TEHRAN, Iran—It took 30 meetings just to create a slim AIDS-awareness handbook for Iran's conservative high schools. A drawing of a condom disappeared early on; a photo of a syringe survived. A mention of sexual transmission was approved, but only with a reminder that sex before marriage is forbidden.
Even after the government's wordsmiths were satisfied, AIDS workers in Tehran had to take the book south to the holy city of Qom, the spiritual center of Iran's all-powerful clergy. To everyone's surprise, the clerics endorsed it.
Iran's fight against the spread of HIV hinges on a delicate give-and-take between activists who talk frankly about sex and drugs and the ruling ayatollahs, who fiercely protect the Islamic Republic's puritan image. The combination has made Iran the Middle East leader in preventing HIV and AIDS.
The country's program, which melds deep-rooted religious values with cutting-edge research, is being exported to Afghanistan, Lebanon, Iraq, Syria, Sudan, Pakistan and other Muslim nations.
"I told my colleagues in the United Arab Emirates, `You're not more rigid than us. We're the only country in the world where it's the law to wear a head scarf, where it's a pure Islamic government, where you can't drink,'" said Dr. Arash Alaei, one of Iran's most respected AIDS researchers. "`If we have a prevention program, why don't you?'"
In a region where other Muslim governments ignore the epidemic, quarantine HIV-infected people or preach abstinence as the only solution, Iran's approach is especially remarkable.
It still doles out floggings to Iranians caught with alcohol, but it gives clean syringes and methadone treatment to heroin addicts. Health workers pass out condoms to prostitutes. Government clinics in every region offer free HIV testing, counseling and treatment. A state-backed magazine just began a monthly column that profiles HIV-positive Iranians, and last year the postal service unveiled a stamp emblazoned with a red ribbon for AIDS awareness. This year the government will devote an estimated $30 million to the program.
One of Iran's most acclaimed advances comes from its notoriously secretive network of prisons, where hundreds of drug-addicted inmates sometimes share the same makeshift syringe to inject heroin smuggled in by guards or visiting relatives. In a startling acknowledgment of sex and drugs even in its most closely guarded quarters, the Tehran administration has made condoms and needles available in detention centers across the country.
"Iran now has one of the best prison programs for HIV in not just the region, but in the world," said Dr. Hamid Setayesh, the coordinator for the U.N. AIDS office in Tehran. "They're passing out condoms and syringes in prisons. This is unbelievable. In the whole world, there aren't more than six or seven countries doing that."
Iran's national response still faces obstacles, especially when it comes to reducing the shame and isolation that HIV-infected Iranians endure. The government reports 12,000 people with HIV; health workers say the real figure is closer to 70,000. Many HIV-positive Iranians are reluctant to tell relatives and co-workers about their diagnosis, fearful they'll be cast out of their homes or fired from their jobs.
But the program's architects are turning to the clergy for help in combating the stigma of a disease that's inextricably linked to sex in the minds of many Muslims.
A year ago, Setayesh sent questionnaires to the most influential Shiite Muslim clerics to elicit their views on condom use, government's role in AIDS prevention and how society should deal with HIV-infected Iranians. He received 17 handwritten responses, nearly all in favor of the government's efforts. The U.N. AIDS office plans to compile them into a book to be distributed at mosques.
"You should not discriminate against these people," one mullah wrote. "You have no excuse not to use condoms," another responded. "You should pay for this from the public funds of the government," an ayatollah ordered.
Iran's first reported HIV infection came in 1987, when a hemophiliac child tested positive after a blood transfusion. The government formed a national committee, but it wasn't until nearly a decade later that it began to take prevention seriously, said Alaei, one of the pioneers of Iranian AIDS research.
In 1997, the government tested for the virus among high-risk populations such as prisoners, truck drivers and patients with other infectious diseases. The highest rate of infection was in Iran's prisons, one of which was in Alei's hometown of Kermanshah, northwest of Tehran. Alaei was startled to learn that 400 cases had been detected there.
In 1999 he and his brother, Kamiar, had just finished their medical studies. They persuaded the nervous director of a local medical school to give them space for research.
"We had one room, the files of 400 infected prisoners and one office worker. We couldn't even have a sign on the door," Alaei recalled. "It was top secret."
The Alaei brothers used the prison files to scour the city for HIV-positive convicts and their families. After the government-testing program had confirmed the infections, he said, most of the men received no care or counseling. By the time Alaei tracked them down, 176 of the 400 already were dead. Most had committed suicide.
"If they were released, their families had disowned them. In jail, other prisoners avoided them and prison workers who didn't know about transmission just kept them in one room and rolled in a food cart for their meals," Alaei said. "When we shook hands with them, they cried. Before that, everyone had rejected them."
When Kermanshah's representative in Parliament asked the government to build an AIDS hospital, residents ransacked his office. Alaei said they were terrified that an AIDS facility in their city would turn the country against them, making them the butt of jokes and limiting their children's chances for marriage. The legislator lost his seat in the next election.
Then the wives of Kermanshah's addicts began testing HIV-positive, 35 in the first year alone. Next came the children. The families were terrified. Opposition to an HIV clinic dried up.
With community and government backing, the Alaei brothers soon expanded their operation to two rooms, then the entire floor of the medical school and, finally, to cities throughout Iran. The World Health Organization named Alaei's clinics the best-practice model for the Middle East and North Africa.
"Paying attention to the programs and progress of the developed countries is very good," Alaei said. "But you should never forget to base your program on your own society, your own demographics, your own religion and culture."
With the election last summer of the ultraconservative President Mahmoud Ahmadinejad, many AIDS workers feared a rollback of their hard-won progress. Indeed, some new Cabinet members expressed disapproval of the national campaign's growing boldness in addressing the sexual transmission of HIV.
Ahmadinejad's health minister told a news conference that AIDS wasn't a priority for the government. The education minister stopped the printing of pamphlets for young students, saying they needed revisions, Setayesh said. Another government official told Alaei that the red handbook he'd worked so hard to publish was embarrassing to Iran's image. It was uncertain whether distribution would continue.
Then Iran's characteristically unpredictable president surprised AIDS workers at a governmental meeting on the intertwined problems of opiate addiction and HIV by coming out in favor of distributing methadone.
AIDS-prevention specialists admit they can't know whether that remark signals that Iran's program won't be scaled back, but researcher Alaei, for one, says he's optimistic that progress will continue.
"Four years ago, if you talked about condoms, you couldn't go on the air," he said, referring to state-run television. "This year, they said, `You are free to say what you like.' I just kept saying, `Use condoms. Use condoms. Use condoms.'"
(c) 2006, Knight Ridder/Tribune Information Services.
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