leaders in the kind of prevention activities you engage in. I was particularly fascinated by something Iranian judiciary head Mahmud Shahrudi said, which was that no one should abandon HIV-prevention programs in cities. What did he mean?

Arash Alaei: I think all leaders would like to help people, but maybe some of them don't know [what they should do to] support people. So it's the role of experts to be close to leaders, to show which way is the effective way, which way we can expand a program to [help make] a better future for the nation. One of the problems was, in the 1980s and 1990s, there was a gap of [communication] between experts and leaders [on the subject of] drug users. [Since] 1999, in Iran we have a committee with members from the universities, government, and the judicial system; and in this way, we have [a way] to [locate] a target group. With this negotiation, the attitude of the judiciary system and of the prison organization changed. And now, they support methadone treatment inside of prisons. And Ayatollah Shahrudi sent a letter to all the courts and judges saying, "You must support needle exchange and methadone maintenance therapy in the cities." So I think we should know the culture and attitude of leaders, and through close contact and negotiation maybe we will [develop] better [programs] for the future.

Arash Alaei: You know, we have rigid attitudes for safe-sex education in the Middle East and North African countries --[in] some of them. I think we should know what [the barriers are]. And we should revise guidelines and operational guidelines, based on the need and based on the time. If we have one guideline for a long time, maybe we find new issue, and we should revise it to have health, to have safety for people. So we have [now] rigidity from some of the area in Iran and different countries in the Middle East and Central Asia for safe-sex education. But I think [with a] peer approach -- by for example, meeting with religious leaders, between scientific [people] -- maybe we will find a way to expand this activity in the region.

RFE/RL: There is still deep denial in Islamic countries of HIV/AIDS, especially in Persian Gulf countries. Has there been any collaboration between you and your colleagues in these countries, and, if so, what has been the outcome?

Kamiar Alaei: It's really an important issue. Because the main attitude in the region is that HIV is a Western disease; so we don't get HIV. So when we broke the silence of denial in Iran and we [successfully got] the support of the religious leaders, we could motivate other countries in the region. So we had a training courses for the key persons in other countries: Afghanistan, Tajikistan, and other countries. And we invited the other experts to come to Iran and we showed [then] the outcome of our project and how we could motivate the government to accept the project. So by this way, we have a lot of memorandums with different countries in the region and they wanted to send their experts to be in our training courses. And it was not only limited to the region -- we had a lot of experts from Indonesia, who came to Iran and after that they did the same [project] in their country.

Arash Alaei: I think all religious leaders don't have similar attitudes. We should find positive people -- religious leaders, leaders of different countries. And by connections and discussion with them, they can find a way to motive negative leaders, and negative religious leaders.

RFE/RL: The official number of drug addicts in Iran in late 1980s was around 140,000. Now there are reports that as many as 3 million-4 million people are addicted to drugs. Is this a result of the country ending its denial of the problem, or are that many more people really addicted?

Arash Alaei: One of the gaps in Iran is that we don't have scientific research to find what [caused] the increase in the rate of addiction in Iran. But we should [consider] different points. One point was eight years of war [the 1980-88 Iran-Iraq War]. The second: decreasing economy. Third: 5 million unemployed. Fourth: different mental-health disorders in Iran. So I think it's a multisectoral problem. And we don't have any scientific research to know what the problem was. We would like to do [more] in this field, but we have a lack of knowledge to design a national program of research to find [the reason] for the increased rate of addiction in Iran. One of the main points is Iran has a 1,300-kilometer border with Afghanistan, which is one of the highest producers of opium [in the world]. So access to drugs and the drug traffic is coming from Afghanistan to Iran and then other countries. So I think this problem is coming by multisectoral problems.

RFE/RL: Can Iran's experience help countries like Afghanistan and Tajikistan, given the fact that they have the same language and the same culture?

