A WORLD AWAY
HIV In Kyrgyzstan, Central Asia
In the spring of 2005, working with a medical NGO, I and five colleagues (two critical care flight paramedics, a registered nurse, a primary care nurse practitioner, and a physician board certified in HIV medicine), spent a month and a half establishing one of the first HIV prevention and primary care treatment programs in Kyrgyzstan, CIS.
This article is based on personal journal entries kept at the time. While at times graphic and disturbing, these events are extremely relevant in a contextual understanding of the subjugation of women and their resultant lack human rights in a strict and oppressive, fundamentalist regime.
Our ride on the ancient school bus from Hell enters hour nineteen. I am convinced this journey will never end. Fifteen minutes later, at two minutes after midnight, I am relieved that it has. We are in a small village of roughly 15, 000. A remote mining town in the south of Kyrgyzstan at the foot of the Tien Shen mountain range, we are here to provide HIV testing and initial treatment to the people living in the rural south, as well as offer desperately needed on the job training to local doctors and nurses.
Identified by WHO officials as an international hot zone, concerns have been growing lately over the skyrocketing rates of venereal disease among many of the miners. Stats will later show that over 19% of the town has already been infected with HIV; a disease that well over half of those infected have never heard of.
Checking in at what is the only guest house in town, we are tired, yet excited with the work to come. Completely unaware of the trajectory it will ultimately take.
2 Days Later
I sit in what was once the cafeteria of a public elementary school, closed several years ago due to neglect and lack of upkeep. Today, it is serving as our teams temporary clinic.
I watch the man escort his wife into the make shift office. Taking a seat in what was once a child’s school chair, she is tense, awkward, the desire to be anywhere but here is clearly evident. Though I don’t know what is to come, I am uneasy.
The man is familiar to me, I think, and quickly recall seeing him yesterday. Mentally, I play out the interaction of less than 24 hours ago.
He was alone then; when he sat in that same chair his wife now sits in and I shared with him the positive result to his HIV test. Though he seemed disinterested, vaguely detached, he had obviously heard of HIV before. His chart from the local clinic indicated a previous history of and treatment for anal gonorrhea, two acute cases of syphilis in the past three years, and a urinary tract infection last month. His only listed sexual contact, his wife. Who, strangely enough, only tested positive for one of the syphilis infections.
“Mistake, this! I am married, not a giver of ass.”
Giver of ass? That’s one for the archive, I think.
Unwilling to engage his obvious denials, I ignore the comment and instead explain that due to a higher than acceptable potential of a false positive result, we won’t consider his oral test as confirmatory until the more accurate blood analysis is in.
“I no understand”, he says to the room in general.
His annoyance is obvious. Abrasively, he offers me his exposed forearm. This, I assume, is my cue to draw his blood. Ignoring the indignant anger beginning to rise, I tighten my jaw, then swab the fat vein with betadine, working the cool, brown liquid off in concentric circles, using strong medicinal smelling alcohol. I use the betadine, as most of these men work in the mines, and dirt three layers thick on exposed skin is the norm. As the first tube in the vacationer fills with blood, he asks,
“So how I get this thing?”
Ah, I see we are going to play the circuitous dance of ignorance. Sounding just a little too clinical, I begin the HIV 101 mantra.
“Well, people acquire HIV through certain types of sex with an infected person, through sharing needles with an infected person, and sometimes through a blood transfusion. Have you ever had a blood transfusion, sir?”
I take the dismissive wave of his hand as a no to the transfusion question. I don’t make a great attempt to navigate a comfort zone here; instinct and experience telling me he has already set the script of what is to follow.
“She is fucking other cocks my whore devil wife”?
Bingo! A narrative that over the next six weeks I will hear from several other men as well.
“These whores, all they want is the cock!”
Careful Skippy, you really aren’t as convincing as you think you are. Though I make a passable attempt to not show it, I’m getting annoyed at his arrogant denials and overcompensation.
“She is cause of this. She bring shame to me!”
Okay. Time to rein in this ever growing narrative a bit.
“No, actually, it does not mean that at all. In fact if your wife is HIV positive, which we don’t know yet, she may have acquired it from you, or she could be negative, or yes, she could in theory have infected you, but that scenario is highly unlikely”.
“What is this, this highly unlikely?”
I briefly toy with telling him an accurate, yet rarely publicized fact; that the likelihood of a man being infected with HIV sexually from a woman, is an occurrence so infrequent as to render it almost statistically insignificant.
I need to preface this by saying that while the dynamic of transmission in Africa is markedly different, due to a few very significant variables, most of the straight men that acquire HIV In North America, Europe, Russia and the CIS and list only heterosexual intercourse as a risk factor, are later discovered to have a history of IV drug use that included sharing syringes, or a history of unprotected anal sex with an HIV positive, and currently infectious, man. Can it theoretically happen via heterosexual, female to male transmission? Yes, it can. However that is the very infrequent exception, not the rule.
Having said that, please be aware that I am only referring to female to male heterosexual transmission potential, as male to female transmission is a very efficient way to transmit and / or become infected with HIV.
Back to the man in the chair.
Instead of getting into a pointless HIV transmission debate, I choose to say nothing. Since it is clear to me that to this man, like so many others who are probably gay or bisexual and have the twisted luck to exist in a repressive, dogmatic, and homophobic culture, one where traditional masculinity = complete heteronormativity and nothing else, is never going to tell me, an openly gay western paramedic, the truth that we both know is behind his infection.
“She has been with the town while I work in mines. Whore devil! Never highly unlikely!”
Oh, the irony.
His over inflated, faux outrage is as equally unpleasant as nails on a chalkboard. Gritting my teeth until they hurt, I pause before offering a response. Meeting his eyes, I explain that this “highly unlikely”, means the chance of being infected by his wife is very remote.
Emphasis placed via continued silence.
That silence follows for what seems an eternity, while air in the windowless room hangs heavy with things not said. My eyes still locked on his, this silly, jocular positioning ends when he breaks gaze, standing abruptly. Tossing me a dismissive once over; it lingers several seconds more than it should, and I have to wonder, is this hate?
Then it suddenly registers…he’s cruising me! No doubt wondering whether to throw the first punch, or hold off til later if he can get a quick fuck. Wow. Who the hell knows what the motivation is; maybe it’s some repressive, self hating combination of both.
Exaggerating for effect, and with a dismissive snort, he tosses the cotton ball at my feet, smiling in a knowing way, and I realize my assessment of his interest was spot on.
“I bring whore wife tomorrow we get to bottom of this.”
“We’ll see you then,” I say neutrally. With an aggressive slam of the door, he is gone.
The jet lag, new routine, and lack of sleep is catching up, as I realize it is past 8 pm and I haven’t eaten anything since breakfast. Dinner would be a good idea!
The Next Morning
She sits in the too small chair, her hands on the relic of a school desk. The same desk where index cards sit, on which results of those tested hours earlier are hand written.
Before the day is out, I will have delivered 96 HIV test results. Of those, 68 of which will be negative.
Turning over her index card, I am not at all surprised by the result I have to offer this woman. With a gentle tone, I explain that her initial test was, in fact, evidence she has been exposed to HIV, but that we need to follow up with another test, etc. The same drill as before. I ask her if she understands. She does. Any questions at all? No. Her affect is flat, and she remains very still. The tension in the room is palatable and it has me on guard. For what, I don’t know. Though I‘m unaware of it now, weeks later I will recall that not once did the woman avert her eyes from my worn hiking boots.
It is as I am filing her index card in the “results given” binder that I notice her expression change ever so slightly. At first I don’t understand, though I should have. Eyes wide, a tight, tonic posture, she is like a terrified animal, freezing when survival would dictate escape. Realizing all at once what is about to happen, I reflexively jump to my feet, attempting to provide a physical barrier, but I am not quick enough. As the man’s closed fist intersects with the woman’s mouth, the force knocks her off the school chair. Blood sprays, and three of her front teeth hit the floor.
Raising his fist again, he is surprised to be lifted off the floor, then slammed into the wall. For the second time in 24 hours, my eyes lock onto his.
“You’re going to need to go through me first.”
He says nothing. It seems this is the time for his English to fail him. The hate in his eyes is seething, but my resolve is equally as strong. Colleagues quickly arrive, though it is not until I am convinced there are enough of us to prevent round 2, do I slowly release my grip.
His wife, the mother of his three children that stand wide eyed and silent at the door, is on all fours, a hand covering her swollen mouth, as she awkwardly attempts to retrieve her teeth with the other. I bend down and pick them up, quietly saying she does not need to go, she and her children can stay here. Though it is not until I explain she is safe now, and she looks at me as if I am floridly psychotic, do I recognize the brutal reality of what has just occurred. Stay? Of course she can’t stay! She can’t stay, because for this woman there is no choice. Her husband has said she must go. And minutes later, in silence, that is what they do.
Like yesterday, I decide it’s probably a good time to break for dinner, though I have little appetite.
2 Days Later
No one on the team says it, but it is clear we are not especially surprised to be called to this families home for medical assistance. Until we arrive, we have no idea that the burns the woman has suffered, from a “grease explosion” on the stove top, are covering almost 90% of her body. Not surprisingly, she is the only victim burned. Beyond recognition.
Her chances? In a remote, mountainous country in Central Asia, one that has nothing resembling a burn center for thousands of miles, this woman has literally no chances. She will die. The one and only blessing; a morphine drip that, due to charred, leathery skin, I took almost an hour to place the IV. Now it is barely keeping her severe pain at bay.
Her husband is almost convincing as a man who will most likely lose his wife. A woman who had the unfortunate circumstance to marry a man who values masculine pride and denial of same gender attraction over the life of his children’s mother.
Not exactly an Oscar winning performance, I think. This time, however, I am not laughing.
Unfortunately, though perhaps mercifully, this woman’s life ended two days after she was set on fire.
Sadly, this situation is not at all uncommon in Central Asia and other countries within the region. Any number of perceived blows to male self image, secret homosexual activity being high on the list, is reason to deflect blame. Doing so with a combination of one part lighter fluid, one part match, and one part spouse, is certainly a tragedy that accomplishes much deflection. In Kyrgyzstan, it is also a tragedy with penalty of only six months in jail. And though it is not at all a rare crime, as of 2005, no man has ever served time for it.
Though the events described above are factual, some non material details have been changed to protect the confidentiality of the victim and the NGO team involved.
In 2006 Allan Rae left a career as a flight paramedic to obtain his MFA in creative nonfiction. Today he is a qualitative public health researcher exploring the intersections of HIV, PTSD, and stigma, through the use of personal and community narrative. Allan is also the editorial team lead for creative nonfiction at daCunha. Starbucks, satire, and stray dogs do not displease him.