Professional Documents
Culture Documents
HIV/AIDS
Epidemic in the Middle East
and North Africa
TIME FOR STRATEGIC ACTION
Washington, D.C.
© 2010 The International Bank for Reconstruction and Development / The World Bank
1818 H Street NW
Washington DC 20433
Telephone: 202-473-1000
Internet: www.worldbank.org
E-mail: feedback@worldbank.org
1 2 3 4 13 12 11 10
This volume is a product of the staff of the International Bank for Reconstruction and
Development / The World Bank. The findings, interpretations, and conclusions expressed in
this volume do not necessarily reflect the views of the Executive Directors of The World Bank
or the governments they represent.
The World Bank does not guarantee the accuracy of the data included in this work. The
boundaries, colors, denominations, and other information shown on any map in this work do
not imply any judgement on the part of The World Bank concerning the legal status of any
territory or the endorsement or acceptance of such boundaries.
ISBN: 978-0-8213-8137-3
eISBN: 978-0-8213-8138-0
DOI: 10.1596/978-0-8213-8137-3
Characterizing the HIV/AIDS epidemic in the Middle East and North Africa : time for strategic
action / Laith Abu-Raddad . . . [et al.].
p. ; cm.
Includes bibliographical references.
ISBN 978-0-8213-8137-3
1. AIDS (Disease)—Middle East. 2. AIDS (Disease)—Africa, North. I. Abu-Raddad, Laith.
II. World Bank.
[DNLM: 1. Acquired Immunodeficiency Syndrome—epidemiology—Africa, Northern.
2. Acquired Immunodeficiency Syndrome—epidemiology—Middle East. 3. HIV Infections—
epidemiology—Africa, Northern. 4. HIV Infections—epidemiology—Middle East. 5. HIV
Infections—transmission—Africa, Northern. 6. HIV Infections—transmission—Middle East.
7. Health Planning—Africa, Northern. 8. Health Planning—Middle East. 9. Health Policy—
Africa, Northern. 10. Health Policy—Middle East. 11. Risk Factors—Africa, Northern. 12. Risk
Factors—Middle East. WC 503.4 JA2 C469 2009]
RA643.86.M628C53 2009
614.5'9939200956—dc22
2009041797
Contents
Acknowledgments .............................................................................................................................. xi
Executive Summary ........................................................................................................................ xiii
Key Definitions and Abbreviations ........................................................................................xxi
Chapter 3 Men Who Have Sex with Men and HIV ........................................31
HIV Prevalence among MSM .................................................................................................................. 31
Prevalence of Homosexuality .................................................................................................................. 31
Men Who Have Sex with Men and Risk Behavior ................................................................................. 33
Knowledge of HIV/AIDS .......................................................................................................................... 38
Analytical Summary ................................................................................................................................. 39
Bibliography ............................................................................................................................................. 39
vi Contents
Chapter 11 Analytical Insights into HIV Transmission
Dynamics and Epidemic Potential in MENA .......................... 179
Evolution of the HIV Epidemic in MENA ............................................................................................... 179
Conceptual Framework: Dynamics of HIV Infectious Spread in MENA............................................... 182
General Features of HIV Spread in MENA............................................................................................ 185
Future HIV Expansion in MENA............................................................................................................. 189
Bibliography ........................................................................................................................................... 191
Appendixes........................................................................................................................................... 221
Index......................................................................................................................................................... 265
Boxes
9.1 Youth, Drug Use, and Marginalization in Lebanon ............................................................ 140
9.2 Iraqi Women Refugees and Commercial Sex in Syria ...................................................... 141
Figures
1.1 Heterogeneity in Risk of Exposure to a Sexually Transmitted Infection .................... 4
1.2 Schematic Diagram of the Concept of R0........................................................................................ 5
1.3 Two Patterns of HIV Infectious Spread in a Population ........................................................ 6
7.1 Fraction of HIV Tests That Are Positive in Different Population
Groups in MENA .........................................................................................................................................83
Contents vii
7.2 Distribution of HIV Tests in MENA by Population Group ...........................................83
10.1 HSV-2 Prevalence for Selected Populations, by Age Group in
Morocco ....................................................................................................................................................154
10.2 Age-Stratified Cervical Cancer Incidence in Select MENA Populations
Compared to the Global Average .............................................................................................158
10.3 A Schematic Diagram of Two Different Kinds of Sexual Networks
with Different Connectivity .........................................................................................................160
10.4 The Natural History of HPV Infection and Cervical Cancer ...................................161
10.5 Trend in STI Notified Cases in Morocco, 1992–2006...................................................169
10.6 Estimated Annual Incidence of Unsafe Abortions per 1,000 Women
Aged 15–44 Years, by United Nations Subregions in 2000......................................170
11.1 Analytical View of HIV Epidemiology in MENA ............................................................185
11.2 A Schematic Diagram of the Overlap between Priority Populations
in MENA ..................................................................................................................................................188
11.3 Simulation of a Typical HIV Epidemic among an MSM Population ..................190
12.1 ART Scale Up in Somalia and Southern Sudan between 2005
and 2008 ..................................................................................................................................................208
Tables
2.1 HIV Prevalence among IDUs in MENA ...................................................................................12
2.2 HCV Prevalence among IDUs in MENA..................................................................................14
2.3 Estimates of the Number and Prevalence of IDUs, Selected MENA
Countries.....................................................................................................................................................15
2.4 Levels of Nonsterile Needle or Syringe Use among IDUs in Several
MENA Countries ....................................................................................................................................18
2.5 Measures of Overlapping Injecting and Sexual Risk Behaviors of
IDUs in MENA.........................................................................................................................................22
3.1 HIV Prevalence among MSM in MENA ..................................................................................32
4.1 HIV Prevalence among FSWs in MENA..................................................................................44
5.1 HIV Prevalence in Potential Bridging Populations in MENA .....................................60
6.1 HIV Prevalence in Population-Based Surveys in MENA ..............................................65
6.2 HIV Prevalence among ANC Attendees and Other Pregnant
Women in MENA..................................................................................................................................66
6.3 HIV Prevalence among Blood Donors in MENA ...............................................................68
7.1 HIV Transmission Modes for a Number of MENA Countries ....................................86
7.2 HIV Prevalence among Populations at Risk of Parenteral HIV
Infection (excluding IDUs) ..............................................................................................................90
8.1 General Knowledge of Condoms including HIV Prevention, in
Different Populations Groups in MENA...............................................................................102
viii Contents
8.2 Condom Use among Different Population Groups in MENA ....................................... 103
9.1 Imprisonment Rates and HIV Prevalence in Select MENA Countries .................... 121
10.1 HSV-2 Prevalence in Different Population Groups ............................................................. 153
10.2 HSV-2 Prevalence in the General Population in Different Regions
of the World Compared to MENA ................................................................................................. 155
10.3 Age-Standardized Rates of Cervical Cancer Incidence and Mortality ..................... 157
10.4 Age-Standardized Rates of Cervical Cancer Incidence and Mortality at
Specific Surveillance Sites or Population Groups ................................................................. 157
10.5 HPV Prevalence in Different Population Groups in MENA ........................................... 159
10.6 Syphilis Prevalence in Different Population Groups .......................................................... 163
10.7 Gonorrhea Prevalence in Different Population Groups ................................................... 166
10.8 Chlamydia Prevalence in Different Population Groups.................................................... 167
11.1 Status of the HIV Epidemic in MENA Countries ................................................................ 184
12.1 Number of PLHIV on ART in Selected Countries, 2006–08 .......................................... 208
A.1 Estimated Number of People Living with HIV in MENA Countries ......................... 221
B.1 Threshold for Sustainable Transmission and Transmission Probability per
Partnership for Key STIs ...................................................................................................................... 222
C.1 HIV Prevalence of Different Population Groups in MENA ............................................ 224
D.1 HIV Prevalence among STD Clinic Attendees, VCT Attendees, and People
Suspected of Living with HIV ........................................................................................................... 226
D.2 HIV Prevalence of Tuberculosis (TB) Patients ........................................................................ 228
D.3 Point-Prevalence Surveys on Different Population Groups ........................................... 229
D.4 Hepatitis C Virus Prevalence in Different Population Groups ...................................... 232
E.1 Levels of HIV/AIDS Basic Knowledge in Different Population Groups.................. 239
E.2 MENA Populations with Low Levels of Comprehensive HIV/AIDS
Knowledge .................................................................................................................................................... 242
E.3 MENA Populations with High Levels of HIV/AIDS Misinformation ........................ 244
E.4 Nature of Attitudes toward People Living with HIV/AIDS by Different
Population Groups ................................................................................................................................... 245
E.5 Television as the Main Source of HIV/AIDS Knowledge, by MENA
Population Groups ................................................................................................................................... 247
Contents ix
Acknowledgments
This report presents the findings of the synthesis Zalduondo (UNAIDS), Robert Lyerla (UNAIDS),
of existing data and other information on the Ying Lo-Ru (WHO), and Yves Souteyrand
HIV/AIDS (human immunodeficiency virus/ (WHO). We appreciate their time and efforts in
acquired immunodeficiency syndrome) epidem- providing useful comments that were helpful in
ics in the Middle East and North Africa (MENA) strengthening the final report.
made up of countries covered by the World We would like to specially acknowledge
Bank, the Joint United Nations Programme on the valuable scientific contributions to this
HIV/AIDS (UNAIDS) MENA Regional Support project of Nahla Hilmi (Research Assistant and
Team (RST), and the Eastern Mediterranean World Bank consultant) and Manal Benkirane
Regional Office (EMRO) of the World Health (Research Assistant and UNAIDS consultant).
Organization (WHO). The synthesis supports Nahla was instrumental in conducting system-
countries to better define their epidemic (“know atic literature reviews and epidemiological
your epidemic”) in order to plan and implement analyses. Manal provided epidemiological sum-
more strategic actions to prevent or reduce fur- maries and translations of French language data
ther transmission of the infection and to also and documents.
mitigate the impact of the infection on those This project could not have been conducted
already infected and affected. without the support of organizations and agen-
The report is a joint interagency effort cies at the international and national levels in
between the World Bank MENA Region, providing documents, other data sources, and
UNAIDS MENA RST, and WHO/EMRO. The input for the purpose of this synthesis. In par-
team was led by Francisca Ayodeji Akala (Task ticular, we thank the UNAIDS MENA RST and
Team Leader and Senior Public Health Spe- WHO/EMRO for providing hundreds of docu-
cialist, World Bank) and includes Laith J. Abu- ments and other data sources to be investigated
Raddad (Principal Investigator of the scientific for this project. Among the many colleagues
study; World Bank Consultant; Director of who provided data, documents, or input are
Epidemiology, Biostatistics and Biomathematics Ahmad Sayed Alinaghi (Iranian Research Center
Research Core; Assistant Professor in Public for HIV/AIDS, the Isalmic Republic of Iran),
Health at Weill Cornell Medical College, Qatar), Ramzi Alsalaq (Fred Hutchinson Cancer
Iris Semini (UNAIDS MENA RST), Gabriele Research Center), Alia Al-Tayyib (Colorado
Riedner (WHO/EMRO), David Wilson (World Department of Public Health), Rhoda Ashley
Bank), Ousama Tawil (UNAIDS MENA RST), Morrow (University of Washington), Ruanne
Hamidreza Setayesh (UNAIDS MENA RST), Barnabas (Fred Hutchinson Cancer Research
Fatou Fall (World Bank), and Juliana Victor- Center), Veronique Bortolotti (WHO/EMRO),
Ahuchogu (World Bank). The report was pre- Hiam Chemaitelly (Weill Cornell Medical
pared under the guidance of Akiko Maeda, College, Qatar), Jesus M. García Calleja (WHO),
World Bank MENA, Health, Nutrition, and Jocelyn DeJong (American University of Beirut),
Population Sector Manager. The peer reviewers Paul Drain (University of Washington), Golda
of the report are Jody Kusek (World Bank), El-Khoury (United Nations Children’s Fund
Partricio Marquez (World Bank), Barbara O. de [UNICEF]), Majdi Al-Touhki (World Bank),
xi
Ali Feizzadeh (UNAIDS/Iran), Sarah Hawkes Schilperoord (United Nations High Commissioner
(London School of Hygiene and Tropical for Refugees), George Schmid (WHO), Joshua
Medicine), Joumana Hermez (WHO/EMRO), Schiffer (Fred Hutchinson Cancer Research
Rachel Kaplan (University of California, Los Center), Sharif Sawires (University of California,
Angeles), Adnan Khan (Research and Los Angeles), Cherif Soliman (Family Health
Development Solutions), Hamida Khattabi International), Anna Wald (University of
(WHO/EMRO), Laura Koutsky (University of Washington), Helen Weiss (London School of
Washington), Abdalla Ismail (WHO/Somalia), Hygiene and Tropical Medicine), Najin Yasrebi
Wadih Maalouf (United Nations Office on Drugs (UNICEF), Saman Zamani (Kyoto University),
and Crime), Carla Makhlouf Obermeyer (WHO), and Hany Ziady (WHO/EMRO).
Yolisa Sarah Mashologu (WHO/EMRO), Willi We greatly appreciate and thank all the
McFarland (University of California, San researchers, research participants, and data con-
Francisco), Dewolfe Miller (University of tributors who contributed to the body of evi-
Hawaii), Ghina Mumtaz (Weill Cornell Medical dence, data, and research that were reviewed
College, Qatar), Agnes Nabaloga (World Bank), and synthesized for this work: the most compre-
Yaa Oppong (World Bank), Assad Rahal hensive research work on HIV/AIDS in MENA
(National AIDS Program/Jordan), Marian since the beginning of the epidemic.
xii Acknowledgments
Executive Summary
Despite a fair amount of progress on under- driven epidemiological synthesis of HIV spread
standing human immunodeficiency virus (HIV) in MENA since the beginning of the epidemic. It
epidemiology globally, the Middle East and is based on a literature review and analysis of
North Africa (MENA) region is the only region thousands of widely unrecognized publications,
where knowledge of the epidemic continues to reports, and data sources extracted from scien-
be very limited, and subject to much contro- tific literature or collected from sources at the
versy. It has been more than 25 years since the local, national, and regional levels.
discovery of HIV, but no scientific study has pro- For the purpose of an epidemiologically rele-
vided a comprehensive data-driven synthesis of vant classification, the MENA population has
HIV/AIDS (acquired immunodeficiency syn- been divided into different risk classes. The first
drome) infectious spread in this region. The class includes the priority groups that are at
region continues to be viewed as the anomaly in the highest risk of HIV infection. These groups
the HIV/AIDS world map and “a real hole in include injecting drug users (IDUs), men who
terms of HIV/AIDS epidemiological data.”1 have sex with men (MSM), and female sex
This report addresses this dearth of strategic workers (FSWs). The second class includes the
information on HIV infections in MENA through bridging populations, such as clients of sex
a joint effort of the World Bank, the MENA workers, who experience an intermediate risk of
Regional Support Team (RST) of the Joint HIV infection and provide links between priority
United Nations Programme on HIV/AIDS groups and the general population. The general
(UNAIDS), and the Eastern Mediterranean population, the third risk class, experiences
Regional Office (EMRO) of the World Health the lowest risk of HIV infection and includes
Organization (WHO). It builds on a series of pub- most of the population in any community. It
lications by the World Bank that focuses on dif- also includes the vulnerable populations that
ferent aspects of HIV/AIDS epidemic and are generally at low risk of HIV infection, such
response. In 2003, the World Bank, in collabora- as prisoners, youth, and mobile populations, but
tion with UNAIDS and WHO/EMRO, issued the are vulnerable to practices that may put them at
HIV/AIDS in the Middle East and North Africa: The higher risk of HIV infection.
Cost of Inaction report, which provided an analysis This report covers all countries that are
of the vulnerability factors in MENA along with included in the definition for the Middle East and
an economic analysis of the impact based on the North Africa Region at the World Bank, UNAIDS
limited HIV data recognized at the time. In 2005, MENA RST, and WHO/EMRO. Explicitly, this
the World Bank issued the Preventing HIV/AIDS in report includes data on Afghanistan, Algeria,
the Middle East and North Africa: A Window of Bahrain, Djibouti, the Arab Republic of Egypt,
Opportunity to Act report, which provided an the Islamic Republic of Iran, Iraq, Jordan, Kuwait,
analysis of a prevention strategy for HIV in Lebanon, Libya, Morocco, Oman, Pakistan,
MENA. The current report provides the first Qatar, Saudi Arabia, Somalia, Sudan, the Syrian
comprehensive scientific assessment and data- Arab Republic, Tunisia, the United Arab Emirates,
West Bank and Gaza (Occupied Palestinian
1
Bohannon, “Science in Libya.” Territories), and the Republic of Yemen.
xiii
KEY FINDINGS of this endemic spread. However, there is no
evidence to date that such considerable endem-
HIV epidemics in MENA ic transmission exists in these countries.
HIV infection has already reached all corners of The second pattern in several MENA coun-
MENA and the majority of HIV infections are tries is that of concentrated HIV epidemics
occurring in the existing sexual and injecting among priority populations. A concentrated
drug risk networks. The region as a whole is fail- epidemic is defined as an epidemic with an HIV
ing to control HIV spread along the contours of prevalence consistently exceeding 5% in a pri-
risk and vulnerability despite promising recent ority population. There is already documented
efforts. Priority populations, including IDUs, evidence for concentrated epidemics among
MSM, and FSWs, are documented to exist in all IDUs in several MENA countries and consider-
MENA countries. IDUs and MSM and their able evidence suggesting concentrated epidem-
sexual partners, along with commercial sex net- ics among MSM. There is no evidence for the
works, are the MENA populations most impacted existence of major concentrated epidemics
by HIV/AIDS. In this sense, MENA is not an among FSWs. All evidence indicates no HIV epi-
anomaly to the global HIV transmission patterns demic among the general population.
apart from the general population epidemics in
sub-Saharan Africa. HIV epidemic typology in the Subregion
There is substantial heterogeneity in HIV with Considerable Prevalence
spread across MENA and different risk contexts Djibouti, parts of Somalia, and Southern Sudan
are present throughout the region. However, the are in a state of generalized HIV epidemics. A
HIV epidemic in MENA can be roughly classified, generalized HIV epidemic is defined as an epi-
in terms of the extent of HIV spread, into two demic with an HIV prevalence consistently
groups. The first is the group of considerable HIV exceeding 1% among pregnant women. Most
prevalence, which includes Djibouti, Somalia, HIV infections in these countries, however, are
and Southern Sudan, and is labeled here as the concentrated in priority groups and bridging
Subregion with Considerable Prevalence. populations. HIV dynamics are focused around
The second group, which includes the rest of the commercial sex networks in settings where the
MENA countries, has a more modest HIV preva- size of the commercial sex network is large
lence and is labeled here as the Core MENA enough to support an epidemic with a preva-
Region. Because the latter group consists of most lence exceeding 1% in the population.
of the MENA countries, HIV epidemiology here There is no evidence of sustainable general
represents the main patterns found in MENA. population HIV epidemics in this group of
MENA countries. Nevertheless, Southern Sudan
HIV epidemic typology in the Core is of particular concern. There are insufficient
MENA Region data to satisfactorily characterize HIV epidemiol-
Two epidemiologic patterns describe HIV epide- ogy in this part of Sudan, and it could be already
miology in this group of MENA countries. The in a state of general population HIV epidemic.
first is the pattern of exogenous HIV expo-
sures among the nationals of these countries,
HIV spread and risk behavior by risk group
or HIV infections among their sexual partners
upon their return. This pattern exists in all Injecting drug users
MENA countries at some level or another, but Injecting drug use is a persistent and a growing
appears to be also the dominant pattern in sev- problem in MENA, with 0.2% of the total
eral MENA countries. The weak surveillance MENA population, almost a million people,
systems of priority populations prevent us from injecting drugs. MENA is a major source, route,
conclusively stating whether this is indeed the and destination for the global trade in illicit
dominant or only epidemiologic pattern in drugs.
these countries. HIV could be spreading among HIV has already established itself among a
some of the priority groups, or within pockets number of IDU populations in MENA, while
of these populations, without public awareness it is still at low or nil prevalence in other
Executive Summary xv
levels, indicating concentrated HIV epidemics in drivers, fishermen, and military personnel.
at least parts of these countries. Nevertheless, Evidence on HIV prevalence, other STI preva-
HIV prevalence among FSWs in these countries lence, sexual risk behavior measures, and drug-
is at lower levels than those found in hyperen- injecting practices among potential bridging
demic HIV epidemics in sub-Saharan Africa. populations remains rather limited. Existing evi-
FSWs report considerable levels of sexual risk dence suggests considerable levels of sexual risk
behavior, including roughly one client per calen- behavior among potential bridging populations,
dar day; low levels of condom use, particularly in but still limited HIV prevalence, except possibly
areas of concentrated HIV epidemics among for Djibouti, Somalia, and Sudan.
FSWs; anal and oral sex in addition to vaginal The limited HIV prevalence among potential
sex; having clients or sexual partners who inject bridging populations is probably a consequence
drugs; and injecting drugs themselves. of the low HIV prevalence among FSWs and the
Considerable levels of STI prevalence other than high coverage of male circumcision among men.
HIV are found among FSWs. STD (sexually In this sense, these populations are not key con-
transmitted disease) clinic attendees repeatedly tributors to the dynamics of HIV infectious
report acquiring STDs through paid sex. Levels of spread in MENA and are not effectively bridging
comprehensive HIV knowledge among FSWs populations capable of spreading the infection
vary across the region, with both high and low further to the general population.
levels being documented in different settings. An important characteristic of HIV in MENA
There is a potential for further HIV spread is the role of the sexual partners of priority
among FSWs, but probably not at high levels in populations: they are shouldering a sizable pro-
most countries, except possibly for Djibouti, portion of HIV disease burden, but they rarely
Somalia, and Sudan. Near universal male circum- transmit the infection further. Women are espe-
cision, with its efficacy against HIV infection, and cially vulnerable because most risk behaviors
the rather lower risk behavior compared to other are practiced by men. HIV prevention efforts in
regions, may prevent massive or even concen- MENA should address this key vulnerability.
trated HIV epidemics among FSWs from material-
izing in most countries in MENA for at least a General population
decade, if ever, should these conditions persist. HIV prevalence in the general population is at
Yet, HIV prevalence among FSWs will be at very low levels in all MENA countries, apart from
levels much higher than those of the general Djibouti, Somalia, and Sudan. There is no evi-
population. Subgroups within FSWs may be dence of a substantial HIV epidemic in the gen-
particularly at high risk of HIV, such as those eral population in any of the MENA countries.
who inject drugs, have clients who inject drugs, Sexual behavior data in the general population
female IDUs who exchange sex for money or in MENA remain rather limited. Existing evidence
drugs, as well as FSWs with low socioeconomic suggests that sexual risk behaviors are present,
status who have poor HIV knowledge or are not but at rather low levels in comparison to other
able to afford or negotiate condom use. regions. However, levels of sexual risk behavior
FSWs need prevention and care services not appear to be increasing, particularly among youth,
only because of HIV infection, but also because though probably not to a level that can support an
of the considerable levels of other STIs in their HIV epidemic in the general population. Available
population. Dedicated STI services for FSWs sexual risk behavior measures suggest limited
need to be established, and in settings where potential for a sustainable HIV epidemic in the
they are already established, they need to be general population in at least the foreseeable
expanded. future, if ever, should these conditions persist.
STI prevalence data, including herpes simplex
Potential bridging populations virus type 2 (HSV-2), human papillomavirus
A sizable fraction of MENA populations belong (HPV), syphilis, gonorrhea, and chlamydia, indi-
to what could be labeled as potential bridging cate low prevalence of these infections among
populations, such as clients of sex workers, other the general population in MENA in comparison
sexual partners of priority populations, truck to other regions. Unsafe abortions are also at
ABBREVIATIONS
AIDS Acquired immunodeficiency syndrome
ANC Antenatal clinic
ART Antiretroviral therapy
ARV Antiretroviral
ASR Age-standardized rates
DHS Demographic and Health Survey
ELISA Enzyme-linked immunoassay
EMRO Eastern Mediterranean Regional Office (World Health Organization)
FBO Faith-based organization
FHI Family Health International
FSW Female sex work(er)
GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria
GONGO Government organized nongovernmental organizations
GST Group of sustainable transmission
GUD Genital ulcer disease
HBV Hepatitis B virus
HCV Hepatitis C virus
xxi
HCWs Health care workers
HIV Human immunodeficiency virus
HPV Human papillomavirus
HSV-1 Herpes simplex virus type 1
HSV-2 Herpes simplex virus type 2
HSW Hjira sex worker
IARC International Agency for Research on Cancer
IEC Information, Education, and Communication
IBBSS Integrated biobehavioral surveillance survey
ICPS International Centre for Prison Studies
IDPs Internally displaced persons
IDU Injecting drug use(r)
INCAS Iranian National Center for Addiction Studies
IOM International Organization for Migration
KAP Knowledge attitudes and practices
MENA Middle East and North Africa
MENAHRA MENA Harm Reduction Association
MeSH Medical subheading
M&E Monitoring and evaluation
MMT Methadone maintenance treatment
MOH Ministry of health
MSM Men who have sex with men
MSW Male sex work(er)
NGO Nongovernmental organization
NSNAC New Sudan National AIDS Council
NSP National strategic plan
NSP Needle and syringe program
OST Opioid substitution therapy
PITC Provider initiated testing and counseling
PLHIV People living with HIV
PMTCT Prevention of mother-to-child transmission
PRB Population Reference Bureau
RSA Rapid situation assessment
RST Regional Support Team
RTI Reproductive tract infection
SAR South Asia Region
SNAP Sudan National AIDS Programme
STD Sexually transmitted disease
STI Sexually transmitted infection
TB Tuberculosis
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
UNODC United Nations Office on Drugs and Crime
UNRWA United Nations Relief and Works Agency for Palestine Refugees in the Near East
USAID United States Agency for International Development
VCT Voluntary counseling and testing
WBA Western blot assays
WHO World Health Organization
BACKGROUND AND RATIONALE FOR THIS anomaly in the HIV/AIDS (acquired immunode-
REPORT ficiency syndrome) world map and “a real hole
in terms of HIV/AIDS epidemiological data.”6
The human immunodeficiency virus (HIV) pan- This report addresses this dearth of strategic
demic continues as one of the most devastating information on HIV infections in MENA through
health crises ever. The Joint United Nations a joint effort by the World Bank, the MENA
Programme on HIV/AIDS (UNAIDS) and the Regional Support Team (RST) of UNAIDS, and
World Health Organization (WHO) estimate that the Eastern Mediterranean Regional Office
35,000 (24,000–46,000) people were infected (EMRO) of WHO. It builds on a series of publica-
with HIV within the UNAIDS definition of the tions by the World Bank that focus on different
Middle East and North Africa (MENA) region1 aspects of the HIV/AIDS epidemic and response.
in 2008.2 This brings the total number of people In 2003, the World Bank, in collaboration with
living with HIV (PLHIV) in MENA to 310,000 UNAIDS and WHO/EMRO, issued the HIV/AIDS
(250,000–380,000).3 It is also estimated that in the Middle East and North Africa: The Cost of
20,000 (15,000–25,000) people died of HIV- Inaction report, which provided an analysis of the
related causes in 2008.4 In appendix A, table A.1 vulnerability factors in MENA along with an eco-
lists the estimated number of PLHIV in a num- nomic analysis of the impact based on the limited
ber of MENA countries. HIV data at the time. In 2005, the World Bank
Despite much progress on understanding HIV issued the Preventing HIV/AIDS in the Middle East
epidemiology globally, MENA stands out as the and North Africa: A Window of Opportunity to Act
only region where knowledge of the epidemic report, which provided an analysis of a prevention
continues to be very limited and subject to strategy for HIV in MENA. This current report
much controversy.5 More than 25 years since provides the first comprehensive scientific assess-
the discovery of the HIV virus, no scientific ment and data-driven epidemiological synthesis of
study has provided a comprehensive data-driven HIV spread in MENA since the beginning of the
synthesis of the HIV infectious spread in this epidemic. It is based on a literature review and the
region. The region continues to be viewed as the analysis of thousands of widely unrecognized
publications, reports, and data sources extracted
1 from the scientific literature or collected from
Excluding Afghanistan, the Islamic Republic of Iran, and Pakistan.
2
UNAIDS and WHO, AIDS Epidemic Update 2009. sources at the local, national, and regional levels.
3
Ibid.
4
Ibid.
5 6
Obermeyer, “HIV in the Middle East.” Bohannon, “Science in Libya.”
1
Just as in other regions, MENA has several and regime sensitivities. In the absence of data-
vulnerability factors for HIV. The process of driven policies, the HIV response will continue
modernization, including mass education and to be beset by numerous challenges.
urbanization, known to occur with the aban- MENA is distinctively characterized by a
donment of traditional patterns of behavior,7 “tidal wave” youth bulge; one-fifth of the popu-
continues in MENA at full throttle. Most coun- lation, 95 million people,13 is in the 15–24 years
tries are experiencing diverse influences includ- age group,14 the normal age range of initiation
ing changing family structures, exposure to of sexual activities.15 Extensive levels of migra-
different cultures, openness of the market, tour- tion, displacement, and mobility exist in MENA,
ism, and enhanced communication and tech- which has the highest number of refugees and
nology, such as satellite television and the internally displaced persons in the world.16
Internet.8 There is a sociocultural transition MENA is flooded with inexpensive drugs due to
leading to more tolerance and acceptance of high levels of heroin production in Afghanistan
behaviors such as premarital and extramarital and major drug trade routes that pass through
sex and increased opportunities for sexual part- the region.17 MENA suffers from the high preva-
nerships beyond traditional forms.9 The cultural lence of unnecessary medical injections and
tradition of balancing premarital chastity with blood transfusions, the reuse of needles and
early marriage is no longer the norm.10 Social syringes, occupational injuries of health care
and gender tensions have been exacerbated by workers (HCWs), and skin scarifications,18 sug-
the clashing forces of traditional culture and gesting a potential for considerable parenteral
modern culture.11 There are numerous strains in HIV transmissions beyond injecting drug use.
preserving traditional values during the mod- The apparent lack of HIV data has fueled an
ernization of society, leading to a communica- intense, but unnecessary, polemical debate on
tion discrepancy as well as social tension at the the status of the epidemic in MENA.19 Some
community and family levels. argued that adherence to cultural values pro-
The social determinants of health in terms of vides “cultural immunity” against HIV spread
political conflict, limited resources, and gender and that MENA is immune to HIV through its
inequity continue to challenge the region.12 fabric of “moral prophylaxis,” including strong
Denial that HIV exists or is an important chal- prohibitions against premarital and extramarital
lenge remains widespread. Priority groups, sex, homosexuality, and alcohol and drug use.20
including injecting drug users (IDUs), female sex Meanwhile, others argued that there is a public
workers (FSWs), and men who have sex with health crisis “behind the veil” and that the fail-
men (MSM), are highly stigmatized and lack ure to combat the disease stems from cultural
access to comprehensive and confidential ser- traditions slowing, if not freezing, the ability of
vices. Community organizations serving at-risk MENA societies to deal with the epidemic.21 This
populations are emerging, but are insufficient to
meet current needs and are not well coordinated. 13
Assaad and Roudi-Fahimi, “Youth in the Middle East and North Africa.”
14
Health promotion approaches remain didactic UNAIDS, “Notes on AIDS in the Middle East and North Africa”; Roudi-
and prescriptive, are divorced from behavioral Fahimi and Ashford, Sexual & Reproductive Health.
15
Roudi-Fahimi and Ashford, Sexual & Reproductive Health.
theory, and are nonparticipatory. There is a lack 16
UNAIDS, “Notes on AIDS in the Middle East and North Africa.”
of evidence-based policies that can guide effec- 17
UNODC, World Drug Report.
18
tive interventions. HIV response in MENA is an Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan”; World
Bank Group, World Bank Update 2005; Yerly et al., “Nosocomial
amalgam of moralism, pragmatism, and political Outbreak”; Khattab et al., “Report on a Study of Women Living with
HIV”; Burans et al., “Serosurvey of Prevalence of Human
7
Carael, Cleland, and Adeokun, “Overview and Selected Findings.” Immunodeficiency Virus”; Zafar et al., “Knowledge, Attitudes and
8
Busulwa, “HIV/AIDS Situation Analysis Study”; Mohammad et al., Practices”; Hossini et al., “Knowledge and Attitudes”; Yemen MOH,
“Sexual Risk-Taking Behaviors”; Abukhalil, “Gender Boundaries and National Strategic Framework; Kennedy, O’Reilly, and Mah, “The Use
Sexual Categories in the Arab World.” of a Quality-Improvement Approach.”
9 19
Busulwa, “HIV/AIDS Situation Analysis Study.” Obermeyer, “HIV in the Middle East.”
10 20
Mohammad et al., “Sexual Risk-Taking Behaviors.” Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan”; Gray, “HIV
11
Abukhalil, “Gender Boundaries and Sexual Categories in the Arab and Islam;” Lenton, “Will Egypt Escape the AIDS Epidemic?”
21
World.” Kelley and Eberstadt, “Behind the Veil”; Kelley and Eberstadt, “The
12
Shaar and Larenas, “Social Determinants of Health.” Muslim Face of AIDS.”
2 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
view also stresses that if leaders continue to theme of this approach is the synthesis and
ignore the problem, HIV/AIDS could debilitate integrated analysis of multiple sources of data,
or even destabilize some of MENA societies by examined side by side, including biological data,
its drastic effects on morbidity, mortality, and risk behavior data, and proxy measures. The
economic productivity among the 15 to 49 years authors examined information collected by dif-
age group.22 Neither of these views has been ferent methods, by different groups, and in
substantiated by the epidemiological data syn- different populations, and corroborated the con-
thesized in this report and both are far from the clusions across datasets, thereby minimizing the
reality of HIV spread in MENA. impact of potential biases that can exist in a
single study, dataset, or line of evidence. This
approach is especially suited for MENA consid-
Objective and scope of report
ering the lack of representation and method-
The main objective of this report is to address ological rigor in a large number of studies.
the dearth of strategic information on HIV in
MENA by delineating an evidence-based and
Conceptual framework for HIV epidemiology
data-driven overview of HIV epidemiology and
an integrated analysis of HIV transmission trends The risk of HIV infection depends on the trans-
and dynamics in this region. This report describes mission mode, HIV prevalence, and the behav-
the major characteristics and the levels of HIV ioral attributes of the population. Human
spread in diverse groups of MENA populations. populations exhibit widely variable sexual and
It also identifies priority population groups with injecting drug risk behaviors, a heterogeneity in
elevated HIV prevalence or risk factors and risk conventionally conceptualized in terms of
examines the major explanations for such varia- three population groupings23 (figure 1.1). The
tions in HIV transmission. The synthesis explores first is the core group, which experiences the
the epidemic potential for further HIV spread by highest risk of exposure to HIV. The high-risk
contrasting HIV transmission, risk patterns, and core population typically includes IDUs, MSM,
trends in different HIV risk groups. and female and male sex workers (MSWs). The
The ultimate goal of this synthesis is to pro- second group is the bridging population, which
vide the scientific evidence necessary for strate- experiences an intermediate risk of exposure
gic prioritization; resource allocation and cover- and provides links, such as through the clients
age; and effective, high-quality interventions. of sex workers, between the high-risk core
To this end, the authors have critically reviewed group and the third group, which is the low-risk
and interpreted data and studies on HIV/AIDS, general population.
sexual and injecting drug risk behaviors, vulner- The general population encompasses most
ability settings, sexually transmitted infections of the population in any community as well as
(STIs), and hepatitis C virus (HCV). the vulnerable populations, who are generally
This report is concerned with an overview of at a low risk of HIV infection, such as prison-
HIV epidemiology in the region as a whole as ers, youth, and mobile populations, but who
opposed to country-level analyses. It is not part are also vulnerable to practices that may put
of the scope of this report to provide interven- them at higher risk of HIV infection. Once
tion recommendations for each MENA country. these vulnerable populations adopt higher-risk
practices, they become part of the core or
bridging populations. Different risk groups for
CONCEPTUAL FRAMEWORK AND different modes of HIV transmission can over-
RESEARCH METHODOLOGY lap, providing opportunities for an infection in
one risk group to seed an epidemic in another
This report uses an evidence-based and data-
group. The size and pattern of the epidemic
driven approach to characterize HIV epidemiol-
also depend on the manner of mixing between
ogy and dynamics in the MENA region. The
the different risk groups, HIV prevalence in
22
Kelley and Eberstadt, “Behind the Veil”; Kelley and Eberstadt, “The
23
Muslim Face of AIDS.” Low et al., “Global Control.”
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Why and How? 3
Figure 1.1 Heterogeneity in Risk of Exposure to a Sexually Transmitted Infection and endemic in some risk groups
(such as FSWs) while being below
the sustainability threshold in other
groups.28 In the latter groups, STIs
can still spread, but the transmission
chains are not sustainable and even-
tually face “dead ends.” This vari-
ability in risk leads to the group of
sustainable transmission (GST)29
Core group Bridging General population concept, where the GST for a spe-
populations (including vulnerable cific STI is the population where the
populations)
infection’s transmission chains are
sustainable (R0 ⬎ 1). The size of the
GST in any community determines
the potential size of the STI epi-
demic, and different STIs have dif-
ferent GST sizes (see appendix B,
table B.1).
Source: Authors. HIV spreads most rapidly in the
high-risk core populations due to
the different risk groups, and size of the the higher levels of risk behavior,
different risk groups. implying an R0 considerably larger than one.
The heterogeneity in the spread of HIV or Therefore, IDUs, MSM, and FSWs are normally
other STIs’ spread can be understood analyti- the groups that first experience the burden of
cally in terms of the basic reproductive number the HIV epidemic (figure 1.3). Subsequently,
(R0): the number of secondary infections that HIV spreads to the bridging populations (sexual
an index case would generate upon entrance partners of core populations). Bridging groups
into an infection-free population.24 For an infec- may or may not pass the infection to the gen-
tion to spread, R0 needs to be larger than one eral population. If bridging populations do pass
(figure 1.2, panel A). If R0 ⬍ 1, the number of the infection to the general population, then the
secondary infections each index case produces is levels of risk behavior in the latter population
on average less than one and the infection would determine the potential for a general
cannot sustain itself and dies out (figure 1.2, population HIV epidemic. If the levels of risk are
panel B). R0 for a specific population depends on sufficiently high, such that R0 ⬎ 1, then the
the risk behavior attributes of this population infectious transmission chains are sustainable
and duration of infection, as well as the trans- among the general population irrespective of
mission probability per coital act. The last can be further sexual contacts with core and bridging
influenced by a number of biological factors populations (figure 1.3, panel A). HIV will
such as stage of HIV infection,25 male circumci- remain endemic in the general population even
sion status,26 and coinfections.27 if all sexual contacts with core and bridging
Since sexual risk behavior and injecting drug populations are protected or stopped. This is
use are characterized by substantial heterogene- what has occurred in parts of sub-Saharan
ity, each risk group in the population has its Africa, resulting in massive HIV epidemics.
own R0. HIV or other STIs can be sustainable On the other hand, if R0 ⬍ 1, the HIV trans-
mission chains are not sustainable, and the
24 waves of HIV spread in the general population
Anderson and May, Infectious Diseases of Humans.
25
Wawer et al., “Rates of HIV-1 Transmission.” would stop shortly after entering this population
26
Auvert et al., “Randomized, Controlled Intervention Trial”; Bailey et al.,
28
“Male Circumcision for HIV Prevention”; Gray et al., “Male Boily and Masse, “Mathematical Models”; Brunham and Plummer, “A
Circumcision for HIV Prevention.” General Model”; Yorke, Hethcote, and Nold, “Dynamics and Control.”
27 29
Abu-Raddad et al., “Genital Herpes”; Abu-Raddad, Patnaik, and Kublin, Abu-Raddad et al., “Genital Herpes”; Boily and Masse, “Mathematical
“Dual Infection with HIV and Malaria.” Models”; Brunham and Plummer, “A General Model.”
4 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
(figure 1.3, panel B). It is then Figure 1.2 Schematic Diagram of the Concept of R0
unlikely that the HIV spread in the
T(0) T(1) T(2)
whole population would reach the
massive scale it reached in sub-
Saharan Africa, and the dynamics
of HIV will be concentrated in the R0 = 2
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Why and How? 5
Figure 1.3 Two Patterns of HIV Infectious Spread in a Population Countries covered in this report
Flow of HIV infection in a general population HIV epidemic
This report covers all countries that are
included in the definition for the MENA
Region at the World Bank, the UNAIDS
MENA Regional Support Team (RST), and
Core groups Bridging populations General population
the Eastern Mediterranean Regional Office
(EMRO) of WHO. Explicitly, this report
includes data on Afghanistan, Algeria,
Bahrain, Djibouti, the Arab Republic of
(a) Egypt, the Islamic Republic of Iran, Iraq,
Jordan, Kuwait, Lebanon, Libya, Morocco,
Flow of HIV infection in a concentrated HIV epidemic
Oman, Pakistan, Qatar, Saudi Arabia,
Somalia, Sudan, the Syrian Arab Republic,
Tunisia, the United Arab Emirates, the West
Bank and Gaza, and the Republic of Yemen.
Core groups Bridging populations General population
Considering similarity in the cultural con-
text and geographic proximity, data were
also occasionally included for Israel (mainly
among Israeli Arabs), Mauritania, and
(b) Turkey, when appropriate, bearing in mind
Source: Authors.
that there are still differences in the epide-
miological context between these countries
and MENA countries.
Reflecting the availability of data at the
sensitivity of sexual and injecting attitudes and country level, this report included more data
practices in conservative cultures, such as in from some countries than others. It is by no
MENA, adds a further limitation to behavioral means an attempt to single out specific countries
research.34 Individuals may find it difficult to as opposed to others. The scale of HIV efforts is
report their true risk practices. Furthermore, it highly heterogeneous in the region and the
is often not possible to ask explicit questions level of willingness to share or report confiden-
about sexual behavior, particularly to women. tial data varies from one country to another.
Asking a general question such as “did you
have a sexual contact” may lead to an affirma- Research methodology
tive answer for the wrong reason, because
what is defined for these women as a sexual The research methodology consists of an
contact may be merely kissing.35 Hence, in evidence-based epidemiological synthesis and
addition to reviewing HIV biological measures analysis to characterize HIV epidemiology and
and risk behavior measures, this report also assess HIV epidemic potential. This is achieved
reviews the evidence for biological markers of by identifying, collecting, reviewing, and ana-
risk behavior, including HCV infection preva- lyzing extensive literature to establish the epide-
lence for injecting drug users and STI preva- miological risk factors, determine the nature
lence, such as that of herpes simplex virus and phases of HIV epidemics, delineate the
type 2 (HSV-2), for the sexually active popula- populations affected, analyze proxy measures,
tions. These proxy measures can gauge differ- and understand the vulnerabilities and drivers
ent aspects of the levels of risk behavior in the of the epidemic in the MENA context.
population and complement and validate
reported levels of risk behavior. Identified and reviewed data sources
In preparing this report, the following publica-
34
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.”
tions, reports, and data sources were identified
35
Hajiabdolbaghi et al., “Insights from a Survey of Sexual Behavior.” and reviewed, and their evidence synthesized:
6 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
1. Scientific literature identified through a Medline 5. Demographic and Health Survey (DHS)
(PubMed) search for the topics covered in this reports of MENA countries including Egypt,
project using a strategy with both free text and Jordan, Mauritania, Morocco, Sudan, Tunisia,
medical subheadings (MeSH). No language or and the Republic of Yemen. The utility of
year limitation was imposed. The literature these reports was determined in terms of
review included searches for HIV infectious measures such as HIV knowledge, prevalence
spread, sexual behavior, HSV-2 prevalence, of symptoms of sexually transmitted diseases
human papillomavirus (HPV) and cervical can- (STDs), and condom use among other behav-
cer prevalence, bacterial STI prevalence, and ioral and demographic measures.
HCV prevalence. The details of the search crite-
6. An extensive WHO/EMRO database of noti-
ria are listed in appendix B. More than 3,900
fied HIV/AIDS cases and surveillance reports.
literature sources were examined in this search.
7. Consultations with key experts, public health
2. Scientific literature on HIV, STIs, and HCV in
officials, researchers, and academics in the
peer-reviewed publications published in local
region and beyond.
and regional research journals not indexed in
PubMed, but identified through the use of Nature of HIV/AIDS epidemiological evidence
Google Scholar. in MENA
This synthesis has highlighted the following
3. Thousands of country-level reports and data-
characteristics of existing HIV/AIDS epidemio-
sources, governmental studies and publica-
logical evidence:
tions, nongovernmental organizations’
(NGOs) studies and publications, and other 1. There is actually a considerable amount of
institutional reports related to HIV in MENA. epidemiological data on HIV/AIDS in MENA,
These reports were obtained from their contrary to the widely accepted perception of
sources or through contacts facilitated by very limited data.
UNAIDS, WHO, and the World Bank.
2. In addition to large sums of data published in
4. Hundreds of international organizations’ peer-reviewed scientific literature, there are
reports and databases, covering a multi- hundreds of studies that have never been
tude of issues related to HIV infectious published in scientific publications and are
spread such as point-prevalence surveys; not easily or widely accessible. A large sum of
vulnerabilities; social studies; cervical can- data and studies continue to be disseminated
cer incidence and mortality rates at surveil- within small circles at the national and
lance sites and at country levels; injecting regional levels in the form of confidential and
drug use prevalence and trends and drug nonconfidential reports, unpublished data,
trade patterns; imprisonment rates; demo- and news articles.
graphic and socioeconomic trends; and
3. Data are fragmented, amorphous, and lack
migration, refugees, and internally dis-
integration. The nature of evidence is best
placed persons. The organizations from
exemplified by shattered glass. Thousands of
which data were obtained include UNAIDS,
studies and point-prevalence surveys are
WHO, the World Bank, the United Nations
fragmented and distributed among a multi-
Children’s Fund (UNICEF), the United
tude of stakeholders at the local, national,
Nations Office on Drugs and Crime
and regional levels with no coherent synthe-
(UNODC), the International Agency for
sis, analysis, or integration.
Research on Cancer (IARC), the
International Organization for Migration 4. Large sums of data have never been method-
(IOM), the International Centre for Prison ically studied or analyzed. Valuable data such
Studies (ICPS), the Office of the UN High as HIV, STI, and HCV point-prevalence
Commissioner for Refugees (UNHCR), the surveys among different general population
Population Reference Bureau (PRB), and groups, vulnerable population groups, and
Family Health International (FHI). priority groups can be found in hundreds
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Why and How? 7
of periodic country reports and case UNAIDS, WHO, and the World Bank. Many
notifications. MENA countries report their notified HIV/AIDS
cases and other HIV-related data to the WHO/
5. The large sums of available data are not
EMRO Regional Database on HIV/AIDS, but the
necessarily representative of the populations
representativeness of these data could not be
that they are supposed to represent and are
evaluated because countries did not report
often not collected using standard and
consistently over time and a description of data
accepted surveillance methodologies. A large
collection methodologies was not usually
fraction of data originates from facility-based
included in their reports.
surveillance on convenient samples of the
The authors of this report elected to use all
population. It is often not clear whether
available data sources in the synthesis while
internationally accepted ethical guidelines for
paying special attention to data sources that
human subject research were strictly fol-
may be questionable on methodological
lowed while conducting the studies.
grounds. The synthesis factored in the limited
representation of some of the data in the analy-
Limitations of this synthesis ses and conclusions. The different data sources,
irrespective of their representativeness or reli-
Epidemiologic evidence in MENA varies sub-
ability, have generally converged on a consis-
stantially in quality. Although the quality of
tent picture of HIV epidemiology that is
point-prevalence surveys in MENA has been
delineated throughout this report.
steadily improving, a proportion of the data
reported here are gleaned from point-prevalence
surveys not conducted using standard methodol-
ogy and internationally accepted guidelines for BIBLIOGRAPHY
HIV sentinel surveillance and population-based Abukhalil, A. 1997. “Gender Boundaries and Sexual
surveys. In this report, an HIV point-prevalence Categories in the Arab World.” Fem Issues 15: 91–104.
survey refers to a measurement of HIV preva- Abu-Raddad, L. J., A. S. Magaret, C. Celum, A. Wald, I.
M. Longini, S. G. Self, and L. Corey. 2008. “Genital
lence: the proportion of a population infected in
Herpes Has Played a More Important Role Than Any
a population sample consisting of a number of Other Sexually Transmitted Infection in Driving HIV
individuals identified with a common attribute. Prevalence in Africa.” PLoS ONE 3: e2230.
Although limited-quality point-prevalence sur- Abu-Raddad, L. J., P. Patnaik, and J. G. Kublin. 2006.
veys provide useful data, they may not be repre- “Dual Infection with HIV and Malaria Fuels the
Spread of Both Diseases in Sub-Saharan Africa.”
sentative of the populations they are supposed to Science 314: 1603–6.
represent.36 In this regard it must be stressed that Anderson, R. M., and R. M. May. 1991. Infectious Diseases
all data reported here for any population group of Humans: Dynamics and Control. Oxford: Oxford
represent only the population sample on which University Press.
the study was conducted. The reported mea- Assaad R., and F. Roudi-Fahimi. 2007. “Youth in the
Middle East and North Africa: Demographic
sures should not be generalized to repre- Opportunity or Challenge?” Population Reference
sent the whole population group in any Bureau, Washington, DC.
given country. Whenever data are cited in Auvert, B., D. Taljaard, E. Lagarde, J. Sobngwi-
this report, the citation refers to a very spe- Tambekou, R. Sitta, and A. Puren. 2005. “Randomized,
Controlled Intervention Trial of Male Circumcision
cific, studied population sample.
for Reduction of HIV Infection Risk: The ANRS 1265
This report found that scientific papers pub- Trial.” PLoS Med 2: e298.
lished in peer-reviewed publications provided Bailey, R. C., S. Moses, C. B. Parker, K. Agot, I. Maclean,
the best empirical evidence. Reports and studies J. N. Krieger, C. F. M. Williams, R. T. Campbell, and
on HIV not published in scientific journals J. O. Ndinya-Achola. 2007. “Male Circumcision for
HIV Prevention in Young Men in Kisumu, Kenya: A
tended to vary in quality and value, with the Randomised Controlled Trial.” Lancet 369: 643–56.
best reports and studies conducted or commis- Bohannon, J. 2005. “Science in Libya: From Pariah to
sioned by international organizations such as Science Powerhouse?” Science 308: 182–84.
Boily, M. C., and B. Masse. 1997. “Mathematical Models
36
Pisani et al., “HIV Surveillance.” of Disease Transmission: A Precious Tool for the
8 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Study of Sexually Transmitted Diseases.” Can J Public Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H.
Health 88: 255–65. Vermund. 1997. “HIV/AIDS and Its Risk Factors in
Brunham, R. C., and F. A. Plummer. 1990. “A General Pakistan.” AIDS 11: 843–48.
Model of Sexually Transmitted Disease Epidemiology Latkin, C. A., and D. Vlahov. 1998. “Socially Desirable
and Its Implications for Control.” Med Clin North Am Response Tendency as a Correlate of Accuracy of
74: 1339–52. Self-Reported HIV Serostatus for HIV Seropositive
Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Injection Drug Users.” Addiction 93: 1191–97.
Tigani, J. George, R. Abu-Elyazeed, and J. N. Woody. Lee, R. M., and C. M. Renzetti. 1990. “The Problems of
1990. “Serosurvey of Prevalence of Human Researching Sensitive Topics.” American Behavioral
Immunodeficiency Virus amongst High Risk Scientist 33: 510–28.
Groups in Port Sudan, Sudan.” East Afr Med J 67: Lenton, C. 1997. “Will Egypt Escape the AIDS Epidemic?”
650–55. Lancet 349: 1005.
Busulwa, R. 2003. “HIV/AIDS Situation Analysis Study.” Low, N., N. Broutet, Y. Adu-Sarkodie, P. Barton, M.
Conducted in Hodeidah, Taiz, and Hadhramut, Hossain, and S. Hawkes. 2006. “Global Control
Republic of Yemen. of Sexually Transmitted Infections.” Lancet 368:
Caldwell, C., and P. Quiggin. 1989. “The Social Context 2001–16.
of AIDS in Sub-Saharan Africa.” Population and Mohammad, K., F. K. Farahani, M. R. Mohammadi, S.
Development Review 15: 185–234. Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani,
Carael, M., J. Cleland, and L. Adeokun. 1991. “Overview A. Hasanzadeh, and H. Ghanbari. 2007. “Sexual Risk-
and Selected Findings of Sexual Behaviour Surveys.” Taking Behaviors among Boys Aged 15–18 Years in
AIDS 5 Suppl 1: S65–74. Tehran.” J Adolesc Health 41: 407–14.
Commission on AIDS in Asia. 2008. Redefining AIDS in Obermeyer, C. M. 2006. “HIV in the Middle East.” BMJ
Asia: Crafting an Effective Response. New Delhi, India: 333: 851–54.
Oxford University Press. Presented to Ban Ki-moon, Pisani, E., S. Lazzari, N. Walker, and B. Schwartlander.
UN Secretary General, on March 26, 2008. 2003. “HIV Surveillance: A Global Perspective.” J
Gray, P. B. 2004. “HIV and Islam: Is HIV Prevalence Acquir Immune Defic Syndr 32 Suppl 1: S3–11.
Lower among Muslims?” Soc Sci Med 58: 1751–56. Roudi-Fahimi, F., and L. Ashford. 2008. Sexual &
Gray, R. H., G. Kigozi, D. Serwadda, F. Makumbi, Reproductive Health in the Middle East and North Africa:
S. Watya, F. Nalugoda, N. Kiwanuka, L. H. Moulton, A Guide for Reporters. Population Reference Bureau,
M. A. Chaudhary, M. Z. Chen, N. K. Sewankambo, Washington, DC.
F. Wabwire-Mangen, M. C. Bacon, C. F. M. Williams, Shaar, A. N., and J. Larenas. 2005. “Social Determinants
P. Opendi, S. J. Reynolds, O. Laeyendecker, T. C. of Health.” Palestine Country Paper, World Health
Quinn, and M. J. Wawer. 2007. “Male Circumcision Organization.
for HIV Prevention in Men in Rakai, Uganda: A
Randomised Trial.” Lancet 369: 657–66. Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge,
Attitudes and Practices concerning HIV/AIDS among
Hajiabdolbaghi, M., N. Razani, N. Karami, P. Kheirandish, Iranian At-Risk Sub-Populations.” Eastern Mediterranean
M. Mohraz, M. Rasoolinejad, K. Arefnia, Z. Kourorian, Health Journal 14.
G. Rutherford, and W. McFarland. 2007. “Insights
from a Survey of Sexual Behavior among a Group of UNAIDS (Joint United Nations Programme on HIV/
At-Risk Women in Tehran, Iran, 2006.” AIDS Educ AIDS). 2008. “Notes on AIDS in the Middle East and
Prev 19: 519–30. North Africa.” RST, MENA.
Hossini, C. H., D. Tripodi, A. E. Rahhali, M. Bichara, D. UNAIDS, and WHO (World Health Organization). 2009.
Betito, J. P. Curtes, and C. Verger. 2000. “Knowledge AIDS Epidemic Update 2009. Geneva.
and Attitudes of Health Care Professionals with UNODC (United Nations Office on Drugs and Crime).
Respect to AIDS and the Risk of Occupational 2007. World Drug Report. New York.
Transmission of HIV in 2 Moroccan Hospitals.” Wadsworth, J., J. Field, A. M. Johnson, S. Bradshaw,
Sante 10: 315–21. and K. Wellings. 1993. “Methodology of the National
Kelley, L., and N. Eberstadt. 2005a. “Behind the Veil of a Survey of Sexual Attitudes and Lifestyles.” J R Stat Soc
Public Health Crisis: HIV/AIDS in the Muslim World.” Ser A Stat Soc 156: 407–21.
National Bureau of Asian Research (NBR) Special Wawer, M. J., R. H. Gray, N. K. Sewankambo, D.
Report, Seattle, Washington. Serwadda, X. Li, O. Laeyendecker, N. Kiwanuka, G.
———. 2005b. “The Muslim Face of AIDS.” Foreign Policy Kigozi, M. Kiddugavu, T. Lutalo, F. Nalugoda, F.
149: 42–48. Wabwire-Mangen, M. P. Meehan, and T. C. Quinn.
Kennedy, M., D. O’Reilly, and M. W. Mah. 1998. “The 2005. “Rates of HIV-1 Transmission per Coital Act, by
Use of a Quality-Improvement Approach to Reduce Stage of HIV-1 Infection, in Rakai, Uganda.” J Infect
Needlestick Injuries in a Saudi Arabian Hospital.” Clin Dis 191: 1403–9.
Perform Qual Health Care 6: 79–83. World Bank Group. 2005. “World Bank Update 2005: HIV/
Khattab, H. A. S., M. A. Gineidy, N. Shorbagui, and N. AIDS in Pakistan.” Washington, DC.
Elnahal. 2007. “Report on a Study of Women Living Yemen MOH (Ministry of Health). Unknown. National
with HIV.” Egyptian Society for Population Studies Strategic Framework for the Control and Prevention of HIV/
and Reproductive Health. AIDS in the Republic of Yemen.
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Why and How? 9
Yerly, S., R. Quadri, F. Negro, K. P. Barbe, J. J. Cheseaux, Zafar, A., N. Aslam, N. Nasir, R. Meraj, and V. Mehraj.
P. Burgisser, C. A. Siegrist, and L. Perrin. 2001. 2008. “Knowledge, Attitudes and Practices of Health
“Nosocomial Outbreak of Multiple Bloodborne Viral Care Workers regarding Needle Stick Injuries at a
Infections.” J Infect Dis 184: 369–72. Tertiary Care Hospital in Pakistan.” J Pak Med Assoc 58:
Yorke, J. A., H. W. Hethcote, and A. Nold. 1978. 57–60.
“Dynamics and Control of the Transmission of
Gonorrhea.” Sex Transm Dis 5: 51–56.
10 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 2
This chapter focuses on the biological evidence Kuwait,9 Oman,10 Pakistan,11 and Tunisia.12 IDU
for the extent of human immunodeficiency has also contributed substantially to the epidemics
virus (HIV) spread among injecting drug users in Algeria and Morocco.13
(IDUs), the behavioral evidence for risky injec- Table 2.1 contains the results of available HIV
tion and sexual practices among this population point-prevalence surveys of IDUs in MENA. HIV
group, and the context of injecting drug use in prevalence varies across and within countries,
the Middle East and North Africa (MENA). and observed levels of prevalence are not dis-
similar to those observed in other regions.14 The
data suggest that HIV prevalence among IDUs in
HIV PREVALENCE AMONG IDUS MENA countries is in the low to intermediate
range compared to other countries around the
Injecting drug use is one of the leading modes world.15 Globally, HIV prevalence ranges at the
of HIV transmission and accounts for about 10% of country level from below 0.01% in eight coun-
HIV/AIDS (acquired immunodeficiency syndrome) tries to 72.1% in Estonia.16
cases worldwide.1 HIV has been documented In what appears to be the first HIV incidence
among IDUs in at least half of the MENA coun- study in MENA, HIV incidence was measured
tries,2 and there is robust evidence of concentrated among IDUs in detention in the Islamic Republic
epidemics among IDUs in the Islamic Republic of of Iran and found to be at a very high level of
Iran and Pakistan.3 IDU has been documented as 16.8% per person-year.17
the dominant transmission mode in the Islamic HIV biological data suggest that HIV has
Republic of Iran (more than 67% of cases)4 and established itself among at least a number of
Libya (as much as 90%).5 Of the 570 new infec- IDU populations in several MENA countries.
tions reported in 2000 in Libya, almost all were
among IDUs.6 IDU is also a significant mode of 9
UNAIDS and WHO, AIDS Epidemic Update 2005.
transmission for HIV in Afghanistan,7 Bahrain,8 10
Ibid.
11
Shah et al., “An Outbreak of HIV Infection”; UNAIDS and WHO, AIDS
Epidemic Update 2005; Rai et al., “HIV/AIDS in Pakistan”; Bokhari
1
UNAIDS and WHO, AIDS Epidemic Update 2003. et al., “HIV Risk in Karachi and Lahore, Pakistan.”
2 12
UNAIDS and WHO, AIDS Epidemic Update 2002. UNAIDS and WHO, AIDS Epidemic Update 2003; UNAIDS and WHO,
3
UNAIDS, “Notes on AIDS in the Middle East and North Africa.” AIDS Epidemic Update 2007.
4 13
Iran Center for Disease Management, “AIDS/HIV Surveillance Report.” Ibid.
5 14
UNAIDS and WHO, AIDS Epidemic Update 2001. Aceijas et al., “Global Overview.”
6 15
Ibid. Mathers et al., “Global Epidemiology.”
7 16
Todd et al., “HIV, Hepatitis C, and Hepatitis B.” Ibid.
8 17
Al-Haddad, Baig, and Ebrahim, “Epidemiology of HIV and AIDS in Bahrain.” Jahani et al., “HIV Seroconversion.”
11
Table 2.1 HIV Prevalence among IDUs in MENA
12 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 2.1 (Continued)
to other regions.24 The prevalence from IDU glob- (400 in Kabul) IDUs29 in Afghanistan; 400,00030
ally is at 0.363%, with a range from 0.056% in in the Arab world; 112,000,31 137,000,32 at least
South Asia to 1.5% in Eastern Europe.25 This 166,000,33 200,000,34 300,000,35 and 70,00036
translates into 15.9 million people injecting drugs in the Islamic Republic of Iran; and 60,00037
around the world.26 and 180,00038 in Pakistan. The average preva-
Table 2.3 provides estimates of the number lence of IDU has been measured to be 4.7 IDUs
of IDUs in a number of MENA countries as per 1,000 men in a number of cities in Pakistan.39
extracted from a global review of IDU.27 In
another study, Aceijas et al. estimated that 29
Action Aid Afghanistan, “HIV AIDS in Afghanistan”; World Bank, HIV/
there are 0.3 to 0.6 million IDUs in MENA.28 30
AIDS in Afghanistan; Ryan, “Travel Report Summary.”
UNODC, World Drug Report 2004.
Further studies estimate that there are 7,500 31
Aceijas et al., “Global Overview.”
32
Gheiratmand et al., “Uncertainty on the Number of HIV/AIDS Patients.”
33
Razzaghi, Rahimi, and Hosseini, Rapid Situation Assessment.
24 34
Aceijas et al., “Global Overview”; Mathers et al., “Global Razzaghi et al., “Profiles of Risk.”
35
Epidemiology”; Aceijas et al., “Estimates of Injecting Drug Users.” Wodak, “Report to WHO/EMRO.”
25 36
Mathers et al., “Global Epidemiology.” Ghys et al., “The Epidemics of Injecting Drug Use and HIV in Asia.”
26 37
Ibid. United Nations Drug Control Programme, “Drug Abuse in Pakistan.”
27 38
Mathers et al., “Global Epidemiology”; Aceijas et al., “Estimates of Haque et al., “High-Risk Sexual Behaviours.”
39
Injecting Drug Users.” Pakistan National AIDS Control Program, HIV Second Generation
28
Aceijas et al., “Global Overview.” Surveillance (Round I).
14 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 2.3 Estimates of the Number and Prevalence of IDUs, Selected MENA Countries
Sources: Adapted from Aceijas et al. (2006), with more recent estimates from Mathers et al. (2008).
In Kabul, Jalalabad, and Mazar-i-Sharif in in the world (1 in every 17 people).44 One study
Afghanistan, the IDU prevalence is estimated at estimated that there are 0.5 million heroin addicts
2.24 IDUs per 1,000 men.40 in Pakistan.45 Another study reported an opiate
There is evidence of a growing IDU problem use prevalence of 0.8% in Pakistan compared to
in both the Islamic Republic of Iran41 and 0.6% in the United States and 0.4% in India.46
Pakistan.42 The proportion of IDUs out of all The prevalence of drug use in Saudi Arabia is esti-
drug users in Pakistan appears to have increased mated at 0.002% to 0.01%.47 There are 27,000
from 3% in 1993, to 15% in 2000–01, and to drug users in Kuwait,48 and 7,000, mostly IDUs,
26% in 2006.43 in Libya.49 A study among Egyptian youth found
Drug injection is only one component of a
wider drug problem in MENA. The Islamic
44
Republic of Iran has the highest rate of heroin and Razzaghi et al., “Profiles of Risk”; UNODC, World Drug Report 2005 ,
Volume I: Analysis.
opium dependence (injecting and noninjecting) 45
UNODCP, “Global Illicit Drug Trends.”
46
UNODC, World Drug Report 2005 , Volume II: Statistics.
40 47
World Bank, “Mapping and Situation Assessment.” Njoh and Zimmo, “The Prevalence of Human Immunodeficiency Virus”;
41
Reid and Costigan, “Revisiting the Hidden Epidemic.” Hafeiz, “Socio-Demographic Correlates.”
42 48
Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.” Jenkins and Robalino, HIV in the Middle East and North Africa.
43 49
UNODC, World Drug Report 2007. Ibid.
50 60
Ibid. Todd, Safi, and Strathdee, “Drug Use and Harm Reduction in
51
Shareef et al., “Assessment Study.” Afghanistan.”
52 61
Shareef et al., “Drug Abuse Situation.” Day et al., “Patterns of Drug Use.”
53 62
UNODC, World Drug Report 2007. Ahmadi, Maharlooy, and Alishahi, “Substance Abuse.”
54 63
Ibid. Pakistan National AIDS Control Program, HIV Second Generation
55
UNODC, Afghanistan: Opium Survey 2003. Surveillance (Round I).
56 64
UNODC, World Drug Report 2007. Oman MOH, “HIV Risk.”
57 65
Beyrer et al., “Overland Heroin Trafficking Routes”; Sarkar et al., Syria Mental Health Directorate, “Assessment of HIV Risk.”
66
“Relationship of National Highway”; Xiao et al., “Expansion of HIV/AIDS Razzaghi, Rahimi, and Hosseini, Rapid Situation Assessment.
67
in China”; Beyrer, “Human Immunodeficiency Virus (HIV) Infection Bolhari et al., “Assessment of Drug Abuse.”
68
Rates.” Jenkins, “Report on Sex Worker Consultation in Iran.”
58 69
UNODC, World Drug Report 2007. Shakeshaft et al., “Perceptions of Substance Use.”
59 70
Shareef et al., “Assessment Study.” Asouab, “Risques VIH/SIDA chez UDI.”
16 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
frequency of drug injection, network structure, Afghanistan reported using nonsterile injecting
engagement in risky sexual behavior, and other equipment.80 Seventy-eight percent of IDUs in
high-risk practices. Pakistan reported reusing syringes.81
The fraction of drug users who are injecting or
reusing injection equipment appears to be increas-
Use of nonsterile injecting equipment among
ing in at least some settings. After the 2001
IDUs
Afghanistan war, levels of needle reuse increased in
The key risk behavior that exposes IDUs to HIV Pakistan from 56% to 76%, possibly due to changes
infection is the use of nonsterile injecting equip- in drug availability, purity and price, as well as the
ment. Evidence on IDUs in MENA depicts gen- number of drug addicts.82 Though the majority of
erally a high-risk environment. Several studies drug users in Pakistan use opiates by inhaling fumes
have documented relatively high levels of injec- of heroin powder burned on foil (a practice known
tion equipment reuse, such as the reuse of nee- as “chasing the dragon”),83 there appears to be a shift
dles or syringes during last injection, last month, toward injecting drugs, possibly due to an increase
last six months, last year, or during lifetime. in heroin quality, which makes it not useful for
Table 2.4 lists prevalence of the use of nonsterile inhalation, as well as the wider availability of inject-
injecting equipment in different studies. able forms and the unavailability or rising cost of
An average of six reuse incidents per person, other forms of drugs after the Afghanistan war.84
per month has been reported among IDUs in Changes in drug supply have been associated with
Oman.71 Half of the IDUs in one district in the increases in IDU in other countries including the
Islamic Republic of Iran used nonsterile injecting Russian Federation, Thailand, and the United
equipment on a daily basis.72 There are also States.85 This highlights the importance of strength-
reports of group injecting, such as in Pakistan, ening surveillance systems to monitor changes in
where, as reported in two studies, 79.5%73 and risky behavior.
78%74 of IDUs reported this practice. Forty percent
of IDUs in Afghanistan reported receiving injec-
Frequency of drug injection
tions by a “street doctor” in the past six months.75
This practice is associated with higher reuse of The higher the frequency of drug injection, the
injecting equipment.76 larger the potential for HIV to spread in injecting
Use of nonsterile injections appears to be com- drug networks. IDUs in MENA appear to inject
mon in MENA, and the cleaning of syringes with drugs at a rate of more than once per day. IDUs
bleach is very limited or not done at all.77 In reported 2.6 injections per day in Afghanistan.86
Pakistan, only 12.2% of IDUs in one study and Also in Afghanistan, 72% reported injecting
30.2% in another study reported using a clean drugs at least once a day and two-thirds reported
syringe every time they injected drugs.78 The use injecting drugs for more than five years.87 In
of nonsterile equipment varies substantially by Egypt, 75.3% of IDUs reported injecting drugs
socioeconomic status, such as in the Islamic at least once per day.88 In studies in Pakistan,
Republic of Iran where it varies between 30% and 89.9%,89 67.7%,90 58%,91 and 38%92 of IDUs
100%, with the highest proportion of those reus-
ing injecting equipment among those at the lowest 80
World Bank, HIV/AIDS in Afghanistan.
socioeconomic level.79 Almost one-third of IDUs in 81
Emmanuel et al., “HIV Risk Behavior.”
