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Features May 2007: Volume 4, Number 2

AIDS in Kabul

Afghanistan is in a tough neighborhood surrounded by Central Asian countries with a high prevalence of HIV, and huge populations of injecting drug users, including Iran, Pakistan, Uzbekistan and Tajikistan.

By Sylvia Tiersten

Photographs by Massoud Hossain/afp


For Catherine Todd, M.D., MPH, Christmas 2003 was a bittersweet affair. A car bomb exploded in Kabul—and blew out the windows of the guesthouse where she was staying. Members of the housekeeping staff wept when they saw the damage — their tears a stinging mix of relief and regret, relief because no one in the house was hurt, regret because hope for a better life was fading.

After that, Todd recalls, “We cleaned up the glass and broke out the holiday cookies. The windows were replaced a few hours later, and we had a nice Christmas dinner.” It was, after all, just another day in the life of Afghanistan’s troubled capital city.

Violence is never far away in Afghanistan, where Todd is researching HIV/drug-harm reduction and reproductive health issues. She is assistant professor for the Division of International Health and Cross Cultural Medicine in the Department of Family and Preventive Medicine, at the UCSD School of Medicine.

From January through October of last year, political unrest claimed the lives of over 5,000 Afghans, including 600 members of the embattled police force. Afghanistan provides 92 percent of the world’s heroin supply, according to UN figures. Since denouncing opium as “un-Islamic” in 2000 and virtually eliminating the poppy crop, the Taliban have dramatically reversed course. Today, Afghanistan’s annual income from the drug trade—over $3 billion—is a major funding source for Taliban insurgency activities.

Everyday health problems also threaten life and limb. Todd rattles off the grim statistics: the world’s second highest maternal mortality rate and third highest for children under five; more than 50 percent of the population surviving on less than $2 a day; some 100 landmine-related injuries a month; a life expectancy at birth of 41 years for men and 43 for women.

Catherine Todd at work on tests in the Kabul laboratory of Dr. Maryam Habib.

And now another health crisis is looming—unless international agencies and donors act quickly to prevent the viral scourge. “The pieces are in place for a full-blown HIV-AIDS epidemic in Afghanistan,” says Todd. “Interventions to reduce high-risk behaviors among injecting drug users (IDUs) are urgently needed here.”

A 2005 UN Office on Drugs and Crime (UNODC) study found that 10 percent of the opium produced by Afghan poppy growers is consumed in-country. Smoking is the traditional way to ingest the drug, but needle use is definitely on the rise.

In the September 2007 issue of the journal Emerging Infectious Diseases, Todd and her collaborating researchers published their findings on the prevalence of blood-borne infections among IDUs in Kabul. The report, based on 2005-2006 data, is among the first to describe the prevalence of HIV and Hepatitis B and C viruses in Afghanistan. Although HIV infection is currently low, the investigators found a high incidence of Hepatitis C and risky drug-injecting and sexual behaviors. They included sharing syringes, paid sex with a woman, and sex with men or boys.

The report’s recommendations for harm-reduction interventions include needle exchange programs, outreach and education, HIV testing and counseling, access to sterile syringes, and drug substitution therapies such as methadone. These methods have been credited with stabilizing HIV rates in other international settings.

“AIDS is definitely a serious threat on Afghanistan’s horizon,” says David MacDonald, an international drug- demand, reduction consultant for UNODC and author of the 2007 book Drugs in Afghanistan: Opium, Outlaws, and Scorpion Tales. “Todd’s study is based on a rigorous scientific methodology—typically lacking in Afghanistan—so her figures regarding HIV rates among IDUs in Kabul are probably accurate.”

Todd consults with Habib (left) and Dr. Samuel Yingst, who is with UN FAO, in Habib's laboratory in the Afghani Ministry of Agriculture

Todd’s research team calculated the prevalence of HIV infection among the males tested at about 3 percent. “That’s hugely important,” says MacDonald, “because evidence suggests that as soon as the HIV rate goes above 5 percent in the IDU community it will rapidly escalate to 20-25 percent.”

Extremely rapid transmission of HIV among IDUs has been documented in North America, Europe and Asia, according to a 1998 World Health Organization (WHO) comparative study. An example is New York City, where HIV prevalence among IDUs increased from under 10 percent in 1978 to 50 percent by 1983. In Bangkok, the percentage rose from
2 percent in the first quarter of 1988 to over 40 percent in the third quarter of that year.

