SAFE SEX EDUCATION AMONG YOUTHS IN IRAN - TIME TO ACT!

Kianoush Dehghani, MD, MPH Montreal, Quebec, Canada

As an Iranian-Canadian physician living outside Iran, I often wondered in the era of HIV/AIDS epidemic, how does the Islamic Republic educate the public about the deadly virus and promote harm reduction strategies such as safe sex among youths? In a country where almost seventy percent of the population is under the age of 30, HIV/AIDS prevalence is progressively rising, according to both official and unofficial national reports. During a recent trip to Iran, I witnessed an "AIDS advocacy" billboard on a busy street in the capital city of Tehran. The billboard, almost covered by two large neighboring trees, depicted a red ribbon and a hand holding a candle on a black background, reading: "Let us make an agreement to know more about AIDS, and let us remain faithful to our agreement". The billboard was funded by several national and international organizations, yet nonetheless perplexing. What message did the poster aspire to communicate, to which target population, and for what end-effect? The message was uninformative and non-instrumental, not even a mention of a "hot-line" or help/referral center.

In fact, in a country governed by Islamic fundamentalists, where homosexuality is illegal and sex outside marriage is sinful, HIV education is challenging. The Director of the Iranian Center for Disease Control (CDC) was quoted in the New York Times in 2002: "Pre-marital sex is inappropriate and un-Islamic. So we can't say things to teenagers like, 'Use a condom' ". In practice, HIV/AIDS advocacy and educational materials produced mainly by state-run agencies and a limited number of non-governmental organizations (NGO's) are under tight scrutiny by state officials to ensure "Islamic decency". For long, government officials and religious leaders have been reluctant to acknowledge that AIDS is a public health problem in Iran. Especially during the initial phase of the epidemic, many officials propagated the false sense that HIV infection is a punishment for the "corrupted" Western lifestyle, and that Islamic faith creates a "cultural immunity" against the epidemic.

The rapid rise in the prevalence of HIV/AIDS in Iran has alarmed state officials and disappointed those who sought comfort in the mirage of "Islamic immunity". According to UNAIDS reports, the estimated number of persons with HIV in Iran increased to 66,000 in 2005. Anecdotal reports from national and international experts suggest that the official estimates of persons with HIV in Iran are highly underestimated. Moreover, based on UNAIDS reports and the available data from the Iranian CDC, sexual contact is the second most common route of HIV transmission after injection drug use. Along with the increase in the prevalence of HIV, as indicated by Mohebbi in an article in the journal of "Sexually Transmitted Infections" (2005), the prevalence of other sexually transmitted infections (STI's), often resistant to standard therapies, has also grown in Iran.

Moreover, as the head of the Iranian Cultural and Artistic Affairs reported to the BBC news in 2000, sex work and illicit drug use have been steadily on the rise among youths. In a country with a predominantly young population, youths are now considered to be among the high-risk groups for HIV infection. Ironically, the survey on knowledge and attitudes of Tehran's high-school students about HIV/AIDS reported by Tavoosi et al. (2004) in BioMed Central (BMC) Public Health, came short of asking questions about safe sex or condoms. The survey indicated that 94% of the students wanted to know more about HIV/AIDS. Another survey quoted by the Economist (2005) suggested that less than 10% of 15-24 year olds in Iran had an "accurate knowledge" of HIV/AIDS. Considering the available evidence for the clear risk of Iranian youths for HIV infection, it is imperative that the policy makers prioritize HIV/AIDS risk communication in this vulnerable target population.

Fortunately, warnings by academics and health care workers regarding the prevalence of HIV/AIDS, along with the increasing concern of state officials, have resulted in acknowledgement of the importance of HIV/AIDS prevention strategies for injection drug users in Iran. In fact, the government has recently allowed the practice of harm reduction strategies such as clean needle distribution amongst injection drug users, in order to reduce HIV transmission. The change in policy with respect to harm reduction measures in injection drug users, was achieved through the efforts of different parties including public health experts, advocacy groups and concerned politicians, with the support of religious leaders who are responsible for interpreting Islamic laws as mandated by the ever-evolving societal needs.

Learning from national and international experiences about a lethal virus that feeds on ignorance, stigmatization and enforced silence, it's time to define clearly "safe sex" for Iranian youths as an effective and an evidence-based harm reduction strategy against HIV transmission. Of course, talking about safe sex mandates clear articulation of the word "condom" or the local term "kaput", without any restrictions. With the support of caring politicians and religious leaders, public health educators in Iran have the crucial task of mainstreaming safe sex practice and condom use, in order to slow the propagation of HIV amongst youths who choose to become sexually active, and those who have no choice but to become sexually active.

REFERENCES

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