82
Strathdee et al., “Rise in Needle Sharing.”
83
Ahmed et al., “HIV/AIDS Risk Behaviors.”
71 84
Oman MOH, “HIV Risk.” Altaf et al., “High Risk Behaviors”; Shah and Altaf, “Prevention and
72
Razzaghi et al., “Profiles of Risk.” Control of HIV/AIDS.”
73 85
Altaf et al., “High Risk Behaviors.” Neaigus et al., “Potential Risk Factors”; Rhodes et al., “Explosive
74
Emmanuel et al., “HIV Risk Behavior.” Spread”; Westermeyer, “The Pro-Heroin Effects.”
75 86
World Bank, “Mapping and Situation Assessment.” World Bank, “Mapping and Situation Assessment.”
76 87
Pakistan National AIDS Control Program, HIV Second Generation Action Aid Afghanistan, “HIV AIDS in Afghanistan.”
88
Surveillance in Pakistan (Round III). Elshimi, Warner-Smith, and Aon, “Blood-Borne Virus Risks.”
77 89
Oman MOH, “HIV Risk”; Parviz et al., “Background Demographics and Kuo et al., “High HCV Seroprevalence.”
90
Risk Behaviors.” Ibid.
78 91
Kuo et al., “High HCV Seroprevalence.” Platt et al., “Prevalence of HIV.”
79 92
Razzaghi et al., “Profiles of Risk.” Ibid.
18 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
reported a daily injection. Also in Pakistan, stud- the IDU was a friend, among 11% of cases the
ies found that IDUs reported a mean of 2,93 person was the usual sexual partner, and among
2.3,94 2.3,95 2.2,96 and 2.1897 injections per day. 4% of the cases the person was an acquain-
In Syria, IDUs reported a mean of 41 injections tance.107 Injection by a dealer was reported by
per month.98 only 5% of the participants.108
A study in two settings in the Islamic Republic
of Iran found that the mean size of the injecting
Network structure among injecting drug users
drug network in the previous month was 2.1
The social and injecting networks of IDUs play and 2.6 persons.109 Most injection equipment
an important role in determining the risk of HIV reuse occurred between people who knew each
infection.99 Collecting data on just a few risky other closely, such as friends or spouses.110 In
behavior measures, such as the use of nonsterile such circumstances, the injecting network and
injecting equipment, is not sufficient to map the the social network appear to overlap and HIV
risk of HIV exposure. MENA appears to have a cannot easily propagate from one subnetwork to
diversity of typologies of risk networks across another.
countries and sometimes within any one coun- In other parts of MENA, the social and inject-
try.100 In Lebanon, it appears that IDUs form ing networks are not necessarily overlapping
closed, small networks with injection occurring and the reuse of injection equipment can occur
in private homes and not at shooting galleries.101 between people who are not necessarily socially
For 56.7% of IDUs, the main partner in injec- related, such as in shooting galleries. This has
tion reuse was a friend, and the average number been observed among some IDU communities in
of partners in syringe reuse was 1.24.102 Group the Islamic Republic of Iran111 and Pakistan.112
injecting with nonsterile injecting equipment Seventy-three percent of IDUs in one study in
was reported by 26.7% of IDUs; this was often part Pakistan injected drugs in groups, with 50% of
of a ritual among friends.103 A similar pattern was them using nonsterile injecting equipment.113 In
found in Syria104 and among some of the IDU another study in Pakistan, between 79% and
communities in the Islamic Republic of Iran.105 89% of IDUs had their last injection in a park or
In Syria, a study has found that when the a street.114 In further studies in Pakistan, this
syringe was given to someone else after use, it was also reported by 77.7%,115 65.7%,116 and
was given to a friend in 62% of cases, usual 82.2%117 of IDUs, although 72.3%,118 64.1%,119
sexual partner in 19% of cases, and to an and 64.4%120 of these IDUs reported injecting
acquaintance in 8% of cases.106 Among 67% of with a friend or an acquaintance. In studies,
the study participants, the person who injected injection by a “professional” injector or street
93 107
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan”; Pakistan Ibid.
National AIDS Control Program, “Pilot Study in Karachi & Rawalpindi.” 108
Ibid.
94 109
Altaf et al., “High Risk Behaviors”; Pakistan National AIDS Control Zamani et al., “Needle and Syringe Sharing Practices.”
Program, HIV Second Generation Surveillance (Round I). 110
Ibid.
95 111
Pakistan National AIDS Control Program, HIV Second Generation Razzaghi et al., “Profiles of Risk.”
Surveillance (Round I). 112
Emmanuel and Fatima, “Coverage to Curb the Emerging HIV Epidemic.”
96 113
Pakistan National AIDS Control Program, HIV Second Generation Ibid.
Surveillance (Round II). 114
Pakistan National AIDS Control Program, “Pilot Study in Karachi &
97
Pakistan National AIDS Control Program, HIV Second Generation Rawalpindi.”
Surveillance (Round III). 115
Pakistan National AIDS Control Program, HIV Second Generation
98
Syria Mental Health Directorate, “Assessment of HIV Risk.” Surveillance (Round I).
99 116
Neaigus et al., “The Relevance of Drug Injectors.” Pakistan National AIDS Control Program, HIV Second Generation
100
Razzaghi et al., “Profiles of Risk.” Surveillance (Round II).
101 117
Mishwar, “An Integrated Bio-Behavioral Surveillance Study.” Pakistan National AIDS Control Program, HIV Second Generation
102
Aaraj, “Report on the Situation Analysis”; Hermez et al., “HIV/AIDS Surveillance (Round III).
Prevention among Vulnerable Groups.” 118
Pakistan National AIDS Control Program, HIV Second Generation
103
Hermez, “HIV/AIDS Prevention through Outreach”; Aaraj, “Report on Surveillance (Round I).
the Situation Analysis.” 119
Pakistan National AIDS Control Program, HIV Second Generation
104
Syria Mental Health Directorate, “Assessment of HIV Risk.” Surveillance (Round II).
105 120
Razzaghi et al., “Profiles of Risk.” Pakistan National AIDS Control Program, HIV Second Generation
106
Syria Mental Health Directorate, “Assessment of HIV Risk.” Surveillance (Round III).
20 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
partner,150 and 42%–62% reported having sex Other high-risk practices
with a woman in the last year.151 Also in
Other high-risk drug-injection practices have
Pakistan, individual studies reported that
been documented in MENA. Ninety-one per-
42.2%,152 45.7%,153 and 37.8%154 of IDUs had
cent of IDUs in a study in Pakistan reported
regular female sexual partners in the last six
deliberately drawing their blood into the syringe
months. A history of a sexually transmitted dis-
when they injected drugs (a practice known as
ease (STD) was reported in different studies to
“jerking”).165 This procedure was associated
be 66%,155 54.1%,156 and 40%157 for IDUs.
with a sevenfold higher chance of HCV infec-
Seven percent of those arrested for drug-related
tion, attesting to the danger of this practice for
crimes were found positive for syphilis (a sexu-
HIV transmission.166 There is also documented
ally transmitted infection [STI]).158 In Syria,
evidence of the commercial sale of blood among
IDUs had a mean number of seven sexual part-
IDUs. In a number of studies in Pakistan,
ners over the last 12 months.159
52%,167 22%,168 30%,169 28%,170 27%,171 and
Further data in MENA indicate that 44% of
3%172 of IDUs reported giving blood for profit.
IDUs in Algeria either had sex with FSWs or sold
This practice led to a large number of HIV infec-
sex.160 Thirty-eight percent of female IDUs in
tions in China through contaminated blood.173
Egypt were previously convicted for prostitu-
Private clinics in Pakistan are known to provide
tion.161 Seventy-four percent of sex partners of
monetary reimbursement for blood donation,
IDUs in one study in the Islamic Republic of Iran
thereby creating an incentive for IDUs to give
were FSWs,162 and for women who injected
blood.174 Lastly, there is evidence of at least
drugs in a study in the Islamic Republic of Iran,
some mobility among drug users; between 54%
the most common source of income was sex
and 72% of different IDU groups in Oman
work.163 Nine percent of IDUs in one study in
reported injecting outside Oman.175
Pakistan reported using nonsterile needles or
syringes with a sex worker in the last week.164
Table 2.5 shows a summary of several other
measures of overlapping injecting and sexual KNOWLEDGE OF HIV/AIDS
risk behaviors among IDUs. The overlap mea-
Levels of HIV/AIDS knowledge among IDUs in
sures include having ever paid for sex and con-
MENA appear to be variable. Only 40% of IDUs
tacting commercial sex workers, engagement in
in Afghanistan176 and 18.3% of Afghani IDUs in
sex work for drugs or money in the last month,
Pakistan177 reported ever hearing of HIV/AIDS.
having sex with a man or a boy, and condom
A report from Egypt indicated a higher level at
use.
43%, but with 40% reporting not knowing that
HIV/AIDS can be transmitted through reuse of
nonsterile needles.178 However, almost all IDUs
150
Pakistan National AIDS Control Program, “Pilot Study in Karachi & in a different study in Egypt were aware of HIV
Rawalpindi.” and some of its transmission modes, but still had
151
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.”
152
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I).
153 165
Pakistan National AIDS Control Program, HIV Second Generation Kuo et al., High HCV Seroprevalence.”
166
Surveillance (Round II). Ibid.
154 167
Pakistan National AIDS Control Program, HIV Second Generation Baqi et al., “HIV Antibody Seroprevalence.”
168
Surveillance (Round III). Ibid.
155 169
Kuo et al., “High HCV Seroprevalence.” Ahmed et al., “HIV/AIDS Risk Behaviors.”
156 170
Ibid. Altaf et al., “High Risk Behaviors.”
157 171
Haque et al., “High-Risk Sexual Behaviours.” Platt et al., “Prevalence of HIV.”
158 172
Baqi, “HIV Seroprevalence.” Ibid.
159 173
Syria Mental Health Directorate, “Assessment of HIV Risk.” Lau, Thomas, and Lin, “HIV-Related Behaviours.”
160 174
Mimouni and Remaoun, “Etude du Lien Potentiel entre l’Usage Ahmed et al., “HIV/AIDS Risk Behaviors.”
175
Problématique de Drogues et le VIH/SIDA.” Oman MOH, “HIV Risk.”
161 176
Salama et al., “HIV/AIDS Knowledge and Attitudes.” Todd, Safi, and Strathdee, “Drug Use and Harm Reduction in
162
Razzaghi, Rahimi, and Hosseini, Rapid Situation Assessment. Afghanistan.”
163 177
Razzaghi et al., “Profiles of Risk.” Zafar et al., “HIV Knowledge and Risk Behaviors.”
164 178
Mayhew et al., “Protecting the Unprotected.” Action Aid Afghanistan, “HIV AIDS in Afghanistan.”
22 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 2.5 Measures
(Continued)of Overlapping Injecting and Sexual Risk Behaviors of IDUs in MENA
Paying for sex and con- Engagement in sex
tacting commercial sex work for drugs or Having sex with a man
Country workers money or a boy Condom use
Pakistan 68.9% (Kuo et al. 2006 5.5% (Emmanuel et al. 37.4% (Kuo et al. 2006) 40.0% (ever use; Emmanuel and
50.4% (Kuo et al. 2006) 2004) 14.0% (Haque et al. 2004) Fatima 2008)
58.3% (Altaf et al. 2007) 14%–20% (Pakistan 10.8% (Emmanuel et al. 37.5% (ever use; Kuo et al. 2006)
49.0% (Haque et al. 2004) National AIDS Control 2004) 14.2% (ever use; Kuo et al. 2006)
Program 2005b) 14.7% (Emmanuel and 7.0% (ever use; Parviz et al. 2006)
42.9% (Strathdee et al.
2003) 5.3% (Emmanuel and Fatima 2008) 34.0% (ever use; Altaf et al. 2007)
Fatima 2008) 14.0% (Bokhari et al. 2007)
20.8% (Emmanuel et al. 10.0% (ever use; Haque et al. 2004)
2004) 5%–11% (Bokhari et al.
17%–32% (last sex; FSW; Bokhari
2007)
41.0% (Afghani refugees; et al. 2007)
Zafar et al. 2003) 19.6% (Pakistan
10%–25% (last sex; sex work;
National AIDS Control
13%–28% (Pakistan Bokhari et al. 2007)
Program 2006–07)
National AIDS Control 7%–13% (last sex; commercial
Program 2005b) 16.8% (Pakistan
sex; Bokhari et al. 2007)
National AIDS Control
12.6% (Emmanuel and 46%–66% (not used last six
Program 2008)
Fatima 2008) months; nonpaid partners;
30%–34% (Bokhari et al. Pakistan National AIDS Control
2007) Program 2005b)
18%–23% (with MSWs; 49%–86% (not used last six
Bokhari et al. 2007) months; commercial sex; Pakistan
8%–27% (with MSWs; National AIDS Control Program
Pakistan National AIDS 2005b)
Control Program 2005b) 25.0% (last sex; regular partner;
3.3% (with hijra; Pakistan National AIDS Control
Emmanuel et al. 2004) Program 2005a)
26.6% (Pakistan National 16.5% (last sex; regular partner;
AIDS Control Program Pakistan National AIDS Control
2005a) Program 2006–07)
12.6% (Pakistan National 33.5% (last sex; regular partner;
AIDS Control Program Pakistan National AIDS Control
2006–07) Program 2008)
17.7% (Pakistan National 16.6% (last sex; FSW; Pakistan
AIDS Control Program National AIDS Control Program
2008) 2005a)
13.2% (with MSW or hijra; 20.9% (last sex; FSW; Pakistan
Pakistan National AIDS National AIDS Control Program
Control Program 2005a) 2006–07)
14.7% (with MSW or hijra; 31.0% (last sex; FSW; Pakistan
Pakistan National AIDS National AIDS Control Program
Control Program 2006–07) 2008)
13.9% (with MSW or hijra; 12.5% (last sex; man or hijra;
Pakistan National AIDS Pakistan National AIDS Control
Control Program 2008) Program 2005a)
24.0% (Platt et al. 2009) 12.9% (last sex; MSW or hijra;
21.0% (Platt et al. 2009) Pakistan National AIDS Control
Program 2006–07)
14.0% (with a transgen-
dered person; Platt et al. 13.8% (last sex; MSW or hijra;
2009) Pakistan National AIDS Control
Program 2008)
2.0% (with a transgen-
dered person; Platt et al. 45.0% (last sex; Platt et al. 2009)
2009) 32.0% (last sex; Platt et al. 2009)
(continued)
Injecting Drug Users and HIV 23
(Continued)of Overlapping Injecting and Sexual Risk Behaviors of IDUs in MENA
Table 2.5 Measures
Paying for sex and con- Engagement in sex
tacting commercial sex work for drugs or Having sex with a man
Country workers money or a boy Condom use
Syrian Arab 47.0% (51% of sample 5.0% (51% of sample are 39.0% (less than half the time;
Republic are IDUs; Syria Mental IDUs; Syria Mental Health 51% of sample are IDUs; Syria
Health Directorate Directorate 2008) Mental Health Directorate 2008)
2008) 21.0% (more than half the time;
51% of sample are IDUs; Syria
Mental Health Directorate 2008)
19.0% (consistent; 51% of sample
are IDUs; Syria Mental Health
Directorate 2008)
27.0% (less than half the time;
commercial sex; 51% of sample
are IDUs; Syria Mental Health
Directorate 2008)
5.0% (more than half the time;
commercial sex; 51% of sample
are IDUs; Syria Mental Health
Directorate 2008)
17.0% (consistent; commercial
sex; 51% of sample are IDUs;
Syria Mental Health Directorate
2008)
Note: CSW⫽commercial sex worker; MSW⫽male sex worker.
24 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
been documented to be high, confirming the Action Aid Afghanistan. 2006. “HIV AIDS in Afghanistan:
potential for further HIV spread among IDUs. A Study on Knowledge, Attitude, Behavior, and Practice
in High Risk and Vulnerable Groups in Afghanistan.”
The levels of HCV prevalence among IDUs have
Agha, A., S. Parviz, M. Younus, and Z. Fatmi. 2003.
also been documented in the intermediate to “Socio-Economic and Demographic Factors Associated
high range, confirming the potential for further with Injecting Drug Use among Drug Users in Karachi,
HIV spread. IDUs are sexually active and report Pakistan.” J Pak Med Assoc 53: 511–16.
high levels of risky sexual behavior, indicating Ahmadi, J., N. Maharlooy, and M. Alishahi. 2004.
“Substance Abuse: Prevalence in a Sample of Nursing
substantial overlap of risks among the three key Students.” J Clin Nurs 13: 60–64.
priority groups: IDUs, men who have sex with Ahmed, M. A., T. Zafar, H. Brahmbhatt, G. Imam, S. Ul
men (MSM), and FSWs. Levels of comprehen- Hassan, J. C. Bareta, and S. A. Strathdee. 2003. “HIV/
sive HIV knowledge vary across the region, with AIDS Risk Behaviors and Correlates of Injection Drug
Use among Drug Users in Pakistan.” J Urban Health
both high and low levels documented in differ- 80: 321–29.
ent settings. Alami, K. 2009. “Tendances récentes de l’épidémie à
The IDU risk context suggests the possibility VIH/SIDA en Afrique du nord.” Presentation,
of further concentrated HIV epidemics among Research and AIDS Workshop in North Africa,
IDUs in MENA over the next decade. The low or Marrakech, Morocco.
nil HIV prevalence in a number of IDU popula- Algeria MOH (Ministry of Health). Unknown. Rapport de
l’enquête nationale de séro-surveillance sentinelle du VIH et
tions could be due to HIV not yet being intro- de la syphilis en Algérie 2004–2005.
duced into these populations; HIV having been Al-Haddad, M. K., B. Z. Baig, and R. A. Ebrahim. 1997.
only recently introduced; or the nature of the “Epidemiology of HIV and AIDS in Bahrain.” J
injecting network structure among IDUs. There Commun Dis 29: 321–28.
is an urgent need for HIV research to better Al-Haddad, M. K., A. S. Khashaba, B. Z. Baig, and S.
Khalfan. 1994. “HIV Antibodies among Intravenous
understand transmission dynamics, risky behav- Drug Users in Bahrain.” J Commun Dis 26: 127–32.
ior practices, and risk group sizes, and to be able Alizadeh, A. H., S. M. Alavian, K. Jafari, and N. Yazdi.
to use this information to plan and implement 2005. “Prevalence of Hepatitis C Virus Infection and
more effective prevention and care services for Its Related Risk Factors in Drug Abuser Prisoners in
Hamedan—Iran.” World J Gastroenterol 11: 4085–89.
IDUs.
Altaf, A., A. Memon, N. Rehman, and S. Shah. 2004.
Considering the above data, there are oppor- “Harm Reduction among Injection Drug Users in
tunities to prevent IDU epidemics in the region Karachi, Pakistan.” International AIDS Conference
through needle exchange programs, access to 2004, Bangkok. Abstract WePeC5992.
frequent testing, prevention of heroin uptake, Altaf, A., N. Saleem, S. Abbas, and R. Muzaffar. 2009.
safe sex messages, and condom distribution. “High Prevalence of HIV Infection among Injection
Drug Users (IDUs) in Hyderabad and Sukkur,
Pakistan.” J Pak Med Assoc 59: 136–40.
Altaf, A., S. A. Shah, N. A. Zaidi, A. Memon, R. Nadeem
BIBLIOGRAPHY ur, and N. Wray. 2007. “High Risk Behaviors of
Injection Drug Users Registered with Harm Reduction
Aaraj, E. Unknown. “Report on the Situation Analysis
Programme in Karachi, Pakistan.” Harm Reduct J 4: 7.
on Vulnerable Groups in Beirut, Lebanon.”
Asouab, F. 2005. “Risques VIH/SIDA chez UDI et plan
Aceijas, C., S. R. Friedman, H. L. Cooper, L. Wiessing, G.
d’action 2006–2010.” Ministry of Health, Morocco.
V. Stimson, and M. Hickman. 2006. “Estimates of
Injecting Drug Users at the National and Local Level Baqi, S. 1995. “HIV Seroprevalence and Risk Factors in
in Developing and Transitional Countries, and Gender Drug Abusers in Karachi.” Second National
and Age Distribution.” Sex Transm Infect 82 Suppl 3: Symposium, Aga Khan University.
iii10–17. Baqi, S., N. Nabi, S. N. Hasan, A. J. Khan, O. Pasha, N.
Aceijas, C., G. V. Stimson, M. Hickman, and T. Rhodes. Kayani, R. A. Haque, I. U. Haq, M. Khurshid, S.
2004. “Global Overview of Injecting Drug Use and Fisher-Hoch, S. P. Luby, and J. B. McCormick. 1998.
HIV Infection among Injecting Drug Users.” AIDS 18: “HIV Antibody Seroprevalence and Associated Risk
2295–303. Factors in Sex Workers, Drug Users, and Prisoners in
Aceijas, C., and T. Rhodes. 2007. “Global Estimates of Sindh, Pakistan.” J Acquir Immune Defic Syndr Hum
Prevalence of HCV Infection among Injecting Drug Retrovirol 18: 73–79.
Users.” Int J Drug Policy 18: 352–58. Beyrer, C. 2002. “Human Immunodeficiency Virus (HIV)
Achakzai, M., M. Kassi, and P. M. Kasi. 2007. Infection Rates and Drug Trafficking: Fearful
“Seroprevalences and Co-Infections of HIV, Hepatitis Symmetries.” Bull Narcotics 54.
C Virus and Hepatitis B Virus in Injecting Drug Users Beyrer, C., M. H. Razak, K. Lisam, J. Chen, W. Lui, and
in Quetta, Pakistan.” Trop Doct 37: 43–45. X. F. Yu. 2000. “Overland Heroin Trafficking Routes
Egypt MOH (Ministry of Health), and Population Hermez, J. Unknown. “HIV/AIDS Prevention through
National AIDS Program. 2006. HIV/AIDS Biological and Outreach to Vulnerable Populations in Beirut,
Behavioral Surveillance Survey. Summary report. Lebanon.” Final report. Lebanon National AIDS
Program, Lebanon.
El-Ghazzawi, E., G. Hunsmann, and J. Schneider. 1987.
“Low Prevalence of Antibodies to HIV-1 and HTLV-I Hermez, J., E. Aaraj, O. Dewachi, and N. Chemaly.
in Alexandria, Egypt.” AIDS Forsch 2: 639. Unknown. “HIV/AIDS Prevention among Vulnerable
Groups in Beirut, Lebanon.” Lebanon National AIDS
El-Ghazzawi, E., L. Drew, L. Hamdy, E. El-Sherbini, Sel D. Program, PowerPoint presentation.
Sadek, and E. Saleh. 1995. “Intravenous Drug Addicts:
A High Risk Group for Infection with Human Imani, R., A. Karimi, R. Rouzbahani, and A. Rouzbahani.
Immunodeficiency Virus, Hepatitis Viruses, Cytomegalo 2008. “Seroprevalence of HBV, HCV and HIV
Virus and Bacterial Infections in Alexandria Egypt.” J Infection among Intravenous Drug Users in Shahr-e-
Egypt Public Health Assoc 70: 127–50. Kord, Islamic Republic of Iran.” East Mediterr Health J
14: 1136–41.
El-Sayed, N., M. Abdallah, A. Abdel Mobdy, A. Abdel
Sattar, E. Aoun, F. Beths, G. Dallabetta, M. Rakha, C. Ingold, R. 1994. “Rapid Assessment on Illicit Drug Use in
Soliman, and N. Wasef. 2002. “Evaluation of Selected Great Beirut.” UNDCP.
Reproductive Health Infections in Various Egyptian Iqbal, J., and N. Rehan. 1996. “Sero-Prevalence of HIV:
Population Groups in Greater Cairo.” MOHP, Six Years’ Experience at Shaikh Zayed Hospital,
IMPACT/FHI/USAID. Lahore.” J Pak Med Assoc 46: 255–58.
Elshimi, T., M. Warner-Smith, and M. Aon. 2004. Iqbal, N. 2000. “Substance Dependence: A Hospital
“Blood-Borne Virus Risks of Problematic Drug Users Based Survey.” Saudi Med J 21: 51–57.
in Greater Cairo.” UNAIDS and UNODC, Geneva.
Iran Center for Disease Management. 2005. “AIDS/HIV
Emmanuel, F., S. Akhtar, A. Attarad, and C. Kamran. Surveillance Report.” Ministry of Health.
2004. “HIV Risk Behavior and Practices among
Heroin Addicts in Lahore, Pakistan.” Southeast Asian J ———. 2006. “Treatment and Medical Education.”
Trop Med Public Health 35: 940–48. Islamic Republic of Iran HIV/AIDS situation and
response analysis.
Emmanuel, F., and M. Fatima. 2008. “Coverage to Curb
the Emerging HIV Epidemic among Injecting Drug Jahani, M. R., P. Kheirandish, M. Hosseini, H. Shirzad, S.
Users in Pakistan: Delivering Prevention Services A. Seyedalinaghi, N. Karami, P. Valiollahi, M. Mohraz,
Where Most Needed.” Int J Drug Policy 19 Suppl 1: and W. McFarland. 2009. “HIV Seroconversion
S59–64. among Injection Drug Users in Detention, Tehran,
Iran.” AIDS 23: 538–40.
Farhoudi, B., A. Montevalian, M. Motamedi, M. M.
Khameneh, M. Mohraz, M. Rassolinejad, S. Jafari, P. Jenkins, C. 2006. “Report on Sex Worker Consultation
Afshar, I. Esmaili, and L. Mohseni. 2003. “Human in Iran.” Sponsored by UNAIDS and UNFPA, Dec
Immunodeficiency Virus and HIV-Associated 2–18, 2006.
Tuberculosis Infection and Their Risk Factors in Jenkins, C., and D. A. Robalino. 2003. HIV in the Middle
Injecting Drug Users in Prison in Iran.” East and North Africa: The Cost of Inaction. Orientations
Gerberding, J. L. 1995. “Management of Occupational in Development Series, World Bank.
Exposures to Blood-Borne Viruses.” N Engl J Med 332: Khani, M., and M. M. Vakili. 2003. “Prevalence and Risk
444–51. Factors of HIV, Hepatitis B Virus, and Hepatitis C
Gheiratmand, R., R. Navipour, M. R. Mohebbi, and A. K. Virus Infections in Drug Addicts among Zanjan
Mallik. 2005. “Uncertainty on the Number of Prisoners.” Arch Iranian Med 6: 1–4.
26 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. Mostashari, G., UNODC (United Nations Office on Drugs
Vermund. 1997. “HIV/AIDS and Its Risk Factors in and Crime), and M. Darabi. 2006. “Summary of the
Pakistan.” AIDS 11: 843–48. Iranian Situation on HIV Epidemic.” NSP Situation
Kheirandish, P., S. SeyedAlinaghi, M. Hosseini, M. Analysis.
Jahani, H. Shirzad, M. Foroughi, M. Seyed Ahmadian, Narenjiha, H., H. Rafiey, A. Baghestani, et al. 2005.
H. Jabbari, M. Mohraz, and W. McFarland. 2009. “Rapid Situation Assessment of Drug Abuse and Drug
“Prevalence and Correlates of HIV Infection among Dependence in Iran.” DARIUS Institute (draft ver-
Male Injection Drug Users in Detention, Tehran, sion, in Persian).
Iran.” Unpublished. Nassirimanesh, B. 2002. “Proceedings of the Abstract for
Kilani, B., L. Ammari, C. Marrakchi, A. Letaief, M. the Fourth National Harm Reduction Conference.”
Chakroun, M. Ben Jemaa, H. T. Ben Aissa, F. Kanoun, Harm Reduction Coalition, Seattle, USA.
and T. Ben Chaabene. 2007. “Seroepidemiology of Neaigus, A. 1998. “The Network Approach and
HCV-HIV Coinfection in Tunisia.” Tunis Med 85: 121–23. Interventions to Prevent HIV among Injection Drug
Kuo, I., S. ul-Hasan, N. Galai, D. L. Thomas, T. Zafar, M. Users.” Public Health Rep 113 Suppl 1: 140–50.
A. Ahmed, and S. A. Strathdee. 2006. “High HCV Neaigus, A., S. R. Friedman, R. Curtis, D. C. Des Jarlais,
Seroprevalence and HIV Drug Use Risk Behaviors R. T. Furst, B. Jose, P. Mota, B. Stepherson, M.
among Injection Drug Users in Pakistan.” Harm Reduct Sufian, T. Ward, et al. 1994. “The Relevance of Drug
J 3: 26. Injectors’ Social and Risk Networks for Understanding
Lau, J. T., J. Thomas, and C. K. Lin. 2002. “HIV-Related and Preventing HIV Infection.” Soc Sci Med 38: 67–78.
Behaviours among Voluntary Blood Donors in Hong Neaigus, A., M. Miller, S. R. Friedman, D. L. Hagen, S. J.
Kong.” AIDS Care 14: 481–92. Sifaneck, G. Ildefonso, and D. C. des Jarlais. 2001.
Mathers, B. M., L. Degenhardt, B. Phillips, L. Wiessing, “Potential Risk Factors for the Transition to Injecting
M. Hickman, S. A. Strathdee, A. Wodak, S. Panda, M. among Non-Injecting Heroin Users: A Comparison of
Tyndall, A. Toufik, and R. P. Mattick. 2008. “Global Former Injectors and Never Injectors.” Addiction 96:
Epidemiology of Injecting Drug Use and HIV among 847–60.
People Who Inject Drugs: A Systematic Review.” Njoh, J., and S. Zimmo. 1997a. “Prevalence of Antibodies
Lancet 372: 1733–45. to Hepatitis C Virus in Drug-Dependent Patients in
Mayhew, S., M. Collumbien, A. Qureshi, L. Platt, N. Jeddah, Saudi Arabia. East Afr Med J 74: 89–91.
Rafiq, A. Faisel, N. Lalji, and S. Hawkes. 2009. Njoh, J., and S. Zimmo. 1997b. “The Prevalence of
“Protecting the Unprotected: Mixed-Method Research Human Immunodeficiency Virus among Drug-
on Drug Use, Sex Work and Rights in Pakistan’s Fight Dependent Patients in Jeddah, Saudi Arabia.” J Subst
against HIV/AIDS.” Sex Transm Infect 85 Suppl 2: Abuse Treat 14: 487–88.
ii31–36. Oman MOH (Ministry of Health). 2006. “HIV Risk
Mimouni, B., and N. Remaoun. 2006. “Etude du Lien among Heroin and Injecting Drug Users in Muscat,
Potentiel entre l’Usage Problématique de Drogues et Oman.” Quantitative survey, preliminary data.
le VIH/SIDA en Algérie 2004–2005.” Ministry of Othman, B. M., and F. S. Monem. 2002. “Prevalence of
Higher Education, Algeria. Hepatitis C Virus Antibodies among Intravenous Drug
Ministry of Health and Medical Education of Iran. 2004. Abusers and Prostitutes in Damascus, Syria.” Saudi
AIDS/HIV Surveillance Report, Fourth Quarter. Tehran. Med J 23: 393–95.
Mishwar. 2008. “An Integrated Bio-Behavioral Pakistan National AIDS Control Program. 2005a. HIV
Surveillance Study among Four Vulnerable Groups in Second Generation Surveillance in Pakistan. National
Lebanon: Men Who Have Sex with Men; Prisoners; Report Round 1. Ministry of Health, Pakistan, and
Commercial Sex Workers and Intravenous Drug Canada-Pakistan HIV/AIDS Surveillance Project.
Users.” Internal document, final report, American ———. 2005b. “Pilot Study in Karachi & Rawalpindi.”
University of Beirut and World Bank, Beirut, Ministry of Health Canada-Pakistan HIV/AIDS
Lebanon. Surveillance Project, Integrated Biological &
Mohammad Alizadeh, A. H., S. M. Alavian, K. Jafari, and Behavioral Surveillance 2004–5.
N. Yazdi. 2003. “Prevalence of Hbs Ag, Hc Ab & Hiv ———. 2005c. National Study of Reproductive Tract and
Ab in the Addict Prisoners of Hammadan Prison Sexually Transmitted Infections: Survey of High Risk Groups
(Iran, 1998).” Journal of Research in Medical Sciences 7: in Lahore and Karachi. Ministry of Health, Pakistan.
311–13.
———. 2006–7. HIV Second Generation Surveillance in
Mojtahedzadeh, V., N. Razani, M. Malekinejad, M. Pakistan. National Report Round II. Ministry of
Vazirian, S. Shoaee, M. B. Saberi Zafarghandi, A. L. Health, Pakistan, and Canada-Pakistan HIV/AIDS
Hernandez, and J. S. Mandel. 2008. “Injection Drug Surveillance Project.
Use in Rural Iran: Integrating HIV Prevention into ———. 2008. HIV Second Generation Surveillance in
Iran’s Rural Primary Health Care System.” AIDS Behav Pakistan. National Report Round III. Ministry of
12: S7–12. Health, Pakistan, Canada-Pakistan HIV/AIDS
Morocco MOH (Ministry of Health). 2007. Surveillance Surveillance Project.
sentinelle du VIH, résultats 2006 et tendances de la séro- Parviz, S., Z. Fatmi, A. Altaf, J. B. McCormick, S. Fischer-
prévalence du VIH. Hoch, M. Rahbar, and S. Luby. 2006. “Background
———. Unknown. “Situation épidémiologique actuelle Demographics and Risk Behaviors of Injecting Drug
du VIH/SIDA au Maroc.” Users in Karachi, Pakistan.” Int J Infect Dis 10: 364–71.
28 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Todd, C. S., A. M. Abed, S. A. Strathdee, P. T. Scott, B. Westermeyer, J. 1976. “The Pro-Heroin Effects of Anti-
A. Botros, N. Safi, and K. C. Earhart. 2007. “HIV, Opium Laws in Asia.” Arch Gen Psychiatry 33: 1135–39.
Hepatitis C, and Hepatitis B Infections and Associated Wodak, A. 1997. “Report to WHO/EMRO regarding
Risk Behavior in Injection Drug Users, Kabul, Control of HIV among and from Injecting Drug Users
Afghanistan.” Emerg Infect Dis 13: 1327–31. in the Islamic Republic of Iran.” Unpublished.
Todd, C. S., N. Safi, and S. A. Strathdee. 2005. “Drug Use World Bank. 2006. HIV/AIDS in Afghanistan. World Bank,
and Harm Reduction in Afghanistan.” Harm Reduct J South Asia Region (SAR).
2: 13.
———. 2008. “Mapping and Situation Assessment of
UNAIDS. 2008. “Notes on AIDS in the Middle East and Key Populations at High Risk of HIV in Three Cities of
North Africa.” RST, MENA. Afghanistan.” Human Development Sector, SAR
UNAIDS and WHO. 2001. AIDS Epidemic Update 2001. AIDS Team, World Bank.
Geneva. Xiao, Y., S. Kristensen, J. Sun, L. Lu, and S. H. Vermund.
———. 2002a. AIDS Epidemic Update 2002. Geneva. 2007. “Expansion of HIV/AIDS in China: Lessons
from Yunnan Province.” Soc Sci Med 64: 665–75.
———. 2002b. “Epidemiological Fact Sheet on HIV/
AIDS and Sexually Transmitted Infections, 2002 Zafar, T., H. Brahmbhatt, G. Imam, S. ul Hassan, and S.
Update.” Libya. Geneva. A. Strathdee. 2003. “HIV Knowledge and Risk
Behaviors among Pakistani and Afghani Drug Users
———. 2003. AIDS Epidemic Update 2003. Geneva.
in Quetta, Pakistan.” J Acquir Immune Defic Syndr 32:
———. 2005. AIDS Epidemic Update 2005. Geneva. 394–98.
———. 2007. AIDS Epidemic Update 2007. Geneva. Zali, M. R., R. Aghazadeh, A. Nowroozi, and H. Amir-
United Nations Drug Control Programme. 2002. “Drug Rasouly. 2001. “Anti-HCV Antibody among Iranian
Abuse in Pakistan.” Results from the Year 2000 IV Drug Users: Is It a Serious Problem?” Arch Iranian
National Assessment. Global Assessment Programme Med 4: 115–19.
on Drug Abuse, Narcotics Control Division A-NFGoP. Zamani, S., S. Ichikawa, B. Nassirimanesh, M. Vazirian,
UNODC (United Nations Office for Drugs and Crime). K. Ichikawa, M. M. Gouya, P. Afshar, M. Ono-Kihara,
2003. Afghanistan: Opium Survey 2003. UNODC-Crop S. M. Ravari, and M. Kihara. 2007. “Prevalence and
Monitoring. Correlates of Hepatitis C Virus Infection among
Injecting Drug Users in Tehran.” Int J Drug Policy 18:
———. 2004. World Drug Report. 359–63.
———. 2005a. World Drug Report 2005, Volume I: Analysis. Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian, B.
———. 2005b. World Drug Report, Volume II: Statistics. Nassirimanesh, M. Ono-Kihara, S. M. Ravari, A.
———. 2007. World Drug Report 2007. Safaie, and S. Ichikawa. 2006. “High Prevalence of
HIV Infection Associated with Incarceration among
UNODCP (United Nations Office for Drug Control and Community-Based Injecting Drug Users in Tehran,
Crime Prevention) and UNAIDS. 1999. “Baseline Iran.” J Acquir Immune Defic Syndr 42: 342–46.
Study of the Relationship between Injecting Drug
Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian, M.
Use, HIV and Hepatitis C among Male Injecting Drug
Ono-Kihara, E. M. Razzaghi, and S. Ichikawa. 2005.
Users in Lahore.” UNDCP and UNAIDS, Islamabad.
“Prevalence of and Factors Associated with HIV-1
———. 2002. “Global Illicit Drug Trends.” New York. Infection among Drug Users Visiting Treatment
Ur Rehman, N., F. Emmanuel, and S. Akhtar. 2007. “HIV Centers in Tehran, Iran.” AIDS 19: 709–16.
Transmission among Drug Users in Larkana, Zamani, S., M. Vazirian, B. Nassirimanesh, E. M.
Pakistan.” Trop Doct 37: 58–59. Razzaghi, M. Ono-Kihara, S. Mortazavi Ravari, M. M.
Watts, D. M., N. T. Constantine, M. F. Sheba, M. Kamal, Gouya, and M. Kihara. 2008. “Needle and Syringe
J. D. Callahan, and M. E. Kilpatrick. 1993. Sharing Practices among Injecting Drug Users in
“Prevalence of HIV Infection and AIDS in Egypt over Tehran: A Comparison of Two Neighborhoods, One
Four Years of Surveillance (1986–1990).” J Trop Med with and One without a Needle and Syringe Program.”
Hyg 96: 113–17. AIDS Behav DOI 10.1007/s10461-008-9404-2.
This chapter focuses on the biological evidence this population. This has been confirmed because
for the extent of human immunodeficiency virus recent data have shown some rapidly rising epi-
(HIV) spread among men who have sex with men demics among MSWs and hijras in Pakistan.5
(MSM), the behavioral evidence for sexual and There is also a pattern of increasing HIV preva-
injecting risk practices among this population lence among MSM in other regions with a simi-
group, and the context of homosexuality in the lar sociocultural background, such as in
Middle East and North Africa (MENA). Indonesia in Southeast Asia.6
31
Table 3.1 HIV Prevalence among MSM in MENA
medieval times, the regularity and apparent more complex and intertwined and there is a full
tolerance of male same-sex relations in the Arab spectrum between these two distinctions.13
and Islamic world were viewed in the West as a Drawing on the experience in India, gender
sign of moral decadence.11 segregation, delayed marriage, difficulty in
There are no reliable estimates of the number accessing females for sex, and overcrowded liv-
of MSM in MENA. “Ever engaging” in anal sex is ing conditions can contribute to casual anal
probably a poor definition for MSM in the context same-sex contacts.14 It is possibly not uncom-
of this region. Male same-sex sexual behavior in mon for adolescent boys to have sex with each
MENA should not be understood in terms of the other,15 for older men to pursue sex with boys,16
Western paradigm of rigid distinction between and for married men to have extramarital
homosexuals and heterosexuals despite recent
Westernization of lifestyles.12 Sexual identities are
13
Ibid.
14
Pappas et al., “Males Who Have Sex with Males.”
11 15
Abukhalil, “Gender Boundaries and Sexual Categories in the Arab World.” Busulwa, “HIV/AIDS Situation Analysis Study.”
12 16
Ibid. Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.”
32 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
homosexual relationships.17 Peer pressure at a and genital ulcer disease among male prisoners was
young age and family instability were identified associated with same-sex anal sex.28
as reasons for engaging in same-sex anal sex and In Sudan, 2% of males in mainly rural popu-
male sex work in Sudan.18 lations reported sex with males.29 Among truck
Male same-sex sexual behavior in MENA drivers, 0.2% reported having had sexual rela-
extends well beyond the concept of an active tions with both sexes, and 0.5% reported hav-
MSM population and takes multiple forms. In ing had sex only with males.30 Among prisoners,
Pakistan, there is a complex tapestry of MSM 2.2% reported having sex with males.31 Taking
activity including hijras or khusras (transvestites advantage of boys and unemployed males for
who dress as women and often practice male anal sex has also been reported in Sudan.32 In
sex work), khotkis (biological males who dress as the Republic of Yemen, it is estimated that there
men but have “female soul” and feminized traits are 25,000 MSM, although there is no basis pro-
and who practice male sex work), banthas (bio- vided for this estimate.33
logical males with a male gender identity who There are also few estimates of the preva-
often practice male sex work), zenanas (she- lence of commercial sex among men. In Pakistan,
males), maalishias (masseurs and mainly boys), there were an estimated average of 2.3 MSWs
and chavas (MSM who switch sex roles) among and 2.4 HSWs per 1,000 adult men across differ-
other forms.19 ent cities.34 The range of prevalence varied from
Various studies have documented same-sex 1 to 4.8 per 1,000 adult men for MSWs and
anal sex among MENA populations. In the Arab 0.4 to 3.7 per 1,000 adult men for HSWs.35
Republic of Egypt, 77.4% of male street children These data on male same-sex sexual behavior
reported ever having sex with males and 37.1% suggest that the prevalence of homosexuality in
reported being forced to have sex with males.20 In MENA is comparable to global levels of a few
Lebanon, 8.4% of prisoners reported anal sex with percentage points of the male population engag-
a man in prison.21 In the Islamic Republic of Iran, ing in anal sex with males.36
29% of single, sexually active males in Tehran
reported homosexual contacts with no definition
provided for the kind of contacts.22 In Pakistan, MEN WHO HAVE SEX WITH MEN
11.3% of truck drivers reported ever having sex AND RISK BEHAVIOR
with an MSW, and 49.3% reported ever having
sex with a man.23 In another study, 21.9% of This section discusses risk behaviors and prac-
truck drivers had sex with a male or hijra.24 tices in relation to HIV among MSM, including
Among truck drivers attending an STD (sexually sexual behavior and partnership formation,
transmitted disease) clinic, 53% reported anal sex commercial sex, condom use, heterosexual sex,
with males.25 Among prisoners, 26% reported and injecting drug use. A few studies have also
sexual relations with other males prior to documented substantial levels of sexually trans-
incarceration,26 and among migrants, 1.7% reported mitted infections (STIs) among MSM, suggest-
ever having sex with a man.27 History of urethritis ing potential for future HIV epidemics (see
chapter 10 on STIs).
17
Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.”
18
Elrashied, “Generating Strategic Information.”
19 28
Hawkes et al., “HIV and Other Sexually Transmitted Infections”; Akhtar and Luby, “Risk Behaviours.”
29
Collumbien et al., “Understanding the Context”; Rajabali et al., “HIV SNAP, UNICEF, and UNAIDS, “Baseline Study.”
30
and Homosexuality in Pakistan.” Farah and Hussein, “HIV Prevalence.”
20 31
Egypt MOH and Population National AIDS Program, HIV/AIDS Assal, “HIV Prevalence.”
32
Biological and Behavioral Surveillance Survey. Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
21 33
Mishwar, “An Integrated Bio-Behavioral Surveillance Study.” Al-Serouri, “Assessment of Knowledge.”
22 34
Ministry of Health and Medical Education of Iran, “Treatment and Pakistan National AIDS Control Program, HIV Second Generation
Medical Education.” Surveillance (Round I).
23 35
Agha, “Potential for HIV Transmission.” Ibid.
24 36
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.” McFarland and Caceres, “HIV Surveillance”; W. McFarland, personal
25
Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.” communication (2008); UNAIDS, Epidemiological Software and Tools,
26
Baqi et al., “HIV Antibody Seroprevalence.” http://www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/
27
Faisel and Cleland, “Study of the Sexual Behaviours.” epi_software2007.asp.; Mercer et al., “Behaviourally Bisexual Men.”
34 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
31.1,66 25.8,67 and 20.368 clients per month. In 34.6%,86 and 31.8%87 of MSWs; 21.1%,88
these same studies, HSWs reported an average of 32.9%,89 and 44.0%90 of HSWs; and 40%91 of
2.5,69 2.5,70 and 2.5971 clients per working day, and hijras. Close to half of the MSWs and HSWs used
an average of 36.3,72 32.0,73 and 49.0774 clients per alcohol or drugs during sex in the last six months92
month, respectively. In another study from or in the last month.93 Hijras performed oral sex
Pakistan, different groups of MSWs reported a with 39% of their one-time clients and 42% of
mean of 3.2 to 7.0 clients in the last week and a their regular clients.94 Selling blood for money in
mean of 1.8 to 4.0 new clients in the last week.75 the last six months was reported by 2.4% of
The mean number of years in sex work was report- MSWs and 1.6% of HSWs.95
ed to be between 6.7 and 12.5 years.76 Hijras con- In further evidence from Pakistan, MSWs
stitute about one-quarter of all male sex workers in reported four clients in the last week and 28%
Pakistan.77 Their clients are reported to be business- reported having sex with a nonpaying male in
men, drivers, students, police/military, rickshaw the last month.96 Twenty-seven percent to 32%
drivers, and the unemployed.78 of different groups of MSWs also reported pay-
Also from studies in Pakistan, 51% of hijras ing to have sex with other males or hijras in the
reported new clients in the past week with a medi- last month.97 Hijras reported four partners in the
an of one, and 68% reported regular clients with a last week,98 and 95% of HSWs have had sex
median of three.79 Payment to anyone for anal sex with other hijras.99 Seventeen percent to 19% of
was reported in several studies by 20%,80 10%,81 MSWs reported selling blood for profit.100 Most
and 4.5%82 of MSWs; 21.1%83 of HSWs; and hijras (84%) in one study were found to have
15%84 of hijras. Noncommercial partners in the last engaged in sex work within the last month and
month were reported in studies by 37.7%,85 99% within the last year.101 Increasingly among
MSWs and HSWs in Pakistan, clients are found
by roaming around in public places such as bus
66
Pakistan National AIDS Control Program, HIV Second Generation stops and markets, or through mobile phones
Surveillance (Round I).
67 and client referral, instead of through the tradi-
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round II). tional pimp or a guru (the leader or patron of a
68
Pakistan National AIDS Control Program, HIV Second Generation small group of hijras).102
Surveillance (Round III).
69
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I).
70
Pakistan National AIDS Control Program, HIV Second Generation
86
Surveillance (Round II). Pakistan National AIDS Control Program, HIV Second Generation
71
Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II).
87
Surveillance (Round III). Pakistan National AIDS Control Program, HIV Second Generation
72
Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round III).
88
Surveillance (Round I). Pakistan National AIDS Control Program, HIV Second Generation
73
Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I).
89
Surveillance (Round II). Pakistan National AIDS Control Program, HIV Second Generation
74
Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II).
90
Surveillance (Round III). Pakistan National AIDS Control Program, HIV Second Generation
75
Hawkes et al., “HIV and Other Sexually Transmitted Infections.” Surveillance (Round III).
76 91
Ibid. Khan et al., “Correlates and Prevalence of HIV.”
77 92
Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I); Khan et al., “Correlates and Prevalence of HIV.” Surveillance (Rounds I, II, and III).
78 93
Khan et al., “Correlates and Prevalence of HIV.” Hawkes et al., “HIV and Other Sexually Transmitted Infections.”
79 94
Ibid. Khan et al., “Correlates and Prevalence of HIV.”
80 95
Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I). Surveillance (Round III).
81 96
Pakistan National AIDS Control Program, HIV Second Generation Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.”
97
Surveillance (Round II). Ibid.
82 98
Pakistan National AIDS Control Program, HIV Second Generation Ibid.
99
Surveillance (Round III). Khan et al., “Correlates and Prevalence of HIV.”
83 100
Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, “Pilot Study in Karachi &
Surveillance (Round I). Rawalpindi.”
84 101
Khan et al., “Correlates and Prevalence of HIV.” Khan et al., “Correlates and Prevalence of HIV.”
85 102
Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I). Surveillance (Rounds I, II, and III).
36 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
In Sudan, 50.9% of MSM used condoms every MSM reported ever being married, 87.7% reported
time or almost every time, 58.5% used a condom having female partners in the last six months, and
during last sex with a commercial sex partner, 14.5% reported living currently with a female part-
48.5% used a condom during last sex with a non- ner.143 In Lebanon, 52.2% of MSM reported ever
commercial partner, and 72.9% had ever used having a female sex partner.144
condoms. Among these MSM, 89.4% used con- In Pakistan, three studies reported, respec-
doms when they had sex with females during the tively, that 14.7%,145 12.4%,146 and 10.5%147 of
last six months.132 Over 50% of MSM in Sudan MSWs, and 15.3%,148 17.4%,149 and 12.2%150 of
were not aware of the risk of HIV transmission in HSWs were married. In another study, 8% of hijras
unprotected anal intercourse and 85.3% did not were married and 20% have had sex with a
use condoms because they were not available.133 woman.151 Also in Pakistan, a study reported that
In Tunisia, 46.4% of MSM used condoms during 10%–19% of different groups of MSWs and
last nonpaid sex; 19.7% of MSM used condoms HSWs were married.152 Paying a female for sex in
consistently during nonpaid sex134; 53.7% of the last month was reported by 42.7% of MSWs
MSM used condoms consistently during sex with in one study,153 and 12%–39% of MSWs in
females; 55.4% of MSM used condoms during last another study.154 Nine percent to 24% of MSWs
paid sex; and 4.3% used condoms consistently had also had sex with a nonpaying female in the
during paid anal sex.135 Further data on condom last month.155 In studies in Sudan, 22.9% of
use among MSM can be found in table 8.1. MSM reported ever being married,156 17.3%
The evidence summarized above suggests reported currently being married,157 and
that the majority of anal same-sex acts in MENA 61.2%158 and 69.2%159 reported ever having
are unprotected against HIV. sex with a female.160 In Tunisia, 31.1% of MSM
reported having sex with females.161
Engagement of MSM in heterosexual Female sexual partners of MSM are vulnerable
risk behavior to HIV. The presence of heterosexual marriage
among MSM, and generally sexual contacts with
Several studies have documented a considerable
female partners, puts these partners at risk of HIV
overlap between homosexual sex and heterosexual
infection.162
sex in MENA, thereby allowing HIV to spread
between homosexual and heterosexual risk net-
works. In Egypt, ever having sex with FSWs was 143
Eftekhar et al., “Bio-Behavioural Survey.”
reported by 73.3% of MSM older than 25 years136 144
Hermez et al., “HIV/AIDS Prevention among Vulnerable Groups.”
145
and 29.3% of younger MSM.137 Forty-four percent Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I).
of MSM were found to be bisexually active.138 Also 146
Pakistan National AIDS Control Program, HIV Second Generation
in Egypt, studies reported current marriage to a Surveillance (Round II).
147
female partner by 5.6%139 and 30%140 of MSM, Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round III).
ever being married was reported by 13%,141 and 148
Pakistan National AIDS Control Program, HIV Second Generation
ever having sex with a female was reported by Surveillance (Round I).
149
56.2%.142 In the Islamic Republic of Iran, 51.8% of Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round II).
150
Pakistan National AIDS Control Program, HIV Second Generation
132
Elrashied, “Generating Strategic Information.” Surveillance (Round III).
133 151
Elrashied, “Prevalence, Knowledge and Related Risky Sexual Khan et al., “Correlates and Prevalence of HIV.”
152
Behaviours.” Hawkes et al., “HIV and Other Sexually Transmitted Infections.”
134 153
Hsairi and Ben Abdallah, “Analyse de la situation de vulnérabilité.” Pakistan National AIDS Control Program, HIV Second Generation
135
Ibid. Surveillance (Round III).
136 154
El-Rahman, “Risky Behaviours for HIV/AIDS Infection”; El-Sayyed, Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.”
155
Kabbash, and El-Gueniedy, “Risk Behaviours.” Ibid.
137 156
El-Sayyed, Kabbash, and El-Gueniedy, “Risk Behaviours.” Elrashied, “Generating Strategic Information.”
138 157
El-Sayed et al., “Knowledge, Attitude, and Practice.” Ibid.
139 158
Egypt MOH and Population National AIDS Program, HIV/AIDS Ibid.
159
Biological and Behavioral Surveillance Survey. Anonymous, “Improving HIV/AIDS Response.”
140 160
El-Sayed et al., “Knowledge, Attitude, and Practice.” Elrashied, “Generating Strategic Information.”
141 161
Egypt MOH and Population National AIDS Program, HIV/AIDS Hsairi and Ben Abdallah, “Analyse de la situation de vulnérabilité.”
162
Biological and Behavioral Surveillance Survey. Jenkins, “Male Sexual Diversity and Culture”; Khilji, “Combating HIV/
142
Ibid. AIDS amongst Zenana Youth.”
38 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
protects fully from HIV infection and most MSM BIBLIOGRAPHY
believed that the risk of contracting HIV through
Abukhalil, A. 1997. “Gender Boundaries and Sexual
anal sex was smaller than that of vaginal sex.196 Categories in the Arab World.” Fem Issues 15: 91–104.
Abu-Nuwwas, Al-Hasan. 1962. Diwan Abu Nuwwas
ANALYTICAL SUMMARY (Poetry Collection of Abu-Nuwwas). Dar Sadir, Beirut.
Agha, S. 2000. “Potential for HIV Transmission among
Although evidence is still limited, there has Truck Drivers in Pakistan.” AIDS 14: 2404–6.
been a considerable increase in knowledge relat- Akhtar, S., and S. P. Luby. 2002. “Risk Behaviours
ing to MSM and HIV in MENA in the last few Associated with Urethritis and Genital Ulcer Disease
in Prison Inmates, Sindh, Pakistan.” East Mediterr
years. MSM are the most hidden and stigma- Health J 8: 776–86.
tized risk group of all HIV risk groups. Alami, K. 2009. “Tendances récentes de l’épidémie à
Nevertheless, homosexuality exists in this region VIH/SIDA en Afrique du nord.” Presentation,
at levels comparable to those in other regions, Research and AIDS Workshop in North Africa,
Marrakech, Morocco.
with a small percentage of the male population
engaging in anal sex with males. Al-Jahiz. 1965. “Kitab Mufakharat Al-Jawari wa-l-
Ghilman.” In Harun, Abd-us-Salam Muhammad, ed.,
HIV has already been documented to be Rasa’il Al-Jahiz (Letters of Al-Jahiz), Vol. 2. Maktabat
spreading among MSM, with apparently a rap- Al-Khanj, Cairo, Egypt.
idly rising epidemic in at least one country Al-Serouri, A. W. 2005. “Assessment of Knowledge,
(Pakistan). HIV prevalence among MSM is Attitudes and Beliefs about HIV/AIDS among Young
People Residing in High Risk Communities in Aden
already at considerable levels in several other Governatore, Republic of Yemen.” Society for the
countries, but data are still too limited to docu- Development of Women & Children (SOUL),
ment the trend. Data on risk behaviors indicate Education, Health, Welfare; United Nations Children’s
Fund, Yemen Country Office, HIV/AIDS Project.
high levels of sexual risk behavior such as multi-
ple sexual partnerships of different kinds, low Anonymous. 2007. “Improving HIV/AIDS Response
among Most at Risk Population in Sudan.” Orientation
condom use, and high prevalence of sex work Workshop, April 16.
among MSM. MSM risk behaviors overlap con- Assal, M. 2006. “HIV Prevalence, Knowledge, Attitude,
siderably with heterosexual sex and injecting Practices, and Risk Factors among Prisoners in
drug risk behaviors. Levels of STIs prevalence are Khartoum State, Sudan.”
substantial, suggesting epidemic potential for As-Siyuti. Tarikh Al-Khulafa’ (History of the Caliphs).
Ahmad Al-Babi al-Halabi, 1305 A.H., Cairo.
HIV. Levels of comprehensive HIV knowledge
vary across the region, with both high and low Ati, H. A. 2005. “HIV/AIDS/STIs Social and Geographical
Mapping of Prisoners, Tea Sellers and Commercial
levels being documented in different settings. Sex Workers in Port Sudan Town, Red Sea State.”
The MSM risk context suggests the possibility Draft 2, Ockenden International, Sudan.
of concentrated HIV epidemics among MSM as Baqi, S., N. Nabi, S. N. Hasan, A. J. Khan, O. Pasha, N.
well as HIV infections among their female part- Kayani, R. A. Haque, I. U. Haq, M. Khurshid, S.
Fisher-Hoch, S. P. Luby, and J. B. McCormick. 1998.
ners over the next decade. Indeed, there may “HIV Antibody Seroprevalence and Associated Risk
already be concentrated HIV epidemics among Factors in Sex Workers, Drug Users, and Prisoners in
MSM in several MENA countries, but definitive Sindh, Pakistan.” J Acquir Immune Defic Syndr Hum
Retrovirol 18: 73–79.
and conclusive data are lacking. There is an
urgent need for HIV surveillance to better Baqi, S., S. A. Shah, M. A. Baig, S. A. Mujeeb, and A.
Memon. 1999. “Seroprevalence of HIV, HBV, and
understand the transmission dynamics and to Syphilis and Associated Risk Behaviours in Male
plan and implement more effective prevention Transvestites (Hijras) in Karachi, Pakistan.” Int J STD
and care services among MSM in MENA. AIDS 10: 300–04.
The key to preventing a considerable HIV ———. 2006. “Seroprevalence of HIV, HBV and Syphilis
and Associated Risk Behaviours in Male Transvestites
epidemic among MSM is expanding preven- (Hijras) in Karachi, Pakistan.” J Pak Med Assoc 56:
tion and treatment efforts, such as condom S17–21.
distribution, counseling, HIV testing, and Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan,
social and medical services. M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, K.
Qayum, P. Girault, E. Pisani, and I. Thaver. 2007.
“HIV Risk in Karachi and Lahore, Pakistan: An
Emerging Epidemic in Injecting and Commercial Sex
196
Elrashied, “Generating Strategic Information.” Networks.” Int J STD AIDS 18: 486–92.
40 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Mercer, C. H., G. J. Hart, A. M. Johnson, and J. A. HIV/AIDS in India: The Hidden Epidemic.” AIDS
Cassell. 2009. “Behaviourally Bisexual Men as a Public Policy Journal 16: 4–17.
Bridge Population for HIV and Sexually Transmitted Pisani, E., P. Girault, M. Gultom, N. Sukartini, J.
Infections? Evidence from a National Probability Kumalawati, S. Jazan, and E. Donegan. 2004. “HIV,
Survey.” Int J STD AIDS 20: 87–94. Syphilis Infection, and Sexual Practices among
Ministry of Health and Medical Education of Iran. 2006. Transgenders, Male Sex Workers, and Other Men
“Treatment and Medical Education.” Islamic Republic Who Have Sex with Men in Jakarta, Indonesia.” Sex
of Iran HIV/AIDS situation and response analysis. Transm Infect 80: 536–40.
Mishwar. 2008. “An Integrated Bio-Behavioral Rajabali, A., S. Khan, H. J. Warraich, M. R. Khanani, and
Surveillance Study among Four Vulnerable Groups in S. H. Ali. 2008. “HIV and Homosexuality in Pakistan.”
Lebanon: Men Who Have Sex with Men; Prisoners; Lancet Infect Dis 8: 511–15.
Commercial Sex Workers and Intravenous Drug Saleem, N. H., A. Adrien, and A. Razaque. 2008. “Risky
Users.” Internal report, American University of Beirut Sexual Behavior, Knowledge of Sexually Transmitted
and World Bank, Beirut, Lebanon. Infections and Treatment Utilization among a
Mostashari, G., UNODC (United Nations Office on Drugs Vulnerable Population in Rawalpindi, Pakistan.”
and Crime), and M. Darabi. 2006. “Summary of the Southeast Asian J Trop Med Public Health 39: 642–48.
Iranian Situation on HIV Epidemic.” NSP Situation
Schmitt, A., and J. Sofer. 1992. Sexuality and Eroticism
Analysis.
among Males in Moslem Countries. New York: Harrington
Moszynski, P. 2008. “Egyptian Doctors Who Took Part in Park Press.
Forced HIV Testing ‘Violated Medical Ethics.’” BMJ
336: 855. SNAP (Sudan National AIDS Program), UNICEF (United
Nations Children’s Fund), and UNAIDS (United
Oman MOH (Ministry of Health). 2006. “HIV Risk Nations Joint Programme on HIV/AIDS). 2005.
among Heroin and Injecting Drug Users in Muscat, “Baseline Study on Knowledge, Attitudes, and
Oman.” Quantitative survey, preliminary data. Practices on Sexual Behaviors and HIV/AIDS
Pakistan National AIDS Control Program. 2004. “Pilot Prevention amongst Young People in Selected States
Study in Karachi & Rawalpindi, Integrated Behavioral in Sudan.” HIV/AIDS KAPB Report. Projects and
and Biological Surveillance.” Ministry of Health, Research Department (AFROCENTER Group).
Pakistan, and Canada-Pakistan HIV/AIDS Surveillance Symington, A. 2008. “Egypt: Court Convicts Men for
Project. ‘Debauchery.’” HIV AIDS Policy Law Rev 13: 63–64.
———. 2005. HIV Second Generation Surveillance in
UNAIDS (United Nations Joint Programme on HIV/
Pakistan. National Report Round 1. Ministry of Health,
AIDS), and WHO (World Health Organization). 2003.
Pakistan, and Canada-Pakistan HIV/AIDS Surveillance
AIDS Epidemic Update 2003. Geneva.
Project.
———. 2006–7. HIV Second Generation Surveillance in World Bank. 2008. “Mapping and Situation Assessment
Pakistan. National Report Round II. Ministry of of Key Populations at High Risk of HIV in Three Cities
Health, Pakistan, and Canada-Pakistan HIV/AIDS of Afghanistan.” Human Development Sector, South
Surveillance Project. Asia Region (SAR) AIDS Team, World Bank,
Washington, D.C.
———. 2008. HIV Second Generation Surveillance in
Pakistan. National Report Round III. Ministry of Yousif, M. E. A. 2006. “Health Education Programme
Health, Pakistan, Canada-Pakistan HIV/AIDS among Female Sex Workers in Wad Medani Town-
Surveillance Project. Gezira State.” Grey Report, final.
Pappas, G., O. Khan, J. Wright, S. Khan, and J. O’Neill. Yuzgun, A. 1993. “Homosexuality and Police Terror in
2001. “Males Who Have Sex with Males (MSM) and Turkey.” J Homosex 24: 159–69.
This chapter focuses on the biological evidence was 14% among men who reported sexual con-
for the extent of human immunodeficiency tacts with an FSW, but was 0% among men
virus (HIV) spread among female sex workers who denied such contacts.4
(FSWs), the behavioral evidence for sexual and
injecting risk practices among this population CONTEXT OF COMMERCIAL SEX IN MENA
group, and the context of commercial sex in the
This section highlights key social, economic, and
Middle East and North Africa (MENA).1
political factors that force women to engage in sex
work in MENA. This profession should not be seen
HIV PREVALENCE AMONG FSWS
as either strictly voluntary or forced,5 and it must
There is documented evidence of some HIV be understood in terms of livelihood and gender
spread among FSWs in MENA. Table 4.1 contains perspective.6 Lack of marketable skills, low educa-
the results of the available point-prevalence sur- tional level, inability to engage in meaningful
veys conducted among FSWs. Generally speak- economic activity, lack of viable alternatives, and
ing, HIV prevalence continues to be at low levels higher income through sex work are key factors in
among FSWs in most countries, though at levels preventing FSWs from seeking other alternative
much higher than those in the general population professions and are contributing to their marginal-
(chapter 6). HIV does not appear to be well estab- ization.7 Social and economic stresses, including
lished among many commercial sex networks in drug use, divorce, legal and social restrictions on
MENA. In three countries, Djibouti, Somalia, and women’s work, family troubles leading to run-
Sudan, HIV prevalence for FSWs has reached high away girls, domestic violence, history of being
levels in at least parts of these countries, but still abused, survival while husband is in jail and
at lower levels than those found in hyperendemic unemployment, are increasingly forcing women
HIV epidemics in sub-Saharan Africa.2 to engage in sex work in MENA.8
Repeatedly in MENA, there are reports of
4
men becoming infected from FSWs. Among McCarthy, Khalid, and El Tigani, “HIV-1 Infection in Juba, Southern
Sudan.”
reported cases in Saudi Arabia, about 90% of 5
ACORD, “Socio Economic Research.”
the men who were infected with HIV hetero- 6
ACORD, “Qualitative Socio Economic Research.”
sexually received the infection from FSWs, with 7
Ati, “HIV/AIDS/STIs Social and Geographical Mapping”; ACORD,
the remaining 10% becoming infected from “Qualitative Socio Economic Research.”
8
Pakistan National AIDS Control Program, HIV Second Generation
their wives.3 HIV prevalence in Southern Sudan Surveillance in Pakistan (Rounds I and II); Razzaghi et al., “Profiles of
Risk”; Jenkins, “Report on Sex Worker Consultation in Iran”; Saleem,
1
Male sex workers (MSWs) are included among MSM. Adrien, and Razaque, “Risky Sexual Behavior”; Štulhofer and Božicevic,
2
Morison et al., “Commercial Sex and the Spread of HIV.” “HIV Bio-Behavioural Survey”; Sepehrad,”The Role of Women “; Dareini,
3
Alrajhi, Halim, and Al-Abdely, “Mode of Transmission of HIV-1.” “Rise in Iranian Prostitution”; Daher and Zayat, “A Matter of Life.”
43
Table 4.1 HIV Prevalence among FSWs in MENA
44 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 4.1 (Continued )
Economic pressures, acute poverty, and mere vival nature of some of the sex work in
survival are repeatedly cited as the main imme- MENA.12
diate factors leading women to engage in sex Family disruption leading to economic pres-
work.9 Sex work is the only source of income sure is often cited as a key cause of sex work.
for a large fraction of sex workers,10 and FSWs Failure in marriage, punishing husband or fam-
often carry the burden of supporting several ily out of grievances, and being forced by a hus-
children, husbands, parents, and other relatives, band or other male relatives to do sex work are
in addition to supporting themselves.11 The pay- commonly reported.13 FSWs often report being
ment for sex work is sometimes made not by lured into this profession by people close to
cash, but rather by consumable commodities them.14 Male pimps are often the father, hus-
such as food and clothes, highlighting the sur- band, or boyfriend of the FSW.15
9 12
Busulwa, “HIV/AIDS Situation Analysis Study”; Ati, “HIV/AIDS/STIs ACORD, “Socio Economic Research”; ACORD, “Qualitative Socio
Social and Geographical Mapping”; ACORD, “Socio Economic Economic Research.”
13
Research”; ACORD, “Qualitative Socio Economic Research”; Zargooshi, Busulwa, “HIV/AIDS Situation Analysis Study”; ACORD, “Socio
“Characteristics of Gonorrhoea.” Economic Research”; ACORD, “Qualitative Socio Economic Research”;
10
Anonymous, “Improving HIV/AIDS Response”; ACORD, “Socio Daher and Zayat, “A Matter of Life”; Syria National AIDS Programme,
Economic Research”; Syria National AIDS Programme, “HIV/AIDS “HIV/AIDS Female Sex Workers.”
14
Female Sex Workers.” Yousif, “Health Education Programme”; Syria National AIDS
11
Ati, “HIV/AIDS/STIs Social and Geographical Mapping”; ACORD, Programme, “HIV/AIDS Female Sex Workers.”
15
“Socio Economic Research”; ACORD, “Qualitative Socio Economic Soins Infirmiers et Developpement Communautaire, “Mapping for FSW
Research.” and IDU Report.”
