HIV in the Middle East

I thank Dr. Barss and his team for their comments in response to my
letter. With respect for the space I am allotted, I will respond
immediately to some of the concerns raised.

Firstly, my response was in the format of a letter to the
editor/readers response, it did not pretend to be a research article or a
systematic scientific analysis.

With respect to Miss El-Khatib, Dr. Barss is correct in stating that
she did not disclose any confidential information to others or myself.
Miss El-Khatib acted with the utmost professional integrity at all times
in her capacity in public health educator while in the UAE and while here
in Canada.

There are two major issues that come from this debate and that is of
the failure to disclose infection rates in the country and the practise of
deciding what is in the best interests of HIV positive Emiratis.

Dr. Mahmoud Fikri, the Assistant Under-Secretary for Preventive
Medicine UAE Ministry of Health, states that there have been no new
infections since 1985, in his address to the United Nations this past June
3, 2006 in New York (available at http://www.un.int/uae/fikri.htm). This
is a curious thing to state when the UAE has at the same time made reports
to the UNAIDS showing new infections up until 1998
(http://www.who.int/GlobalAtlas/predefinedReports/EFS2004/EFS_PDFs/EFS200...).

Regardless of where the truth lies, what results is a generation of
youth and adults who perceive that there is no HIV threat because the
government has not declared it to be so. In numerous presentations that I
have done, some in Dr. Barss faculty and some in other educational
institutions with students of various levels, I have frequently
encountered both denial and shock at the very hint that there is HIV in
the country at all. When I asked students why this is so, the categorical
response has been, because "the government says there is none." While this
may not be the case with Dr. Barss students, who represent an elite crop
of students in the country, it is certainly a widespread perception in
lower academic levels.

Comments like those made by Dr. Mahmoud add to the perception that
HIV is not a concern in the country and increase the vulnerability of
those youth who think HIV is a problem with foreigners, Westerners and Non
-Muslims. By failing to publicly state that HIV is a concern in the UAE
and that the infection rate is increasing, the lack of disclosure
undermines the very preventive efforts that are occurring.

I do wish to acknowledge the good work that Dr. Barss is doing in his
efforts at increasing HIV awareness and state that I am aware of his
project. However, his project is one of very few (in fact, I believe it
was and still is the only one in the country). My concern is not about
preventive efforts per se but rather about the quality of the prevention
work being done to date.

In my own HIV presentations and discussions with students, I became
aware that not only was their knowledge about HIV (gained in government
secondary schools) lacking and in some cases non-existent, but their
knowledge about sexuality, reproductive health, and basic anatomy was
almost nil. Indeed, Visiting Professor Dr. Ganzak, who was also named on
Dr. Barss letter, presented much of the same findings with respect to HIV
knowledge in her own study (unpublished findings) of the UAE. While we can
say there is some preventive work being done, it is largely reserved in
and for the medical field. Where it is delivered in the general
population, it is still medically oriented and largely incomprehensible to
most people, including many of whom (like the mothers of many of my own
students) are illiterate or have little schooling.

I myself, attended a government sponsored AIDS awareness presentation
and quickly became perplexed with all the medical jargon, slides of viral
replication, and immune system functioning. There was nothing in the way
of prevention other than the standard message of “get married and be
faithful to your husband.” Condoms were never mentioned, safe and unsafe
sexual practises were never discussed, in fact, sex was never spoken of at
all. A session done with the Harvard doctor that Dr. Barss mentioned
showed us that a majority of the young women (many already married) we
spoke to did not even know what condoms were.

My concerns are that “prevention” work is being done to satisfy those
who are asking for it, but that the actual issues that increase the
susceptibility of acquiring HIV, especially in women, like domestic
violence, safe sex, partner drug use, infidelity, marital rape and the
like are not being addressed. To know how a virus replicates does not
inform a person to know what to do if her husband is cheating on her with
a sex worker. To know how a virus replicates does not inform a young woman
who wants to experiment with her illicit boyfriend how to keep herself
safe from contracting HIV or any other sexually transmitted disease.

The practise of offering a choice to HIV positive Emiratis about
continuing to work, go to school or retire is an interesting one. Many of
the HIV positive Emiratis I spoke with no longer worked because, in their
estimation, they had either been asked to leave their place of work or
were not offered a contract renewal. However, others chose not to return
on their own because they were met with such stigma that they felt they
could not return to work because of the shame they experienced.

My concern is that this process that prohibits a return, or prevents
entry (the difference is in semantics and the end result is the same) is
not uniform, and may not take into account the wishes of the HIV positive
person. This process is subjective and because of widespread stigma seems
to generally result in a withdrawal (either imposed or chosen) from civil
society, rather than an advocacy process that would encourage or better
yet, enforce the rights of HIV positive Emiratis to stay in school, stay
in their work place and tap into the Marriage Fund like all other
Emiratis. Any process to decide on any of the three options mentioned is
still a contravention of rights since it is based on a positive HIV
status. Whether the patient is ill or not should result in a discussion
with his or her case worker to find accommodations in the workplace or
school environment that would permit regular life to continue as normally
as possible and not a committee to decide on his or her behalf.

With respect to school admissions, my own work place made it clear
that no HIV positive Emirati would be admitted. The ministry of Health and
Education continues to make an HIV negative status a prerequisite to
attendance in schools. In discussion with other Ministry of Health workers
in different emirates and also members of international NGOs, it was clear
that attendance in schools for HIV positive Emiratis routinely results in
a withdrawal or refusal of entry. Whether this is legislation or merely
common practise, there is little accountability and government advocacy
for change where HIV positive Emiratis can decide for themselves without
the threat of their status being disclosed or being pressured to withdraw
from civic life under the guise of ‘their protection.’

Finally, Dr. Barss is correct in stating that some of the evidence
presented is anecdotal. This is a simple result of the widespread fear
that exists about talking of HIV – as it relates specifically to the UAE –
and also of the widespread denial that it is an issue worth talking about.

I do not disagree with Dr. Barss in his estimation that there is a
willingness to address HIV in the country, certainly the economic
resources and expertise exists. My concern rather is the lack of
implementation in doing so as stated in my letter. There exists no public
advocacy for HIV positive Emiratis because officially there are no
positive Emiratis. Failing to disclose the fact that there are HIV
positive Emiratis (infected after 1985) makes it difficult to publicly
convince the population that it is an issue worth knowing about and
understanding. The very act of hiding numbers makes it harder to convince
youth that they are at risk through their practises, beliefs and
knowledge. Furthermore, not discussing practises, beliefs and knowledge
makes them vulnerable because they are not aware of the consequences
(which can be deadly) of their actions, nor how to make those consequences
less harmful.

I thank Dr. Barss for his letter and encourage him to continue
addressing HIV in his community. At the risk of making this an issue
between myself and him (which it is not), it would perhaps make the most
sense to ask the Ministry of Health and Education (those responsible
specifically for HIV) to comment for themselves rather than let others do
the talking for them by commenting on the following:

What is the exact process indicated above of selecting how an HIV
positive Emirati proceeds once they are diagnosed and what legislated
provisions exist to protect HIV positive citizens rights in employment,
education and access to social programs?

What is the rationale in removing or preventing HIV positive Emiratis
from educational institutions and what is being done to promote their
rights in education and protect their status in schools?

What legislative pieces are in place to protect the rights of
Emiratis who are HIV positive and who petition the decisions of private
school boards and government school systems who prevent their entry into
schools?

What future actions can we expect on the part of these two Ministries
to protect and promote the rights of HIV positive citizens?

I would be most appreciative for these responses as would those who
work in the HIV field in the UAE and certainly on behalf of the HIV
positive Emiratis who seek these answers but have been too afraid to ask
the questions.

I will not be corresponding further in this forum, however, I welcome
letters or comments to my personal address in Canada if needed.

Sincerely,
Louise Lambert

Competing interests:
None declared