www.thelancet.com Vol 370 December 22/29, 2007 2167
Responding to HIV in Afghanistan
Saif-ur-Rehman, Mohammad Zafar Rasoul, Alex Wodak, Mariam Claeson, Jed Friedman, Ghulam Dastagir Sayed
Impoverished and war-torn Afghanistan is now facing an
epidemic of HIV infection owing to its increasing numbers
of injecting drug users, many of whom have returned
from refugee settings in Pakistan and Iran. Other
vulnerable groups are also at high risk of HIV infection.
As a low-prevalence but high-risk country, Afghanistan’s
national authorities recognise HIV control as a major
priority. The country is adopting a public-health approach
that includes harm reduction to reduce the spread of HIV
among injecting drug users. Although the fi nancial costs
of HIV prevention will be substantial, the costs of failing
to control HIV and AIDS will be far greater. Early and
decisive action is crucial for containing HIV infection.
Afghanistan is one of the poorest countries in the world,
with a yearly income per head estimated at $US300
in 2005.1 After nearly three decades of war and 5 years of
drought, the population’s health, social, and economic
conditions have declined greatly. Life expectancy at birth
is only 43 years, and maternal and child mortality remains
among the highest in the world. The literacy rate in the
general population is very low (28%), especially for
women (13%).2,3 The government, installed after the
military intervention that began in 2001, now controls
most of the country, with continuing major US and NATO
military support. However, anti-government forces have
made some advances in recent years, especially in the
southern provinces bordering Pakistan, where 70% of the
country’s opium is cultivated.
Only recently has Afghanistan had to face the problem
of HIV and AIDS. The Ministry of Public Heath reported
a total of 69 cases of HIV infection in Afghanistan in late
January, 2007, based on data from the Kabul blood bank
and an HIV seroprevalence survey of injecting drug users
in Kabul. Only a few months later (August, 2007), the
government reported 245 cases of HIV infection in
Afghanistan, although the actual number is likely to be
much higher. Injecting drug use has ignited HIV
epidemics in many central, east, and south Asian
countries. As seen in these neighbouring countries,4 the
epidemic in Afghanistan has the potential to grow quickly
from a small base of injecting drug users and their
partners. In countries with a concentrated HIV epidemic
dominated by injecting drug users, a previous modelling
study5 indicated a substantial risk of extensive spread to
heterosexual men and women unless eff ective, vigorous,
and sustained action is started early.
Almost all the known cases of HIV infection in
Afghanistan today are due to injecting drug use. The
sharing of contaminated injecting equipment is thought to
confer the greatest risk of contracting HIV compared with
other risk factors. Although the dominant routes of drug
use in Afghanistan have previously been oral and
inhalation, injecting practices are be coming increasingly
prevalent. About 8 million Afghans fl ed to neighbouring
countries, especially Pakistan and Iran, during the recent
decades of confl ict. Some began using, and injecting,
heroin during their diffi cult years as refugees. HIV has
spread rapidly among injecting drug users in Pakistan and
Iran. In Quetta, a town in Pakistan bordering Afghanistan,
for example, a 24% prevalence of HIV infection has been
reported in a cluster of injecting drug users.6,7 These data
have increased the fears of an epidemic in Afghanistan,
since an estimated 5·7 million Afghans have returned
home in the past few years.
