Despite strict rules against promiscuity, homosexuality, drug use and sex work, the Islamic world is nevertheless – and perhaps as a result – facing up to a growing HIV problem.
When the HIV epidemic hit in the 1980s, governments in the Islamic world declared their countries were immune from the "Western" virus because of religious and cultural values shunning pre-marital sex while encouraging faithfulness. They were partly correct; this way of life resulted in a very low HIV prevalence. For years, many Muslim leaders denied the existence of HIV within their borders, until they could no longer.
In most parts of the world HIV infections and deaths from Aids have been falling, even in southern and eastern Africa, where more than half of the global HIV population lives. New drugs to prevent infection and lessen the impact of the virus on the body have blunted its impact.
Yet in the conservative, Muslim-majority regions of North Africa, the Middle East and parts of Asia, new HIV infections have been on the rise since 2001. The latest figures show that, despite the availability of antiretroviral drugs, the region is one of two global hotspots (the other is Eastern Europe) where new HIV infections and deaths from Aids are increasing. Damningly, in the Middle East and North Africa, the proportion of people living with HIV who are receiving lifesaving antiretroviral treatment is the lowest in the world.
So how are religion, culture and politics in the region helping, or hindering, efforts to deal with what could become – especially in the face of war and upheaval – an HIV epidemic?
A couple of weeks ago I went to the 21st International Aids Conference in Durban, South Africa, the scene 16 years ago of a major turnaround in the way HIV was tackled in Africa. At the conference there was a session dedicated to how Islamic communities were dealing with rising HIV. The panel consisted of experts from around the Muslim world, including Wafaa Jlassi, a woman living with HIV in Tunisia. Her story was pretty shocking.
She found out she had HIV after her husband died. A post-mortem discovered he had died from Aids, so she was tested and found to have the virus. Her husband's family wrongly presumed, because she was a woman, that she had passed the infection onto him. The local police told all her neighbours she has the "disease". She was thrown out of her family home. Only by the skin of her teeth did she manage to keep custody of her two daughters. The sudden impact of losing her husband, being told she had HIV and being treated like dirt by her community left her close to suicide.
Speaking in French, she told the conference of her native Tunisia: "I'm scared of the society I live in, where homosexuals live in fear of the law; where women lose their jobs because of their HIV status and people with HIV are refused medicine," said Jlassi, who now works for a charity helping to raise awareness of HIV in the country. "We need to stop this ignorance and suffering."
Tunisia is one of the region's less conservative societies. In Saudi Arabia, for example, homosexuality can be punishable by death, which is not the ideal start to dealing with HIV. In Iraq, a country enmeshed in bloody conflict and where HIV positive people are murdered, Amir Ashour of gay rights organisation Iraqueer says the country pretends HIV does not exist.
The reality is that, from Marrakesh and Mogadishu to Dubai and Karachi, stigma and discrimination against people with HIV – especially sex workers, gay men and drug addicts – is a problem. Prejudice against those with HIV and vulnerable groups exists the world over, from developing countries to the UK: one of Nigel Farage's 2015 election pledges was to ban people with HIV entering the country. It wasn't that long ago that the virus was being labelled by British tabloids as the "gay plague". But the dominance of traditional, conservative attitudes in societies across North Africa, the Middle East and parts of Asia has created a significant barrier to dealing with HIV.
In the region, a positive HIV test is far from being a private matter. Police often report HIV+ people to their neighbours. Patients risk being branded with their HIV status for life. Amir Ashour tells me that in Iraq "the bad practices are usually committed by doctors, clinics and hospitals. Like outing persons living with HIV to the government, which puts the lives of those individuals at great danger."
Rita Wahab, of Middle East-based HIV organisation MENA Rosa described having HIV in the region as a double bind: "Those who are at greatest risk of infection are also engaged in practices, such as sex work or same-sex relations, that are condemned by religious doctrine, social norms and the law. This wide-ranging stigma and discrimination further fuels the epidemic by driving those living with HIV and those most at risk of infection away from testing and disclosure, making HIV prevention and treatment increasingly difficult."
This deep-rooted prejudice is highly tangible: it can directly be the cause of destitution, lack of healthcare, violence and death. As UN Secretary-General Ban Ki-Moon warned back in 2008: "Stigma helps make Aids the silent killer, because people fear the social disgrace of speaking about it. Stigma is the chief reason why the Aids epidemic continues to devastate societies around the world."
Beneath the umbrella of the Islamic world, amid the undercurrent of prejudice, there are marked disparities in the way the virus is being tackled. In North African countries such as Morocco, governments have set up extensive programmes to prevent and treat HIV. In Iran and Pakistan, spiralling HIV infections caused by high levels of injecting drug use have been confronted head on by governments.
