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Are You at Risk?

ABDALLA F. HASSAN | Egypt Today | November 1998 | pp. 84–90

With infection by heterosexual contact and blood transfusions the two biggest causes of AIDS in Egypt, think again before you dismiss the idea that you could be at risk, and consider the dilemma of those infected.

The only people who should worry about contracting AIDS in Egypt are homosexuals, foreigners and intravenous drug users, right? Wrong. Contraction of the disease from tainted blood, imported blood products or unsterilized surgical instruments is the biggest source of transmission after heterosexual sex, according to government figures.

Less than two years ago, dozens of people were infected with HIV while undergoing kidney dialysis at a Cairo hospital. Although the national blood supply has been screened for HIV since 1986, there are still problems. The first cases of HIV in Egypt were reported that year, six years after the epidemic captured international attention. As of May 1998, the Ministry of Health had officially recorded 680 cases of Egyptians infected with HIV over the past 12 years. Of those, 286 have died and 183 have begun to exhibit the symptoms of AIDS. Heterosexual relationships accounted for 51 percent of reported cases; blood transfusions for 20 percent; homosexual relations for 14 percent and intravenous drug use for 10 percent, according to government records.

Using a statistical model of known risk factors and HIV’s long incubation period, the World Health Organization (WHO) estimates the number of adult Egyptians (aged 15 to 49) infected with HIV at 8,100, a figure much higher than the government reports, and one highly contested by the Ministry of Health. Furthermore, WHO calculates that 5,400 adults and children have already died of AIDS in Egypt.

Despite efforts to increase public awareness of the deadly virus, many Egyptians continue to believe that AIDS is only transmitted by foreigners and is a problem outside their everyday realm of concern. In a renewed effort to counteract such misconceptions and stop the spread of AIDS, several non-governmental organizations (NGOs) and government groups are now stepping up their efforts.

This month NGO Caritas Egypt is launching a two-year program with the Ministry of Social Affairs to train more than 700 youth and women peer educators in 15 governorates to spread the word about AIDS, reproductive health, sexually transmitted diseases and sex education. Education and outreach have been core elements of prevention programs in Egypt since the virus was identified, but experts say more is needed to be effective.

On December 1—World’s AIDS Day—Mexican Ambassador to Egypt Hector Cardenas will host a gala dinner to raise money for a Caritas facility to provide the first source of confidential and anonymous HIV testing and counseling in Egypt. Alexandria’s Egyptian AIDS Society, with support from UNICEF, will also publicize World AIDS Day with a month-long program of youth projects, plays and poetry. Channel Five will also get involved by airing programs on AIDS during December.

“Prevention and detection are the ways you can start tackling the problem,” says Cardenas. “It takes a long time to make people aware of this sickness, particularly because nobody thinks he is going to suffer from it.”

Egyptians with AIDS

For the past two decades, Insaf Migahid has been a nurse at Abbassiya Fever Hospital, one of 107 public hospitals with staff members trained to care for AIDS patients. Half of her years there have been spent tending to patients in the hospital’s AIDS ward, established in 1986 with two beds, and expanded in 1997 to six beds in order to handle the increasing number of cases. Migahid has seen how AIDS patients gradually waste away physically and emotionally.

“A patient who finds out he is HIV-positive enters into depression,” she says. “His relatives begin to distance themselves from him. Visits decrease. We try to relax him emotionally, to talk to him, to bring him closer to God, to have him pray and read the Quran.” At the terminal stage of the illness, she says, the patient requires constant care.

Migahid points to one of the patients who has been at the hospital for 20 days. “He is due to go home today. He is going to live his normal life. We teach him how to live with his family, to care for his family, sister, mother, children, to take care of the ways of infection.” The HIV patient she is referring to sits outside, sipping a glass of tea. His eyes project a distant gaze. His tired, bearded face reflects the emaciation often associated with his illness. This is the first time he has been hospitalized for AIDS, despite the fact he believes he was infected six years ago at Demerdash Hospital in Ain Shams during an appendectomy.

More than 650 health care professionals have been trained to treat HIV patients. Each hospital that cares for AIDS patients has three physicians and three nurses trained for AIDS clinical and nursing care, explains Dr. Nasr M. El-Sayed, manager of the Ministry of Health’s National AIDS Control Program. Private hospitals often have no trained staff to treat those who are HIV-positive.