A recent study of 464 injecting drug users in Kabul
showed an HIV prevalence rate of 3% and highlighted the
extremely high risk of the spread of the disease among
injecting drug users and their partners, and to the general
population.8 An earlier study of the same population
showed that high-risk behaviours were very common:
35% had ever shared syringes; 76% had ever paid for sex
with a woman; 27% of men had ever had sex with men;
23% had received so-called therapeutic injections in the
previous 6 months; 4% had ever been paid for donating
blood; and 35% had injected drugs in prison.9 The four
viral samples assessed in the study had the same genome
sequences previously identifi ed in injecting drug users in
Iran, where HIV prevalence is known to be much higher
than Afghanistan. Moreover,
hepatitis C—also predominantly spread by the sharing of
injecting equipment—was already 37%, which indicates
the very high risk of spread of blood-borne viruses in this
Production of opium in Afghanistan has reached record
levels in 2007, with the estimated amount produced
reaching 8200 metric tonnes, an increase from the
previous year of 34%, and amounting to 93% of the world’s
supply.10–12 The 2006 opium crop was estimated to have
provided $3·1 billion to Afghanistan, representing 46% of
the licit economy (excluding opium cultivation and drug
traffi cking) or 32% of the entire national economy.11
Whereas almost all of the opium and heroin produced in
the country was previously exported, 2% of the output is
now believed to be consumed locally. Since production is
now believed to exceed worldwide demand by a vast
margin, large quantities are probably being stockpiled.10
A 2005 survey estimated that Afghanistan has almost
1 million drug users including 200 000 opium users and
19 000 injecting users, of whom 12 000 inject prescription
drugs and 7000 inject heroin.13 A 2006 survey in Kabul
estimated that several categories of drug use had increased
by more than 200% in 12 months. Most drug users were
men but the proportion of women using prescription
drugs was high, probably indicating the very diffi cult living
conditions for many Afghan women. As the overall drug
problem in Afghanistan continues to receive international
the prevalence of
Lancet 2007; 370: 2167–69
National AIDS Control
Programme, Ministry of Public
Health, Kabul, Afghanistan
(Saif-ur-Rehman MD); Ministry
of Counter Narcotics, Kabul,
Afghanistan (M Z Rasoul MD);
Alcohol and Drug Service,
St Vincent’s Hospital,
Darlinghurst, NSW, Australia
(A Wodak FRACP); AIDS South
Asia Region, World Bank,
Washington DC, USA
(M Claeson MD); Development
Economics Research Group,
World Bank, Washington, DC,
USA (J Friedman PhD); and
World Bank, Kabul,
Afghanistan (G D Sayed MD)
Mariam Claeson, AIDS South Asia
Region, World Bank,
Washington, DC, USA
www.thelancet.com Vol 370 December 22/29, 2007
attention, aggressive counter-narcotic eff orts focus largely
on supply reduction. A proposal to eradicate opium poppy
cultivation by use of aerial herbicides and other chemicals
is being debated. However, there is a real danger that more
vigorous counter-narcotics policies are not without risk of
exacerbating a transition from smoking or eating opium to
injecting heroin, with subsequent risk of increased HIV
infection associated with injecting drug use. The complex-
ity of the problem is also highlighted by the risk that
more vigorous counter-narcotics policies could under-
mine counter-insurgency eff orts, which might also weaken
eff orts to control HIV infection. Opium eradication might
predominantly aff ect poorer farmers. Opium cultivation
generates an estimated 36 million days of farm labour and
is deeply entrenched in the rural economy.
As in many other traditional and deeply religious
countries, estimation of the scale of HIV spread associated
with sex workers or men who have sex with men is
diffi cult in Afghanistan. Local opinion varies as to the
importance of these factors. Ex-inmates report that a
substantial amount of drug injection occurs in Afghan
prisons, a situation also reported in many other countries.
Vulnerable groups potentially at risk of HIV infection
include long-distance truck drivers and their helpers, the
many women who have lost husbands or provide care for
severely disabled husbands or sons, and the many
abandoned children. Only a small proportion of transfused
blood or blood products is currently tested for HIV, which
will be of increasing concern as HIV prevalence rises.
There is much re-use of injecting equipment and other
medical equipment in the formal and informal health-care
sectors, although there is little documentation about the
extent and distribution of this practice.
Averting large numbers of HIV infections through harm
reduction programmes will not only save lives but also
makes sound development policy, even for a resource-
constrained country such as Afghanistan. Because much
HIV-related mortality occurs in adults in their productive
age, the short-term and medium-term economic conse-
quences for infected individuals, partners, and households
are severe.14–15 Although application of esti mates from
other regions and countries to the Afghan context is
diffi cult, prevailing urban wages and health-care expendi-
ture patterns in Afghanistan,16,17 combined with standard
mortality estimates by duration since infection,18 suggest
that even if Afghanistan and international donors spend
up to $2000 per HIV infection averted, the total economic
returns (both private and public) on such an investment
would be large—possibly as high as 300% per infection
averted. This estimated return takes into account only the
costs of wages foregone and of health and home care. The
economic benefi ts would presumably be even higher if
the subsequent detrimental outcomes to children and
others in a household that suff ers an HIV-related death
are also included.
Control of HIV infection is a development priority in
Afghanistan, in view of the links between poverty, drugs,
and HIV. One of the pillars of the Interim Afghanistan
National Development Strategy is to improve the wellbeing
of the poor through social protection, counter-narcotics
initiatives, and keeping HIV prevalence in the general
population below 0·5%. The Millennium Development
Goals for Afghanistan include halting and reversing the
spread of HIV infection by 2020 and increasing sub-
stantially the proportion of injecting drug users in treat-
ment by 2015.19 A national plan of operation to achieve
these objectives has been prepared through a broad consul-
tative process. To ensure the protection and rights of
vulnerable populations at greatest risk of HIV infection, the
Ministry of Public Health has drafted a code of ethics to be
widely endorsed.20 Additionally, a national policy of harm
reduction jointly prepared by the Ministries of Counter
Narcotics and Public Health has been adopted, providing a
sound framework for eff ective interventions to break HIV
transmission for injecting drug users and their partners.
