59410 November 2010 . Number 34 HIV/AIDS IN MENA: ASSESSMENT AND POLICY RECOMMENDATIONS Laith Abu-Raddad, Francisca Ayodeji Akala, Iris Semini, epidemiological and demographic contours of Gabriele Riedner, David Wilson and Ousama Tawil1 the HIV epidemic in the region, and the conclusions drawn from it can potentially be Introduction: The HIV pandemic in the Middle used as the basis for further research and policy East and North Africa (MENA) region2 development at the national level. Policy is continues as one of the most devastating health variously discussed in this report both as a crises ever. UNAIDS and WHO estimate that in conceptual approach to HIV/AIDS prevention 2009, 76,000 people were newly infected with programming and as the concrete form of the infection in MENA (as defined by UNAIDS) programming itself. It offers examples of best and 24,000 people died of HIV-related causes in practice, makes recommendations on where to this year.3 target resources and funding, and outlines the most effective strategies in HIV/AIDS The recent regional HIV/AIDS epidemiological prevention. All the information presented in synthesis report entitled Characterizing the this policy report is based on the HIV/AIDS Epidemic in the Middle East and North comprehensive research, findings, and Africa: Time for Strategic Action, provides the recommendations recorded in the synthesis scientific basis for the policy recommendations report. detailed here and provides policy makers with an overview of the specific character of the Epidemiological patterns in MENA: Two main HIV/AIDS (human immunodeficiency patterns describe HIV epidemiology in most virus/acquired immune deficiency syndrome) MENA region countries: epidemic in the MENA region. The report also · A pattern of exogenous HIV exposures among sets out policy and programming nationals who contract HIV outside their recommendations that respond to the country and then transmit the virus to their sexual partners on their return to their home 1 Brief is based on the report "Characterizing the country. HIV/AIDS Epidemic in the Middle East and North Africa: · A pattern of concentrated or low-intensity HIV Time for Strategic Action" by Laith J. Abu-Raddad, epidemic among priority populations. A Francisca Ayodeji Akala, Iris Semini, Gabriele Riedner, concentrated epidemic is defined as HIV David Wilson, and Ousama Tawil, and the related policy note drafted by Camille Nurka. The Quick Note was prevalence that consistently exceeds 5% in at cleared by Akiko Maeda, HNSHD Health Sector Manager. least one priority population. Priority 2 The MENA region as defined for the synthesis report by populations comprise injecting drug users the World Bank, the Joint United Nations Programme on (IDUs), men who have sex with men (MSM), HIV/AIDS (UNAIDS) MENA Regional Support Team, and and female sex workers (FSWs). All MENA the World Health Organization (WHO) Eastern Mediterranean Regional Office, comprises the following countries have populations in which concentrated countries: Afghanistan, Algeria, Bahrain, Djibouti, the Arab epidemics have the potential to occur. Republic of Egypt, the Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, In terms of the extent of HIV/AIDS spread, the Qatar, Saudi Arabia, Somalia, Sudan, the Syrian Arab Republic, Tunisia, the United Arab Emirates, the West Bank epidemic in MENA is not homogeneous and and Gaza, and the Republic of Yemen. can be broken down coarsely into two groups: 3 UNAIDS and WHO, AIDS Epidemic Update, 2010. · A core group of MENA countries that have a spread to below sustainability would control more modest HIV prevalence that includes the HIV epidemic in the whole population. As most countries in the region. Jenkins and Robalino have noted, "Small · A sub-region with considerable prevalence groups of people involved in high-risk that includes Djibouti, parts of Somalia, and activities can form the core of transmission for a Southern Sudan. nation."4 Hence, targeting priority populations plays a key role in addressing HIV prevention Most MENA countries have a low HIV needs. prevalence, and the regional synthesis data suggest that no evidence exists for a major HIV Populations and Risk Groups: World Bank epidemic in the general population in any of HIV/AIDS reports since 2003 have consistently the MENA countries. Djibouti, Somalia, and listed IDUs, MSM, and FSWs and their clients Southern Sudan stand out from the rest of the as populations that are immediately at high risk MENA region as having a state, or near state, of in comparison with the general population. generalized HIV epidemics. Southern Sudan is This report terms those high- risk groups of particular concern and could already be in a priority populations. Vulnerable populations, by state of considerable HIV epidemic in the contrast, form a subset of the general general population, but conclusive evidence is population that is generally at low risk of HIV still lacking. exposure--such as prisoners, youth, and mobile populations--but that is at risk of HIV prevalence in MENA: The specific adopting practices that may put them at higher constellation of HIV prevalence in MENA can risk of HIV infection. When those