The Middle East and North Africa (MENA) region has one of the lowest HIV prevalence rates in the world (0.1%). This is in contrast to sub-Saharan Africa, which has the highest HIV prevalence rate of all regions (7.1%).1
In 2015, an estimated 230,000 people were living with HIV in the MENA region. In the same year, there were roughly 21,000 new HIV infections and 12,000 AIDS-related deaths.2
MENA is increasingly becoming a region of concern regarding HIV and AIDS. Since 2001, new HIV infections have risen by 35%. Furthermore, between 2005 and 2013, AIDS-related deaths increased by 66% in comparison with a worldwide fall of 35%.3 This is largely due to the fact that this region has the lowest antiretroviral treatment (ART) coverage of any region in the world at 17%.4
Routes of transmission in this region vary between countries. In Iran, Libya and Morocco, for example, there is a much higher prevalence of HIV transmission between people who inject drugs (also referred to as PWID) and their networks of sexual partners. By comparison, sex work is thought to be behind the spread of HIV in countries such as Djibouti, South Sudan and parts of Somalia.
Despite substantial progress in the understanding of the global HIV epidemic in recent years, knowledge of this region's epidemic is comparatively limited and is often perceived as a ‘black hole’ in terms of HIV and AIDS data.5 One study showed that only four of the 23 MENA countries assessed had effective HIV surveillance systems enabling them to track their epidemics.6
Key affected populations in the Middle East and North Africa
The mid-1980s saw the first reported cases of HIV and AIDS in the Middle East and North Africa. By 1990, every country in the region had detected HIV in their populations. This was linked primarily to exposure abroad as well as contaminated blood transfusions and organ transplants.
However, by the early 1990s, a new pattern of transmission had emerged among certain groups.
People who inject drugs in MENA
People who inject drugs are one of the groups of people vulnerable to HIV transmission in many parts of the Middle East and North Africa.
One study that has collated data on the HIV epidemic among people who inject drugs in MENA estimated that there are around 626,000 in the region. HIV among this group was present in one third of MENA countries and HIV prevalence was between 10 and 15%.7 More alarming statistics have come from places like Tripoli in Libya, where studies have detected an HIV prevalence of up to 87.2% among people who inject drugs.8
Injecting drug use is the major route of HIV transmission in Afghanistan, Pakistan and Iran and accounts for an estimated 90% of HIV cases in Libya. This practice is also common in Oman and Bahrain, and a growing issue in Morocco and Egypt.9
Men who have sex with men in MENA
Men who have sex with men (also referred to as MSM) in MENA, as in many other regions, are one of the groups most affected by HIV and AIDS.
Compared to the concentrated HIV epidemic seen among people who inject drugs, the epidemic among men who have sex with men in MENA has not reached the same levels but affects a larger number of countries.
Across the region, fewer than 1 in 10 men who have sex with men are living with HIV, but some countries have a higher HIV prevalence than others. In Egypt, Morocco, Pakistan, Sudan, Tunisia and Yemen, HIV prevalence among men who have sex with men is nearing 10%. In Tunisia, 5% of men who have sex with men were living with HIV - by 2011, this had risen to 13%. Significant HIV epidemics among men who have sex with men have also been reported in Jordan, Lebanon and Syria.11
Female sex workers in MENA
In 2012, 1.7% of female sex workers (also referred to as FSW) in MENA were thought to be living with HIV, with no country having an HIV prevalence among this group over 5%.12 13 However, networks of female sex workers are thought to be a key driver of HIV epidemics in a number of countries.