Afghanistan is in a tough neighborhood—surrounded by Central Asian countries with a high prevalence of HIV and huge populations of IDUs, including Iran, Pakistan, Uzbekistan and Tajikistan. In Kazakhstan, for instance, HIV prevalence among IDUs in Kashgar City was 56 percent, according to a 2006 Joint United Nations Program on HIV/AIDS (UNAIDS) report. In Iran, 15 percent of IDUs attending Tehran drug treatment centers tested positive for HIV.

Human traffic across Afghanistan’s porous borders includes IDUs, truck drivers and men returning from work in the Gulf States and Iran. “Most of the IDUs we’ve been able to access for our studies are men, but half of them are married. They can certainly infect their wives through sexual contact,” says Todd.

Poverty and unemployment are also high-risk factors. “For opiate addicts,” says Todd, “injecting the drug is more cost effective than smoking it. Users can get by on one-third of the amount.”

Afghanistan has received a three-year, $10 million grant from the World Bank and has a pending proposal to the Global Fund for harm-reduction initiatives. Todd’s research can provide accurate baseline data for planning purposes.
“With HIV epidemics, people tend only to respond after there’s already an epidemic in process,” says Todd. “Here’s a chance to do something before the window of opportunity closes.”

Neighboring Pakistan is a cautionary tale. When the U.S.-led invasion of Afghanistan in 2001 disrupted the cross-border heroin supply chain, Pakistani addicts switched from sniffing, inhaling and smoking opiates to injecting inexpensive, over-the-counter liquid pharmaceuticals.
Epidemiologist Steffanie Strathdee and her colleagues published a series of papers in Pakistan about an epidemic waiting to happen. “We told people what to do—and they didn’t do it,” recalls Strathdee, now professor and chief, Division of International Health and Cross Cultural Medicine, Department of Family and Preventive Medicine at the UCSD School of Medicine. Today, according to World Health Organization (WHO) estimates, Pakistan has 85,000 HIV-infected persons.

Because Afghanistan is still pretty much on the global radar screen, Strathdee sees some cause for optimism—”as long as we don’t just invest in our military but also invest in health. Secure borders is one thing, but if we don’t secure the health of the people, we will see decades more of devastation. It’s human capital that will be lost,” she warns.

* * *

“I’m a displaced gynecologist,” says Todd, reflecting on life’s twists and turns. “Five years ago, I would not have anticipated this career path at all.”

As an assistant professor in the Department of Obstetrics and Gynecology at Johns Hopkins Bayview Medical Center, overseas work was not on her to-do list. But meeting Sam Yingst, her future husband, changed the trajectory of her professional life and her thinking. Yingst is a veterinary virologist who works on zoonotic disease diagnostics. (Zoonotic diseases, such as avian influenza, can be transmitted from animals to humans). “Sam told me his career would require him to live overseas for a couple of years, and I was game for it,” says Todd.

In 2003 the couple moved to Egypt, where Todd worked as an international medical consultant. The two-month clinical assignment that initially took her to Afghanistan was a training update program for Afghan OB/GYN physicians.

“The country had been essentially closed off from the world for 30 years,” she says. “Afghan doctors were doing surgical procedures that had fallen out of favor in the U.S. about two decades ago.” Fundamental research concepts such as secure data storage and informed consent were all but unknown. A large number of medical workers had spent time living outside the country and were among the four million Afghans who have repatriated since 2001.

The OB/GYN updating assignment was a life-changing experience for her, setting the stage for her interest in Afghanistan. “I do research projects that inform programs and policies for people who are marginalized,” she says of
her international health career. “I’d like to think that the information we find and our relationships with the harm-reduction programs in Kabul will help them have better programs on offer.”

UCSD’s Division of International Health and Cross Cultural Medicine seemed like a good fit for Todd, who joined the faculty in 2004. “Katy is a promising scientist who helps the helpless,” says Strathdee, who is currently collaborating with Todd on several projects.

“She collected the first data on IDUs and the first data on antenatal patients in a part of the world where there is no data on HIV/AIDS whatsoever,” Strathdee continues. “That’s pretty remarkable for a new investigator.”
Todd and her husband moved to Kabul in May 2006 and spent a year and a half in-country. She travels to Kabul every few months to monitor her research and intervention programs.


Sylvia Tiersten is a freelance writer based in San Diego.


International Health & Cross-Cultural Medicine, UCSD


Catherine Todd's Website


"Afghanistan is in a tough neighborhood surrounded by Central Asian countries with a high prevalence of HIV, and huge populations of injecting drug users, including Iran, Pakistan, Uzbekistan and Tajikistan"