THE MIDDLE EAST AND NORTH AFRICA

http://www.unaids.org/

HIV prevalence in this region is still very low,
with the exception of southern Sudan and recent outbreaks among injecting drug users in some countries.

The notion that this region has sidestepped the global HIV epidemic is not borne out by the latest estimates, which indicate that 55,000 people acquired HIV infection in the past year, bringing to 600,000 the total number of people living with HIV/AIDS in the Middle East and North Africa. AIDS killed a further 45,000 people in 2003. There is the potential for a considerable rise in the number of HIV infections in this region.

By far the most seriously affected country at present is the Sudan-specifically the south, where a mainly heterosexual epidemic is well under way. Available data indicate a national adult HIV prevalence of more than 2%, but conflict is hampering both surveillance of the epidemic and the mounting of a potentially effective response. The last round of surveillance data showed that HIV prevalence among pregnant women was 6-8 times higher in the south of Sudan, compared to Khartoum.

In most other countries, HIV spread in this region appears to be nascent, although scant surveillance data in several countries could mean that serious outbreaks in certain populations (including men who have sex with men and injecting drug users) may be being missed.

There also appears to be significant movement of HIV-infected persons between some countries. More than half of those officially reported to have HIV in Tunisia, for example, are believed to have crossed the border from Libya to seek antiretroviral treatment and/or to undergo drug rehabilitation. (Tunisia has been providing free and universal antiretroviral treatment since the turn of the century.)

The epidemic threatens to expand along diverse routes in the region, including through blood transfusions and blood collection. Universal precautions and blood screening have greatly reduced the risks of transmission in health-care settings in most countries, but HIV transmission through blood and blood products remains a potentially significant danger in some.

Also of concern is the rise in HIV infections among injecting drug users, particularly in Bahrain, Libya and Iran, while HIV infections linked to this mode of transmission have been reported in Algeria, Egypt, Kuwait, Morocco, Oman and Tunisia. Most of the HIV infections occurring in Iran appear to be associated with injecting drug use and serious levels of HIV infection have been reported in the country's prison system. HIV prevalence among injecting drug users in 10 Iranian prisons has reached as high as 63%. It has been estimated that Iran could be home to as many as 200,000 injecting drug users, most of them men. An earlier study in Iran revealed that about half of injecting drug users were married, and a third had reported extra-marital sex, pointing to the potential for secondary heterosexual transmission. To date, the HIV epidemic among adults in Libya has been driven by injecting drug use, with 90% of all known HIV infections occurring among injecting drug users. In the one drug-dependence treatment facility in Libya, 49% of all new patients have been found to be HIV-positive in the past three years.

Several other vulnerable groups face increasing risk of HIV infection in the region, notably sex workers and men who have sex with men. A recent report from Yemen, for example, suggests that 7% of sex workers are HIV-positive. Across the region, more in-depth studies are needed to examine sex work realities, especially street-based situations, and their potential contribution to HIV spread, first among sex workers and their clients, and subsequently to clients' wives and children.

Too little is known about the transmission of HIV between men who have sex with men in this region, and the shortfall of information is largely due to the stigma attached to sex between men. Egypt is one of the few countries to have monitored the transmission of HIV in groups of men who have sex with men, among whom HIV prevalence appears to have been around 1% at the turn of the century. The proportion of AIDS cases attributed to men who have sex with men was reported to be 21% in 2000. A review of HIV epidemiology in Morocco similarly found that sexual transmission between men accounted for over 7% of cumulative cases of HIV infection in the previous decade.

Surveillance systems are being improved in some
countries and examples of positive prevention efforts are on the increase. But denial and stigma create an ideal context for the spread of HIV.

Up-to-date surveillance and behavioural data have been scant, though steps to remedy the situation are now being taken in much of the region. Effective prevention is needed speedily across the region, designed to target both vulnerable groups and groups that could be drawn into the next phase of HIV spread, such as migrant workers, refugees and displaced persons, transport route workers, tourists, and young people generally. At present, however, even basic activities such as condom promotion are largely absent in the region. Yet there are encouraging exceptions to what appears to be a general pattern of official denial in the region. Algeria, Iran, Lebanon and Morocco, for example, are developing more substantial prevention programmes, while some countries (notably Iran and Libya) appear more willing to acknowledge and tackle epidemics associated with injecting drug use.

The AIDS epidemic history presents ample proof that it is among these groups that HIV often gains a foothold before spreading more generally. Part of the challenge facing countries of this region is to defuse the stigma and blame that are so often attached to vulnerable groups, and to deepen the wider public's knowledge and understanding of the epidemic. The social and cultural barriers to directing attention towards populations at higher risk are sometimes so great that the political costs of prevention are perceived to eclipse the public health benefits.