46 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
sex work covered under other professions41; the Republic of Yemen,53and 1,500 street-based
arrangement for clients through pimps/aunty42; FSWs in Djibouti.54 In the three cities of Kabul,
reliance on older clients43; solicitation of sex at Jalalabad, and Mazar-i-Sharif in Afghanistan, there
truck stops44; FSWs accompanying truck drivers are an estimated 1,160 FSWs, including 898 in
for a whole trip45; and arranging for clients Kabul alone.55
through taxis. In the more conservative parts of Few estimates are available on the prevalence
MENA, sex work is often based at homes with of sex work among women in MENA. In three
interaction with clients through phones, such as in cities in Afghanistan, there were on average 1.9
Afghanistan.46 Increasingly mobile phones are FSWs per 1,000 women, with the highest con-
used to facilitate sex work, such as through female centration in Mazar-i-Sharif at 2.8 FSWs per
brokers in the Arab Republic of Egypt,47 or simply 1,000 women.56 In a study among hospital
by direct phone contacts with clients such as in attendees in Morocco, 0.5% reported engaging
Pakistan.48 This is leading to a larger dispersion of in sex work.57 In Pakistan, mapping has found
the FSW population into the community.49 that there are between 4.5 and 12.6 FSWs per
1,000 adult women, or between 4.2 and 11.4
FSWs per 1,000 adult men.58 In Sudan, 1.4% of
PREVALENCE OF COMMERCIAL SEX females in a mainly rural population reported
engaging in commercial sex.59 Also in Sudan,
Knowledge of the sizes of commercial sex net-
exchanging sex for money was reported by
works, including group size estimations of FSWs
0.5% of antenatal clinic (ANC) women attend-
and the proportion of men who sexually contact
ees60 and 1% of tea sellers.61
FSWs, is needed to assess the HIV epidemic
The above estimates suggest that the ratio of
potential and to estimate the resources needed
women in MENA who engage in sex work may
for HIV prevention in this priority group.
range from about 1 to 10 FSWs per 1,000 adult
women (0.1% up to 1%). This estimate is con-
FSWs risk group size estimation
sistent with the prevalence of FSWs in Indonesia
There are no reliable estimates of the number of and Malaysia, two predominantly Muslim
FSWs in MENA. Globally speaking, sex work nations, at 0.4%62 and 0.9%,63 respectively. It is
varies widely across regions and can be as high also consistent with the global range of the per-
as 7% of the female population.50 Sex workers centage of women who engage in sex work, but
are never a negligible part of the total popula- it is on the low side of this range.64
tion of a community.51
It is estimated that there are 30,000 to Clients of FSWs
60,000 FSWs in the Islamic Republic of Iran.52
Clients of sex workers come from all sectors of
It is also estimated that there are 5,000 FSWs in
society and often include military personnel,
police and other members of security forces,
41
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
42 53
Pakistan National AIDS Control Program, “Pilot Study in Karachi & Al-Serouri, “Assessment of Knowledge”; Lambert, “HIV and
Rawalpindi.” Development Challenges.”
43 54
Ibid. Rodier et al., “Trends of Human Immunodeficiency Virus.”
44 55
Farah and Hussein, “HIV Prevalence.” World Bank, “Mapping and Situation Assessment.”
45 56
Ibid. Ibid.
46 57
World Bank, “Mapping and Situation Assessment.” Chaouki et al., “The Viral Origin of Cervical Cancer.”
47 58
Jenkins and Robalino, “HIV in the Middle East and North Africa.” Pakistan National AIDS Control Program, HIV Second Generation
48
Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I); Blanchard, Khan, and Bokhari, “Variations in the
Surveillance (Round II); Hawkes et al., “HIV and Other Sexually Population Size.”
59
Transmitted Infections.” SNAP, UNICEF, and UNAIDS, “Baseline Study.”
49 60
Pakistan National AIDS Control Program, HIV Second Generation Ahmed, Antenatal.
61
Surveillance (Round II). Ahmed, Tea Sellers.
50 62
Vandepitte et al., “Estimates of the Number of Female Sex Workers.” Indonesia MOH, National Estimates of Adult HIV Infection, Indonesia.
51 63
Ibid. WHO, Consensus Report.
52 64
Ministry of Health and Medical Education of Iran, “Treatment and Blanchard, Khan, and Bokhari, “Variations in the Population Size”;
Medical Education”; Mostashari, UNODC, and Darabi, “Summary of Vandepitte et al., “Estimates of the Number of Female Sex Workers”;
the Iranian Situation on HIV Epidemic.” Blanchard et al., “Variability in the Sexual Structure.”
48 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
with another report indicating an average of was reported in the Red Sea State.106 The
nine customers per week.88 In Lebanon, FSWs demand for sex work was found to rise during
reported an average of 3.1 nonregular partners holidays, festivals, and at the end of the
and 2.1 regular partners per week, with a month.107 In Southern Sudan, FSWs reported
monthly average of 11.7 sexual partners.89 about two clients per day.108 In the Syrian Arab
Almost all FSWs (97%) in another study had Republic, 86.8% of FSWs reported one to three
more than five clients within the last month.90 clients per day.109 FSWs often report sexual
Also in Lebanon, most FSWs reported three to activity with other sexual partners beyond sex
seven clients each week.91 work such as 53.8%110 and 43.2%111 in two
In Pakistan, 7%–48% of FSWs in different studies of FSWs in Pakistan, and 57%112 in a
settings reported more than 20 clients last study in Syria.
month, and more than 80% of the FSWs Alcohol consumption is associated with higher
reported less than one paid client per day.92 The sexual risk behavior and HIV infection,113 and
median number of clients per week in another there is some evidence in MENA of alcohol and
study was three one-time clients and four regu- drug use in the context of commercial sex. In
lar clients.93 In further studies from Pakistan, Pakistan, for example, in two studies, 27.4%114
FSWs reported 4.5,94 4.6,95 and 2.696 clients per and 28.2%115 of FSWs reported taking alcohol
workday and 31.6,97 36,98 33.1,99 and 23100 or drugs in the context of sex work in the last six
clients per month. Young FSWs were found to months.
have the highest client volume.101 Another
study from Pakistan reported a mean of 5.5 cli-
Structure of commercial sex networks
ents in the past week, with a mean of 1.7 new
clients in the past week.102 This suggests that the The data on the nature of commercial sex net-
number of new clients is relatively low, with works are limited. In parts of MENA, such as in
many FSWs servicing a few regular clients.103 Egypt, FSWs do not appear to form strong net-
The mean number of years in sex work was works and do not have close ties.116 This pattern
reported to be 13.9 years.104 appears to hold true in Lebanon as well, where
In Sudan, more than half of FSWs reported FSWs have limited interaction among them-
more than two clients per day in Khartoum selves due to intense competition.117 In Southern
State,105 and an average of four clients per week Sudan, 92.8% of FSWs were working individu-
ally and not through mediators or organized sex
88
work.118 Understanding the network structure
Ministry of Health and Medical Education of Iran, “Treatment and
Medical Education.”
of sex workers and their clients is important in
89
Hermez et al., “HIV/AIDS Prevention among Vulnerable Groups.” understanding the transmission patterns of HIV
90
Mishwar, “An Integrated Bio-Behavioral Surveillance Study.”
91
Rady, “Knowledge, Attitudes and Prevalence of Condom Use.”
92 106
Pakistan National AIDS Control Program, “Pilot Study in Karachi & Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
107
Rawalpindi.” Ibid.
93 108
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.” ACORD, “Socio Economic Research.”
94 109
Pakistan National AIDS Control Program, HIV Second Generation Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.”
110
Surveillance (Round I). Pakistan National AIDS Control Program, HIV Second Generation
95
Blanchard, Khan, and Bokhari, “Variations in the Population Size.” Surveillance (Round I).
96 111
Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round II). Surveillance (Round II).
97 112
Pakistan National AIDS Control Program, HIV Second Generation Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.”
113
Surveillance (Round I). Mbulaiteye et al., “Alcohol and HIV”; Kaljee et al., “Alcohol Use”;
98
Blanchard, Khan, and Bokhari, “Variations in the Population Size.” Fisher, Bang, and Kapiga, “The Association between HIV Infection and
99
Pakistan National AIDS Control Program, HIV Second Generation Alcohol Use.”
114
Surveillance (Round II). Pakistan National AIDS Control Program, HIV Second Generation
100
Saleem, Adrien, and Razaque, “Risky Sexual Behavior.” Surveillance (Round I).
101 115
Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round I). Surveillance (Round II).
102 116
Hawkes et al., “HIV and Other Sexually Transmitted Infections.” Family Health International, “Implementing AIDS Prevention and Care
103
Ibid. (IMPACT) Project.”
104 117
Ibid. Mishwar, “An Integrated Bio-Behavioral Surveillance Study.”
105 118
ACORD, “Qualitative Socio Economic Research.” ACORD, “Socio Economic Research.”
50 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
MENA settings. Only 41%142 in Afghanistan and In Egypt, 44% of FSWs reported difficulty in
17.2%,143 28%,144 45%,145 and 45.1%146 in getting condoms and 89% reported difficulty in
studies in Sudan were aware of condoms. using them.160 One-third to two-thirds of FSWs
Condoms are often not seen as an HIV preven- in different settings in Pakistan reported that
tion measure, but as a contraceptive measure.147 condoms were readily available.161
Between 37% and 77% of FSWs in Pakistan
knew that condoms can prevent HIV.148 The
Commercial sex and STI transmission
dominant mode of HIV prevention reported by
FSWs in Sudan was minimizing the number of A number of studies have documented substan-
sexual partners.149 tial levels of STIs among FSWs (chapter 10 on
Knowledge of condoms does not necessarily STIs). Furthermore, a number of studies have
translate into actual use. A fraction of FSWs do documented STI transmission during contacts
not perceive condom use as necessary, such as with FSWs, confirming the presence of active
29.1% of FSWs in Syria.150 Only a quarter of commercial sex networks all over MENA and
FSWs in Southern Sudan negotiate condom use indicating the heightened risk of exposure to
with their clients.151 FSWs may not have the HIV and other STIs in these networks. In the
power to negotiate condom use,152 and fear insis- Islamic Republic of Iran, 64% of gonorrhea
tence on condom use would upset customers and patients reported acquiring their infection
result in clients leaving them for other FSWs or through contacts with street-based FSWs.162 In
offering a lower price.153 Dire financial need Kuwait, 77% of STD clinic attendees reported
undermines the ability of FSWs to negotiate con- acquiring their infection from FSWs.163 A similar
dom use,154 and partner refusal and low desirabil- outcome was found in another study in Kuwait
ity are two other barriers to condom use. In Syria, where the common source of STIs was contact
45.2% of FSWs reported partner refusal as the with FSWs.164 The contacts occurred both in
reason for not using condoms and 25.9% reported (50%) and outside (48%) of Kuwait.165
that they do not like using them.155 Some FSWs In Lebanon, a large fraction of the HIV infec-
are also willing not to use condoms in exchange tions acquired abroad were through contacts
for a higher price such as in Lebanon,156 Sudan,157 with FSWs.166 In Pakistan, a history of urethritis
and the Republic of Yemen.158 or genital ulcer disease among male prisoners
Access to condoms appears to be variable was associated with sex with FSWs.167 The
even within each MENA country. In the Republic majority of Pakistanis who acquired HIV while
of Yemen, FSWs in Aden reported easy access to working in the Persian Gulf region reported
condoms while other FSWs in other parts of the contacts with FSWs as the source of their infec-
country reported difficulty in obtaining them.159 tion.168 Among truck drivers attending STD clin-
ics in Pakistan, 40% reported contact with
142
World Bank, “Mapping and Situation Assessment.”
FSWs.169 Also in Pakistan, 78% of STD clinic
143
ACORD, “Qualitative Socio Economic Research.” attendees who acquired STIs heterosexually
144
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” reported that the source of infection was a sex
145
Ahmed, Sex Sellers.
146
Anonymous, “Improving HIV/AIDS Response.”
147
ACORD, “Socio Economic Research”; Ahmed, Sex Sellers.
148 160
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.” El-Sayed et al., “Evaluation of Selected Reproductive Health
149
ACORD, “Qualitative Socio Economic Research.” Infections.”
150 161
Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.” Pakistan National AIDS Control Program, “Pilot Study in Karachi &
151
ACORD, “Socio Economic Research.” Rawalpindi.”
152 162
ACORD, “Socio Economic Research”; ACORD, “Qualitative Socio Zargooshi, “Characteristics of Gonorrhoea.”
163
Economic Research.” Al-Mutairi et al., “Clinical Patterns.”
153 164
Ati, “HIV/AIDS/STIs Social and Geographical Mapping”; ACORD, Al-Fouzan and Al-Mutairi, “Overview.”
165
“Qualitative Socio Economic Research.” Al-Owaish et al., “HIV/AIDS Prevalence.”
154 166
ACORD, “Socio Economic Research.” Pieniazek et al., “Introduction of HIV-2.”
155 167
Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.” Akhtar and Luby, “Risk Behaviours.”
156 168
Hermez et al., “HIV/AIDS Prevention among Vulnerable Groups.” Shah et al., “HIV-Infected Workers Deported”; Baqi, Kayani, and Khan,
157
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” “Epidemiology and Clinical Profile of HIV/AIDS “; Khan et al., “HIV-1
158
Štulhofer and Božicevic, “HIV Bio-Behavioural Survey.” Subtype A Infection.”
159 169
Busulwa, “HIV/AIDS Situation Analysis Study.” Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.”
52 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
In Sudan, 4.8% of FSWs used drugs and 14.5% FSWs seek treatment for STIs through self-
reported substance abuse among their clients.198 treatment or through friends rather than
In Syria and the Republic of Yemen, 10%199 and through knowledgeable health personnel.213
2%200 of FSWs injected drugs, respectively. They continue to suffer from unavailability of
medical and support services,214 and continue to
fear pursuing such services due to social stigma-
KNOWLEDGE OF HIV/AIDS tization, marginalization, and law enforce-
ment.215 All of the above factors contribute to
Levels of HIV knowledge among sex workers the precarious and vulnerable position that
appear to vary substantially in MENA. In FSWs endure in MENA.
Afghanistan, only 4% of FSWs in one study had
heard of HIV/AIDS,201 but in another study most
FSWs reported knowing of HIV/AIDS, though ANALYTICAL SUMMARY
very few ever tested for it.202 In Egypt, all FSWs
were aware of HIV and some of its transmission Commercial sex is prevalent all over MENA,
modes, but still had misconceptions about its although at lower levels compared to other
transmission.203 In the Islamic Republic of Iran, regions. Economic pressure, family disruption or
FSWs were found to be significantly less knowl- dysfunction, and political conflicts are major
edgeable about HIV/AIDS than both youth and pressures for commercial sex in MENA. Roughly
truck drivers.204 0.1% to 1% of women appear to exchange sex
In Lebanon, almost all FSWs were aware of for money or other commodities, and a few per-
HIV/AIDS, its transmission modes, the condom’s centage points of men report sexual contacts
role in prevention, and other prevention mea- with FSWs. Accordingly, commercial sex net-
sures.205 However, 21.5% of these FSWs per- works are the largest of the three key priority
ceived no chance of becoming infected with HIV, group networks in MENA.
possibly because of condom use.206 In two studies There is considerable evidence on HIV preva-
in Pakistan, 60%207, and 68%–98%208 of FSWs lence and risk behavior practices among FSWs
reported ever hearing of HIV/AIDS, but only in MENA. Earlier evidence suffered from meth-
15%–39% of FSWs felt at risk of HIV infection.209 odological limitations, but the quality of evi-
In Somalia, both men and women not engaged in dence has improved significantly in recent years.
sex work were found to know more than FSWs Regardless, all evidence suggests that HIV preva-
about HIV/AIDS.210 In Sudan, 75.5% of FSWs lence continues to be at low levels among FSWs
were aware of HIV and its symptoms, and 54.9% in most countries, though at levels much higher
were aware of some of its transmission modes.211 than those in the general population. HIV does
In the Republic of Yemen, 85.9% of FSWs per- not appear to be well established in many com-
ceived no high risk of HIV infection.212 mercial sex networks in MENA. In three coun-
tries, however (Djibouti, Somalia, and Sudan),
HIV prevalence has reached high levels, indicat-
198
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” ing concentrated HIV epidemics in at least parts
199
UNAIDS, “Notes on AIDS in the Middle East and North Africa”; Syria
National AIDS Programme, “HIV/AIDS Female Sex Workers.” of these countries. Nevertheless, HIV prevalence
200
Štulhofer and Božicevic, “HIV Bio-Behavioural Survey.” in these countries is at lower levels than those
201
Action Aid Afghanistan, “HIV AIDS in Afghanistan.” found in hyperendemic HIV epidemics in sub-
202
World Bank, “Mapping and Situation Assessment.”
203
Egypt MOH and Population National AIDS Program, HIV/AIDS
Saharan Africa.
Biological and Behavioral Surveillance Survey. FSWs report considerable levels of sexual risk
204
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” behavior including roughly one client per calen-
205
Hermez et al., “HIV/AIDS Prevention among Vulnerable Groups.”
206
dar day; low levels of condom use, particularly
Ibid.
207
Ali and Khanani, Interventions Aimed at Behavior Modification. in areas of concentrated HIV epidemics among
208
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.”
209
Ibid.
210 213
Corwin et al., “HIV-1 in Somalia.” Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.”
211 214
Anonymous, “Improving HIV/AIDS Response.” Mohebbi, “Female Sex Workers and Fear of Stigmatisation.”
212 215
Štulhofer and Božicevic, “HIV Bio-Behavioural Survey.” Zargooshi, “Characteristics of Gonorrhoea.”
drugs; and injecting drugs themselves. ———. 2006. “Qualitative Socio Economic Research on
Female Sex Workers and Their Vulnerability to HIV/
Considerable levels of STI prevalence other than AIDS in Khartoum State.”
HIV are found among FSWs. STD clinic attend- Action Aid Afghanistan. 2006. “HIV AIDS in Afghanistan:
ees repeatedly report acquiring STDs through A Study on Knowledge, Attitude, Behavior, and
paid sex. Levels of comprehensive HIV knowl- Practice in High Risk and Vulnerable Groups in
Afghanistan.”
edge among FSWs vary across the region, with
Agha, S. 2000. “Potential for HIV Transmission among
both high and low levels being documented in Truck Drivers in Pakistan.” AIDS 14: 2404–6.
different settings. Ahmed, S. M. 2004a. Antenatal: Situation Analysis-
The above factors suggest a potential for fur- Behavioral Survey Results & Discussions. Report. Sudan
ther HIV spread among FSWs, but probably not National AIDS Control Program.
at high levels in most countries, except for ———. 2004b. Military: Situation Analysis-Behavioral
Survey Results & Discussions. Report. Sudan National
Djibouti, Somalia, and Sudan. Near universal AIDS Control Program.
male circumcision, with its efficacy against HIV ———. 2004c. Prisoners: Situation Analysis-Behavioral
acquisition (chapter 6), and the lower risk Survey Results & Discussions. Report. Sudan National
behavior compared to other regions may pre- AIDS Control Program.
vent massive or even concentrated HIV epidem- ———. 2004d. Sex Sellers: Situation Analysis-Behavioral
ics among FSWs from materializing in most Survey Results & Discussions. Report. Sudan National
AIDS Control Program.
countries in MENA for at least a decade, if ever.
———. 2004e. Tea Sellers: Situation Analysis-Behavioral
Furthermore, the dynamics of HIV infection Survey Results & Discussions. Report. Sudan National
among FSWs are different from those for MSM AIDS Control Program.
and IDUs. FSWs are infected by their clients ———. 2004f. Truck Drivers: Situation Analysis-Behavioral
who are at lower risk behavior than themselves, Survey Results & Discussions. Report. Sudan National
AIDS Control Program.
as opposed to MSM and IDUs who are infected
Ahmed, H. J., K. Omar, S. Y. Adan, A. M. Guled, L.
by members of their own risk group. Grillner, and S. Bygdeman. 1991. “Syphilis and
Yet HIV prevalence among FSWs will be at Human Immunodeficiency Virus Seroconversion
levels much higher than those among the gen- during a 6-Month Follow-Up of Female Prostitutes in
Mogadishu, Somalia.” Int J STD AIDS 2: 119–23.
eral population. Subgroups within FSWs may be
Akhtar, S., and S. P. Luby. 2002. “Risk Behaviours
particularly at high risk of HIV, such as those Associated with Urethritis and Genital Ulcer Disease
who inject drugs, those who have clients who in Prison Inmates, Sindh, Pakistan.” East Mediterr
inject drugs, and female IDUs who exchange sex Health J 8: 776–86.
for money or drugs, as well as FSWs with low Al-Ali, N. 2005. “Reconstructing Gender: Iraqi Women
socioeconomic status who have poor HIV between Dictatorship, War, Sanctions and
Occupation.” Third World Quarterly 26: 739–58.
knowledge or are not able to afford or negotiate
———. 2007. “Iraqi Women: Untold Stories from 1948
condom use. These subgroups are highly mar- to the Present.”
ginalized and in dire need of prevention and Alami, K. 2009. “Tendances récentes de l’épidémie à
care programs. Furthermore, all FSWs are in VIH/SIDA en Afrique du nord.” Presentation,
need of prevention and care services not only Research and AIDS Workshop in North Africa,
Marrakech, Morocco.
because of HIV, but also because of the consider-
Al-Fouzan, A., and N. Al-Mutairi. 2004. “Overview of
able levels of other STIs in this population. Incidence of Sexually Transmitted Diseases in
Dedicated STI services for FSWs need to be Kuwait.” Clin Dermatol 22: 509–12.
established, and in settings where they are Algeria MOH (Ministry of Health). Unknown. Rapport de
already established, they need to be expanded. l’enquête nationale de séro-surveillance.
Ali, S., and R. Khanani. 1996. Interventions Aimed at
Behavior Modification of Commercial Sex Workers in
Pakistan. Karachi: Pakistan AIDS Prevention Society.
BIBLIOGRAPHY Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, I.
El-Adawy, and M. Rijhwani. 2007. “Clinical Patterns
ACORD (Agency for Co-operation and Research in of Sexually Transmitted Diseases, Associated
Development). 2005. “Socio Economic Research on Sociodemographic Characteristics, and Sexual
HIV/AIDS Prevention among Informal Sex Workers.” Practices in the Farwaniya Region of Kuwait.” Int J
Federal Ministry of Health, Sudan National AIDS Dermatol 46: 594–99.
54 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Al-Owaish, R. A., S. Anwar, P. Sharma, and S. F. Shah. “HIV Risk in Karachi and Lahore, Pakistan: An
2000. “HIV/AIDS Prevalence among Male Patients in Emerging Epidemic in Injecting and Commercial Sex
Kuwait.” Saudi Med J 21: 852–59. Networks.” Int J STD AIDS 18: 486–92.
Al-Qadhi, H. 2001. “A Silent Threat in Yemen: Burans, J. P., E. Fox, M. A. Omar, A. H. Farah, S. Abbass,
Confronting HIV/AIDS Choices.” United Nations S. Yusef, A. Guled, M. Mansour, R. Abu-Elyazeed,
Development Programme. and J. N. Woody. 1990. “HIV Infection Surveillance
Alrajhi, A. A., M. A. Halim, and H. M. Al-Abdely. 2004. in Mogadishu, Somalia.” East Afr Med J 67: 466–72.
“Mode of Transmission of HIV-1 in Saudi Arabia.” Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani,
AIDS 18: 1478–80. J. George, R. Abu-Elyazeed, and J. N. Woody. 1990.
Al-Serouri, A. W. 2005. “Assessment of Knowledge, “Serosurvey of Prevalence of Human Immunodefi-
Attitudes and Beliefs about HIV/AIDS among Young ciency Virus amongst High Risk Groups in Port
People Residing in High Risk Communities in Aden Sudan, Sudan.” East Afr Med J 67: 650–55.
Governatore, Republic of Yemen.” Society for the Busulwa, R. 2003. “HIV/AIDS Situation Analysis Study.”
Development of Women & Children (SOUL), Conducted in Hodeidah, Taiz and Hadhramut,
Education, Health, Welfare, United Nations Republic of Yemen. Grey Report.
Children’s Fund, Yemen Country Office, HIV/AIDS Carael, M., E. Slaymaker, R. Lyerla, and S. Sarkar. 2006.
Project. “Clients of Sex Workers in Different Regions of the
Anonymous. 2007. “Improving HIV/AIDS Response World: Hard to Count.” Sex Transm Infect 82 Suppl 3:
among Most at Risk Population in Sudan.” Orientation iii26–33.
Workshop, April 16. Chaouki, N., F. X. Bosch, N. Munoz, C. J. Meijer, B. El
Aral, S. O., and J. S. St. Lawrence. 2002. “The Ecology of Gueddari, A. El Ghazi, J. Deacon, X. Castellsague, and
Sex Work and Drug Use in Saratov Oblast, Russia.” J. M. Walboomers. 1998. “The Viral Origin of Cervical
Sex Transm Dis 29: 798–805. Cancer in Rabat, Morocco.” Int J Cancer 75: 546–54.
Aral, S. O., J. S. St Lawrence, L. Tikhonova, E. Safarova, Commission on AIDS in Asia. 2008. Redefining AIDS in
K. A. Parker, A. Shakarishvili, and C. A. Ryan. 2003. Asia: Crafting an Effective Response. New Delhi, India:
“The Social Organization of Commercial Sex Work in Oxford University Press. Presented to Ban Ki-moon,
Moscow, Russia.” Sex Transm Dis 30: 39–45. UN Secretary General, on March 26, 2008. Oxford
Ardalan, A., K. H. Na’ini, A. M. Tabrizi, and A. Jazayeri. University Press.
2002. “Sex for Survival: The Future of Runaway Corwin, A. L., J. G. Olson, M. A. Omar, A. Razaki, and
Girls.” Social Welfare Research Quarterly 2: 187–219. D. M. Watts. 1991. “HIV-1 in Somalia: Prevalence
Assal, M. 2006. “HIV Prevalence, Knowledge, Attitude, and Knowledge among Prostitutes.” AIDS 5: 902–4.
Practices, and Risk Factors among Prisoners in Daher, C., and D. Zayat. 2007. “A Matter of Life: Views,
Khartoum State, Sudan.” Grey Report. Perceptions, and Practices of Commercial Sex Workers
Ati, H. A. 2005. “HIV/AIDS/STIs Social and Geographical and Intravenous Drug Users regarding HIV/AIDS Risk
Mapping of Prisoners, Tea Sellers and Commercial Behaviors.” Grey Report.
Sex Workers in Port Sudan Town, Red Sea State.” Dareini, A. 2002. “Rise in Iranian Prostitution Blamed
Ockenden International, Sudan. Draft 2. on Strict Sex Rules, Economy.” Associated Press
Baqi, S., N. Kayani, and J. A. Khan. 1999. “Epidemiology September 15.
and Clinical Profile of HIV/AIDS in Pakistan.” Trop Dewachi, O. 2001. “Men Who Have Sex with Other Men
Doct 29: 144–48. and HIV AIDS: A Situation Analysis in Beirut,
Baqi, S., N. Nabi, S. N. Hasan, A. J. Khan, O. Pasha, N. Lebanon; HIV/AIDS Prevention through Outreach to
Kayani, R. A. Haque, I. U. Haq, M. Khurshid, S. Vulnarable Populations.” Grey Report, April 29.
Fisher-Hoch, S. P. Luby, and J. B. McCormick. 1998. Egypt MOH (Ministry of Health), and Population National
“HIV Antibody Seroprevalence and Associated Risk AIDS Program. 2006. HIV/AIDS Biological and Behavioral
Factors in Sex Workers, Drug Users, and Prisoners in Surveillance Survey. Summary report.
Sindh, Pakistan.” J Acquir Immune Defic Syndr Hum El-Gawhary, K. 1995. Sex Tourism in Cairo. Middle East
Retrovirol 18: 73–79. Report (September–October). Middle East Research
Basha, H. M. 2006. “Vulnerable Population Research in and Information Project.
Darfur.” Grey Report. Elmore-Meegan, M., R. M. Conroy, and C. B. Agala.
Blanchard, J. F., S. Halli, B. M. Ramesh, P. Bhattacharjee, 2004. “Sex Workers in Kenya, Numbers of Clients
R. G. Washington, J. O’Neil, and S. Moses. 2007. and Associated Risks: An Exploratory Survey.” Reprod
“Variability in the Sexual Structure in a Rural Indian Health Matters 12: 50–57.
Setting: Implications for HIV Prevention Strategies.” El-Sayed, N., M. Abdallah, A. Abdel Mobdy, A. Abdel
Sex Transm Infect 83 Suppl 1: i30–36. Sattar, E. Aoun, F. Beths, G. Dallabetta, M. Rakha, C.
Blanchard, J. F., A. Khan, and A. Bokhari. 2008. Soliman, and N. Wasef. 2002. “Evaluation of Selected
“Variations in the Population Size, Distribution and Reproductive Health Infections in Various Egyptian
Client Volume among Female Sex Workers in Seven Population Groups in Greater Cairo.” MOHP,
Cities of Pakistan.” Sex Transm Infect 84 Suppl 2: IMPACT/FHI/USAID.
ii24–27. Etchepare, M. 2001. “Programme National de Lutte con-
Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan, tre le SIDA et les MST.” Draft report, World Bank
M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, K. Mission for Health Project Strategy Development,
Qayum, P. Girault, E. Pisani, and I. Thaver. 2007. Djibouti.
56 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck, Orak, S., A. E. Dalkilic, and Y. Ozbal. 1991. “Serological
M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M. Investigation of HIV Infections, HBsAg and Syphilis in
Huraux, and N. Dupin. 2001. “Comparative Study of Prostitutes in Elazig.” Mikrobiyol Bul 25: 51–56.
Heterosexual Transmission of HIV-1, HSV-2 and Pakistan National AIDS Control Program. 2005a. HIV
KSHV in Djibouti.” 8th Retrovir Oppor Infect (abstract Second Generation Surveillance in Pakistan. National
no. 585). Report Round 1. Ministry of Health, Pakistan, and
Marcelin, A. G., M. Grandadam, P. Flandre, E. Nicand, C. Canada-Pakistan HIV/AIDS Surveillance Project.
Milliancourt, J. L. Koeck, M. Philippon, R. Teyssou, ———. 2005b. “Pilot Study in Karachi & Rawalpindi.”
H. Agut, N. Dupin, and V. Calvez. 2002. “Kaposi’s Ministry of Health Canada-Pakistan HIV/AIDS
Sarcoma Herpesvirus and HIV-1 Seroprevalences in Surveillance Project, Integrated Biological &
Prostitutes in Djibouti.” J Med Virol 68: 164–67. Behavioral Surveillance 2004–5.
Mayhew, S., M. Collumbien, A. Qureshi, L. Platt, N. Rafiq, ———. 2006–7. HIV Second Generation Surveillance in
A. Faisel, N. Lalji, and S. Hawkes. 2009. “Protecting the Pakistan. National Report Round II. Ministry of
Unprotected: Mixed-Method Research on Drug Use, Health, Pakistan, and Canada-Pakistan HIV/AIDS
Sex Work and Rights in Pakistan’s Fight against HIV/ Surveillance Project.
AIDS.” Sex Transm Infect 85 Suppl 2: ii31–36.
———. 2008. HIV Second Generation Surveillance in
Mbulaiteye, S. M., A. Ruberantwari, J. S. Nakiyingi, L. Pakistan. National Report Round III. Ministry of
M. Carpenter, A. Kamali, and J. A. Whitworth. 2000. Health, Pakistan, Canada-Pakistan HIV/AIDS
“Alcohol and HIV: A Study among Sexually Active Surveillance Project.
Adults in Rural Southwest Uganda.” Int J Epidemiol
29: 911–15. Philippon, M., M. Saada, M. A. Kamil, and H. M.
Houmed. 1997. “Attendance at a Health Center by
McCarthy, M. C., J. P. Burans, N. T. Constantine, A. A. Clandestine Prostitutes in Djibouti.” Sante 7: 5–10.
el-Hag, M. E. el-Tayeb, M. A. el-Dabi, J. G. Fahkry, J.
Pieniazek, D., J. Baggs, D. J. Hu, G. M. Matar, A. M.
N. Woody, and K. C. Hyams. 1989. “Hepatitis B and
Abdelnoor, J. E. Mokhbat, M. Uwaydah, A. R. Bizri, A.
HIV in Sudan: A Serosurvey for Hepatitis B and
Ramos, L. M. Janini, A. Tanuri, C. Fridlund, C. Schable,
Human Immunodeficiency Virus Antibodies among
L. Heyndrickx, M. A. Rayfield, and W. Heneine. 1998.
Sexually Active Heterosexuals.” Am J Trop Med Hyg
“Introduction of HIV-2 and Multiple HIV-1 Subtypes to
41: 726–31.
Lebanon.” Emerg Infect Dis 4: 649–56.
McCarthy, M. C., I. O. Khalid, and A. El Tigani. 1995.
Rady, A. 2005. “Knowledge, Attitudes and Prevalence of
“HIV-1 Infection in Juba, Southern Sudan.” J Med
Condom Use among Female Sex Workers in Lebanon:
Virol 46: 18–20.
Behavioral Surveillance Study.” UNFPA.
Ministry of Health and Medical Education of Iran. 2006.
Razzaghi, E. M., A. R. Movaghar, T. C. Green, and K.
“Treatment and Medical Education.” Islamic Republic
Khoshnood. 2006. “Profiles of Risk: A Qualitative
of Iran HIV/AIDS situation and response analysis.
Study of Injecting Drug Users in Tehran, Iran.” Harm
Mishwar. 2008. “An Integrated Bio-Behavioral Reduct J 3: 12.
Surveillance Study among Four Vulnerable Groups in
Rehan, N. 2006. “Profile of Men Suffering from Sexually
Lebanon: Men Who Have Sex with Men; Prisoners;
Transmitted Infections in Pakistan.” J Pak Med Assoc
Commercial Sex Workers and Intravenous Drug
56: S60–65.
Users.” Mid-term Report, American University of
Beirut and World Bank. Rodier, G. R., B. Couzineau, G. C. Gray, C. S. Omar, E.
Fox, J. Bouloumie, and D. Watts. 1993. “Trends of
Mohebbi, M. R. 2005. “Female Sex Workers and Fear of Human Immunodeficiency Virus Type-1 Infection in
Stigmatisation.” Sex Transm Infect 81: 180–81. Female Prostitutes and Males Diagnosed with a
Morison, L., H. A. Weiss, A. Buve, M. Carael, S. C. Abega, Sexually Transmitted Disease in Djibouti, East Africa.”
F. Kaona, L. Kanhonou, J. Chege, and R. J. Hayes. 2001. Am J Trop Med Hyg 48: 682–86.
“Commercial Sex and the Spread of HIV in Four Cities in Saleem, N. H., A. Adrien, and A. Razaque. 2008. “Risky
Sub-Saharan Africa.” AIDS 15 Suppl 4: S61–69. Sexual Behavior, Knowledge of Sexually Transmitted
Morocco MOH (Ministry of Health, Ministère de la Infections and Treatment Utilization among a
Santé). 2003–4. Bulletin épidemiologique de surveillance Vulnerable Population in Rawalpindi, Pakistan.”
du VIH/SIDA et des infections sexuellement transmissibles. Southeast Asian J Trop Med Public Health 39: 642–48.
Rabat, Ministère de la Santé Maroc. Sepehrad, R. 2002. “The Role of Women in Iran’s New
———. 2005. Bulletin épidemiologique de surveillance du Popular Revolution.” Brown J World Aff 9: 217.
VIH/SIDA et des infections sexuellement transmissibles. Shah, S. A., O. A. Khan, S. Kristensen, and S. H.
Rabat, Ministère de la Santé Maroc. Vermund. 1999. “HIV-Infected Workers Deported
———. 2007. Surveillance sentinelle du VIH, résultats 2006 et from the Gulf States: Impact on Southern Pakistan.”
tendances de la séroprévalence du VIH. Int J STD AIDS 10: 812–14.
Mostashari, G., UNODC (United Nations Office on Drugs SNAP (Sudan National AIDS Program), UNICEF (United
and Crime), and M. Darabi. 2006. “Summary of the Nations Children’s Fund), and UNAIDS (United
Iranian Situation on HIV Epidemic.” NSP Situation Nations Joint Programme on HIV/AIDS). 2005.
Analysis. “Baseline Study on Knowledge, Attitudes, and
Practices on Sexual Behaviors and HIV/AIDS
Omer, E. E., M. H. Ali, O. M. Taha, M. A. Ahmed, and S.
Prevention amongst Young People in Selected States
A. Abbaro. 1982. “Sexually Transmitted Diseases in
in Sudan.” HIV/AIDS KAPB Report. Projects and
Sudanese Males.” Trop Doct 12: 208–10.
Research Department (AFROCENTER Group).
Commercial Sex and HIV 57
Soins Infirmiers et Developpement Communautaire. Vandepitte, J., R. Lyerla, G. Dallabetta, F. Crabbe, M.
2008. “Mapping for FSW and IDU Report.” Grey Alary, and A. Buve. 2006. “Estimates of the Number
Report. of Female Sex Workers in Different Regions of the
Strathdee, S. A., R. Lozada, S. J. Semple, P. Orozovich, World.” Sex Transm Infect 82 Suppl 3: iii18–25.
M. Pu, H. Staines-Orozco, M. Fraga-Vallejo, H. Vittinghoff, E., J. Douglas, F. Judson, D. McKirnan, K.
Amaro, A. Delatorre, C. Magis-Rodriguez, and T. L. MacQueen, and S. P. Buchbinder. 1999. “Per-Contact
Patterson. 2008. “Characteristics of Female Sex Risk of Human Immunodeficiency Virus Transmission
Workers with U.S. Clients in Two Mexico-U.S. Border between Male Sexual Partners.” Am J Epidemiol 150:
Cities.” Sex Transm Dis 35: 263–68. 306–11.
Štulhofer, A., and I. Božicevic. 2008. “HIV Bio- Watts, D. M., N. T. Constantine, M. F. Sheba, M. Kamal,
Behavioural Survey among FSWs in Aden, Yemen.” J. D. Callahan, and M. E. Kilpatrick. 1993. “Prevalence
Grey Report. of HIV Infection and AIDS in Egypt over Four Years
Syria National AIDS Programme. 2004. “HIV/AIDS of Surveillance (1986–1990).” J Trop Med Hyg 96:
Female Sex Workers KABP Survey in Syria.” Grey 113–17.
Report. Watts, D. M., A. L. Corwin, M. A. Omar, and K. C.
Taha, O. M., M. H. Ali, E. E. Omer, M. A. Ahmed, and S. Hyams. 1994. “Low Risk of Sexual Transmission of
A. Abbaro. 1979. “Study of STDs in Patients Attending Hepatitis C Virus in Somalia.” Trans R Soc Trop Med
Venereal Disease Clinics in Khartoum, Sudan.” Br J Hyg 88: 55–56.
Vener Dis 55: 313–15. Wawer, M. J., R. H. Gray, N. K. Sewankambo, D.
Tassie, J.-M. Unknown. “Assignment Report HIV/AIDS/ Serwadda, X. Li, O. Laeyendecker, N. Kiwanuka, G.
STD Surveillance in I.R. of Iran.” UNAIDS, Mission Kigozi, M. Kiddugavu, T. Lutalo, F. Nalugoda, F.
Internal Report. Wabwire-Mangen, M. P. Meehan, and T. C. Quinn.
2005. “Rates of HIV-1 Transmission per Coital Act, by
Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge, Stage of HIV-1 Infection, in Rakai, Uganda.” J Infect
Attitudes and Practices concerning HIV/AIDS among Dis 191: 1403–9.
Iranian At-Risk Sub-Populations.” Eastern Mediterranean
Health Journal 14. WHO (World Health Organization). 1999. Consensus
Report on STI, HIV, and AIDS Epidemiology, Malaysia.
Testa, A. C., and K. Kriitmaa. 2009. “HIV and Syphilis Regional Office for the Western Pacific.
Bio-Behavioural Surveillance Survey (BSS+) among
Female Transactional Sex Workers in Hargeisa, WHO, UNICEF (United Nations Children’s Fund), and
Somaliland.” International Organization for Migration, UNAIDS (United Nations Joint Programme on HIV/
World Health Organization. AIDS). 2006. “Yemen, Epidemiological Facts Sheets
on HIV/AIDS and Sexually Transmitted Infections.”
Tiras, M. B., O. Karabacak, Ö. Himmetoglu, and S.
Yüksel. 1998. “Seroprevalence of Hepatitis B and HIV Wilson, D., P. Chiroro, S. Lavelle, and C. Mutero. 1989.
Infection in High-Risk Turkish Population.” Turkiye “Sex Worker, Client Sex Behaviour and Condom Use
Klinikleri J Gynecol Obst 8: 157–58. in Harare, Zimbabwe.” AIDS Care 1: 269–80.
UNAIDS (United Nations Joint Programme on HIV/ World Bank. 2008. “Mapping and Situation Assessment
AIDS). 2008. “Notes on AIDS in the Middle East and of Key Populations at High Risk of HIV in Three Cities
North Africa.” RST, MENA. of Afghanistan.” Human Development Sector, South
Asia Region (SAR) AIDS Team, World Bank.
UNFPA (United Nations Population Fund). 2009.
“UNFPA, Local NGO Partner for HIV Education Yousif, M. E. A. 2006. “Health Education Programme
Efforts Aimed at Pakistani Sex Workers.” Kaisernetwork among Female Sex Workers in Wad Medani Town-
Daily News January 7. Gezira State.” Final Report.
Unknown. “Statut de la réponse nationale: Zargooshi, J. 2002. “Characteristics of Gonorrhoea in
Caractéristiques de l’épidémie des IST/VIH/SIDA.” Kermanshah, Iran.” Sex Transm Infect 78: 460–61.
Algeria.
58 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 5
This chapter focuses on the biological evidence and 60,000 domestic drivers in Afghanistan,2
for the extent of human immunodeficiency and 1 million truck drivers in Pakistan.3 Migrant
virus (HIV) spread among potential bridging males constitute 15%–20% of all adult men in
populations, the behavioral evidence for sexual Pakistan.4
and injecting risk practices among these popula- Given the limited HIV prevalence found in
tion groups, and the context of bridging the MENA, one must be cautious in labeling any
infection to the general population in the Middle population group in the region as a bridging
East and North Africa (MENA). population. The evidence on the role of conven-
tionally defined bridging populations in the HIV
epidemics in MENA needs to be well estab-
CONTEXT OF BRIDGING POPULATIONS lished. Based on current evidence as discussed
IN MENA below, one cannot conclude that there is a clear
contribution of such populations in the HIV epi-
Bridging populations are defined as the popula- demic. Therefore bridging populations have
tions that bridge HIV infections from the high- been labeled here as potential bridging populations
risk priority groups to the low-risk general to highlight the specific nature of their context
population. These conventionally include groups in MENA.
such as clients of female sex workers (FSWs),
truck drivers, taxi drivers, military personnel,
fishermen, sailors, migrant labor, and the sexual HIV PREVALENCE IN POTENTIAL
partners of injecting drug users (IDUs), FSWs, BRIDGING POPULATIONS
and men who have sex with men (MSM). A siz-
able segment of the MENA population belongs HIV point-prevalence surveys of potential bridg-
to these groups. Djibouti has a major trade cor- ing populations are still limited in MENA.
ridor with Ethiopia and large military installa- Table 5.1 lists available data. The low HIV preva-
tions of foreign troops that facilitated a strong lence found in these surveys, along with the
demand for an active and complex sex trade context of HIV spread in the rest of risk groups,
that caters to truck drivers, foreign military per- suggests that HIV spread may be still limited in
sonnel, and the local population.1 It is estimated
that there are 2,000 international truck drivers 2
Ryan, “Travel Report Summary.”
3
Agha, “Potential for HIV Transmission.”
1 4
El-Saharty and Ali, “An Effective Well-Coordinated Response to HIV in Faisel and Cleland, “Study of the Sexual Behaviours”; Faisel and
Djibouti.” Cleland, “Migrant Men.”
59
Table 5.1 HIV Prevalence in Potential Bridging Populations in MENA
Jordan 0.0% (military personnel; Jordan National AIDS Program, personal communication)
Iran, Islamic Republic of 0.0% (truck drivers; S. Seyed Alinaghi, personal communication [2009])
Morocco 1.0% (truck drivers; Bennani and Alami 2006)
0.0% (truck drivers; Morocco MOH 2007)
0.0% (sailors; Khattabi and Alami 2005)
0.28% (sailors; Bennani and Alami 2006)
0.62% (sailors; Morocco MOH 2007)
Pakistan 0.0% (truck drivers; Ahmed et al. 1995)
0.0% (truck drivers; Bokhari et al. 2007)
1.0% (truck drivers; Bokhari et al. 2007)
0.6% (seafarers; Mujeeb and Hafeez 1993)
Sudan 0.0% (truck drivers; Burans et al. 1990)
0.5% (truck drivers; Farah and Hussein 2006)
1.1% (truck drivers; Ahmed 2004b)
1.7% (military personnel; McCarthy et al. 1989)
0.5% (military personnel; Ahmed 2004a)
2.9% (military personnel; Yei town, Southern Sudan; SNAP, NSNAC, and UNAIDS 2006)
0.8% (military personnel; Rumbek town, Southern Sudan; SNAP, NSNAC, and UNAIDS 2006)
14% (clients of FSWs; Southern Sudan; McCarthy, Khalid, and El Tigani 1995)
Other 1.54% (truck driversa; Botros et al. 2007)
a
A complex network of truck drivers serving Europe, the Russian Federation, Caucasus, Central Asia, China, and the Middle East.
bridging populations in MENA, apart from In Pakistan, 40% of truck drivers attending a
Djibouti, Somalia, and Sudan. sexually transmitted disease (STD) clinic report-
ed contact with FSWs and 53% reported male
same-sex contacts.9 Most truck drivers in one
POTENTIAL BRIDGING POPULATIONS study were married, but they were away from
AND RISK BEHAVIOR their wives for up to two months at a time.10
Among them, 34% had sex with an FSW, 11.3%
Several studies have documented risk behaviors had sex with a male sex worker (MSW), and
among potential bridging populations in MENA. 49.3% had sex with a man. Most truckers had
In Afghanistan, 39% of truck drivers reported limited knowledge of HIV and were not aware
access to FSWs and 7% paid for sex in the last that condoms can protect against HIV. Only
12 months.5 In Djibouti, 22.7% of dockers had 3%–6% of them used condoms during last sex
two or three wives and of those who had one with a nonspousal partner. In another study,
wife, 53.2% of their wives were living away in 32.3% of truck drivers paid for sex with a female,
Ethiopia.6 Among truck drivers, 14% were in 1.7% used a condom during last sex with an
polygamous unions, 24.8% had more than one FSW, 21.9% had sex with a male or hijra, and
sex partner, 18.4% had a nonregular sex partner, 0% used condoms during last sex with a male or
and 17.5% had contacted FSWs in the previous hijra.11 Truck drivers in Pakistan are reported to
year.7 In the Islamic Republic of Iran, 38.3% of have male helpers or “cleaners” who accompany
truck drivers reported premarital or extramarital them during their travel and who may be
sex and 35.2% had never used condoms.8 expected to have sex with the driver.12 Syphilis
5 9
Action Aid Afghanistan, “HIV AIDS in Afghanistan.” Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.”
6 10
O’ Grady, WFP Consultant Visit to Djibouti Report. Agha, “Potential for HIV Transmission.”
7 11
Ibid. Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.”
8 12
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.”
60 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
prevalence has been reported as 9.4% among were IDUs.22 The study also reported prevalence
truck drivers, indicating considerable prevalence of sexual contacts with FSWs and other males
of risk behaviors.13 and that these contacts were associated with
Among urban migrant males in Pakistan, HIV prevalence.
63.5% had sex with one or more nonmarital Existing evidence suggests considerable levels
partners, 34.7% had sex with an FSW, and of sexual risk behavior among potential bridging
1.7% had sex with a man.14 About half of the populations including sexual contacts with
nonmarital partners over the last year were FSWs and other nonmarital females as well as
FSWs and the other half were identified as other males. There is hardly any evidence on
female “friends.” Three-quarters of those who injecting drug practices among these population
reported having sex with a female friend also groups.
reported having sex with an FSW. Most of the
high-risk behaviors were concentrated, but not
confined to, between puberty and marriage. VULNERABILITY OF SEXUAL PARTNERS
In Somalia, 30.3% of traveling merchants OF PRIORITY POPULATIONS
and drivers had more than one sexual partner in
the previous year,15 and the majority of truck A key highlight of HIV epidemiology in MENA
drivers reported contacts with FSWs.16 In Sudan, is the vulnerability of sexual partners of both
2.4% of truck drivers had ever used condoms, priority populations and FSW clients to HIV
29.6% had premarital or extramarital sex, infection, and their limited role in transmitting
12.9% had premarital sex, and 8.1% had paid HIV to the general population. Women are
for sex.17 In another study, 55% of truck drivers especially vulnerable because most risk behav-
reported no current sexual partners, 13.4% iors in MENA are practiced by men. The major-
reported one partner, 7.4% reported two part- ity of women living with HIV in MENA were
ners, 10.8% reported three partners, and 13.4% infected through their husbands or partners,
reported more than three partners.18 Among who were mostly not aware of their infections.23
them, 3.4% had sex before marriage, 0.2% had Ninety-seven percent of women living with HIV
sex with males and females, 0.5% had sex only in Saudi Arabia were infected by their hus-
with males, and 72.1% had heard of condoms bands.24 Seventy-six percent of women living
but only 8.9% ever used them.19 Among military with HIV in the Islamic Republic of Iran were
personnel, 2.7% had ever used condoms, 42.5% also infected by their husbands, who were pre-
had premarital or extramarital sex, 5.2% had dominantly IDUs.25 HIV infections are repeatedly
premarital sex, and 11.7% had paid for sex.20 In found among pregnant women with no identifi-
another study, 39.6% of sexually active military able risk behaviors, suggesting that the risk fac-
personnel had one sexual partner, 13.4% had tor is heterosexual sex with the spouse.26 The
two partners, 12.5% had three partners, and average age at HIV infection among women in
31.2% had more than three partners.21 the West Bank and Gaza is close to a decade
A study among truck drivers serving a com- younger than that of men, and most women
plex network from Europe, the Russian were infected by their husbands.27
Federation, Caucasus, Central Asia, China, and Given the low levels of risk behavior in the
the Middle East found that 1.9% of the drivers general population (chapters 6 and 10), sexual
partners of priority populations appear to rarely
engage in risky behavior (beyond sexual con-
13
WHO/EMRO, “Prevention and Control.” tacts with their partners who engage in risk
14
Faisel and Cleland, “Study of the Sexual Behaviours”; Faisel and
Cleland, “Migrant Men.”
15 22
WHO/EMRO, “Presentation of WHO Somalia’s Experience.” Botros et al., “HIV Prevalence and Risk Behaviours.”
16 23
Burans et al., “HIV Infection Surveillance in Mogadishu, Somalia.” McGirk, “Religious Leaders Key.”
17 24
Ahmed, Truck Drivers. Alrajhi, Halim, and Al-Abdely, “Mode of Transmission of HIV-1.”
18 25
Farah and Hussein, “HIV Prevalence.” Ramezani, Mohraz, and Gachkar, “Epidemiologic Situation”; Burrows,
19
Ibid. Wodak, and WHO, Harm Reduction in Iran.
20 26
Ahmed, Military. Aidaoui, Bouzbid, and Laouar, “Seroprevalence of HIV Infection.”
21 27
Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence. UNAIDS, “Key Findings.”
belongs to what can be labeled as potential bridg- Alrajhi, A. A., M. A. Halim, and H. M. Al-Abdely. 2004.
“Mode of Transmission of HIV-1 in Saudi Arabia.”
ing populations. Evidence on HIV prevalence, AIDS 18: 1478–80.
other STIs’ prevalence, sexual risk behavior Bennani, A., and K. Alami. 2006. “Surveillance senti-
measures, and drug injecting practices among nelle VIH, résultats 2005 et tendances de la séro-
potential bridging populations remains rather prévalence du VIH.” Morocco Ministry of Health,
UNAIDS.
limited. Existing evidence suggests considerable
Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan,
levels of sexual risk behavior among potential M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, K.
bridging populations, but limited HIV preva- Qayum, P. Girault, E. Pisani, and I. Thaver. 2007.
lence, except possibly for Djibouti, Somalia, and “HIV Risk in Karachi and Lahore, Pakistan: An
Emerging Epidemic in Injecting and Commercial Sex
Sudan. Networks.” Int J STD AIDS 18: 486–92.
The limited HIV prevalence among potential Botros, B. A., Q. Aliyev, M. Saad, M. Monteville, A.
bridging populations is probably a consequence Michael, Z. Nasibov, H. Mustafaev, P. Scott, J.
of the low HIV prevalence among FSWs and the Sanchez, J. Carr, and K. Earhart. 2007. “HIV
high coverage of male circumcision among men. Prevalence and Risk Behaviours among International
Truck Drivers in Azerbaijan.” 17th European Congress
In this sense, these populations are not key con- of Clinical Microbiology and Infectious Diseases
tributors to the dynamics of HIV infectious (ECCMID) and 25th International Congress of
spread in MENA and are not effectively bridging Chemotherapy (ICC), Munich, Germany.
populations capable of spreading the infection Burans, J. P., E. Fox, M. A. Omar, A. H. Farah, S. Abbass,
S. Yusef, A. Guled, M. Mansour, R. Abu-Elyazeed,
further to the general population. and J. N. Woody. 1990. “HIV Infection Surveillance
Indeed, a key characteristic of sexual partners in Mogadishu, Somalia.” East Afr Med J 67: 466–72.
of priority populations in this region is their vul- Burrows, D., A. Wodak, and WHO (World Health
nerability to HIV, rather than their role in HIV Organization). 2005. Harm Reduction in Iran: Issues in
National Scale-Up. Report for WHO.
spread. Sexual partners of priority groups are
El-Saharty, S., and O. Ali. 2006. “An Effective Well-
enduring a sizable proportion of the HIV disease Coordinated Response to HIV in Djibouti.” World
burden, though they rarely transmit the infec- Bank Global HIV/AIDS Program.
tion further, except to their own children. Faisel, A., and J. Cleland. 2006a. “Migrant Men: A
Women are especially vulnerable because most Priority for HIV Control in Pakistan?” Sex Transm Infect
risk behaviors are practiced by men. HIV pre- 82: 307–10.
vention efforts in MENA should address this key ———. 2006b. “Study of the Sexual Behaviours and
Prevalence of STIs among Migrant Men in Lahore,
vulnerability. Pakistan.” Arjumand and Associates, Centre for
Population Studies, London School of Hygiene and
Tropical Medicine.
BIBLIOGRAPHY Farah, M. S., and S. Hussein. 2006. “HIV Prevalence,
Knowledge, Attitude, Practices and Risk Factors
Action Aid Afghanistan. 2006. “HIV AIDS in Afghanistan: among Truck Drivers in Khartoum State.” Grey
A Study on Knowledge, Attitude, Behavior, and Report. Sudan National AIDS Program.
Practice in High Risk and Vulnerable Groups in Khattabi, H., and K. Alami. 2005. “Surveillance senti-
Afghanistan.” nelle du VIH, Résultats 2004 et tendance de la séro-
Agha, S. 2000. “Potential for HIV Transmission among prévalence du VIH.” Morocco Ministry of Health,
Truck Drivers in Pakistan.” AIDS 14: 2404–6. UNAIDS.
62 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. SNAP (Sudan National AIDS Program), NSNAC (New
Vermund. 1997. “HIV/AIDS and Its Risk Factors in Sudan National AIDS Council), and UNAIDS (United
Pakistan.” AIDS 11: 843–48. Nations Joint Programme on HIV/AIDS). 2006.
McCarthy, M. C., K. C. Hyams, A. el-Tigani el-Hag, M. A. “Scaling-up HIV/AIDS Response in Sudan.” National
el-Dabi, M. el-Sadig el-Tayeb, I. O. Khalid, J. F. Consultation on the Road towards Universal Access
George, N. T. Constantine, and J. N. Woody. 1989. to Prevention, Treatment, Care, and Support.
“HIV-1 and Hepatitis B Transmission in Sudan.” AIDS Sudan National HIV/AIDS Control Program. 2004. HIV/
3: 725–29. AIDS/STIs Prevalence, Knowledge, Attitude, Practices and
McCarthy, M. C., I. O. Khalid, and A. El Tigani. 1995. Risk Factors among University Students and Military
“HIV-1 Infection in Juba, Southern Sudan.” J Med Personnel. Federal Ministry of Health, Khartoum.
Virol 46: 18–20. Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge,
McGirk, J. 2008. “Religious Leaders Key in the Middle Attitudes and Practices concerning HIV/AIDS
East’s HIV/AIDS Fight.” Lancet 372: 279–80. among Iranian At-Risk Sub-Populations.” Eastern
Mediterranean Health Journal 14.
Morocco MOH (Ministry of Health). 2007. Surveillance
sentinelle du VIH, résultats 2006 et tendances de la séro- UNAIDS (United Nations Joint Programme on HIV/AIDS).
prévalence du VIH. 2007. “Key Findings on HIV Status in the West Bank
and Gaza.” Working document, UNAIDS Regional
Mujeeb, S. A., and A. Hafeez. 1993. “Prevalence and Support Team for the Middle East and North Africa.
Pattern of HIV Infection in Karachi.” J Pak Med Assoc
43: 2–4. WHO/EMRO (World Health Organization, Eastern
Mediterranean Region). 2000. “Presentation of WHO
O’Grady, M. 2004. WFP Consultant Visit to Djibouti Report. Somalia’s Experience in Supporting the National
United Nations World Food Programme, July 30. Response.” Somalia. Regional Consultation towards
Ramezani, A., M. Mohraz, and L. Gachkar. 2006. Improving HIV/AIDS & STD Surveillance in the
“Epidemiologic Situation of Human Immuno- Countries of EMRO, Beirut, Lebanon, Oct 30–Nov 2.
deficiency Virus (HIV/AIDS Patients) in a Private ———. 2007. “Prevention and Control of Sexually
Clinic in Tehran, Iran.” Arch Iran Med 9: 315–18. Transmitted Infections in the WHO Eastern
Ryan, S. 2006. “Travel Report Summary.” Kabul, Mediterranean Region.” Intercountry meeting,
Afghanistan. UNAIDS, February 27–March 7, 2006. PowerPoint presentation.
This chapter focuses on the biological evidence with the exception Djibouti, Somalia, and
for the extent of human immunodeficiency Sudan. Tables 6.1–6.3 and C.1 (appendix c) list
virus (HIV) spread among the general popula- the results of available point-prevalence surveys
tion, the behavioral evidence for sexual risk in population-based and national surveys;
practices among this population group, and the among antenatal clinic (ANC) attendees and
context of the general population in the Middle other pregnant women; blood donors; and other
East and North Africa (MENA). different subpopulation groups in MENA.
The data below indicate that there is no evi-
dence of a substantial HIV epidemic in the gen-
HIV PREVALENCE IN THE GENERAL
POPULATION eral population in any of the MENA countries.
There appears to be very limited HIV transmis-
HIV prevalence has been measured in a number sion within the general population in MENA,
of general population groups in MENA. apart from Djibouti, Somalia, and Sudan. In
Prevalence levels are very low in all countries these nations, HIV is already generalized in parts
Djibouti 2.9% (national; Djibouti, Ministère de La Santé, and Association Internationale de Développement 2002)
3.4% (in Djibouti-ville; UNAIDS 2008)
1.1% (out of Djibouti-ville; UNAIDS 2008)
2.0% (Maslin et al. 2005)
2.2% (Maslin et al. 2005)
Iran, Islamic Republic of 0.0% (Hamadan province; Amini et al. 1993)
0.01% (Massarrat and Tahaghoghi-Mehrizi 2002)
Libya 0.13% (Libya National Center for the Prevention of and Control of Infectious Diseases 2005)
0.67% (Alkoufra; El-Gadi, Abudher, and Sammud 2008)
0.4% (Tripoli; El-Gadi, Abudher, and Sammud 2008)
Sudan 2.6% (national; SNAP 2005a)
2.0% (national; UNAIDS and WHO 2003)
1.6% (national; Sudan MOH 2006)
1.4% (national; SNAP 2008)
0.4% (Rumbek town, Southern Sudan; Kaiser et al. 2006)
4.4% (Yei town, Southern Sudan; Kaiser et al. 2006)
2.7% (in overall in Yei area; Southern Sudan; SNAP, NSNAC, and UNAIDS 2006)
65
Table 6.2 HIV Prevalence among ANC Attendees and Other Pregnant Women in MENA
66 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 6.2 (Continued)
Country HIV prevalence
68 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 6.3 (Continued)
Country HIV prevalence
of these countries, as defined technically by prev- behavior among the general population, including
alence larger than 1% among pregnant women.1 the nature of sexual behavior, nonconventional
Southern Sudan is of particular concern and marriage forms and polygamy, and the overall
could already be in a state of general population nature and trends of risky behavior. Further data
HIV epidemic, but conclusive evidence is still on sexual risk behavior among key vulnerable
lacking. Technically speaking, the HIV epidem- subgroups in the general population, such as pris-
ics in Djibouti and parts of Somalia are already oners, youth, and mobile populations, can be
generalized, but the context of HIV infection found in chapter 9. Further data on condom use
and risk groups in these countries suggest that and HIV knowledge and attitudes in the general
HIV dynamics are mainly focused around con- population can be found in chapter 8. Levels of
centrated epidemics in the commercial sex net- sexually transmitted infections (STIs) in the gen-
works. The generalization of the epidemic, being eral population can be found in chapter 10.
larger than 1% among pregnant women, mainly
reflects the large commercial sex networks in
Nature of sexual behavior
these countries in the context of major trade
corridors, large foreign military installations, Two case-control studies in Algeria and Morocco
and political conflict. HIV prevalence in these examining the epidemiology of human papillo-
countries is also much lower than HIV preva- mavirus (HPV) infection, an STI that causes
lence in countries in sub-Saharan Africa that cervical cancer, provided valuable data on the
truly have a general population HIV epidemic.2 sexual behavior of general population women
who were in the control arm of this study. In the
Algeria study, almost 30% of women reported
GENERAL POPULATION AND RISK more than one lifetime sexual partner, with 5%
BEHAVIOR reporting three or more partners.3 Twenty-six
percent of the women reported that their hus-
Data on sexual behavior among the general popu- bands had extramarital affairs with other women
lation continue to be rather limited. In particular, and 25% were unsure about their husbands’
it does not appear that any nationwide sexual extramarital affairs. Thirty-four percent reported
behavior survey has ever been conducted in that their husbands had sex with female sex
MENA. Several studies, however, collected a rea- workers (FSWs) and 10% were unsure about
sonable amount of data in a few countries and their husbands’ contacts with FSWs. Women in
these data provide a partial profile of sexual polygamous marriages (6% of women) were at
behavior in the general population. Below is a higher risk of cervical cancer, suggesting that
review of evidence on different aspects of risky polygamy implies a higher level of sexual risk
1
Pisani et al., “HIV Surveillance.”
2 3
UNAIDS/WHO, AIDS Epidemic Update 2007. Hammouda et al., “Cervical Carcinoma in Algiers.”
70 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Oman, 13% of male members of social clubs 13.8 for males and 18 for females.43 Recent
reported extramarital relations in the last year.26 extramarital sex was reported by 4.5% of males
In Somalia, 34% of general population men and and 1.7% of females.44
22.5% of general population women had more
than one sexual partner in the previous year.27
Nonconventional marriage forms and polygamy
The average age at first sex was 17 years for males
and 15 years for females.28 Also in Somalia, 32% Anecdotal evidence suggests an increasing preva-
of women attending STD (sexually transmitted lence of nonconventional forms of marriage in
disease) clinics were unmarried,29 and 4% of preg- MENA.45 One of these forms is zawaj al-muta’a or
nant women attending ANC centers were also sigheh (temporary marriage), sanctioned among
unmarried.30 Among Somali refugees in Kenya, Shiites, but not among Sunnis, and common in
HIV prevalence was associated with polygamy, the Islamic Republic of Iran and Lebanon.46 This
although not with statistical significance.31 form of marriage is legally permitted in the Islamic
In Sudan, 14.9% of males and 5.7% of Republic of Iran and consists of a marriage con-
females of mainly rural populations in six states tract between a man and a woman agreeing,
reported extramarital sex at the present time, often privately and verbally, to marry each other
but only 2.2% of males and 1.2% of females for a fixed term that can range from 1 hour to
used condoms during last sex.32 Sexual contacts 99 years.47 Sigheh appears to be common in the
between males were reported by 2% of the Islamic Republic of Iran, such as among divorced
males, and commercial sex was reported by women with limited financial resources.48 It was
3.1% of males and 1.4% of females.33 In further also encouraged by political leaders following the
studies from Sudan, 12% of adults reported a Islamic Revolution and is seen as an alternative to
nonregular sexual partner in the last year,34 and premarital or extramarital sex.49 Over a quarter of
premarital or extramarital sex was reported by the youth (27.1%) in the Islamic Republic of Iran
14.4% of university students,35 5.4% of ANC and almost half of the truck drivers (43.3%)
women attendees,36 10.3% of tea sellers,37 and found sigheh more acceptable than extramarital
15.3% of tuberculosis (TB) patients.38 sex.50 Institutionalizing temporary marriages
Furthermore, premarital sex was reported by through the construction of “chastity houses,”
1.2% of ANC women attendees,39 0.5% of tea where women would be paid for sex according to
sellers,40 and 1% of TB patients.41 In Southern some established rules, was suggested by some
Sudan, 44% of sexually active men and 4% of scholars in the Islamic Republic of Iran, but this
women reported that they have had sex with was never enacted.51
another person apart from their spouse or regu- Another form of nonconventional marriage is
lar sexual partner.42 Median age at first sex was ‘urfi marriage (clandestine marriage).52 This
form is religiously sanctioned among Sunnis
and Shiites, but has no legal bearings. It is most
26
Jenkins and Robalino, “HIV in the Middle East and North Africa.” common in the Arab Republic of Egypt and
27
WHO/EMRO, “Presentation of WHO Somalia’s Experience.” there is anecdotal evidence suggesting that it is
28
WHO, 2004 First National Second Generation HIV/AIDS/STI Sentinel increasing in prevalence in this country.53 While
Surveillance Survey (Somalia).
29
Somaliland Ministry of Health and Labour, Somaliland 2007. there are no reliable estimates of the number of
30
WHO, 2004 First National Second Generation HIV/AIDS/STI Sentinel
43
Surveillance Survey (Somalia). Ibid.
31 44
UNHCR, HIV Sentinel Surveillance among Antenatal Clients. Ibid.
32 45
SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.” Rashad and Osman, “Nuptiality in Arab Countries.”
33 46
Ibid. Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.”
34 47
SNAP, Situation Analysis. Mohammad et al., “Sexual Risk-Taking Behaviors among Boys”; Haeri,
35
Ahmed, University Students. “Temporary Marriage.”
36 48
Ahmed, Antenatal. Aghajanian, Family and Family Change in Iran.
37 49
Ahmed, Tea Sellers. Haeri, “Temporary Marriage.”
38 50
Ahmed, TB Patients. Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.”
39 51
Ahmed, Antenatal. Sepehrad, “The Role of Women “; Recknagel and Gorgin, “Iran.”
40 52
Ahmed, Tea Sellers. Roudi-Fahimi and Ashford, “Sexual & Reproductive Health”; DeJong
41
Ahmed, TB Patients. et al., “The Sexual and Reproductive Health of Young People.”
42 53
NSNAC and UNAIDS, HIV/AIDS Integrated Report South Sudan. Beamish, “Adolescent Reproductive Health in Egypt.”
72 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
and STI risk of exposure is complex in MENA, Intergenerational sex puts women at higher risk
because polygamy tends to be associated with of exposure to STIs.94 Among women who had
closed sexual networks rather than open and cervical cancer and reported first marriage/
intertwined networks.86 However, the above intercourse before age 15 in Morocco, 57%
evidence does give credence to the possibility married a husband in the 20–30 years age range
that polygamy could be associated with higher and 19% married a husband older than 30 years
risk of exposure to STIs within the context of of age.95 Intergenerational sex has been impli-
this region. cated as the main reason behind the large gap in
HIV prevalence between men and women in
Overall nature and trends of sexual risk behavior sub-Saharan Africa.96 Though age at marriage
has increased rapidly over the last three
The above evidence suggests that the levels of decades,97 a substantial fraction of women still
sexual risk behavior among the general popula- marry at an early age. Early age at marriage was
tion in MENA appear to be rather low in com- found to be associated with higher risk of expo-
parison to other regions.87 The MENA popula- sure to STIs in two studies of women in MENA.98
tion views sex outside of marriage very nega- While the overall levels of sexual risk behav-
tively, particularly for women.88 Premarital sex iors appear to be rather low, there are indica-
is one of the leading causes of suicide among tions that they are increasing in MENA.
young women. In Algeria, 30% of women who Behavioral surveys in Lebanon and Turkey sug-
commit suicide are pregnant but unmarried.89 gest increased risky behavior among youth.99
In Turkey, hymen examination is the most fre- Anecdotal evidence points to increases in sexual
quent cause of suicide among young Turkish activity, sexual risk behavior, and STIs among
women.90 boys and girls.100
Most of the sexual risk behavior appears to be
practiced by men rather than women.