Most importantly, best practices in HIV prevention in
injecting drug users, including harm reduc tion, are being
implemented by local non-govern mental organisations
and community-based organisations, pro viding successful
local models for scaling up.21,22
A comprehensive approach to HIV prevention for
injecting drug users is
communication, such as peer education and counselling,
provision of the means for behaviour change (sterile
needles, syringes, and condoms), substitution treatment
(such as methadone or buprenorphine), and provision of
eff ective outreach through drop-in centres. Special
subpopulations (such as prison inmates) have to be
adequately reached by these interventions.
A national policy decision will have to be made soon on
substitution treatment. Some believe that methadone and
buprenorphine are inappropriate for resource-constrained
settings such as Afghanistan. Certainly, these interventions
are too expensive to off er the large proportion of the
200 000 opium smokers and eaters who seek help. Many
decades ago, opium registration systems in countries in
west and south Asia were an inexpensive response to a
widely prevalent problem before falling into disfavour.
Although probably diffi cult to reintroduce in the present
international environment, some form of carefully
regulated opium dispensing could still be an option in this
context. Afghanistan will pilot options to assess the most
feasible, cost eff ective, and locally appropriate way to
provide substitution treatment to its large drug-dependent
population, who are mostly young people.
Afghanistan has much in common with the culture,
language, and religion of neighbouring Iran, where
injecting drug use is also the major driver of the HIV
epidemic. Pragmatic responses to the control of HIV
transmission among injecting drug users have received
strong support in Iran, and there are encouraging
indications that the Afghan government and religious
authorities might also support these interventions. For
example, triangular clinics, which provide harm reduction
required. It includes
www.thelancet.com Vol 370 December 22/29, 2007 2169
services to injecting drug users, treatment of sexually
transmitted diseases, and care and support for people
living with HIV and AIDS, are being implemented in
Although interventions targeting injecting drug users
and their partners are the fi rst priority in responding to
the threat of HIV in Afghanistan, comprehensive pack-
ages of preventive interventions are also needed for other
vulnerable groups at high risk. Selling and buying sex,
unprotected sex between men, and migration are all risk
factors, especially where they intersect with injecting
drug use. Raising awareness and advocacy eff orts to build
stronger political commitment, communication activities
aimed at reducing stigma and improving knowledge
among the general population, and capacity-building to
ensure sustained and eff ective implementation are other
Afghanistan is now deciding on its national response to
the HIV epidemic. HIV prevention and AIDS treatment
are not aff ordable for the Afghans and will require
substantial external fi nancial support (currently over half
of the Afghan national budget is fi nanced by external
donors). France has already committed support to secure a
safer blood supply, and the United Nations Population
Fund will support HIV prevention for sex workers. A
national implementation plan has been agreed on for
World Bank support for surveillance, targeted interventions
for vulnerable groups at high risk, communications and
advocacy, and building programme management capacity.23
An application to the seventh round of the Global Fund to
fi ght AIDS, Tuberculosis and Malaria has been approved.
However, money alone will not be enough. Afghanistan
will also need substantial technical assistance to support
its HIV prevention priorities because of serious capacity
constraints. Despite the very diffi cult local conditions,
Afghanistan has several dedicated national and inter-
national non-governmental organisations and community-
based organisations in almost all the provinces and most
districts, and substantial progress has been made in
reaching remote areas with basic health services.24 The
developed world has, in the past, failed to fulfi l many
generous promises to Afghanistan. This time, promises
made will have to be kept.
We thank Phoebe Folger and Roselind Rajan for their assistance.
1 International Monetary Fund. World economic outlook database,
September 2006. http://tinyurl.com/2fv6vr (accessed April 4, 2007).
2 Central Intelligence Agency. The world fact book Afghanistan.
af.html (accessed Aug 15, 2007).
3 UNICEF. Afghanistan statistics. http://www.unicef.org/infoby
country/afghanistan_afghanistan_statistics.html (accessed Oct 1, 2007).
4 Moses S, Blanchard J, Kang H, et al. AIDS in South Asia:
understanding and responding to a heterogeneous epidemic.
Washington DC: World Bank, 2006.
5 Saidel TJ, Des Jarlais D, Peerapatanapokin W, Dorabjee J, Singh S,
Brown T. Potential impact of HIV among IDUs on heterosexual
transmission in Asian settings: scenarios from the Asian epidemic
model. Int J Drug Policy 2003; 14: 63–74.
