- There are major gaps in the treatment cascade which need to be strengthened if countries in the Middle East and North Africa are to meet the Fast-track 2020 targets.
- Just over half of the people living with HIV in the region are aware of their HIV status and under a quarter are virally suppressed.
- The Middle East and North Africa is one of only two global regions where AIDS-related deaths continue to rise.
- The production of opiate drugs in many Middle East and North African countries has led to an increase of prisoners and people who inject drugs - groups particularly vulnerable to HIV infection.
Explore this page to read more about groups most affected by HIV, testing and counselling, prevention programmes, antiretroviral treatment availability, civil society's role, HIV and TB, barriers to the response, funding and the future of HIV in the Middle East and North Africa.
The Middle East and North Africa (MENA) region has the lowest HIV prevalence in the world (less than 0.1%) with 220,000 people recorded to be living with HIV in 2017. This is in contrast to sub-Saharan Africa, which has the highest HIV prevalence of all regions (6.8%).1
Despite its low prevalence, the MENA region is an area of increasing concern. In 2017, MENA was one of the only regions (joined by the Eastern Europe and Central Asia) with such a small drop in AIDS-related deaths (from 11,000 in 2016 to 9,800 in 2017). This is a result of very poor access to antiretroviral treatment (ART), with only 29% of those needing ART in the region having access - far below the global level of 59%.2
Almost two thirds of new HIV infections in 2017 were in Egypt, the Islamic Republic of Iran and Sudan.3
Common 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 and parts of Somalia.4
Although substantial progress has been made 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
As a result, the MENA region is far from reaching the UNAIDS 90-90-90 targets to end HIV by 2030. Across the region’s countries in 2017, just 50% of people living with HIV were aware of their status, 29% of all people living with HIV and aware of their status were on treatment, and just 22% of those people were on treatment were achieving viral suppression.7
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.8
However, by the early 1990s, a new pattern of transmission had emerged among certain groups.
People who inject drugs (PWID)
The Middle East and North Africa region faces intense drug-related pressures: with the majority (80%) of the global supply of heroin is produced in Afghanistan, and over three-quarters of this is trafficked through Iran and Pakistan. The increased purity and ready availability of heroin at lower cost also cause people who inject drugs to be one of the most vulnerable groups to HIV infection within the region.9
One study that has collated data on the HIV epidemic in MENA estimated that there are around 626,000 people who inject drugs in the region. HIV epidemics among people who inject drugs were found in one third of MENA countries and HIV prevalence was between 10 and 15%.1011
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. In these countries, HIV transmission is largely confined to people who inject drugs and has a particularly low prevalence among the rest of the population. Drug practice is also common in Oman and Bahrain, and a growing issue in Morocco and Egypt.12
Men who have sex with men (MSM)
Compared to the concentrated HIV epidemic seen among people who inject drugs, the epidemic among men who have sex with men (also referred to as MSM) in MENA is assumed not to have reached the same levels but affects a larger number of countries.
However, the lack of official acknowledgement of the existence of non-heterosexual groups has meant that surveillance data has historically been difficult to get hold of in this region. Many more men who have sex with men may be affected by HIV than data reveals.13
According to the available data, 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.14
Female sex workers
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%.15 16 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.17 18
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.19
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. 20
In MENA, there is still very limited access to HIV testing and counselling even though the service is an integral component of HIV prevention programmes. For example, in Sudan, only one in five people living with HIV are aware of their status.21
According to UNAIDS, Algeria was one of the few countries in the region close to achieving the first 90 target in 2017, with 84% of people living with HIV knowing their status. Figures across the other reporting countries remain disappointing - Tunisia and Morocco reported below 70% awareness, Egypt below 60%, and Iran and Sudan around 40% awareness of status.22
However, particular efforts have been made to increase testing coverage within a human rights framework. Egypt, Iran and Sudan conducted community testing campaigns in 2015. A surveillance of key populations in the same year 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%.23
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 Djibouti Parliament in 2012. With the help of more than 21,000 tests distributed in 2015, Djibouti reported that 75% of people living with HIV were aware of their status (the latest data available). 24
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.
People who inject drugs (PWID)
Iran has been implementing harm reduction programmes, such as distributing clean needles and syringes in pharmacies across the country since the mid-2000s, in an attempt to prevent the transmission of HIV among people who inject drugs25
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.26
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, 4,249 outlets were providing OST for over half a million people who inject drugs.27
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.28
Men who have sex with men (MSM)
In 2010, 5.7% and 5.9% of men who have sex with men in Cairo and Alexandria, Egypt, respectively were reported to be living with HIV.29
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 2017.30
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.31
Prevention of mother-to-child transmission (PMTCT)
The HIV epidemic in MENA impacts heavily upon pregnant women in a region where there is a shortage of comprehensive sexual and reproductive health services, including HTC and follow-up treatment services for pregnant women.32
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.33
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.34
Although there has been little change in the number of new HIV infections among children (aged 0-14 years) in the region between 2010 and 2017,35 the biggest reduction in new infections among children during this time was seen in Djibouti (44%), where the integration of PMTCT services into maternal and child health programmes has been expanded.36
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.
Since 2005, the number of people receiving antiretroviral treatment (ART) in MENA has increased dramatically. For example, in Algeria coverage increased from 24% in 2010 to 76% in 2016 while in Morocco coverage increased from 16% to 48%. However, as in Eastern Europe and Central Asia, the increase has been much too slow, and treatment coverage continues to be outpaced by the rate of new infections, highlighting the need for the scale-up of treatment services.3738
In 2017, the MENA region had one of the lowest ART coverage statistics in the world (29%). For those who do have access to treatment, the consistently poor viral suppression rates across MENA countries suggests that treatment adherence is also major issue.39
Despite low treatment uptake across the region, UNAIDS did find in 2017, that for those enrolled in HIV care, 88% of people on ART were still retained in care after 12 months. Remarkably, this rate of retention was much better than other regions in the world - such as Western and Central Africa where only 77% were retained in care after 12 months.40
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
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.47
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.48
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 HIV prevention, treatment and support services they need.49
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.50
In 2011, the conflict in Libya caused significant disruption to the supply of antiretroviral drugs (ARVs) for six 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.51
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.52
Throughout many regions in the world, punitive laws and practices deter those most at risk of HIV from seeking the essential services they need.53
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).54
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. 55
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.56
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.57
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.58
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.59
Though the number of people living with HIV in MENA is small compared with many other regions, many countries within the region have fast-growing HIV epidemics and the gaps in HIV service provision in these areas needs to be addressed immediately as a result. The scaling up of antiretroviral treatment coverage is key to this. UNAIDS states that an ‘intensified scale-up‘ of at least 130,000 people initiated on treatment is needed in order for MENA to reach the second fast-track target of having 90% of people living with HIV on treatment.60
Furthermore, keeping people on treatment must be a priority. UNAIDS has highlighted that those countries which are marshaling community-based initiatives in getting people tested and linked to treatment are seeing the benefits of better retention in care. For example, in Morocco, this community-based approach has improved treatment retention from 75% to 95% over one year in 2016.61
Domestic funding towards the HIV response within MENA has increased by 14% in the last decade, and countries in the region now fund 73% of their response. However, in 2016 UNAIDS suggested that this is not enough – and low-income countries such as Djibouti and Somalia rely on international donor support for 90% of their response.62
If more innovative mechanisms to boost HIV funding are not found, UNAIDS has warned that the current resource levels are too small to close the region’s existing gaps in reaching both the Fast-Track Targets by 2020 and ending AIDS as a public health threat by 2030.63
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