Nevertheless, women endure a large share of
the STD burden through exposures to infected MALE CIRCUMCISION
husbands. Sex with an infected partner was Male circumcision is nearly universal in
found to be a significant predictor of women’s MENA,101 and there is extensive scientific evi-
exposure to STDs in Egypt.91 Infection with dence for its protective effects against HIV,
STDs in Morocco was more associated with male including a measured efficacy of 60% against
rather than female sexual behavior.92 HIV infection established in three randomized
Most of the sexual risk behavior appears to be clinical trials.102 Southern Sudan is the only part
concentrated in, but not confined to, youth and of MENA where universal male circumcision is
before marriage. Eighty-one percent of STD not the norm. A study in Juba, Southern Sudan,
clinic attendees in Kuwait were either single or found that only 44% of men were circumcised
married patients living alone.93 Most of them (90% of Muslim men and 39% of non-Muslim
were in the 21–30 years age group. Nonetheless, men).103 The prevalence of male circumcision is
sexual risk exists for all age groups, its form
varying depending on the age group. 94
Chaouki et al., “The Viral Origin of Cervical Cancer”; Burchell et al.,
There appears to be a substantial gap in age “Chapter 6.”
in sexual partnerships between men and 95
Chaouki et al., “The Viral Origin of Cervical Cancer.”
96
women, with women marrying older men. Hallett et al., “Behaviour Change”; Gregson et al., “Sexual Mixing
Patterns.”
97
Rashad, “Demographic Transition.”
86 98
Huff, “Male Circumcision: Cutting the Risk?” Chaouki et al., “The Viral Origin of Cervical Cancer”; Hassen et al.,
87
Wellings et al., “Sexual Behaviour in Context”; Durex, “Global Sex “Cervical Human Papillomavirus Infection.”
99
Survey 2005.” Kassak et al., “Final Working Protocol”; Yamazhan et al., “Attitudes
88
Sakalli-Ugurlu and Glick, “Ambivalent Sexism.” towards HIV/AIDS.”
89 100
International Planned Parenthood Federation, “Unsafe Abortion.” Busulwa, “HIV/AIDS Situation Analysis Study.”
90 101
Gursoy and Vural, “Nurses’ and Midwives’ Views.” Weiss et al., “Male Circumcision.”
91 102
Mostafa and Roshdy, “Risk Profiles.” Auvert et al., “Randomized, Controlled Intervention Trial”; Bailey
92
Ryan et al., “Reproductive Tract Infections.” et al., “Male Circumcision”; Gray et al., “Male Circumcision.”
93 103
Al-Mutairi et al., “Clinical Patterns.” UNHCR, “HIV Behavioural Surveillance Survey.”
74 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
limited inroads into the general population.115 ———. 2004c. Internally Displaced People: Situation
This further indicates limited potential for a sus- Analysis-Behavioral Survey Results & Discussions. Report.
Sudan National AIDS Control Program.
tainable HIV epidemic in the general population.
———. 2004d. Military: Situation Analysis-Behavioral
At a global level, there is no evidence for a Survey Results & Discussions. Report. Sudan National
sustainable general population HIV epidemic AIDS Control Program.
apart from specific parts of sub-Saharan Africa.116 ———. 2004e. Prisoners: Situation Analysis-Behavioral
It is inconceivable that MENA will be the excep- Survey Results & Discussions. Report. Sudan National
AIDS Control Program.
tion to this pattern after consistently very low
———. 2004f. Sex Sellers: Situation Analysis-Behavioral
HIV prevalence in the general population over Survey Results & Discussions. Report. Sudan National
the two decades since the virus’s introduction AIDS Control Program.
into the MENA population in the 1980s. ———. 2004g. STDs: Situation Analysis-Behavioral Survey
All of the above considerations affirm that it Results & Discussions. Report. Sudan National AIDS
Control Program.
is unlikely that the MENA region will experi-
———. 2004h. Street Children: Situation Analysis-Behavioral
ence a sustainable or substantial HIV epidemic Survey Results & Discussions. Report. Sudan National
in the general population in at least the foresee- AIDS Control Program.
able future, if ever. Nevertheless, prevention ———. 2004i. TB Patients: Situation Analysis-Behavioral
resources in MENA continue to be focused Survey Results & Discussions. Report. Sudan National
among the general population, as opposed to AIDS Control Program.
priority groups, despite its lowest risk of HIV ———. 2004j. Tea Sellers: Situation Analysis-Behavioral
Survey Results & Discussions. Report. Sudan National
exposure of all HIV risk groups. HIV programs AIDS Control Program.
focused on the general population in MENA ———. 2004k. Truck Drivers: Situation Analysis-Behavioral
should stress stigma reduction, rather than per- Survey Results & Discussions. Report. Sudan National
sonal risk reduction, and prevention efforts AIDS Control Program.
should be focused on priority populations. ———. 2004l. University Students: Situation Analysis-
Behavioral Survey, Results & Discussions. Report. Sudan
National AIDS Control Program.
Aidaoui, M., S. Bouzbid, and M. Laouar. 2008.
“Seroprevalence of HIV Infection in Pregnant Women
BIBLIOGRAPHY in the Annaba Region (Algeria).” Rev Epidemiol Sante
Publique 56: 261–66.
Abdul Mujeeb, S., K. Aamir, and K. Mehmood. 2000.
“Seroprevalence of HBV, HCV and HIV Infections Al Katheeb, M. S., M. S. Tarawneh, and A. S. Awidi.
among College Going First Time Voluntary Blood 1988. “Antibodies to HIV in Jordanian Blood Donors
Donors.” J Pak Med Assoc 50: 269–70. and Patients with Congenital Bleeding Disorders.” IV
International Conference on AIDS, Stockholm,
Abdul Mujeeb, S., and M. R. Hashmi. 1988. “A Study of abstract 5003.
HIV-Antibody in Sera of Blood Donors and People at
Al Rasheed, A. M., D. Fairclough, Abu Al Sand, and A.
Risk.” J Pak Med Assoc 38: 221–22.
O. Osoba. 1988. “Screening for HIV Antibodies
Afghanistan Central Blood Bank. 2006. Report of Testing of among Blood Donors at Riadh Armed Forces
Blood Donors from March–December, 2006. Ministry of Hospital.” IV International Conference on AIDS,
Public Health, Kabul, Afghanistan. Stockholm, abstract 5001.
Afsar, I., S. Gungor, A. G. Sener, and S. G. Yurtsever. Alamawi, S., A. Abutaleb, L. Qasem, S. Masoud, Z.
2008. “The Prevalence of HBV, HCV and HIV Memish, K. Al Khairy, O. Kheir, S. Bernvil, and A. H.
Infections among Blood Donors in Izmir, Turkey.” Hajeer. 2003. “HIV-1 p24 Antigen Testing in Blood
Indian J Med Microbiol 26: 288–89. Banks: Results from Saudi Arabia.” Br J Biomed Sci 60:
Aghajanian, A. 2001. Family and Family Change in Iran. 102–4.
Fayetteville: Fayetteville State University. Alami, K. 2009. “Tendances récentes de l’épidémie à
VIH/SIDA en Afrique du nord.” Presentation,
Ahmed, S. M. 2004a. AIDS Patients: Situation Analysis-
Research and AIDS Workshop in North Africa,
Behavioral Survey Results & Discussions. Report. Sudan
Marrakech, Morocco.
National AIDS Control Program.
Algeria MOH (Ministry of Health). “Rapport de l’enquête
———. 2004b. Antenatal: Situation Analysis-Behavioral
nationale de séro-surveillance sentinelle du VIH et de
Survey Results & Discussions. Report. Sudan National
la syphilis en Algérie 2004–2005.”
AIDS Control Program.
Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, I.
El-Adawy, and M. Rijhwani. 2007. “Clinical Patterns
115
Alsallaq et al., “Quantitative Assessment.” of Sexually Transmitted Diseases, Associated
116
UNAIDS/WHO, AIDS Epidemic Update 2007. Sociodemographic Characteristics, and Sexual
76 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
in a Middle Eastern Community.” BMC Womens Health Iqbal, J., and N. Rehan. 1996. “Sero-Prevalence of HIV:
4: 3. Six Years’ Experience at Shaikh Zayed Hospital,
Gray, R. H., G. Kigozi, D. Serwadda, F. Makumbi, Lahore.” J Pak Med Assoc 46: 255–58.
S. Watya, F. Nalugoda, N. Kiwanuka, L. H. Moulton, IRC (International Rescue Committee). 2002. CDC.
M. A. Chaudhary, M. Z. Chen, N. K. Sewankambo, Kakuma Refugee Camp Sentinel Surveillance Report.
F. Wabwire-Mangen, M. C. Bacon, C. F. M. Williams, Nairobi.
P. Opendi, S. J. Reynolds, O. Laeyendecker, T. C. Jama, H., L. Grillner, G. Biberfeld, S. Osman, A. Isse, M.
Quinn, and M. J. Wawer. 2007. “Male Circumcision Abdirahman, and S. Bygdeman. 1987. “Sexually
for HIV Prevention in Men in Rakai, Uganda: A Transmitted Viral Infections in Various Population
Randomised Trial.” Lancet 369: 657–66. Groups in Mogadishu, Somalia.” Genitourin Med 63:
Gregson, S., C. A. Nyamukapa, G. P. Garnett, P. R. 329–32.
Mason, T. Zhuwau, M. Carael, S. K. Chandiwana, Jenkins, C., and D. A. Robalino. 2003. “HIV in the
and R. M. Anderson. 2002. “Sexual Mixing Patterns Middle East and North Africa: The Cost of Inaction.”
and Sex-Differentials in Teenage Exposure to HIV Orientations in Development Series, World Bank.
Infection in Rural Zimbabwe.” Lancet 359: 1896–
1903. Jurjus, A. R., J. Kahhaleh, National AIDS Program, and
WHO/EMRO (World Health Organization/Eastern
Gursoy, E., and G. Vural. 2003. “Nurses’ and Midwives’ Mediterranean Regional Office). 2004. “Knowledge,
Views on Approaches to Hymen Examination.” Nurs Attitudes, Beliefs, and Practices of the Lebanese
Ethics 10: 485–96. concerning HIV/AIDS.” Grey Report, Beirut,
Gutbi, O. S.-A., and A. M. G. Eldin. 2006. “Women Tea- Lebanon.
Sellers in Khartoum and HIV/AIDS: Surviving Against Kaiser, R., T. Kedamo, J. Lane, G. Kessia, R. Downing, T.
the Odds.” Grey Report, Khartoum, Sudan. Handzel, E. Marum, P. Salama, J. Mermin, W. Brady,
Haeri, S. 1994. “Temporary Marriage: An Islamic and P. Spiegel. 2006. “HIV, Syphilis, Herpes Simplex
Discourse on Female Sexuality in Iran.” In The Eye of Virus 2, and Behavioral Surveillance among Conflict-
the Storm: Women in Post-Revolutionary Iran, ed. M. Affected Populations in Yei and Rumbek, Southern
Afkhami and E. Friedl, 98–114. New York, NY: Tauris Sudan.” AIDS 20: 942–44.
Publishers. Kakepoto, G. N., H. S. Bhally, G. Khaliq, N. Kayani, I. A.
Hajiabdolbaghi, M., N. Razani, N. Karami, P. Kheirandish, Burney, T. Siddiqui, and M. Khurshid. 1996.
M. Mohraz, M. Rasoolinejad, K. Arefnia, Z. Kourorian, “Epidemiology of Blood-Borne Viruses: A Study of
G. Rutherford, and W. McFarland. 2007. “Insights Healthy Blood Donors in Southern Pakistan.”
from a Survey of Sexual Behavior among a Group of Southeast Asian J Trop Med Public Health 27: 703–6.
At-Risk Women in Tehran, Iran, 2006.” AIDS Educ Kandela, P. 1993. “Arab Nations: Attitudes to AIDS.”
Prev 19: 519–30. Lancet 341: 884–85.
Hallett, T. B., S. Gregson, J. J. Lewis, B. A. Lopman, and Kapiga, S. H. 1996. “Determinants of Multiple Sexual
G. P. Garnett. 2007. “Behaviour Change in Generalised Partners and Condom Use among Sexually Active
HIV Epidemics: Impact of Reducing Cross- Tanzanians.” East Afr Med J 73: 435–42.
Generational Sex and Delaying Age at Sexual Debut.”
Sex Transm Infect 83 Suppl 1: i50–54. Kapiga, S. H., and J. L. Lugalla. 2002. “Sexual Behaviour
Patterns and Condom Use in Tanzania: Results from
Hammouda, D., N. Munoz, R. Herrero, A. Arslan, A. the 1996 Demographic and Health Survey.” AIDS Care
Bouhadef, M. Oublil, B. Djedeat, B. Fontaniere, P. 14: 455–69.
Snijders, C. Meijer, and S. Franceschi. 2005. “Cervical
Carcinoma in Algiers, Algeria: Human Papillomavirus Kassak, K., J. DeJong, Z. Mahfoud, R. Afifi, S. Abdurahim,
and Lifestyle Risk Factors.” Int J Cancer 113: 483–89. M. L. Sami Ramia, F. El-Barbir, M. Ghanem, S.
Shamra, K. Kreidiyyeh, and D. El-Khoury. 2008.
Hashim, M. S., M. A. Salih, A. A. el Hag, Z. A. Karrar, E. “Final Working Protocol for an Integrated Bio-
M. Osman, F. S. el-Shiekh, I. A. el Tilib, and N. E. Behavioral Surveillance Study among Four
Attala. 1997. “AIDS and HIV Infection in Sudanese Vulnerable Groups in Lebanon: Men Who Have Sex
Children: A Clinical and Epidemiological Study.” with Men; Prisoners; Commercial Sex Workers; and
AIDS Patient Care STDS 11: 331–37. Intravenous Drug Users.” Grey Report.
Hassen, E., A. Chaieb, M. Letaief, H. Khairi, A. Zakhama, Kayani, N., A. Sheikh, A. Khan, C. Mithani, and M.
S. Remadi, and L. Chouchane. 2003. “Cervical Khurshid. 1994. “A View of HIV-I Infection in
Human Papillomavirus Infection in Tunisian Karachi.” J Pak Med Assoc 44: 8–11.
Women.” Infection 31: 143–48.
Khattabi, H., and K. Alami. 2005. “Surveillance senti-
Huff, B. 2000. “Male Circumcision: Cutting the Risk?” nelle du VIH, Résultats 2004 et tendance de la séro-
American Foundation for AIDS Research, August. prévalence du VIH.” Morocco Ministry of Health,
Institut de Formation Paramédicale de Parnet. 2004. UNAIDS.
Rapport de la réunion d’évaluation a mis-parcours de Khedmat, H., F. Fallahian, H. Abolghasemi, S. M.
l’enquête de sero-surveillance du VIH. Juin. Alavian, B. Hajibeigi, S. M. Miri, and A. M. Jafari.
International Planned Parenthood Federation. 1992. 2007. “Seroepidemiologic Study of Hepatitis B Virus,
“Unsafe Abortion and Sexual Health in the Arab Hepatitis C Virus, Human Immunodeficiency Virus
World: The Damascus Conference.” Proceedings of and Syphilis Infections in Iranian Blood Donors.” Pak
the Damascus Conference, Arab World Region. J Biol Sci 10: 4461–66.
78 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Raza, M. I., A. Afifi, A. J. Choudhry, and H. I. Khan. SNAP, and UNAIDS. 2006. “HIV/AIDS Integrated Report
1998. “Knowledge, Attitude and Behaviour towards North Sudan, 2004–2005 (Draft).” With United
AIDS among Educated Youth in Lahore, Pakistan.” Nations General Assembly Special Session on HIV/
J Pak Med Assoc 48: 179–82. AIDS Declaration of Commitment.
Recknagel, C., and A. Gorgin. 2002. “Iran: Proposal SNAP, UNICEF (United Nations Childrens Fund), and
Debated for Solving Prostitution with ‘Chastity UNAIDS. 2005. “Baseline Study on Knowledge,
Houses.’” Prague, 7 August (RFE/RL). Attitudes, and Practices on Sexual Behaviors and
Rezvan, H., H. Abolghassemi, and S. A. Kafiabad. 2007. HIV/AIDS Prevention amongst Young People in
“Transfusion-Transmitted Infections among Selected States in Sudan.” HIV/AIDS KAPB Report,
Multitransfused Patients in Iran: A Review.” Transfus Projects and Research Department (AFROCENTER
Med 17: 425–33. Group).
Roudi-Fahimi, F., and L. Ashford. 2008. “Sexual & Somaliland Ministry of Health and Labour. 2007.
Reproductive Health in the Middle East and North Somaliland 2007 HIV/Syphilis Seroprevalence Survey, A
Africa. A Guide for Reporters.” Population Reference Technical Report. Ministry of Health and Labour in col-
Bureau. laboration with the WHO, UNAIDS, UNICEF/
GFATM, and SOLNAC.
Ryan, C. A., A. Zidouh, L. E. Manhart, R. Selka, M. Xia,
M. Moloney-Kitts, J. Mahjour, M. Krone, B. N. Southern Sudan AIDS Commission. 2007. Southern
Courtois, G. Dallabetta, and K. K. Holmes. 1998. Sudan ANC Sentinel Surveillance Data. U.S. Centers
“Reproductive Tract Infections in Primary Healthcare, for Disease Control and Prevention (CDC), Sudan,
Family Planning, and Dermatovenereology Clinics: and Southern Sudan AIDS Commission. Database.
Evaluation of Syndromic Management in Morocco.” Sudan Department of Statistics. 1991. Sudan Demographic
Sex Transm Infect 74 Suppl 1: S95–105. and Health Survey 1989/1990. Ministry of Economic
Sakalli-Ugurlu, N., and P. Glick. 2003. “Ambivalent and National Planning Sudan, Macro International.
Sexism and Attitudes toward Women Who Engage in Columbia MD: Department of Statistics and Macro
Premarital Sex in Turkey.” J Sex Res 40: 296–302. International.
Scott, D. A., A. L. Corwin, N. T. Constantine, M. A. Sudan MOH (Ministry of Health). 2006. 2005 ANC
Omar, A. Guled, M. Yusef, C. R. Roberts, and D. M. Sentinel Sites Results. Khartoum.
Watts. 1991. “Low Prevalence of Human Sudan National AIDS/STIs Program. 2008. 2007 ANC HIV
Immunodeficiency Virus-1 (HIV-1), HIV-2, and Sentinel Sero-survey, Technical Report. Federal Ministry
Human T Cell Lymphotropic Virus-1 Infection in of Health, Preventive Medicine Directorate, Draft.
Somalia.” American Journal of Tropical Medicine and Sultan, F., T. Mehmood, and M. T. Mahmood. 2007.
Hygiene 45: 653. “Infectious Pathogens in Volunteer and Replacement
Sepehrad, R. 2002. “The Role of Women in Iran’s New Blood Donors in Pakistan: A Ten-Year Experience.”
Popular Revolution.” Brown J World Aff 9: 217. Int J Infect Dis 11: 407–12.
SeyedAlinaghi, S. 2009. “Seroprevalence of HIV Infection Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge,
among Pregnant Women in Tehran, Iran, by Rapid Attitudes and Practices concerning HIV/AIDS
HIV Test.” Personal communication. among Iranian At-Risk Sub-Populations.” Eastern
Sharifi-Mood, B., and F. Keikha. 2008. “Seroprevalence Mediterranean Health Journal 14.
of Human Immunodeficiency Virus (HIV) in Pregnant Todd, C. S., M. Ahmadzai, F. Atiqzai, S. Miller, J. M.
Women in Zahedan, Southeastern Iran.” Journal of Smith, S. A. Ghazanfar, and S. A. Strathdee. 2008.
Research in Medical Sciences 13: 186–88. “Seroprevalence and Correlates of HIV, Syphilis, and
SNAP (Sudan National AIDS Program). 2002. Situation Hepatitis B and C Virus among Intrapartum Patients
Analysis: Behavioral & Epidemiological Surveys & Response in Kabul, Afghanistan.” BMC Infect Dis 8: 119.
Analysis. HIV/AIDS Strategic Planning Process Report, Todd, C. S., M. Ahmadzai, F. Atiqzai, H. Siddiqui, P.
Federal Ministry of Health, Khartoum. Azfar, S. Miller, J. M. Smith, S. A. S. Ghazanfar, and
———. 2004. HIV/AIDS/STIs Prevalence, Knowledge, S. A. Strathdee. 2007. “Seroprevalence and Correlates
Attitude, Practices and Risk Factors among University of HIV, Syphilis, and Hepatitis B and C Infection
Students and Military Personnel. Federal Ministry of among Antenatal Patients and Testing Practices and
Health, Khartoum. Knowledge among Obstetric Care Providers in
Kabul.” PowerPoint presentation.
———. 2005a. National Policy on HIV/AIDS. SNAP.
UNAIDS (United Nations Joint Programme on HIV/AIDS).
———. 2005b. Sentinel Sero-Surveillance—2005 Data. 2000. Epidemiological Country Fact Sheet, Sudan.
Annual newsletter, SNAP.
———. 2008. “Notes on AIDS in the Middle East and
———. 2008. “Update on the HIV Situation in Sudan.” North Africa.” RST, MENA.
PowerPoint presentation, SNAP.
UNAIDS, and WHO (World Health Organization). 2003.
SNAP (Sudan National AIDS Program), NSNAC (New AIDS Epidemic Update 2003. Geneva.
Sudan National AIDS Council), and UNAIDS (United
Nations Joint Programme on HIV/AIDS). 2006. ———. 2005. AIDS Epidemic Update 2005. Geneva.
“Scaling-up HIV/AIDS Response in Sudan.” National ———. 2007. AIDS Epidemic Update 2007. Geneva.
Consultation on the Road towards Universal Access UNHCR (United Nations High Commissioner for
to Prevention, Treatment, Care and Support. Refugees). 2003. National AIDS and Sexually Transmitted
80 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 7
This chapter covers other relevant aspects of clinic attendees2 and suspected AIDS patients3 in
human immunodeficiency virus (HIV) epidemiol- Sudan, 5.4% and 0% reported ever using a con-
ogy in the Middle East and North Africa (MENA) dom, 13.2% and 17.4% reported premarital and
gleaned from various sources and available data. extramarital sex, 0.8% and 8.7% reported pre-
marital sex, and 3.9% and 4.3% paid for sex,
respectively. Consistently in MENA, studies
HIV AND SEXUALLY TRANSMITTED report that the main source of the STD infection
DISEASE CLINIC ATTENDEES, VOLUNTARY is sexual contact with female sex workers (FSWs),
COUNSELING AND TESTING ATTENDEES, such as in the Islamic Republic of Iran,4 Kuwait,5
AND SUSPECTED AIDS PATIENTS Pakistan,6 Somalia,7 and Sudan.8
81
Available data illustrate that the passive lines for HIV surveillance. There is also very
facility-based surveillance at STD clinics and limited information on the populations on
VCT centers is to a large extent not capturing which these measurements were made. Given
the dynamics of HIV transmission in MENA. An theses limitations, the prevalence levels may
active surveillance among priority populations not be representative of the populations that
incorporating an integrated biobehavioral sur- they are supposed to represent. However,
veillance methodology would be a much more despite these limitations, these measures are
effective approach in generating interpretable useful to corroborate the rest of the point-
data on HIV epidemiology in MENA. prevalence surveys discussed in the previous
chapters and, indeed, convey the same picture
of HIV epidemiology in MENA.
HIV/AIDS AMONG TUBERCULOSIS
PATIENTS
Analytical summary
HIV/AIDS among tuberculosis (TB) patients is a
The further point-prevalence surveys in table D.3
useful indicator of the maturity of the HIV epi-
are generally consistent with those reported in
demic in a given setting because it reflects the
the previous chapters and follow similar pat-
presence of advanced HIV or AIDS cases in the
terns. Injecting drug users (IDUs) and men who
population. Table D.2 (appendix D) summarizes
have sex with men (MSM) are the key priority
the results of available point-prevalence sur-
groups for HIV infectious spread in MENA, fol-
veys among TB patients.
lowed by FSWs, but mainly in Djibouti, Somalia,
and Sudan. There is very limited HIV prevalence
Analytical summary
in the general population.
Available prevalence surveys among TB patients The fluctuations among some of these data
suggest that apart from Djibouti, Somalia, and may suggest a lack of representation. To maxi-
Sudan, HIV prevalence among TB patients is gen- mize the explanatory power of point-prevalence
erally low. HIV has clearly been making inroads data, MENA countries need to conduct point-
into a subset of the populations in Djibouti, prevalence measurements using consistent and
Somalia, and Sudan for at least a decade. The lim- standard methodology and internationally ac-
ited prevalence among TB patients in the rest of cepted guidelines for HIV surveillance.
MENA countries is probably a consequence of
either the recent introduction of HIV into high-
risk networks or the very low levels of HIV preva- HIV-POSITIVE RESULTS EXTRACTED
lence in the whole population, except possibly for FROM HIV/AIDS CASE NOTIFICATION
small pockets of high-risk priority groups. SURVEILLANCE REPORTS
Many countries in MENA routinely test different
FURTHER POINT-PREVALENCE SURVEYS population groups for HIV. These groups include
blood tissue and organ donors, blood recipients,
Table D.3 (appendix D) lists a summary of
pregnant women, marriage applicants, university
point-prevalence surveys extracted from the
students, public sector employees, out-migrants
United Nations Joint Programme on HIV/AIDS
(for visa to work abroad), in-migrants (for resi-
(UNAIDS) epidemiological facts sheets on each
dency or visa renewal), prisoners, TB patients,
MENA country over the years. Some of the data
suspected AIDS cases, VCT attendees, STD clinic
reported here are gleaned from country-based
attendees, sexual contacts of people living with
case notification surveillance reports9 or are
HIV (PLHIV), “bar girls,” FSWs, MSM, drug
provided through national-level agencies. These
users, and IDUs.
surveys may not be conducted using sound
The results of 53 million HIV tests reported to
methodology or internationally accepted guide-
the World Health Organization (WHO), as
part of the HIV/AIDS case notification surveil-
9
WHO/EMRO Regional Database on HIV/AIDS. lance reports, show an overall prevalence of
82 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
0.09%.10 Figure 7.1 displays the Figure 7.1 Fraction of HIV Tests That Are Positive in Different Population
percentage of these tests that were Groups in MENA
positive among different population 10
groups.11 Figure 7.2 shows the 9
distribution of HIV tests by population 8
group. Not all countries report these
7
tests and among those that do, they
prevalence (%)
6
may not do so consistently. Therefore,
these point-prevalence measurements 5
d)
s
rs
n
g
nts
mig s
ts
Ws
ers
ts
s
g
ts
M
"
ses
ts
ee
irls
t
IDU
me
stin
stin
ifie
an
ran
ien
no
(no gran
en
MS
ipie
nd
son
FS
alence across these measures, suggesting
ca
rg
o
igr
do
ec
l te
ati
D c nd te
tw
pa
tte
rec
mi
"ba
pri
t-m
t sp
IDS
Sp
od
rita
the lack of representation.
ca
an
B
in-
a
blo
T
ou
od
AID
dA
gn
ma
lini
ing
The pattern emerging in these test- blo
pre
cte
pre
ers
of
nse
pe
cts
oth
ST
ing reports is that of consistently very
ou
sus
nta
yc
low HIV prevalence in the general
l co
tar
population in the majority of coun-
un
ua
vol
sex
tries. HIV prevalence is nearly nil
among blood donors, pregnant Source: WHO/EMRO Regional Database on HIV/AIDS.
women, marriage applicants, kidney
donors, and migrants. In over 3 mil- Figure 7.2 Distribution of HIV Tests in MENA by Population Group
lion HIV tests conducted in the Syrian
STD clinic attendees Sexual contacts of AIDS patients
Arab Republic over eight years up to
Voluntary counseling and testing "Bar girls"
2003, less than 300 HIV cases were
12 TB patients FSWs
identified. Most HIV infections are
Prisoners MSM
found among priority and vulnerable
Suspected AIDS cases IDUs
populations, their sexual partners, or
in populations with suspected infec- Others (not specified) Blood donors
tion or identifiable risks. Even in Migrants
these populations, the majority of In-migrants
testing reports show relatively low
HIV prevalence. Out-migrants
It is evident in figure 7.2 that the Blood recipients
vast majority of HIV tests in MENA Premarital testing
are conducted on populations at low Pregnant women
risk of HIV infection. This suggests
that resources may not be prioritized
for testing the priority groups at high
risk of infection. HIV testing in MENA Source: WHO/EMRO Regional Database on HIV/AIDS.
appears to be disconnected with the
reality of HIV epidemiology in the region. The recent years. These fluctuations confirm the
reported numbers of positive tests have also nonsustained and sporadic nature of HIV test-
fluctuated substantially in several countries in ing and the lack of standard and effective
methodological surveillance by MENA
10
countries. The Islamic Republic of Iran, for
Ibid.
11
Ibid. example, observed two large blips in reported
12
Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.” cases in 1996 and 2001, which turned out to be
84 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
men rather than women. However, the propor- return. In the rest of the countries with endogenous
tion of females among PLHIV appears to be HIV epidemics, the dominant transmission mode
increasing. This pattern may suggest a matura- reflects the nature of the epidemics in these
tion of the second wave of infection spread from countries. For example, the dominant transmission
men with identifiable risk behaviors to their mode in the Islamic Republic of Iran is injecting
wives, who are vulnerable to the infection drug use, while the dominant mode in Sudan is
despite engaging in no risky behavior of their heterosexual sex, echoing the nature of the
own. HIV infections are repeatedly found among epidemics in these two countries.
women with no identifiable risk behaviors, sug-
gesting that the risk factor is heterosexual sex
with the spouse.34 PATTERN OF EXOGENOUS HIV EXPOSURES
IN MENA
86 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 7.1 (Continued)
Heterosexual Homosexual Injecting drug Blood or blood prod- Mother-to-child
Country transmission transmission transmission ucts transmission transmission
Saudi Arabia 37.9% (Al-Mazrou 2.5% (Al-Mazrou 1.3% (Al-Mazrou 25.0% (Al-Mazrou 6.5%
et al. 2005) et al. 2005) et al. 2005) et al. 2005) (Al-Mazrou
46.0% (Alrajhi, 5.0% (Alrajhi, 2.0% (Alrajhi, 26.0% (Alrajhi, Halim, et al. 2005)
Halim, and Halim, and Halim, and and Al-Abdely 2004) 12.0% (Alrajhi,
Al-Abdely 2004) Al-Abdely 2004) Al-Abdely 2004) Halim, and
Al-Abdely 2004)
Sudan 97.0% (UNAIDS
and WHO 2007;
SNAP, UNICEF, and
UNAIDS 2005;
Farah and Hussein
2006)
Syrian Arab 70.0% (Syria 8.0% (Syria 4.0% (Syria 12.0% (Syria National 3.0% (Syria
Republic National AIDS National AIDS National AIDS AIDS Programme 2004) National AIDS
Programme 2004) Programme 2004) Programme Programme
2004) 2004)
Tunisia 56.3% (Kilani et al. 6.5% (men; Hsairi 37.1% (Hsairi
2007) and Ben Abdallah and Ben
75.0% (women; 2007) Abdallah 2007)
Zouiten et al. 2002)
67.2% (women;
Hsairi and Ben
Abdallah 2007)
25.7% (men; Hsairi
and Ben Abdallah
2007)
West Bank 52.0% (UNAIDS 1.0% (UNAIDS 4.7% (UNAIDS 17.6% (UNAIDS 2007)
and Gaza 2007) 2007) 2007)
Yemen, 77.3% (Lambert 16.0% (Lambert 6.8% (Lambert 2007)
Republic of 2007) 2007)
of these countries, or HIV transmissions to their populations. This could also facilitate the
sexual partners upon their return. The weak detection of emerging epidemics and would
surveillance systems of priority populations offer a window of opportunity for targeted
prevent us from definitively concluding whether prevention at an early phase of an epidemic.
this is indeed the dominant epidemiologic Pakistan is a relevant example; after nearly two
pattern in these countries. HIV could be still decades of an epidemiologic pattern of
spreading among some of the priority groups, exogenous HIV exposures, HIV found its way
or within pockets of these populations, without to priority populations and has spread rapidly
awareness of this endemic spread. However, among IDUs and, to some extent, MSM.42
there is no evidence to date that such Monitoring recent infections and examining
considerable endemic transmission exists in the nature of exposures could also be useful in
these countries. detecting emerging endemic transmission
Effective and repeated surveillance of chains in these countries.
priority populations (IDUs, MSM, and FSWs) is
key for these countries to conclusively confirm 42
Pakistan National AIDS Control Program, HIV Second Generation
that HIV spread is indeed limited in priority Surveillance (Rounds I, II, and III).
88 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
incidence of needlestick injuries in Saudi Arabia outbreak in HIV/AIDS history occurred in a chil-
was estimated at 11% per nurse per year and 6% dren’s hospital in Libya and involved 402 chil-
per doctor per year.65 There is not sufficient dren, 19 mothers (through breastfeeding), and
knowledge of risks of needlestick injuries even two nurses.76 The first documented HIV out-
among HCWs.66 Despite what appeared to be break in renal dialysis centers in the history of
good knowledge, the performance of HCWs for the HIV epidemic occurred in Egypt,77 which
universal blood precautions in public hemodialy- had a second HIV outbreak in renal dialysis cen-
sis units in Egypt was poor, and performance was ters as well.78 HCV incidence among hemodialy-
worse in private units.67 sis patients in Morocco was very high at 9.41%
At 4.3 per year, MENA has the highest rate of per person per year,79 and moderately high in
injections per person per year of all regions.68 the Islamic Republic of Iran at 1.8% per person
In Egypt, 26.8% of women in the 2005 Demo- per year,80 suggesting elevated levels of nosoco-
graphic and Health Survey reported receiving an mial transmissions. Incidence of blood-borne
injection in the last six months, with an average diseases was found to be common in dialysis
number of two injections.69 MENA also has the centers in Jordan.81
highest levels of all regions of incidences of HBV There is at least one documented HIV infec-
(58.3%) and HCV infections (81.7%) attribut- tion in MENA that resulted from hijamah (tradi-
able to contaminated injections.70 It is estimated tional medicine practice of phlebotomy by
that 7.2% of HIV infections in the region are due applying glass cupping and skin scarification).82
to contaminated injections.71 Every year in A history of hijamah has been associated with
MENA, contaminated injections appear to be the HCV infection in two Iranian studies.83
cause of 2.5 million HBV infections, 645,000 Parenteral transmission of HIV has been
HCV infections, and 2,200 HIV infections.72 documented in several MENA countries and
Reuse of needles and syringes; major and minor HIV prevalence has been measured among a
surgery; hospitalization; a history of invasive number of populations at risk of parenteral HIV
procedures; a history of dental procedures; high infection. Table 7.2 lists these HIV prevalence
levels of injections; medical abortion; and formal measurements. The sizable prevalence in these
and informal health care were repeatedly linked studies reflects infections that occurred mostly
to HCV infection in MENA.73 before improvements in safety precautions were
Egypt has witnessed the world’s largest iatro- implemented. Meanwhile, the nil prevalence
genic transmission of blood-borne pathogens mainly reflects point-prevalence surveys after
during the era of parenteral antischistosomal safety precautions were implemented.
therapy.74 This led to a massive increase in HCV The above factors pose a concern as to whether
and HBV infections in the general population, there is substantial parenteral HIV transmission
and today Egypt has the world’s highest HCV in MENA beyond IDU, and whether such trans-
prevalence.75 The largest documented nosoco- mission accounts for some of the HIV infections
mial (contracted as a result of being hospitalized) where apparently there are no identifiable risk
behaviors. To address this question, and given
65
the limitations on HIV data, the authors con-
Jahan, “Epidemiology of Needlestick Injuries.”
66
Moghimi et al., “Knowledge, Attitude, and Practice.” ducted a review of HCV prevalence in MENA.
67
Kabbash et al., “Risk Perception and Precautions.”
68
Hauri, Armstrong, and Hutin, “The Global Burden of Disease.”
69
Measure DHS, “Egypt: Demographic and Health Survey 2005.”
70 76
Hauri, Armstrong, and Hutin, “The Global Burden of Disease.” Yerly et al., “Nosocomial Outbreak”; Visco-Comandini et al.,
71
Ibid. “Monophyletic HIV Type 1”; de Oliveira et al., “Molecular
72
Ibid. Epidemiology.”
73 77
Barut et al., “Analysis of Risk Factors”; Idrees and Riazuddin, Hassan et al., “HIV Infection.”
78
“Frequency Distribution”; Stoszek et al., “Prevalence of and Risk El Sayed et al., “Epidemic Transmission.”
79
Factors”; Khan et al., “Prevalence of Hepatitis ‘B’ and ‘C’”; Gulcan Sekkat et al., “Prevalence of Anti-HCV Antibodies.”
80
et al., “Evaluation of Risk Factors”; Abbas et al., “Prevalence and Mode Nemati et al., “Hepatitis C Virus Infection.”
81
of Spread”; Younus, Siddiqi, and Akhtar, “Reassessment of Selected Al Hijazat and Ajlouni, “Hepatitis B Infection.”
82
Healthcare”; Ben Alaya Bouafif et al., “A Case Control Study.” Alrajhi, Halim, and Al-Abdely, “Mode of Transmission.”
74 83
Frank et al., “The Role of Parenteral Antischistosomal Therapy.” Zali et al., “Anti-HCV Antibody”; Hosseini Asl, Avijgan, and
75
Waked et al., “High Prevalence of Hepatitis C.” Mohamadnejad, “High Prevalence.”
Bahrain 1.6% (children with hereditary hemolytic anemias; Al-Mahroos and Ebrahim 1995)
Egypt, Arab Republic of 4.8% (blood or blood products recipients; Watts et al. 1993)
Iran, Islamic Republic of 0.0% (thalassemia patients; Mirmomen et al. 2006)
0.0% (thalassemia patients; Ansar and Kooloobandi 2002)
0.0% (thalassemia patients; Alavian, Gholami, and Masarrat 2002)
0.0% (thalassemia patients; Javadzadeh, Attar, and Taher Yavari 2006)
0.0% (thalassemia patients; Khamispoor and Tahmasebi 1999)
0.0% (thalassemia patients; Basiratnia, HosseiniAsl, and Avijegan 1999)
0.0% (thalassemia patients; Kadivar et al., 2001)
0.0% (thalassemia patients; Nakhaie and Talachian 2003)
0.0% (thalassemia patients; Rezvan, Abolghassemi, and Kafiabad 2007)
0.0% (thalassemia patients; Marcelin et al. 2001)
0.0% (multitransfused thalassaemic children; Karimi and Ghavanini 2001b)
0.71% (multitransfused patients with hemophilia; Karimi and Ghavanini 2001a)
2.3% (hemophiliacs; Alavian, Ardeshiri, and Hajarizadeh 2001)
0.0% (hemophiliacs; Karimi, Yarmohammadi, and Ardeshiri 2002)
0.9% (hemophiliacs; Torabi et al. 2006)
1.4% (hemophiliacs; Javadzadeh, Attar, and Taher Yavari 2006)
0.0% (hemophiliacs; Mansour-Ghanaei et al. 2002)
0.0% (hemophiliacs; Khamispoor and Tahmasebi 1999)
Jordan 0.0% (multitransfused patients; Al-Sheyyab, Batieha, and El-Khateeb 2001)
Lebanon 6.0% (multitransfused patients; Mokhbat et al. 1989)
Morocco 0.0% (hemodialysis patients; Boulaajaj et al. 2005)
Pakistan 0.98% (multitransfused patients; Mujeeb and Hafeez 1993; hemodialysis patients; Khamispoor and
Tahmasebi 1999)
Qatar 38.5% (children with thalassemia; Novelli et al. 1987)
Saudi Arabia 1.3% (multitransfused thalassemic and sickle cell disease patients; El-Hazmi and Ramia 1989)
0.0% (children undergoing cancer therapy; Bakir et al. 1995)
Tunisia 0.0% (hemodialysis patients; Hmida et al. 1995)
8.6% (hemophiliacs; Langar et al. 2005)
HCV is a major cause of chronic liver dis- mission modes.87 Table D.4 (appendix D)
ease and hepatocellular carcinoma.84 HCV summarizes the review of HCV prevalence.
prevalence is a powerful proxy of the poten- Although overall the region has the second
tial spread of HIV through the parenteral highest HCV prevalence after sub-Saharan
transmission modes in different populations,85 Africa,88 this is largely due to the contribution
and HCV is the most prevalent transfusion- of the high prevalence found in Egypt89 and
transmitted infection.86 It is also a better Pakistan.90 For the rest of the countries, inter-
proxy of parenteral transmissions than HBV, mediate prevalence levels are found in the
which has other major nonparenteral trans- general population. These levels are not
87
Maayan et al., “Exposure to Hepatitis.”
84 88
Colombo, Rumi, and Ninno, “Treatment of Chronic Hepatitis C in WHO, Global Surveillance and Control of Hepatitis C; WHO, Weekly
Europe.” Epidemiological Record.
85 89
Goldmann, “Blood-Borne Pathogens and Nosocomial Infections”; Frank et al., “The Role of Parenteral Antischistosomal Therapy.”
90
Walker et al., “Epidemiology: Sexual Transmission of HIV in Africa”; Raja and Janjua, “Epidemiology of Hepatitis C Virus Infection in
Schmid et al., “Transmission of HIV-1.” Pakistan”; Khokhar, Gill, and Malik, “General Seroprevalence of
86
Rezvan, Abolghassemi, and Kafiabad, “Transfusion-Transmitted Hepatitis “; Aslam et al., “Association between Smallpox Vaccination
Infections.” and Hepatitis C.”
90 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
dissimilar to those found in the Americas, deficient.96 This is also of concern because
Asia, and Europe.91 there is a tradition in MENA of barbers prac-
Table D.4 suggests the following regarding ticing medicine.97
the parenteral transmission of blood-borne
HCV prevalence is a proxy for the cumulative
pathogens in MENA:
risk of parenteral transmission over an extended
1. There is ongoing transmission of HCV in the period of time and may not be representative of
general population, largely at intermediate recent trends. It is plausible that more stringent
levels. safety precautions have been implemented recently.
Improvements in blood safety measures have
2. There are specific population groups that
reduced HIV infections due to contaminated blood
are at high risk of infection, such as hemo-
in MENA from 12.1% in 1993 to 0.4% in 2003.98
dialysis patients, multitransfused patients,
In Lebanon and the West Bank and Gaza, no new
and household contacts of HCV-infected
HIV cases through blood transfusion have been
patients.92
detected for several years.99 In the Islamic Republic
3. There is ongoing blood-borne transmission in of Iran, HCV prevalence among thalassemia patients
health facilities as evidenced by the higher decreased from 22.8% to 2.6% following the
prevalence of HCV among HCWs and hospi- implementation of blood donor screening.100 Also
talized patients. in the Islamic Republic of Iran, HCV prevalence
among hemodialysis patients decreased from 18%
4. HCV prevalence is high among prisoners,
in 2001 to 12% in 2006 in one study,101 and from
suggesting that IDU and the use of nonsterile
14.4% in 1999 to 4.5% in 2006 in another study.102
injecting and noninjecting utensils are com-
Similar reductions were also achieved for HBV in
mon in prisons.
both the Islamic Republic of Iran and Turkey.103 In
5. There is not sufficient awareness about the Egypt, 95% of women in the 2005 Demographic
dangers of reusing the nonsterile injection and Health Survey reported that the medical pro-
equipment of others, as suggested by the vider followed basic injection safety procedures.104
higher prevalence among diabetes patients, Nevertheless, improvements in safety mea-
who likely use self-administered or relative- sures may not have been uniform across MENA.
administered injections. A study in Pakistan observed an increase in HCV
prevalence in recent years.105 There is evidence
6. Persons in certain professional categories
of ongoing HCV incidence at the household and
might be at higher risk of becoming in-
population levels in Egypt,106 and intrafamilial
fected, or transmitting the infection, due to
and household clustering of HCV infection in
exposures to bodily fluids, such as barbers,
Pakistan.107
who appear to have about a fivefold higher
HCV prevalence than the general popula-
tion (5% in Morocco93 and 2.8% in 96
Zahraoui-Mehadji et al., “Infectious Risks”; Janjua and Nizamy,
Turkey94). HCV infection at barber shops “Knowledge and Practices of Barbers.”
97
has also been suggested in Pakistan.95 Zahraoui-Mehadji et al., “Infectious Risks.”
98
UNAIDS, “Notes on AIDS in the Middle East and North Africa.”
Studies of traditional barbers in Morocco 99
UNAIDS, “Key Findings “; Jurjus et al., “Knowledge, Attitudes,
and Pakistan have shown that the risk of Beliefs, and Practices.”
100
blood-borne infectious diseases was not Mirmomen et al., “Epidemiology of Hepatitis.”
101
Taziki and Espahbodi, “Prevalence of Hepatitis.”
known to barbers nor to their customers 102
Alavian et al., “Hepatitis B and C.”
and that the hygiene conditions were 103
Rezvan, Abolghassemi, and Kafiabad, “Transfusion-Transmitted
Infections”; Alavian et al., “Hepatitis B and C”; Kocak et al., “Trends
in Major Transfusion-Transmissible Infections.”
91 104
Sy and Jamal, “Epidemiology of Hepatitis C Virus (HCV) Infection.” Measure DHS, “Egypt: Demographic and Health Survey 2005.”
92 105
Ali et al., “Hepatitis B and Hepatitis C in Pakistan.” Mujeeb and Pearce, “Temporal Trends in Hepatitis B and C.”
93 106
Zahraoui-Mehadji et al., “Infectious Risks.” Mujeeb and Pearce, “Temporal Trends in Hepatitis B and C”; Saleh
94
Candan et al., “Prevalence of Hepatitis.” et al., “Incidence and Risk Factors”; Mohamed et al., “Transmission of
95
Raja and Janjua, “Epidemiology of Hepatitis C Virus Infection in Hepatitis C Virus between Parents and Children”; Magder et al.,
Pakistan”; Ali et al., “Hepatitis B and Hepatitis C in Pakistan”; “Estimation of the Risk of Transmission.”
107
Khattak et al. “Factors Influencing Hepatitis C.” Abbas et al., “Prevalence and Mode of Spread of Hepatitis.”
92 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
different risk populations in the Islamic East Africa, while others clustered with those
Republic of Iran. The HIV epidemic among in West Africa. The majority of strains were
IDUs in Kabul, Afghanistan, has also been similar to those in Uganda, Kenya, and Ethiopia.
linked through sequence analyses to the In Tunisia, subtype B was by far the dominant
Iranian epidemic.125 One other study from the subtype.137 In a study of 19 strains in the
Islamic Republic of Iran supports a close link Republic of Yemen, 47.3% were of subtype B,
between the virus subtypes circulating in the 31.6% of subtype C, 10.5% of subtype D, 5.3%
Islamic Republic of Iran and Afghanistan.126 of subtype A, and 5.3% were recombinant
In Lebanon, a complex HIV subtype distribu- forms.138 Of the two subtype D strains, one clus-
tion pattern was found representing the infec- tered with strains from Uganda and the other
tion’s travel history from its point of origina- with strains from Cameroon. The one subtype A
tion.127 Even within a single subtype, high levels strain was similar to a Cameroon variant. Overall,
of genetic intrasubtype diversity were found, the strains found in the study suggest multiple
suggesting multiple introductions of the virus to introductions of HIV to the Republic of Yemen
Lebanon.128 from East and West Africa, Europe, and India.
A study of a nosocomial HIV outbreak in a
children’s hospital in Libya linked the virus to a
Analytical summary
strain originating in West Africa.129 In Morocco,
93.5% of HIV infections were found to be of It is difficult to draw firm conclusions from just a
subtype B.130 More recent data, however, suggest few studies, including a small number of HIV
an increasing diversity of subtypes, with 34% of isolates that may be reflecting transmission pat-
the cases carrying nonsubtype B viruses.131 In the terns from the past. More often than not though,
West Bank and Gaza, subtype B was also sequence analyses indicate multiple distinct sub-
dominant and the phylogenetic tree analyses types in the isolated strains.139 This suggests mul-
indicated multiple introductions of HIV into the tiple introductions rather than endemic exis-
population.132 Subtype A was the only subtype tence of genetically diverse HIV subtypes in a
observed among a group of IDUs in Pakistan.133 number of MENA countries. The diversity found
In Saudi Arabia, high strain diversity suggesting in Algeria, Lebanon, Saudi Arabia, the West
multiple introductions was found, with subtypes Bank and Gaza, and the Republic of Yemen may
C, G, B, D, and A accounting for 39.3%, 25%, suggest that HIV dynamics are mainly driven by
17.9%, 3.6%, and 1.8% of the infections, respec- exogenous exposures, generally among the
tively.134 Two kinds of sequences (CRF25_cpx and nationals of these countries while abroad, or HIV
CRF43_02G) were found to form distinct subclus- transmissions to their sexual partners upon their
ters, suggesting a transmission network within return. Most endogenous HIV infections could
Saudi Arabia.135 be direct transmissions from index cases follow-
In Sudan, 50% of the strains from blood ing multiple introductions. HIV dynamics are not
donors in Khartoum were of subtype D and dominated by a specific epidemic in one or mul-
30% of subtype C, with limited frequencies of tiple risk groups.
subtypes A, B, and recombinant forms.136 Some On the other hand, the dominance of specific
of the D subtype strains clustered with those in subtypes with limited sequence variability in
Djibouti, the Islamic Republic of Iran, and Sudan,
125
in addition to possibly two subclusters in Saudi
Sanders-Buell et al., “A Nascent HIV Type 1 Epidemic.”
126
Soheilli et al., “Presence of HIV-1 CRF35_AD in Iran.”
Arabia, suggests that HIV infections are occurring
127
Pieniazek et al., “Introduction of HIV-2.” in transmission chains that have been propagating
128
Ibid. locally for at least several years. This suggests a
129
de Oliveira et al., “Molecular Epidemiology.”
130 local epidemic-type HIV transmission in one or
Elharti et al., “HIV-1 Diversity in Morocco.”
131
Morocco MOH, “Situation épidémiologique.” multiple risk groups.
132
Gehring et al., “Molecular Epidemiology of HIV in Israel.”
133
Khan et al., “HIV-1 Subtype A.”
134 137
Badreddine et al., “Identification and Characterization of HIV Type 1.” Ben Halima et al., “First Molecular Characterization.”
135 138
Yamaguchi et al., “Identification of New CRF43_02G and CRF25_cpx.” Saad et al., “HIV Type 1 Strains.”
136 139
Hierholzer et al., “HIV Type 1 Strains.” Earhart, “The Molecular Epidemiology of HIV-1 in Central Asia.”
94 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Dentists with Regard to HIV-Related Disease.” Infect Candan, F., H. Alagozlu, O. Poyraz, and H. Sumer. 2002.
Control Hosp Epidemiol 28: 83–87. “Prevalence of Hepatitis B and C Virus Infection in
Askarian, M., K. Mirzaei, and M. L. McLaws. 2006. Barbers in the Sivas Region of Turkey.” Occup Med
“Attitudes, Beliefs, and Infection Control Practices of (Lond) 52: 31–34.
Iranian Dentists Associated with HIV-Positive Chemtob, D., and S. F. Srour. 2005. “Epidemiology of
Patients.” Am J Infect Control 34: 530–33. HIV Infection among Israeli Arabs.” Public Health 119:
Aslam, M., J. Aslam, B. D. Mitchell, and K. M. Munir. 138–43.
2005. “Association between Smallpox Vaccination Colombo, M., M. G. Rumi, and E. D. Ninno. 2003.
and Hepatitis C Antibody Positive Serology in “Treatment of Chronic Hepatitis C in Europe.”
Pakistani Volunteers.” J Clin Gastroenterol 39: 243–46. J Hepatobiliary Pancreat Surg 10: 168–71.
Badreddine, S., K. Smith, H. van Zyl, P. Bodelle, de Oliveira, T., O. G. Pybus, A. Rambaut, M. Salemi,
J. Yamaguchi, P. Swanson, S. G. Devare, and C. A. S. Cassol, M. Ciccozzi, G. Rezza, G. C. Gattinara,
Brennan. 2007. “Identification and Characterization R. D’Arrigo, M. Amicosante, L. Perrin, V. Colizzi, and
of HIV Type 1 Subtypes Present in the Kingdom of C. F. Perno. 2006. “Molecular Epidemiology: HIV-1
Saudi Arabia: High Level of Genetic Diversity Found.” and HCV Sequences from Libyan Outbreak.” Nature
AIDS Res Hum Retroviruses 23: 667–74. 444: 836–37.
Bakir, T. M. F., K. M. Kurbaan, I. A. Fawaz, and S. Ramia. Earhart, K. 2004. “The Molecular Epidemiology of HIV-1
1995. “Infection with Hepatitis Viruses (B and C) and in Central Asia.” PowerPoint presentation.
Human Retro Viruses (HTLV-1 and HIV) in Saudi El Sayed, N. M., P. J. Gomatos, C. M. Beck-Sague,
Children Receiving Cycled Cancer Chemotherapy.” U. Dietrich, H. von Briesen, S. Osmanov, J. Esparza,
Journal of Tropical Pediatrics 41: 206–9. R. R. Arthur, M. H. Wahdan, and W. R. Jarvis. 2000.
Barut, S., U. Erkorkmaz, S. Yuce, and U. Uyeturk. 2008. “Epidemic Transmission of Human Immunodeficiency
“Analysis of Risk Factors in Anti-HCV Positive Patients Virus in Renal Dialysis Centers in Egypt.” J Infect Dis
in Gaziosmanpasa University Hospital, Tokat, 181: 91–97.
Turkey.” Mikrobiyol Bul 42: 675–80. Elharti, E., M. Alami, H. Khattabi, A. Bennani, A. Zidouh,
Basiratnia, M., S. M. K. HosseiniAsl, and M. Avijegan. A. Benjouad, and R. El Aouad. 2002. “Some
1999. “Hepatitis C Prevalence in Thalassemia Patients Characteristics of the HIV Epidemic in Morocco.” East
in Sharkord, Iran (Farsi).” Shahrkord University Medical Mediterr Health J 8: 819–25.
Science Journal 4: 13–18. Elharti, E., R. Elaouad, S. Amzazi, H. Himmich,
Ben Alaya Bouafif, N., H. Triki, S. Mejri, O. Bahri, S. Z. Elhachimi, C. Apetrei, J. C. Gluckman, F. Simon,
Chlif, J. Bettaib, S. Hechmi, K. Dellagi, and A. Ben and A. Benjouad. 1997. “HIV-1 Diversity in Morocco.”
Salah. 2007. “A Case Control Study to Assess Risk AIDS 11: 1781–83.
Factors for Hepatitis C among a General Population in El-Hazmi, M. A., and S. Ramia. 1989. “Frequencies of
a Highly Endemic Area of Northwest Tunisia.” Arch Hepatitis B, Delta and Human Immune Deficiency Virus
Inst Pasteur Tunis 84: 21–27. Markers in Multi-Transfused Saudi Patients with
Ben Halima, M., C. Pasquier, A. Slim, T. Ben Chaabane, Thalassaemia and Sickle-Cell Disease.” J Trop Med Hyg
Z. Arrouji, J. Puel, S. Ben Redjeb, and J. Izopet. 2001. 92: 1–5.
“First Molecular Characterization of HIV-1 Tunisian Farah, M. S., and S. Hussein. 2006. “HIV Prevalence,
Strains.” J Acquir Immune Defic Syndr 28: 94–96. Knowledge, Attitude, Practices and Risk Factors
Boulaajaj, K., Y. Elomari, B. Elmaliki, B. Madkouri, among Truck Drivers in Khartoum State.” Sudan
D. Zaid, and N. Benchemsi. 2005. “Prevalence of National AIDS Program.
Hepatitis C, Hepatitis B and HIV Infection among Frank, C., M. K. Mohamed, G. T. Strickland, D. Lavanchy,
Haemodialysis Patients in Ibn-Rochd University R. R. Arthur, L. S. Magder, T. El Khoby, Y. Abdel-
Hospital, Casablanca.” Nephrol Ther 1: 274–84. Wahab, E. S. Aly Ohn, W. Anwar, and I. Sallam.
Bouzeghoub, S., V. Jauvin, P. Pinson, M. H. Schrive, 2000. “The Role of Parenteral Antischistosomal
A. C. Jeannot, A. Amrane, B. Masquelier, H. Belabbes Therapy in the Spread of Hepatitis C Virus in Egypt.”
el, and H. J. Fleury. 2008. “First Observation of HIV Lancet 355: 887–91.
Type 1 Drug Resistance Mutations in Algeria.” AIDS Gehring, S., S. Maayan, H. Ruppach, P. Balfe,
Res Hum Retroviruses 24: 1467–73. J. Juraszczyk, I. Yust, N. Vardinon, A. Rimlawi,
Bouzeghoub, S., V. Jauvin, P. Recordon-Pinson, I. S. Polak, Z. Bentwich, H. Rubsamen-Waigmann,
Garrigue, A. Amrane, H. Belabbes el, and H. J. Fleury. and U. Dietrich. 1997. “Molecular Epidemiology of
2006. “High Diversity of HIV Type 1 in Algeria.” AIDS HIV in Israel.” J Acquir Immune Defic Syndr Hum
Res Hum Retroviruses 22: 367–72. Retrovirol 15: 296–303.
Burans, J. P., E. Fox, M. A. Omar, A. H. Farah, S. Abbass, Gerberding, J. L. 1995. “Management of Occupational
S. Yusef, A. Guled, M. Mansour, R. Abu-Elyazeed, Exposures to Blood-Borne Viruses.” N Engl J Med 332:
and J. N. Woody. 1990. “HIV Infection Surveillance 444–51.
in Mogadishu, Somalia.” East Afr Med J 67: 466–72. Ghannad, M. S., S. M. Arab, M. Mirzaei, and A.
Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani, Moinipur. 2009. “Epidemiologic Study of Human
J. George, R. Abu-Elyazeed, and J. N. Woody. 1990. Immunodeficiency Virus (HIV) Infection in the
“Serosurvey of Prevalence of Human Immuno- Patients Referred to Health Centers in Hamadan
deficiency Virus amongst High Risk Groups in Port Province, Iran.” AIDS Res Hum Retroviruses 25:
Sudan, Sudan.” East Afr Med J 67: 650–55. 277–83.
96 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Karimi, M., and A. A. Ghavanini. 2001a. “Seroprevalence Kocak, N., S. Hepgul, S. Ozbayburtlu, H. Altunay, M. F.
of Hepatitis B, Hepatitis C and Human Ozsoy, E. Kosan, Y. Aksu, G. Yilmaz, and A. Pahsa.
Immunodeficiency Virus Antibodies among 2004. “Trends in Major Transfusion-Transmissible
Multitransfused Thalassaemic Children in Shiraz, Infections among Blood Donors over 17 Years in
Iran.” J Paediatr Child Health 37: 564–66. Istanbul, Turkey.” J Int Med Res 32: 671–75.
———. 2001b. “Seroprevalence of HBsAg, Anti-HCV, Kuruuzum, Z., N. Yapar, V. Avkan-Oguz, H. Aslan, O. A.
and Anti-HIV among Haemophiliac Patients in Shiraz, Ozbek, N. Cakir, and A. Yuce. 2008. “Risk of Infection
Iran.” Haematologia (Budap) 31: 251–55. in Health Care Workers Following Occupational
Exposure to a Noninfectious or Unknown Source.”
Karimi, M., H. Yarmohammadi, and R. Ardeshiri. 2002.
Am J Infect Control 36: e27–31.
“Inherited Coagulation Disorders in Southern Iran.”
Haemophilia 8: 740–44. Lambert, L. 2007. “HIV and Development Challenges in
Yemen: Which Grows Fastest?” Health Policy and
Kassak, K., J. DeJong, Z. Mahfoud, R. Afifi, S. Abdurahim,
Planning 22: 60.
M. L. Sami Ramia, F. El-Barbir, M. Ghanem, S.
Shamra, K. Kreidiyyeh, and D. El-Khoury. 2008. Langar, H., H. Triki, E. Gouider, O. Bahri, A. Djebbi, A.
“Final Working Protocol for an Integrated Bio- Sadraoui, A. Hafsia, and R. Hafsia. 2005. “Blood-
Behavioral Surveillance Study among Four Transmitted Viral Infections among Haemophiliacs
Vulnerable Groups in Lebanon: Men Who Have Sex in Tunisia.” Transfusion clinique et biologique 12:
with Men; Prisoners; Commercial Sex Workers; and 301–5.
Intravenous Drug Users.” Grey Report. Laraqui, O., S. Laraqui, D. Tripodi, M. Zahraoui, A.
Kayani, N., A. Sheikh, A. Khan, C. Mithani, and Caubet, C. Verger, and C. H. Laraqui. 2008. “Assessing
M. Khurshid. 1994. “A View of HIV-I Infection in Knowledge, Attitude, and Practice on Occupational
Karachi.” J Pak Med Assoc 44: 8–11. Blood Exposure in Caregiving Facilities, in Morocco.”
Med Mal Infect 38: 658–66.
Kennedy, M., D. O’Reilly, and M. W. Mah. 1998. “The
Lasky, M., J. L. Perret, M. Peeters, F. Bibollet-Ruche,
Use of a Quality-Improvement Approach to Reduce
F. Liegeois, D. Patrel, S. Molinier, C. Gras, and
Needlestick Injuries in a Saudi Arabian Hospital.” Clin
E. Delaporte. 1997. “Presence of Multiple Non-B
Perform Qual Health Care 6: 79–83.
Subtypes and Divergent Subtype B Strains of HIV-1
Khamispoor, G., and R. Tahmasebi. 1999. “Prevalence of in Individuals Infected after Overseas Deployment.”
HIV, HBV, HCV and Syphilis in High Risk Groups of AIDS 11: 43–51.
Bushehr Province (Farsi).” Iranian South Medical Lebanon National AIDS Control Program. 2008. “A Case
Journal 1: 53–59. Study on Behavior Change among Female Sex
Khan, M. S., M. Jamil, S. Jan, S. Zardad, S. Sultan, and Workers.” Beirut, Lebanon.
A. S. Sahibzada. 2007. “Prevalence of Hepatitis ‘B’ and Luby, S., R. Khanani, M. Zia, Z. Vellani, M. Ali, A. H.
‘C’ in Orthopaedics Patients at Ayub Teaching Hospital Qureshi, A. J. Khan, S. Abdul Mujeeb, S. A. Shah,
Abbottabad.” J Ayub Med Coll Abbottabad 19: 82–84. and S. Fisher-Hoch. 2000. “Evaluation of Blood Bank
Khan, O. A., and A. A. Hyder. 1998. “HIV/AIDS among Practices in Karachi, Pakistan, and the Government’s
Men Who Have Sex with Men in Pakistan.” Sex Health Response.” Health Policy Plan 15: 217–22.
Exch 12–13, 15. Maayan, S., E. N. Shufman, D. Engelhard, and
Khan, S., M. A. Rai, M. R. Khanani, M. N. Khan, and S. H. D. Shouval. 1994. “Exposure to Hepatitis B and C and
Ali. 2006. “HIV-1 Subtype A Infection in a Community to HTLV-1 and 2 among Israeli Drug Abusers in
of Intravenous Drug Users in Pakistan.” BMC Infect Dis 6: Jerusalem.” Addiction 89: 869–74.
164. Magder, L. S., A. D. Fix, N. N. Mikhail, M. K. Mohamed,
Khattab, H. A. S., M. A. Gineidy, N. Shorbagui, and M. Abdel-Hamid, F. Abdel-Aziz, A. Medhat, and G. T.
N. Elnahal. 2007. “Report on a Study of Women Strickland. 2005. “Estimation of the Risk of
Living with HIV in Egypt.” Egyptian Society for Transmission of Hepatitis C between Spouses in Egypt
Population Studies and Reproductive Health. Based on Seroprevalence Data.” Int J Epidemiol 34:
160–65.
Khattak, M. N., S. Akhtar, S. Mahmud, and T. M.
Roshan. 2008. “Factors Influencing Hepatitis C Virus Mansoor, A. B., W. Fungladda, J. Kaewkungwal, and W.
Sero-Prevalence among Blood Donors in North West Wongwit. 2008. “Gender Differences in KAP Related
Pakistan.” J Public Health Policy 29: 207–25. to HIV/AIDS among Freshmen in Afghan
Universities.” Southeast Asian J Trop Med Public Health
Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. 39: 404–18.
Vermund. 1997. “HIV/AIDS and Its Risk Factors in
Mansour-Ghanaei, F., M. S. Fallah, A. Shafaghi,
Pakistan.” AIDS 11: 843–48.
M. Yousefi-Mashhoor, N. Ramezani, F. Farzaneh, and
Khokhar, N., M. L. Gill, and G. J. Malik. 2004. “General R. Nassiri. 2002. “Prevalence of Hepatitis B and C
Seroprevalence of Hepatitis C and Hepatitis B Virus Seromarkers and Abnormal Liver Function Tests
Infections in Population.” J Coll Physicians Surg Pak 14: among Hemophiliacs in Guilan (Northern Province of
534–36. Iran).” Med Sci Monit 8: CR797–800.
Kilani, B., L. Ammari, C. Marrakchi, A. Letaief, Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck,
M. Chakroun, M. Ben Jemaa, H. T. Ben Aissa, F. M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M.
Kanoun, and T. Ben Chaabene. 2007. “Seroepidemiology Huraux, and N. Dupin. 2001. “Comparative Study of
of HCV-HIV Coinfection in Tunisia.” Tunis Med 85: Heterosexual Transmission of HIV-1, HSV-2 and KSHV
121–23. in Djibouti.” 8th Retrovir Oppor Infect (abstract no. 585).
98 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Saad, M. D., A. Al-Jaufy, R. R. Grahan, Y. Nadai, K. C. Students and Military Personnel. Federal Ministry of
Earhart, J. L. Sanchez, and J. K. Carr. 2005. “HIV Type 1 Health, Khartoum.
Strains Common in Europe, Africa, and Asia Cocirculate Sy, T., and M. M. Jamal. 2006. “Epidemiology of
in Yemen.” AIDS Res Hum Retroviruses 21: 644–48. Hepatitis C Virus (HCV) Infection.” Int J Med Sci 3:
Saleh, D. A., F. Shebl, M. Abdel-Hamid, S. Narooz, N. 41–46.
Mikhail, M. El-Batanony, S. El-Kafrawy, M. El-Daly, Syria National AIDS Programme. 2004. “HIV/AIDS
S. Sharaf, M. Hashem, S. El-Kamary, L. S. Magder, S. Female Sex Workers KABP Survey in Syria.”
K. Stoszek, and G. T. Strickland. 2008. “Incidence and
Risk Factors for Hepatitis C Infection in a Cohort of Tagliamonte, M., H. R. Naderi, M. L. Tornesello, F. Farid,
Women in Rural Egypt.” Trans R Soc Trop Med Hyg F. M. Buonaguro, and L. Buonaguro. 2007. “HIV
102: 921–28. Type 1 Subtype A Epidemic in Injecting Drug User
(IDU) Communities in Iran.” AIDS Res Hum Retroviruses
Sanders-Buell, E., M. D. Saad, A. M. Abed, M. Bose, C. 23: 1569–74.
S. Todd, S. A. Strathdee, B. A. Botros, N. Safi, K. C.
Earhart, P. T. Scott, N. Michael, and F. E. McCutchan. Tawilah, J., and O. Tawil. 2001. Visit to Sultane of Oman.
2007. “A Nascent HIV Type 1 Epidemic among Travel Report Summary. National AIDS Programme
Injecting Drug Users in Kabul, Afghanistan is at the Ministry of Health in Muscat and Salalah
Dominated by Complex AD Recombinant Strain, and WHO Representative Office. World Health
CRF35_AD.” AIDS Res Hum Retroviruses 23: 834–39. Organization, Regional Office for the Eastern
Mediterranean.
Sarrami-Forooshani, R., S. R. Das, F. Sabahi, A. Adeli, R.
Esmaeili, B. Wahren, M. Mohraz, M. Haji-Abdolbaghi, Taziki, O., and F. Espahbodi. 2008. “Prevalence of
M. Rasoolinejad, S. Jameel, and F. Mahboudi. 2006. Hepatitis C Virus Infection in Hemodialysis Patients.”
“Molecular Analysis and Phylogenetic Charac- Saudi J Kidney Dis Transpl 19: 475–78.
terization of HIV in Iran.” J Med Virol 78: 853–63. Todd, C. S., Y. Barbera-Lainez, S. C. Doocy,
Schmid, G. P., A. Buve, P. Mugyenyi, G. P. Garnett, R. J. A. Ahmadzai, F. M. Delawar, and G. M. Burnham.
Hayes, B. G. Williams, J. G. Calleja, K. M. De Cock, J. 2007. “Prevalence of Human Immunodeficiency
A. Whitworth, S. H. Kapiga, P. D. Ghys, C. Hankins, Virus Infection, Risk Behavior, and HIV Knowledge
B. Zaba, R. Heimer, and J. T. Boerma. 2004. among Tuberculosis Patients in Afghanistan.” Sex
“Transmission of HIV-1 Infection in Sub-Saharan Transm Dis 34: 878–82.
Africa and Effect of Elimination of Unsafe Injections.” Torabi, S. A., K. Abed-Ashtiani, R. Dehkhoda, A. N.
Lancet 363: 482–88. Moghadam, M. K. Bahram, R. Dolatkhah, J. Babaei,
Sekkat, S., N. Kamal, B. Benali, H. Fellah, K. Amazian, and N. Taheri. 2006. “Prevalence of Hepatitis B, C and
A. Bourquia, A. El Kholti, and A. Benslimane. 2008. HIV in Hemophiliac Patients of East Azarbaijan in
“Prevalence of Anti-HCV Antibodies and 2004.” Blood 2: 291–99.