6 Saidel TJ, Des Jarlais D, Peerapatanapokin W, Dorabjee J, Singh S,
Brown T. High HCV seroprevalence and HIV drug use risk behaviors
among injection drug users in Pakistan. Harm Reduction J 2006; 3: 26.
Kassi M. HIV in injecting drug users of Quetta, Pakistan: reporting
another outbreak. http://www.harmreductionjournal.com/
content/3/1/26/comments (accessed Oct 1, 2007).
Todd CS, Abed AMS, Strathdee SA, et al. HIV, hepatitis C, and
hepatitis B infections and associated risk behavior in injection
drug users, Kabul, Afghanistan. Emerging Infect Dis 2007;
(accessed Sept 17, 2007).
Todd CS, Abed A, Strathdee S, Botros A, Safi N, Earhart KC.
Prevalence of HIV, viral hepatitis, syphilis, and risk behaviors among
injecting drug users in Kabul, Afghanistan [abstract TUAC0304].
Toronto: 16th International AIDS Conference, 2006.
10 United Nations Offi ce of Drugs and Crimes and the Government of
Afghanistan, Ministry of Counter Narcotics. Kabul, Afghanistan
Opium Survey 2007. http://www.unodc.org/pdf/research/AFG07_
ExSum_web.pdf (accessed Oct 1, 2007).
11 United Nations Offi ce of Drugs and Crime and the Government of
Afghanistan, Ministry of Counter Narcotics. Afghanistan Opium
Survey 2006. http://www.unodc.org/pdf/research/AFG05%20_full_
web_2006.pdf (accessed Oct 1, 2007).
12 United Nations Offi ce on Drugs and Crime, and The World Bank.
Afghanistan’s drug industry. Structure, functioning, dynamics, and
implications for counter-narcotics policy. http://www.unodc.org/pdf/
Afgh_drugindustry_Nov06.pdf (accessed April 4, 2007).
13 United Nations Offi ce on Drugs and Crime. Government of
Afghanistan Ministry of Counter Narcotics. Afghanistan drug use
survey 2005. http://www.unodc.org/pdf/afg/publications/
afghanistan_drug_use_survey_2005.pdf (accessed April 4, 2007).
14 Bertozzi S, Padian N, Wegbreit J, et al. HIV/AIDS prevention and
treatment. Disease control priorities in developing countries,
2nd edn, New York: Oxford University Press, 2006: 331–70.
15 Mills A, Shilcutt S. Challenge paper on communicable diseases.
Copenhagen Consensus Challenge Paper. http://www.copenhagen
consensus.com/Admin/Public/Download.aspx?fi le=fi les/fi ler/cc/
papers/communicable_diseases_160404.pdf (accessed July 2, 2007).
16 Beall J, Schütte S. Urban livelihoods in Afghanistan. Synthesis Paper
Series, Afghanistan Research and Evaluation Unit. http://www.lse.
SP%20FINAL%20PROOF%205Oct2006.pdf (accessed Dec 1, 2007).
17 2004 Afghan National Health Services Performance Assessment.
Health seeking behavior, health expenditures, and cost sharing
practices in Afghanistan. Kabul: Johns Hopkins University Third-
Party Evaluation Team and Afghanistan Ministry of Public Health,
Policy and Planning Division, 2006.
18 Zaba B, Whiteside A, Boerma T. Demographic and socioeconomic
impact of AIDS: taking stock of the empirical evidence. AIDS 2004;
18 (suppl 2): S1–7.
19 Afghanistan Country Management Unit, South Asia Region, World
Bank. Interim strategy note for the Islamic Republic of Afghanistan.
Resources/305984-1173464648944/ISNFullEnglish.pdf (accessed Oct 1,
20 HIV and AIDS Coordinating Committee, National AIDS Control
Program, DG Preventive Medicine and Primary Health Care.
Afghanistan national HIV code of ethics (draft). Kabul: Ministry of
Public Health 2007.
21 Atanasijevic M. MDM harm reduction (needle exchange) program in
Kabul, Afghanistan. Kolkata, India: Inter-Country Consultation on
Prevention of HIV among IDUs, April 9–13, 2007,
22 Razzaghi E, Nassirimanesh B, Afshar P, Ohiri K, Claeson M, Power R.
HIV/AIDS harm reduction in Iran. Lancet 2006; 368: 434–35.
23 World Bank. Afghanistan HIV/AIDS prevention project.
49114~theSitePK:282511,00.html (accessed Aug 28, 2007).
24 Waldman R, Strong L, Wali A. Afghanistan’s health system since
2001: condition improved, prognosis cautiously optimistic.
Afghanistan Research and Evaluation Unit, Briefi ng Paper Series,