"A country's politics, its culture and the mentality of the policymakers can have a stronger impact on policy than religion. In some Muslim countries the religious leaders are more open minded than the politicians," says Iranian Kamiar Alaei, a human rights expert at the State University of New York.
With his brother Arash, a physician, Kamiar set up Iran's first HIV clinic in the late 1990s, establishing a network of needle exchanges primarily aimed at stemming the spread of the virus through intravenous heroin use. Swimming against the tide in a conservative society such as Iran can get you in trouble. The Alaei brothers were jailed for three years between 2008 and 2011 for "attempting to overthrow the Islamic regime" just because they attended a few HIV conferences in the US. Now, Iran's HIV treatment service is not perfect – in fact, the very people supposed to be helping patients discriminate against them – but for a country where homosexuality is punishable by death, it's progress.
For most governments in the Islamic world, public health pragmatism has trumped religious doctrine, the outlawing of homosexuality and public prejudice. Governments have responded to the rising tide of HIV by stepping up the distribution of condoms, clean needles and treatment for drug addiction and for those with HIV. Much of this is implemented with the help of foreign NGOs, which is also a convenient way for conservative regimes to avoid being seen as helping the "unworthy" by a less than sympathetic public.
A 2013 survey in Pakistan – which, like Iran, has had to tackle an HIV epidemic fuelled largely by drug use – found only two percent of people said homosexuality was "acceptable". In Qatar, a country which deported a foreign journalist working for Al Jazeera after secretly testing him for HIV, only five percent of young men and two percent of young women expressed tolerance for people with the virus. Across the border in Saudi Arabia, a survey found three quarters of college students believed people with HIV or Aids should be "isolated from the public".
In Sudan, which has the second highest HIV+ population in the region after Iran, HIV is tackled at arms length. The Sudanese government is happy to give the silent nod, opening the back door to allow foreign NGOs to work inside their country, without being seen to sanction what could be seen as an irreligious health intervention.
In Turkey, the only Muslim country where legalised homosexuality is enshrined in law, President Recep Erdogan flexed his anti-gay muscles in June by banning Istanbul's Gay Pride in a flurry of water cannons and plastic bullets. But behind the reactionary veil, officials have reacted quickly to an HIV epidemic that has seen a 900 percent rise in new infections in under a decade, from 180 in 2005 to 1,800 in 2014. Unlike many Muslim countries, the country's 10,000 HIV+ population now has access to life-saving antiretroviral drugs to boost their immune systems. Consequently, the number of people dying of Aids in Turkey has fallen dramatically.
So what do imams say about HIV? In Morocco there is one imam known as the "Imam of Aids" because he helps people with HIV. But not all imams are as HIV-friendly. When asked at the conference in Durban why some encouraged hate crimes against people with HIV, Mohammed Abou Zaid, an imam and one of Lebanon's senior court judges, said there were two types of religious leader. One who thinks they are superior to other men, who claim to represent the divine, the one truth. Or the other who serves the people, who accepts he is a fallible human being. "The second man, he has better understanding of the role of religion in our lives," said Abou Zaid. "But if you find the first imam, please get away from him – he's very dangerous; more dangerous than the HIV virus."
Abou Zaid said that, in his view, Islam should be an agent for change in attitudes to HIV. "It all started when I met a transgender Muslim woman who said her father had thrown her out aged 14. He did not accept her at home. He closed his door to her. I was moved. I said to her, 'Maybe your father has closed the door, but I'm sure God will never ever close his door.' God created us, God loves us, his doors always stay open. If I'm related to God and I claim I'm a religious figure, I should also open my doors, and my heart and mind."
In the UK, which has around 100,000 people living with HIV, the number of new HIV infections each year has fallen by 25 percent since 2005. NAZ, a charity in London, helps around 60 Muslims in the UK with HIV and has trained over 50 imams in the capital on how to address sexual health and HIV at mosques. Muslim service coordinator Khaiser Khan tells me clients can feel ostracised from their families and their religion. But, he says, although it can take time, people are usually able to tell their family and do not feel they have to turn away from their faith.
Tariq, an accountant from Berkshire, used partying, drugs, alcohol, clubbing and sex as a form of escapism because he was secretly gay. He found out he was HIV+ in 2008 and locked himself in his room for two days. He went for help at NAZ, told his sister and ended up helping to train a group of 10 imams to deal with the issue. "It's about dealing with the shame of being gay, of being a Muslim with HIV, understanding what's happening to you and recovering from it," says Tariq.
As younger generations of Muslims become more Westernised, the old cultural mores that have historically kept the HIV problem in check are gradually evaporating. However tempting otherwise, perhaps it is time for religious leaders to step into the breach, and follow the example of people like Abou Zaid, to become the public face in the fight against HIV and against the stigma and ignorance that is driving its rise in the Islamic world.
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