Seroconversion Incidence in Five Haemodialysis UNAIDS (United Nations Joint Programme on HIV/
Units in Morocco.” Nephrol Ther 4: 105–10. AIDS). 2006a. “Country Alignment and Harmonisation
Simonsen, L., A. Kane, J. Lloyd, M. Zaffran, and M. Support to Scaling Up the HIV/AIDS Response: The
Kane. 1999. “Unsafe Injections in the Developing Somali Experience.”
World and Transmission of Bloodborne Pathogens: A ———. 2006b. “Common Country Assessment: Key
Review.” Bull World Health Organ 77: 789–800. Challenges in Health; HIV Prevention in Jordan.”
SNAP (Sudan National AIDS Program), UNICEF (United ———. 2007. “Key Findings on HIV Status in the West
Nations Children’s Fund), and UNAIDS (United Bank and Gaza.” Working document, RST, MENA.
Nations Joint Programme on HIV/AIDS). 2005. ———. 2008. “Notes on AIDS in the Middle East and
“Baseline Study on Knowledge, Attitudes, and North Africa.” RST, MENA.
Practices on Sexual Behaviors and HIV/AIDS
UNAIDS, and WHO (World Health Organization). 2005.
Prevention amongst Young People in Selected States
AIDS Epidemic Update 2005. Geneva.
in Sudan.” HIV/AIDS KAPB Report, Projects and
Research Department (AFROCENTER Group). ———. 2006. AIDS Epidemic Update 2006. Geneva.
Soheilli, Z. S., Z. Ataiee, S. Tootian, M. Zadsar, S. Amini, ———. 2007. AIDS Epidemic Update 2007. Geneva.
K. Abadi, V. Jauvin, P. Pinson, H. J. Fleury, and S. Visco-Comandini, U., G. Cappiello, G. Liuzzi, V. Tozzi, G.
Samiei. 2009. “Presence of HIV-1 CRF35_AD in Iran.” Anzidei, I. Abbate, A. Amendola, L. Bordi, M. A.
AIDS Res Hum Retroviruses 25: 123–24. Budabbus, O. A. Eljhawi, M. I. Mehabresh, E. Girardi,
Stoszek, S. K., M. Abdel-Hamid, S. Narooz, M. El Daly, A. Antinori, M. R. Capobianchi, A. Sonnerborg, and
D. A. Saleh, N. Mikhail, E. Kassem, Y. Hawash, S. El G. Ippolito. 2002. “Monophyletic HIV Type 1 CRF02-
Kafrawy, A. Said, M. El Batanony, F. M. Shebl, M. AG in a Nosocomial Outbreak in Benghazi, Libya.”
Sayed, S. Sharaf, A. D. Fix, and G. T. Strickland. 2006. AIDS Res Hum Retroviruses 18: 727–32.
“Prevalence of and Risk Factors for Hepatitis C in Waked, I. A., S. M. Saleh, M. S. Moustafa, A. A. Raouf,
Rural Pregnant Egyptian Women.” Trans R Soc Trop D. L. Thomas, and G. T. Strickland. 1995. “High
Med Hyg 100: 102–7. Prevalence of Hepatitis C in Egyptian Patients with
Sudan National HIV/AIDS Control Program. 2004a. Chronic Liver Disease.” Gut 37: 105–7.
Annual Report. Federal Ministry of Health, Khartoum. Walker, P. R., M. Worobey, A. Rambaut, E. C. Holmes,
———. 2004b. HIV/AIDS/STIs Prevalence, Knowledge, and O. G. Pybus. 2003. “Epidemiology: Sexual
Attitude, Practices and Risk Factors among University Transmission of HIV in Africa.” Nature 422: 679.
100 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 8
This chapter discusses condom knowledge and its Condom knowledge as a means of HIV pre-
use in the Middle East and North Africa (MENA) vention does not necessarily relate to actual
populations, and then delineates the characteris- condom use. Only a fraction of those who are
tics of HIV/AIDS (human immunodeficiency aware of the efficacy of condoms against HIV
virus/acquired immune deficiency syndrome) actually use condoms,3 and they may do so out
knowledge and attitudes in this region. of pregnancy concerns rather than for HIV pre-
vention.4 Of those who use condoms, only a
small minority use them consistently. In a nut-
KNOWLEDGE OF CONDOM AS A
PREVENTION METHOD AND ITS USE shell, consistent condom use for HIV prevention
is limited in MENA and the majority of at-risk
Levels of general condom knowledge, levels of sexual acts are not protected against HIV infec-
condom knowledge as a means of HIV preven- tion. Condom use is low even among the prior-
tion, and levels of condom use have been docu- ity populations (table 8.2).
mented in different populations in multiple stud- Repeatedly, pharmacies are cited as the most
ies in MENA. Tables 8.1 and 8.2 summarize these accessible source for condoms.5 Several priority
levels for a number of MENA countries. Condom populations have reported limitations in con-
knowledge varies substantially within MENA, dom accessibility and difficulty in using them,
and it is rather low in resource-limited settings. such as in Egypt, where 44% of female sex
Condom knowledge does not necessarily mean workers (FSWs) and 22% of men who have sex
condom knowledge as a means of HIV prevention. with men (MSM) had trouble obtaining con-
Parts of the populations have heard of condoms as doms, and 89% of FSWs and 38% of MSM had
a birth control method, but are not aware of its use trouble using them.6 The most cited reasons for
for HIV prevention. Among rural populations in not using condoms are high condom prices,7
Sudan, 31.6% had heard of condoms, but only 4%
3
identified them as a means of HIV prevention.1 Hajiabdolbaghi et al., “Insights from a Survey”; Ministry of Health and
Medical Education of Iran, AIDS/HIV Surveillance Report; Syria MOH,
Avoidance of nonsanctioned sex is often cited as a HIV/AIDS Female Sex Workers.
means of HIV prevention rather than safe sex. 4
Faisel and Cleland, “Study of the Sexual Behaviours.”
5
Only 0.4% of tourism and industrial workers in the Mohammad et al., “Sexual Risk-Taking Behaviors”; Hermez et al., “HIV/
AIDS Prevention”; Jurjus et al., “Knowledge, Attitudes, Beliefs, and
Arab Republic of Egypt reported knowing con-
Practices.”
doms can be used for HIV prevention.2 6
El-Sayed et al., “Evaluation of Selected Reproductive Health Infections.”
7
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices”;
1
SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.” Ministry of Health and Medical Education of Iran, AIDS/HIV
2
El-Sayyed, Kabbash, and El-Gueniedy, “Knowledge, Attitude and Practices.” Surveillance Report.
101
Table 8.1 General Knowledge of Condoms including HIV Prevention, in Different Populations Groups in MENA
Note: ANC ⫽ antenatal clinic; HSW ⫽ hijra sex worker; IDU ⫽ injecting drug user; STD ⫽ sexually transmitted disease; TB ⫽ tuberculosis.
(continued)
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 103
Table 8.2 (Continued)
Iran, Islamic Republic of 71.7% (ever use; youth; Mohammad et al. 2007)
48.0% (ever use; university students; Simbar, Tehrani, and Hashemi 2005)
64.8% (ever use; truck drivers; Tehrani and Malek-Afzalip 2008)
89.0% (recent use; clients of FSWs; Zargooshi 2002)
53.0% (ever use; IDUs; Zamani et al. 2005)
52.0% (ever use; IDUs; Narenjiha et al. 2005)
37.0% (last sex; IDUs; Zamani et al. 2005)
11.3%–12.4% (ever use; IDU prisoners; Farhoudi et al. 2003)
52.0% (ever use; FSWs; Tehrani and Malek-Afzalip 2008)
50.0% (ever use; FSWs; Ministry of Health and Medical Education of Iran 2004)
24%–83.2% (last client; FSWs; Jahani et al. 2005; Ardalan et al. 2002)
19.4% (last anal sex; steady partners; MSM; Eftekhar et al. 2008)
59.5% (last anal sex; commercial sex partners; MSM; Eftekhar et al. 2008)
59.9% (last anal sex; casual partners; MSM; Eftekhar et al. 2008)
Jordan Moderately high (nonmarital sex; youth; UNAIDS and WHO 2005)
4.0% (last sex; general population women; Measure DHS 2003)
Kuwait 1.5% (recent use; STD clinic attendees; Al-Mutairi et al. 2007)
Lebanon 7.0% (current use; married women; Kulczycki 2004)
24.0% (current use; married women; Kulczycki 2004)
32.0% (ever use; general population; Lebanon National AIDS Control Program 1996)
25.0% (last sex regular partnerships; general population; Jurjus et al. 2004)
71.7% (last sex nonregular partnerships; general population; Jurjus et al. 2004)
15.3% (ever use; general population; Jurjus et al. 2004)
23.4% (last sex while drunk; prisoners; Mishwar 2008)
88.0% (ever use; IDUs; Aaraj [unknown])
59.0% (ever use; IDUs; Ingold 1994)
5.8% (last sex; regular; IDUs; Aaraj [unknown]; Hermez et al. [unknown])
34.6% (last sex; casual sex; IDUs; Aaraj [unknown]; Hermez et al. [unknown])
39.3% (last sex; commercial sex, IDUs; Aaraj [unknown]; Hermez et al. [unknown])
28.1% (always; nonregular clients; FSWs; Hermez et al. [unknown])
34.8% (always; regular clients; FSWs; Hermez et al. [unknown])
11.9% (always; regular partners; FSWs; Hermez et al [unknown])
79.0% (ever use; FSWs; Hermez [unknown])
98.0% (last sex; FSWs; Mishwar 2008)
94.0% (last sex; FSWs; Mishwar 2008)
43.0% (last sex; FSWs; Mishwar 2008)
80.0% (last sex; FSWs; Rady 2005)
32.3% (consistent; regular client; FSWs; Lebanon National AIDS Control Program 2008)
26.2% (consistent; nonclient; FSWs; Lebanon National AIDS Control Program 2008)
35.1% (consistent; vaginal sex; FSWs; Lebanon National AIDS Control Program 2008)
13.9% (consistent; oral sex; FSWs; Lebanon National AIDS Control Program 2008)
36.1% (consistent; anal sex; FSWs; Lebanon National AIDS Control Program 2008)
88.0% (ever use; MSM; Aaraj [unknown])
47.1% (always; regular partners; MSM; Hermez et al.; Dewachi 2001)
54.5% (always; noncommercial casual partner; MSM; Hermez et al. [unknown]; Dewachi 2001)
47.0% (last anal sex; regular partner; MSM; Mishwar 2008)
66.0% (last anal sex; noncommercial casual partner; MSM; Mishwar 2008)
Morocco 16.0% (ever use; general population women; Chaouki et al. 1998)
9.0% (regular use; incarcerated women; El Ghrari et al. 2007)
10.0% (always; males; mainly IDUs; Asouab 2005; Morocco MOH [unknown])
8.1% (usually; males; mainly IDUs; Asouab 2005)
38.4% (rarely; males; mainly IDUs; Asouab 2005)
43.6% (never; males; mainly IDUs; Asouab 2005)
22.0% (always; females; mainly IDUs; Asouab 2005; Morocco MOH [unknown])
104 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 8.2 (Continued)
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 105
Table 8.2 (Continued)
24.0% (last anal sex; MSWs; Pakistan National AIDS Control Program 2005)
13.0% (last oral sex; MSWs; Pakistan National AIDS Control Program 2005)
34.0% (last commercial sex; MSWs; Pakistan National AIDS Control Program 2008)
32.5% (last sex; noncommercial partners; MSWs; Pakistan National AIDS Control Program 2008)
7.1% (consistent last month; MSWs; Pakistan National AIDS Control Program 2005)
8.0% (consistent last month; MSWs; Pakistan National AIDS Control Program 2006–07)
24.0% (consistent last month; commercial sex; MSWs; Pakistan National AIDS Control Program 2008)
22.2% (consistent last month; noncommercial partners; MSWs; Pakistan National AIDS Control Program 2008)
21.0% (last anal sex; HSWs; Pakistan National AIDS Control Program 2005)
15.0% (last oral sex; HSWs; Pakistan National AIDS Control Program 2005)
32.3% (last commercial sex; HSWs; Pakistan National AIDS Control Program 2008)
26.0% (last sex; noncommercial partners; HSWs; Pakistan National AIDS Control Program 2008)
7.5% (consistent last month; HSWs; Pakistan National AIDS Control Program 2005)
5.6% (consistent last month; HSWs; Pakistan National AIDS Control Program 2006–07)
19.7% (consistent last month; commercial sex; HSWs; Pakistan National AIDS Control Program 2008)
19.6% (consistent last month; noncommercial partners; HSWs; Pakistan National AIDS Control Program 2008)
20%–52% (ever use; hijras; Pakistan National AIDS Control Program 2005)
20.0% (ever use; hijras; Baqi et al. 1999)
4.0% (consistent; hijras; Saleem, Adrien, and Razaque 2008)
18.0% (last sex; one-time client; hijras; Khan et al. 2008)
12.0% (last receptive anal sex; one-time client; hijras; Khan et al. 2008)
15.0% (last sex; regular client; hijras; Khan et al. 2008)
13.0% (last receptive anal sex; regular client; hijras; Khan et al. 2008)
9.0% (last sex; MSWs; Bokhari et al. 2007)
17.0% (last month; nonpaying female; MSWs; Bokhari et al. 2007)
23.0% (last commercial anal sex; banthas; Hawkes et al. 2009)
31.0% (last commercial anal sex; khotkis; Hawkes et al. 2009)
25.0% (last commercial anal sex; khusras; Hawkes et al. 2009)
10.0% (consistent last month during commercial anal sex; banthas; Hawkes et al. 2009)
8.0% (consistent last month during commercial anal sex; khotkis; Hawkes et al. 2009)
4.0% (consistent last month during commercial anal sex; khusras; Hawkes et al. 2009)
10.0% (last commercial oral sex; banthas; Hawkes et al. 2009)
8.0% (last commercial oral sex; khotkis; Hawkes et al. 2009)
4.0% (last commercial oral sex; khusras; Hawkes et al. 2009)
0.0% (last sex with gyria; banthas; Hawkes et al. 2009)
27.0% (last sex with gyria; khotkis; Hawkes et al. 2009)
7.0% (last sex with gyria; khusras; Hawkes et al. 2009)
0.0% (consistent last month with gyria; banthas; Hawkes et al. 2009)
8.0% (consistent last month with gyria; khotkis; Hawkes et al. 2009)
7.0% (consistent last month with gyria; khusras; Hawkes et al. 2009)
Somalia 12.7% (ever use; general population men; WHO 2004)
5.0% (ever use; general population women; WHO 2004)
2.6% (recent use; general population; Scott et al. 1991)
14.0% (last sex; general population women; WHO/EMRO 2000)
15.2% (last sex; general population men; WHO/EMRO 2000)
10.3% (last sex; merchants/drivers; WHO/EMRO 2000)
Sudan 5.8% (ever use; street children; Ahmed 2004h)
6.2% (ever use; university students; Ahmed 2004l)
37.6% (ever use; university students; Sudan National HIV/AIDS Control Program 2004)
3.6% (consistent; university students; Sudan National HIV/AIDS Control Program 2004)
1.2% (last sex; rural population females; SNAP, UNICEF, and UNAIDS 2005)
2.2% (last sex; rural population males; SNAP, UNICEF, and UNAIDS 2005)
3.0% (last year; general population; Southern Sudan; NSNAC and UNAIDS 2006)
2.0% (last sex with casual partner; general population; Sudan National HIV/AIDS Control Program 2004)
106 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 8.2 (Continued)
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 107
Table 8.2 (Continued)
19.7% (consistent during nonpaid sex; MSM; Hsairi and Ben Abdallah 2007)
53.7% (last sex with females; MSM; Hsairi and Ben Abdallah 2007)
55.4% (last paid sex; MSM; Hsairi and Ben Abdallah 2007)
Turkey 70.0% (always; FSWs; Gul et al. 2008)
Yemen, Republic of 57.1% (last paid sex; FSWs; Štulhofer and Božicevic 2008)
28.8% (last nonpaid sex; FSWs; Štulhofer and Božicevic 2008)
50.0% (consistent; nonregular clients; FSWs; Štulhofer and Božicevic 2008)
58.0% (consistent; regular clients; FSWs; Štulhofer and Božicevic 2008)
Note: ANC ⫽ antenatal clinic; CSW ⫽ commercial sex worker; HSW ⫽ hijra sex worker; IDU ⫽ injecting drug user; STD ⫽ sexually transmitted
disease; TB = tuberculosis.
partner refusal,8 pharmacies are too far,9 not There appears to be a gender gap in condom
thinking of them as necessary,10 or fear of knowledge. In the Islamic Republic of Iran, male
imprisonment if caught possessing them (such college students were almost twice as likely as
as for FSWs and MSM).11 Condom accessibility females, 62% versus 39%, to know about con-
varies by population group. In Pakistan, condom doms as a sexually transmitted infection (STI)
accessibility at any time varied between 5.9% prevention method.17 Lack of culturally sensitive
among truck drivers and 67.5% among FSWs.12 and gender-specific information appears to
Condom use as a contraception method also contribute to this gap, suggesting the need for
appears to be low in MENA. In Jordan, 84.4% targeted, gender-specific, and culturally sensi-
of women knew about condoms, but only 2.4% tive information regarding condom use for HIV
reported using them for family planning.13 prevention.18 Men in MENA also appear to have
Several factors have been cited for their limited a negative attitude toward condom use.19
use as a contraception method including reduced
sexual pleasure, inconvenience, adverse experi-
Analytical summary
ences, gender-related issues, and social stigma
attached to condoms as a birth control method.14 Condom knowledge varies in MENA and tends
Nevertheless, effective national family planning to be low in resource-limited settings. Although
programs appear to have increased condom a substantial fraction of the MENA population
knowledge and its use for HIV prevention, such knows about condoms, people are not as aware
as in the Islamic Republic of Iran, where rela- about their use for HIV prevention. Condom
tively higher levels of condom knowledge and knowledge as a means of HIV prevention does
use can be found.15 The Islamic Republic of Iran not translate into actual condom use. And even
also appears to be the only MENA country to when condoms are used for HIV prevention,
possess a condom manufacturing facility, which they are not used consistently. Condom use is
produces 45 million condoms per year.16 low even among the priority populations that
are at the highest risk of infection. Though con-
doms are accessible from pharmacies in many
8
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” parts of MENA, they are less accessible in other
9
Hermez et al., “HIV/AIDS Prevention.”
10
Khan et al., “Correlates and Prevalence of HIV.”
parts, particularly in resource-limited settings.
11
Rajabali et al., “HIV and Homosexuality in Pakistan”; Lebanon National All of these factors indicate that the majority of
AIDS Control Program, “A Case Study.” at-risk sexual acts in MENA are not protected
12
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.”
13
against HIV infection.
Measure DHS, “Jordan Demographic and Health Survey 1997.”
14
Kulczycki, “The Sociocultural Context.”
15 17
Hajiabdolbaghi et al., “Insights from a Survey”; Roudi, “Iran’s Simbar, Tehrani, and Hashemi, “Reproductive Health Knowledge.”
18
Revolutionary Approach.” Lazarus et al., “HIV/AIDS Knowledge.”
16 19
Mehryar, Ahmad-Nia, and Kazemipour, “Reproductive Health in Iran.” Ibid.
108 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Knowledge of condoms as a means of HIV Many people may have heard of HIV/AIDS, but
prevention needs to be increased and their use are unaware of its different transmission modes
for safe sex must be highlighted. This would be and clinical manifestations of infection and dis-
best achieved through culturally sensitive and ease.26 Knowledge of transmission modes is biased
gender-specific awareness programs. by the sociocultural context, where some trans-
mission modes, such as sharing of injections, can
be widely known, but other transmission modes,
HIV/AIDS KNOWLEDGE AND ATTITUDES such as sexual relations within marriage, are not
thought of as a transmission mode.27 This pattern
One of the few areas relevant to HIV/AIDS for of low comprehensive knowledge has been seen
which there has been ample research in MENA in many studies (table E.2 in appendix E).
is that of the levels of HIV/AIDS knowledge and A few studies, however, have identified fairly
attitudes in different population groups. The good levels of comprehensive knowledge in spe-
evidence confirms the variability in the levels of cific populations, including a general population
knowledge and nature of attitudes across and group in the Islamic Republic of Iran28 and pris-
within MENA countries, but there are still key oners, FSWs, MSM, and injecting drug users
features that characterize much of HIV/AIDS (IDUs) in Lebanon.29 Comparing knowledge,
knowledge and attitudes in this region. attitudes, and practices (KAP) surveys in Sudan
from 2002 and 2005 found a substantial
improvement in HIV/AIDS knowledge.30 The
Levels of HIV/AIDS basic knowledge
level of HIV/AIDS knowledge appears to be
In the majority of MENA populations, the level steadily improving.
of HIV/AIDS basic knowledge is high. In Egypt,
84.4% of ever-married women reported know-
ing about HIV/AIDS.20 In Pakistan, 86.8% of Levels of HIV/AIDS misinformation
migrant workers had heard of HIV/AIDS.21 This There is a high level of misinformation and many
high basic knowledge level has been seen in the misconceptions about HIV/AIDS in MENA.31 In
majority of studies (table E.1 in appendix E). In the Islamic Republic of Iran, one-third of high
some settings in MENA, however, low levels of school students believed that HIV can be trans-
basic knowledge have also been documented. In mitted by mosquitoes.32 In Saudi Arabia, 49% of
Afghanistan, 50.8% of women were aware of health care workers (HCWs) identified casual
HIV/AIDS in one study and only 20% knew that kissing as a transmission mode.33 In Sudan, one-
HIV is sexually transmitted.22 This limited basic fifth of antenatal clinic (ANC) attendees believed
knowledge has been observed in a minority of they could acquire HIV by sharing a meal with an
studies (table E.1 in appendix E). HIV-positive person.34 This high level of misinfor-
mation has been seen in many other studies
Levels of HIV/AIDS comprehensive knowledge (table E.3 in appendix E).
Despite widespread basic knowledge, the level Perception of risk of HIV infection
of comprehensiveness of HIV/AIDS knowledge
is inadequate.23 In Egypt, only 6.1% of ever-mar- Most people in MENA do not consider them-
ried women had comprehensive knowledge of selves at risk of HIV infection. In Djibouti, 80%
HIV/AIDS.24 In Somalia, only 4% of young women
26
had comprehensive knowledge of HIV/AIDS.25 Genc et al., “AIDS Awareness and Knowledge.”
27
UNAIDS, “Key Findings.”
28
Montazeri, “AIDS Knowledge and Attitudes.”
20 29
Measure DHS, “Egypt: Demographic and Health Survey 2005.” Mishwar, “An Integrated Bio-Behavioral Surveillance Study”; Rady,
21
Faisel and Cleland, “Study of the Sexual Behaviours.” “Knowledge, Attitudes and Prevalence.”
22 30
Todd et al., “Seroprevalence and Correlates of HIV.” SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.”
23 31
Abolfotouh, “The Impact of a Lecture”; Farghaly and Kamal, “Study of Abolfotouh, “The Impact of a Lecture”; Farghaly and Kamal, “Study of
the Opinion and Level of Knowledge about AIDS.” the Opinion and Level of Knowledge about AIDS.”
24 32
Measure DHS, “Egypt: Demographic and Health Survey 2005.” Tavoosi et al., “Knowledge and Attitude.”
25 33
Somaliland Ministry of Health and Labour, Somaliland 2007 HIV/ Mahfouz et al., “Knowledge and Attitudes.”
34
Syphilis Seroprevalence Survey. Ahmed, Antenatal.
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 109
of high school students reported not being at are deemed unacceptable.47 The attitudes toward
risk of HIV infection.35 In Jordan, 82% of gen- PLHIV depend strongly on the social acceptabil-
eral population women reported not being at ity of the transmission mode by which people
risk for HIV at all.36 In the Republic of Yemen, become infected.48 Religiosity has been associ-
95.1% of secondary school students believed ated with both positive49 and negative50 atti-
that young people are not susceptible to HIV tudes toward PLHIV.
infection.37 The negative attitudes may be due in part to the
invisible nature of the epidemic.51 As a consequence
of low HIV prevalence, most people have never
Attitudes toward people living with HIV
been in contact with a patient with an AIDS-related
Attitudes toward people living with HIV (PLHIV) illness. In the Syrian Arab Republic, only 2.8% of
vary within and between populations, though FSWs reported knowing a relative or a friend who
generally the norm is that of negative and dis- was HIV positive.52 The lack of comprehensive
criminatory attitudes. Different studies have and proper knowledge of HIV/AIDS is a major
documented both tolerant and intolerant atti- factor in discriminatory attitudes. In the Islamic
tudes, often even within the same population. Republic of Iran, positive attitudes were found to be
In Egypt, 99% of general population women did directly correlated with higher knowledge of this
not accept all four positive attitudes toward disease.53 The increasing visibility of HIV in MENA
PLHIV, including caring for patients with AIDS- may lead to improved attitudes toward PLHIV.
related illness, buying from HIV-positive shop- Despite prevailing negative attitudes, several
keepers, allowing HIV-positive women to teach, studies have documented positive attitudes in a
and being willing to disclose the infection of a few MENA populations. In the Islamic Republic
family member.38 The stigma, discrimination, of Iran, 84% of general population respondents
and phobia are most worrying among HCWs. supported the social rights of PLHIV to work and
There is an environment of risk exaggeration in study,54 and 95% said that patients with AIDS-
dealing with PLHIV,39 such as among nurses in related illness deserve respect as human beings.55
both Egypt40 and the Islamic Republic of Iran.41 In Libya, 91% of high school students supported
Over half of Kuwaiti physicians would avoid providing free care to PLHIV.56 In Morocco,
contact with PLHIV.42 These negative attitudes 68% of general population women said they
have been seen in many other studies (table E.4 would take care of PLHIV.57 Encouragingly,
in appendix E). there appears to be a trend of decreasing dis-
There is an immense stigma and human crimination and stigmatization toward PLHIV.
rights issues surrounding HIV in MENA.43 Fear In Jordan, the percentages of youth who
of stigmatization and feelings of anxiety, hope- believed that PLHIV have the right to keep their
lessness, and depression are frequently reported illness a secret has increased from 18% in 1994,58
by PLHIV.44 High profile violations of basic rights to 29% in 1999,59 and to 34.3% in 2005.60
of PLHIV have been widely reported.45 The rights
47
to confidentiality and consent are repeatedly Mohammadi et al., “Reproductive Knowledge, Attitudes and Behavior.”
48
violated.46 Several aspects of human sexuality Badahdah, “Saudi Attitudes towards People Living with HIV/AIDS.”
49
Paruk et al., “Compassion or Condemnation?”
50
Badahdah, “Saudi Attitudes towards People Living with HIV/AIDS.”
51
UNAIDS, “Key Findings.”
35 52
Rodier et al., “HIV Infection.” Syria MOH, “HIV/AIDS Female Sex Workers.”
36 53
Measure DHS, “Jordan: Demographic and Health Survey 1997.” Mazloomy and Baghianimoghadam, “Knowledge and Attitude”;
37
Gharamah and Baktayan, “Exploring HIV/AIDS Knowledge.” Hedayati-Moghaddam, “Knowledge of and Attitudes.”
38 54
Measure DHS, “Egypt: Demographic and Health Survey 2005.” Montazeri, “AIDS Knowledge and Attitudes in Iran.”
39 55
Duyan, Agalar, and Sayek, “Surgeons’ Attitudes toward HIV/AIDS in IRIB, “Poll of Teharan Public on AIDS (2006).”
56
Turkey.” El-Gadi, Abudher, and Sammud, “HIV-Related Knowledge and Stigma.”
40 57
Shouman and Fotouh, “The Impact of Health Education.” Zidouh, “VIH/SIDA et Infections sexuellement transmissibles.”
41 58
Askarian et al., “Knowledge about HIV Infection.” Jordan National AIDS Control Programme, Report on the National
42
Fido and Al Kazemi, “Survey of HIV/AIDS Knowledge.” KABP Survey (1994).
43 59
DeJong et al., “The Sexual and Reproductive Health.” Jordan National AIDS Control Programme, Report on the National
44
Kabbash et al., “Needs Assessment.” KABP Survey (1999).
45 60
Moszynski, “Egyptian Doctors.” Jordan National AIDS Control Programme, Report on the National
46
Mobeireek et al., “Information Disclosure and Decision-Making.” KABP Survey (2005).
110 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Similar improvement in attitudes was also identified schools as a main source of HIV/AIDS
reported among university students in Sudan.61 knowledge, indicating a potential role for schools
in disseminating correct knowledge about HIV/
Sources of HIV/AIDS knowledge AIDS to youth. Still, 60%75 and 88.4%76 of the
students also identified television as a main
Television is by far the main source of HIV/AIDS source of knowledge.
knowledge in MENA. The percentage of different Religious leaders are not a main source of
populations who identified television as the main HIV/AIDS information in MENA, although
source of their HIV/AIDS knowledge was 98% in strong preference has been reported for them to
Egypt,62 83.6% in the Islamic Republic of Iran,63 be the source of HIV/AIDS knowledge.77 In
92% in Pakistan,64 and 90% in Sudan.65 This has Jordan, only 7.3%78 and 11.6%79 of youth
been seen in many other studies (table E.5 in reported religious leaders as a source of infor-
appendix E). Radio is also a major source of HIV/ mation about HIV/AIDS. Parents are also not a
AIDS information in resource-limited parts of the main source of HIV/AIDS knowledge. Only 27%
region, such as Sudan.66 Mass media is undoubt- of Iranian adolescents reported parents as a
edly the most effective method of disseminating source of HIV/AIDS information.80
HIV/AIDS knowledge in this region, but messages
cannot be sexually explicit due to cultural
sensitivities.67 Television has already proven to be Differentials in HIV/AIDS knowledge
an effective tool in disseminating birth control Research in MENA has identified differentials in
information during family planning campaigns in HIV/AIDS knowledge. Gender differential varies
MENA.68 Television has also been reported as a across populations, though males tend to have
preferred mode of disseminating information, better knowledge than females. Women appear
particularly among youth.69 to have inferior access to HIV/AIDS sources of
Educational institutions are seldom a main information compared to men.81 They may also
source of HIV/AIDS knowledge. Only 24% of have limited knowledge about their bodies and
high school students in the Islamic Republic of reproductive health, leading to feelings of help-
Iran reported educational programs,70 and only lessness.82 In Egypt, female IDUs were found to
15% reported schoolbooks,71 as a source of HIV/ have significantly less knowledge about HIV/
AIDS information. In the Republic of Yemen, AIDS than male IDUs.83 In Pakistan,84 Turkey,85
only 29% heard about HIV/AIDS from their and the Republic of Yemen,86 male youth had
teachers.72 However, two studies from the better knowledge of HIV/AIDS than female
Republic of Yemen provide rare examples where youth. In the Republic of Yemen, 94.3% and
schools were the main source of knowledge: 55.6% of males had ever heard of HIV/AIDS
63%73 and 71.3%74 of high school students and condoms, respectively, but for females, the
61 corresponding percentages were 80.8 and 41,
Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence.
62
Measure DHS, “Egypt: Demographic and Health Survey 2005.” respectively.87
63
Karimi and Ataei, “The Assessment of Knowledge.”
64
Khan et al., “Awareness about Common Diseases.”
65 75
SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.” Gharamah and Baktayan, “Exploring HIV/AIDS Knowledge.”
66 76
Yousif, “Health Education Programme”; Ahmed, Sex Sellers; Ahmed, Raja and Janjua, “Epidemiology of Hepatitis C.”
77
Antenatal; Ahmed, Tea Sellers; Ahmed, Military; Ahmed, Truck Drivers; Ibid.
78
Ahmed, Prisoners; Sudan National HIV/AIDS Control Program, HIV/ Jordan National AIDS Control Programme, Report on the National
AIDS/STIs Prevalence; UNHCR, “HIV Behavioural Surveillance Survey”; KABP Survey (2004).
79
Ahmed, University Students; Ahmed, TB Patients; Ahmed, Internally Jordan National AIDS Control Programme, Report on the National
Displaced People; Ahmed, Street Children; Ahmed, STDs; Ahmed, AIDS KABP Survey (2005).
80
Patients. Yazdi et al., “Knowledge, Attitudes and Sources of Information.”
67 81
Lynn, “Pakistan Launches Media Blitz on AIDS.” Manhart et al., “Sexually Transmitted Diseases in Morocco.”
68 82
El-Bakly and Hess, “Mass Media Makes a Difference.” Boyacioglu and Turkmen, “Social and Cultural Dimensions.”
69 83
Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence. Salama et al., “HIV/AIDS Knowledge and Attitudes.”
70 84
Karimi and Ataei, “The Assessment of Knowledge.” Raza et al., “Knowledge, Attitude and Behaviour.”
71 85
Yazdi et al., “Knowledge, Attitudes and Sources of Information.” Savaser, “Knowledge and Attitudes.”
72 86
Al-Serouri, “Assessment of Knowledge.” Yemen Central Statistical Organization, Yemen Demographic, Maternal
73
Gharamah and Baktayan, “Exploring HIV/AIDS Knowledge.” and Child Health Survey 1997.
74 87
Raja and Farhan, “Knowledge and Attitude.” Busulwa, “HIV/AIDS Situation Analysis Study.”
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 111
Bucking the trend, several studies have docu- transmission through breastfeeding.103 However,
mented the opposite tendency, probably reflect- in Sudan, only 4.3% to 39.8% of diverse popu-
ing female mass education gains over the last lation groups reported knowing about the risk of
few decades.88 In Afghanistan, female university mother-to-child transmission.104 Yet in a more
students were more knowledgeable than recent study, 80% of a general population
males.89 In the Islamic Republic of Iran, HIV/ group in Southern Sudan knew of the risk of
AIDS knowledge among female high school mother-to-child transmission during pregnancy
students,90 youth,91 teachers,92 and prisoners93 and birth, and 71% knew of the risk through
was found to be higher than that of males. In breastfeeding.105
further studies of college students94 and the gen- Finally, it appears that knowledge of STIs
eral population95 in the Islamic Republic of Iran, other than HIV is substantially lower than that
of high school students96 in Libya, and of high of HIV/AIDS.106 While 98% of women in Egypt
school students97 in the Republic of Yemen, no knew of HIV/AIDS, only 21.8% knew of other
gender differential in knowledge was found. STIs.107 In Jordan, only 27.4% of women knew
Other common differentials in knowledge are of other STIs,108 and in Morocco, 69% of gen-
those of urban versus rural populations, and eral population women declared that they do
refugees, internally displaced populations, or not know of other STIs.109 However, a study
minorities versus the bulk of the general popu- among a general population in Southern Sudan
lation. Rural residents have been found, such as found that 90% have heard of STIs.110
in Egypt98 and Jordan,99 to have inferior HIV/
AIDS knowledge compared to urban popula-
Analytical summary
tions. Refugees in the Republic of Yemen were
found to have lower knowledge than a margin- MENA countries have made considerable gains
alized minority (Al-Akhdam), and Al-Akhdam in increasing HIV/AIDS basic awareness and
were found to have lower knowledge than the knowledge in recent years. The vast majority of
rest of the general population.100 the populations are aware of HIV/AIDS and
some of its transmission modes. Seventy-five
Other aspects of HIV/AIDS knowledge percent of university students in Sudan have
been exposed to HIV/AIDS education.111
It appears that a considerable fraction of women
Substantial gains in knowledge and prevention
who have heard of HIV/AIDS also know of the
practices have been reported in Pakistan among
risk of transmission from mothers to their
priority populations, partially due to an expan-
babies. In Egypt, 75.8%, 70.4%, and 51.7% of
sion of prevention programs in recent years.112
general population women knew that HIV can
be transmitted during pregnancy, delivery, and Yet, comprehensive and proper knowledge of
HIV/AIDS remains elusive, and misinformation,
breastfeeding, respectively.101 In Jordan these
misconceptions, and myths abound. Most peo-
percentages were 70.1, 54.6, and 42.3, respec-
ple appear to perceive greater risk for others
tively.102 In Morocco, 58% knew of the risk of
than for themselves, and behavioral practices
88
may be combining a low level of partner
Roudi-Fahimi and Moghadam, “Empowering Women, Developing
Society.”
89 103
Mansoor et al., “Gender Differences in KAP.” Zidouh, “VIH/SIDA et Infections sexuellement transmissibles.”
90 104
Karimi and Ataei, “The Assessment of Knowledge.” Ahmed, Sex Sellers; Ahmed, Antenatal; Ahmed, Tea Sellers; Ahmed,
91
Yazdi et al., “Knowledge, Attitudes and Sources of Information.” Military; Ahmed, Truck Drivers; Ahmed, Prisoners; Ahmed, University
92
Mazloomy and Baghianimoghadam, “Knowledge and Attitude.” Students; Ahmed, TB Patients; Ahmed, Internally Displaced People;
93
Nakhaee, “Prisoners’ Knowledge.” Ahmed, Street Children; Ahmed, STDs; Ahmed, AIDS Patients.
94 105
Simbar, Tehrani, and Hashemi, “Reproductive Health Knowledge.” UNHCR, “HIV Behavioural Surveillance Survey.”
95 106
Montazeri, “AIDS Knowledge.” SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.”
96 107
El-Gadi, Abudher, and Sammud, “HIV-Related Knowledge and Stigma.” Measure DHS, “Egypt: Demographic and Health Survey 2005.”
97 108
Gharamah and Baktayan, “Exploring HIV/AIDS Knowledge.” Measure DHS, “Jordan: Demographic and Health Survey 2002.”
98 109
Measure DHS, “Egypt: Demographic and Health Survey 2005.” Zidouh, “VIH/SIDA et Infections sexuellement transmissibles.”
99 110
Measure DHS, “Jordan: Demographic and Health Survey 2002.” UNHCR, “HIV Behavioural Surveillance Survey.”
100 111
Al-Serouri, “Assessment of Knowledge.” Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence.
101 112
Measure DHS, “Egypt: Demographic and Health Survey 2005.” Pakistan National AIDS Control Program, HIV Second Generation
102
Measure DHS, “Jordan: Demographic and Health Survey 2002.” Surveillance (Rounds I, II, and III).
112 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
exchange with widespread disregard for safe and individual counseling programs have been
sex.113 There are, however, some encouraging proven useful in increasing knowledge in
trends, such as in the Islamic Republic of Iran, Egypt,122 the Islamic Republic of Iran,123 Saudi
where more emphasis is placed on safe sex.114 Arabia,124 and Sudan.125 Education should be
Of particular concern is the limited HIV/AIDS expanded in schools, colleges, and universities
knowledge among priority populations, because because these institutions are currently far
these are the populations where HIV has the below their potential of being among the main
greatest potential for spread. Illiteracy is a bar- sources and disseminators of HIV/AIDS know-
rier to expanding HIV/AIDS knowledge in some ledge.126 Well-designed peer education programs
countries, such as Afghanistan, where only 47% may also be effective considering the dense
of males and 15% of females can read.115 social and family networks in MENA.127 Peer
Stakeholders continue to view reproductive group education has been found effective among
health and sex education as encouraging high- prisoners in the Islamic Republic of Iran.128
risk activities, though increased knowledge has
been associated with less risky behavior.116 HIV/
AIDS information is normally acquired through BIBLIOGRAPHY
mass media or personal experiences rather than Aaraj, E. Unknown. “Report on the Situation Analysis
awareness programs.117 Media and peers may on Vulnerable Groups in Beirut, Lebanon.” Grey
not provide accurate information on sexual Report.
health.118 Abdelwahab, O. 2006. “Prevalence, Knowledge of AIDS
and HIV Risk-Related Sexual Behaviour among Police
There is immense stigma and human rights Personnel in Khartoum State, Sudan 2005.” XVI
issues surrounding HIV in MENA. Attitudes International AIDS Conference, Toronto, August
toward PLHIV are generally negative and dis- 13–18, abstract CDC0792.
criminatory. Encouragingly, there appears to be Abolfotouh, M. A. 1995. “The Impact of a Lecture on
AIDS on Knowledge, Attitudes and Beliefs of Male
a trend of decreasing discrimination and stigma- School-Age Adolescents in the Asir Region of
tization, but the region as a whole is still far Southwestern Saudi Arabia.” J Community Health 20:
from addressing this challenge. 271–81.
Media and religious scholars are often cited ACORD. 2006. “Qualitative Socio Economic Research on
Female Sex Workers and Their Vulnerability to HIV/
as preferred sources of HIV/AIDS knowl- AIDS in Khartoum State.” Agency for Co-operation
edge.119 Peers, teachers, and HCWs are also and Research in Development.
cited as preferred sources of HIV/AIDS knowl- Afshar, P. Unknown. “From the Assessment to the
edge.120 Proper HIV/AIDS knowledge and stig- Implementation of Services Available for Drug Abuse
and HIV/AIDS Prevention and Care in Prison Setting:
ma reduction programs can be expanded by The Experience of Iran.” PowerPoint presentation.
taking advantage of mass media, especially Agha, S. 2000. “Potential for HIV Transmission among
television, and by involving religious scholars Truck Drivers in Pakistan.” AIDS 14: 2404–6.
in educational campaigns. Educational pro- Ahmed, S. M. 2004a. AIDS Patients: Situation Analysis-
Behavioral Survey Results & Discussions. Report. Sudan
grams can also contribute to the expansion of
National AIDS Control Program.
knowledge. Even a single educational session ———. 2004b. Antenatal: Situation Analysis-Behavioral
has been found to be useful in significantly Survey Results & Discussions. Report. Sudan National
increasing HIV/AIDS knowledge and aware- AIDS Control Program.
ness in a MENA context.121 Group education ———. 2004c. Internally Displaced People: Situation
Analysis-Behavioral Survey Results & Discussions. Report.
Sudan National AIDS Control Program.
113
Chemtob et al., “Getting AIDS.”
114
Kalkhoran and Hale, “AIDS Education in an Islamic Nation.”
115 122
World Bank, HIV/AIDS in Afghanistan. Salama et al., “HIV/AIDS Knowledge and Attitudes.”
116 123
Grunseit, “Impact of HIV.” Jodati et al., “Impact of Education.”
117 124
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” Saleh et al., “Impact of Health Education.”
118 125
El-Kak et al., “High School Students.” Yousif, “Health Education Programme.”
119 126
Farah and Hussein, “HIV Prevalence”; Al-Serouri, “Assessment of Yazdi et al., “Knowledge, Attitudes and Sources of Information”;
Knowledge.” Jodati et al., “Impact of Education.”
120 127
Al-Serouri, “Assessment of Knowledge”; Mohammadi et al., Ergene et al., “A Controlled-Study”; Jodati et al., “Impact of
“Reproductive Knowledge.” Education.”
121 128
Ergene et al., “A Controlled-Study”; Khan, “Country Watch: Pakistan.” Afshar, “From the Assessment to the Implementation of Services.”
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 113
———. 2004d. Military: Situation Analysis-Behavioral Ati, H. A. 2005. “HIV/AIDS/STIs Social and Geographical
Survey Results & Discussions. Report. Sudan National Mapping of Prisoners, Tea Sellers and Commercial
AIDS Control Program. Sex Workers in Port Sudan Town, Red Sea State.”
———. 2004e. Prisoners: Situation Analysis-Behavioral Draft 2, Ockenden International, Sudan.
Survey Results & Discussions. Report. Sudan National Badahdah, A. 2005. “Saudi Attitudes towards People
AIDS Control Program. Living with HIV/AIDS.” Int J STD AIDS 16: 837–38.
———. 2004f. Sex Sellers: Situation Analysis-Behavioral Baqi, S., S. A. Shah, M. A. Baig, S. A. Mujeeb, and A.
Survey Results & Discussions. Report. Sudan National Memon. 1999. “Seroprevalence of HIV, HBV, and
AIDS Control Program. Syphilis and Associated Risk Behaviours in Male
———. 2004g. STDs: Situation Analysis-Behavioral Survey Transvestites (Hijras) in Karachi, Pakistan.” Int J STD
Results & Discussions. Report. Sudan National AIDS AIDS 10: 300–4.
Control Program. Basha, H. M. 2006. “Vulnerable Population Research in
———. 2004h. Street Children: Situation Analysis-Behavioral Darfur.” Grey Report.
Survey Results & Discussions. Report. Sudan National Blanchard, J. F., A. Khan, and A. Bokhari. 2008. “Variations
AIDS Control Program. in the Population Size, Distribution and Client Volume
———. 2004i. TB Patients: Situation Analysis-Behavioral among Female Sex Workers in Seven Cities of Pakistan.”
Survey Results & Discussions. Report. Sudan National Sex Transm Infect 84 Suppl 2: ii24–27.
AIDS Control Program. Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan,
———. 2004j. Tea Sellers: Situation Analysis-Behavioral M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, K.
Survey Results & Discussions. Report. Sudan National Qayum, P. Girault, E. Pisani, and I. Thaver. 2007.
AIDS Control Program. “HIV Risk in Karachi and Lahore, Pakistan: An
———. 2004k. Truck Drivers: Situation Analysis-Behavioral Emerging Epidemic in Injecting and Commercial Sex
Survey Results & Discussions. Report. Sudan National Networks.” Int J STD AIDS 18: 486–92.
AIDS Control Program. Boyacioglu, A. O., and A. Turkmen. 2008. “Social and
———. 2004l. University Students: Situation Analysis- Cultural Dimensions of Pregnancy and Childbirth in
Behavioral Survey, Results & Discussions. Report. Sudan Eastern Turkey.” Cult Health Sex 10: 277–85.
National AIDS Control Program. Busulwa, R. 2003. “HIV/AIDS Situation Analysis Study.”
Alami, K. 2009. “Tendances récentes de l’épidémie à Conducted in Hodeidah, Taiz and Hadhramut,
VIH/SIDA en Afrique du nord.” Presentation, Republic of Yemen.
Research and AIDS Workshop in North Africa/ Chaouki, N., F. X. Bosch, N. Munoz, C. J. Meijer, B. El
Marrakech, Morocco. Gueddari, A. El Ghazi, J. Deacon, X. Castellsague, and
Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, I. J. M. Walboomers. 1998. “The Viral Origin of Cervical
El-Adawy, and M. Rijhwani. 2007. “Clinical Patterns Cancer in Rabat, Morocco.” Int J Cancer 75: 546–54.
of Sexually Transmitted Diseases, Associated Chemtob, D., B. Damelin, N. Bessudo-Manor, R.
Sociodemographic Characteristics, and Sexual Hassman, Y. Amikam, J. M. Zenilman, and D. Tamir.
Practices in the Farwaniya Region of Kuwait.” Int J 2006. “Getting AIDS: Not in My Back Yard: Results
Dermatol 46: 594–99. from a National Knowledge, Attitudes and Practices
Al-Serouri, A. W. 2005. “Assessment of Knowledge, Survey.” Isr Med Assoc J 8: 610–14.
Attitudes and Beliefs about HIV/AIDS among Young DeJong, J., R. Jawad, I. Mortagy, and B. Shepard. 2005.
People Residing in High Risk Communities in Aden “The Sexual and Reproductive Health of Young
Governatore, Republic of Yemen.” Society for the People in the Arab Countries and Iran.” Reprod Health
Development of Women & Children (SOUL), Matters 13: 49–59.
Education, Health, Welfare; United Nations Children’s Dewachi, O. 2001. “Men Who Have Sex with Other Men
Fund, Yemen Country Office, HIV/AIDS Project. and HIV AIDS: A Situation Analysis in Beirut,
Altaf, A., S. A. Shah, N. A. Zaidi, A. Memon, R. Nadeem Lebanon: HIV/AIDS Prevention through Outreach to
ur, and N. Wray. 2007. “High Risk Behaviors of Vulnerable Populations.” Grey Report, April 29.
Injection Drug Users Registered with Harm Reduction Duyan, V., F. Agalar, and I. Sayek. 2001. “Surgeons’
Programme in Karachi, Pakistan.” Harm Reduct J 4: 7. Attitudes toward HIV/AIDS in Turkey.” AIDS Care 13:
Anonymous. 2007. “Improving HIV/AIDS Response 243–50.
among Most at Risk Population in Sudan.” Orientation Eftekhar, M., M.-M. Gouya, A. Feizzadeh, N. Moshtagh,
Workshop, 16 April 2007. H. Setayesh, K. Azadmanesh, and A.-R. Vassigh.
Ardalan, A., K. H. Na’ini, A. M. Tabrizi, and A. Jazayeri. 2008. “Bio-Behavioural Survey on HIV and Its Risk
2002. “Sex for Survival: The Future of Runaway Factors among Homeless Men Who Have Sex with
Girls.” Social Welfare Research Quarterly 2: 187–219. Men in Teharan, 2006–07.”
Askarian, M., Z. Hashemi, P. Jaafari, and O. Assadian. Egypt MOH (Ministry of Health), and Population
2006. “Knowledge about HIV Infection and Attitude National AIDS Program. 2006. HIV/AIDS Biological and
of Nursing Staff toward Patients with AIDS in Iran.” Behavioral Surveillance Survey. Summary report.
Infect Control Hosp Epidemiol 27: 48–53. El-Bakly, S., and R. W. Hess. 1994. “Mass Media Makes
Asouab, F. 2005. “Risques VIH/SIDA chez UDI et plan a Difference.” Integration 13–15.
d’action 2006–2010.” Grey Report. El Ghrari, K., Z. Terrab, H. Benchikhi, H. Lakhdar, I.
Assal, M. 2006. “HIV Prevalence, Knowledge, Attitude, Jroundi, and M. Bennani. 2007. “Prevalence of Syphilis
Practices, and Risk Factors among Prisoners in and HIV Infection in Female Prison Population in
Khartoum State, Sudan.” Grey Report. Morocco.” East Mediterr Health J 13: 774–79.
114 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
El-Gadi, S., A. Abudher, and M. Sammud. 2008. “HIV- among Truck Drivers in Karthoum State.” Sudan
Related Knowledge and Stigma among High School National AIDS Program.
Students in Libya.” Int J STD AIDS 19: 178–83. Farghaly, A. G., and M. M. Kamal. 1991. “Study of the
El-Kak, F. H., R. A. Soweid, C. Taljeh, M. Kanj, and M. Opinion and Level of Knowledge about AIDS Problem
C. Shediac-Rizkallah. 2001. “High School Students in among Secondary School Students and Teachers in
Postwar Lebanon: Attitudes, Information Sources, Alexandria.” J Egypt Public Health Assoc 66: 209–25.
and Perceived Needs Related to Sexual and Farhoudi, B., A. Montevalian, M. Motamedi, M. M.
Reproductive Health.” J Adolesc Health 29: 153–55. Khameneh, M. Mohraz, M. Rassolinejad, S. Jafari,
El-Rahman, A. 2004. “Risky Behaviours for HIV/AIDS P. Afshar, I. Esmaili, and L. Mohseni. 2003. “Human
Infection among a Sample of Homosexuals in Cairo Immunodeficiency Virus and HIV-Associated
City, Egypt.” XV International AIDS Conference, Tuberculosis Infection and Their Risk Factors in
Bangkok, July 11–16. Abstract WePeC6146. Injecting Drug Users in Prison in Iran.”
Elrashied, S. M. 2006. “Generating Strategic Information Fido, A., and R. Al Kazemi. 2002. “Survey of HIV/AIDS
and Assessing HIV/AIDS Knowledge, Attitude and Knowledge and Attitudes of Kuwaiti Family
Behaviour and Practices as well as Prevalence of HIV1 Physicians.” Fam Pract 19: 682–84.
among MSM in Khartoum State, 2005.” A draft Genc, M., G. Gunes, L. Karaoglu, and M. Egri. 2005.
report submitted to Sudan National AIDS Control “AIDS Awareness and Knowledge among Married
Programme. Together Against AIDS Organization Women Living in Malatya (Turkey): Implications for
(TAG), Khartoum, Sudan. Province-Based Prevention Programs.” New Microbiol
El-Sayed, N., M. Abdallah, A. Abdel Mobdy, A. Abdel 28: 161–64.
Sattar, E. Aoun, F. Beths, G. Dallabetta, M. Rakha, C. Gharamah, F. A., and N. A. Baktayan. 2006. “Exploring
Soliman, and N. Wasef. 2002. “Evaluation of Selected HIV/AIDS Knowledge and Attitudes of Secondary
Reproductive Health Infections in Various Egyptian School Students (10th & 11th grade) in Al-Tahreer
Population Groups in Greater Cairo.” MOHP, District, Sana’a City.” Republic of Yemen, March–April.
IMPACT/FHI/USAID. Grunseit, A. 1997. “Impact of HIV and Sexual Health
El-Sayed, N., A. Darwish, and M. El Geneidy. 1994. Education on the Sexual Behavior of Young People:
“Knowledge, Attitude, and Practice of Homosexuals A Review Update.” UNAIDS, Geneva.
regarding HIV in Egypt.” National AIDS Program, Gul, U., A. Kilic, B. Sakizligil, S. Aksaray, S. Bilgili, O.
Ministry of Health and Population, Egypt. Demirel, and C. Erinckan. 2008. “Magnitude of Sexually
El-Sayed, N. M., P. J. Gomatos, G. R. Rodier, T. F. Transmitted Infections among Female Sex Workers in
Wierzba, A. Darwish, S. Khashaba, and R. R. Arthur. Turkey.” J Eur Acad Dermatol Venereol 22: 1123–24.
1996. “Seroprevalence Survey of Egyptian Tourism Haider, G., N. Zohra, N. Nisar, and A. A. Munir. 2009.
Workers for Hepatitis B Virus, Hepatitis C Virus, “Knowledge about AIDS/HIV Infection among
Human Immunodeficiency Virus, and Treponema Women Attending Obstetrics and Gynaecology Clinic
Pallidum Infections: Association of Hepatitis C Virus at a University Hospital.” J Pak Med Assoc 59: 95–98.
Infections with Specific Regions of Egypt.” Am J Trop
Med Hyg 55: 179–84. Hajiabdolbaghi, M., N. Razani, N. Karami, P. Kheirandish,
M. Mohraz, M. Rasoolinejad, K. Arefnia, Z. Kourorian,
El-Sayyed, N., I. A. Kabbash, and M. El-Gueniedy. 2008. G. Rutherford, and W. McFarland. 2007. “Insights
“Knowledge, Attitude and Practices of Egyptian from a Survey of Sexual Behavior among a Group of
Industrial and Tourist Workers towards HIV/AIDS.” At-Risk Women in Tehran, Iran, 2006.” AIDS Educ
East Mediterr Health J 14: 1126–35. Prev 19: 519–30.
Elshimi, T., M. Warner-Smith, and M. Aon. 2004. Haque, N., T. Zafar, H. Brahmbhatt, G. Imam, S. ul
“Blood-Borne Virus Risks of Problematic Drug Users Hassan, and S. A. Strathdee. 2004. “High-Risk Sexual
in Greater Cairo.” UNAIDS and UNODC, Geneva. Behaviours among Drug Users in Pakistan:
El-Tawila, S., O. El-Gibaly, B. Ibrahim, et al. 1999. Implications for Prevention of STDs and HIV/AIDS.”
Transitions to Adulthood: A National Survey of Adolescents Int J STD AIDS 15: 601–7.
in Egypt. Cairo, Egypt: Population Council. Hassen, E., A. Chaieb, M. Letaief, H. Khairi, A. Zakhama,
Emmanuel, F., and M. Fatima. 2008. “Coverage to Curb S. Remadi, and L. Chouchane. 2003. “Cervical
the Emerging HIV Epidemic among Injecting Drug Human Papillomavirus Infection in Tunisian
Users in Pakistan: Delivering Prevention Services Women.” Infection 31: 143–48.
Where Most Needed.” Int J Drug Policy 19 Suppl 1: Hawkes, S., M. Collumbien, L. Platt, N. Lalji, N. Rizvi,
S59–64. A. Andreasen, J. Chow, R. Muzaffar, H. ur-Rehman,
Ergene, T., F. Cok, A. Tumer, and S. Unal. 2005. “A N. Siddiqui, S. Hasan, and A. Bokhari. 2009. “HIV
Controlled-Study of Preventive Effects of Peer and Other Sexually Transmitted Infections among
Education and Single-Session Lectures on HIV/AIDS Men, Transgenders and Women Selling Sex in Two
Knowledge and Attitudes among University Students Cities in Pakistan: A Cross-Sectional Prevalence
in Turkey.” AIDS Educ Prev 17: 268–78. Survey.” Sex Transm Infect 85 Suppl 2: ii8–16.
Faisel, A., and J. Cleland. 2006. “Study of the Sexual Hedayati-Moghaddam, M. R. 2008. “Knowledge of and
Behaviours and Prevalence of STIs among Migrant Attitudes towards HIV/AIDS in Mashhad, Islamic
Men in Lahore, Pakistan.” Arjumand and Associates, Republic of Iran.” East Mediterr Health J 14: 1321–32.
Centre for Population Studies, London School of Hermez, J. “HIV/AIDS Prevention through Outreach to
Hygiene and Tropical Medicine. Vulnerable Populations in Beirut, Lebanon.” Final
Farah, M. S., and S. Hussein. 2006. “HIV Prevalence, Report, Beirut, Lebanon. Lebanon National AIDS
Knowledge, Attitude, Practices and Risk Factors Program.
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 115
Hermez, J., E. Aaraj, O. Dewachi, and N. Chemaly. “HIV/ 25th International Congress of Chemotherapy,
AIDS Prevention among Vulnerable Groups in Beirut, Munich, Germany.
Lebanon.” PowerPoint presentation, Beirut, Lebanon, Khan, A. A., N. Rehan, K. Qayyum, and A. Khan. 2008.
Lebanon National AIDS Program. “Correlates and Prevalence of HIV and Sexually
Holt, B. Y., P. Effler, W. Brady, J. Friday, E. Belay, K. Transmitted Infections among Hijras (Male
Parker, and M. Toole. 2003. “Planning STI/HIV Transgenders) in Pakistan.” Int J STD AIDS 19: 817–20.
Prevention among Refugees and Mobile Populations: Khan, S. J., Q. Anjum, N. U. Khan, and F. G. Nabi. 2005.
Situation Assessment of Sudanese Refugees.” Disasters “Awareness about Common Diseases in Selected
27: 1–15. Female College Students of Karachi.” J Pak Med Assoc
Hsairi, M., and S. Ben Abdallah. 2007. “Analyse de la 55: 195–98.
situation de vulnérabilité vis-à-vis de l’infection à VIH Khan, T. M. 1995. “Country Watch: Pakistan.” AIDS STD
des hommes ayant des relations sexuelles avec des Health Promot Exch 7–8.
hommes.” For ATL MST sida NGO–Tunis Section, Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H.
National AIDS Programme/DSSB, UNAIDS. Final Vermund. 1997. “HIV/AIDS and Its Risk Factors in
report, abridged version. Pakistan.” AIDS 11: 843–48.
IGAD (Intergovernmental Authority on Development). Kulczycki, A. 2004. “The Sociocultural Context of
2006. “IGAD/World Bank Cross Border Mobile Condom Use within Marriage in Rural Lebanon.”
Population Mapping Exercise.” Sudan, draft report. Stud Fam Plann 35: 246–60.
Ingold, R. 1994. “Rapid Assessment on Illicit Drug Use in Kuo, I., S. ul-Hasan, N. Galai, D. L. Thomas, T. Zafar, M. A.
Great Beirut.” UNDCP. Ahmed, and S. A. Strathdee. 2006. “High HCV
IRIB. 2006. “Poll of Tehran Public on AIDS.” Seroprevalence and HIV Drug Use Risk Behaviors among
Unpublished. Injection Drug Users in Pakistan.” Harm Reduct J 3: 26.
Jahani, M. R., S. M. Alavian, H. Shirzad, A. Kabir, and Lazarus, J. V., H. M. Himedan, L. R. Ostergaard, and
B. Hajarizadeh. 2005. “Distribution and Risk Factors J. Liljestrand. 2006. “HIV/AIDS Knowledge and
of Hepatitis B, Hepatitis C, and HIV Infection in a Condom Use among Somali and Sudanese Immigrants
Female Population with ‘Illegal Social Behaviour.’” in Denmark.” Scand J Public Health 34: 92–99.
Sex Transm Infect 81: 185. Lebanon National AIDS Control Program. 1996. “General
Jodati, A. R., G. R. Nourabadi, S. Hassanzadeh, S. Population Evaluation Survey Assessing Knowledge,
Dastgiri, and K. Sedaghat. 2007. “Impact of Education Attitudes, Beliefs and Practices Related to HIV/AIDS
in Promoting the Knowledge of and Attitude to HIV/ in Lebanon.” Ministry of Public Health.
AIDS Prevention: A Trial on 17,000 Iranian Students.” ———. 2008. “A Case Study on Behavior Change
Int J STD AIDS 18: 407–9. among Female Sex Workers.” Beirut, Lebanon.
Jordan National AIDS Control Programme. 1994. Report Lynn, W. 1994. “Pakistan Launches Media Blitz on
on the National KABP Survey on HIV/AIDS among AIDS.” Glob AIDSnews 1–2.
Jordanian Youth. NAP Jordan.
Mahfouz, A. A., W. Alakija, A. A. al-Khozayem, and R.
———. 1999. Report on the National KABP Survey on HIV/ A. al-Erian. 1995. “Knowledge and Attitudes towards
AIDS among Jordanian Youth. NAP Jordan. AIDS among Primary Health Care Physicians in the
———. 2004. Report on the National KABP Survey on HIV/ Asir Region, Saudi Arabia.” J R Soc Health 115: 23–25.
AIDS among Jordanian Youth. NAP Jordan. Manhart, L. E., A. Dialmy, C. A. Ryan, and J. Mahjour.
———. 2005. Report on the National KABP Survey on HIV/ 2000. “Sexually Transmitted Diseases in Morocco:
AIDS among Jordanian Youth. NAP Jordan. Gender Influences on Prevention and Health Care
Jurjus, A. R., J. Kahhaleh, National AIDS Program, and Seeking Behavior.” Soc Sci Med 50: 1369–83.
WHO/EMRO (World Health Organization/Eastern Mansoor, A. B., W. Fungladda, J. Kaewkungwal, and W.
Mediterranean Regional Office). 2004. “Knowledge, Wongwit. 2008. “Gender Differences in KAP Related to
Attitudes, Beliefs, and Practices of the Lebanese con- HIV/AIDS among Freshmen in Afghan Universities.”
cerning HIV/AIDS.” Beirut, Lebanon. Southeast Asian J Trop Med Public Health 39: 404–18.
Kabbash, I. A., M. El-Gueneidy, A. Y. Sharaf, N. M. Mazloomy, S. S., and M. H. Baghianimoghadam. 2008.
Hassan, and N. Al-Nawawy. 2008. “Needs Assessment “Knowledge and Attitude about HIV/AIDS of
and Coping Strategies of Persons Infected with HIV in Schoolteachers in Yazd, Islamic Republic of Iran.” East
Egypt.” East Mediterr Health J 14: 1308–20. Mediterr Health J 14: 292–97.
Kabbash, I. A., N. M. El-Sayed, A. N. Al-Nawawy, I. K. Measure DHS. 1998. “Jordan: Demographic and Health
Shady, and M. S. Abou Zeid. 2007. “Condom Use Survey 1997.”
among Males (15–49 Years) in Lower Egypt: ———. 2003. “Jordan: Demographic and Health Survey
Knowledge, Attitudes and Patterns of Use.” East 2002.”
Mediterr Health J 13: 1405–16.
———. 2006. “Egypt: Demographic and Health Survey
Kalkhoran, S., and L. Hale. 2008. “AIDS Education in an 2005.”
Islamic Nation: Content Analysis of Farsi-Language
AIDS-Education Materials in Iran.” Promot Educ 15: ———. 2007. “Pakistan Demographic and Health Survey
21–25. 2006–7.” Preliminary report, National Institute for
Population Studies, Measure DHS, and Macro
Karimi, I., and B. Ataei. 2007. “The Assessment of International.
Knowledge about AIDS and Its Prevention on Isfahan
High School Students.” 17th European Congress of Mehryar, A. H., S. Ahmad-Nia, and S. Kazemipour.
Clinical Microbiology and Infectious Diseases, and 2007. “Reproductive Health in Iran: Pragmatic
116 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Achievements, Unmet Needs, and Ethical Challenges Health, Pakistan, and Canada-Pakistan HIV/AIDS
in a Theocratic System.” Stud Fam Plann 38: 352–61. Surveillance Project.
Ministry of Health and Medical Education of Iran. 2004. ———. 2008. HIV Second Generation Surveillance in
AIDS/HIV Surveillance Report, Fourth Quarter. Tehran. Pakistan. National Report Round III. Ministry of
Mishwar. 2008. “An Integrated Bio-Behavioral Health, Pakistan, Canada-Pakistan HIV/AIDS
Surveillance Study among Four Vulnerable Groups in Surveillance Project.
Lebanon: Men Who Have Sex with Men; Prisoners; Paruk, Z., S. D. Mohamed, C. Patel, and S. Ramgoon.
Commercial Sex Workers and Intravenous Drug 2006. “Compassion or Condemnation? South African
Users.” Final report, Beirut, Lebanon Muslim Students’ Attitudes to People with HIV/
Mobeireek, A. F., F. Al-Kassimi, K. Al-Zahrani, A. AIDS.” Sahara J 3: 510–15.
Al-Shimemeri, S. al-Damegh, O. Al-Amoudi, S. Parviz, S., Z. Fatmi, A. Altaf, J. B. McCormick, S. Fischer-
Al-Eithan, B. Al-Ghamdi, and M. Gamal-Eldin. 2008. Hoch, M. Rahbar, and S. Luby. 2006. “Background
“Information Disclosure and Decision-Making: The Demographics and Risk Behaviors of Injecting Drug
Middle East versus the Far East and the West.” J Med Users in Karachi, Pakistan.” Int J Infect Dis 10: 364–71.
Ethics 34: 225–29. PFPPA. 2005. “Assessment of Palestinian Students’
Mohammad, K., F. K. Farahani, M. R. Mohammadi, S. Knowledge about AIDS and Their Attitudes toward
Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani, the AIDS Patient.” Jerusalem, Palestine.
A. Hasanzadeh, and H. Ghanbari. 2007. “Sexual Risk- Platt, L., P. Vickerman, M. Collumbien, S. Hasan, N. Lalji,
Taking Behaviors among Boys Aged 15–18 Years in S. Mayhew, R. Muzaffar, A. Andreasen, and S.
Tehran.” J Adolesc Health 41: 407–14. Hawkes. 2009. “Prevalence of HIV, HCV and Sexually
Mohammadi, M. R., K. Mohammad, F. K. Farahani, S. Transmitted Infections among Injecting Drug Users in
Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani, Rawalpindi and Abbottabad, Pakistan: Evidence for
and F. Alaeddini. 2006. “Reproductive Knowledge, an Emerging Injection-Related HIV Epidemic.” Sex
Attitudes and Behavior among Adolescent Males in Transm Infect 85 Suppl 2: ii17–22.
Tehran, Iran.” Int Fam Plan Perspect 32: 35–44. Population Studies Research Institute. 2000. “Baseline
Montazeri, A. 2005. “AIDS Knowledge and Attitudes in Survey on Reproductive Health and Family Planning
Iran: Results from a Population-Based Survey in in Northeast and Northwest Regions of Somalia.”
Tehran.” Patient Educ Couns 57: 199–203. University of Nairobi, WHO.
Morocco MOH. 2004. “Survey on Population and Family Rady, A. 2005. “Knowledge, Attitudes and Prevalence of
Health.” Condom Use among Female Sex Workers in Lebanon:
———. 2007. “Survey of Knowledge, Attitude, and Behavioral Surveillance Study.” UNFPA.
Practices of Sex Workers on STD and AIDS.” National Raja, N. S., and K. A. Janjua. 2008. “Epidemiology of
Programme of Fight against AIDS. Hepatitis C Virus Infection in Pakistan.” J Microbiol
———. Unknown. “Situation épidémiologique actuelle du Immunol Infect 41: 4–8.
VIH/SIDA au Maroc.” Raja, Y., and A. Farhan. 2005. “Knowledge and Attitude
Morocco MOH, with the support of GTZ. 2007. of 10th and 11th Grade Students towards HIV/AIDS in
“Knowledge, Attitudes, and Practices of Youth Aden Governorate.” Republic of Yemen, Grey Report.
Regarding STDs and AIDS.” Rajabali, A., S. Khan, H. J. Warraich, M. R. Khanani, and
Moszynski, P. 2008. “Egyptian Doctors Who Took Part in S. H. Ali. 2008. “HIV and Homosexuality in Pakistan.”
Forced HIV Testing ‘Violated Medical Ethics.’” BMJ Lancet Infect Dis 8: 511–15.
336: 855. Raza, M. I., A. Afifi, A. J. Choudhry, and H. I. Khan.
Nakhaee, F. H. 2002. “Prisoners’ Knowledge of HIV/ 1998. “Knowledge, Attitude and Behaviour towards
AIDS and Its Prevention in Kerman, Islamic Republic AIDS among Educated Youth in Lahore, Pakistan.” J
of Iran.” East Mediterr Health J 8: 725–31. Pak Med Assoc 48: 179–82.
