HIV/AIDS: Trends in the Middle East and North Africa Region

HIGHLIGHTS

• New HIV infections have been on the rise in the Middle East and North Africa (MENA) region in recent years.
• There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region.
• Overall, the major route of infection in the MENA region seems to be sexual transmission, but a range of challenges limit interventions to determine the actual sexual trends.
• Despite unfavorable conditions, many countries in the region have put significant efforts into scaling up their response to this growing epidemic.

OBJECTIVES:

To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region.

METHODS:

Articles on the MENA region were reviewed.

RESULTS:

The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues.

CONCLUSIONS:

The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed...

Overall, the major route of infection in the MENA region seems to be sexual transmission. In 2011, heterosexual sex was the most common reported mode of HIV transmission among men in Tunisia (44.4%), UAE (50.0%), Syria (54.5%), Jordan (66.7%), Morocco (81.9%), Kuwait (100%), and Palestine (100%).⁸However, a range of challenges including (but not limited to) those listed below, limit interventions to determine the actual sexual trends, making the current data unreliable.

• The prevalence data available for KPs are principally derived from passive surveillance data, which tend to underestimate the role of high-risk behaviors because of individuals’ fear of disclosure.⁹
• There is intense HIV-related stigma and discrimination in the region, which is likely a major challenge for behavioral research.¹⁰
• Same-sex conduct is illegal in 76 countries, 19 of which are in MENA. In seven countries, including Iran, Saudi Arabia, Somalia, Sudan, and Yemen, homosexual acts are subject to the death penalty in some cases.⁶ Other countries, including Algeria, Egypt, Iraq, Kuwait, Lebanon, Libya, Morocco, Oman, Qatar, the Syrian Arab Republic, Tunisia, and the UAE, either criminalize adult consensual same-sex sexual conduct or have criminally prosecuted lesbian, gay, bisexual, and transgender people under other laws on the basis of their sexual orientation and gender identity.⁶
• Cultural and religious norms disapproving and penalizing sex between men may contribute to the nondisclosure of homosexual orientation and/or sexual conduct.¹¹

Other challenges that may be related to HIV surveillance in the MENA countries include infrequent surveillance of populations most at risk of HIV infection, lack of behavioral data, over-reliance on HIV case reporting and facility-based surveillance, and limited quality of HIV surveillance in general.¹²

  

Full article at:   http://goo.gl/e48IMn

By:  Gökengin D1, Doroudi F2, Tohme J3, Collins B4, Madani N5.

¹Department of Clinical Microbiology and Infectious Diseases, Medical Faculty, Ege University, Bornova, Izmir, Turkey. Electronic address: deniz.gokengin@ege.edu.tr.

²UNAIDS - The Joint United Nations Programme on HIV/AIDS (UNAIDS), Islamic Republic of Iran. Electronic address: DoroudiF@unaids.org.

³M-Coalition, Yazbeck Center, Achrafieh, Beirut, Lebanon. Electronic address: jtohme@afemena.org.

⁴International HIV Partnerships, London, UK. Electronic address: bc@ihp.hiv.

⁵Department of Cancer Immunology and Virology, Dana-Farber Cancer Institute, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA. Electronic address: navid_madani@dfci.harvard.edu.

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Hepatitis C Virus and HIV Infections among People Who Inject Drugs in the Middle East and North Africa: A Neglected Public Health Burden?

People who inject drugs (PWID) are a key population at risk of hepatitis C virus (HCV) and HIV infections. Globally, 63% of PWID are HCV infected [1, 2] and 19% are HIV infected [2], leading to an estimated 10 million and 3 million HCV- and HIV-infected PWID, respectively [1–3]. The Middle East and North Africa (MENA), a region comprising 23 countries from Morocco in the West to Pakistan in the East, is at the centre of major drug production and trade, creating a context of vulnerability to injecting drug use [4]. PWID in MENA are a large, mostly young and stigmatized population experiencing a substantial HCV and HIV burden, with potential for even further HIV epidemic growth. Yet, they lack access to comprehensive and confidential HCV and HIV testing, prevention and treatment services.