Arash Alaei: I think HIV/AIDS harm-reduction programs for drug addicts and [people with] tuberculosis need to have regional activities and regional cooperation. So for regional cooperation, we need to have similar activities. Iran, Tajikistan, and Afghanistan have similar languages, [common] borders, so we think one of the approaches should be that [similar] countries [should] be part of the global action. By this way, we have had several meetings, conferences, and training courses for Tajik colleagues, for Afghan colleagues, in Tehran and in Tajikistan. And we hope to design a similar program in Afghanistan in the future.

RFE/RL: Most HIV/AIDS materials that deal with prevention and education are designed for people who have at least a little education. But in Iran and Afghanistan, we cannot assume that everyone is educated. How do you reach these people?

Kamiar Alaei: It's [a] very important issue because, based on our study, we found that the majority of [people] in the vulnerable group for HIV/AIDS are illiterate, or they have a [very] limited education. So we have [a] peer-education approach and peer-counseling approach. We have some ex-drug users or people living with HIV/AIDS; we have counseling with them, and we motivate them; and after that, they go to the shooting galleries or other high-risk places and encourage the other high-risk population to come to our clinic, or they provide our services such as condoms, needles, methadone in that area. We have to have face-to-face contact; we want to have a verbal approach instead of having materials such as newspapers and pamphlets.

RFE/RL: Have you ever noticed any inequality in the way an HIV/AIDS-infected person is treated, based on their education level, religion, or other factors?

Arash Alaei: The program is for health, and health-care workers are working for all people -- different nations, different religions. [The Iranian poet] Sa'di says nations are a symbol of bodies. If you have problem with one organ, other organs cannot do. So I think Jewish, Christian, Muslim -- all people must live together and health-care workers are working for all without [regard] to equality or other [issues].

RFE/RL: How much does antiretroviral therapy in Iran cost?

Arash Alaei: All programs in the triangular clinics are free of charge, and the medical university supports the budget of the clinic, such as antiretroviral treatment, needle exchange, methadone treatment, condom promotion, and all inpatient programs.

RFE/RL: That means that an infected person can come to one of your clinics and ask for medicine, and needles, and everything?

Arash Alaei: Yes, yes. And in the clinic, we don't ask for ID. We think all programs [should be] anonymous, because we think we should decrease stigma. We don't need their name, we don't need their address. We [only] would like to support health care of their life.

RFE/RL: You provide medical care and treatment to HIV/AIDS patients and drug addicts, but you also sometimes try to bring them together in a kind of matchmaking service. What is your motivation for doing this?

Kamiar Alaei: As you know, our mission is not limited to care. We want to change the behavior of our patients, and [of] high-risk groups. So when we motivate them to come to be tested, to prevent transmission of their infection to the community, we have to have respect for them. And they have the right to get married, and to have a job. We have to increase the quality of life for them. So by this way, we thought, what are their main problems? And we wanted to have some solution, and some options for them. So one of their problems was matchmaking. So we wanted to provide them and encourage them -- that you have the right to get married. But it's very important that you tell your partner about your problem; because you have to have a long marriage, not a short, one-night thing. We have some programs for them, so some people get together who are living with HIV/AIDS -- and even some high-risk groups who are not HIV-infected, [as well]. And some of them get married to each other; but they use condoms, and if they have a failure, we have post-exposure prophylactics for them. We have a lot of couples -- one of them is [HIV-]positive and one is [HIV-]egative, and [in] five years [neither] of them have been infected. So by this way, we encourage them to be in the community.

RFE/RL: Do you have any goals to expand the program?

Kamiar Alaei: Yes, my mission is that even if there is one HIV case in the region, or in the country, or in the world, they should have the right to receive all of the services and to know what's going on [with their health]. So we want to, as much as possible, encourage the high-risk group to be tested, and to protect them. And it is not only in Iran or in the region. This is a global health...[problem]. And for HIV/AIDS, we have to involve different parts of the community -- for education, for communication, for social support. We hope that [someday] in the future we don't have any new HIV cases in the world.

Arash Alaei: One of the other goals is to be part of the global action. We would like to have an exchange of experience with different countries, with different experts, to know what is their model and to show our model. We think this program, and the health program, should be part of the exchange of experience by different people in [all] different areas.