KEBRE DEHAR- Lying on a raffia mat on the floor, staring listlessly at a passing nurse, a young boy finds it too much effort to move his limbs, or his head. Only his huge sunken eyes move, slowly. "Tuberculosis I think," says the senior nurse, Abdullahi Bedel Teken.

Most of the patients in the grimy, dark wards of Kebre Dehar hospital are considered tuberculosis (TB) patients, but with limited testing facilities and no working X-ray, doctors and nurses must often go on symptoms and professional instinct to make a diagnosis. AIDS may also be a killer here, they fear.

Chronic malnutrition and very high TB rates would disguise the presence of HIV/AIDS, local and international health workers agree. Death is so common in this region, burdened with disaster and underdevelopment, that no alarm bells are ringing. "There is definitely suspicion that AIDS is here, but the problem is that we have no way of testing for HIV," Abdullahi Bedel Teken told IRIN.

There is a small laboratory to test for TB, and some medicine supplied by the health NGO Medecins sans frontieres (MSF), but here in Kebre Dehar, in one of the remotest corners of the Ethiopian Somali Region in southeastern Ethiopia, there is no sign yet of the national campaign against HIV/AIDS: no posters, no public information, no testing, and no counselling.

The absence of the campaign has nothing to do with national denial. Ethiopia is openly coming to terms with the enormity of the HIV-AIDS pandemic.

[AIDS, the Acquired ImmunoDeficiency Syndrome, is the late stage of infection by the Human Immunodeficiency Virus (HIV)] "An estimated 2.9 million Ethiopian adults and 150,000 children are living with HIV/AIDS, more than in any other country except South Africa and India", according to the Ethiopia Multi-Sectoral HIV/AIDS project, prepared this year by the central government.

UNAIDS estimates that the rate of HIV infection in the adult population at the end of 1999 was about 10.6 percent, and that AIDS was responsible for some 280,000 deaths in Ethiopia in that year [for details, visit UNAIDS].

"Stigma, fear and denial are still common among the population... actions are largely concentrated in and around the main cities, and have so far had little impact on the rural population," according to a document from the Multi-Sectoral HIV/AIDS project. The National AIDS Prevention Council was established in April 2000, when its first meeting was opened by Ethiopian President Negaso Gidada - a demonstration of how much importance the government places on the campaign.

"It is high time for all of us to realise that if the HIV/AIDS situation is allowed to continue unabated, we will reach the point where the loss of a generation will be a real possibility," Negaso said. The Council meets three times a year, is headed by President Gidada and includes government members, NGOs and religious bodies. In large urban centres like Addis Ababa, the national campaign has become a part of everyday life. Explicit information on sexual behaviour is regularly broadcast on television.

Theatre, nightclub shows and posters carry messages about condoms and promiscuity. But in the Somali Region, there is cultural resistance even to entertaining the idea that HIV/AIDS could exist, according to a local NGO worker. "Much depends on culture, and there is the deep-seated belief that there is less sexual contact among this Moslem Somali population," he said.

A national campaign would have to be "culturally sensitive" regarding information displays of sexual behaviour and explicit advice about protection, the source said. "Somali women and men here don't use condoms," he added. Such is the taboo against HIV/AIDS that there is even a nervousness to talk publicly about the need for testing, for fear it would be seen as a declaration that the disease was present in the community.

"The important thing is to first see if the disease is here, through tests, and then, if it is, to have a campaign," said one local humanitarian worker, on the condition of anonymity. In Gode regional hospital, the doctor-in-charge, Taj al-Din Ahmad, told IRIN there was an urgent need for HIV testing facilities.

Gode hospital receives patients from a radius of up to 250 km and serves the remote Somali Region, but has no HIV testing facilities. Tuberculosis is prevalent, often related to malnutrition, and would disguise the presence of AIDS, Taj al-Din said. He warned, however, that if testing facilities were established, counselling facilities must also be put in place.

"You can't start with just one nurse telling people, 'Oh, you have HIV'," he added. Taj al-Din Ahmad believes he has nursed AIDS patients in his hospital but said that, in the absence of testing facilities and resources, staff "just treat it as a secondary disease." He said he had tried to raise the issue of HIV/AIDS with the regional health bureau, based in the capital of the Somali Region, Jijiga, but got no real response.

In an area characterised by underdevelopment, drought and political instability, HIV/AIDS has not yet received attention. "There is no priority for it here... the issue needs attention from politicians," Taj al-Din told IRIN. Regionalisation and decentralisation in Ethiopia in the early 1990s had the affect of cutting back large, centralised HIV/AIDS teams.

They also placed the burden of responsibility - and resource provision - on regional governments. The national programme was streamlined and cut down, and handed over to the regions. This weakened the Ministry of Health, reducing both resources and capacity, humanitarian and official sources told IRIN. "A gap is created between what is on paper and what can be done on the ground. Programmes suffer," an official source said.

The Somali Region was particularly vulnerable to these weaknesses, as one of the most underdeveloped regions in Ethiopia. It has also been one of the most politically unstable, with a high turnover of regional presidents and administrations.

In garrison towns like Kebre Dehar, there is likely to be some level of awareness of the disease, according to Dr Taj-al Din. Many of the soldiers come from other regions, including urban centres, where the national campaign has visibility. There are also HIV/AIDS campaigns in the barracks and the garrisons.

But it is the large military presence in the Somali Region - particularly in the Ogaden - that increases humanitarian workers' concern that HIV/AIDS is "very likely" to be present. Armies are known to be one of the primary social institutions responsible for the spread of the disease, humanitarian workers and campaigners point out.

Kebre Dehar is the site of "a big garrison with soldiers from all parts of Ethiopia, and established prostitution to service it," according to one aid worker. Prostitutes serving the garrison are typically women from the highlands rather than local Somalis, and their long-standing presence has led to a small but noticeable group of children who survive on the margins of society and receive little support or health care. "They are 'mixed' children without a real home or cultural support, and they are effectively street kids", said one local source.

Otherwise, there is little contact between the indigenous community and the soldiers, with the Somali population suspicious of an army commonly considered "occupiers". Apart from the local administration, those most likely to interact with the garrison are informers and prostitutes, who receive some benefits, including extra rations, humanitarian sources told IRIN.

It is a matter of urgency to begin an HIV/AIDS campaign in all areas of the Ethiopian Somali Region, said Connie Osborne, acting Country Programme Adviser with UNAIDS/Ethiopia. "Even if the HIV/AIDS rates are low there, you need to protect the region," she said.

Osborne told IRIN that the high TB rates and the military presence were "worrying", and that other factors such as malnutrition and poverty related-diseases would disguise AIDS deaths. In chronically underdeveloped regions where basic health facilities are lacking, and pastoralist communities live on the edge of survival, AIDS is unlikely to be visible, according to Osborne.

Immediate priorities like the drought and political instability can push HIV/AIDS to the back of the queue. Given the extreme underdevelopment of the Somali Region, moreover, national testing surveys cannot be undertaken.

Sentinel screening sites have been established in seven regions and 21 sites since 1999, but need to be set up where there are ante-natal centres, laboratories and adequately equipped and staffed hospitals and health clinics. "If the tuberculosis rates are high and there is a military presence in the region, something needs to be done", said Osborne.

Drought, malnourishment and disaster should not push HIV/AIDS off the agenda, because it may be disguising a growing problem, she said. "If death is common, it is often difficult to identify the impact of the disease, unlike places where death is unusual".