AIDS CRISIS BRINGS RADICAL CHANGE IN IRAN'S RESPONSE TO HEROIN USE
Health Concerns Given Precedence Over Prosecution
TEHRAN -- Fearing an AIDS epidemic, Iran's theocratic government has dropped a zero-tolerance policy against increasingly common heroin use and now offers addicts low-cost needles, methadone and a measure of social acceptance.
For two decades, Iran largely avoided the global AIDS crisis. But today, officials are alarmed by a 25 percent HIV infection rate that one survey has found among hard-core heroin users and worry that addicts may channel the virus into the population of 68 million.
Supporters of the government's new approach laud it as practical and devoid of the wishful thinking and moralism that they contend hampers policies on drug abuse and AIDS in some other countries, including the United States. "I have to pay tribute to Iran on this," said Roberto Arbitrio, head of the U.N. Office on Drugs and Crime in Tehran.
Bijan Nasirimanesh, who heads a drop-in clinic that dispenses needles, bleach and methadone in a hard-hit area of south Tehran, said, "It's ironic that Iran, very fundamentalist, very religious -- very religious -- has been able to convince itself" to embrace such policies.
Opponents often argue that tolerance of life-destroying drugs is simply unacceptable and in the long run breeds acceptance and higher drug use. But in the theocracy's most dramatic rejection of that approach, the ayatollah who heads Iran's conservative judiciary issued an executive order embracing "such needed and fruitful programs" as needle exchanges and methadone maintenance.
Ayatollah Mohammad Esmail Shoshtari, the justice minister who has shut more than 100 newspapers and imprisoned political opponents, instructed prosecutors in a Jan. 24 letter to ignore laws on the books and defer to Iran's Health Ministry to counter the spread of AIDS and hepatitis C.
"This was a very crucial step," said Ali Hashemi, director of Iran's Drug Control Headquarters, a cabinet-level office. "Inevitably we have to do this in order to reduce the risk of AIDS."
The policy demonstrates the complexities of Iran a quarter-century after the Islamic revolution and U.S. Embassy takeover that still defines its theocratic government for many Americans. Though power remains concentrated in unelected clerics who brook little political dissent, the government has demonstrated flexibility on a variety of subjects, including birth control and sex-change operations, which the clerics recently authorized.
After the revolution, Iran treated drug users as criminals, throwing hundreds of thousands of them in jail. Now it has joined the ranks of countries that acknowledge the difficulty of eradicating drug addiction and focus instead on curbing the most immediate dangerous behaviors that go with it.
Surveys of Iranians who test positive for HIV show that two-thirds were infected by dirty needles. To reduce the spread of infections, the government not only makes needles available without a prescription, but through subsidies makes them extremely cheap, so as to discourage re-use.
"You pay less than 5 cents for a syringe," said Azarakhsh Mokri, of the government's National Center for Addiction Studies. "People purchase up to 100 at a time."
The government also encourages addicts to stop injecting by providing free methadone, a surrogate opiate that is taken orally. This spring, the parliament, dominated by conservatives, voted to allow any doctor in Iran to dispense methadone, though under strict monitoring guidelines.
"It's quite amazing there's been this shift," said Rich Schottenfeld, a professor of psychiatry at Yale University, which won a waiver from U.S. sanctions on Iran to carry out a study financed by the National Institute of Drug Abuse to compare drug treatments. "Five years ago, my colleagues there didn't anticipate that methadone would even be allowed," he said.
Robert Newman, director of the Baron Edmond de Rothschild Chemical Dependency Institute at Beth Israel Medical Center in New York, said Iranian policies are "in very dramatic contrast to what has been happening with increasing frequency in America, where the judiciary and the criminal justice system in general . . . does not let the patients receive the treatment that the physician says is necessary."
Newman, who has traveled twice to Iran in the last five years to consult on addiction programs, said only a quarter of an estimated 900,000 heroin addicts in the United States receive treatment. He attributes that in large part to laws that restrict methadone to large-scale treatment facilities. "In other words, the AIDS epidemic has done nothing to open the way for treatment with methadone or any other treatment for heroin addiction" in the United States, Newman said.
In Iran, heroin addiction is rising in a population of drug users estimated at between 2 million and 4 million. Heroin use rose abruptly about five years ago, when the Taliban rulers in neighboring Afghanistan sharply reduced opium production. That drove up the price of opium, leading people who had been smoking or swallowing it to switch to heroin, which remained comparatively cheap.
Because heroin is often injected, the switch resulted in a surge of HIV infections as users shared needles.
Until recently, the HIV infection rate among intravenous drug users in Iran had been estimated at 5 percent. But in blood tests of 900 users over eight months, the Persepolis clinic headed by Nasirimanesh found a rate of 25 percent. "The bomb exploded," he said.
Officials said that rate was confirmed by a more recent study conducted through Japan's Kyoto University. A lower rate, about 13 percent, was recorded among users who get their methadone at the addiction studies treatment center. Mokri said that was presumably because the center's clients are typically better off than the often homeless junkies at the Persepolis drop-in center and have avoided time in prisons where dirty needles are far more common.
But the rates in all surveys are headed up. "The potential is very bad," said Arbitrio of the U.N. agency. "If you have 160,000 injecting plus 3 million drug users, you have all the elements to have the spread of HIV/AIDS very quickly."
How quickly the virus might reach into the general population via sexual contact is a sensitive issue in Iran. Experts here do not see transmission though gay sex as an important avenue, but fear HIV will spread in a big way through heterosexual sex.
Though the government has promoted a puritanical view on premarital sex, it has tolerated prostitutes, who by many accounts have risen sharply in numbers in recent years.
"I know some who are drug addicts," said Sorraya Heidari, 39, as she waited for methadone at the Persepolis clinic. "To get the money they need for drugs, they have to work as prostitutes."
There is also evidence that young people -- half of Iran's population is under age 20 -- are more sexually active than some researchers believed. Fully 70 percent of capital residents ages 15 to 20 have had sex outside marriage, and almost none reported using condoms, according to a survey of 2,000 Tehran young people by Tehran University and the State Welfare Organization.
"Before, Iran always said this is something from outside," said Hamid Reza Setayesh, the UNAIDS officer for Iran. "Now they are accepting this is not only for drug users, but growing among people who are sexually active."
Experts say the official reluctance to promote condom use generally is a major drawback in Iran's evolving policy toward AIDS. Another is the lack of anonymous testing for the virus. "They ask for your name,"
Setayesh said. "And they should not ask."
Public health specialists also caution that many of the new policies have yet to be launched on a large scale. "The policies are very good," said Gelareh Mostashari, a physician in the U.N. drugs office.
"But there are practical applications that have to be executed."
Still, many drug experts say the government has shown a consistent disregard for orthodoxies in this fight. Mokri said he was astonished to encounter no official resistance when he set out to launch a pilot program that will dispense actual opium instead of methadone to addicts.
He noted a bill pending in the U.S. Congress calling for imprisoning Americans who failed to report marijuana dealers. "Sometimes I think the ayatollahs are more liberal," Mokri said.