General Manager of Abbassiya Fever Hospital Dr. Yahya Ahmed Sultan doesn’t think AIDS is a major problem in Egypt. After all, there are only a few hundred reported cases in a population of 65 million, he says. “Liver diseases are more prevalent than AIDS,” Dr. Sultan points out. “Hepatitis B is 100 times more contagious than AIDS, and Hepatitis C is 60 times more contagious than AIDS.”

Treatment for the Afflicted

For those people who live in Egypt and contract HIV, readily available treatments lag far behind those in other countries. The Egyptian government does not officially allow the import of, or subsidize the cost of, the life-prolonging combination antiviral therapy, which reduces the amount of virus in the body and delays the onset of AIDS. While treatment for opportunistic infections (diseases related to AIDS) is available and free at public hospitals, the cost of the new combination of the three drugs which are widely available in other countries, is deemed too high to be covered by government resources. Costs run to about LE 4,000 a month for the treatment of one patient. Moreover, the follow-up tests are costly and the side effects need to be carefully monitored.

“Patients with weak immune systems acquire respiratory infections, fevers of unknown origin, sores in the mouth and cancers,” says Dr. Sultan. “Tests are done and the ailment is treated accordingly. The antiviral drugs are not present in Egypt. We only treat the illnesses associated with immune deficiency.”

The absence of antiviral medication in Egypt angers the families of people infected with HIV. “These medicines help patients to live a better life,” maintains the brother of an HIV-positive woman. “We want to give her a chance for life. Why does the minister of health prevent this?” The family cannot afford antiviral treatment and public hospitals offer no solution. “She is waiting for a cure, or death,” says her brother.

Advanced methods of treatment are only available for those who can afford them. About 15 HIV-positive individuals in Egypt are currently taking antiviral drugs and are paying the full price of their medication and treatment, according to Dr. El-Sayed. Only two pharmacies, Aly and Aly and El-Arabi, both located in downtown Cairo, are known to carry the medication. HIV drugs are not on the list of drugs allowed for import.

In addition to prolonging people’s lives, making antiviral treatment available may also have less obvious benefits. “If medication is provided free of charge, then people will feel there is a reason to get tested—because they can be treated,” explains Jocelyn DeJong, program officer at the Ford Foundation, which has funded numerous AIDS and reproductive health projects in Egypt. “There will be many more people coming forward to get tested because they may be at risk. It means that treatment is not only treatment; it is prevention.”


Getting Tested

An HIV test at the Ministry of Health’s AIDS testing facilities costs LE 20 to LE 30, and the results are available between 24 hours and three days later. More than 250 private laboratories also offer the test for LE 80 to LE 100, but they are required by law to report positive results to the Ministry of Health.

“What scares people is the lack of anonymity,” says Wahba I. Ghaly, AIDS program director at Caritas. “The test in Egypt is not anonymous yet.” Fearing scandal, or harassment in the event of a positive test, many potential HIV carriers choose not to get tested. Furthermore, private labs in Egypt do not offer pre- and post-test counseling for individuals who do get tested.

Education: What Is Being Done?

While treatment remains costly, an inexpensive preventive tool against the spread of HIV is education. A study published in a 1998 volume of Eastern Mediterranean Health Journal shows that awareness of AIDS in Egypt is much higher than the awareness of other sexually transmitted diseases. While more than 90 percent of the 1,100 students aged 13 to 20 polled from Monoufia, Beheira and Beni Sueif said they know nothing about syphilis and gonorrhea, only 10 percent claimed they knew nothing about AIDS. Yet, while the majority did know something about the virus, the facts were hazy: 37 percent of males and 27 percent of females thought that homosexuality causes AIDS.

Socially conservative attitudes in the Middle East make it difficult for governments to address risky behavior directly, often making NGOs more effective in reaching out to high-risk groups. Several NGOs are making significant inroads in educating the population about AIDS. The Alexandria-based Egyptian AIDS Society, founded in June 1993, has raised the public profile of AIDS by appearing on local television programs, sponsoring poster competitions for school children, and promoting other educational and artistic events. Working in collaboration with government bodies and international health organizations, the group has reached out to some of the marginalized members of society such as prostitutes and residents of slums and shantytowns.


Among the first projects it worked on (in collaboration with WHO) was to educate prostitutes about how to protect themselves from AIDS. Educating factory leaders and businessmen about AIDS and the workplace rights of HIV-positive employees is another priority of the group. “People withdraw at the mere mention of the word ‘AIDS,’” says Sawsan El-Sheikh, president of the Egyptian AIDS Society. Through women’s associations and family planning centers, the Egyptian AIDS Society (with funding from UNICEF) has reached out in Alexandria, Minia, Assiut and Sohag to educate women in slums about protection and other issues, including prenatal care and female circumcision.


