Human Immunodeficiency Virus & Viral Hepatitis among High-Risk Groups: Understanding the Knowledge Gap in the Middle East & North Africa Region

To identify gaps in the existing knowledge on single, dual and triple infections of human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV) in the Middle East and North Africa (MENA) region among men who have sex with men (MSMs), female sex workers (FSWs), injecting drug users (IDUs) and prisoners.

We performed an extensive literature search on articles published on the topic in the 25 countries of the MENA region. PubMed database was used as the main search engine. Case reports, case series, qualitative studies, editorials, commentaries, authors’ replies and animal studies were excluded. Original articles and reviews dealing with the prevalence of HIV, HBV and HCV and their co-infection were included. Data on population type, sample size, age and markers of infections were extracted from the relevant studies.

HIV, HBV and HCV are blood-borne viruses with similar modes of transmission. The categories of people at high risk of acquiring HIV-1, HBV and HCV commonly include: MSMs, FSW and IDUs. It is well established that HIV-positive individuals co-infected with HBV or HCV suffer from liver pathology associated with morbidity and mortality. Moreover, HIV-infected individuals do not respond well to treatment for HBV or HCV and hence are at increased risk of hepatic toxicity. Consequently, co-infection of HIV-positive individuals with HBV and/or HCV is a global health problem of significant magnitude. Our review reveals the paucity of epidemiological data for key populations in many countries of the region. Limited number of studies exists in the MENA region on the status of HIV, HBV and HCV and their co-infections among prisoners, MSMs and FSWs. Evidence support the continued increase of the HIV epidemic among MSMs. In addition to the lack of studies on MSMs and FSWs in the MENA region, our review highlights the lack of data on the practices, characteristics, or the status of HIV infection and viral hepatitis among male sex workers selling or exchanging sex for money.

The MENA countries are in urgent need of advanced research and strengthening of the data collection systems and reporting practices of these infections among key populations.

Table 1

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among prisoners from Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
Egypt	500	41.0	0.0	9.8	15.8	0.0	0.0	0.0	[14]
Iran	160	16.6	0.6	0.6	NS	0.0	NS	NS	[15]
	392a	35.9	17.0	4.5	80.5	0.8	14.5	0.8	[16]
	358b	34.7	0.0	6.1	8.1	0.0	0.0	0.0	[17]
	163	34.5	0.0	7.4	7.4	0.0	0.0	0.0	[18]
	249a	35.4	15.1	4.7	64.8	1.1	14.3	1.1	[19]
	150a	31.4	42.5	18.9	75.9	NR	NR	NR	[20]
Lebanon	580	31.7	0.2	2.4	3.4	0.0	0.0	0.0	[21]
Libya	6371	> 16	18.2	6.9	23.7	NR	NR	1.5	[22]

aAmong prisoners who inject drugs;

bDrug-related convictions; n: Sample size; NR: Not reported; NS: Not studied. All numbers were rounded to the nearest 1. HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 2

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among female sex workers and men who have sex with men in Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
FSWs
Lebanon	103a	≥ 18	0.0	0.0	0.0	0.0	0.0	0.0	[23]
Libya	69a	≥ 15	10.1	2.9	7.2	0.0	4.3	0.0	[24]
Turkey	130	38.9	0.0	3.1	0.8	0.0	0.0	0.0	[25]
MSM
Lebanon	101a	≥ 18	1.0	1.0	0.0	0.0	0.0	0.0	[23]
Libya	227a	≥ 15	5.3	3.1	8.4	0.0	4.4	0.0	[24]

aNon-adjusted prevalence using respondent-driven sampling method. All numbers were rounded to the nearest 1. HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 3

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among injecting drug users in Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
Cyprus	40	25-31	0.0	0.0	50.0	0.0	0.0	0.0	[27]
Iran	202	-	NR	NS	52.0	NS	9.4	NS	[28]
	417	≥ 17	24.4	NS	80.0	NS	24.0	NS	[29]
	258	28.8	18.8	NS	65.9	NS	NR	NS	[30]
	233	32.3	7.7	22.7	40.3	4.7	6.4	4.7	[31]
	117a	< 30	0.7	0.7	59.0	0.0	0.0	0.0	[32]
	899	33.9	10.7	50.7	34.5	7.8	8.7	6.5	[33]
	100	17-58	19.0	6.0	56.0	NR	15.0	5.0	[34]
	268	37.0	10.8	6.0	39.2	NR	NR	NR	[35]
	153	30.7	5.9	22.9	59.5	2.0	5.2	1.3	[36]
	539	35.3	NR	NR	NR	0.0	1.1	NR	[37]
	200	36.5	1.5	4.5	12.0	0.0	0.0	0.0	[38]
	1327	26.5	20.2	NS	13.5	NS	NR	NS	[39]
	518	35.2	15.5	3.7	69.5	0.6	11.2	0.6	[16]
Israel	743	33.8	1.9	8.6	69.3	NR	NR	NR	[40]
Lebanon	106a	≥ 18	0.9	2.8	52.8	0.0	0.0	0.0	[44]
Libya	328a	≥ 15	87.1	4.5	94.2	4.2	83.2	NR	[41]
Palestine	192	41.3	0.0	2.6	43.8	0.0	0.0	0.0	[42]
Saudi Arabia	297	31.0	0.7	6.1	37.7	NR	NR	NR	[43]