Narenjiha, H., H. Rafiey, A. Baghestani, et al. 2005. Refaat, A. 2004. “Practice and Awareness of Health Risk
“Rapid Situation Assessment of Drug Abuse and Behaviour among Egyptian University Students.”
Drug Dependence in Iran.” DARIUS Institute (draft East Mediterr Health J 10: 72–81.
version, in Persian). Rodier, G. R., J. J. Morand, J. S. Olson, D. M. Watts, and
NSNAC (New Sudan AIDS Council), and UNAIDS (United S. Said. 1993. “HIV Infection among Secondary School
Nations Joint Programme on HIV/AIDS). 2006. HIV/ Students in Djibouti, Horn of Africa: Knowledge,
AIDS Integrated Report South Sudan, 2004–2005. With Exposure and Prevalence.” East Afr Med J 70: 414–17.
United Nations General Assembly Special Session on Roudi, F. 1999. “Iran’s Revolutionary Approach to
HIV/AIDS Declaration of Commitment. Family Planning.” Popul Today 27: 4–5.
Oman MOH (Ministry of Health). 2006. “HIV Risk Roudi-Fahimi, F., and V. M. Moghadam. 2003.
among Heroin and Injecting Drug Users in Muscat, “Empowering Women, Developing Society: Female
Oman.” Quantitative Survey, Preliminary Data. Education in the Middle East and North Africa.”
Pakistan National AIDS Control Program. 2005. HIV Population Reference Bureau.
Second Generation Surveillance in Pakistan. National Salama, I. I., N. K. Kotb, S. A. Hemeda, and F. Zaki.
Report Round 1. Ministry of Health, Pakistan, 1998. “HIV/AIDS Knowledge and Attitudes among
and Canada-Pakistan HIV/AIDS Surveillance Alcohol and Drug Abusers in Egypt.” J Egypt Public
Project. Health Assoc 73: 479–500.
———. 2006–7. HIV Second Generation Surveillance in Saleem, N. H., A. Adrien, and A. Razaque. 2008. “Risky
Pakistan. National Report Round II. Ministry of Sexual Behavior, Knowledge of Sexually Transmitted
Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 117
Infections and Treatment Utilization among a Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge,
Vulnerable Population in Rawalpindi, Pakistan.” Attitudes and Practices concerning HIV/AIDS
Southeast Asian J Trop Med Public Health 39: 642–48. among Iranian At-Risk Sub-Populations.” Eastern
Saleh, M. A., Y. S. al-Ghamdi, O. A. al-Yahia, T. M. Mediterranean Health Journal 14.
Shaqran, and A. R. Mosa. 1999. “Impact of Health Todd, C. S., M. Ahmadzai, F. Atiqzai, H. Siddiqui, P.
Education Program on Knowledge about AIDS and Azfar, S. Miller, J. M. Smith, S. A. S. Ghazanfar, and
HIV Transmission in Students of Secondary Schools S. A. Strathdee. 2007. “Seroprevalence and Correlates
in Buraidah City, Saudi Arabia: An Exploratory of HIV, Syphilis, and Hepatitis B and C Infection
Study.” East Mediterr Health J 5: 1068–75. among Antenatal Patients and Testing Practices and
Sanders-Buell, E., M. D. Saad, A. M. Abed, M. Bose, C. Knowledge among Obstetric Care Providers in
S. Todd, S. A. Strathdee, B. A. Botros, N. Safi, K. C. Kabul.” PowerPoint presentation.
Earhart, P. T. Scott, N. Michael, and F. E. McCutchan. UNAIDS (United Nations Joint Programme on HIV/AIDS).
2007. “A Nascent HIV Type 1 Epidemic among 2007. “Key Findings on HIV Status in the West Bank
Injecting Drug Users in Kabul, Afghanistan Is and Gaza.” Working document, RST, MENA.
Dominated by Complex AD Recombinant Strain, UNAIDS, and WHO (World Health Organization). 2005.
CRF35_AD.” AIDS Res Hum Retroviruses 23: 834–39. AIDS Epidemic Update 2005. Geneva.
Savaser, S. 2003. “Knowledge and Attitudes of High UNHCR (United Nations High Commissioner for
School Students about AIDS: A Turkish Perspective.” Refugees). 2007. “HIV Behavioural Surveillance
Public Health Nurs 20: 71–79. Survey Juba Municipality, South Sudan.” Grey Report.
Scott, D. A., A. L. Corwin, N. T. Constantine, M. A. Omar, Wassef, H. H., E. Fox, E. A. Abbatte, J. F. Toledo, and G.
A. Guled, M. Yusef, C. R. Roberts, and D. M. Watts. Rodier. 1989. “Knowledge of Sexually Transmitted
1991. “Low Prevalence of Human Immunodeficiency Diseases and Attitudes towards Them in Populations at
Virus-1 (HIV-1), HIV-2, and Human T Cell Lymphotropic Risk in Djibouti.” Bull World Health Organ 67: 549–53.
Virus-1 Infection in Somalia.” American Journal of WHO (World Health Organization). 2004. The 2004 First
Tropical Medicine and Hygiene 45: 653. National Second Generation HIV/AIDS/STI Sentinel
Shouman, A. E., and A. A. Fotouh. 1995. “The Impact of Surveillance Survey, Somalia: A Technical Report. Grey
Health Education on the Knowledge and Attitude of Report.
Egyptian Nurses towards Occupational HIV Infection.” WHO/EMRO (Eastern Mediterranean Regional Office).
J Egypt Public Health Assoc 70: 25–35. 2000. “Presentation of WHO Somalia’s Experience in
Simbar, M., F. R. Tehrani, and Z. Hashemi. 2005. Supporting the National Response.” Regional
“Reproductive Health Knowledge, Attitudes and Consultation towards Improving HIV/AIDS & STD
Practices of Iranian College Students.” East Mediterr Surveillance in the Countries of EMRO, Beirut,
Health J 11: 888–97. Lebanon, Oct. 30–Nov. 2.
SNAP (Sudan National AIDS Program), UNICEF (United World Bank. 2006. HIV/AIDS in Afghanistan. South Asia
Nations Children’s Fund), and UNAIDS (United Region.
Nations Joint Programme on HIV/AIDS). 2005. ———. 2008. “Mapping and Situation Assessment of
“Baseline Study on Knowledge, Attitudes, and Key Populations at High Risk of HIV in Three Cities of
Practices on Sexual Behaviors and HIV/AIDS Afghanistan.” Human Development Sector, South
Prevention amongst Young People in Selected States Asia Region (SAR) AIDS Team, World Bank.
in Sudan.” HIV/AIDS KAPB Report, Projects and
Research Department (AFROCENTER Group). Yazdi, C. A., K. Aschbacher, A. Arvantaj, H. M. Naser, E.
Abdollahi, A. Asadi, M. Mousavi, M. R. Narmani, M.
Somaliland Ministry of Health and Labour. 2007. Kianpishe, F. Nicfallah, and A. K. Moghadam. 2006.
Somaliland 2007 HIV/Syphilis Seroprevalence Survey: A “Knowledge, Attitudes and Sources of Information
Technical Report. Ministry of Health and Labour in col- regarding HIV/AIDS in Iranian Adolescents.” AIDS
laboration with WHO, UNAIDS, UNICEF/GFATM, Care 18: 1004–10.
and SOLNAC.
Yemen Central Statistical Organization. 1998. Yemen
Štulhofer, A., and I. Božicevic. 2008. “HIV Bio- Demographic, Maternal and Child Health Survey 1997.
Behavioural Survey among FSWs in Aden, Yemen.” Macro International. Calverton, MD: Central Statistical
Grey Report. Organization and Macro International.
Sudan National HIV/AIDS Control Program. 2004. HIV/
Yousif, M. E. A. 2006. “Health Education Programme
AIDS/STIs Prevalence, Knowledge, Attitude, Practices and
among Female Sex Workers in Wad Medani Town-
Risk Factors among University Students and Military
Gezira State.” Final report.
Personnel. Federal Ministry of Health, Khartoum.
Syria Mental Health Directorate. 2008. “Assessment of Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian, M.
HIV Risk and Sero-Prevalence among Drug Users in Ono-Kihara, E. M. Razzaghi, and S. Ichikawa. 2005.
Greater Damascus.” Programme SNA, Syrian Ministry “Prevalence of and Factors Associated with HIV-1
of Health, UNODC, UNAIDS. Infection among Drug Users Visiting Treatment
Centers in Tehran, Iran.” AIDS 19: 709–16.
Syria MOH (Ministry of Health). 2004. “HIV/AIDS Female
Sex Workers KABP in Syria.” National AIDS Program. Zargooshi, J. 2002. “Characteristics of Gonorrhoea in
Kermanshah, Iran.” Sex Transm Infect 78: 460–61.
Tavoosi, A., A. Zaferani, A. Enzevaei, P. Tajik, and Z.
Ahmadinezhad. 2004. “Knowledge and Attitude Zidouh, A. Unknown. “VIH/SIDA et Infections sexuelle-
towards HIV/AIDS among Iranian Students.” BMC ment transmissibles: connaissance et attitudes.” Grey
Public Health 4: 17. Report.
118 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 9
Vulnerable populations are defined in our con- A number of general vulnerability factors
ceptual framework as subpopulations within the have also been identified in the region. These
general population who are in principle not at include weak systems of surveillance for all
high risk of human immunodeficiency virus sexually transmitted infections (STIs), a seasonal
(HIV) infection, such as prisoners, youth, and influx of tourists from both within and outside
mobile populations, but are vulnerable, because the region, migrant workers engaging in risky
of the nature of their living experiences, to prac- behavior while abroad, a low level of condom
tices that may expose them to HIV. Once these knowledge and use, and a lack of adequate
vulnerable populations adopt high-risk practices, knowledge of HIV/AIDS.
they are no longer part of our definition of the Considering the established evidence in other
general population, but become part of the regions of vulnerabilities driving HIV trans-
high-risk priority or bridging populations. mission,3 this chapter discusses the settings of
The settings of vulnerabilities in the Middle vulnerability from the angle of how these vul-
East and North Africa (MENA) are diverse and a nerabilities may contribute as drivers of the
large fraction of the population belongs to one region’s HIV epidemic. This chapter focuses on
or multiple vulnerability settings. A number of the three key vulnerable populations: prisoners,
populations have been widely identified as vul- youth, and mobile populations.
nerable in the MENA context including prison-
ers, youth, refugees, internally displaced persons
(IDPs), migrant workers, industrial zone work- PRISONERS AND HIV
ers, fishermen, road builders, the unemployed,
sexual partners of injecting drug users (IDUs), The prison environment is conducive to high-
tea and qat sellers, geeza women (serve men who risk behaviors, and priority groups, such as
chew qat)1, domestic maids, noninjecting drug IDUs, are often vastly overrepresented among
users, frequent travelers, tourism workers, prison inmates.4 Imprisonment and repeated
health care workers (HCWs), street children, imprisonments are common among IDUs.5
runaway and divorced women, minorities (such Outbreaks of HIV among prisoners driven by
as the 200,000 Al-Akhdam in the Republic of
Yemen2), and temporary and casual workers.
3
Parker, Easton, and Klein, “Structural Barriers and Facilitators in HIV
1
Tchupo, Les maladies sexuellement transmissibles. Prevention.”
2 4
Busulwa, “HIV/AIDS Situation Analysis Study”; Al Ahmadi and Beatty, Gaughwin, Douglas, and Wodak, “Behind Bars.”
5
“Participatory-Socio Economic Needs Survey.” Dolan et al., “HIV in Prison.”
119
IDU have been reported in different countries hepatitis C virus (HCV) prevalence, a proxy of
around the globe.6 IDU, of as much as 78% were found among pris-
The prison population is dynamic, with pris- oners in MENA, suggesting the prevalence of
oners and staff moving in and out on a frequent current or previous injecting drug use.20
basis.7 There is extensive evidence of a higher risk HIV prevalence among prisoners in select
of HIV infection among prisoners in both devel- MENA countries can be found in table 9.1.21
oping8 and developed settings.9 In the United Though overall HIV prevalence levels are lower
States, one-fourth of the people living with HIV than those found among prisoners in Latin
(PLHIV) pass through a correctional facility every America, South Asia, and sub-Saharan Africa,22
year.10 Also in the United States, having sex with they are still substantial in several countries.
a partner who has been incarcerated is a major
HIV risk factor for African American women.11 Imprisonment rates
The proportion of people who engage in Imprisonment rates in MENA are not as high
high-risk behavior in prisons is known to be as in some other regions, with some notable
higher than that in the rest of the population.12 exceptions.23 Table 9.1 shows imprisonment rates
There is a history of prisons serving as a “social in several countries for which there are data.24
petri dish” for increasing the HIV epidemic.13 The prison population in MENA appears to be
The evidence reviewed below suggests that the dynamic. In the Islamic Republic of Iran, during
prisoner population in MENA is a key HIV vul- the 2004–5 Persian fiscal year, there were on
nerable population. average 135,000 prisoners in 230 prisons, but
600,000 persons entered and exited prisons at
HIV prevalence among prisoners this time.25 The Islamic Republic of Iran has made
efforts to reduce the prison population by 25%
Different levels of HIV prevalence have been
through a comprehensive approach including
documented among prisoners in MENA. HIV
reducing the terms for drug-related charges, fast-
prevalence among prisoners is generally found
er prosecution procedures, and alternative penal-
to be much higher than that of the general popu-
ties to imprisonment for drug-related crimes, but
lation.14 Outbreaks of HIV infection in prisons
still the rate is high at 185 per 100,000 persons.26
have been documented in several MENA coun-
About half of the prisoners in the Islamic Republic
tries.15 HIV incidence among IDUs in a detention
of Iran are first-time offenders and about half
center was found to be at very high levels of
spend under 11 days incarcerated.27
16.8% per person per year, in a study in the
Islamic Republic of Iran.16 HIV prevalence among
Risk behaviors and prisons
prisoners in Sudan increased from 2% in 200217
to 8.6% in 2006.18 Country surveillance reports The risk and vulnerability factors cited for pris-
of notified HIV/AIDS cases repeatedly document ons in MENA include injecting and noninjecting
HIV infection among prisoners.19 High levels of drug use, tattooing, sharing of razors, unprotected
20
Khani and Vakili, “Prevalence and Risk Factors of HIV”; Alizadeh et al.,
6
Dolan and Wodak, “HIV Transmission”; Bobrik et al., “Prison Health in “Prevalence of Hepatitis C”; Nassirimanesh, “Proceedings of the
Russia”; Taylor et al., “Outbreak of HIV Infection in a Scottish Prison.” Abstract”; Zali et al., “Anti-HCV Antibody among Iranian IV Drug
7
Dolan et al., “HIV in Prison.” Users”; Quinti et al., “Seroprevalence of HIV and HCV “; Afshar, “From
8
Ibid. the Assessment to the Implementation of Services”; Mutter, Grimes,
9
Dolan and Wodak, “HIV Transmission “; Pont et al., “HIV Epidemiology and Labarthe, “Evidence of Intraprison Spread of HIV”; Javadi, Avijgan,
and Risk Behavior.” and Hafizi, “Prevalence of HBV and HCV Infections.”
10 21
Spaulding et al., “Human Immunodeficiency Virus.” Dolan et al., “HIV in Prison.”
11 22
Ibid. Ibid.
12 23
Bray and Marsden, “Drug Use in Metropolitan America.” Dolan et al., “HIV in Prison.”
13 24
Mutter, Grimes, and Labarthe, “Evidence of Intraprison Spread of HIV.” Dolan et al., “HIV in Prison”; International Centre for Prison Studies,
14
Spaulding et al., “Human Immunodeficiency Virus.” World Prison Brief Country Profiles.
15 25
Dolan et al., “HIV in Prison.” Iran Prison Organization, “Health and Treatment Headquarter.”
16 26
Jahani et al., “HIV Seroconversion.” Burrows, Wodak, and WHO, Harm Reduction in Iran; S. Zamani
17
Ahmed, Prisoners. personal communication (2008).
18 27
Assal, “HIV Prevalence.” Mostashari, UNODC, and Darabi, “Summary of the Iranian Situation on
19
WHO/EMRO Regional Database on HIV/AIDS. HIV Epidemic.”
120 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 9.1 Imprisonment Rates and HIV Prevalence in Select MENA Countries
122 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
sex, overcrowding, poor medical facilities, an studies in the Islamic Republic of Iran, 41%,37
unhealthy environment, inadequate awareness 75%,38 and 74.3%39 of IDUs reported being
and education programs, and bullying.28 previously imprisoned, and 6% of prisoners
reported starting drug injection while in prison.40
Imprisonment as a risk factor for HIV infection Among prisoners in Lebanon, 12% reported
Several studies have documented the link a history of injecting drugs.41 Two percent of
between HIV infection and incarceration in
female prisoners in Morocco reported IDU.42
MENA, mainly in the Islamic Republic of Iran. Between 61% and 83% of IDUs in Oman
This link arises from the vulnerability of prison- reported ever being arrested for drug-related
ers to risky practices such as using nonsterile offenses.43 One-third of IDUs in one study in
drug-injecting equipment and having unpro- Pakistan have been incarcerated in the previous
tected sex while in prison. HIV prevalence year,44 and 14% and 40% of IDUs in two other
among repeat prisoners in the Islamic Republic settings reported a history of imprisonment.45
of Iran was 22%–24%, which is much higher Twenty-six percent of prisoners in Sudan
than that of first-time prisoners at 6%.29 Among reported drug use, of whom 8.4% injected
HIV and tuberculosis (TB) coinfected persons in drugs prior to incarceration.46 In the Syrian
the Islamic Republic of Iran, 80% reported a his- Arab Republic, 55% of a group, half of which
tory of imprisonment.30 HIV infection was sig- are IDUs, reported a history of imprisonment,
nificantly associated with imprisonment and the
and in 68% of the cases, the imprisonment was
use of nonsterile injecting equipment in prison
due to drug-related offenses.47
in several studies in the Islamic Republic of
Iran.31 Among PLHIV in the Islamic Republic of
Injecting drug use in prisons
Iran, 74% reported a history of incarceration.32
Injecting drug use in prisons appears to be present
Drug use and incarceration in several MENA countries. Evidence for this
Ample evidence suggests a strong link between practice in the Islamic Republic of Iran has been
drug use and incarceration in MENA. Fifty- firmly established through multiple studies. Drugs
seven percent of IDUs in Afghanistan have been are easily available in prisons, although five to
incarcerated, of whom 71.6% were incarcerated eight times as expensive.48 Between 27.6% and
for drug-related offenses.33 Forty-eight percent 53.6% of IDUs reported ever injecting drugs in
of prisoners in the Islamic Republic of Iran enter prison,49 and about 10% of prisoners are believed
prison for drug-related crimes and 64% of them to inject drugs.50 Fifty-two percent of inmates
have a history of drug use.34 In 2001, the Islamic confirmed the occurrence of injections in pris-
Republic of Iran reported that more than ons.51 One study found that one-third of IDUs
300,000 people were arrested on drug-related 37
Day et al., “Patterns of Drug Use.”
charges and 47% of the prison population was 38
Razzaghi, Rahimi, and Hosseini, Rapid Situation Assessment (RSA) of
incarcerated for drug-related offenses.35 Almost Drug Abuse.
39
64% (treatment centers) and 94% (community- Kheirandish et al., “Prevalence and Correlates of Hepatitis C.”
40
Farhoudi et al., “Human Immunodeficiency Virus and HIV-Associated
based) of IDUs in the Islamic Republic of Iran
Tuberculosis Infection.”
reported a history of incarceration.36 In further 41
Mishwar, “An Integrated Bio-Behavioral Surveillance Study.”
42
El Ghrari et al., “Prevalence of Syphilis and HIV.”
28 43
Assal, “HIV Prevalence, Knowledge, Attitude, Practices, and Risk Oman MOH, “HIV Risk among Heroin and Injecting Drug Users.”
44
Factors among Prisoners in Khartoum State, Sudan.” Pakistan National AIDS Control Program, National Study of
29
Spaulding et al., “Human Immunodeficiency Virus in Correctional Reproductive Tract.
45
Facilities.” Platt et al., “Prevalence of HIV, HCV, and Sexually Transmitted
30
Tabarsi et al., “Clinical and Laboratory Profile.” Infections.”
31 46
Zamani et al., “Prevalence of and Factors Associated with HIV-1 Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
47
Infection”; Zamani et al., “High Prevalence of HIV”; Kheirandish et al., Syria Mental Health Directorate, “Assessment of HIV Risk and
“Prevalence and Correlates of Hepatitis C ”; Zamani et al., “Shared Sero-Prevalence.”
48
Drug Injection inside Prison.” Zamani, “Methadone Maintenance Treatment (MMT).”
32 49
Ramezani, Mohraz, and Gachkar, “Epidemiologic Situation.” Farhoudi et al., “Human Immunodeficiency Virus and HIV-Associated
33
Todd et al., “HIV, Hepatitis C, and Hepatitis B Infections.” Tuberculosis Infection.”
34 50
Afshar, “Health and Prison.” UNAIDS and WHO, AIDS Epidemic Update 2002.
35 51
UNODC, “Drug Situation in the I.R. of Iran.” Bolhari and Mirzamani, “Assessment of Substance Abuse in Iran’s
36
Zamani et al., “Shared Drug Injection inside Prison.” Prisons.”
124 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
This evidence of nonsterile injection equip- reported having sex with other males.92 In
ment use in prison is further supported by the Sudan, 1.4% of male prisoners reported having
repeated confiscation of injecting equipment in sex with other males in one prison, but social
MENA prisons.79 Prison authorities could also be workers in this prison estimated that about 20%
forcing prisoners to increase the use of nonster- of prisoners engage in such activity.93 The latter
ile equipment by limiting their access to safe assertion is corroborated by the fact that 14.5%
injecting utensils. In the Islamic Republic of of prisoners have been diagnosed with gonorrhea
Iran, incarcerated IDUs reported using nonster- while incarcerated.94 In Syria, 5% of imprisoned
ile injecting equipment at a rate close to three drug users reported ever having sex in prison.95
times as high as the rate among nonincarcerated Anecdotal evidence in Sudan suggests the
IDUs.80 It has been reported that syringes are occurrence of sexual acts between female prison-
used at least 30 to 40 times in Iranian prisons ers and their guards in exchange for better treat-
before disposal.81 ment in prison.96 Prisoners also generally report
Tattooing is a risk factor for HIV infection,82 higher levels of sexual risk behavior than the rest
and there is evidence of tattooing using nonster- of the general population even prior to incarcera-
ile utensils in Iranian prisons.83 About 65% of tion. In Morocco, only 9% of female prisoners
imprisoned IDUs have tattoos,84 and tattooing reported using condoms and the average number
was reported by 24.9%–25.1% of Iranian pris- of lifetime sexual partners was 5.17.97 In Sudan,
oners.85 Two studies in the Islamic Republic of only 4% of male prisoners reported ever using a
Iran have also identified tattooing as a risk factor condom, 41.9% reported premarital and extra-
for HCV infection for incarcerated IDUs.86 marital sex, and 8.6% had paid for sex.98 Also in
Sudan among male prisoners, 23.7%, 2.8%,
Sexual risk behavior and prisoners 4.7%, and 17.7% reported having one, two,
Several studies have documented risky sexual three, and more than three lifetime sexual part-
behavior among prisoners in MENA. In the ners, respectively; 11.4% reported having sex
Islamic Republic of Iran, 17% of incarcerated before marriage; and 2.2% reported having sex
drug users reported paying for drugs in prison with another male.99 Another study in Sudan
through sex work,87 and 5.4% of incarcerated found that 65.2% of prisoners had extramarital
male IDUs reported sex with another male while relations prior to incarceration.100 Though by law
in prison.88 Sexual abuse of prisoners by other prisoners in Sudan have the right to conjugal
prisoners has also been reported in the Islamic visits, this right is rarely practiced.101
Republic of Iran.89 In Lebanon, 2.6% of male
prisoners reported anal sex with another Analytical summary
male while in prison.90 In Oman, 6%–18% of Prisoners are a large share of the population vul-
male IDUs reported having sex in prison without nerable to HIV in MENA. History of imprison-
condoms.91 In Pakistan, 4% of male prisoners ment was demonstrated to be linked to higher
risk of HIV infection in the Islamic Republic of
79
Iran and may have contributed to the HIV epi-
Bolhari and Mirzamani, “Assessment of Substance Abuse in Iran’s
Prisons.” demics in other countries. High HIV prevalence
80
Rahbar, Rooholamini, and Khoshnood, “Prevalence of HIV Infection.” levels and HIV outbreaks have been documented
81
Nassirimanesh, Trace, and Roberts, “The Rise of Harm Reduction.” among prisoners in MENA. High levels of injecting
82
Martin et al., “Predictive Factors of HIV-Infection”; Buavirat et al.,
“Risk of Prevalent HIV.”
83 92
Zamani et al., “High Prevalence of HIV.” Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.”
84 93
Afshar, “From the Assessment to the Implementation of Services.” Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
85 94
Farhoudi et al., “Human Immunodeficiency Virus.” Ibid.
86 95
Khani and Vakili, “Prevalence and Risk Factors of HIV”; Kheirandish Syria Mental Health Directorate, “Assessment of HIV Risk and
et al., “Prevalence and Correlates of Hepatitis C Infection.” Sero-Prevalence.”
87 96
Bolhari and Mirzamani, “Assessment of Substance Abuse in Iran’s Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
97
Prisons.” El Ghrari et al., “Prevalence of Syphilis and HIV.”
88 98
Zamani et al., “Needle and Syringe Sharing Practices.” Ahmed, Prisoners.
89 99
Afshar, “From the Assessment to the Implementation of Services.” Assal, “HIV Prevalence.”
90 100
Mishwar, “An Integrated Bio-Behavioral Surveillance Study.” Ati, “HIV/AIDS/STIs Social and Geographical Mapping.”
91 101
Oman MOH, “HIV Risk among Heroin and Injecting Drug Users.” Assal, “HIV Prevalence.”
126 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Unemployment never married or formerly married men.136 The
age of marriage is steadily rising in MENA.137 In
The region has the highest youth unemploy-
more than a third of MENA countries, the aver-
ment rate of all regions at 26%,124 twice that of
age age at first marriage has increased between
South Asia. About 43 million youth are expected
4.7 and 7.7 years over a span of 20 years.138 In
to enter the labor force between 2000 and 2010,
the Islamic Republic of Iran, it increased from
compared with 47 million who entered the labor
19.8 years for females and 23.6 years for males in
market during the four decades from 1950 to
1986 to 22.4 years and 25.6 years in 1996,
1990.125 Three-quarters of those unemployed in
respectively.139 In Jordan, the average marriage
a country, such as Syria, are youth.126 The
age increased for females from 19.6 years in 1990
unemployment rate in the West Bank and Gaza
to 21.8 years in 2002.140 In Lebanon, the average
is at 26.8%, and most of those unemployed are
marriage age is 30.9 years for males and 27.5 years
young adults.127 Among rural youth in Sudan,
for females,141 and has increased by 3.9 years
63.5% were found unemployed.128 The high
from 1989 to 1996.142 In Saudi Arabia, the aver-
unemployment among youth has left young
age marriage age has increased from 18.22 to
people with ample spare time to spend in cafés
19.90 years over 20 years.143 In Tunisia, the aver-
and entertainment centers, thereby potentially
age marriage age is at 33 years for men and
exposing them to pressures for risky behaviors.
29 years for women.144
MENA is experiencing the phenomenon of
Marriage marriage squeeze, defined as an imbalance
between the numbers of males and females in
The rising costs of marriage are a large barrier
the prime age for marriage.145 Marriage squeeze
toward marriage in the region.129 High dowries
has been documented in Lebanon among both
have made it difficult if not impossible for youth
Lebanese and Palestinian refugees, where it is
to marry, thereby preventing them from having
forcing many to delay or forego marriage.146
the opportunity for sanctioned sex.130 It is not
Marriage squeeze also seems to be occurring in
uncommon for families to spend as much as 15
many other countries around MENA because
times the annual household expenditure per
the mate availability ratios are distorted by
capita on marriage-related costs.131 Consumerism
demographic stresses driven by delayed age at
and rising expectations have contributed substan-
marriage, high male migration, and conflict-
tially to the rising cost of marriage.132 The difficul-
related morbidity and mortality.147
ties facing youth in marriage may have contrib-
The large cohort of single young women is a
uted to the large gap in age between spouses:
recent phenomenon in MENA.148 By 1990, the
25% of recent marriages in Egypt and Lebanon
proportion of women in the sexually active
included a husband at least 10 years older than
population of 15–49 years of age who are not
his wife.133 Also, more and more people are
currently married has reached between 24% and
adopting modern lifestyles and delaying marriage
46% in most countries.149 Between 7% and
for education or work outside the home.134
The gap between biological adulthood and 136
Carael, Cleland, and Adeokun, “Overview”; Carael, “Urban-Rural
marriage is conducive to premarital sex.135 Studies Differentials.”
137
have shown that paying for sex is higher among Rashad and Osman, “Nuptiality in Arab Countries”; Fargues,
“Terminating Marriage.”
138
Rashad, “Demographic Transition in Arab Countries.”
124 139
Assaad and Roudi-Fahimi, “Youth in the Middle East and North Africa.” Mohammadi et al., “Reproductive Knowledge, Attitudes and Behavior.”
125 140
Ibid. Naffa, “Jordanian Women: Past and Present.”
126 141
Ibid. El-Kak et al., “High School Students in Postwar Lebanon.”
127 142
UNAIDS, “Key Findings on HIV Status in the West Bank and Gaza.” Saxena, Kulczycki, and Jurdi, “Nuptiality Transition.”
128 143
SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.” Babay et al., “Age at Menarche.”
129 144
Rashad et al., Marriage in the Arab World. Fargues, “Terminating Marriage.”
130 145
Busulwa, “HIV/AIDS Situation Analysis Study.” Akers, “On Measuring the Marriage Squeeze”; Schoen, “Measuring
131
Rashad et al., Marriage in the Arab World. the Tightness of a Marriage Squeeze.”
132 146
Ibid. Saxena, Kulczycki, and Jurdi, “Nuptiality Transition.”
133 147
Ibid. Ibid.
134 148
Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.” DeJong et al., “The Sexual and Reproductive Health of Young People.”
135 149
DeJong et al., “The Sexual and Reproductive Health of Young People.” Rashad, “Demographic Transition in Arab Countries.”
128 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
commercial sex at an average age of 16.9,176 teenagers.191 Most reported STDs among STD
15.9,177 and 16.2178 years, respectively. clinic attendees in Kuwait were in the age range
As for FSWs, 71.4% of FSWs in one study in of 21–30 years.192 The age group most affected by
Sudan were below 30 years of age, including HIV in Jordan is the 15–35 years age group.193
8.4% who were under 18 years of age.179 The majority of reported HIV/AIDS cases in
Further studies among FSWs in Sudan have the West Bank and Gaza are in the 20–40 years
found that the majority are under 30 years of age group, with 31% among the 20–29 years
age,180 19.6% are less than 18 years of age,181 age group.194 Women under 25 years of age in
and the majority are younger than 28 years and Oman were twice as likely to acquire an STI
started sex work before 22 years of age.182 Fifty- compared to women older than 25 years of
three percent of FSWs in a study in Syria were age.195 Forty percent of recorded STD cases in
25 years of age or younger.183 In Djibouti, 63% Morocco were among youth ages 15–29 years.196
of FSWs reported their first commercial sex at Most HIV infections in Morocco (63%) and
under 20 years of age.184 In Lebanon, 57% of Tunisia (93%) are among single and often
FSWs reported first sex at ages between 11 and young persons.197
18 years.185 In Pakistan, young FSWs were The highest prevalence of both HIV and
found to have the highest client volume.186 Also syphilis in Somalia (4%) was in the 15–24 years
in Pakistan, the median age of initiating sex age group.198 Forty-seven percent of HIV cases
work was reported to be 22 years of age.187 in the ANC HIV sentinel sero-survey in Sudan
were in the 20–24 years age group.199 Also in
Sudan, HIV prevalence among youth is esti-
Youth and STIs
mated to be 1% among females and 0.3%
Youth contribute disproportionately to the dis- among males.200 The dominant profile of STD
ease burden of STIs in MENA. Fifty-nine percent clinic attendees in Tunisia was that of young
of sexually transmitted disease (STD) cases in single men with multiple sexual partners.201
Egypt were among young and predominantly
single adults.188 Almost 41% of HIV infections in
Sexual behavior among youth
the Islamic Republic of Iran are found in the
25–34 years age group,189 and 27.9% of youth Despite data limitations, several studies have
report a previous history of STDs.190 Almost half documented the nature of sexual behavior
(45%) of reported STD cases in the Islamic among youth in MENA. The outcomes of behav-
Republic of Iran occurred in the 20–29 years ioral surveys show substantial variability within
age group, and 10% of all cases involved the region.
In Afghanistan, 14.6% of university students
176
Pakistan National AIDS Control Program, HIV Second Generation were sexually active, with risk behaviors more
Surveillance (Round I).
177 prevalent among males than females.202 In
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round II). Djibouti, 22% of high school students reported
178
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Round III).
179 191
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” Iran Center for Disease Management, Three Month Statistics of the
180
ACORD, “Socio Economic Research on HIV/AIDS Prevention.” MoH AIDS Office.
181 192
Yousif, Health Education Programme. Al-Mutairi et al., “Clinical Patterns.”
182 193
ACORD, “Qualitative Socio Economic Research.” Anonymous, Scaling Up the HIV Response.
183 194
Syria National AIDS Programme, “HIV/AIDS Female Sex Workers UNAIDS, “Key Findings on HIV Status.”
195
KABP Survey in Syria.” Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.”
184 196
Michael, Ahmed, and Lemma, “HIV/AIDS Behavioral Surveillance Survey.” Roudi-Fahimi and Ashford, “Sexual & Reproductive Health”; Jenkins
185
Mishwar, “An Integrated Bio-Behavioral Surveillance Study.” and Robalino, “HIV in the Middle East and North Africa.”
186 197
Pakistan National AIDS Control Program, HIV Second Generation Jenkins and Robalino, “HIV in the Middle East and North Africa.”
198
Surveillance (Round I). WHO, The 2004 First National Second Generation HIV/AIDS/STI
187
Pakistan National AIDS Control Program, HIV Second Generation Sentinel Surveillance Survey.
199
Surveillance (Round II). Sudan National AIDS/STIs Program, 2007 ANC HIV Sentinel
188
Ali et al., “Prevalence of Certain Sexually Transmitted Diseases in Egypt.” Sero-Survey.
189 200
Iran Center for Disease Management, Country Report on UNGASS. SNAP, “Update on the HIV Situation in Sudan.”
190 201
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices Sellami et al., “Epidemiologic Profile.”
202
concerning HIV/AIDS.” Mansoor et al., “Gender Differences in KAP.”
130 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
condom use with commercial sex workers found to embrace Western values, associated
(CSWs), and 9.5% reported nonregular partners with liberal attitudes toward sexuality,241 rather
in the last year.230 than traditional values, and appear to have
While not part of this report’s definition of the relaxed attitudes toward sexuality.242
MENA region, 19% of college students in Turkey Youth in MENA do not seem to be concerned
reported having had sexual intercourse and 30% about HIV infection. Only 14.2% in Iran243 and
reported using a condom during the last sex.231 20% in Djibouti244 reported concern about HIV
In another study, 61.2% of males and 18.3% of infection. Furthermore, the lack of meaningful
females reported sexual intercourse among final- engagements among youth, coupled with the
year university students aged 20–25 years.232 In a availability of financial resources, appears to lead
third study, 36.6% of college students were to riskier behaviors. A higher allowance in Egypt
sexually active, with males being more sexually has been associated with risky sexual behavior
active than females, but using condoms less fre- among youth.245 There are no satisfactory data
quently.233 In a fourth study, 46% of male ado- that clarify the engagement of youth in noncon-
lescents and 3% of female adolescents had sexual ventional forms of marriage,246 but there is evi-
intercourse.234 The median age at first inter- dence of significantly higher approval of such
course was 17 years for males and 16 years for marriage forms among youth compared to older
females.235 Among those who had intercourse, age groups.247 More than a quarter of Iranian
44% of the males and 67% of the females had youth approve of temporary marriages.248
their first experience with their lovers.236 The Reproductive knowledge among youth, spe-
rates of sexual activity among high school stu- cifically in the Islamic Republic of Iran, has been
dents were found in yet another study to be associated with lower sexual risk behavior and
much higher among males compared to females, increased condom use,249 just as in other
with generally low condom use.237 Also among regions.250 This highlights the utility of increasing
high school students, the percentage of people HIV knowledge among youth. Only the Islamic
who reported having sexual experiences increased Republic of Iran and Tunisia have national pro-
from 11.3% in 1997 to 22.8% in 2004.238 grams on young people’s sexual and reproductive
health.251 Some young populations in the Islamic
Other issues related to sexual behavior of youth Republic of Iran appear to have higher levels of
knowledge than even priority populations. Youth
The rapid cultural and socioeconomic transfor- in the Islamic Republic of Iran were found to be
mation in MENA is particularly affecting youth, more knowledgeable about HIV and prevention
who are experiencing enormous strains with the measures than FSWs and truck drivers.252
rapid social changes, urbanization, and genera- The limited behavioral evidence among youth
tion gap induced in part by mass education. should be interpreted with caution. Considering
Among youth who have lived abroad, higher cultural barriers, youth are not often asked
levels of sexual intercourse have been reported, specifically about the kind of sexual contacts
suggesting the influence of cultural exchanges on they engage in and therefore their responses
sexual behavior.239 Youth emigration is prevalent
in MENA, and in Lebanon, a third of the popula- 241
Sigusch, “The Neosexual Revolution.”
tion emigrated for at least some time during the 242
El-Kak et al., “High School Students in Postwar Lebanon.”
civil war.240 Students in Lebanon are increasingly 243
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices
concerning HIV/AIDS.”
230 244
Sudan National AIDS Control Program, Situation Analysis. Rodier et al., “HIV Infection among Secondary School Students.”
231 245
Ungan and Yaman, “AIDS Knowledge and Educational Needs.” Refaat, “Practice and Awareness of Health Risk Behaviour.”
232 246
Aras et al., “Sexual Behaviours and Contraception.” Haeri, “Temporary Marriage.”
233 247
Gokengin et al., “Sexual Knowledge.” Mohammad et al., “Sexual Risk-Taking Behaviors.”
234 248
Dagdeviren, Set, and Akturk, “Sexual Activity among Turkish Adolescents.” Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices
235
Ibid. concerning HIV/AIDS.”
236 249
Ibid. Mohammad et al., “Sexual Risk-Taking Behaviors.”
237 250
Aras et al., “Sexual Attitudes and Risk-Taking Behaviors.” Rock, Ireland, and Resnick, “To Know That We Know What We Know.”
238 251
Yamazhan et al., “Attitudes towards HIV/AIDS.” DeJong et al., “The Sexual and Reproductive Health of Young People.”
239 252
El-Kak et al., “High School Students in Postwar Lebanon.” Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices
240
Ibid. concerning HIV/AIDS.”
132 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
POPULATION MOBILITY AND HIV antiretroviral treatment or to undergo drug
rehabilitation.278
One of the most vulnerable groups in MENA is
that of mobile populations, including voluntary Migrants
or economic migrants, refugees, internally dis-
placed persons, individuals who move for other In this section we discuss migration as vulnera-
compelling reasons, nomads, and pastoralists.271 bility for HIV infection.
Other groups such as truck drivers, seafarers,
Prevalence of migration
and uniformed personnel are also mobile popu-
The Arab Middle East has received more than
lations, but here these groups are classified as
10% of the world’s migrants,279 with the Persian
potential bridging populations (see chapter 6).
Gulf region hosting the largest share of guest
The vulnerability of mobile populations stems
workers to indigenous populations anywhere.280
from poverty, separation from family and regu-
The International Organization for Migration
lar sexual partners, differences in language and
(IOM) estimates that there are 14 million inter-
culture leading to isolation, separation from
national migrants in the Arab Middle East.281
native sociocultural background, lack of com-
Saudi Arabia is the leading source of remittances
munity support, lack of access to health and
in MENA, and second only to the United States
social services, and a sense of anonymity.272
as a source of migrant worker remittances glob-
Displacement, migration, and high urban poverty
ally.282 Three MENA countries, Egypt, Lebanon,
provide fertile grounds for the establishment of
and Jordan, are among the nine largest recipi-
sex work.273 The loneliness and anonymity asso-
ents of remittances from migrant workers among
ciated with living in a foreign country can be
developing countries.283
conducive to practicing high-risk behavior.274
Migration has enormously affected demograph-
Complex emergencies are prevalent in MENA,
ics in MENA. It is estimated that a million Afghanis
such as in Afghanistan, Iraq, Lebanon, Somalia,
leave Afghanistan every year to work abroad.284
and the West Bank and Gaza, and these emer-
Seasonal economic migration also appears to be
gencies are key drivers of population mobility.
high in Afghanistan.285 The migrant workforce
Emergencies can lead to rapid changes in risk
accounted for 4.7% of the total population in the
behavior and may facilitate HIV infectious
Republic of Yemen in 1994.286 There are 875,000
spread.275 The presence of foreign troops and
Yemenis registered as living abroad.287 It is esti-
military occupations can complicate HIV efforts.
mated that there are 2 million economic migrants288
The presence of a large number of foreign troops
and 16 million pastoralists289 in the Horn of Africa
in Afghanistan has been associated with rapid
region. Migration and being away from family are
economic development, but has yielded more
associated with higher exposure to STIs.290
opportunities for risky behavior such as IDU and
female sex work.276 The presence of the African Structural factors related to migration
Peace Keepers in Darfur has added another risk There are structural problems in MENA that
factor for HIV infection, particularly among drive the high levels of migration. The Arab
women.277
There is evidence in MENA that HIV patients 278
UNAIDS, and WHO, AIDS Epidemic Update 2003.
are mobile and have crossed national boundar- 279
Jaber, Métral, and Doraï, “Migration in the Arab Middle East.”
ies. Half of the reported HIV cases in Tunisia 280
IOM, “World Migration.”
281
were believed to have at some point crossed the Ibid.
282
Ibid.
border into Tunisia, mainly from Libya, to seek 283
Ibid.
284
Ryan, “Travel Report Summary.”
271 285
IGAD, IGAD/World Bank Cross Border Mobile Population Mapping World Bank, “Mapping and Situation Assessment.”
286
Exercise. Yemen Ministry of Planing and Development, Yemen Human
272
Ibid. Development Report 1998.
273 287
Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” Yemen MOH, National Strategic Framework.
274 288
Al-Mutairi et al., “Clinical Patterns.” HOAP, “Regional Partnership on HIV Vulnerability.”
275 289
Salama and Dondero, “HIV Surveillance in Complex Emergencies.” Morton, “Conceptualising the Links.”
276 290
World Bank, “Mapping and Situation Assessment.” Carael, Cleland, and Adeokun, “Overview”; Obasi et al., “Antibody to
277
Basha, “Vulnerable Population Research in Darfur.” Herpes Simplex Virus Type 2.”
134 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
from other cities.318 In the Islamic Republic of the Islamic Republic of Iran.331 Among married
Iran, 14.5% of the population had migrated STD clinic attendees in Kuwait, 70% were living
within the country.319 alone and the average number of sexual part-
The immigration systems in MENA are gener- ners was 2.3.332
ally those of guest-worker-based labor systems Over 55% of single migrant men in Pakistan
where a large fraction of migrants are single or reported sexual experiences and 36% of married
without their spouses.320 These workers are vul- migrant men reported premarital sex.333 Over
nerable to practices that increase the risk of the preceding 12 months, 13% of single migrant
exposure to HIV.321 There is a large male-to- men reported nonmarital female sexual part-
female disparity among migrant workers. In ners, 7% reported contacts with FSWs, and 2%
Saudi Arabia, 69.5% of migrant workers are reported sexual contacts with other males.334
males while 30.5% are females, and the vast Among Pakistani workers in the Middle East,
majority of these workers are single or away there is evidence of high-risk behaviors such as
from spouses.322 A large share of the population contacts with sex workers.335
in some MENA countries, if not the majority of Women from the former Soviet Union repre-
the population, is made up of migrants, such as sent the majority of FSWs in the United Arab
23% in Oman,323 76% in the United Arab Emirates.336 FSWs come to the Persian Gulf
Emirates,324 and 62% in Kuwait.325 The ratio of region through a manipulation of immigration
nonnationals among the adult population is laws that makes it possible for these women to
even higher, such as in Kuwait, where it is 70% stay as irregular migrants.337 Official efforts con-
and almost half of nonnationals are single.326 tinue to focus on drug smuggling and money
The sizable contribution of migrants in the laundering in the entertainment industry rather
labor force is not limited to the oil-rich econo- than on sex trade.
mies. Even in a country like Jordan, with a resi-
dent labor force of 1,150,000 people, there were HIV spread among migrants
around 125,000 documented migrant workers The Persian Gulf countries have instituted a
in 2003 and as many undocumented migrants.327 policy of mandatory and periodic HIV testing of
In the Maghreb region of MENA, the dominant migrant workers since at least 2002.338 Most
pattern of migration is to Western Europe.328 often the testing happens without counseling or
The Maghreb region is also increasingly used as informed consent.339 Migrant workers who test
a transit route toward Europe, or as a destina- positive for HIV are deported. Already this policy
tion of sub-Saharan African migrants.329 has resulted in the deportation of over 400 HIV-
positive people from Bahrain alone.340
Sexual and injecting risk behaviors
The rate of positive HIV testing among
among migrants
migrant workers has been hovering around
Several studies have documented some aspects
0.021%, with a range of 0.011% to 0.031%
of sexual and injecting drug behaviors among
over several years in Kuwait,341 0.05% in
migrants. About 73% of IDUs in Afghanistan
Qatar,342 0.1% to 0.2% in Saudi Arabia,343 and
lived or worked outside of Afghanistan,330 and
66% reported starting drug use while living in 331
Action Aid Afghanistan, “HIV AIDS in Afghanistan.”
332
Al-Mutairi et al., “Clinical Patterns.”
318 333
Pakistan National AIDS Control Program, “Report of the Pilot Study in Faisel and Cleland, “Migrant Men.”
334
Karachi & Rawalpindi.” Ibid.
319 335
Iranian Statistics Center, “Iran as Reflected by Statistics.” Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan”; Shah
320
IOM, “World Migration.” et al., “HIV-Infected Workers Deported”; Baqi, Kayani, and Khan,
321
UNAIDS, “Notes on AIDS in the Middle East and North Africa.” “Epidemiology and Clinical Profile.”
322 336
Madani, “Sexually Transmitted Infections in Saudi Arabia.” IOM, “World Migration.”
323 337
UNAIDS, “Notes on AIDS in the Middle East and North Africa.” Ibid.
324 338
Ibid. Khoja, “Rules & Regulations.”
325 339
Al-Fouzan and Al-Mutairi, “Overview.” UNDP, “HIV Vulnerabilities of Migrant Women.”
326 340
Ibid. S. A. Jowder, Director, National HIV/AIDS/STI Program, personal com-
327
IOM, “World Migration.” munication (2007).
328 341
Ibid. Akhtar and Mohammad, “Spectral Analysis of HIV Seropositivity.”
329 342
Ibid. Saeed, “Thirty-Two HIV/AIDS Cases Detected in June.”
330 343
World Bank, “Mapping and Situation Assessment.” T. A. Madani, personal communication (2007).
136 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Vulnerability to HIV In Sudan, 9.1% of refugees reported extramari-
The characteristics that define a complex emer- tal affairs,377 and among IDPs, 5.0% reported
gency, such as conflict, social instability, ever using a condom, 21.3% reported premari-
increased poverty, environmental destruction, tal and extramarital sex, 2.4% reported pre-
and powerlessness, can increase vulnerability to marital sex, and 1.9% exchanged sex for
HIV by reducing access to HIV prevention ser- money.378 Also in Sudan, 41% of unmarried
vices, breaking down health infrastructure, dis- male refugees had casual sex in the last year and
rupting social support networks, increasing 0% had ever had transactional sex partners.379
exposure to sexual violence (rape, sexual abuse, Among IDPs as well as the nondisplaced popula-
and exploitation), increasing the number of per- tion, these percentages were 18% and 2%,
sons having sex in return for food and shelter, respectively.380 Condom use was found to be
and forcing population movement to an area of much higher among refugees (35%) than
higher HIV prevalence.371 among IDPs and those not displaced (8%).381
Studies have shown that the factors that A systematic review of HIV infection in
affect HIV transmission during humanitarian conflict-affected and displaced people in seven
emergencies are complex, depending upon sub-Saharan African countries found insuffi-
many dynamic and interacting factors, including cient data to support the assertion that conflict,
HIV prevalence rates in the area of origin and forced displacement, and wide-scale rape
that of the host population, level of interaction increase HIV prevalence.382 There is evidence in
between the displaced and surrounding popula- MENA that does not support a link between
tions, length of time of displacement, and loca- increased HIV risk and population displacement
tion of displacements (for example, urban camps such as among Somali and Sudanese refugees
versus isolated camps).372 and IDPs.383 There is also evidence that suggests
Levels of HIV knowledge tend to differ among better HIV knowledge and prevention practices
displaced persons, and the location of refuge among refugees. A behavioral surveillance study
affects the level of knowledge. Among IDUs in in Juba, Southern Sudan, showed that return-
Pakistan, Afghani refugees had lower HIV/AIDS ing refugees compared to settled populations
knowledge than Pakistani nationals.373 Among had greater HIV knowledge and better HIV pre-
refugees returning to Afghanistan, 79% of vention practices, such as condom use.384
returnees from the Islamic Republic of Iran However, there is also some evidence in
reported receiving information about HIV, but MENA that seems to suggest some link between
only 51% of returnees from Pakistan reported displacement and risk of exposure to HIV. Yet, it
receiving such information.374 Low levels of is not clear whether this merely reflects the influ-
knowledge were found among IDPs in Sudan in ence of home country risk factors and HIV preva-
comparison to other population groups.375 lence, or HIV risks specific to the refugees in the
Refugees in the Republic of Yemen were found host country. For instance, Afghani IDUs in
to have lower knowledge than both citizen and Pakistan reported higher injecting drug use
marginalized populations.376 This may be due to (18.8% versus 12.3%) and nonsterile needle use
lack of access to appropriate HIV awareness (72.2% versus 48.2%) compared to Pakistani
messages in languages refugees can understand. IDUs.385 A survey in Somalia showed that women
in IDP camps have higher HIV prevalence than
Risky behavior and risk of HIV infection
A few studies in MENA have attempted to docu-
ment sexual behavior among refugees and com- 377
Elkarim et al., The National Strategic Plan.
378
pare this to the surrounding host communities. Ahmed, Internally Displaced People.
379
UNHCR, “HIV Behavioural Surveillance Survey.”
380
Ibid.
371 381
UNAIDS and UNHCR, “Strategies.” Ibid.
372 382
Spiegel et al., “Prevalence of HIV.” Spiegel et al., “Prevalence of HIV.”
373 383
Zafar et al., “HIV Knowledge and Risk Behaviors.” UNHCR, HIV Sentinel Surveillance among Antenatal Clients and STI
374
Action Aid Afghanistan, “HIV AIDS in Afghanistan.” Patients; UNHCR, “HIV Behavioural Surveillance Survey.”
375 384
Ahmed, Internally Displaced People. UNHCR, “HIV Behavioural Surveillance Survey.”
376 385
Al-Serouri, “Assessment of Knowledge.” Zafar et al., “HIV Knowledge and Risk Behaviors.”
138 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
police, or other men, particularly at night.409 Among males, 77.4% reported engaging in sex
Seventeen percent of these girls report sex work with other males.
as their main means of earning money.410 Street Condom use was low among both males and
children are especially threatened by police.411 females: 12% with commercial sex partners and
Gang rape and substance abuse are common 2% with noncommercial partners among males,
and 14% of street girls and 1% of street boys and 13% with commercial sex partners and 6%
reported that sexual abuse is their greatest dan- with noncommercial partners among females.
ger on the street.412 IDU was also reported by 1% of the males and
The number of street children appears to be 13.5% of the females. Other forms of substance
growing in Sudan as a consequence of high rates abuse were reported by 67.9% of the males and
of population mobility resulting from civil strife, 71.4% of the females. Knowledge of HIV/AIDS,
political conflict, and economic hardship, par- STIs, and condoms was low among the surveyed
ticularly in rural areas.413 It is estimated that street children.420
there are 70,000 working and street children in Among street children in Sudan, 5.8% reported
Sudan, of which 86% are males.414 It is also esti- ever using a condom, 56.3% reported premarital
mated that there are 200,000 street children in and extramarital sex, and 11.1% exchanged sex
Egypt,415 and 5,000–7,000 street children416 in for money.421 In the Islamic Republic of Iran, 60%
Lahore, Pakistan. of runaway girls are reported to become victims of
Child prostitution appears to be a growing sexual abuse within one week of leaving home, as
problem in Morocco where street children well as having a substance abuse rate of 80%.422
approach tourists offering their sexual services.417 These studies suggest a high-risk environ-
A study of male street children in Pakistan ment for street children in several MENA coun-
found that 40% of the boys had exchanged sex tries and provide clear evidence of how the
for money, drugs, or goods over the last three vulnerability of this group is leading to high lev-
months.418 els of risky behavior. Although no HIV cases
An integrated biological and behavioral surveil- were found in one of the studies in Egypt,423 the
lance survey was conducted among street children levels of reported risk behavior suggest potential
12–17 years old in Egypt.419 Substantial levels of HIV transmission if the infection enters this
sexual activity were found, with 54.7% of males population. Indeed, there is documented evi-
and 50% of females reporting previous sexual dence for some HIV prevalence among street
activity. Of these, 75.3% of the males and 71.9% children in MENA; HIV prevalence was reported
of the females reported sexual activity within the to be 1.3%424 and 0%425 by two studies in Egypt,
12 months preceding the survey. Alarmingly, and by other studies as 0%426 in the Islamic
14.9% of these males and 33.3% of these females Republic of Iran and 2.2%427 in Sudan.
reported commercial sexual activity. Thirty-seven
percent of the males reported being forced to have VULNERABILITY SETTINGS: ANALYTICAL
sex with males, and 6% reported being forced to SUMMARY
have sex with females. Among females, 44.9%
reported being forced to have sex with males. MENA has several vulnerability factors and the
vulnerable populations are diverse, with a large
409
Kudrati, Plummer, and Yousif, “Children of the Sug”; Lalor et al., fraction of the population belonging to one or
“Victimisation amongst Street Children.”
410
Kudrati et al., “Sexual Health and Risk Behaviour.”
411 420
Awad, “Sudanese Street Children.” Egypt Ministry of Health and Population, and National AIDS Program,
412
Kudrati, Plummer, and Yousif, “Children of the Sug”; Plummer et al., HIV/AIDS Biological and Behavioral Surveillance Survey.
421
“Beginning Street Life.” Ahmed, Street Children.
413 422
Khalil, Street Children and HIV/AIDS. Navipour and Mohebbi, “Street Children.”
414 423
Consortium for Street Children, “A Civil Society Forum.” Egypt Ministry of Health and Population, and National AIDS Program,
415
Jenkins and Robalino, “HIV in the Middle East and North Africa.” HIV/AIDS Biological and Behavioral Surveillance Survey.
416 424
Towe et al., “Street Life and Drug Risk Behaviors.” SNAP, UNICEF, and UNAIDS, “Baseline Study on Knowledge.”
417 425
Kandela, “Child Prostitution and the Spread of AIDS.” Egypt Ministry of Health and Population, and National AIDS Program,
418
Towe et al., “Street Life and Drug Risk Behaviors.” HIV/AIDS Biological and Behavioral Surveillance Survey.
419 426
Egypt Ministry of Health and Population, and National AIDS Program, Vahdani et al., “Prevalence of Hepatitis.”
427
HIV/AIDS Biological and Behavioral Surveillance Survey. Ahmed, Street Children.
Ramy discussed several problems that face him to, and eventually to make the “life-
drug users, especially those of being exposed changing” decision to stop using drugs.
to HIV and other sexually transmitted infec- Two years after health and psychologi-
tions, depression, and marginalization by cal treatment and follow-up for Ramy, in
family members, society, and law enforce- addition to his work of outreach and peer
ment officers. education, he is transformed from being a
Ramy stated the example of “female drug user to a companion and supporting
drug users, who are engaged in sex work in figure for his drug users friends.
order to purchase drugs, [and] cannot oblige
their sexual partners to use condoms as pre- They [drug users] have confidence in ex-
vention from HIV/AIDS and other STIs.” He drug users who are cured and who give
them hope of becoming cured themselves,
added: “I guarantee that more than 90% of
and who also help them to be prevented
people who use drugs would seek opioid
from HIV and hepatitis . . . those people
substitution therapy if provided at low- [drug users] are exposed to several kinds of
prices and available within specialized marginalization within their families, the
centers [drop-in centers] that offer health, society where they live, some of the health
social and counseling services.” and medical centers, and law enforcement
Ramy continued the story of the despair officers who specifically contribute to their
that he lived and that took over his life after unemployment because of their judicial
10 years of drug use. This led him to search record as a drug user.
for a solution, a way out of a worse situation—
suicide—a solution [that] would stop his Finally for Ramy, [a] “drug abuser is not a
long suffering with drugs. criminal, but a victim, and others have to
Then, Ramy met a social worker who accept him in the society without any dis-
introduced him to Soins Infirmiers et crimination, an attitude which helps to
Développement Communautaire (SIDC) improve his health and helps him to be
while visiting his friends in prison. SIDC cured from drugs and thus he will become
was the NGO [nongovernmental organiza- a productive and effective person in his
tion] that led him down the road of reduc- society far from being marginalized and
ing the harms that drugs were exposing judged.”
Source: Middle East and North Africa Harm Reduction Network 2008.
multiple vulnerability settings. There are three behavior. There appears to be increasingly risky
key vulnerable populations in MENA: prisoners, behavior among the youth population and it
youth, and mobile populations. The above evi- would be useful for surveillance efforts to mon-
dence highlights the vulnerability of these pop- itor trends of youth behavior and STI incidence.
ulations to HIV infection. Mobile populations have an extensive presence
Prisoners are the most vulnerable group and across the region, but their vulnerability to risk
prevention efforts need to focus on this popula- practices is not widely acknowledged.
tion. Youth are enduring immense challenges Vulnerability settings will continue to be
that may compel them to engage in risky among the drivers of HIV transmission for the
140 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
BOX 9.2
years to come unless efforts are created to Action Aid Afghanistan. 2006. “HIV AIDS in Afghanistan:
address them. Nevertheless, addressing these A Study on Knowledge, Attitude, Behavior, and Practice
in High Risk and Vulnerable Groups in Afghanistan.”
vulnerabilities should not distract us from
Adib, S. M., S. Akoum, S. El-Assaad, and A. Jurjus.
focusing prevention efforts on priority popula- 2002. “Heterosexual Awareness and Practices among
tions, including IDUs, MSM, and FSWs, which Lebanese Male Conscripts.” East Mediterr Health J 8:
are at the highest risk of HIV infection in 765–75.
MENA. Afifi, M., and S. El-Sousi. 2004. “Drug Abuse and
Related Behaviors among High School Student
Children in Palestine Authority (2002–2004).”
Afshar, P. Unknown (a). “From the Assessment to the
Implementation of Services Available for Drug Abuse
BIBLIOGRAPHY and HIV/AIDS Prevention and Care in Prison Setting:
The Experience of Iran.” PowerPoint presentation.
ACORD. 2005. “Socio Economic Research on HIV/AIDS
Prevention among Informal Sex Workers.” Agency ———. Unknown (b). “Health and Prison.” Director
for Co-operation and Research in Development, General of Health, Office of Iran Prisons Organization.
Federal Ministry of Health, Sudan National AIDS Afshar, P., and F. Kasraee. 2005. “HIV Prevention
Control Program, and the World Health Organization. Experiences and Programs in Iranian Prisons”
———. 2006. “Qualitative Socio Economic Research on [MoPC0057]. Presented at the Seventh International
Female Sex Workers and Their Vulnerability to HIV/ Congress on AIDS in Asia and the Pacific, Kobe.
AIDS in Khartoum State.” Agency for Co-operation Ahmed, H. 1997. “STD/HIV Prevalence and Chemo-
and Research in Development. therapy Studies in Somalia.” Department of
142 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Bobrik, A., K. Danishevski, K. Eroshina, and M. McKee. Middle-Income Countries.” Lancet Infect Dis 7:
2005. “Prison Health in Russia: The Larger Picture.” J 32–41.
Public Health Policy 26: 30–59. Dolan, K. A., and A. Wodak. 1999. “HIV Transmission in
Bolhari, J., and S. M. Mirzamani. 2002. “Assessment of a Prison System in an Australian State.” Med J Aust
Substance Abuse in Iran’s Prisons.” United Nations 171: 14–17.
Drug Control Program in Cooperation with the Drug Egypt Ministry of Health and Population. 2001. “HIV/
Control Headquarters. AIDS Surveillance in Egypt, 2001.” Proceedings of the
Bray, R. M., and M. E. Marsden. 1998. “Drug Use in WHO 11th Intercountry Meeting of National AIDS
Metropolitan America.” Sage Publications. Program Managers.
Buavirat, A., K. Page-Shafer, G. J. van Griensven, J. S. Egypt Ministry of Health and Population, and National
Mandel, J. Evans, J. Chuaratanaphong, S. AIDS Program. 2006. HIV/AIDS Biological and
Chiamwongpat, R. Sacks, and A. Moss. 2003. “Risk of Behavioral Surveillance Survey. Summary report.
Prevalent HIV Infection Associated with Incarceration El-Ghazzawi, E., G. Hunsmann, and J. Schneider. 1987.
among Injecting Drug Users in Bangkok, Thailand: “Low Prevalence of Antibodies to HIV-1 and HTLV-I
Case-Control Study.” BMJ 326: 308. in Alexandria, Egypt.” AIDS Forsch 2: 639.
Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani, El Ghrari, K., Z. Terrab, H. Benchikhi, H. Lakhdar, I.
J. George, R. Abu-Elyazeed, and J. N. Woody. 1990. Jroundi, and M. Bennani. 2007. “Prevalence of
“Serosurvey of Prevalence of Human Syphilis and HIV Infection in Female Prison Population
Immunodeficiency Virus amongst High Risk Groups in Morocco.” East Mediterr Health J 13: 774–79.
in Port Sudan, Sudan.” East Afr Med J 67: 650–55.
Elharti, E. E., Z. A. Zidouh, M. R. Mengad, B. O. Bennani,
Burrows, D., A. Wodak, and WHO (World Health S. A. Siwani, K. H. Khattabi, A. M. Alami, and E. R.
Organization). 2005. Harm Reduction in Iran: Issues in Elaouad. 2002. “Result of HIV Sentinel Surveillance
National Scale-Up. Report for WHO. Studies in Morocco during 2001.” Int Conf AIDS: 14.
Busulwa, R. 2003. “HIV/AIDS Situation Analysis Study.” El-Kak, F. H., R. A. Soweid, C. Taljeh, M. Kanj, and M.
Conducted in Hodeidah, Taiz, and Hadhramut, C. Shediac-Rizkallah. 2001. “High School Students in
Ministry of Health, Republic of Yemen. Postwar Lebanon: Attitudes, Information Sources,
Carael, M. 1997. “Urban-Rural Differentials in HIV/STDs and Perceived Needs Related to Sexual and
and Sexual Behaviour.” In Sexual Cultures and Reproductive Health.” J Adolesc Health 29: 153–55.
Migration in the Era of AIDS, ed. G. Herdt, 107–26. Elkarim, M. A. A., H. A. Ahmed, S. M. Ahmed, I. Bashir,
Oxford: Oxford University Press. and S. Musa. 2003. The National Strategic Plan for the
Carael, M., J. Cleland, and L. Adeokun. 1991. “Overview Prevention and Control of HIV/AIDS in the Sudan, 2003–2007.
and Selected Findings of Sexual Behaviour Surveys.” Sudan National AIDS Control Program, Federal Ministry
AIDS 5 Suppl 1: S65–74. of Health, Republic of the Sudan, Khartoum, Sudan.
Consortium for Street Children. 2004. “A Civil Society El-Rahman, A. 2004. “Risky Behaviours for HIV/AIDS
Forum for North Africa and the Middle East on Infection among a Sample of Homosexuals in Cairo
Promoting and Protecting the Rights of Street City, Egypt.” XV International AIDS Conference,
Children.” Consortium for Street Children, London. Bangkok, July 11–16, abstract WePeC6146.
Cairo, Egypt, March 3–6. Elrashied, S. M. 2006. “Generating Strategic Information
Coskun, O., C. Gul, H. Erdem, O. Bedir, and C. P. and Assessing HIV/AIDS Knowledge, Attitude and
Eyigun. 2008. “Prevalence of HIV and Syphilis among Behaviour and Practices as well as Prevalence of HIV1
Turkish Blood Donors.” Ann Saudi Med 28: 470. among MSM in Khartoum State, 2005.” A draft
Curtis, S. L., and E. G. Sutherland. 2004. “Measuring report submitted to Sudan National AIDS Control
Sexual Behaviour in the Era of HIV/AIDS: The Programme. Together Against AIDS Organization
Experience of Demographic and Health Surveys and (TAG), Khartoum, Sudan.
Similar Enquiries.” Sex Transm Infect 80 Suppl 2: ii22–27. El-Sayyed, N., I. A. Kabbash, and M. El-Gueniedy. 2008.
Dagdeviren, N., T. Set, and Z. Akturk. 2008. “Sexual “Risk Behaviours for HIV/AIDS Infection among Men
Activity among Turkish Adolescents: Once More the Who Have Sex with Men in Cairo, Egypt.” East
Distinguished Male.” Int J Adolesc Med Health 20: Mediterr Health J 14: 905–15.
431–39. Elshimi, T., M. Warner-Smith, and M. Aon. 2004.
Dallape, F. 1996. “Urban Children: A Challenge and an “Blood-Borne Virus Risks of Problematic Drug Users
Opportunity.” Childhood 3(2): 283–94. in Greater Cairo.” UNAIDS and UNODC, Geneva.
Day, C., B. Nassirimanesh, A. Shakeshaft, and K. Dolan. El-Zanaty, F., and A. El-Daw. 1996. “Behavior Research
2006. “Patterns of Drug Use among a Sample of Drug among Egyptian University Students.” International
Users and Injecting Drug Users Attending a General Medical Technology Egypt (MEDTRIC), Family
Practice in Iran.” Harm Reduct J 3: 2. Health International, Behavioural Research Unit,
unpublished report.
DeJong, J., R. Jawad, I. Mortagy, and B. Shepard. 2005.
“The Sexual and Reproductive Health of Young Faisel, A., and J. Cleland. 2006. “Migrant Men: A Priority
People in the Arab Countries and Iran.” Reprod Health for HIV Control in Pakistan?” Sex Transm Infect 82:
Matters 13: 49–59. 307–10.
Fargues, P. 2003. “Terminating Marriage.” In The New
Dolan, K., B. Kite, E. Black, C. Aceijas, and G. V.
Arab Family, Cairo, Papers in Social Science, Vol. 24,
Stimson. 2007. “HIV in Prison in Low-Income and
144 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Kassak, K., J. DeJong, Z. Mahfoud, R. Afifi, S. Abdurahim, Lambert, L. 2007. “HIV and Development Challenges in
M. L. Sami Ramia, F. El-Barbir, M. Ghanem, S. Yemen: Which Grows Fastest?” Health Policy and
Shamra, K. Kreidiyyeh, and D. El-Khoury. 2008. Planning 22: 60.
“Final Working Protocol for an Integrated Bio- Madani, T. A. 2006. “Sexually Transmitted Infections in
Behavioral Surveillance Study among Four Saudi Arabia.” BMC Infect Dis 6: 3.
Vulnerable Groups in Lebanon: Men Who Have Sex
Mansoor, A. B., W. Fungladda, J. Kaewkungwal, and W.
with Men; Prisoners; Commercial Sex Workers; and
Wongwit. 2008. “Gender Differences in KAP Related
Intravenous Drug Users.” Grey Report.
to HIV/AIDS among Freshmen in Afghan
Kayani, N., A. Sheikh, A. Khan, C. Mithani, and M. Universities.” Southeast Asian J Trop Med Public Health
Khurshid. 1994. “A View of HIV-I Infection in 39: 404–18.
Karachi.” J Pak Med Assoc 44: 8–11.
Martin, V., J. A. Cayla, M. L. Moris, L. E. Alonso, and R.
Khalil, J. H. 2006. Street Children and HIV/AIDS. Report on Perez. 1998. “Predictive Factors of HIV-Infection in
training of counselors and peer educators. Afrocenter Injecting Drug Users upon Incarceration.” Eur J
Projects and Research Department, SNAP/UNFPA Epidemiol 14: 327–31.
Joint HIV/AIDS/STIs Project.
Michael, T., M. Ahmed, and W. Lemma. 2003. “HIV/
Khani, M., and M. M. Vakili. 2003. “Prevalence and Risk AIDS Behavioral Surveillance Survey (BSS): Round
Factors of HIV, Hepatitis B Virus, and Hepatitis C One.” Djibouti, Ministry of Health.