Affiliated with the Rome-based Caritas Internationalis, Caritas Egypt is another development and relief organization with project offices in Cairo, Alexandria, Minia, Assiut and Sohag. The Caritas HIV/AIDS Counseling Center opened in 1995, and its drop-in service and outreach projects focus on specific target groups such as youth, women, intravenous drug users, delinquents in juvenile institutions, street children and commercial sex workers. Ghaly remembers a discussion with one sex worker that illustrates the need to openly teach about prevention. “I asked him if he uses condoms,” recalls Ghaly. “He said, ‘Of course,’ and pulled a used condom out of his pocket. I told him, ‘You cannot use a condom twice.’ He answered, ‘Do you think I will go out and buy a condom every time for LE 2?’”


There have been many other obstacles to overcome; one long-held misconception about HIV transmission was actually reinforced by a 1987 film entitled El-Hob fi Taba (Love in Taba), released when few facts on AIDS were available. To many Egyptians, it confirmed the notion that foreigners are the source of the infection. For years, annual HIV testing has been required of foreign nationals working or studying in Egypt, although it is not required for Egyptians. Thus far, 395 persons—the overwhelming majority from African countries—have tested positive for HIV and were deported to their home countries, according to the Ministry of Health.


Educating people about AIDS must begin through health awareness at the local level, stresses Dr. Sami Sidarous, project officer at Catholic Relief Services, one of the donor organizations for Caritas projects. “The first thing is to break down the sexual taboo and to spread the right information to the young generations.”


Drug counseling and rehabilitation are other Caritas initiatives associated with AIDS prevention. Narcotics Anonymous, a support group for former and active drug users, emerged from group counseling sessions arranged by Caritas. Most intravenous drug users in Egypt get their high from a mixture of stimulants and depressants colloquially known as “Max,” dispensed by a dealer from a shared syringe. Caritas aims to fight drug use and educate about the dangers of sharing syringes. Another anonymous support group for homosexuals is in the development stage, which could also serve as a forum to discuss safe sex practices.


Ministry of Health Efforts

The Ministry of Health has also gotten involved, most notably by establishing the National AIDS Control Program when the first HIV cases surfaced. The program has conducted surveys, education and awareness campaigns, promoted a telephone hot line, and provided clinical care for HIV patients, as well as counseling and support for HIV-positive individuals and their families.


Billboards in metro and bus stations announcing, “Ask about AIDS,” are perhaps the most visible reminders of the Ministry of Health’s AIDS hot line, the first in Africa and the Middle East. Since its inauguration in September 1996, the hot line has received between 30 and 100 phone calls daily, answered by 12 trained staff, including psychologists, social workers, physicians and health educators. Calls are kept confidential and anonymous. Plans are in the works to expand the service to Alexandria and Upper Egypt.


Most callers are young teenagers, and about 80 percent are male, says Dr. El-Sayed. “But the most important group is teenage girls. They need to know. They are shy about asking their mother or their sister, but they can ask through the hot line. They can ask about AIDS. They can ask about sexual issues and can find the right answers.”


Caritas also staffs an HIV/AIDS help line with trained counselors who provide information on AIDS and sexually transmitted diseases. Callers are encouraged to meet counselors face to face.


Since 1993, AIDS education has also been integrated into the secondary school curriculum. In addition, more than 30 publications on AIDS published by U.N. organizations are distributed through the Ministry of Health. The Egyptian Red Crescent Society and the ministry have produced 11 television public service announcements and six radio spots on the transmission and prevention of AIDS. Although it’s difficult to talk about sexual issues openly, the media has been essential in diffusing health information.


As a result of all these efforts, discussion about AIDS is evolving in Egypt, but health educators and activists working in the field stress that there is still a long way to go. Even the widely seen, one-minute television spots have not been able to provide enough information about AIDS to dispel common myths, and some educators argue that the media could play a much bigger role. “More is being done at a very fast rate,” says Naglaa Shams, unit manager at the Center for Development Services, which works with NGOs to provide training and technical assistance. “This time two or three years ago, AIDS wasn’t an issue that could be discussed very easily. People have worked to make it more palatable to the community.”


Despite this, however, DeJong laments: “[AIDS] is still associated with foreigners; it is not perceived as something also experienced by Egyptians. I think that every country where an epidemic has struck has realized that the sooner they deal with it as a national problem, the more effective they are.”

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