aEstimated prevalence using respondent-driven sampling method. All numbers were rounded to the nearest 1. n: Sample size; NR: Not reported; NS: Not studied; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 4

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus and their co-infection status among different populations from Middle East and North Africa countries between 2005 and 2015

Country	n	Mean age/age	HIV (%)	HBV (%)	HCV (%)	HIV-HBV co-infection (%)	HIV-HCV co-infection (%)	Triple infection (%)	Ref.
HIV infected individuals
Iran	64	-	-	-	-	18.8	NS	NS	[49]
	168	38.7	-	-	-	NS	87.5	NS	[50]
	1338	32-42	-	-	-	NS	78.0	NS	[51]
	106	36.6	-	-	-	20.8	67.0	NR	[52]
	80	37.0	-	-	-	11.3	33.8	25.0	[53]
	130	50.2	-	-	-	11.5	77.0	9.2	[54]
	391	-	-	-	-	14.5	72.0	7.9	[55]
	201	36.0	-	-	-	44.3	67.2	36.3	[56]
	1444	38.4	-	-	-	NS	78.4	NS	[57]
Morocco	503	39.0	-	-	-	29.4	5.4	NR	[58]
Sudan	358	35.0	-	-	-	26.8	NS	NS	[59]
Turkey	949	37.9	-	-	-	0.0	0.9	0.0	[60]
Blood donors
Cyprus	5057	34.5	0.0	3.0	0.5	0.0	0.0	0.0	[61]
Iran	6499851	-	< 0.1	0.6	0.1	NR	NR	NR	[62]
	2026628	38.0	< 0.1	0.4	0.1	NR	NR	NR	[63]
UAE	592	-	1.2	67.2	31.6	NR	NR	NR	[64]
Others
Cyprus
Soldiers	12488	34.5	0.0	2.2	0.5	0.0	0.0	0.0	[61]
Iran
HBV patients	264	41.6	0.4	-	4.5	0.4	NR	NR	[65]
HIV infected patients’ partners	168	33.2	NR	NS	NR	NS	9.5	NS	[50]
Non-injecting drug users	336	28.5	1.5	5.6	4.5	1.2	0.9	0.9	[31]
Referral from behavioral counseling center	379	29.7	4.0	2.9	35.6	0.8	3.4	0.3	[66]
Libya
General Population	9170	34.0	0.2	3.7	0.9	< 0.1	0.1	< 0.1	[67]
Medical waste handlers	300	-	0.0	2.3	2.7	0.0	0.0	0.0	[68]
Non-Medical waste handlers	300	-	0.0	0.3	0.0	0.0	0.0	0.0	[68]
Turkey
ER patients	1000	51.7	0.0	5.0	1.8	0.0	0.0	0.0	[69]
In and out-patients	97000-225000	-	0.3	33.9	1.2	NR	NR	NR	[70]

All number were rounded to the nearest 1. n: Sample size; NR: Not reported; NS: Not studied; HIV: Human immunodeficiency virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Full article at:  http://goo.gl/FW5TbL

  

By:  Nada M Melhem, Nour Rahhal, Rana Charide, Khalil Kreidieh, and Rolla El-Khatib

Nada M Melhem, Khalil Kreidieh, Rolla El-Khatib, Medical Laboratory Sciences Program, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Nour Rahhal, Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Rana Charide, Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut 1107-2020, Lebanon

Author contributions: Melhem NM designed and wrote the paper; Rahhal N, Charide R and Kreidieh K reviewed the literature, prepared the tables and contributed to the write-up; El-Khatib R critically read the manuscript.

Correspondence to: Nada M Melhem, PhD, Assistant Professor of Infectious Diseases, Medical Laboratory Sciences Program, Faculty of Health Sciences, American University of Beirut, 325 Van Dyck Hall, 11-0236 Riad El Solh, Beirut 1107-2020, Lebanon. bl.ude.bua@nmehlem

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