Virus Infections in Drug Addicts among Zanjan
Prisoners.” Arch Iranian Med 6: 1–4. Middle East and North Africa Harm Reduction Network.
2008. News bulletin, sixth issue, November.
Khattabi, H., and K. Alami. 2005. “Surveillance senti-
nelle du VIH, Résultats 2004 et tendance de la séro- Mimouni, B., and N. Remaoun. 2006. “Etude du Lien
prévalence du VIH.” Morocco Ministry of Health, Potentiel entre l’Usage Problématique de Drogues et
UNAIDS. le VIH/SIDA en Algérie 2004–2005.” Ministry of
Higher Education, Algeria.
Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H.
Vermund. 1997. “HIV/AIDS and Its Risk Factors in Ministère de la Santé Maroc. 2003–4. Bulletin épidemi-
Pakistan.” AIDS 11: 843–48. ologique de surveillance du VIH/SIDA et des infections
sexuellement transmissibles. Rabat, Ministère de la
Kheirandish, P., S. SeyedAlinaghi, M. Jahani, H. Shirzad,
Santé Maroc.
M. Seyed Ahmadian, A. Majidi, A. Sharifi, M.
Hosseini, M. Mohraz, and W. McFarland. 2009. Ministére de la Santé-PNLS, de la Jeunesse, de la
“Prevalence and Correlates of Hepatitis C Infection Promotion Femme, de l’Education, ADEPF
among Male Injection Drug Users in Detention, (Association Djiboutienne pour l’Equilibre et la
Tehran, Iran.” Unpublished, Iranian Center for HIV Promotion de la Famille), and UNICEF (United
AIDS Research, Department of Infectious and Tropical Nations Children’s Fund). 2001. “Etude des connais-
Diseases, Tehran University. sances attitudes-practiques des jeunes et leurs partici-
Khoja, T. A. 2002. “Rules & Regulations for Medical pations a la promotion de leurs activités et a la
Examination of Expatriates Recruited for Work in the prévention des VIH/SIDA/MST a Djiboutiville.”
Arab States of the Gulf Cooperation Council.” Ministry of Health and Medical Education of Iran. 2006.
Executive Board of the Health Ministers’ Council for “Treatment and Medical Education.” Islamic Republic
the GCC States. of Iran HIV/AIDS Situation and Response Analysis.
Kocak, N., S. Hepgul, S. Ozbayburtlu, H. Altunay, M. F. Mishwar. 2008. “An Integrated Bio-Behavioral
Ozsoy, E. Kosan, Y. Aksu, G. Yilmaz, and A. Pahsa. Surveillance Study among Four Vulnerable Groups in
2004. “Trends in Major Transfusion-Transmissible Lebanon: Men Who Have Sex with Men; Prisoners;
Infections among Blood Donors over 17 Years in Commercial Sex Workers and Intravenous Drug
Istanbul, Turkey.” J Int Med Res 32: 671–75. Users.” Internal document, final report, American
Kudrati, M., M. L. Plummer, and N. D. Yousif. 2008. University of Beirut and World Bank, Beirut, Lebanon.
“Children of the Sug: A Study of the Daily Lives of Mohammad, K., F. K. Farahani, M. R. Mohammadi, S.
Street Children in Khartoum, Sudan, with Intervention Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani,
Recommendations.” Child Abuse Negl 32: 439–48. A. Hasanzadeh, and H. Ghanbari. 2007. “Sexual Risk-
Kudrati, M., M. Plummer, N. Dafaalla El Hag Yousif, A. Taking Behaviors among Boys Aged 15–18 Years in
Mohamed Adam Adham, W. Mohamed Osman Tehran.” J Adolesc Health 41: 407–14.
Khalifa, A. Khogali Eltayeb, J. Mohamed Jubara, V. Mohammadi, M. R., K. Mohammad, F. K. Farahani, S.
Omujwok Apieker, S. Ali Yousif, and S. Mohamed Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani,
Elnour. 2002. “Sexual Health and Risk Behaviour of and F. Alaeddini. 2006. “Reproductive Knowledge,
Full-Time Street Children in Khartoum, Sudan.” Attitudes and Behavior among Adolescent Males in
International Conference on AIDS, Barcelona, Spain, Tehran, Iran.” Int Fam Plan Perspect 32: 35–44.
July 7–12; 14: abstract no. LbOr04.
Mohtasham Amiri, Z., M. Rezvani, R. Jafari Shakib, and
Lalor, K., M. Taylor, A. Veale, A. H. Ali, and M. E. A. Jafari Shakib. 2007. “Prevalence of Hepatitis C
Bushra. 1993. “Victimisation amongst Street Children Virus Infection and Risk Factors of Drug Using
in Sudan and Ethiopia: A Preliminary Analysis.” In Prisoners in Guilan Province.” East Mediterr Health J
Understanding Crime: Experiences of Crimes and Crime 13: 250–56.
Control, ed. A. Frate, U. Zvekic, and J. Dijk, 343–49.
Monasch, R., and M. Mahy. 2006. “Young People: The
United Nations Crime and Justice Research Institute
Centre of the HIV Epidemic.” World Health Organ Tech
Publication No. 49. Rome: UNICRI.
Rep Ser 938: 15–41.
146 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Rashad, H. 2000. “Demographic Transition in Arab Sellami, A., M. Kharfi, S. Youssef, M. Zghal, B. Fazaa, I.
Countries: A New Perspective.” Journal of Population Mokhtar, and M. R. Kamoun. 2003. “Epidemiologic
Research 17: 83–101. Profile of Sexually Transmitted Diseases (STD)
Rashad, H., and M. Osman. 2003. “Nuptiality in Arab through a Specialized Consultation of STD.” Tunis
Countries: Changes and Implications.” In The New Med 81: 162–66.
Arab Family, Cairo Papers in Social Science, Vol. 24, SeyedAlinaghi, S. 2009. “Assessing the Prevalence of
Nos. 1–2, ed. N. Hopkins, 20–50. Cairo: American HIV among Afghani Immigrants in Iran through
University in Cairo Press. Rapid HIV Testing in the Field.” Personal communica-
Rashad, H., M. I. Osman, and F. Roudi-Fahimi. 2005. tion of unpublished document.
Marriage in the Arab World. Population Reference Shah, S. A., O. A. Khan, S. Kristensen, and S. H.
Bureau. Vermund. 1999. “HIV-Infected Workers Deported
Razzaghi, E., A. Rahimi, and M. Hosseini. 1999. Rapid from the Gulf States: Impact on Southern Pakistan.”
Situation Assessment (RSA) of Drug Abuse in Iran. Tehran: Int J STD AIDS 10: 812–14.
Prevention Department, State Welfare Organization, Shareef, A., A. J. Burqan, A. Abed, E. Kalloub, and A.
Ministry of Health, I.R. of Iran and United Nations Alaiwi. 2006. “Drug Abuse Situation and ANGA
International Drug Control Program. Needs Study.” PowerPoint presentation.
Refaat, A. 2004. “Practice and Awareness of Health Risk Shirazi, K. K., and M. A. Morowatisharifabad. 2009.
Behaviour among Egyptian University Students.” “Religiosity and Determinants of Safe Sex in Iranian
East Mediterr Health J 10: 72–81. Non-Medical Male Students.” J Relig Health 48: 29–36.
Rock, E. M., M. Ireland, and M. D. Resnick. 2003. “To Shrestha, P. 1999. “Forthcoming WER Global Update of
Know That We Know What We Know: Perceived AIDS Cases.” Reported to WHO, WHO/EMRO/ASD,
Knowledge and Adolescent Sexual Risk Behavior.” J 9/28/A5/61/2, Sept. 21, document tables. Geneva.
Pediatr Adolesc Gynecol 16: 369–76. Sigusch, V. 1998. “The Neosexual Revolution.” Archives
Rodier, G. R., J. J. Morand, J. S. Olson, D. M. Watts, and of Sexual Behavior 27: 331–59.
S. Said. 1993. “HIV Infection among Secondary School Simbar, M., F. R. Tehrani, and Z. Hashemi. 2005.
Students in Djibouti, Horn of Africa: Knowledge, “Reproductive Health Knowledge, Attitudes and
Exposure and Prevalence.” East Afr Med J 70: 414–17. Practices of Iranian College Students.” East Mediterr
Roudi-Fahimi, F., and L. Ashford. 2008. “Sexual & Health J 11: 888–97.
Reproductive Health in the Middle East and North SNAP (Sudan National AIDS Programme). 2006. “HIV
Africa. A Guide for Reporters.” Population Reference Sentinel Surveillance among Tuberculosis Patients in
Bureau. Sudan.” Federal Ministry of Health, General
Ryan, S. 2006. “Travel Report Summary.” Kabul, Directorate of Preventive Medicine, SNAP.
Afghanistan. Joint United Nations Programme on ———. 2008. “Update on the HIV Situation in Sudan.”
HIV/AIDS, February 27 through March 7, 2006. PowerPoint presentation.
Saad, M. D., A. Al-Jaufy, R. R. Grahan, Y. Nadai, K. C.
SNAP, and UNAIDS (Joint United Nations Programme
Earhart, J. L. Sanchez, and J. K. Carr. 2005. “HIV
on HIV/AIDS). 2006. “HIV/AIDS Integrated Report
Type 1 Strains Common in Europe, Africa, and Asia
North Sudan, 2004–2005 (draft).” With United
Cocirculate in Yemen.” AIDS Res Hum Retroviruses 21:
Nations General Assembly Special Session on HIV/
644–48.
AIDS Declaration of Commitment.
Sabban, R. 2002. “United Arab Emirates: Migrant Women
SNAP, UNICEF (United Nations Children’s Fund), and
in the United Arab Emirates, the Case of Female
UNAIDS. 2005. “Baseline Study on Knowledge,
Domestic Workers.” GENPROM Working Paper.
Attitudes, and Practices on Sexual Behaviors and
Saeed, Mohamed. “Thirty-Two HIV/AIDS Cases Detected HIV/AIDS Prevention amongst Young People in
in June,” The Peninsula Qatar, July 21, 2008. http:// Selected States in Sudan.” HIV/AIDS KAPB Report.
thepeninsulaqatar.com/Display_news.asp?section= Projects and Research Department (AFROCENTER
local_news&month=july2008&file=local_ Group).
news2008072122852.xml.
Somaliland Ministry of Health and Labour. 2007.
Safdar, S., A. Mehmood, and S. Q. Abbas. 2009. Somaliland 2007 HIV/Syphilis Seroprevalence Survey: A
“Prevalence of HIV/AIDS among Jail Inmates in Technical Report. Ministry of Health and Labour in col-
Sindh.” J Pak Med Assoc 59: 111–12. laboration with the WHO, UNAIDS, UNICEF/GFATM,
Salama, P., and T. J. Dondero. 2001. “HIV Surveillance and SOLNAC.
in Complex Emergencies.” AIDS 15 Suppl 3: S4–12. Spaulding, A., B. Stephenson, G. Macalino, W. Ruby, J.
Sammud, A. 2005. “HIV in Libya.” Ministry of Health, G. Clarke, and T. P. Flanigan. 2002. “Human
Tripoli, August. Immunodeficiency Virus in Correctional Facilities: A
Saxena, P., A. Kulczycki, and R. Jurdi. 2004. “Nuptiality Review.” Clin Infect Dis 35: 305–12.
Transition and Marriage Squeeze in Lebanon.” Spiegel, P. B., A. R. Bennedsen, J. Claass, L. Bruns, N.
Journal of Comparative Marriage Studies 35: 241. Patterson, D. Yiweza, and M. Schilperoord. 2007.
Schoen, R. 1983. “Measuring the Tightness of a Marriage “Prevalence of HIV Infection in Conflict-Affected and
Squeeze.” Working Papers in Population Studies No. Displaced People in Seven Sub-Saharan African
PS 8201. Countries: A Systematic Review.” Lancet 369: 2187–95.
148 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
UNICEF (United Nations Children’s Fund). 2006. The Yousif, M. E. A. 2006. Health Education Programme among
State of the World’s Children 2006: Excluded and Invisible. Female Sex Workers in Wad Medani Town-Gezira State.
New York: UNICEF. Final report.
UNODC (United Nations Office on Drugs and Crime). Zafar, T., H. Brahmbhatt, G. Imam, S. ul Hassan, and S.
2002. “Drug Situation in the I.R. of Iran (May 2002).” A. Strathdee. 2003. “HIV Knowledge and Risk
Tehran, UNODC. Behaviors among Pakistani and Afghani Drug Users
in Quetta, Pakistan.” J Acquir Immune Defic Syndr 32:
Vahdani, P., S. M. Hosseini-Moghaddam, L. Gachkar,
394–98.
and K. Sharafi. 2006. “Prevalence of Hepatitis B,
Hepatitis C, Human Immunodeficiency Virus, and Zali, M. R., R. Aghazadeh, A. Nowroozi, and H. Amir-
Syphilis among Street Children Residing in Southern Rasouly. 2001. “Anti-HCV Antibody among Iranian
Tehran, Iran.” Arch Iran Med 9: 153–55. IV Drug Users: Is It a Serious Problem?” Arch Iranian
Med 4: 115–19.
WHO (World Health Organization). 2004. The 2004 First
National Second Generation HIV/AIDS/STI Sentinel Zamani, S. 2008. “Methadone Maintenance Treatment
Surveillance Survey, Somalia: A Technical Report. (MMT) for Drug-Using Prisoners in Ghezel Hesar
Prison, Karaj, Iran: A Qualitative Study.” UNAIDS
WHO/EMRO (Eastern Mediterranean Regional Office).
Collaborating Centre on Socio-Epidemiological HIV
2000. “Presentation of WHO Somalia’s Experience in
Research, Kyoto University, Japan.
Supporting the National Response.” Somalia. Regional
Consultation towards Improving HIV/AIDS & STD Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian, B.
Surveillance in the Countries of EMRO, Beirut, Nassirimanesh, M. Ono-Kihara, S. M. Ravari, A.
Lebanon, Oct. 30–Nov. 2. Safaie, and S. Ichikawa. 2006. “High Prevalence of
HIV Infection Associated with Incarceration among
World Bank. 2008. “Mapping and Situation Assessment
Community-Based Injecting Drug Users in Tehran,
of Key Populations at High Risk of HIV in Three Cities
Iran.” J Acquir Immune Defic Syndr 42: 342–46.
of Afghanistan.” Human Development Sector, South
Asia Region (SAR) AIDS Team, World Bank. Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian, M.
Ono-Kihara, E. M. Razzaghi, and S. Ichikawa. 2005.
Yamazhan, T., D. Gokengin, E. Ertem, R. Sertoz, S.
“Prevalence of and Factors Associated with HIV-1
Atalay, and D. Serter. 2007. “Attitudes towards HIV/
Infection among Drug Users Visiting Treatment
AIDS and Other Sexually Transmitted Diseases in
Centers in Tehran, Iran.” AIDS 19: 709–16.
Secondary School Students in Izmir, Turkey: Changes
in Time.” Trop Doct 37: 10–12. Zamani, S., G. M. Mehdi, M. Ono-Kihara, S. Ichikawa,
and M. Kuhara. 2007. “Shared Drug Injection inside
Yazdi, C. A., K. Aschbacher, A. Arvantaj, H. M. Naser, E.
Prison as a Potent Associated Factor for Acquisition of
Abdollahi, A. Asadi, M. Mousavi, M. R. Narmani, M.
HIV Infection: Implication for Harm Reduction
Kianpishe, F. Nicfallah, and A. K. Moghadam. 2006.
Interventions in Correctional Settings.” Journal of
“Knowledge, Attitudes and Sources of Information
AIDS Research 9: 217–22.
regarding HIV/AIDS in Iranian Adolescents.” AIDS
Care 18: 1004–10. Zamani, S., M. Vazirian, B. Nassirimanesh, E. M.
Razzaghi, M. Ono-Kihara, S. Mortazavi Ravari, M. M.
Yemen Ministry of Planning and Development. 1998.
Gouya, and M. Kihara. 2008. “Needle and Syringe
Yemen Human Development Report 1998.
Sharing Practices among Injecting Drug Users in
Yemen MOH (Ministry of Health). Unknown. National Tehran: A Comparison of Two Neighborhoods, One
Strategic Framework for the Control and Prevention of HIV/ with and One without a Needle and Syringe Program.”
AIDS in the Republic of Yemen. AIDS Behav. DOI 10.1007/s10461-008-9404-2.
Sexual and injecting drug use (IDU) risk behav- sexual activity.3 The validity of reported risk
ior measures in the Middle East and North behaviors from people whose risk behaviors are
Africa (MENA) tend to be poor, partially due to illegal, such as those of priority groups, is open to
limited surveillance efforts and partially due to question.4
the conservative nature of its societies and the It is also challenging to precisely quantify risky
stigma associated with sexual and IDU risk behavior due to the multitude of facets of sexual
behaviors. Even when such risk behavior mea- behavior, from partnership formation to contact
sures exist, they may not provide us with a precise with sex workers, to heterogeneity in partner
or even accurate assessment of the risk of expo- change rates, to assortative and age cohort mixing,
sure to human immunodeficiency virus (HIV). among others. Network structure and concurrency
Sexual risk behavior, and to some extent inject- of partnerships can further play a major role in
ing drug use, is a complex phenomenon that can- HIV transmission.5 A monogamous person in a
not be directly observed. Only indirect data are stable sexual partnership, who is considered to
available on sexual activity and these data are have low-risk behavior, can still be considered at
typically collected from questionnaires, interviews, high risk of infection because she/he can be con-
focus group discussions, and other qualitative nected through her/his partner, or the partner of
methods.1 The indirect nature of evidence, the the partner, to a high-risk sexual network.
private and sensitive nature of sexual behavior, Conversely, a person with frequent partnership
the informational limitations of egocentric sexual changes who is considered to have high-risk
behavior data, and the nonrandom biases in sexu- behavior, can still be at low risk of infection if his/
al behavior reporting, including social desirability her network is virtually closed with a low risk of
and memory, can introduce elements of bias and HIV penetration.
uncertainty in available measures.2 Part of the Despite some evidence for substantial levels
population, such as women, may under-report of reported sexual and IDU risk behaviors in
their sexual activity while another part of the some priority groups in MENA, HIV prevalence
population, such as men, may over-report their appears to remain at low levels. This may
1 3
Obasi et al., “Antibody to Herpes Simplex Virus Type 2.” Catania et al., “Methodological Problems.”
2 4
Lee and Renzetti, “The Problems of Researching Sensitive Topics”; Pisani et al., “HIV Surveillance.”
5
Caldwell and Quiggin, “The Social Context of AIDS”; Wadsworth et al., Kretzschmar and Morris, “Measures of Concurrency in Networks”;
“Methodology of the National Survey”; Morris, “Telling Tails”; Morris, Morris, “Sexual Networks and HIV”; Watts and May, “The Influence of
Network Epidemiology; Cleland et al., “Measurement of Sexual Concurrent Partnerships”; Ghani, Swinton, and Garnett, “The Role of
Behaviour.” Sexual Partnership Networks.”
151
suggest the limited explanatory power of avail- increases HIV infection and transmission,12 and
able risk behavior measures. Faced with this that it had played a leading role in fueling the HIV
dilemma, this chapter focuses on available data epidemic in different populations.13 The vast
for sexually transmitted infections (STIs) with a majority of HIV-positive people are also infected
special focus on herpes simplex virus type 2 with HSV-2, and HSV-2 is most often acquired
(HSV-2) and human papillomavirus (HPV), before HIV.14
which are relevant to the dynamics of HIV infec- Due to the common risk factors between HIV
tious spread. Biological markers of STIs provide and HSV-2 but the larger infectivity of the
inexpensive and reliable tools to gauge the HSV-2 infection, HSV-2 spreads faster than HIV
nature of sexual activity in MENA and its mani- along the paths of sexual risk and it delineates
festation in terms of the risk of HIV exposure. the potential avenues of future HIV spread in
Most important, these measures provide us with the population. In a sense, HSV-2 infection acts
an indication of the potential HIV spread in dif- as a “tour guide” for HIV infection. HSV-2 can
ferent population groups. quantify the risk of exposure to STIs even when
conventional behavioral measures, such as part-
nership change rates, may fail to quantify the
HSV-2 AS A MARKER OF SEXUAL RISK risk posed by the structure of sexual networks.15
BEHAVIOR
Why HSV-2? HSV-2 prevalence levels
Several studies have documented HSV-2 preva-
HSV-2, which causes the disease known as genital
lence levels in MENA and in related cultural set-
herpes, is one of the most infectious and wide-
tings as listed in table 10.1. It is estimated that
spread STIs,6 and is the leading cause of genital
there are 9.6 million females and 8.6 million males
ulcer disease (GUD) in both developed and devel-
infected with HSV-2 in this region, and that
oping countries.7 It is estimated that there were
388,000 and 195,000 new infections occurred in
536 million people living with this infection in
the year 2003 among females and males, respec-
2003, and 23.6 million people were newly infected
tively.16 The pattern in table 10.1 is that of low or
in this same year.8 Genital herpes is almost exclu-
very low HSV-2 prevalence among general popu-
sively transmitted sexually and induces the pro-
lations groups, but substantial prevalence among
duction of lifelong antibodies.9
groups with identifiable risk factors such as male
The strong observed correlations between
sex workers (MSWs), female sex workers (FSWs),
HSV-2 infection and sexual risk behavior10 sug-
“bar girls,” IDUs, and sexually transmitted disease
gested the use of HSV-2 antibodies in the blood as
a convenient and objective serological marker of (STD) clinic attendees.
A few other studies found higher HSV-2
sexual behavior in different populations.11 In addi-
prevalence levels in MENA. In the Arab Republic
tion to its role as a behavioral biomarker, there
of Egypt, an HSV-2 prevalence of 32% was
is extensive evidence that HSV-2 infection in
both its clinical and subclinical forms substantially reported among female clinic attendees.17 In the
Islamic Republic of Iran, a 28% prevalence was
reported among a randomly selected population
6
O’Farrell, “Increasing Prevalence of Genital Herpes”; Smith and of women attending nine primary health care
Robinson, “Age-Specific Prevalence of Infection”; Weiss, centers.18 In Jordan, a prevalence of 53% for
“Epidemiology of Herpes.”
7
Ahmed et al., “Etiology of Genital Ulcer Disease”; Mertz et al.,
males and 42% for females was reported among
“Etiology of Genital Ulcers”; Morse, “Etiology of Genital Ulcer
Disease.”
8 12
Looker, Garnett, and Schmid, “An Estimate of the Global Prevalence.” Freeman et al., “Herpes Simplex Virus 2 Infection.”
9 13
van de Laar et al., “Prevalence and Correlates of Herpes.” Abu-Raddad et al., “Genital Herpes”; Corey et al., “The Effects of
10
Obasi et al., “Antibody to Herpes Simplex Virus Type 2”; van de Laar Herpes.”
14
et al., “Prevalence and Correlates of Herpes”; Cowan et al., “Antibody Corey et al., “The Effects of Herpes.”
15
to Herpes Simplex Virus Type 2”; Cunningham et al., “Herpes Simplex Nagelkerke et al., “Body Mass Index.”
16
Virus Type 2 Antibody.” Looker, Garnett, and Schmid, “An Estimate of the Global Prevalence.”
11 17
Nahmias, Lee, and Beckman-Nahmias, “Sero-Epidemiological and El-Sayed, Zaki, and Goda, “Relevance of Parvovirus B19.”
18
Sociological Patterns.” Kasraeian, Movaseghii, and Ghiam, “Seroepidemiological Study.”
152 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.1 HSV-2 Prevalence in Different Population Groups
Arab Israelis 9.0% (Arab and Jewish non-Soviet immigrants; pregnant women; Dan et al. 2003)
2.4% (Arabs; STD clinic attendees; Feldman et al. 2003)
Bangladesh 12.0% (women attending basic health care clinic; Bogaerts et al. 2001)
Djibouti 2.0% (general population women; Marcelin et al. 2001)
5.0% (male blood donors; Marcelin et al. 2001)
49.0% (luxury bar FSWs; Marcelin et al. 2001)
81% (street-based FSWs; Marcelin et al. 2001)
Egypt, Arab Republic of 6.2% (STD clinic attendees; Saleh et al. 2000)
Iran, Islamic Republic of 8.25% (pregnant women; Ziyaeyan et al. 2007)
Lebanon 0.027% (general population women; Karam et al. 2007)
Morocco 12.9% (ANC attendees; Cowan et al. 2003)
16.2% (ANC attendees; WHO/EMRO Regional Database on HIV/AIDS)
13.0% (general population women; WHO/EMRO Regional Database on HIV/AIDS)
10.0% (general population men; WHO/EMRO Regional Database on HIV/AIDS)
26.0% (urban women with a median age of 40 years; Patnaik et al. 2007)
9.2% (male HIV sentinel surveillance attendees; Cowan et al. 2003)
6.5% (military personnel; Cowan et al. 2003)
6.7% (STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS)
Pakistan 11.0% (IDUs; Platt et al. 2009)
6.0% (IDUs; Platt et al. 2009)
8.0% (FSWs; Hawkes et al. 2009)
4.7% (FSWs; Hawkes et al. 2009)
7.4% (MSWs; banthas; Hawkes et al. 2009)
2.5% (MSWs; banthas; Hawkes et al. 2009)
14.0% (MSWs; khotkis; Hawkes et al. 2009)
25.0% (MSWs; khotkis; Hawkes et al. 2009)
54.0% (MSWs; khusras; Hawkes et al. 2009)
31.3% (MSWs; khusras; Hawkes et al. 2009)
Sudan 5.5% (household cluster survey; Southern Sudan; Kaiser et al. 2006)
27.0% (male Sudanese refugees in Ethiopia; Holt et al. 2003)
26.0% (female Sudanese refugees in Ethiopia; Holt et al. 2003)
Syrian Arab Republic 0.0% (pregnant women; Ibrahim, Kouwaitli, and Obeid 2000)
0.0% (general population women; Ibrahim, Kouwaitli, and Obeid 2000)
0.3% (general population men; Ibrahim, Kouwaitli, and Obeid 2000)
0.0% (neonates; Ibrahim, Kouwaitli, and Obeid 2000)
9.5% (STD clinic attendees; Ibrahim, Kouwaitli, and Obeid 2000)
8.0% (women with cervical cancer; Ibrahim, Kouwaitli, and Obeid 2000)
20.0% (“bar girls”; Ibrahim, Kouwaitli, and Obeid 2000)
34.0% (FSWs; Ibrahim, Kouwaitli, and Obeid 2000)
Turkey 5.0% (pregnant women; Dolar et al. 2006)
8.0% (women with pregnancy complications; Cengiz et al. 1993)
5.5% (blood donors; Dolar et al. 2006)
4.8% (sexually active adults; Dolar et al. 2006)
8.3% (hotel staff; Dolar et al. 2006)
17.3% (patients with genital warts; Dolar et al. 2006)
60.0% (FSWs; Dolar et al. 2006)
6.15% (IgM; FSWs; Gul et al. 2008)
80.0% (IgG; FSWs; Gul et al. 2008)
United Arab Emirates 12.0% (migrant workers; N. J. Nagelkerke, personal communication [2007])
15
Figure 10.1 shows the age-
stratified prevalence in a study
10 from Morocco.27 The prevalence
grows rather slowly for both males
5 and females compared to other
regions,28 suggesting that it takes a
0 long time after sexual debut for
0 5 10 15 20 25 30 35 40 45 50 the risk of exposure to this STI to
age be appreciable in magnitude. An
HSV-2 prevalence among adult females HSV-2 prevalence among adult males
alternative explanation might be a
changing experience of successive
Source: Cowan et al. 2003. birth cohorts in being exposed to
HSV-2 infection in different eras.29 However,
this explanation seems unlikely because recent
healthy university students aged 18–24 years.19 trends suggest increasing, rather than declining,
In Saudi Arabia, a prevalence of 27% was sexual risk behaviors.
reported among pregnant women.20 Finally, in
Turkey, a prevalence of 63% was reported
among pregnant women,21 53.5% was reported Implications, limitations, and future applications
among general population women in a rural
The above data suggest that HSV-2 prevalence
area,22 and 26% was reported among men who
in the general population in MENA is low, and
have sex with men (MSM).23
indeed among the lowest globally compared
However, some of the results of these studies
to other regions (table 10.2).30 This provides
appear to contradict the results in table 10.1
an indication that the levels of sexual risk
and need confirmation, because the serology
behavior in the general population are low
tests used appear to suffer from high levels of
and that HIV infection is likely to have limited
cross-reactivity with herpes simplex virus type 1
inroads into this population. However, HSV-2
(HSV-1) antibodies and use of nonspecific
prevalence levels in populations with identifi-
serologic assays.24 HSV-1 infection is predom-
able risk behaviors are considerable, and com-
inantly transmitted orally (not sexually), has
25 parable to those in other regions, though at
a very high prevalence in MENA, and shows
somewhat lower levels.31 This suggests the
extensive sequence homology with HSV-2.26
potential for HIV to spread among priority
19
populations.
Abuharfeil and Meqdam, “Seroepidemiologic Study.”
20
Ghazi, Telmesani, and Mahomed, “TORCH Agents in Pregnant Saudi
Women.”
21
Duran et al., “Asymptomatic Herpes.”
22
Maral et al., “Seroprevalences of Herpes.”
23 27
Cengiz et al., “Detection of Herpes”; Cengiz et al., “Demonstration of Cowan et al., “Seroepidemiological Study.”
28
Herpes.” Smith and Robinson, “Age-Specific Prevalence of Infection”; Cowan
24
Ashley et al., “Inability of Enzyme Immunoassays to Discriminate”; et al., “Seroepidemiological Study.”
29
R. Ashley, personal communication (2007); Abu-Raddad et al., “HSV-2 Burchell et al., “Chapter 6.”
30
Serology.” O’Farrell, “Increasing Prevalence of Genital Herpes”; Smith and
25
Smith and Robinson, “Age-Specific Prevalence of Infection”; Cowan Robinson, “Age-Specific Prevalence of Infection”; Weiss,
et al., “Seroepidemiological Study.” “Epidemiology of Herpes”; Pebody et al., “The Seroepidemiology of
26
R. Ashley, personal communication (2007); H. Weiss, personal Herpes”; Paz-Bailey et al., “Herpes Simplex Virus Type 2.”
31
communication (2007). Smith and Robinson, “Age-Specific Prevalence of Infection.”
154 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.2 HSV-2 Prevalence in the General prevalence in older age cohorts may not be as
Population in Different Regions of the World informative because the infection may have
Compared to MENA been acquired long before the serology test was
performed. Monitoring of HSV-2 infection
Region HSV-2 prevalence
should be conducted using serology tests rather
Asia 10% to 30% than diagnosis of herpetic ulcers because up to
Europe 4% to 24% 90% of HSV-2 infections are asymptomatic or
Latin America 20% to 40% not clinically apparent.35 Furthermore, the
Middle East and North Africa 0% to 15% dominant form of herpetic ulceration may not
North America 18% to 26% be due to HSV-2 in MENA, but to HSV-1 (oro-
Sub-Saharan Africa 10% to 80% genital transmission rather than purely genital
transmission), as has been observed in Israel.36
Sources: O’Farrell 1999; Smith and Robinson 2002; Pebody et al. 2004; Weiss 2004; In terms of limitations, HSV-1 infection has
Paz-Bailey et al. 2007.
near universal prevalence in MENA37 and may
have a protective effect against HSV-2
HSV-2 serology is a powerful marker of sexual acquisition,38 thereby partially contributing to
risk behavior and should be a standard compo- the low prevalence of HSV-2 in MENA. However,
nent in any planned or proposed surveillance the evidence for a protective effect is conflicting,39
efforts in MENA. HSV-2 prevalence can also and despite high HSV-1 prevalence in most
help in identifying subgroups with an elevated populations around the globe,40 this has not
risk of exposure to HIV that may benefit most tainted the predictive power of HSV-2 as a proxy
from interventions. For example, in table 10.1, for sexual risk behavior. Indeed, the over-
it is manifest that due to substantial HSV-2 whelming evidence confirms the utility of HSV-2
prevalence among MSWs, FSWs, “bar girls,” and as a marker of risky behavior irrespective of
STD clinic attendees, these groups are likely to HSV-1 prevalence.41 The near universal male
be at an elevated risk of exposure to HIV and circumcision coverage in MENA is also unlikely
would benefit most from interventions. Given to explain the low and limited HSV-2 preva-
the difficulty of identifying populations at high lence because male circumcision does not appear
risk in MENA, HSV-2 prevalence can be helpful to substantially reduce HSV-2 sero-incidence.42
in assessing the levels of risky behavior when Some of the HSV-2 research work in MENA
data are limited or HIV prevalence is still at low reflects methodological limitations. HSV-2 sero-
levels, particularly among priority populations. logy tests must be conducted carefully to avoid
HSV-2 prevalence and incidence data can cross-reactivity with HSV-1 infection. Serological
further be used in MENA for the evaluation of assays need to be validated in different populations
changes in sexual risk behavior or assessing the
impact of interventions in different age cohorts 35
Cowan et al., “Antibody to Herpes Simplex Virus Type 2”; Corey and
over time.32 Rates of HSV-2 prevalence change Handsfield, “Genital Herpes and Public Health”; Fleming et al., “Herpes
most rapidly among adolescents and young Simplex Virus Type 2.”
36
Samra, Scherf, and Dan, “Herpes Simplex Virus Type 1.”
adults, suggesting that HSV-2 can be used to 37
Smith and Robinson, “Age-Specific Prevalence of Infection”; Cowan
gauge recent changes in risky behavior among et al., “Seroepidemiological Study.”
the young age cohorts.33 Population-based data 38
Cowan et al., “Antibody to Herpes Simplex Virus Type 2”; Mertz et al.,
of HSV-2 collected sequentially in time would “Frequency of Acquisition.”
39
Cowan et al., “Seroepidemiological Study”; Brown et al., “The
be valuable to determine the trends of sexual Acquisition of Herpes “; Langenberg et al., “A Prospective Study of
risk behavior.34 This is pertinent given the rapid New Infections with Herpes.”
40
socioeconomic changes and liberalization of cul- Smith and Robinson, “Age-Specific Prevalence of Infection”; Cowan
et al., “Seroepidemiological Study.”
ture that this region is experiencing. HSV-2 41
Obasi et al., “Antibody to Herpes Simplex Virus Type 2”; van de Laar
et al., “Prevalence and Correlates of Herpes”; Cowan et al., “Antibody
to Herpes Simplex Virus Type 2”; Cunningham et al., “Herpes Simplex
32
van de Laar et al., “Prevalence and Correlates of Herpes”; Slomka, Virus”; Cowan et al., “Seroepidemiological Study”; Dan et al.,
“Seroepidemiology and Control of Genital Herpes.” “Prevalence and Risk Factors.”
33 42
Obasi et al., “Antibody to Herpes Simplex Virus Type 2.” Weiss et al., “Male Circumcision”; Bailey, “Scaling Up Circumcision
34
Looker, Garnett, and Schmid, “An Estimate of the Global Prevalence.” Programmes.”
156 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.3 Age-Standardized Rates of Cervical Table 10.4 Age-Standardized Rates of Cervical
Cancer Incidence and Mortality Cancer Incidence and Mortality at Specific
(per 100,000 women per year) Surveillance Sites or Population Groups
(per 100,000 women per year)
Country/Region Incidence ASR Mortality ASR
Afghanistan 6.9 3.6 Country ASR
Algeria 15.6 12.7 Algeria
Bahrain 8.5 4.8 Setif 11.6
Djibouti 42.7 34.6
Egypt, Arab Rep. of
Egypt, Arab Rep. of 9.7 7.9
Iraq 3.3 1.8 Gharbiah 2.1
Iran, Islamic Republic of 4.4 2.4 Tunis
Israel 4.6 2.3 Centre, Sousse 7.1
Jordan 4.3 2.4 Bahrain
Kuwait 6.1 3.4 Bahraini 6
Lebanon 15.4 8.0
Israel
Libya 11.9 9.6
Non-Jews 2.4
Morocco 13.2 10.7
Oman 6.9 3.9 Kuwait
Pakistan 6.5 3.6 Kuwaitis 4.5
Qatar 3.9 2.2 Non-Kuwaitis 5.3
Saudi Arabia 4.6 2.5 Malaysia
Somalia 42.7 34.6 Penang 17.9
Sudan 15.4 12.7 Sarawak 15.9
Syrian Arab Republic 2.0 1.0
Tunisia 6.8 5.5 Oman
Turkey 4.5 2.4 Omani 6.5
United Arab Emirates 9.9 5.3 Pakistan
Yemen, Republic of 8.0 4.6 South Karachi 7.5
Source: Ferlay et al. 2004. Singapore
Note: ASR = age-standardized rates. Malay 7.3
Turkey
incidence in select MENA populations com- Antalya 4.4
pared to the global average.59 Izmir 5.4
Globally, the incidence of cervical cancer per Source: Curado et al. 2007.
country varies widely with rates ranging from 3 Note: Rates derived using robust methodology; ASR ⫽ age-
to 61 per 100,000 women per year.60 As evident standardized rates.
in the table, the rates in MENA are mostly low,
and, in fact, the list of the lowest seven cervical in Ardabil, Islamic Republic of Iran.64 Data from
cancer rates in the world (Syrian Arab Republic, MENA also show a generally low prevalence of
Iraq, Turkey, Azerbaijan, Jordan, the Republic cervical intraepithelial neoplasia, the precursor
of Yemen, and Saudi Arabia) includes five to cervical cancer.65
MENA countries.61 The Middle Eastern region Nonetheless, there is substantial variability in
has the lowest cervical cancer incidence rate of the region, with Djibouti and Somalia recording
all regions at 5.6 per 100,000 women per year.62 relatively high levels of cervical cancer. Cervical
Of the distribution by predominant religion, cancer is the most common cancer in Somalia
Muslim states have the lowest cervical cancer among women,66 just as it is the most common
rates at 15.6 per 100,000 women per year.63 The cancer in developing countries.67 It is the second
lowest recorded incidence rate of cervical cancer
worldwide is 0.4 per 100,000 women per year
64
Sadjadi et al., “Cancer Occurrence in Ardabil.”
65
El-All, Refaat, and Dandash, “Prevalence of Cervical Neoplastic
59
Parkin et al., Cancer Incidence in Five Continents, Vol. VIII. Lesions”; Hammad, Jones, and Zayed, “Low Prevalence of Cervical
60
Drain et al., “Determinants of Cervical Cancer Rates.” Intraepithelial Neoplasia”; Komoditi, “Cervical and Corpus Uterine
61
Ibid. Cancer”; Altaf, “Pattern of Cervical Smear Cytology.”
62 66
Ibid. Elattar, “Cancer in the Arab World.”
63 67
Ibid. WHO, “Human Papillomavirus and HPV Vaccination.”
5–9
14
19
24
29
34
39
44
49
54
59
64
69
74
79
84
85+
ually transmitted.79
10–
15–
20–
25–
30–
35–
40–
45–
50–
55–
60–
65–
70–
75–
80–
age A few HPV and cervical cancer stud-
Algeria, Algiers Algeria, Setif Wilaya Israel: Non-Jews
ies in MENA indicated an association
between level of HPV prevalence (or
Oman: Omani Pakistan, South Karachi global average
Kuwait: Kuwaitis
cervical cancer) and socioeconomic
status, including rural versus urban
Source: Parkin et al. 2002. environment, type of household and
occupation, and hygiene, sanitation,
most common cancer in Algeria,68 Morocco,69 and income, and education levels.80 It is not clear what
Tunisia,70 but not one of the five leading cancers drives this association and whether it reflects a
among women in Egypt, Jordan, Kuwait, Lebanon, higher sexual risk behavior with lower socioeco-
and Saudi Arabia.71 Cervical cancer accounts for nomic status or not.
28.4% of cancer cases in Somalia, 16.3% in
Algeria, 14.7% in Morocco, and 8.6% in Tunisia,
but accounts for less than 6% in Egypt, Iraq, Implications, limitations, and future applications
Kuwait, Lebanon, Saudi Arabia, and the Republic
of Yemen.72 In Jordan, cervical cancer accounts for HPV and cervical cancer levels in MENA suggest
only 2% of female cancers, ranking 13th to 16th that the average level of sexual risk behavior in
among female cancers in the years 2000 to 2004.73 MENA populations is considerably less than that
in other regions of the globe. However, there is
substantial heterogeneity of HPV and cervical can-
HPV prevalence levels
cer levels, indicating variability of sexual risk
A number of studies have documented HPV behavior within MENA. It appears that countries
prevalence in different population groups. closest to sub-Saharan Africa have the highest
Table 10.5 lists a summary of these studies as levels of risky behavior followed by the Maghreb
measured by DNA detection. These results countries in the western part of MENA. The lowest
suggest low-to-intermediate prevalence levels
compared to other settings worldwide.74 Yet,
75
Munoz et al., “Chapter 1.”
76
68 Al-Muammar et al., “Human Papilloma Virus-16/18 Cervical Infection.”
Elattar, “Cancer in the Arab World.” 77
69 Jamal and Al-Maghrabi, “Profile of Pap Smear Cytology.”
Chaouki et al., “The Viral Origin of Cervical Cancer.” 78
70 Hamkar et al., “Prevalence of Human Papillomavirus.”
Elattar, “Cancer in the Arab World.” 79
71 Baseman and Koutsky, “The Epidemiology of Human Papillomavirus
Ibid.
72 Infections”; R. Barnabas, personal communication (2007); P. Drain,
Ibid.
73 personal communication (2007); L. Koutsky, personal communication
Jordan National Cancer Registry, Cancer Incidence in Jordan;
(2007).
Mahafzah et al., “Prevalence of Sexually Transmitted Infections.” 80
74 Roudi-Fahimi and Ashford, “Sexual & Reproductive Health”; Chaouki
Curado et al., Cancer Incidence in Five Continents; Drain et al.,
et al., “The Viral Origin of Cervical Cancer”; Hammouda et al., “Cervical
“Determinants of Cervical Cancer Rates.”
Carcinoma in Algiers.”
158 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.5 HPV Prevalence in Different Population Groups in MENA
levels of risk appear to be in the Mashriq countries of men contacting FSWs. This is illustrated in the
in the eastern part of the region. schematic diagrams in figure 10.3. In these two
The apparent differences in the levels of risk sexual networks, the number of sexual partnerships
behavior across MENA may not be strictly due to is equal, but the distribution of these partnerships
substantial differences in how often people is different. In figure 10.3a, the network is sparse,
acquire new sexual partners, but may reflect the while in figure 10.3b the network has a high
nature of sexual networks in different parts of the degree of connectivity as people are connected to
region. Cervical cancer rates appear to be deter- each other through contacts with a node with a
mined by male rather than female sexual behav- large number of partners. HPV could have a high
ior.81 A leading cause of this could be contacts prevalence in network (b), but a much lower
with sex workers and the role of commercial sex prevalence in network (a).
in linking individuals within sexual networks.82 One of the limitations of using cervical cancer
Since HPV is very infectious and its transmission as a proxy for sexual risk behavior is that
probability may be as high as 40% per coital act,83 women develop cervical cancer close to 20 years
HPV can be easily transmitted between men and after HPV infection, as can be seen in figure 10.4.84
FSWs even after very few sex acts. Men pass this The mean age of women with cervical cancer in
infection to their spouses who become infected MENA, as well as globally, is around 50 years.85
despite practicing strict monogamy. Current levels of cervical cancer reflect levels of
Accordingly, HPV infection levels provide a exposure among women two decades earlier,
“snapshot” of sexual network connectivity in the which may not be predictive of current risk
region. The data suggest that sexual networks tend behavior among young men and women. There
to be sparser in most countries of MENA com- could be a cohort effect of changing risk behavior
pared to other regions, but fairly connected in across generations in different eras.86 Measures
other countries, perhaps through a higher fraction
84
Schiffman and Castle, “The Promise of Global Cervical-Cancer
Prevention.”
81 85
Bosch et al., “Importance of Human Papillomavirus.” Baseman and Koutsky, “The Epidemiology of Human Papillomavirus
82
Skegg et al., “Importance of the Male Factor.” Infections”; Altaf, “Pattern of Cervical Smear Cytology.”
83 86
Burchell et al., “Modeling the Sexual Transmissibility.” Burchell et al., “Chapter 6.”
160 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
In part, this is due to the lack of sat- Figure 10.4 The Natural History of HPV Infection and Cervical Cancer
isfactory awareness of this health
Viral
issue among both the population persistence
and medical practitioners as well as and
progression
the lack of a national screening policy HPV- Precancerous
Normal infected lesion Cancer
for cervical cancer. In Pakistan, only cervix cervix
Clearance Regression Invasion
5% of women knew that screening
was available for cervical cancer.98 HPV
98
Imam et al., “Perceptions and Practices.”
99 106
Bener, Denic, and Alwash, “Screening for Cervical Cancer.” Chaouki et al., “The Viral Origin of Cervical Cancer”; Hassen et al.,
100
Al Sairafi and Mohamed, “Knowledge, Attitudes, and Practice.” “Cervical Human Papillomavirus Infection”; Hammouda et al.,
101
Chaouki et al., “The Viral Origin of Cervical Cancer”; Hammouda et al., “Cervical Carcinoma in Algiers”; Lalaoui et al., “Human Papillomavirus
“Cervical Carcinoma in Algiers.” DNA”; Khair et al., “Molecular Detection.”
102 107
Allahverdipour and Emami, “Perceptions of Cervical Cancer.” Baykal et al., “Knowledge and Interest.”
103 108
Al Sairafi and Mohamed, “Knowledge, Attitudes, and Practice.” WHO, “Human Papillomavirus and HPV Vaccination.”
104 109
Goldie et al., “Policy Analysis of Cervical Cancer Screening.” Ibid.
105 110
WHO, “Human Papillomavirus and HPV Vaccination.” Ibid.
162 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.6 Syphilis Prevalence in Different Population Groups
Afghanistan 0.0% (ANC attendees; Todd et al. 2007; Todd et al. 2008)
1.1% (blood donors; Afghanistan Central Blood Bank 2006)
2.2% (IDUs; Todd et al. 2007)
Algeria 0.8% (pregnant women; Alami 2009)
0.8% (pregnant women; Alami 2009)
0.53% (pregnant women; Aidaoui, Bouzbid, and Laouar 2008)
3.62% (ANC attendees; Unknown, Statut de la réponse nationale)
2.3% (STI clinic attendees; Alami 2009)
5.8% (STI clinic attendees; Alami 2009)
11.9% (FSWs; Alami 2009)
8.4% (FSWs; Alami 2009)
Djibouti 0.0% (high school students; Rowe 2007)
3.1% (pregnant women; WHO and EMRO 1998)
4.0% (ANC attendees; Unknown 2002)
0.4% (blood donors; Massenet and Bouh 1997)
41.0% (FSWs; Rowe 2007)
46.0% (FSWs; Rodier et al. 1993; Rowe 2007)
Egypt, Arab Republic of 0.05% (university students; El-Gilany and El-Fedawy 2006)
0.0% (family planning attendees; El-Sayed et al. 2002)
0.0% (ANC attendees; El-Sayed et al. 2002)
0.3% (tourism workers; El-Sayed et al. 1996)
1.0% (STD clinic attendees; El-Sayed et al. 1996)
1.0% (active syphilis; STD clinic attendees; El-Sayed et al. 1996)
1.3% (IDUs; El-Sayed et al. 2002)
5.8% (FSWs; El-Sayed et al. 2002)
7.5% (MSM; El-Sayed et al. 2002)
Iran, Islamic Republic of 0.0% (street children; Vahdani et al. 2006)
0.1% (general population; Dezfulimanesh and Tehranian 2005)
0.0% (runaways and other women seeking safe haven; Hajiabdolbaghi et al. 2007)
0.0% (blood donors; Khedmat et al. 2007)
Jordan 0.0% (symptomatic hospital attendees; Jordan Ministry of Health 2004)
0.0% (asymptomatic hospital attendees; Jordan Ministry of Health 2004)
0.0% (symptomatic hospital attendees; As’ad 2004)
0.0% (asymptomatic hospital attendees; As’ad 2004)
0.0% (symptomatic hospital attendees; Mahafzah et al. 2008)
0.0% (asymptomatic hospital attendees; Mahafzah et al. 2008)
Kuwait 0.0% (STD clinic attendees; Al-Mutairi et al. 2007)
Lebanon 0.0% (rural population; Deeb et al. 2003)
Morocco 3.4% (family planning center attendees; Ryan et al. 1998)
5.6% (symptomatic primary health care center attendees; Ryan et al. 1998)
2.8% (ANC attendees; WHO/EMRO Regional Database on HIV/AIDS)
3.0% (pregnant women; WHO/EMRO 1998)
1.0% (pregnant women; Khattabi and Alami 2005)
0.73% (pregnant women; Bennani and Alami 2006)
2.8% (general population; WHO/EMRO Regional Database on HIV/AIDS)
1.3% (blood donors; WHO/EMRO 1998)
0.4% (hotel staff; Khattabi and Alami 2005)
0.94% (hotel staff; Bennani and Alami 2006)
2.9% (seasonal female laborers; Khattabi and Alami 2005)
2.17% (seasonal female laborers; Bennani and Alami 2006)
0.0% (male laborers; Khattabi and Alami 2005)
4.51% (male laborers; Bennani and Alami 2006)
9.55% (truck drivers; Khattabi and Alami 2005)
(continued)
164 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.6 (Continued)
MENA and are common among priority popula- of Iran, almost all FSWs reported a previous his-
tions. It is estimated that the general prevalence of tory of STDs and 60% reported frequent STD
syphilis in MENA is at 1%.116 In Afghanistan, a infections.118 Among truck drivers and youth,
15-fold increase in syphilis prevalence was 31.9% and 27.9% reported a previous history
reported among blood donors from 2002 to 2003, of STDs, respectively.119 In Lebanon, a large
apparently due to a massive influx of refugees study of general population women reported a
returning to the country.117 In the Islamic Republic
116 118
WHO/EMRO Regional Database on HIV/AIDS. Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.”
117 119
Todd et al., “Prevalence of and Barriers to Testing.” Ibid.
166 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table 10.8 Chlamydia Prevalence in Different Population Groups
Algeria 100% (antichlamydia antibodies; obstetric clinic attendees; Kadi et al. 1989)
100% (antichlamydia antibodies; FSWs; Kadi et al. 1989)
Djibouti 5.7% (promiscuous males; Fox 1989)
Egypt, Arab Republic of 2.8% (family planning attendees; El-Sayed et al. 2002)
1.3% (ANC attendees; El-Sayed et al. 2002)
2.7% (IDUs; El-Sayed et al. 2002)
7.7% (FSWs; El-Sayed et al. 2002)
8.8% (MSM; El-Sayed et al. 2002)
Iran, Islamic Republic of 8.8% (male STI clinic attendees; Darougar et al. 1982)
9.3% (male patients with urethritis; Ghanaat et al. 2008)
6.9% (FSWs; Darougar et al. 1983)
Jordan 1.3% (symptomatic hospital attendees; Jordan Ministry of Health 2004)
0.5% (asymptomatic hospital attendees; Jordan Ministry of Health 2004)
0.8% (symptomatic hospital attendees; As’ad 2004)
0.0% (asymptomatic hospital attendees; As’ad 2004)
0.9% (symptomatic hospital attendees; Mahafzah et al. 2008)
2.2% (asymptomatic hospital attendees; Mahafzah et al. 2008)
3.9% (women attending infertility clinic; Al-Ramahi et al. 2008)
0.7% (hospital attendees; Al-Ramahi et al. 2008)
4.6% (symptomatic patients with urethritis; Awwad, Al-Amarat, and Shehabi 2003)
3.9% (symptomatic patients with urethritis; Al Ramahi et al. 2008)
Kuwait 4.1% (STD clinic attendees; Al-Mutairi et al. 2007)
Lebanon 0.0% (rural population; Deeb et al. 2003)
Morocco 2.6% (family planning center attendees; Ryan et al. 1998)
6.3% (symptomatic primary health care center attendees; Ryan et al. 1998)
4.2% (ANC attendees; WHO/EMRO Regional Database on HIV/AIDS)
5.6% (female STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS)
51.5% (STD clinic attendees; Heikel et al. 1991)
6.0% (STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS)
17.1% (STD clinic attendees; Alami et al. 2002)
5.0% (STD clinic attendees; Ryan et al. 1998)
19.1% (FSWs; WHO/EMRO Regional Database on HIV/AIDS)
Pakistan 1.0% (truck drivers; Pakistan National AIDS Control Program 2005a)
0%–1% (IDUs; Pakistan National AIDS Control Program 2005a)
0.7% (IDUs; Platt et al. 2009)
0.0% (IDUs; Platt et al. 2009)
5%–11% (FSWs; Pakistan National AIDS Control Program 2005a)
10.0% (anal; MSWs; Pakistan National AIDS Control Program 2005a)
1%–2% (genital; MSWs; Pakistan National AIDS Control Program 2005a)
29.0% (anal; hijras; Pakistan National AIDS Control Program 2005a)
0%–2% (genital; hijras; Pakistan National AIDS Control Program 2005a)
9.0% (anal; hijras; Khan et al. 2008)
1.0% (urethral; hijras; Khan et al. 2008)
4.7% (anal; MSWs; banthas; Hawkes et al. 2009)
4.9% (anal; MSWs; banthas; Hawkes et al. 2009)
3.6% (anal; MSWs; khotkis; Hawkes et al. 2009)
0.0% (anal; MSWs; khotkis; Hawkes et al. 2009)
9.9% (anal; MSWs; khusras; Hawkes et al. 2009)
6.3% (anal; MSWs; khusras; Hawkes et al. 2009)
Saudi Arabia 0.0% (asymptomatic females attending genitourinary or gynecological clinics; Massoud et al. 1991)
2.0% (asymptomatic males attending genitourinary or gynecological clinics; Massoud et al. 1991)
35.0% (symptomatic females attending genitourinary or gynecological clinics; Massoud et al. 1991)
46.0% (symptomatic males attending genitourinary or gynecological clinics; Massoud et al. 1991)
(continued)
Proxy Biological Markers of Sexual Risk Behavior 167
Table 10.8 (Continued)
trichomonas prevalence of 0.53%.120 In Pakistan, among adults in MENA.129 The yearly incidence
15%–45% of different risk groups, including IDUs, of the four leading curable STIs (gonorrhea,
FSWs, MSWs, and hijras, reported having an STI chlamydia, syphilis, and trichomonas) is esti-
in the past six months.121 Also in Pakistan, 3.2% of mated at 7% per person, per year.130 This is the
migrant workers had etiologically confirmed STI second lowest incidence rate of all regions. In
prevalence.122 In Sudan, 7.3% of ANC attendees Djibouti, it is estimated that there are 25,000
were found to have multiple STIs.123 It appears reported STD cases every year.131 In the Islamic
that gonorrhea and chlamydia are the most com- Republic of Iran, 850,000 STDs are registered
mon bacterial STIs among MSM in MENA.124 annually.132 In Morocco, between 180,000 and
A few studies have also documented chan- 240,000 new STDs used to be reported annually
croid in MENA, a bacterial STI characteristic of in the late 1990s,133 but in recent years the
very high levels of risky behavior.125 This infec- number of reported cases has increased consid-
tion reappeared in Algeria in 1988 and was con- erably (370,000 in 2005).134 Figure 10.5 shows
sistently associated with contacts with FSWs.126 the trend in STI notified cases in Morocco from
The infection was also common among STD 1992 to 2006.135 In Saudi Arabia, gonorrhea
clinic attendees in Kuwait.127 incidence was estimated at 4.9 per 100,000 per-
The magnitude of the burden of STIs is not sons per year,136 compared to 131.4 per 100,000
well known in most countries of MENA due to persons per year in the United States.137 In the
the limited STI surveillance. In 2002, HIV and Republic of Yemen, it is estimated that there are
STIs together became the second leading cause 150,000 to 170,000 new STDs per year.138
of mortality among all infectious (and parasitic) Reproductive tract infections include, in addi-
diseases among people 15–44 years old in the tion to STIs, infections arising from overgrowth
region.128 It is estimated that there are 3.5 mil- of natural organisms in the genital tract and
lion curable (mainly bacterial) STIs every year infections acquired during improperly per-
formed medical procedures such as unsafe
120 129
Karam et al., “Prevalence of Sexually Transmitted Infections.” WHO, “Global Prevalence and Incidence.”
121 130
Pakistan National AIDS Control Program, “Report of the Pilot Study in Glasier et al., “Sexual and Reproductive Health.”
131
Karachi & Rawalpindi.” WHO/EMRO, “Prevention and Control.”
122 132
Faisel and Cleland, “Migrant Men” Iran Center for Disease Management, Three Month Statistics.
123 133
Ortashi, El Khidir, and Herieka, “Prevalence of HIV.” Heikel et al., “The Prevalence of Sexually Transmitted Pathogens.”
124 134
WHO/EMRO, Strengthening Health Sector Response. Morocco MOH, “Situation épidémiologique actuelle du VIH/SIDA au
125
Brunham and Plummer, “A General Model”; Glasier et al., “Sexual and Maroc.”
135
Reproductive Health.” WHO/EMRO data reported to the WHO office of the Eastern
126
Boudghene-Stambouli and Merad-Boudia, “Chancroid in Algeria.” Mediterranean Region.
127 136
Brunham and Plummer, “A General Model”; Al-Mutairi et al., “Clinical Madani, “Sexually Transmitted Infections in Saudi Arabia.”
137
Patterns.” CDC, “Tracking the Hidden Epidemics.”
128 138
WHO, Shaping the Future. Lambert, “HIV and Development Challenges in Yemen.”
168 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
abortions.139 Hence, caution Figure 10.5 Trend in STI Notified Cases in Morocco, 1992–2006
needs to be exercised when inter- 400
preting STD data with no con-
139
Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.”
140 144
Deeb et al., “Prevalence of Reproductive Tract Infections.” Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.”
141 145
Measure DHS, “Egypt: Demographic and Health Survey 2005.” WHO, Unsafe Abortion; Ahman and Shah, “Unsafe Abortion.”
142 146
Ibid. Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.”
143 147
WHO, Unsafe Abortion. Glasier et al., “Sexual and Reproductive Health.”
The designations employed and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers
or boundaries. Dashed lines represent approximate border lines for which there may not yet be full agreement.
ter 7). However, the data on priority popula- Agacfidan, A., J. M. Chow, H. Pashazade, G. Ozarmagan,
and S. Badur. 1997. “Screening of Sex Workers in
tions suggest that there is potential for HIV Turkey for Chlamydia Trachomatis.” Sex Transm Dis
spread among these populations. 24: 573–75.
170 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Ahman, E., and I. Shah. 2002. “Unsafe Abortion: Neoplastic Cervical Specimens from Pakistan and
Worldwide Estimates for 2000.” Reprod Health Matters Japan by Non-Isotopic in situ Hybridization.” Int J
10: 13–17. Cancer 47: 675–80.
Ahmed, H. J., J. Mbwana, E. Gunnarsson, K. Ahlman, As’ad, A. 2004. “Final Report: Sexually Transmitted
C. Guerino, L. A. Svensson, F. Mhalu, and T. Lagergard. Infections (STI) Prevalence Study.” National AIDS
2003. “Etiology of Genital Ulcer Disease and Association Program, Jordan.
with Human Immunodeficiency Virus Infection in Ashley, R., A. Cent, V. Maggs, A. Nahmias, and L. Corey.
Two Tanzanian Cities.” Sex Transm Dis 30: 114–19. 1991. “Inability of Enzyme Immunoassays to
Ahmed, H. J., K. Omar, S. Y. Adan, A. M. Guled, Discriminate between Infections with Herpes Simplex
L. Grillner, and S. Bygdeman. 1991. “Syphilis and Virus Types 1 and 2.” Ann Intern Med 115: 520–26.
Human Immunodeficiency Virus Seroconversion Ashley, R. L., and A. Wald. 1999. “Genital Herpes:
during a 6-Month Follow-Up of Female Prostitutes in Review of the Epidemic and Potential Use of Type-
Mogadishu, Somalia.” Int J STD AIDS 2: 119–23. Specific Serology.” Clin Microbiol Rev 12: 1–8.
Aidaoui, M., S. Bouzbid, and M. Laouar. 2008. Awwad, Z. M., A. A. Al-Amarat, and A. A. Shehabi.
“Seroprevalence of HIV Infection in Pregnant Women 2003. “Prevalence of Genital Chlamydial Infection in
in the Annaba Region (Algeria).” Rev Epidemiol Sante Symptomatic and Asymptomatic Jordanian Patients.”
Publique 56: 261–66. Int J Infect Dis 7: 206–9.
Al Sairafi, M., and F. A. Mohamed. 2009. “Knowledge, Azaiza, F., and M. Cohen. 2008. “Between Traditional
Attitudes, and Practice Related to Cervical Cancer and Modern Perceptions of Breast and Cervical
Screening among Kuwaiti Women.” Med Princ Pract Cancer Screenings: A Qualitative Study of Arab
18: 35–42. Women in Israel.” Psychooncology 17: 34–41.
Alami, K. 2009. “Tendances récentes de l’épidémie à Bailey, R. 2007. “Scaling Up Circumcision Programmes:
VIH/SIDA en Afrique du nord.” Presentation, The Road from Evidence to Practice.” PowerPoint
Research and AIDS Workshop in North Africa, presentation at the 4th IAS Conference on HIV
Marrakech, Morocco. Pathogenesis, Treatment & Prevention, Sydney,
Alami, K., N. Ait Mbarek, M. Akrim, B. Bellaji, A. Hansali, Australia, July 22–25, 2007.
H. Khattabi, A. Sekkat, R. El Aouad, and J. Mahjour. Baseman, J. G., and L. A. Koutsky. 2005. “The Epide-
2002. “Urethral Discharge in Morocco: Prevalence of miology of Human Papillomavirus Infections.” J Clin
Microorganisms and Susceptibility of Gonococcos.” Virol 32 Suppl 1: S16–24.
East Mediterr Health J 8: 794–804. Baqi, S. 1995. “HIV Seroprevalence and Risk Factors in
Alim, A., M. O. Artan, Z. Baykan, and B. A. Alim. 2009. Drug Abusers in Karachi.” Second National
“Seroprevalence of Hepatitis B and C Viruses, HIV, Symposium, the Aga Khan University.
and Syphilis Infections among Engaged Couples.” Baykal, C., A. Al, M. G. Ugur, N. Cetinkaya, R. Attar, and
Saudi Med J 30: 541–45. P. Arioglu. 2008. “Knowledge and Interest of Turkish
Allahverdipour, H., and A. Emami. 2008. “Perceptions of Women about Cervical Cancer and HPV Vaccine.”
Cervical Cancer Threat, Benefits, and Barriers of Eur J Gynaecol Oncol 29: 76–79.
Papanicolaou Smear Screening Programs for Women Bener, A., S. Denic, and R. Alwash. 2001. “Screening for
in Iran.” Women Health 47: 23–37. Cervical Cancer among Arab Women.” Int J Gynaecol
Al-Muammar, T., M. N. Al-Ahdal, A. Hassan, G. Kessie, Obstet 74: 305–7.
D. M. Dela Cruz, and G. E. Mohamed. 2007. “Human Bennani, A., and K. Alami. 2006. “Surveillance sentinelle
Papilloma Virus-16/18 Cervical Infection among VIH, résultats 2005 et tendances de la séroprévalence
Women Attending a Family Medical Clinic in Riyadh.” du VIH.” Morocco Ministry of Health, UNAIDS.
Ann Saudi Med 27: 1–5. Bennis, S., S. Meniar, A. Amarti, and A. Bijou. 2007.
Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, “Role of Cervical Smear in the Diagnosis of Cervical
I. El-Adawy, and M. Rijhwani. 2007. “Clinical Cancer in Fes-Boulemane Region of Morocco.” East
Patterns of Sexually Transmitted Diseases, Associated Mediterr Health J 13: 1153–59.
Sociodemographic Characteristics, and Sexual Bogaerts, J., J. Ahmed, N. Akhter, N. Begum, M. Rahman,
Practices in the Farwaniya Region of Kuwait.” Int J S. Nahar, M. Van Ranst, and J. Verhaegen. 2001.
Dermatol 46: 594–99. “Sexually Transmitted Infections among Married
Al-Ramahi, M., A. Mahafzah, S. Saleh, and K. Fram. Women in Dhaka, Bangladesh: Unexpected High
2008. “Prevalence of Chlamydia Trachomatis Prevalence of Herpes Simplex Type 2 Infection.” Sex
Infection in Infertile Women at a University Hospital Transm Infect 77: 114–19.
in Jordan.” East Mediterr Health J 14: 1148–54. Bosch, F. X., M. M. Manos, N. Munoz, M. Sherman,
Altaf, F. J. 2001. “Pattern of Cervical Smear Cytology in A. M. Jansen, J. Peto, M. H. Schiffman, V. Moreno,
the Western Region of Saudi Arabia.” Ann Saudi Med R. Kurman, and K. V. Shah. 1995. “Prevalence of
21: 92–96. Human Papillomavirus in Cervical Cancer: A
Worldwide Perspective.” International Biological
———. 2006. “Cervical Cancer Screening with Pattern of Study on Cervical Cancer (IBSCC) Study Group.
Pap Smear: Review of Multicenter Studies.” Saudi J Natl Cancer Inst 87: 796–802.
Med J 27: 1498–502.
Bosch, F. X., N. Munoz, S. de Sanjose, E. Guerrerro,
Anwar, K., M. Inuzuka, T. Shiraishi, and K. Nakakuki. A. M. Ghaffari, J. Kaldor, X. Castellsague, and K. V.
1991. “Detection of HPV DNA in Neoplastic and Non- Shah. 1994. “Importance of Human Papillomavirus
172 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Curado, M. P., B. Edwards, H. R. Shin, H. Storm, El-Sayed, N. M., P. J. Gomatos, G. R. Rodier, T. F.
J. Ferlay, et al., eds. 2007. Cancer Incidence in Five Wierzba, A. Darwish, S. Khashaba, and R. R. Arthur.
Continents, Vol. IX. IARC Scientific Publications 1996. “Seroprevalence Survey of Egyptian Tourism
No. 160, International Agency for Research on Cancer. Workers for Hepatitis B Virus, Hepatitis C Virus,
Dan, M., O. Sadan, M. Glezerman, D. Raveh, and Z. Human Immunodeficiency Virus, and Treponema
Samra. 2003. “Prevalence and Risk Factors for Herpes Pallidum Infections: Association of Hepatitis C Virus
Simplex Virus Type 2 Infection among Pregnant Infections with Specific Regions of Egypt.” Am J Trop
Women in Israel.” Sex Transm Dis 30: 835–38. Med Hyg 55: 179–84.
Darougar, S., B. Aramesh, J. A. Gibson, J. D. Treharne, El-Sayed, M. Zaki, and H. Goda. 2007. “Relevance of
and B. R. Jones. 1983. “Chlamydial Genital Infection Parvovirus B19, Herpes Simplex Virus 2, and
in Prostitutes in Iran.” Br J Vener Dis 59: 53–55. Cytomegalovirus Virologic Markers in Maternal
Serum for Diagnosis of Unexplained Recurrent
Darougar, S., B. R. Jones, L. Cornell, J. D. Treharne, Abortions.” Arch Pathol Lab Med 131: 956–60.
R. S. Dwyer, and B. Aramesh. 1982. “Chlamydial
Urethral Infection in Teheran: A Study of Male Faisel, A., and J. Cleland. 2006. “Migrant Men: A Priority
Patients Attending an STD Clinic.” Br J Vener Dis 58: for HIV Control in Pakistan?” Sex Transm Infect 82:
374–76. 307–10.
Deeb, M. E., J. Awwad, J. S. Yeretzian, and H. G. Farhadi, M., Z. Tahmasebi, S. Merat, F. Kamangar,
Kaspar. 2003. “Prevalence of Reproductive Tract D. Nasrollahzadeh, and R. Malekzadeh. 2005.
Infections, Genital Prolapse, and Obesity in a Rural “Human Papillomavirus in Squamous Cell Carcinoma
Community in Lebanon.” Bull World Health Organ of Esophagus in a High-Risk Population.” World
81: 639–45. J Gastroenterol 11: 1200–203.
Dezfulimanesh, M., and N. Tehranian. 2005. “Endocervical Feldman, P. A., J. Steinberg, R. Madeb, G. Bar, O. Nativ,
Gonorrhea in Pregnant and Non-Pregnant Women J. Tal, and I. Srugo. 2003. “Herpes Simplex Virus Type
and Follow Up of the Infected Cases in Kermanshah, 2 Seropositivity in a Sexually Transmitted Disease
Iran, 2004.” Pak J Med Sci July–September 21: 313–17. Clinic in Israel.” Isr Med Assoc J 5: 626–28.
Dolar, N., S. Serdaroglu, G. Yilmaz, and S. Ergin. 2006. Ferlay, J., F. Bray, P. Pisani, and D. M. Parkin. 2004.
“Seroprevalence of Herpes Simplex Virus Type 1 and “GLOBOCAN 2002: Cancer Incidence, Mortality and
Type 2 in Turkey.” J Eur Acad Dermatol Venereol 20: Prevalence Worldwide.” IARC CancerBase 5.
