Better Data Highlight Growing Problem

In politically unstable regions of the Middle East and North Africa, a weak AIDS response is stoking an alarming rise in HIV incidence and AIDS-related deaths

By Regina McEnery

In last year’s annual report on the status of the pandemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported a 33% decline in new HIV infections since 2001, with the most dramatic declines occurring in sub-Saharan Africa and the Caribbean.

Unfortunately, the epidemic is on the upswing in another region: the Middle East and North Africa (referred to as MENA). In 2012, an estimated 32,000 individuals from this region acquired HIV—a more than 50% higher rate of new infections than reported in this region in 2001, according to UNAIDS. Moreover, the number of people dying from AIDS-related illnesses in this region more than doubled between 2001 and 2012, again an opposite trend compared to what has been occurring in sub-Saharan Africa and most other regions thanks to the success of increased accessibility to antiretroviral drugs (ARVs).

MENA, which encompasses a swath of 23 countries stretching from Morocco to the west, Pakistan to the east, and Somalia to the south, is not the only region experiencing a surge in new infections. UNAIDS has also seen a 13% increase in new HIV cases in Central Asia and Eastern Europe between 2001 to 2012, which the agency has attributed to both a lack of access to ARVs and the criminalization of injection drug users (IDUs).

Compared to sub-Saharan Africa, the HIV burden in MENA is still quite small—the HIV/AIDS prevalence is thought to be less than 0.2% in most countries. Meanwhile, despite the dramatic decline in HIV incidence in sub-Saharan Africa, there were still an estimated 1.5 million new HIV infections and 1.2 million AIDS-related deaths in this region in 2012. But the emerging epidemic in MENA over the past decade, which is just coming into better view because of improved surveillance, is concerning none the less because it runs counter to a global effort to end the AIDS epidemic by stopping HIV transmission and halting AIDS-related deaths.

The data and the response

The paucity of quality HIV/AIDS data to emerge from the MENA region makes it difficult to know for sure whether the spike in HIV incidence over the past decade is a recent phenomenon or evidence of a longer-term trend that countries either ignored, or lacked the resources to detect. One recent study conducted by the World Health Organization (WHO) suggests only three of the 23 countries that comprise MENA have HIV surveillance programs capable of tracking their epidemics.

In the past, data being collected in many countries in MENA often resulted in questionable estimates of HIV incidence, and even when the estimates seemed plausible, they often came with wide confidence intervals, noted Laith Abu-Raddad and two colleagues from the WHO and Weill Cornell Medical College (Curr. Opin. HIVAIDS 9183, 2014). It’s only been in the last four to five years that that various global health organizations, academic scientists, and non-governmental organizations (NGOs) in these countries have begun collecting data that more reliably illustrates the status of the epidemic in this region, particularly within specific high-risk populations, which vary by country. The 2010 data for Libya showed that this country had the highest reported HIV prevalence among IDUs in the MENA region at 87%. Data also indicate emerging HIV epidemics among IDUs in Iran, Afghanistan, Egypt, Morocco, and Pakistan. In Lebanon and Tunisia, the highest risk group is men who have sex with men (MSM), and there is also evidence of concentrated epidemics among MSM in Egypt, Morocco, Pakistan, Sudan, and Yemen. In Somalia and Djibouti, there is evidence of a concentrated epidemic among female commercial sex workers (CSWs).

In some respects, MENA is not all that different from the AIDS-battered region of sub-Saharan Africa, where HIV stigma and discrimination are high and the behaviors associated with HIV transmission are either culturally prohibited or illegal, such as drug use, commercial sex work, or homosexual sex. But unlike sub-Saharan Africa, MENA stands out as the “only region where knowledge of the epidemic continues to be very limited and subject to much controversy,” according to a report released in 2010 by the World Bank.

This could partly be due to the widespread political instability and extensive poverty in the region, which is home to the highest number of refugees and internally displayed persons in the world, according to the World Bank report. Vulnerability of women and girls could also be a factor. Some of the highest rates of HIV in MENA have been reported among females, and in three countries where HIV incidence among females is dramatically rising—Yemen, Sudan, and Somalia—child marriage is still common, wrote Navid Madani, an Iranian biochemist and AIDS researcher at the Dana-Farber Cancer Institute in Boston and Harvard Medical School who travels frequently to the MENA region, in a recent commentary (JAIDS dx.doi.org/10.7448/IAS.17.1.19074).

Lack of awareness of one’s HIV infection status is also high. A report released last year by the WHO and UNAIDS estimates that about 80% of people living with HIV in the MENA region are not aware they are infected with the virus.

An overall weak response to the epidemic in this region may also be to blame. Various groups, including UNAIDS, the World Bank, the WHO, and The Global Fund to Fight AIDS, Tuberculosis and Malaria are working to address the epidemic in MENA, but with a few exceptions—such as Morocco and Iran—the responses have been pretty weak, some researchers contend.

Abu-Raddad, an associate professor of public health at Weill Cornell Medical College in Qatar, who has studied the HIV/AIDS epidemic in MENA extensively, says in countries where NGOs are strong, the HIV response has also been strong. “In a few countries though, and this is worrying, civil society organizations are very weak and barely exist in relation to HIV,” he says.

Some of the countries with the fastest growing rates of HIV/AIDS are Afghanistan, Egypt, and Pakistan, where war and civil unrest reign. But Abu-Raddad doesn’t think that political instability in those countries is the main cause of the rising HIV/AIDS burden. “It is too early to link the political instability to the epidemic, and the link may not be a one-directional one,” said Abu-Raddad. “Some of the countries that are witnessing large epidemics, such as Iran, are largely stable politically.”

Nor is Abu-Raddad convinced that socio-cultural factors, including religious beliefs, are the cause. “One can see examples where socio-cultural factors, well beyond religion, have in fact benefited the HIV response,” he said.

How effectively countries have responded to the HIV/AIDS crisis varies as well. Madani notes in her recent JAIDS commentary that the NGO El Hayet in Algeria is coordinating projects that are designed to ensure the “socio-economic re-entry of women affected by HIV into the workforce,” while across the region female religious leaders and imams have also been trained to reach out to women in religious institutions about HIV prevention and awareness. Morocco, meanwhile, has expanded voluntary counseling and testing services across the country, provided a range of HIV services aimed at high-risk groups (female CSWs, MSM, and IDUs), offered harm reduction programs, and expanded access to ARVs.

“The extent of the HIV epidemic in the region is now undeniable, and governments, some reluctantly and others readily, are now beginning to address the problem,” wrote Egyptian journalist Pakinam Amer in a recent commentary (Nature Middle East doi: 10.1038/nmiddleeast.2013.228).