Below:  Median HCV prevalence among people who inject drugs in the Middle East and North Africa as per available studies [6]. Error bars represent the lower and upper bounds of the interquartile range if more than one data point was available per country.

Full article at:   http://goo.gl/qK72Up

By:   Ghina R Mumtaz,§,1,2 Helen A Weiss,3 and Laith J Abu-Raddad1,4

¹Infectious Disease Epidemiology Group, Weill Cornell Medical College – Qatar, Cornell University, Qatar Foundation – Education City, Doha, Qatar

²Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

³MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

⁴Department of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, New York, NY, USA

^§Corresponding author: Ghina R Mumtaz, Infectious Disease Epidemiology Group, Weill Cornell Medical College – Qatar, Cornell University, Qatar Foundation – Education City, P.O. Box 24144, Doha, Qatar. Tel: +(974) 4492 8406. Fax: +(974) 4492 8422. (Email:ude.llenroc.dem-rataq@6002mig) 

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HIV Infection in Migrant Populations in the European Union and European Economic Area in 2007-2012: An Epidemic on the Move

Migrants are considered a key group at risk for HIV infection. This study describes the epidemiology of HIV and the distribution of late HIV presentation among migrants within the European Union/European Economic Area during 2007-2012.

HIV cases reported to European Surveillance System (TESSy) were analyzed. Migrants were defined as people whose geographical origin was different than the reporting country. Multiple logistic regression was used to model late HIV presentation.

Overall, 156,817 HIV cases were reported, of which 60,446 (38%) were migrants. Of these, 

• 53% were from Sub-Saharan Africa, 
• 12% from Latin America, 
• 9% from Western Europe, 
• 7% from Central Europe, 
• 5% from South and Southeast Asia, 
• 4% from East Europe, 
• 4% from Caribbean, and 
• 3% from North Africa and Middle East. 

Male and female migrants from Sub-Saharan Africa and Latin America had higher odds of late HIV presentation than native men and women. Migrants accounted for 40% of all HIV notifications in 2007 versus 35% in 2012. HIV cases in women from Sub-Saharan Africa decreased from 3725 in 2007 to 2354 in 2012. The number of HIV cases from Latin America peaked in 2010 to decrease thereafter. HIV diagnoses in migrant men who have sex with men increased from 1927 in 2007 to 2459 in 2012.

Migrants represent two-fifths of the HIV cases reported and had higher late HIV presentation. HIV epidemic in migrant populations in European Union/European Economic Area member states is changing, probably reflecting the global changes in the HIV pandemic, the impact of large-scale ART implementation, and migration fluctuations secondary to the economic crisis in Europe.

Purchase full article at: http://goo.gl/1GDUIx

By: Hernando V1, Alvárez-Del Arco D, Alejos B, Monge S, Amato-Gauci AJ, Noori T, Pharris A, Del Amo J.

• 1*Red de Investigación en Sida, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain; †CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; ‡Department of Surgery, Medical and Social Sciences, Universidad Alcalá, Alcalá de Henares, Spain; and §Surveillance and Response Section, European Centre for Disease Prevention and Control, Stockholm, Sweden.  

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Using Hepatitis C Prevalence to Estimate HIV Epidemic Potential among People Who Inject Drugs in the Middle East & North Africa

The objective of this study is to understand the association between HIV and hepatitis C virus (HCV) among people who inject drugs (PWIDs) in the Middle East and North Africa (MENA), and to estimate HIV epidemic potential among PWIDs using HCV prevalence...

The review identified 88 HCV prevalence measures among PWID in MENA, of which 54 had a paired HIV prevalence measure. The pooled RR_HCV/HIV were 16, 4 and 3 in low-level, emerging and established HIV epidemics, respectively. There was a significant linear relationship between HCV and HIV at endemic equilibrium. The predicted endemic HIV prevalence ranged between 8% (Tunisia) and 22% (Pakistan). Of the nine countries with data, five have high and three medium HIV epidemic potential. Only one country, Pakistan, appears to have reached saturation.

HCV prevalence could be a predictor of future endemic HIV prevalence. In MENA, we predict that there will be further HIV epidemic growth among PWID. The proposed methodology can identify PWID populations that should be prioritized for HIV prevention interventions.

Below:  Mathematical modelling simulation of an HIV epidemic expansion among a prototype PWID population. (a) A case scenario for an HIV epidemic expansion in a PWID population wherein HCV is endemic at a prevalence level of about 75% indicating high injecting risk behaviour. HIV is introduced in 1990, starts emerging with increasing prevalence about two decades later in the late 1990s, and saturates near the year 2020 at a prevalence of about 20%. The corresponding three HIV epidemic states – low level, emerging and established – are shown on the graph. (b) The risk ratio of HCV to HIV prevalence (RRHCV/HIV) among this PWID population.

Read more at: http://ht.ly/Spnrs 

By: Ghina R. Mumtaz,a,b Helen A. Weiss,b Peter Vickerman,c Natasha Larke,b and Laith J. Abu-Raddada,d,e

^bMRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London

^cSchool of Social and Community Medicine, University of Bristol, Bristol, UK

^dDepartment of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, Ithaca, New York

^e

aInfectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar

bMRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London

cSchool of Social and Community Medicine, University of Bristol, Bristol, UK

dDepartment of Healthcare Policy and Research, Weill Cornell Medical College, Cornell University, Ithaca, New York

eVaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.

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aInfectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar

An Exploratory Study of HIV Risk Behaviours and Testing among Male Sex Workers in Beirut, Lebanon

Male sex workers (MSW) are a particularly high-risk subset of men who have sex with men in Lebanon and report higher numbers of sex partners and lower rates of condom use. The purpose was to explore the factors influencing sexual risk behaviors and HIV testing among MSW. Qualitative interviews were conducted with 16 MSW living in Beirut and working in bathhouses (hammam) or as escorts; content analysis identified emergent themes. 

Escorts reported more consistent condom use with clients and HIV testing than hammam MSW, with influential factors including HIV risk knowledge and perceived risk susceptibility, job security, and internalized stigma and related feelings of self-worth and fatalism regarding health and HIV risk. In contrast, both groups of MSW typically opted not to condoms with nonclient sex partners, in an effort to differentiate sex for work versus pleasure. 

The uptake of HIV testing was limited by concerns about the confidentiality of the test results and fear of repercussions of a positive test result for their health and employment. The respondents described an insular existence within the sex work culture, in part to limit exposure to stigma, which has implications for access to support as well as the influence of peer norms regarding sexual risk behavior and health seeking behaviors such as HIV testing. 

Further research is needed to tailor prevention and HIV testing efforts to reflect the distinct sexual health “cultures” that distinguish these two populations of MSW in Lebanon.

Read more at:  http://ht.ly/S8jMU 

By:  Frances M. Aunon,a Glenn J. Wagner,a Rabih Maher,b Danielle Khouri,c Rachel L. Kaplan,d and Jacques Mokhbatc,e

^bOui pour la vie, Beirut, Lebanon

^cLebanese AIDS Society, Beirut, Lebanon

^dUniversity of California, Berkeley; School of Social Welfare; Mack Center on Mental Health & Social Conflict, Berkeley, CA, USA

^e

aRAND Corporation, Santa Monica, CA, USA
bOui pour la vie, Beirut, Lebanon
cLebanese AIDS Society, Beirut, Lebanon
dUniversity of California, Berkeley; School of Social Welfare; Mack Center on Mental Health & Social Conflict, Berkeley, CA, USA
eDivision of Infectious Diseases, University Medical Center Rizk Hospital, Beirut, Lebanon

aRAND Corporation, Santa Monica, CA, USA