1232–36. Fleming, D. T., G. M. McQuillan, R. E. Johnson, A. J.
Drain, P. K., K. K. Holmes, J. P. Hughes, and L. A. Nahmias, S. O. Aral, F. K. Lee, and M. E. St. Louis.
Koutsky. 2002. “Determinants of Cervical Cancer 1997. “Herpes Simplex Virus Type 2 in the United
Rates in Developing Countries.” Int J Cancer 100: States, 1976 to 1994.” N Engl J Med 337: 1105–11.
199–205. Fox, E., R. L. Haberberger, E. A. Abbatte, S. Said, D.
Duran, N., F. Yarkin, C. Evruke, and F. Koksal. 2004. Polycarpe, and N. T. Constantine. 1989. “Observations
“Asymptomatic Herpes Simplex Virus Type 2 (HSV-2) on Sexually Transmitted Diseases in Promiscuous
Infection among Pregnant Women in Turkey.” Indian Males in Djibouti.” J Egypt Public Health Assoc 64:
J Med Res 120: 106–10. 561–69.
El-All, H. S., A. Refaat, and K. Dandash. 2007. “Prevalence Freeman, E. E., H. A. Weiss, J. R. Glynn, P. L. Cross, J. A.
of Cervical Neoplastic Lesions and Human Papilloma Whitworth, and R. J. Hayes. 2006. “Herpes Simplex
Virus Infection in Egypt: National Cervical Cancer Virus 2 Infection Increases HIV Acquisition in Men
Screening Project.” Infect Agent Cancer 2: 12. and Women: Systematic Review and Meta-Analysis
Elattar, I. A. A. 2004. “Cancer in the Arab World: of Longitudinal Studies.” AIDS 20: 73–83.
Magnitude of the Problem.” The 132nd Annual Meeting. Ghaffari, S. R., T. Sabokbar, H. Mollahajian, J. Dastan,
El-Gilany, A. H., and S. El-Fedawy. 2006. “Bloodborne F. Ramezanzadeh, F. Ensani, F. Yarandi, A.
Infections among Student Voluntary Blood Donors in Mousavi-Jarrahi, M. A. Mohagheghi, and A.
Mansoura University, Egypt.” East Mediterr Health J Moradi. 2006. “Prevalence of Human Papillomavirus
12: 742–48. Genotypes in Women with Normal and Abnormal
Cervical Cytology in Iran.” Asian Pac J Cancer Prev 7:
El Ghrari, K., Z. Terrab, H. Benchikhi, H. Lakhdar,
529–32.
I. Jroundi, and M. Bennani. 2007. “Prevalence of
Syphilis and HIV Infection in Female Prison Population Ghanaat, J., J. T. Afshari, K. Ghazvini, and M. Malvandi.
in Morocco.” East Mediterr Health J 13: 774–79. 2008. “Prevalence of Genital Chlamydia in Iranian
Males with Urethritis Attending Clinics in Mashhad.”
El-Sayed, N., M. Abdallah, A. Abdel Mobdy, A. Abdel
East Mediterr Health J 14: 1333–37.
Sattar, E. Aoun, F. Beths, G. Dallabetta, M. Rakha,
C. Soliman, and N. Wasef. 2002. “Evaluation of Ghani, A. C., J. Swinton, and G. P. Garnett. 1997. “The
Selected Reproductive Health Infections in Various Role of Sexual Partnership Networks in the Epide-
Egyptian Population Groups in Greater Cairo.” miology of Gonorrhea.” Sex Transm Dis 24: 45–56.
Ministry of Health and Population (MOHP), Ghazal-Aswad, S., P. Badrinath, N. Osman, S. Abdul-
Implementing AIDS Prevention and Care (IMPACT), Khaliq, S. Mc Ilvenny, and I. Sidky. 2004. “Prevalence
Family Health International (FHI), and the United of Chlamydia Trachomatis Infection among Women
States Agency for International Development in a Middle Eastern Community.” BMC Womens
(USAID). Health 4: 3.
174 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Kasraeian, M., M. Movaseghii, and A. F. Ghiam. 2004. U.S. Men: A Prospective Study.” J Infect Dis 199:
“Seroepidemiological Study of Herpes Simplex Virus 362–71.
Type 2 (HSV-2) Antibody in Shiraz, Iran.” Iranian Lubbad, A. M., and A. I. Al-Hindi. 2007. “Bacterial, Viral
Journal of Immunology 1: 3 (autumn). and Fungal Genital Tract Infections in Palestinian
Khair, M. M., M. E. Mzibri, R. A. Mhand, A. Benider, N. Pregnant Women in Gaza, Palestine.” West Afr J Med
Benchekroun, E. M. Fahime, M. N. Benchekroun, and 26: 138–42.
M. M. Ennaji. 2009. “Molecular Detection and Gen- Madani, T. A. 2006. “Sexually Transmitted Infections in
otyping of Human Papillomavirus in Cervical Carcinoma Saudi Arabia.” BMC Infect Dis 6: 3.
Biopsies in an Area of High Incidence of Cancer from
Moroccan Women.” J Med Virol 81: 678–84. Mahafzah, A. M., M. Q. Al-Ramahi, A. M. Asa’d, and
M. S. El-Khateeb. 2008. “Prevalence of Sexually
Khan, A. A., N. Rehan, K. Qayyum, and A. Khan. 2008. Transmitted Infections among Sexually Active
“Correlates and Prevalence of HIV and Sexually Jordanian Females.” Sex Transm Dis 35: 607–10.
Transmitted Infections among Hijras (Male
Transgenders) in Pakistan.” Int J STD AIDS 19: 817–20. Malkawi, S. R., R. M. Abu Hazeem, B. M. Hajjat, and
F. K. Hajjiri. 2004. “Evaluation of Cervical Smears at
Khattabi, H., and K. Alami. 2005. “Surveillance senti- King Hussein Medical Centre, Jordan, over Three and
nelle du VIH, résultats 2004 et tendance de la a Half Years.” East Mediterr Health J 10: 676–79.
séroprévalence du VIH.” Morocco Ministry of Health,
UNAIDS. Maral, I., A. Biri, U. Korucuoglu, C. Bakar, M. Cirak, and
M. Ali Bumin. 2009. “Seroprevalences of Herpes
Khedmat, H., F. Fallahian, H. Abolghasemi, S. M. Simplex Virus Type 2 and Chlamydia Trachomatis in
Alavian, B. Hajibeigi, S. M. Miri, and A. M. Jafari. Turkey.” Arch Gynecol Obstet 280: 739–43.
2007. “Seroepidemiologic Study of Hepatitis B Virus,
Hepatitis C Virus, Human Immunodeficiency Virus Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck,
and Syphilis Infections in Iranian Blood Donors.” Pak M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M.
J Biol Sci 10: 4461–66. Huraux, and N. Dupin. 2001. “Comparative Study of
Heterosexual Transmission of HIV-1, HSV-2 and KSHV
Komoditi, C. 2005. “Cervical and Corpus Uterine in Djibouti.” 8th Retrovir Oppor Infect (abstract no. 585).
Cancer.” In Cancer Incidence in Four Member Countries
(Cyprus, Egypt, Israel, and Jordan) of the Middle East Massenet, D., and A. Bouh. 1997. “Aspects of Blood
Cancer Consortium (MECC) Compared with US SEER, eds. Transfusion in Djibouti.” Med Trop (Mars) 57: 202–5.
L. S. Freedman, B. K. Edwards, L. A. Ries, and J. L. Massoud, M., A. Noweir, M. Salah, and W. A. Saleh.
Young, 83–90. Bethesda, MD: National Cancer Institute, 1991. “Chlamydial Infection in Riyadh, Saudi Arabia.”
NIH Pub. No. 06–5873. J Egypt Public Health Assoc 66: 411–19.
Kretzschmar, M., and M. Morris. 1996. “Measures of Matin, M., and S. LeBaron. 2004. “Attitudes toward
Concurrency in Networks and the Spread of Infectious Cervical Cancer Screening among Muslim Women: A
Disease.” Mathematical Biosciences 133: 165–95. Pilot Study.” Women Health 39: 63–77.
Lacey, C. J., C. M. Lowndes, and K. V. Shah. 2006. McCaffery, K., S. Forrest, J. Waller, M. Desai, A.
“Chapter 4: Burden and Management of Non- Szarewski, and J. Wardle. 2003. “Attitudes towards
Cancerous HPV-Related Conditions: HPV-6/11 Disease.” HPV Testing: A Qualitative Study of Beliefs among
Vaccine 24 Suppl 3: S35–41. Indian, Pakistani, African-Caribbean and White
Lalaoui, K., M. El Mzibri, M. Amrani, M. A. Belabbas, British Women in the UK.” Br J Cancer 88: 42–46.
and P. A. Lazo. 2003. “Human Papillomavirus DNA McCarthy, M. C., J. P. Burans, N. T. Constantine, A. A.
in Cervical Lesions from Morocco and Its el-Hag, M. E. el-Tayeb, M. A. el-Dabi, J. G. Fahkry,
Implications for Cancer Control.” Clin Microbiol Infect J. N. Woody, and K. C. Hyams. 1989. “Hepatitis B and
9: 144–48. HIV in Sudan: A Serosurvey for Hepatitis B and
Lambert, L. 2007. “HIV and Development Challenges in Human Immunodeficiency Virus Antibodies among
Yemen: Which Grows Fastest?” Health Policy and Sexually Active Heterosexuals.” Am J Trop Med Hyg
Planning 22: 60. 41: 726–31.
Langenberg, A. G., L. Corey, R. L. Ashley, W. P. Leong, Measure DHS. 2006. “Egypt: Demographic and Health
and S. E. Straus. 1999. “A Prospective Study of New Survey 2005.”
Infections with Herpes Simplex Virus Type 1 and Mertz, G. J., O. Schmidt, J. L. Jourden, M. E. Guinan,
Type 2.” Chiron HSV Vaccine Study Group. N Engl J M. L. Remington, A. Fahnlander, C. Winter, K. K.
Med 341: 1432–38. Holmes, and L. Corey. 1985. “Frequency of Acquisition
Lee, R. M., and C. M. Renzetti. 1990. “The Problems of of First-Episode Genital Infection with Herpes Simplex
Researching Sensitive Topics.” American Behavioral Virus from Symptomatic and Asymptomatic Source
Scientist 33: 510–28. Contacts.” Sex Transm Dis 12: 33–39.
Looker, K. J., G. P. Garnett, and G. P. Schmid. 2008. “An Mertz, K. J., D. Trees, W. C. Levine, J. S. Lewis,
Estimate of the Global Prevalence and Incidence of B. Litchfield, K. S. Pettus, S. A. Morse, M. E. St. Louis,
Herpes Simplex Virus Type 2 Infections.” Bulletin of J. B. Weiss, J. Schwebke, J. Dickes, R. Kee, J. Reynolds,
the World Health Organization 86: 805–12, A. D. Hutcheson, D. Green, I. Dyer, G. A. Richwald,
J. Novotny, I. Weisfuse, M. Goldberg, J. A. O’Donnell,
Lu, B., Y. Wu, C. M. Nielson, R. Flores, M. Abrahamsen, and R. Knaup. 1998. “Etiology of Genital Ulcers and
M. Papenfuss, R. B. Harris, and A. R. Giuliano. 2009. Prevalence of Human Immunodeficiency Virus
“Factors Associated with Acquisition and Clearance Coinfection in 10 US Cities.” The Genital Ulcer Disease
of Human Papillomavirus Infection in a Cohort of Surveillance Group. J Infect Dis 178: 1795–98.
176 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Sadjadi, A., R. Malekzadeh, M. H. Derakhshan, Testa, A. C., and K. Kriitmaa. 2009. “HIV and Syphilis
A. Sepehr, M. Nouraie, M. Sotoudeh, A. Yazdanbod, Bio-Behavioural Surveillance Survey (BSS⫹) among
B. Shokoohi, A. Mashayekhi, S. Arshi, A. Majidpour, Female Transactional Sex Workers in Hargeisa,
M. Babaei, A. Mosavi, M. A. Mohagheghi, and Somaliland.” International Organization for
M. Alimohammadian. 2003. “Cancer Occurrence in Migration, World Health Organization.
Ardabil: Results of a Population-Based Cancer Todd, C. S., A. M. Abed, S. A. Strathdee, P. T. Scott, B.
Registry from Iran.” Int J Cancer 107: 113–18. A. Botros, N. Safi, and K. C. Earhart. 2007. “HIV,
Saleh, E., W. McFarland, G. Rutherford, J. Mandel, M. Hepatitis C, and Hepatitis B Infections and Associated
El-Shazaly, and T. Coates. 2000. “Sentinel Surveillance Risk Behavior in Injection Drug Users, Kabul,
for HIV and Markers for High Risk Behaviors among Afghanistan.” Emerg Infect Dis 13: 1327–31.
STD Clinic Attendees in Alexandria, Egypt.” XIII Todd, C. S., M. Ahmadzai, F. Atiqzai, S. Miller, J. M.
International AIDS Conference, Durban, South Africa, Smith, S. A. Ghazanfar, and S. A. Strathdee. 2008.
Poster MoPeC2398. “Seroprevalence and Correlates of HIV, Syphilis, and
Samra, Z., E. Scherf, and M. Dan. 2003. “Herpes Simplex Hepatitis B and C Virus among Intrapartum Patients
Virus Type 1 Is the Prevailing Cause of Genital Herpes in Kabul, Afghanistan.” BMC Infect Dis 8: 119.
in the Tel Aviv Area, Israel.” Sex Transm Dis 30: 794–96. Todd, C. S., M. Ahmadzai, F. Atiqzai, H. Siddiqui, P.
Schiffman, M., and P. E. Castle. 2005. “The Promise of Azfar, S. Miller, J. M. Smith, S. A. S. Ghazanfar, and
Global Cervical-Cancer Prevention.” N Engl J Med S. A. Strathdee. 2007. “Seroprevalence and Correlates
353: 2101–4. of HIV, Syphilis, and Hepatitis B and C Infection
Scott, D. A., A. L. Corwin, N. T. Constantine, M. A. Omar, among Antenatal Patients and Testing Practices and
A. Guled, M. Yusef, C. R. Roberts, and D. M. Watts. Knowledge among Obstetric Care Providers in
1991. “Low Prevalence of Human Immunodeficiency Kabul.” PowerPoint presentation.
Virus-1 (HIV-1), HIV-2, and Human T Cell Lymphotropic Todd, C. S., S. Strathdee, F. Atiqzai, M. Ahmadzai, M.
Virus-1 Infection in Somalia.” American Journal of Appelbaum, S. Miller, J. A. McCutchan, J. Smith, and
Tropical Medicine and Hygiene 45: 653. K. Earhart. 2006. “Prevalence of and Barriers to
Shafiq, M., and S. H. Ali. 2006. “Sexually Transmitted Testing for Blood-Borne Infections in an Afghan
Infections in Pakistan.” Lancet Infect Dis 6: 321–22. Antenatal Population.” Study proposal.
Trottier, H., and E. L. Franco. 2006. “The Epidemiology
Skegg, D. C., P. A. Corwin, C. Paul, and R. Doll. 1982.
of Genital Human Papillomavirus Infection.” Vaccine
“Importance of the Male Factor in Cancer of the
24 Suppl 1: S1–15.
Cervix.” Lancet 2: 581–83.
UNHCR (United Nations High Commissioner for
Slomka, M. J. 1996. “Seroepidemiology and Control of
Refugees). 2006–07. HIV Sentinel Surveillance among
Genital Herpes: The Value of Type Specific Antibodies
Antenatal Clients and STI Patients. Dadaab Refugee
to Herpes Simplex Virus.” Commun Dis Rep CDR
Camps, Kenya.
Rev 6: R41–45.
Unknown. “Statut de la réponse nationale: Caractéristiques
Smith, J. S., and N. J. Robinson. 2002. “Age-Specific
de l’épidémie des IST/VIH/SIDA.” Algeria.
Prevalence of Infection with Herpes Simplex Virus
Types 2 and 1: A Global Review.” J Infect Dis 186 Unknown. 2002. “Surveillance des infections à VIH et de
Suppl 1: S3–28. la syphilis chez les femmes enceintes vues dans 8
Somaliland Ministry of Health and Labour. 2007. Somaliland centres de consultations prénatales dans le district de
2007 HIV/Syphilis Seroprevalence Survey, A Technical Djibouti.” Grey Report.
Report. Ministry of Health and Labour in collaboration Vahdani, P., S. M. Hosseini-Moghaddam, L. Gachkar,
with WHO, UNAIDS, UNICEF/GFATM, and SOLNAC. and K. Sharafi. 2006. “Prevalence of Hepatitis B,
Southern Sudan AIDS Commission. 2007. Southern Hepatitis C, Human Immunodeficiency Virus, and
Sudan ANC Sentinel Surveillance Data. Database, Syphilis among Street Children Residing in Southern
U.S. Centers for Disease Control and Prevention (CDC), Tehran, Iran.” Arch Iran Med 9: 153–55.
Sudan, and Southern Sudan AIDS Commission. van de Laar, M. J. W., F. Termorshuizen, M. J. Slomka, G.
Štulhofer, A., and I. Božicevic. 2008. “HIV Bio- J. J. van Doornum, J. M. Ossewaarde, D. W. G. Brown,
Behavioural Survey among FSWs in Aden, Yemen.” R. A. Coutinho, and J. A. R. van den Hoek. 2001.
“Prevalence and Correlates of Herpes Simplex Virus
Sudan National AIDS Program. 2008. “Update on the
Type 2 Infection: Evaluation of Behavioural Risk
HIV Situation in Sudan.” PowerPoint presenation.
Factors.” International Journal of Epidemiology 27:
Sudan National AIDS/STIs Program. 2008. “2007 ANC HIV 127–34.
Sentinel Sero-Survey, Technical Report.” Federal Ministry
Wadsworth, J., J. Field, A. M. Johnson, S. Bradshaw,
of Health, Preventive Medicine Directorate, draft.
and K. Wellings. 1993. “Methodology of the National
Sultan, F., T. Mehmood, and M. T. Mahmood. 2007. Survey of Sexual Attitudes and Lifestyles.” J R Stat Soc
“Infectious Pathogens in Volunteer and Replacement Ser A Stat Soc 156: 407–21.
Blood Donors in Pakistan: A Ten-Year Experience.”
Walboomers, J. M., M. V. Jacobs, M. M. Manos, F. X.
Int J Infect Dis 11: 407–12.
Bosch, J. A. Kummer, K. V. Shah, P. J. Snijders, J.
Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge, Peto, C. J. Meijer, and N. Munoz. 1999. “Human
Attitudes and Practices concerning HIV/AIDS among Papillomavirus Is a Necessary Cause of Invasive
Iranian At-Risk Sub-Populations.” Eastern Mediterranean Cervical Cancer Worldwide.” J Pathol 189: 12–19.
Health Journal 14.
178 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 11
Understanding the current status and future products were behind a large fraction of report-
potential of the human immunodeficiency virus ed cases such as in the Arab Republic of Egypt,3
(HIV) epidemic is central to designing appropri- the Islamic Republic of Iran,4 Saudi Arabia,5 and
ate epidemic responses because surveillance the West Bank and Gaza.6 Quite often the blood
efforts and the effectiveness and cost-effectiveness or the blood products were imported.7
of interventions depend on the epidemiological A high prevalence of blood-borne diseases
context in which they are implemented.1 This was found at the time among people in need of
chapter discusses the analytical insights reached blood or blood products. In Bahrain in the early
based on the conceptual framework described in 1990s, the prevalence of HIV among children
chapter 1 and the data synthesis presented in the with hereditary hemolytic anemias was 1.6%,
following chapters. 40% for people with hepatitis C virus (HCV),
and 20.5% for people with hepatitis B virus
(HBV).8 In Egypt, recipients of blood or blood
EVOLUTION OF THE HIV EPIDEMIC products had an HIV prevalence of 4.8% in the
IN MENA period from 1986 to 1990.9 In Lebanon, multi-
HIV found its way to the Middle East and North transfused patients had an HIV prevalence of
Africa (MENA) countries by the 1980s at the 6%.10 In Qatar, more than 75% of reported HIV
latest. Virtually all countries had reported their infections up to 1989 were acquired via
first HIV or AIDS (acquired immunodeficiency transfusion of imported blood,11 and 38.5% of
syndrome) case by 1990.2 The majority of cases
3
Faris and Shouman, “Study of the Knowledge, Attitude of Egyptian
were linked to blood or blood products or
Health Care Workers.”
exposures abroad. Transfusions of blood or blood 4
Rao, Strengthening of AIDS/HIV Surveillance.
5
El-Hazmi and Ramia, “Frequencies of Hepatitis B”; Alrajhi, “Human
1
Grassly et al., “The Effectiveness of HIV Prevention.” Immunodeficiency Virus in Saudi Arabia”; Al-Nozha et al., “Horizontal
2
Shah et al., “An Outbreak of HIV”; Ryan, “Travel Report Summary”; versus Vertical Transmission.”
6
Jenkins and Robalino, “HIV in the Middle East and North Africa”; Maayan et al., “HIV/AIDS among Palestinian Arabs”; Moses et al.,
Al-Fouzan and Al-Mutairi, “Overview of Incidence of Sexually “HIV Infection and AIDS in Jerusalem.”
7
Transmitted Diseases in Kuwait”; Elharti et al., “Some Characteristics Mokhbat et al., “Clinical and Serological Study”; Novelli et al., “High
of the HIV Epidemic in Morocco”; Kalaajieh, “Epidemiology of Human Prevalence of Human Immunodeficiency Virus”; Harfi and Fakhry,
Immunodeficiency Virus”; Iran Center for Disease Management, HIV/ “Acquired Immunodeficiency Syndrome in Saudi Arabia”; Kingston
AIDS and STIs Surveillance Report; Woodruff et al., “A Study of Viral et al., “Acquired Immune Deficiency Syndrome.”
8
and Rickettsial Exposure”; Khanani et al., “Human Immunodeficiency Al-Mahroos and Ebrahim, “Prevalence of Hepatitis B.”
9
Virus-Associated Disorders in Pakistan”; Toukan and Schable, “Human Watts et al. “Prevalence of HIV Infection and AIDS.”
10
Immunodeficiency Virus (HIV) Infection in Jordan”; Rodier et al., Mokhbat et al., “Clinical and Serological Study.”
11
“Infection by the Human Immunodeficiency Virus.” Milder and Novelli, “Clinical, Social and Ethical Aspects of HIV-1.”
179
children with thalassemia were found to be HIV were among travelers and expatriates who
positive.12 In Saudi Arabia, 1.3% of multitrans- worked abroad.22 However, the pattern of a
fused thalassemic and sickle cell disease patients large share of HIV acquisitions related to expo-
tested positive for HIV,13 and 34.5% of HIV- sures abroad appears to persist in several coun-
positive children became infected through blood tries. In Jordan, 450 out of 501 notified HIV/
or blood products.14 AIDS cases by 2006 were acquired abroad.23 In
Organ transplants have also contributed to a Lebanon, 45.36% of notified HIV/AIDS cases up
number of HIV infections in this early phase of to 2004 were linked to travel abroad.24 Half of
the epidemic. HIV infections were diagnosed reported AIDS cases in the Republic of Yemen
among kidney transplant patients in Oman, were linked to traveling abroad.25
Saudi Arabia, and the United Arab Emirates The travel-related exposures were from mul-
who bought kidneys from donors in Egypt and tiple destinations. In Lebanon, a considerable
India.15 HIV prevalence was 4.3% among 540 number of HIV/AIDS cases were found among
Saudi hemodialysis patients who received a returning migrants who resided in western and
commercial kidney transplant in India.16 Central Africa.26 In the West Bank and Gaza, HIV
Although blood safety measures were not cases appeared among migrant workers working
implemented satisfactorily until the late 1990s, legally or illegally in Israel.27 In Oman, a number
the region nonetheless made substantial progress of HIV cases were related to Omani historical
in reducing HIV infections due to contaminated links to East Africa.28 In Pakistan, the majority of
blood, from 12.1% in 1993 to 0.4% in 2003.17 cases were acquired through contacts with
This progress, however, was not universal and female sex workers (FSWs) while working in the
some countries, such as Afghanistan and the Persian Gulf region.29 In Tunisia, HIV infections
Republic of Yemen, continued to lag behind in were found among Tunisian injecting drug users
the screening of blood products.18 It is believed (IDUs) deported from France.30 Generally, HIV
that currently only 30% of all donated blood is infections in Maghreb countries were linked to
screened in Afghanistan.19 exposures in Western Europe.31
The majority of reported infections acquired A number of HIV sero-prevalence studies
by a mode other than blood or blood products that were conducted in MENA in the 1980s and
were either related to sexual or injecting drug early 1990s included Djibouti,32 Egypt,33 the
exposures abroad20 or acquired by sexual part- Islamic Republic of Iran,34 Jordan,35 Lebanon,36
ners of those who worked or lived abroad.21 This
trend is not dissimilar to other regions such as
in Western Europe, where the first AIDS cases
22
Hawkes et al., “Risk Behaviour.”
12 23
Novelli et al., “High Prevalence of Human Immunodeficiency Virus.” Jordan National AIDS Program, personal communication.
13 24
El-Hazmi and Ramia, “Frequencies of Hepatitis B.” Jurjus et al., “Knowledge, Attitudes, Beliefs, and Practices.”
14 25
Kordy et al., “Human Immunodeficiency Virus Infection.” WHO, UNICEF, and UNAIDS, “Yemen, Epidemiological Facts Sheets.”
15 26
Alrajhi, Halim, and Al-Abdely, “Mode of Transmission of HIV-1”; Jenkins and Robalino, “HIV in the Middle East and North Africa.”
27
Salahudeen et al., “High Mortality among Recipients”; Aghanashinikar UNAIDS, “Key Findings on HIV Status in the West Bank and Gaza.”
28
et al., “Prevalence of Hepatitis B.” Tawilah and Tawil, Visit to Sultane of Oman.
16 29
Anonymous, “Commercially Motivated Renal Transplantation.” Shah et al., “HIV-Infected Workers Deported”; Baqi, Kayani, and Khan,
17
UNAIDS, “Notes on AIDS in the Middle East and North Africa.” “Epidemiology and Clinical Profile“; Khan et al., “HIV-1 Subtype A
18
WHO/EMRO, “Progress Report on HIV/AIDS and ‘3 by 5.’” Infection.”
19 30
Global Fund, Afghanistan Proposal, www.theglobalfund.org/search/ Jenkins and Robalino, “HIV in the Middle East and North Africa.”
31
docs/4AFGT_764_0_full.pdf. “Global Update: Morocco.”
20 32
Iqbal and Rehan, “Sero-Prevalence of HIV”; Ryan, “Travel Report Rodier et al., “HIV Infection among Secondary School Students.”
33
Summary”; Kayani et al., “A View of HIV-I Infection in Karachi”; Toukan Watts et al. “Prevalence of HIV Infection and AIDS”; El-Ghazzawi,
and Schable, “Human Immunodeficiency Virus (HIV) Infection in Hunsmann, and Schneider, “Low Prevalence of Antibodies”;
Jordan”; Faris and Shouman, “Study of the Knowledge”; Maayan et al., Constantine et al., “HIV Infection in Egypt”; Kandela, “Arab Nations:
“HIV/AIDS among Palestinian Arabs”; Naman et al., “Seroepidemiology Attitudes to AIDS.”
34
of the Human Immunodeficiency Virus”; Dan, Rock, and Bar-Shany, Arbesser, Bashiribod, and Sixl, “Serological Examinations of HIV-I
“Prevalence of Antibodies”; Jemni et al., “AIDS and Tuberculosis in in Iran.”
35
Central Tunisia.” Al Katheeb, Tarawneh, and Awidi, “Antibodies to HIV.”
21 36
Tiouiri et al., “Study of Psychosocial Factors”; “Global Update: Naman et al., “Seroepidemiology of the Human Immunodeficiency
Morocco.” Virus.”
180 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Libya,37 Mauritania,38 Pakistan,39 Saudi Arabia,40 at levels as high as 70%.49 The epidemic among
Somalia,41 Sudan,42 Turkey,43 the West Bank bar-based FSWs was also growing rapidly;50 over
and Gaza,44 and the Republic of Yemen.45 These this period, it was documented by individual
studies included tens of thousands of blood studies to be 1.4%,51 2.7%,52 5%,53 7%,54
samples from populations including pregnant 14.2%,55 15.3%,56 21.7%,57 and 25.6%.58
women, healthy women, healthy men, neo- While HIV prevalence was stabilizing among
nates, drug users, IDUs, FSWs, sexually trans- FSWs by about 1990,59 it was rising rapidly
mitted disease (STD) patients, prisoners, truck among their clients. The HIV prevalence among
drivers, soldiers, refugees, leprous patients, out- STD clinic attendees increased fivefold between
patients, hospital patients, and blood or blood 1990 and 1991 and reached 10.4%.60 HIV infec-
product donors and recipients. tion then found its way to spouses of clients of
In almost all of these surveys, few HIV infec- FSWs and their children through mother-to-child
tions were identified, if any. HIV prevalence was transmission. HIV prevalence was rising among
consistently at very low levels even in priority the spouses, but at a slower rate, and reached
groups. The vast majority of diagnosed cases levels of about 5% by the late 1990s and has
were linked to HIV exposures abroad, blood remained stable at about this level since then.61
or blood products, or organ transplants. Women from the general population in
Nevertheless, a new pattern of HIV infectious Djibouti were the dam at which the tide of HIV
spread started to appear in MENA by the early spread was absorbed and then stopped. Being at
1990s. HIV found its way to some of the high- the receiving end, they carried a higher overall
risk networks in a few countries. Growing HIV HIV prevalence than men (3.6% versus 3.1% in
prevalence was identified among a number of Djibouti-ville and 1.7% versus 0.3% in the rest of
priority populations. the country62). However, it does not appear that
A classic example highlighting this emerging they engaged in much risk behavior and it seems
pattern is the epidemic in Djibouti. The first that they rarely spread the infection further. This
reported AIDS case was in 1986.46 Although HIV limited further inroads of HIV into the popula-
prevalence was still nil in general population tion. HIV prevalence appears to have leveled off
groups, such as high school students,47 it was at about 3% nationally since the late 1990s.63
growing rapidly along the complex network of Although Djibouti was predicted to have a sky-
commercial sex. HIV prevalence among street- rocketing epidemic a decade ago, this has not
based FSWs, the most vulnerable of sex work- materialized.64 HIV may have already traveled
ers, increased tenfold from 4.6% in 1987 to along the contours of risk and vulnerability in this
41.7% in 1990.48 By the early 1990s, HIV preva- country and saturated its potential.
lence among these sex workers appeared to be
49
Etchepare, “Programme National de Lutte”; Rodier et al., “Trends of
Human Immunodeficiency Virus”; Marcelin et al., “Comparative Study.”
50
Couzineau et al., “Prevalence of Infection.”
37 51
Giasuddin et al., “Failure to Find Antibody.” Etchepare, “Programme National de Lutte.”
38 52
Lepers et al., “Sero-Epidemiological Study in Mauritania.” Ibid.
39 53
Mujeeb and Hafeez, “Prevalence and Pattern of HIV “; Mujeeb et al., Ibid.
54
“Prevalence of HIV-Infection among Blood Donors.” Marcelin et al., “Comparative Study.”
40 55
Al Rasheed et al., “Screening for HIV Antibodies.” Etchepare, “Programme National de Lutte.”
41 56
Jama et al., “Sexually Transmitted Viral Infections”; Burans et al., “HIV Rodier et al., “Trends of Human Immunodeficiency Virus”; Rodier et al.,
Infection Surveillance in Mogadishu”; Ismail et al., “Sexually “Infection by the Human Immunodeficiency Virus.”
57
Transmitted Diseases in Men”; Fox et al., “AIDS.” Etchepare, “Programme National de Lutte.”
42 58
Burans et al., “Serosurvey of Prevalence”; McCarthy et al., Ibid.
59
“Hepatitis B and HIV in Sudan”; Hashim et al., “AIDS and HIV Rodier et al., “Infection by the Human Immunodeficiency Virus.”
60
Infection in Sudanese Children.” Rodier et al., “Trends of Human Immunodeficiency Virus”; Rodier et al.,
43
Rota et al., “HIV Antibody Screening”; Demiroz et al., “HIV Infections “Infection by the Human Immunodeficiency Virus.”
61
among Turkish Citizens.” Marcelin et al., “Kaposi’s Sarcoma Herpesvirus.”
44 62
Maayan et al., “HIV-1 Prevalence.” WHO, “Summary Country Profile.”
45 63
Leonard et al., “Prevalence of HIV Infection.” UNAIDS, “Notes on AIDS in the Middle East and North Africa”;
46
Rodier et al., “Infection by the Human Immunodeficiency Virus.” Djibouti (Ministère de La Santé de) and Association Internationale de
47
Rodier et al., “HIV Infection among Secondary School Students.” Développement, Tome I; Maslin et al., “Epidemiology and Genetic
48
Rodier et al., “Trends of Human Immunodeficiency Virus”; Rodier et al., Characterization.”
64
“Infection by the Human Immunodeficiency Virus.” O’Grady, “WFP Consultant Visit to Djibouti Report.”
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 181
In the Islamic Republic of Iran, the first HIV/ CONCEPTUAL FRAMEWORK: DYNAMICS
AIDS case among IDUs was reported in 1992.65 OF HIV INFECTIOUS SPREAD IN MENA
Only a few cases were reported per year in the
three following years.66 However, starting from There is substantial heterogeneity in HIV spread
1996, the number of reported cases suddenly rose across MENA and different risk contexts are
by thirtyfold.67 The first reported outbreak was in present throughout the region. However, we
1996 in the prisons of Kerman and Kermanshah.68 can grossly classify the HIV epidemic in MENA,
By 2000, the prevalence remained under 1%–2% in terms of the extent of HIV spread, into two
in most studies.69 In 2003, the prevalence started groups. The first group, which has a consider-
growing rapidly and was consistently above 5% in able HIV prevalence and includes Djibouti,
most point-prevalence surveys among IDUs.70 Somalia, and Southern Sudan, is labeled here as
Through overlapping risk behaviors,71 HIV infec- Subregion with Considerable Prevalence.
tion appears to have crossed into the sexual net- The second group has a more modest HIV prev-
works of men who have sex with men (MSM),72 alence and includes the rest of MENA countries
and, to a lesser extent, FSWs.73 Then HIV infection and is labeled here as the Core MENA Region.
moved to spouses of IDUs, whose contribution to Because the latter group consists of most MENA
the number of HIV/AIDS cases increased fourfold countries, HIV epidemiology here represents the
from 0.5% of all cases in 2001 to 2% of all cases in main patterns found in MENA.
2004.74 Seventy-six percent of HIV-positive
women in the Islamic Republic of Iran acquired HIV epidemic typology in the Core MENA Region
the infection from their husbands, who were pre-
dominantly IDUs.75 Two patterns describe HIV epidemiology in this
More than two decades since the introduc- group of MENA countries. The first is the pattern
tion of HIV into MENA populations, the epide- of exogenous HIV exposures among the nation-
miological landscape continues to be dominated als of these countries, and HIV transmissions to
by two patterns. The first is that of exogenous their sexual partners upon their return. This pat-
HIV infections related to sexual and injecting tern exists in all MENA countries at some level
drug exposures abroad among the nationals of or another, but also appears to be the dominant
MENA countries, followed by HIV transmissions pattern in several MENA countries. The weak
to their sexual partners upon their return. The surveillance systems of priority populations pre-
second is that of concentrated or low-intensity vent us from definitively concluding whether
HIV epidemics among priority populations. this is indeed the dominant epidemiologic pat-
tern in these countries. HIV could be spreading
65
Iran Center for Disease Management, Country Report on UNGASS.
among some of the priority groups, or within
66
Ibid. pockets of these populations, without current
67
Ministry of Health and Medical Education of Iran, “Treatment and awareness of this endemic spread. However,
Medical Education”; Iran Center for Disease Management, Country
there is no evidence to date that such consider-
Report on UNGASS.
68
Afshar, “Health and Prison.” able endemic transmission exists in these MENA
69
Ministry of Health and Medical Education of Iran, “Treatment and countries.
Medical Education.” The second pattern in several MENA coun-
70
Ibid.
71
Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices”; Farhoudi tries is that of concentrated or low-intensity HIV
et al., “Human Immunodeficiency Virus”; Razzaghi, Rahimi, and Hosseini, epidemics among priority populations, particu-
Rapid Situation Assessment (RSA) of Drug Abuse; Narenjiha et al., “Rapid larly IDUs and MSM. Concentrated epidemics
Situation Assessment”; Eftekhar et al., “Bio-Behavioural Survey on HIV”;
Ministry of Health and Medical Education of Iran, “Treatment and Medical
are defined as HIV epidemics in subpopulations
Education”; Mostashari, UNODC, and Darabi, “Summary of the Iranian at higher risk of HIV infection, such as IDUs,
Situation on HIV Epidemic”; Jahani et al., “Distribution and Risk Factors.” MSM, and FSWs; and HIV prevalence is consis-
72
Eftekhar et al., “Bio-Behavioural Survey on HIV.”
73 tently above 5% in at least one priority group,
WHO/EMRO Regional Database on HIV/AIDS; Jahani et al.,
“Distribution and Risk Factors”; Tassie, “Assignment Report.” but remains below 1% in pregnant women
74
Ministry of Health and Medical Education of Iran, “Treatment and in the general population.76 There is already
Medical Education.”
75
Ramezani, Mohraz, and Gachkar, “Epidemiologic Situation”; Burrows,
76
Wodak, and WHO, Harm Reduction in Iran. Pisani et al., “HIV Surveillance.”
182 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
documented evidence for concentrated epidem- defined as an epidemic with an HIV prevalence
ics among priority groups in several MENA consistently exceeding 1% among pregnant
countries, such as the HIV epidemics among women.91 However, it appears that the epidem-
IDUs in the Islamic Republic of Iran and Pakistan, ics in Djibouti and Somalia, and possibly
which are established concentrated epidemics.77 Southern Sudan, are dynamically similar to
There is evidence that suggests that this could those in West Africa where most HIV infections
also be the case in Afghanistan (in Kabul),78 are concentrated in priority groups and bridging
Bahrain,79 Libya,80 North Sudan,81 and Oman.82 populations. The high HIV prevalence among
There is no definitive evidence of the existence of FSWs in Djibouti92 and Southern Sudan93 sug-
concentrated epidemics among MSM, the most gests that commercial sex networks are playing
hidden of all risk groups, in any of the MENA coun- the central role in these epidemics, just as in
tries. However, there is evidence that suggests that West Africa.94
this could be the case in Egypt,83 North Sudan,84 There is no evidence of sustainable general
and Pakistan.85 Though the evidence is not strong, population HIV epidemics in this group of
there is an indication of an epidemic among MSM MENA countries. The prevailing epidemics are
in Lebanon; however, it is not yet at the level to be best understood as concentrated epidemics
categorized as a concentrated epidemic.86 focused around the commercial sex networks in
There is no evidence of the existence of con- settings where the size of the commercial sex
centrated epidemics among FSWs in this group network is large enough to support an epidemic
of MENA countries. HIV prevalence among with a prevalence exceeding 1% in the whole
FSWs has been found on occasions to be sub- population.
stantially higher than that of the general popu- Southern Sudan is of particular concern.
lation, but not to the level of concentrated HIV There are no sufficient data to characterize satis-
epidemics (greater than 5%). Concentrated epi- factorily HIV epidemiology in this part of Sudan.
demics may exist, though, among subgroups of Southern Sudan is the only part of MENA
FSWs, such as in southern Algeria.87 where limited male circumcision coverage is
found. It could already be in a state of general
HIV epidemic typology in the Subregion population epidemic. With the recent peace
with Considerable Prevalence treaty, the resettlement of refugees and inter-
nally displaced persons (IDPs), demobilization of
Djibouti,88 parts of Somalia,89 and Southern
soldiers, influx of peacekeepers, and mush-
Sudan90 are in a state of generalized HIV epidemic,
rooming of commercial centers, there is a con-
77
Pakistan National AIDS Control Program, HIV Second Generation
cern as to whether there is fertile ground for
Surveillance (Rounds I, II, and III); Ministry of Health and Medical further HIV expansion in Southern Sudan.95
Education of Iran, “Treatment and Medical Education.” The two key epidemiologic characteristics
78
Todd et al., “HIV, Hepatitis C, and Hepatitis B Infections”; Sanders-
that distinguish this subregion of MENA from
Buell et al., “A Nascent HIV Type 1 Epidemic.”
79
Al-Haddad et al., “HIV Antibodies among Intravenous Drug Users.” the Core MENA Region are the concentrated
80
UNAIDS, and WHO, AIDS Epidemic Update 2003; Groterah, “Drug epidemics among FSWs, implying higher levels
Abuse and HIV/AIDS.” of risk behavior in commercial sex networks,
81
Bayoumi, Baseline Survey of Intravenous Drug Users.
82
Aceijas et al., “Global Overview”; Tawilah and Tawil, Visit to Sultane and the sizes of commercial sex networks, which
of Oman; Oman MOH, “HIV Risk among Heroin and Injecting Drug appear to be significantly larger than those in the
Users.” rest of MENA.
83
Egypt Ministry of Health and Population, and National AIDS Program,
HIV/AIDS Biological and Behavioral Surveillance Survey.
84
Elrashied, “Prevalence.”
85
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Rounds I, II, and III).
86 91
Mishwar, “An Integrated Bio-Behavioral Surveillance Study” (final Pisani et al., “HIV Surveillance.”
92
report). Etchepare, “Programme National de Lutte.”
87 93
Fares et al., Rapport sur l’enquête nationale. McCarthy, Khalid, and El Tigani, “HIV-1 Infection in Juba, Southern
88
UNAIDS, “Notes on AIDS in the Middle East and North Africa.” Sudan.”
89 94
WHO, The 2004 First National Second Generation HIV/AIDS/STI Cote et al., “Transactional Sex”; Alary and Lowndes, “The Central Role
Sentinel Surveillance Survey. of Clients.”
90 95
Ibid. NSNAC and UNAIDS, HIV/AIDS Integrated Report South Sudan.
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 183
Status of the HIV epidemic of the surveillance systems in MENA are manifest
in this table. There are only a few examples where
Table 11.1 summarizes what is known of the cur-
there are sufficient data to conclusively determine
rent status of the HIV epidemic in MENA coun-
the status of the epidemic in the different risk
tries from the data collected through this synthe-
groups in a given MENA country.
sis and the epidemiological context. The limitations
Source: Authors.
Note: Established: direct empirical data support this conclusion; Likely: evidence suggests strongly the possibility, but no conclusive, direct,
empirical evidence to date; Possibly: fragmented evidence suggests the possibility, but no direct empirical evidence; Apparently not: fragmented
evidence suggests that this is not the case; Unlikely: evidence suggests that this is a very remote possibility; Unknown: evidence not available.
184 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Essence of HIV dynamics in MENA that drive HIV dynamics across the region. In
Djibouti, parts of Somalia, and Southern Sudan,
The essence of the HIV dynamics in MENA, with
there are concentrated epidemics in commercial
regard to the conceptual framework delineated in
sex networks that continue to drive HIV trans-
chapter 1, is illustrated in figure 11.1. The levels
mission in these localities. The levels of sexual
of HIV prevalence, risk behaviors, and biomarkers
risk behaviors in the commercial sex networks
of risk all indicate that the HIV dynamics are
are substantial and the sizes of these networks
focused in the circle containing priority and bridg-
are significant, leading to a considerable HIV
ing populations. The groups of potential sustain-
prevalence in the population of as much as a
able HIV transmission for each MENA country
few percentage points. In the rest of the MENA
include the priority populations of IDUs, MSM,
countries, there do not appear to be concen-
and possibly FSWs in a few countries. Concen-
trated HIV epidemics in commercial sex net-
trated epidemics among these groups either have
works and the sizes of these networks appear to
occurred or have the potential to occur as
be considerably smaller.
described earlier in figure 1.3b. HIV is not sustain-
Similar heterogeneities apply to the rest of
able in the general population in any MENA
the priority groups. While IDU is large in scale in
country, except possibly for Southern Sudan.
the Islamic Republic of Iran and Pakistan and
In addition to this epidemiologic profile, there
continues to be the major driver of the HIV epi-
is an epidemiologic pattern of randomly distrib-
demics in these countries, it is likely to be rela-
uted exogenous HIV exposures among the
tively smaller in scale and have a minor role in
nationals of MENA countries, and HIV infec-
the HIV epidemics in Djibouti, Somalia, and
tions among their sexual partners upon their
Sudan. The nature and levels of HIV spread
return. This pattern appears to be dominant in a
among MSM are the least understood in MENA.
number of MENA countries where considerable
HIV epidemics among priority populations have
GENERAL FEATURES OF HIV SPREAD
not occurred.
IN MENA
The conceptual framework describes HIV epi-
demiology in MENA, but there are still hetero- HIV infection has already reached all corners of
geneities in scale and types of priority groups MENA and the vast majority of HIV infections
IDUs
FSWs Bridging
populations
MSM
Source: Authors.
Note: The majority of infections are focused in the circle containing priority and bridging populations.
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 185
are coming from within the already existing in recent years.101 The large fraction of AIDS
sexual and injecting drug risk networks. MENA cases among newly discovered HIV infections
countries have made enormous progress in con- and the short interval from HIV notification to
trolling parenteral HIV transmissions due to AIDS diagnosis102 suggest that HIV diagnosis and
contaminated blood and poor safety measures. testing rates are low, and that a large fraction of
Nonetheless, the region as a whole is failing to HIV infections are being missed. The inertia in
control HIV spread along the contours of risk diagnosing HIV infections may be preventing a
and vulnerability, despite promising recent prompt response to ongoing or emerging HIV
efforts, such as in the Islamic Republic of Iran epidemics.
and Morocco. Priority populations, including
IDUs, MSM, and FSWs, are documented to exist
HIV prevalence
in every country of MENA. With the volume of
evidence collected in this synthesis, there is no HIV prevalence overall continues to be at low
more room for denial that risk behaviors do levels compared to other regions. The overarch-
exist and indeed are common in MENA. ing pattern is that of very limited HIV spread in
the general population but growing epidemics in
priority populations, including IDUs and MSM
Number of HIV infections
and, to a lesser extent, FSWs. Although there is
It is estimated that Sudan has the largest number a considerable fraction of HIV infections that are
of HIV infections, about 320,000 to 350,000, being characterized as unknown,103 these infec-
which account for roughly 60% of all HIV infec- tions possibly reflect the under-reporting of risky
tions in the broad definition of the MENA region behavior due to the perceived adverse conse-
used in this report (chapter 1).96 The majority of quences that might come with admitting to cul-
infections in this country appear to be concen- turally unacceptable behavior. The epidemic has
trated in Southern Sudan, where the limitations reached the stages of a generalized epidemic,
in terms of public health are most severe.97 HIV prevalence greater than 1% among pregnant
prevalence in Southern Sudan is estimated to be women, in three countries, and the stages of a
up to eight times higher than that in the capital, concentrated epidemic, prevalence greater than
Khartoum.98 For the rest of the MENA coun- 5% in at least one priority group, in several
tries, the estimated number of HIV infections other countries. The levels of reported sexual
ranges between a few hundred in the small and injecting drug risk behaviors are substantial
countries to tens of thousands in the larger among the majority of the priority populations
countries.99 It is important to note that these and are comparable to levels reported in other
estimates have wide confidence margins and are regions. The levels of proxy biomarkers includ-
based on limited data. Given the evidence col- ing sexually transmitted infections (STIs) and
lected in this synthesis, there might be room to HCV are also substantial in these groups. These
conduct a more precise quantitative assessment facts confirm the potential for HIV infection to
of the number of HIV infections. spread among at least some of the priority popu-
Reported numbers of HIV cases remain small lations.
and most HIV infections appear to be occurring HIV is spreading at different rates among
in men and in urban areas.100 However, the priority populations. Consistent with global
number of case notifications has been increasing patterns,104 IDU epidemics are the fastest in
terms of speed of growth. In Pakistan, HIV
96
UNAIDS, AIDS Epidemic Update 2007; SNAP, “Update on the HIV prevalence was 0.63% at the end of 2003 at a
Situation in Sudan;” UNAIDS Country Database 2007, http://
www.unaids.org/en/CountryResponses/Countries/default.asp.
97
Del Viso, “UNDP Supports HIV/AIDS/STD Project”; Mandal, Purdin, 101
WHO/EMRO Regional Database on HIV/AIDS; Madani et al.,
and McGinn “A Study of Health Facilities.” “Epidemiology of the Human Immunodeficiency Virus.”
98
SNAP, HIV/AIDS/STIs Prevalence. 102
WHO/EMRO Regional Database on HIV/AIDS; Chemtob and Srour,
99
UNAIDS, AIDS Epidemic Update 2007; UNAIDS Country Database “Epidemiology of HIV Infection among Israeli Arabs.”
2007, http://www.unaids.org/en/CountryResponses/Countries/ 103
UNAIDS and WHO, AIDS Epidemic Update 2006.
default.asp. 104
Piyasirisilp et al., “A Recent Outbreak”; Nguyen et al., “Genetic
100
WHO/EMRO Regional Database on HIV/AIDS. Analysis.”
186 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
site in Karachi,105 but the prevalence increased Protective factors
to 23% at this site by mid-2004.106 This pattern
Several protective factors have slowed and lim-
has been witnessed in a few other MENA coun-
ited HIV transmissions in MENA relative to
tries. However, it is also possible for HIV epi-
other regions. Male circumcision is almost uni-
demics among MSM to grow rapidly as well.
versally practiced in MENA and is associated
There are multiple indications that the epidemic
with a 60% efficacy against HIV infection for
among MSM is growing in the region. In a num-
men.108 Male circumcision can also substantially
ber of MENA countries, HIV prevalence among
slow the expansion of HIV in a population,
MSM could already be at considerable levels
thereby providing a window of opportunity to
despite limited HIV prevalence among IDUs.
intervene against an epidemic before it reaches
MSM, however, are the most hidden and the
higher levels.109
hardest-to-reach priority group through surveil-
The cultural traditions in MENA are influ-
lance and interventions.
enced by Islamic teachings. Islam promotes a
Apart from the notable exceptions of Djibouti,
line of behavior that is consonant with several
Somalia, and Southern Sudan, HIV prevalence
themes of HIV/AIDS prevention including pro-
is at relatively low levels among commercial sex
hibitions against premarital and extramarital
networks. The prevalence among FSWs appears
sex110; prohibitions against alcohol consumption
to grow slowly in MENA and may not reach the
because of alcohol’s strong association with
high levels it reached in other regions. Given the
higher risk behavior, paying for sex, and misuse
prominent role of commercial sex networks in
of protective measures such as condoms111;
the epidemics of Djibouti, Somalia, and Sudan,
closed sexual networks of monogamous or
interventions with FSWs and their clients might
polygamous marriages112; prohibition against
be the best method to control HIV spread in this
intercourse during menstruation113; and possibly
part of MENA.107
ritual washing and penile and vaginal hygiene
following intercourse.114 Being a Muslim has been
No general population HIV epidemic in MENA repeatedly associated with lower risk behavior,115
and lower HIV prevalence,116 in Muslim-
There is no evidence of an HIV epidemic in the
majority countries as well as in Muslim minori-
general population in any of the MENA coun-
ties in predominantly non-Muslim nations.117
tries. Available HIV prevalence and behavioral
Islamic religiosity was found in one study not to
data suggest that HIV infectious spread is not
be associated with lower use of condoms for
self-sustainable in the general population of
MENA countries, except possibly for Southern 108
Auvert et al., “Randomized, Controlled Intervention Trial”; Bailey et al.,
Sudan. Low levels of STI prevalence including “Male Circumcision”; Gray et al., “Male Circumcision.”
109
human papillomavirus (HPV) and herpes sim- Alsallaq et al., “Quantitative Assessment.”
110
Pickthall, The Meaning of the Glorious Qur’an.
plex virus 2 (HSV-2) in the general population 111
Mbulaiteye et al., “Alcohol and HIV”; Kaljee et al., “Alcohol Use and
support this inference. The fact that HIV is HIV Risk Behaviors”; Fisher, Bang, and Kapiga, “The Association
more likely to be sustainable and focused in between HIV Infection and Alcohol Use.”
112
priority populations does not imply that the Huff, “Male Circumcision: Cutting the Risk?”
113
Elharti et al., “Some Characteristics.”
general population is immune against HIV 114
Lerman and Liao, “Neonatal Circumcision.”
spread. HIV will find its way into the general 115
Bailey, Neema, and Othieno, “Sexual Behaviors”; Shirazi and
population through transmission chains origi- Morowatisharifabad, “Religiosity and Determinants of Safe Sex”;
Rakwar et al., “Cofactors for the Acquisition of HIV-1”; Isiugo-
nating at the high-risk cores, although these Abanihe, “Extramarital Relations”; Biaya, “Les plaisirs de la ville”;
chains are not self-sustainable and will eventu- Gilbert, “The Influence of Islam on AIDS.”
116
ally die out. Gray, “HIV and Islam”; Mbulaiteye et al., “Alcohol and HIV”; Rakwar
et al., “Cofactors for the Acquisition of HIV-1”; Kengeya-Kayondo et
al., “Incidence of HIV-1 Infection in Adults”; Malamba et al., “Risk
Factors for HIV-1 Infection in Adults”; Gray et al., “Male Circumcision
and HIV”; Bwayo et al., “Human Immunodeficiency Virus Infection”;
105
Altaf et al., “Harm Reduction among Injection Drug Users.” Nunn et al., “Risk Factors for HIV-1 Infection”; Abebe et al., “HIV
106
Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.” Prevalence”; Drain et al., “Correlates of National HIV Seroprevalence”;
107
Boily, Lowndes, and Alary, “The Impact of HIV Epidemic Phases”; Meda et al., “Low and Stable HIV Infection Rates.”
117
Lowndes et al., “Interventions among Male Clients.” Gray, “HIV and Islam”; Kagee et al., “HIV Prevalence.”
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 187
those who are sexually active.118 Islamic cultural Figure 11.2 A Schematic Diagram of the Overlap
traditions have been cited as a protective factor between Priority Populations in MENA
even after adjustment for male circumcision.119
While Islamic values provide protection
against HIV/AIDS,120 several studies suggest IDUs
that adherence to Islamic codes of conduct is
not perfect and that Muslims do engage in
sexual and injecting drug activities not sanc-
MSM
tioned in Islam.121 What is promoted religiously FSWs
is not necessarily what is put into practice.122
Though the social fabric of MENA societies is
heavily influenced by Islamic traditions, the Source: Authors.
region is also experiencing a sociocultural tran-
sition that is leading to more tolerance and
acceptance of behaviors such as premarital sex
Risk network structures are not well understood
and extramarital sex.123 The evidence for recent
increases in risky behavior points to this direc- Network structures among priority populations,
tion (see youth section in chapter 9). Counting and even the general population, appear to be
only on the “cultural immunity” of religious complex and intricate and are not yet well
and traditional mores124 is not enough to pre- understood. Some of the injecting drug and
vent the worst of the HIV epidemic. sexual networks appear to be sparse, consisting
of many subcomponents that are loosely con-
nected to each other. Each of these components
Overlap of risky behaviors is small and tightly knit, such as possibly among
IDUs in Lebanon.127 Figure 10.3a illustrates this
A hallmark of risky behavior in MENA is the kind of network. Networks of this nature are not
intersection of priority groups, with abundant conducive to substantial HIV spread because the
evidence of overlapping risk factors.125 The infection finds many obstacles in propagating
social, sexual, and injecting drug networks of from one subcomponent to another. It is not yet
priority groups overlap and intersect, allowing determined whether the sparse nature of some
HIV to easily propagate between different prior- network structures has contributed to the
ity populations (figure 11.2). HIV is spreading limited HIV prevalence in MENA.
from one priority group to another. In the
Islamic Republic of Iran and Pakistan, the epi-
demic among MSM appears to have been Vulnerability of spouses and other regular
sparked by ample overlap with injecting drug sexual partners
practices.126 If HIV establishes itself in one prior-
Ample evidence documents men acquiring the
ity population, it can easily find ways to spread
infection through high-risk practices including
through the overlapping risks to other priority
IDU and sexual contacts with FSWs or other
populations.
males, and then passing the infection to their
wives. Matrimony, rather than sexual or inject-
118 ing risk behavior, is the leading risk factor for
Gilbert, “The Influence of Islam.”
119
Hargrove, “Migration, Mines and Mores.” HIV infection among women in MENA. Sexual
120
Ridanovic, “AIDS and Islam.” partners of priority populations form a key
121
Gilbert, “The Influence of Islam”; Gibney et al., “Behavioural Risk group at risk of exposure to HIV, but they
Factors”; Kagimu et al., “Evaluation of the Effectiveness.”
122
Ridanovic, “AIDS and Islam.” appear to rarely engage in risky behavior or
123
Busulwa, “HIV/AIDS Situation Analysis Study.” pass the infection further. Ninety-seven percent
124
Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.” of HIV-positive women in Saudi Arabia, who
125
UNAIDS, “Fact Sheet on Drug Use.”
126
Pakistan National AIDS Control Program, HIV Second Generation
127
Surveillance (Rounds I, II, and III); Eftekhar et al., “Bio-Behavioural Mishwar, “An Integrated Bio-Behavioral Surveillance Study” (midterm
Survey on HIV.” and final report).
188 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
acquired the infection sexually, acquired the safe sex practices. The majority of at-risk hetero-
infection from their husbands.128 Seventy-six sexual and homosexual sex acts in MENA are
percent of HIV-positive women in the Islamic unprotected against HIV. The concept that every
Republic of Iran acquired the infection from their sex act with any partner can carry some risk of
husbands, who were predominantly IDUs.129 HIV infection still eludes the majority of the
HIV infections are repeatedly found among preg- population. The fact that a large fraction of HIV
nant women with no identifiable risk behaviors, infections are being transmitted within socially
suggesting that the risk factor is heterosexual sex acceptable partnerships, such as from a husband
with the spouse.130 Prevention efforts in the to his wife, is still beyond public comprehension.
region need to address this vulnerability.
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 189
Figure 11.3 Simulation of a Typical HIV Epidemic among an MSM Population
30
25
15
HIV prevalence among some IDU groups con- from a mother to her child in the absence of
tinues to be at low levels despite reported high- HIV treatment,138 the region may also be des-
risk behaviors and high HCV prevalence. tined to see a rise in easily preventable HIV
Therefore, it is likely that we will see further HIV infections among children, as the HIV disease
spread and possibly explosive epidemics among burden moves further to women.
IDUs in at least a few MENA countries. HIV epi- Though the prevalence of drug injection is in
demic expansion among MSM is a real possibil- the intermediate to high range at 0.2%,139 it
ity over the next few years in MENA considering seems not as likely that drug injection alone will
the high levels of risky behavior. Although it be the major driver of a substantial HIV epi-
does not appear that there is substantial HIV epi- demic at the level of the whole population in
demic potential among FSWs in most MENA any MENA country. The prevalence of male
countries, commercial sex networks are much same-sex practices, at a few percentage points, is
larger than IDU and MSM networks,137 and consistent with global levels.140 Therefore, it also
there could be a considerable rise in the number seems unlikely that male same-sex contacts
of HIV infections if HIV establishes itself in some alone, within MSM networks as well as beyond
commercial sex networks or in subgroups of these networks, will be the major driver of a
FSWs, such as those who inject drugs. large epidemic at the whole population level in
It is unlikely that MENA will experience a a manner that is distinct from other regions.
sustainable or a substantial HIV epidemic in the Prevalence of sex work among women and
general population in the next decade, if ever. the fraction of men who visit sex workers
However, the region could be poised to see a appear to be on the lower side of the global
rise in the number women in the general popu- range.141 Furthermore, the near universal cov-
lation who are infected with HIV largely due to erage of male circumcision and the apparently
the wave of HIV transmissions moving from lower risk behaviors in commercial sex networks
priority populations and bridging populations to
138
spouses of partners involved in these networks. Coutsoudis et al., “Late Postnatal Transmission”; Connor et al.,
“Reduction of Maternal-Infant Transmission.”
Considering the relatively high probability of 139
Aceijas et al., “Global Overview”; Aceijas et al., “Estimates of
vertical and breastfeeding HIV transmission Injecting Drug Users.”
140
McFarland and Caceres, “HIV Surveillance”; W. McFarland, personal
communication; UNAIDS, Epidemiological Software and Tools.
137 141
Blanchard, Khan, and Bokhari, “Variations in the Population.” Vandepitte et al., “Estimates of the Number of Female Sex Workers.”
190 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
may prevent concentrated HIV epidemics BIBLIOGRAPHY
among FSWs from materializing for at least a
Abebe, Y., A. Schaap, G. Mamo, A. Negussie, B. Darimo,
decade, if ever (apart from Djibouti, Somalia, D. Wolday, and E. J. Sanders. 2003. “HIV Prevalence
and Sudan). Hence, it seems also unlikely that in 72,000 Urban and Rural Male Army Recruits,
commercial sex networks alone will be the Ethiopia.” AIDS 17: 1835–40.
major driver of a large epidemic at the whole Abu-Raddad, L. J. 2009. “A Model for HIV Infectious
Spread in an MSM Population in the Middle East and
population level, except again for Djibouti, North Africa.” Ongoing modeling work, Weill Cornell
Somalia, and Sudan. Medical College, Doha, Qatar.
Considering all of the above, it is unlikely Aceijas, C., S. R. Friedman, H. L. Cooper, L. Wiessing, G. V.
that the HIV epidemic in MENA will take a Stimson, and M. Hickman. 2006. “Estimates of Injecting
course similar to that in sub-Saharan Africa if Drug Users at the National and Local Level in Develop-
ing and Transitional Countries, and Gender and Age
the existing social and epidemiological context Distribution.” Sex Transm Infect 82 Suppl 3: iii10–17.
in the region remains largely the same. At Aceijas, C., G. V. Stimson, M. Hickman, and T. Rhodes.
most, the region may face up to few percent- 2004. “Global Overview of Injecting Drug Use and
age points prevalence in several of its coun- HIV Infection among Injecting Drug Users.” AIDS 18:
2295–303.
tries. This would still imply an immense dis-
Afshar, P. Unknown. “Health and Prison.” Director
ease burden and subsequent economic burden General of Health, Office of Iran Prisons Organization.
in a region that is mostly unprepared for such Aghanashinikar, P. N., S. H. al-Dhahry, H. A. al-Marhuby,
an epidemic. M. R. Buhl, A. S. Daar, and M. K. Al-Hasani. 1992.
A key unknown in the understanding of the “Prevalence of Hepatitis B, Hepatitis Delta, and
Human Immunodeficiency Virus Infections in Omani
epidemiology of HIV in MENA is that of the lev- Patients with Renal Diseases.” Transplant Proc 24:
els of recent increases, and future trends, in risky 1913–14.
behavior. If the increases in risky behavior are Aidaoui, M., S. Bouzbid, and M. Laouar. 2008.
substantial, this could put some aspects of this “Seroprevalence of HIV Infection in Pregnant Women
analytical view of the dynamics in question. The in the Annaba Region (Algeria).” Rev Epidemiol Sante
Publique 56: 261–66.
trajectory of the HIV epidemic may be different
Al Katheeb, M. S., M. S. Tarawneh, and A. S. Awidi.
and we may observe somewhat considerable HIV 1988. “Antibodies to HIV in Jordanian Blood Donors
epidemics in some MENA populations. Studying and Patients with Congenital Bleeding Disorders.” IV
the levels of risky behavior and STI incidence International Conference on AIDS, Stockholm,
abstract 5003.
among youth, such as using multicenter cohort
Al Rasheed, A. M., D. Fairclough, Abu Al Sand, and
studies, should be considered by scientific A. O. Osoba. 1988. “Screening for HIV Antibodies
researchers in MENA. among Blood Donors at Riadh Armed Forces
The analytical insights drawn here from a Hospital.” VI International Conference on AIDS,
Stockholm, abstract 5001.
synthesis of thousands of studies and data
Alary, M., and C. M. Lowndes. 2004. “The Central Role
sources indicate that there is no escape from the of Clients of Female Sex Workers in the Dynamics of
necessity of developing robust surveillance sys- Heterosexual HIV Transmission in Sub-Saharan
tems to monitor HIV spread among priority Africa.” AIDS 18: 945–47.
populations. Effective and repeated surveillance Al-Fouzan, A., and N. Al-Mutairi. 2004. “Overview of
Incidence of Sexually Transmitted Diseases in
of priority populations, particularly among IDUs
Kuwait.” Clin Dermatol 22: 509–12.
and MSM, is key in MENA countries to defini-
Al-Haddad, M. K., A. S. Khashaba, B. Z. Baig, and
tively conclude whether HIV spread is indeed S. Khalfan. 1994. “HIV Antibodies among Intravenous
limited in priority populations, and to detect Drug Users in Bahrain.” J Commun Dis 26: 127–32.
emerging epidemics among these groups at an Al-Mahroos, F. T., and A. Ebrahim. 1995. “Prevalence of
early stage. This would offer a window of Hepatitis B, Hepatitis C and Human Immune
Deficiency Virus Markers among Patients with
opportunity for targeted prevention at an early Hereditary Haemolytic Anaemias.” Ann Trop Paediatr
phase of an epidemic. Monitoring recent infec- 15: 121–28.
tions and examining the nature of exposures Al-Nozha, M. M., A. R. Al-Frayh, M. Al-Nasser, and
could also be useful in detecting emerging epi- S. Ramia. 1995. “Horizontal versus Vertical
Transmission of Human Immunodeficiency Virus
demic chains of transmission within MENA Type 1 (HIV-1): Experience from Southwestern Saudi
populations. Arabia.” Trop Geogr Med 47: 293–95.
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 191
Alrajhi, A. A. 2004. “Human Immunodeficiency Virus in K. Qayum, P. Girault, E. Pisani, and I. Thaver. 2007.
Saudi Arabia.” Saudi Med J 25: 1559–63. “HIV Risk in Karachi and Lahore, Pakistan: An
Alrajhi, A. A., M. A. Halim, and H. M. Al-Abdely. 2004. Emerging Epidemic in Injecting and Commercial Sex
“Mode of Transmission of HIV-1 in Saudi Arabia.” Networks.” Int J STD AIDS 18: 486–92.
AIDS 18: 1478–80. Burans, J. P., E. Fox, M. A. Omar, A. H. Farah, S. Abbass,
Alsallaq, R. A., B. Cash, H. A. Weiss, I. M. Longini, S. B. S. Yusef, A. Guled, M. Mansour, R. Abu-Elyazeed,
Omer, M. J. Wawer, R. H. Gray, and L. J. Abu- and J. N. Woody. 1990. “HIV Infection Surveillance in
Raddad. 2008. “Quantitative Assessment of the Role Mogadishu, Somalia.” East Afr Med J 67: 466–72.
of Male Circumcision in HIV Epidemiology at the Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani,
Population Level.” Epidemics. J. George, R. Abu-Elyazeed, and J. N. Woody. 1990.
Altaf, A., A. Memon, N. Rehman, and S. Shah. 2004. “Serosurvey of Prevalence of Human Immuno-
“Harm Reduction among Injection Drug Users in deficiency Virus amongst High Risk Groups in Port
Karachi, Pakistan.” International AIDS Conference Sudan, Sudan.” East Afr Med J 67: 650–55.
2004, Bangkok, abstract WePeC5992. Burrows, D., A. Wodak, and WHO (World Health
Anonymous. 1997. “Commercially Motivated Renal Organization). 2005. Harm Reduction in Iran: Issues in
Transplantation: Results in 540 Patients Transplanted National Scale-Up.
in India: The Living Non-Related Renal Transplant Busulwa, R. 2003. “HIV/AIDS Situation Analysis Study.”
Study Group.” Clin Transplant 11: 536–44. Conducted in Hodeidah, Taiz and Hadhramut,
Republic of Yemen.
Arbesser, C., H. Bashiribod, and W. Sixl. 1987. “Serological
Examinations of HIV-I in Iran.” J Hyg Epidemiol Bwayo, J., F. Plummer, M. Omari, A. Mutere, S. Moses,
Microbiol Immunol 31: 504–5. J. Ndinya-Achola, P. Velentgas, and J. Kreiss. 1994.
“Human Immunodeficiency Virus Infection in Long-
Auvert, B., D. Taljaard, E. Lagarde, J. Sobngwi-Tambekou,
Distance Truck Drivers in East Africa.” Arch Intern Med
R. Sitta, and A. Puren. 2005. “Randomized, Controlled
154: 1391–96.
Intervention Trial of Male Circumcision for Reduction
of HIV Infection Risk: The ANRS 1265 Trial.” PLoS Chemtob, D., and S. F. Srour. 2005. “Epidemiology of
Med 2: e298. HIV Infection among Israeli Arabs.” Public Health 119:
138–43.
Baidy, Lo B., M. Adimorty, C. Fatimata, and S. Amadou.
1993. “Surveillance of HIV Seroprevalence in Connor, E. M., R. S. Sperling, R. Gelber, P. Kiselev,
Mauritania.” Bull Soc Pathol Exot 86: 133–35. G. Scott, M. J. O’Sullivan, R. VanDyke, M. Bey,
W. