“The only thing that has changed since the revolution is that the police no longer arrest drug users,” said 40-year-old Salem, who is HIV positive. He still cannot work unless he forges a health certificate and would only be able to marry an HIV inflicted woman after the approval of Dar al-Fatwa, (office that announces laws, or fatwas, issued by the grand mufti).
“The only thing that has changed since the revolution is that the police no longer arrest drug users,” said 40-year-old Salem, who is HIV positive. He still cannot work unless he forges a health certificate and would only be able to marry an HIV inflicted woman after the approval of Dar al-Fatwa, (office that announces laws, or fatwas, issued by the grand mufti).
Salem was arrested by anti-narcotics police in July 2000 where he was tested for drugs and found to have HIV, the virus that causes AIDS. He was isolated at Tajora Shelter for 20 months. “The shelter was far worse than prison. I was forced to stay with more than 1,500 HIV infected individuals where I was treated inhumanely and my family was allowed to visit me only once a month,” he said.
Salem left school at an early age and began using drugs at the age of 17 including heroin injections where he used to exchange the same syringe with seven or eight of his friends. “Gaddafi’s regime deliberately brought in HIV-contaminated heroin to kill the youth of the country,” Salem said.
Unprecedented national survey in Libya
In June 2012, the Libyan Ministry of Health met with other international organizations to hear new evidence about the concentrated HIV epidemic among people who inject drugs in Libya. The Liverpool School of Tropical Medicine presented the results of the Bio Behavioral Surveillance Study conducted among drug users in Libya, which indicated that the rate of HIV among young intravenous drug users in Libya is the highest ever reported in the world.
Heavy legacy for a conservative society
Activists have attributed HIV prevalence in Libya to the lack of comprehensive programs aimed at preventing the spread of the disease— including sharing of needles and unsafe sexual practices.
In 2003, Gaddafi claimed that homosexuality was the only cause of the spread of HIV, disregarding substantial medical evidence confirming that HIV could be transmitted in numerous ways including heterosexual sex and sharing needles.
Due to the conservative nature of the Libyan society, Gaddafi’s regime adopted a strict policy to conceal any revelations of HIV infection, which was deemed a matter of national security and consequently the issue remained neglected and HIV infected people were isolated in prison. A ban on selling syringes at pharmacies in 1996 exacerbated the problem.
Hussein Mohammed Othman, head of the anti-AIDS department, believes that the armed conflict greatly contributed to the prevalence of the HIV epidemic in Libya. He pointed to the fragile security apparatus that was incapable of controlling the illegal immigration at loose borders, in addition to the spread of cheap drugs amongst youngsters.
HIV epidemic among intravenous drug users the highest rate in the world
Samir Ben Yahmed, Head of Libyas World Health Organization (WHO) Office in Libya, said at the National HIV Symposium: “Libya is on the verge of declaring the prevalence of an HIV epidemic.”
His statement was a response to the results presented by the Liverpool School’s study, which reported that 87% of people who inject drugs are positive for HIV, amounting to 2.6% in Tunisia and 7.7% in Egypt. The study also indicated that HIV transmission has a prevalence of 3.5% among men who have sex with men and 5.6% among sex workers.
Omar Khaled, Head of the General National Congress Health Committee and former Chief of Eastern Province Forensic Medicine, doubted the presented results and said: “HIV in Libya is not deemed an epidemic but rather a disease. The main cause of HIV transmission is contaminated blood transfusions and dental clinics. It is not related to sex or drug injection since most drug users in Libya rely on marijuana rather than injected cocaine or heroin,” he said.
On the other hand, Nader Shlaka, Doctor at the Communicable Diseases Department at Tripoli Medical Centre, said 97% of HIV infections in Tripoli are transmitted through drug injection and constitute the highest rates in the Mediterranean Basin.
In contrast, NGCHC member Fathi Arabi said, “There was a communication problem between the Ministry of Health specialists and the NGCHC. I am not aware of the results of the Liverpool School on HIV prevalence among intravenous drug users and we did not receive any reports in this regard.”
Another NGCHC member Magda Falah said the government has failed in distributing reports about the prevalence of HIV.
In response, Badriddin Najjar, Head of the National Center for Endemics Control stated, “How come the NGCHC was not informed of the results of the National HIV Symposium while one of its members Mohammed Samoud, former Head of the National Center for Endemics Control, is fully aware of the situation of HIV patients in Libya?”
Alarming danger
The United Nations Support Mission to Libya reported in 2012 the urgent need for implementing an effective national strategy to curb the spread of HIV. The report alarmed the Libyan government into allocating more funds for harm reduction programs including safe injecting, condoms, health education and research.
Shlaka stressed that 15 to 25 new HIV cases, particularly juveniles, are admitted monthly at the Communicable Diseases Department at Tripoli Medical Center, in addition to new cases from outside the capital that emerged after the revolution as a result of unsafe sex with sex workers. “If the situation persists, we will witness a growing number of HIV patients similar to those affected with diabetes and blood pressure,” he warned.
Governmental response and social taboos
Despite the Libyan government’s pledge to contain the prevalence of HIV among intravenous drug users, as a matter of national priority, nothing has been achieved as none of the recommendations presented in the report were implemented including injections, condoms and awareness programs.
Khaled said he is well informed of the Liverpool School report’s recommendations and syringes have been provided for free. However, he said: “The Libyan population is a conservative Muslim majority and will not tolerate the idea. We will be accused of contributing to the spread of the disease rather than eliminating it.”
“Instead of distributing syringes, which will encourage the spread of HIV, we must work on eliminating the root causes. Our top priority at the moment is to ensure the safety of health facilities,” he stressed.
Education and counseling
Hussein Mohamed Osman said the National Center for Disease Control is waiting for Dar al-Fatwa’s approval to broadcast awareness advertisements about safe intravenous drug use, in order to avoid adverse reactions against the center. “We wanted to involve the government to gain its support in this project so that we would not be accused of promoting immorality as was the case in Syria years before the revolution,” he underlined.
Alia Chiboub, Head of Education and Counseling at the National HIV Program, provided psychological support, counseling and advice to numerous HIV-infected people at the center. She said during last June, we have received 11 cases including a child who sought advice and assistance. According to Chiboub, proposals to establish mobile and fixed advice units were submitted to the Ministry of Health, but the ministry has not yet responded.
As for the free hotline which provides advice and assistance for people infected with HIV, she said it activated prior to and during the revolution, but for unknown reasons, it was deactivated after the revolution.
Doctor Wafaa Khafafah said awareness brochures were not enough. “Public and private media are neglectful of the danger of HIV prevalence,” she added.
Health services for addicts
“Health services are limited and we do not have centers for addiction treatment except for Irada Clinic in Benghazi, which only accommodates 40 patients. The other centers at the western and southern regions are closed in addition to the shortage of doctors specialized in addiction treatment,” Chiboub said. “Unfortunately, addiction treatment at Irada Clinic is undeveloped. The clinic has set conditions that are not in line with modern medical standards. For example, a patient who begins using drugs again is not re-admitted.”
Chiboub reported that a center to accommodate drug addicts was available in Tajora, but patients were treated as prisoners and the National Center sent a memorandum to the Ministry of Health to transform Tajora prison, affiliated to the Supreme Security Committee, into a center for addiction treatment, but the ministry has not yet responded.
“The society’s conviction should be changed to view the addict as a victim rather than a criminal whereby he/she would be treated as a patient,” said Khaled. “Regrettably, the Libyan law deems drug users as criminals who are punished with imprisonment.”
Scarce and contradicted data
It is difficult to obtain reliable data on HIV or the number of intravenous drug users. Hussein Mohamed Othman, Head of HIV and Sexually Transmitted Diseases Control, said there is no record revealing the number of intravenous drug users and available records of accumulated cases since 1990 indicate 1,2025 HIV infections, 5,559 registered cases in hospitals and 2,444 undergoing treatment. Such cited statistics are the same as those reported at the National HIV Symposium in June 2012, later officially published by the center in December 2012.
