Background
The nation of Turkey has one of the lowest rates of HIV infection in the world. While this rate has increased in the last several years, the reason is likely due to better reporting by health facilities around the country, rather than simply more infections. Also cited as part of the reason for increasing rates of infection is the recent influx of refugees and other immigrants from regions such as Africa, where infection rates are much higher than in Turkey proper.
The primary mode of transmission is through heterosexual contact, although the stigma of homosexuality has probably influenced patient reporting on this point. Mother-to-child transmission is quite low due to Turkey’s decades-long push to improve the overall accessibility of healthcare throughout the country. This focus on access, along with the provision of health insurance to most of the population, began in 2003 and initially placed particular emphasis on improving the rate of maternal mortality. As a consequence, this emphasis brought increased attention to preventing mother-to-child transmission of HIV.
There are two interesting features of HIV/AIDS in Turkey that set it apart from most other nations in the European region. First, unlike in the developed world, eye infections are uncommon in HIV-positive patients. The reasons for this are not clear, but it is thought that there may be a genetic factor that confers protection against common eye diseases suffered by people living with HIV/AIDS. ( Akçakaya, et.al., 2012, 160-161).
Also of a genetic origin is another condition that sets Turkey apart, and that is the presence of a protective allele among a portion of the population in the Anatolia region (Karakaya, et.al., 2013, 886). This allele, a mutation in the CCR5 receptor, makes individuals who carry it nearly immune to infection from the HIV-1 strand of virus. Interestingly, the CCR5 mutation has a unique, geographic distribution and is prevalent among populations that live much further north, in and around Scandinavia. The region of prevalence extends in a north-south axis down to southern Germany, approximately. Thus, to see it manifest in Turkey indicates certain patterns of human migration at a time after the mutation first appeared, thought to be during the Bronze Age, probably in response to some form of plague. Furthermore, the allele is seen far less often in other regions of Turkey and is virtually nonexistent in Marmara. This knowledge has helped Turkey target its HIV healthcare screenings and practices to meet particular conditions in various areas of the country.
Rates of HIV Infection and Transmission Paths
In 2013, Turkey’s HIV infection rate was 1.7 per 100,000 individuals in the population. While this is low compared to other European nations, the fact remains that this rate more than tripled since 2004, when consistent reporting began. (Turkey has reported AIDS statistics since 1985, but the data is too spotty to be of much value.) This increase in the HIV infection rate is probably due to underreporting in the early years, rather than to a large increase over time.
Since 2004, when HIV information was first reported in a statistically relevant manner, through the end of 2013, 6,763 individuals in Turkey were diagnosed with HIV. In 2013 alone, 1,126 individuals were diagnosed with HIV, 93 individuals developed full-blown AIDS, and 10 individuals died as a result of an AIDS-related condition. More than half of those diagnosed in 2013 were identified through screens or check-up tests.
The male-to-female diagnostic ratio is 4.3 to 1, which gives rise to the suspicion that many men who claim to have been infected by women were likely infected through having sex with other men. The extreme stigma of homosexuality prevents newly infected men from acknowledging their true circumstances. Therefore, while the official statistics show that the main mode of transmission in the nation is through heterosexual contact, those figures are suspect. See Table 1 for transmission routes in 2013, as reported by the European Centre for Disease Prevention and Control (ECDPC)/World Health Organization (WHO) (2013, n.pag.).
In 2014 Yemisen et. al. (2014, 61) studied 829 naive, untreated HIV-1 positive patients in Istanbul to determine the route of transmission and circumstances of the original diagnosis. Of those, 700 (84.4%) were male. The results are summarized in Table 2.
Clinical Presentation
Altunas, et. al. (2010, 220) developed a profile of the clinical presentation of HIV/AIDS in a tertiary clinic in Istanbul between January 2006 and May 2010. Of 156 patients, 73 (47%) showed signs and symptoms of HIV infection when they first entered the clinic. Slightly more individuals—83 or 53%—showed no clinical symptoms and had been diagnosed through routine HIV screenings. These results are encouraging because they demonstrate that more people are being diagnosed before they show definite signs of AIDS illnesses, which in turn indicates that education and prevention efforts are having a positive affect.
Of those patients who showed signs of infection or disease, Altunas et. al. (221) recorded the most frequent clinical symptoms. They are summarized in Table 3 below.
Stigma, Work and Social Issues
There are many misconceptions about HIV and AIDS in Turkey and this has led to stigmatizing those who are affected; not just patients but their associates as well. Patients and their families have encountered discrimination at work, in social settings, and even in clinics among health personnel. (Kose, et.al., 2012,34) There is a general lack of education on the causes of HIV/AIDS, how it is transmitted, and the options for treatment. Patients are not properly educated on their responsibility to prevent the spread of HIV.
