Turkmen officials swear up and down that there have only been two cases of HIV/AIDS in their country, which is led by a former dentist and deputy health minister, President Gurbanguly Berdymukhamedov, author of various books on health.

But according to a recent report from the Turkmen Initiative for Human Rights (TIHR), 68 HIV-positive individuals have been identified in the town of Turkmenbashi.

"For a town with a population of slightly more than 40,000 people, this is quite a considerable number," says TIHR.

Turkmenbashi, named for the title used by past dictator Saparmurat Niyazov, which means "head of all Turkmen," is a Caspian Sea town near the Avaza tourist zone. The coastal resort area is a pet project of the current Turkmen leader, lavishly funded and frequently used for meetings with heads of state and other prominent figures at what are inevitably described by the state media as "fashionable hotels".

The area is flooded now with foreign construction workers and business people, says TIHR. They are mainly males without their families who earn good salaries -- by comparison with the desperately poor people of Turkmenistan.

So the pattern is the same as in other countries -- sex workers have flocked to the area from other provinces in Turkmenistan, and reportedly charge from $50 to $200 for services, or even lower, if they are also drug users looking for the cost of a dose, which is said to be $3-$5.

The UNAIDS website with information about country responses and programs does not even have any information about Turkmenistan at all. A study of neighboring Uzbekistan, however, says 15,892 HIV-positive persons were reported there in 2007, a rapid increase from the 1,400 reported in 2001.

The Paris-based Doctors Without Borders (MSF) worked in Turkmenistan for 10 years, constantly attempting to warn officials at the Turkmen Ministry of Health and Medical Industry that like other Eurasian countries, they could face the rapid spread of HIV/AIDS unless they started publicizing the true story and accepting assistance. MSF left Turkmenistan last year when it could not gain the government's cooperation, and indicated in a devastating report that they suspected some people were ill with AIDS whose disease was disguised by doctors fearful of facing dismissal.

“It is undeniable that tuberculosis and sexually transmitted infections including HIV/AIDS are more prevalent than reported figures would suggest and the Turkmen government is refusing to acknowledge this reality” said Dr Leslie Shanks, MSF’s Medical Director in a press release last April on the organization's web site.

Says the MSF report:

A study released in 2008 of blood services in four Central Asian health systems reported serious problems in the testing and use of blood products, adding that the greatest increases are found among injecting drug users, a problem that Turkmenistan shares. Unlike these countries, however, Turkmenistan has not reported any new HIV infections in the last three years and has not performed sentinel surveillance.

The World Health Organization (WHO) has had little to say on the issue. Like other UN bodies, WHO has preferred to laud progress publicly and reserve criticism -- if any -- for private meetings, in order to maintain a presence in the country. Turkmenistan is therefore heaped with praise for good deeds like iodizing salt or eradicating malaria -- in this largely desert-covered land with few swamps -- but not openly criticized on the issue of HIV/AIDS. An "Epidemiological Fact Sheet" on HIV/AIDS on Turkmenistan published by WHO in 2008 contains largely blank tables, and indicates that there is a low estimate of 500 cases, and an estimate of no higher than 1,000 possible cases -- and only 2 cases of females officially reported in 1999 and 2002.

WHO then stated in a 2008 country review:

By the end of 2006, Turkmen authorities had reported a cumulative total of just two HIV cases, one of which developed AIDS and died. Almost no other national data are available… Unofficial reports indicate a substantial and unaddressed epidemic in progress.

This statement was not covered on the official UN Turkmenistan website at untuk.org and these reports cannot be found there. Meanwhile, more upbeat stories are featured, such as the delivery in February 2009 of 500,000 condoms donated by the UN Population Fund (UNFPA) at a cost of $18,335, to be distributed to health care facilities and supposedly to be made available to at-risk groups such as drug users and sex workers.

As MSF says,

The impossibility of Turkmenistan having had only two cases of HIV/AIDS, as per their official reports, is widely recognised. Surprisingly, however, this has received relatively little attention from the international community, and the government’s neglect of the issue is rarely directly addressed. For every comment on the WHO website such as the above, there is a bland and reassuring statement from UNICEF such as the following:

Although Turkmenistan is a country with a low level of HIV/AIDS (one case of HIV reported in 2004), the government recognizes that it must remain vigilant if it is to protect the country from becoming yet another casualty of this illness.

So yes, Turkmenistan does mention HIV/AIDS as an issue for prevention in the state-controlled press, cooperates with the UN and other international bodies on educational seminars, and even sponsors large demonstrations to mark World AIDS Day on December 1. A law was passed on HIV in 1999, along with a national program for prevention.

Yet as MSF found, HIV testing was extremely difficult to procure and not readily available to people. When anti-retrovirals were finally added to Turkmenistan's official drug list in March 2009, tellingly, they were not described as agents to prevent mother-to-child transmission and treating HIV but were renamed "immunomodulators".

The Institute for War & Peace Reporting (IWPR) has characterized Turkmenistan as "in denial" about a potential HIV/AIDS epidemic. The Ministry of Health has banned staff from listing AIDS as a cause of death, but some medical workers have confidentially told reporters that they have diagnosed cases of AIDS, says IWPR.

The Turkmen government fiercely denounced the MSF report, and recently the head of the TIHR was targeted with a death threat reportedly from the Ministry of National Security for publishing these kinds of frank reports from internal sources. But with this alarming signal from Turkmenbashi, international organizations and foreign governments dealing with Turkmenistan will need to find a way to persuade the insular regime to increase access to HIV testing and produce honest reporting.