vulnerable be understood through the interaction of three populations engage in higher-risk practices, population types: priority, bridging, and they become part of the priority or bridging general. HIV spreads most rapidly in the populations. This report recommends that priority populations, which have higher levels policy be directed toward intervention in risky of risk behavior: IDUs, MSM, and FSWs are practices first among at-risk populations and normally the first groups to experience the then among vulnerable populations. burden of the HIV epidemic. Subsequently, HIV spreads from those groups to the bridging Priority populations: A hallmark of high-risk populations usually the sexual partners of the behavior in MENA is the intersection where the high-risk populations), who may or may not risk factors of priority groups overlap. If HIV pass the infection to the general population. establishes itself in one priority population, it Among MENA populations, a sizable fraction can easily spread through the overlapping risks belongs to what could be labeled potential to other priority populations. In addition, the bridging populations, such as clients of sex chance of contracting HIV is increased within workers, other sexual partners of priority the same risk group if multiple risk behaviors populations, truck drivers, fishermen, and are present. For example, one person can military personnel. From the evidence, those occupy two of the risk groups simultaneously. populations do not appear to be key contributors to the dynamics if HIV infectious Injecting drug users: MENA is a major source, spread in MENA and are not, at least so far, route, and destination for the global trade in effectively bridging HIV infection to the general illicit drugs and injecting drug use (IDU) is a population. Although no evidence shows a persistent and a growing problem in MENA, clear dynamic contribution of bridging with 0.2% of the total population--close to a populations to HIV transmission in MENA, million people--injecting drugs. HIV has potential bridging populations do engage in already established itself among a number of considerable levels of risky sexual behaviors IDU populations in MENA, whereas it is still at that need to be monitored and addressed. The low or nil prevalence in other populations. general pattern in MENA countries points Levels of risky behavior practices, such as toward growing epidemics in priority populations. The synthesis report argues that 4 Jenkins and Robalino, "HIV/AIDS in the Middle East and these high-risk groups are where curtailing HIV Northern Africa", 2003. November 2010 · Number 34· 2 sharing of injecting equipment, are generally HIV knowledge, or who are not able to afford high, thus affirming the potential for further condoms or to negotiate condom use are at HIV spread among IDUs. particularly higher risk of HIV. Men who have sex with men: form the most Vulnerable populations: People are said to be hidden and stigmatized risk group of all HIV in a state of vulnerability if their living risk groups in MENA. Social stigmatization conditions are prone to shifting factors that and legal persecution of male sex workers would place them at risk. MENA has several (MSM) have made state interventions vulnerability factors, and the settings of challenging and have presented difficulties for vulnerability are diverse, with a large section of researchers seeking to access and document the population belonging to one or multiple trends among this population. There is vulnerability settings. The MENA region has evidence that HIV is spreading among MSM, three key vulnerable populations: (a) prisoners; but data are still too limited to fully document (b) mobile populations, including migrant the trend. Although MSM in MENA generally workers, refugees, and internally displaced have a reasonable level of awareness of persons (IDPs); and (c) young people. Among HIV/AIDS and of modes of transmission and the groups listed, prisoners are the most methods of protection (specifically through vulnerable. Mobile populations have an condoms), misconceptions about the risk of extensive presence across the region, but their HIV acquisition also exist. HIV prevalence levels and epidemiological characteristics are still not well known. Youths Female sex workers (FSW): Economic pressure, often endure immense challenges (such as family disruption or dysfunction, and political unemployment, displacement, homelessness, conflicts are major drivers of commercial sex and drug dependence) that may compel them work in MENA. Commercial heterosexual sex to engage in risk behavior. networks are the largest of the three priority group networks in MENA. However, HIV Policy and Programs: For any HIV response to prevalence among FSWs continues to be at low be successful and cost effective, it must be levels in most countries and does not appear to tailored to the epidemiological reality of HIV be well established in many of the region's transmission patterns. In the MENA region, commercial sex networks. HIV prevalence scaling up HIV prevention for those who are among FSWs is, nevertheless, much higher than most at risk is imperative. HIV/AIDS policy in that in the general population and FSWs in MENA was initially implemented primarily MENA countries report (a) considerable levels through the health sector. From those of risky sexual behavior, including roughly one beginnings, a range of innovative intervention client per calendar day; (b) low levels of strategies have since become available to policy condom use, particularly in areas of makers: (a) surveillance; (b) blood screening; (c) concentrated HIV epidemics among SWs condom distribution; (d) behavior change (Djibouti); (c) anal in addition to vaginal sex; communication; (e) testing and counseling; (f) (d) clients or sexual partners who inject drugs; information, education, and communication and (e) the fact that they inject themselves with materials; (g) peer education; (h) safe injection drugs. facilities; (i) STI control; (j) antiretroviral therapy (ART); and (k) programs for Levels of HIV knowledge among sex workers prevention of mother-to-child transmission appear to vary substantially in MENA, and (PMTCT). However, the experience of available evidence suggests that researchers, scientists, policy makers, people misconceptions exist about HIV transmission living with HIV (PLHIV), NGOs, and civil among FSWs and that many are not using society representatives has shown that limiting testing and counseling services. FSWs tend to the response to the health sector is ineffective seek treatment for STIs through self-treatment and that a multisectoral response is needed. or through friends rather than through Although the acquisition of knowledge about knowledgeable health personnel. FSWs who the epidemic over time is reflected in the have low socioeconomic status, who have poor changes in policy response--from large November 2010 · Number 34· 3 investments in ART to the development of insights drawn in the report from a synthesis of national AIDS strategic plans--strategies still thousands of studies and data sources indicate have room for improvement. Surveillance and that MENA countries must develop robust research have always been crucial components surveillance systems to monitor HIV spread in policy recommendations, yet the region among priority populations. Effective and continues to grapple with limited information repeated surveillance of priority populations and capacity, and its national strategic plans across MENA is key both to knowing reveal a prevention strategy that is limited in conclusively whether HIV spread is indeed scope and scale. Prevention among priority limited to priority populations and to detecting populations at higher risk of HIV infection and emerging epidemics among those groups at an vulnerable populations is a funding priority, early stage. This surveillance strategy offers a yet prevention remains largely unprioritized in window of opportunity for targeted prevention policy. Generic and routine planning, at an early stage of an epidemic, when halting competing priorities, limited human capital, new infections among priority populations is a and lack of monitoring and evaluation impede less resource-intensive exercise than having to prevention efforts in the region. At the national bear the cost in the later stages of massive level, policies remain inadequate and do not epidemics among some subpopulation groups. sufficiently engage with the epidemiological evidence. Very few prevention programs in MENA have adopted a comprehensive Contact MNA K&L: approach that uses research data in Emmanuel Mbi, Director, MNA Operational Core Services Unit consultation with concerned populations to David Steel, Manager, MNA Development create the right mix of intervention strategies Effectiveness Unit that are adaptable to the national Regional Quick Notes Team: epidemiological context and the specific risk Omer Karasapan, Roby Fields, Hafed Al-Ghwell and contexts. Morocco and the Islamic Republic of Aliya Jalloh Iran are notable exceptions, having made Tel #: (202) 473 8177 MENA K&L Quick Notes: commendable progress in developing and http://www.worldbank.org/mena-quicknotes implementing their prevention strategies. The MNA Quick Notes are intended to summarize Those promising examples should be the rule lessons learned from MNA and other Bank and not the exception. Knowledge and Learning activities. The Notes do not necessarily reflect the views of the World Bank, Conclusion: Public acknowledgment of the its board or its member countries. HIV/AIDS epidemic in the region has been a recent development. In 2000, HIV/AIDS had only just begun gaining recognition as a leading public health, social, and development concern. By 2003, several MENA countries were at various stages of development or implementation of national strategic plans and had begun to make real efforts toward prevention. Today, MENA governments are making progress in acknowledging that priority populations exist and in working with nongovernmental organizations (NGOs) to provide and extend HIV prevention services (including social support networks) to priority groups. HIV infection has already reached all corners of the MENA region, and most HIV infections are arising within the already existing sexual and injecting-drug risk networks. The analytical November 2010 · Number 34· 4