There are an estimated 60,000 female sex workers in Morocco with commercial sex networks accounting for roughly 50% of all new infections despite only 2% of female sex workers living with HIV. This significant proportion of all HIV transmissions throughout the region is due to the size of their sexual networks compared with both people who inject drugs and men who have sex with men.14 15
By contrast, one study in Tripoli, Libya, found a HIV prevalence of 15.7% among female sex workers. These high prevalence rates were mainly attributed to a high number of sexual partners and low levels of condom use. However, this particular epidemic was thought to be concentrated and not necessarily representative of all cities, or highly urbanised areas in the region.16
Peer education has proved effective: in Sudan, a 2015 study of key populations showed 70% of 1,000 men who had sex with sex workers reported using condoms during the past six months and the last time they had sex. 17Peer education has proved effective: in Sudan, a 2015 study of key populations showed 70% of 1,000 men who had sex with sex workers reported using condoms during the past six months and the last time they had sex. 18
HIV testing and counselling (HTC) in the Middle East and North Africa
HIV testing and counselling (HTC) is an integral component of HIV prevention programmes. It helps people to learn their HIV status, and ensures those who test positive receive vital treatment, care and support.
In MENA, there is still very limited access to HIV testing and counselling. For example, in Sudan, only one in five people living with HIV are aware of their status.19
Surveillance of key populations in 2015 revealed that testing coverage among sex workers and men who had sex with other men more than tripled between 2013 and 2015, reaching 29% and 17%.20
Particular efforts have been made to increase testing coverage within a human rights framework. Egypt, Iran and Sudan conducted community testing campaigns in 2015, as did Morocco, where less than 40% of people living with HIV were aware of their status before the introduction of a pilot prevention programme for key populations. Alongside the integration of testing services into basic healthcare facilities, this resulted in nearly half of the country’s population living with HIV being aware of their status.21
Djibouti became the first country to ratify the Arab Convention on Preventing HIV and Protecting the Rights of People Living with HIV, providing a legal framework to apply human rights principles in HIV responses, as adopted by the Arab Parliament in 2012.
More than 770,000 HIV tests took place at more than 2,000 testing sites in Algeria, increasing the estimated coverage of people living with HIV and aware of their status to more than 90%. In Djibouti, the proportion grew to 70% with the help of more than 21,000 tests in 2015. But the figures remain below 50% in Egypt, Iran and Sudan, leading to the development of roadmaps for fast-tracking testing and linking to services in order to reach the 90-90-90 target.22
The resulting agreement, the Algiers Declaration on Fast-Tracking HIV Testing in the Middle East and North Africa, called for investment in strategic information to guide an increase in testing, annual testing targets, strategic approaches for testing and enhanced services, resources and partnerships.
HTC for pregnant women
In countries such as Lebanon, efforts to prevent the mother-to-child transmission of HIV have been undermined by a lack of testing services in combination with expensive referral systems, fears around testing, as well as a lack of awareness and stigma.24
By comparison, HIV testing has been offered to women attending antenatal clinics in Oman since 2010, and has an acceptance rate of 99%. Along with the United Arab Emirates and Morocco, Oman has one of the highest testing coverages for pregnant women in the region.25
HIV prevention in the Middle East and North Africa
In recent years, many governments of MENA countries have taken major steps towards the prevention of HIV and AIDS. Just a few of these efforts are detailed below.
HIV prevention for people who inject drugs in Iran
In the mid-2000s, the government launched a campaign distributing clean needles and syringes in pharmacies across the country.27 By September 2012, free needles and syringes were available in 559 locations, and according to the 2010 behavioural survey, 91.7% reported using a clean needle or syringe during their last injection.28
As the majority of people who inject drugs in Iran are incarcerated, the government has implemented a number of projects distributing free needles in prisons and providing opioid substitution therapy (OST). By 2012, 4249 outlets were providing OST for over half a million people who inject drugs.29
However, the fact that injecting drug use remains the primary route of HIV transmission in Iran emphasises the need to scale up these types of prevention initiatives.30
HIV prevention for men who have sex with men in Egypt
In 2010, 5.7% and 5.9% of men who have sex with men in Cairo and Alexandria respectively were reported to be living with HIV.31
In these two cities, HIV prevention projects initiated by civil society organisations and supported by UNAIDS and the National AIDS programme use teams of outreach workers to engage and enrol people belonging to key affected populations, particularly men who have sex with men.
Upon enrolment, clients become part of a coding system that enables them to access subsidised HIV prevention services such as condoms and lubricants, HIV testing and counselling, medical services, psychosocial support, legal services as well as follow-up support. In Alexandria, the initiative is being scaled-up and will be supported until 2017.32
A similar programme in Morocco combines condom distribution, outreach work and HIV testing with a strong online presence. In Marrakesh, there is a speciality clinic for men who have sex with men addressing issues such as sexual health and substance abuse.33
Preventing mother-to-child transmission (PMTCT) in Morocco
In Morocco, in 2012, a preventing mother-to-child transmission (PMTCT) programme supported by UNICEF was implemented in three regions and will run until 2016. It includes efforts to engage private health providers to offer HIV testing and counselling (HTC) and HIV awareness for pregnant women.
By 2012, 250 basic health facilities had been established to provide HTC services for pregnant women. During 2012, 38,000 tests were conducted among pregnant women compared with just 5,630 in 2011. Nearly 200 pregnant HIV positive women (representing 48% coverage) benefitted from PMTCT compared to 124 in 2011 (33%). Moreover, 244 children under the age of 15 received antiretroviral drugs, including 210 new-borns and infants less than two years of age.34
In December, a national campaign promoting HTC saw 43,000 women who were either of child-bearing age or pregnant, tested.35
Scaling up HIV prevention is integral to averting the further spread of the HIV epidemic in MENA. Prevention must target those groups most at risk. As the epidemic is comparatively small in relation to other regions, there remains a window of opportunity to control further HIV transmission before it becomes a serious health and socioeconomic burden in MENA.
Antiretroviral treatment (ART) in the Middle East and North Africa
Since 2005, the number of people receiving antiretroviral treatment (ART) in MENA has increased dramatically. However, as in Eastern Europe and Central Asia, the increase has been much slower than elsewhere.36 In 2013, the MENA region had the lowest ART coverage in the world (11%).37
Only one in every eight people eligible for ART are receiving it in Djibouti, Egypt, Iran, Somalia, Sudan and Yemen in accordance with 2010 WHO treatment guidelines (people with CD4 counts under 350). Only Algeria makes people with a CD4 count of less than 500 eligible for ART - as per 2013 WHO guidelines.38
While the number of people receiving treatment has been on the rise, cases of new HIV infections have also increased requiring a scale up in treatment as prevention (TasP). Moreover, AIDS-related deaths increased by 17% between 2011 and 2012 highlighting the need for greater access to ART.39
Indeed, increasing access and effective delivery of ART is a big priority for MENA countries. While the adoption of the 2010 WHO guidelines increased the number of people eligible for ART, this was not matched by a similar increase in those receiving it. 40
Barriers to HIV prevention programmes in the Middle East and North Africa
Cultural and social barriers
The low HIV prevalence seen among the general population in MENA is thought to be due to religious and cultural values, which discourage pre-marital sex, encourage married people to be faithful, and emphasise universal male circumcision.41
During the 1980s and 1990s, MENA governments relied on these values to protect their populations from HIV transmission with many denying the existence of the epidemic within their borders.42
However, MENA governments now acknowledge the presence of HIV in their populations. As in other regions, there is a gap between what is preached by religion and what is actually practiced by believers.43
While HIV prevalence has been increasing among both men and women, gender inequality and the low status of women has meant that women and girls have been disproportionately affected by the epidemic.47 For example, between 2001 and 2012, cases of HIV infections among women increased from 4,400 to 11,000 in Morocco, and from 1,300 to 7,700 in Yemen.48
Those with the greatest risk of HIV infection are also often engaged in high-risk activities (such as sex work), which are condemned by religious doctrines and cultural values, and are often reinforced in law by criminalisation.49
One study of mental health issues among men who have sex with men in selected MENA countries found that 33.2% of participants had been physically assaulted because people knew/thought they had sex with men.50
These high levels of stigma and discrimination drive the epidemic in the region, preventing those living with HIV, and those at high risk of HIV transmission from seeking the treatment and support they need.51
Since the start of the decade, political uprisings in a number of MENA countries have undermined efforts to tackle the HIV epidemic in this region.
Unrest and conflict disrupts the implementation of HIV prevention programmes and act as barriers to service implementation (including the provision of antiretroviral treatment). It can also create circumstances that exacerbate issues associated with HIV epidemics.
The conflict in Syria has displaced two million people, the majority of whom have fled to neighbouring countries including Egypt, Iraq, Jordan, Lebanon and Turkey. Migration can put people in vulnerable situations increasing the risk of transmission. Research has shown how the resulting isolation and stress can encourage unsafe, casual and commercial sex at a time when access to HIV prevention information and services is low.52
In 2011, the conflict in Libya caused significant disruption to the supply of antiretroviral drugs (ARVs) for 6 months, creating a difficult situation for those in need of treatment. People who were unable to acquire ARVs reported sharing with others and relying on partial treatment, thereby increasing the risk of resistance to first-line ARVs.53
In Somalia, security challenges make implementation of HIV prevention programmes and ART provision challenging. Moreover, it restricts access to HIV services for those already on treatment.54
- Punitive laws
Throughout many regions in the world, punitive laws and practices deter those most at risk of HIV from seeking the essential services they need.55
In MENA, high-risk behaviours associated with HIV transmission are culturally prohibited, and in some cases illegal. Laws prohibit activities including drug use, commercial sex and sex between men. In fact, five of the seven countries where homosexual acts are punishable by death are in the MENA region (Iran, Saudi Arabia, Sudan, parts of Somalia and Yemen).56
Drug use and the possession of drugs are criminalised in most countries throughout the region. Tunisia is the only country in MENA where some forms of commercial sex are legal and condom distribution is allowed in regulated establishments. 57
These types of laws fuel stigma and discrimination towards key affected populations and other people living with HIV. Moreover, in countries such as Lebanon, they have been used to justify illegal police conduct including torture.58
However some progress has been made in gaining legal protection for those living with HIV in the region. In February 2016, a court in Cairo ruled that people living with HIV cannot be dismissed because of their HIV-positive status. This seminal ruling has been applauded by civil society and activists engaged in the AIDS response in Egypt and across the region. The ruling sets an important legal precedent for future discrimination cases.59
- Restrictions on entry, stay and residence
A number of countries in the MENA region have restrictions on entry, stay or residence for people living with HIV. These laws, and the ways they are implemented, often impinge upon the human rights of people living with HIV.
These restrictions based on HIV status have been adopted by all Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates), which are major destinations for migrant workers, particularly from Asia.60
These restrictions do not just affect people migrating from other parts of the world but people living with HIV within this region. For example, Jordan has reported the use of restrictions on migrants from neighbouring countries (including Egypt, Iraq and Syria) and the impact of mandatory HIV screening policies on the estimated one million Jordanians working abroad in GCC countries.61
The way forward
The MENA region is of increasing concern with regards to the global HIV epidemic. Though the number of people living with HIV is small compared with many other regions, it currently has one of the world's fastest growing HIV epidemics, which needs to be addressed immediately.
The scaling up of antiretroviral treatment coverage is key to this. However, MENA has the lowest ART coverage in the world, and the implementation of the 2013 WHO guidelines is likely to see an even greater gap between those eligible for treatment and those receiving ART as seen under the 2010 guidelines.
A number of key affected groups have been identified in MENA in the past two decades. HIV prevention initiatives need to target these groups to stop the epidemic spreading among the general population. However, in order to target HIV prevention initiatives effectively, there needs to be better and more comprehensive HIV surveillance in these countries.
There are a host of barriers to effective HIV prevention in MENA. Cultural and social factors exacerbate the transmission of HIV, and in many places, undermine the implementation of HIV services. Moreover, punitive laws and restrictions on entry, stay and residence in many of these countries deter people living with HIV from seeking the services they need. In recent years, political unrest throughout the region has made the provision of HIV services extremely challenging and complex.
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