Fathi Arabi is skeptical of the figures presented by Wafa Khafafah, Deputy of Treatment Management at the National Center, indicating nearly 100 new monthly HIV infections in Libya.
Najjar said: “We face difficulties in compiling statistics on HIV. We only publish verified statistics that are compatible with epidemiology. The number of submitted cases does not reflect the spread of HIV,” he stressed.
Huge budget for HIV medications
Eleven million Libyan dinars (US $8,800,000) were allocated for HIV treatment medications in 2012, according to the National Center for Disease Control. Shlaka said HIV medications are expensive and a patient’s treatment costs 1,000 dinars (US $800) per month if purchased from private pharmacies, but the Libyan government provides it for free. Strict monitoring is conducted by state pharmacies in order to ensure that medications are not being sold to private pharmacies.
Shlaka underlined that since last December, 200 HIV patients suffered from the unavailability of medications. In response, Najjar said, “The Center gives technical and scientific advice on medications. Most drugs are available and are distributed to hospitals. Unavailability of medications is due to the closure of manufacturing plants in Europe. Only one factory in China remained, but when drugs arrived to Libya, pharmaceutical companies refused to buy them, awaiting the technical opinion of the communicable disease sections. If the medications were approved, we will distribute them accordingly,” he added. “The situation has improved with regards to the availability of medications by 95% compared to its previous condition two years ago and now over 20 various HIV medications are available,” Najjar said.
Stigmatization and discrimination
Thirty-six-year-old Ahmad was admitted to the Communicable Disease Department in Tripoli Medical Centre for a neck operation after serving in the Libyan army for 17 years. He discovered his HIV infection in 2011, two weeks before his wedding when he was tested in order to obtain a health certificate for a marriage license. He said the treatment and care are at the department were good, where he said doctors were keen to follow up on his condition and that medications were available.
Shlaka said many Libyans believe that HIV is deadly, yet HIV patients in the early stages, like diabetic patients, can lead a normal life if they take appropriate medications and lead a healthy lifestyle.
“Many Libyans believe that HIV is transmitted through a handshake and the use of personal belongings such as a comb, toothbrush and shaving tools, which is not true,” said Shlaka. “That is why society alienates people with HIV,” he said, pointing out the scientifically proven ways of HIV transmission: intravenous drug use, unsafe sexual intercourse (without condoms), mother-child virus transmit and HIV-contaminated blood transfusions.
Salem says he was lucky since his family was tolerant about his infection. “My friends who are aware of my illness have not deserted me, but rather supported me since they are fully aware of how HIV is transmitted. They know that the virus is not transmitted by shaking hands or touching personal belongings as is mistakenly believed. The HIV virus, unlike Hepatitis C, diminishes in three seconds if exposed to external air, but numerous HIV patients are, unfortunately, also infected with Hepatitis C,” he said.
Ahmed, on the other hand, was not that lucky. Once his family knew about his illness, everyone avoided him, including his fiancée and friends, of whom only two have kept in touch. He was forced to move out of his family’s house to a small room in the camp where he serves.
Unfair laws and cruel suffering
“We are not allowed to work because it requires a health certificate stating that the applicant is free of any endemic or transmissible disease, which is not required by most countries in the world,” says Ahmed. “We are given a security compensation of only 225 Libyan dinars (US $180). In addition, most hospitals refuse to receive or treat people with HIV. A man recently died because the hospital refused to admit him (he was also a kidney patient) and some doctors at the communicable disease sections are even afraid to deal with people infected with HIV.”
“I have not been able to get married yet because marrying a girl with HIV requires the approval of the prosecution, which in turn forms a committee after submitting all the test results to decide on the matter. Dar al-Fatwa has not issued a fatwa in this regard and is not willing to deal with us. I feel that they do not approve or tolerate our presence in the society,” Salem said.