Nazik, et. al. (2013, 263) conducted a study and found that 31% of HIV patients felt ashamed of being HIV positive; 16.7% indicated that they were not invited to social events; 56.8% indicated that they had been discriminated against; and 39.3% indicated that they had been excluded. Furthermore, study participants indicated that they knew an HIV-positive person who did not have access to health services (43%), had been exposed to violence (60%) or had been excluded from society (65%). Since the relationship between quality of life and social supports is strong, this type of stigma tends to isolate people living with HIV/AIDS and leads to poor quality of life for many infected individuals in Turkey.
Policies, Programs and Funding
In 2003, Turkey began a major overhaul of its healthcare system. An initial focus on maternal health led to a great decrease in mother-to-child transmission of HIV so that today’s rate is very low. Between 1970 and 2011, Turkey achieved the highest average reduction in infant mortality of all states in the European region, reducing infant deaths by nearly 7% each year (OECD/WHO, 2014, n.pag.). In reducing infant mortality, Turkey also reduced the number of infants born with HIV infection, even though prevention of HIV was not the policy’s specific intent.
Turkey introduced universal health care, which is funded by workers’ payments into a national system. Even though they don’t pay into the system, the poor and documented refugees are covered. Sadly, undocumented migrants and asylum seekers are not. The system provides for free medical examinations and screening for HIV, other sexually transmitted infections (STIs), and tuberculosis (Macherey, 2015, 120). However, everyone—even individuals with healthcare insurance—must pay for their own HIV treatment, which is very expensive. This cost, plus the lack of coverage for undocumented individuals, means that a sizable number of HIV-positive people probably go untreated. Perhaps worse, they also go about uninformed as to how to prevent infecting other people.
According to Macherey (122) and her team in Istanbul, most undocumented migrants would have better access to HIV/AIDS treatment in their countries of origin. Working through nongovernmental organizations (NGOs) medical personnel try to help infected migrants return to their home nations to be treated. This, obviously, is problematic, as the reason most undocumented people arrive in Turkey to begin with is because they are at some type of political, economic or social risk in their own countries.
Needs Going Forward
After spending the last two decades increasing access to healthcare and medical treatments for all its citizens, Turkey recently began to focus on quality in addition to quantity. With more health centers accessible to more people, along with increased focus on HIV/AIDS education, the government expects to achieve better rates of reporting.
It recently launched a cooperative partnership with a British group to plan and carry out a national HIV/AIDS public education program. It is expected that better education programs will lead to a more informed, and less frightened, citizenry. This, in turn, may begin to address the problem of stigma and the host of social problems that are its consequence.
Works Cited
Altuntas, Aydin, H. Kumbasar Karaosmanoglu, R. Korkusuz, and O. Nazlican. “Clinical Profile of HIV/AIDS Patients Admitted to a Tertiary Outpatient Clinic in Istanbul, Turkey.” Journal of the International AIDS Society 13 (Suppl 4) (2010): 220. Web. doi:10.1186/1758-2652-13-S4-P220. 9 Feb. 2016.
Akçakaya, Aylin Ardagil, Fatma Sargın, Hasan Hasbi Erbil, Asiye Aybar, Fariz Sadigov, Sevil Ari Yaylal, Güzide Akçay, and Neils Güneş. “HIV-related Eye Disease in Patients Presenting to a Tertiary Care Government Hospital in Turkey.” Ocular Immunology & Inflammation (2012) 20(3): 158–162. Web. doi: 10.3109/09273948.2012.676701. 9 Feb. 2016.
European Centre for Disease Prevention and Control (ECDPC)/WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2013. Stockholm: European Centre for Disease Prevention and Control, 2014. Web. 8 Feb. 2016.
Karakaya, Gamze, Fatma Azize Budak Yildiran, and Sukran Akir Arica. “Investigation of the Frequency of the Mutant CCR5-Δ32 Allele Related to HIV Resistance in Turkey.” Turkish Journal of Medicine (2013) 43: 886-890.
Kose, Sukran, Aliye Mandiracioglu, Gulsen Mermut, Figen Kaptan, and Yusuf Ozbel. “The Social and Health Problems of People Living with HIV/AIDS.” Eurasian Journal of Medicine (2012) 44:32-39. Web. doi:10.5152/eajm.2012.07. 9 Feb. 2016.
Macherey, Anne-Laure. Legal Report on Access to Healthcare in 12 Countries. Paris: MdM International Network (Médecins du monde international network), 2015. Web. 8 Feb. 2016.
Nazik, Evsen, Sevban Arslan, Hakan Nazik, Behice Kurtaran, Selcuk Nazik, Aslıhan Ulu, and Yesim Tasova. “Determination of Quality of Life and Their Perceived Social Support from Family of Patients with HIV/AIDS.” Sex Disabilities (2013) 31:263–274. Web. doi: 10.1007/s11195-013-9304-x
Yemisen, M., O.A. Aydin, A. Gunduz, N. Ozgunes, B. Mete, B. Ceylan, H.K.
Karaosmanoglu, D. Yildiz, F. Sargin, R. Ozaras and F. Tabak. “Epidemiological Profile of Naive HIV-1/AIDS Patients in Istanbul: The Largest Case Series from Turkey.” Current HIV Research (2014) 12(1):60-64. Web. 9 Feb. 2016.
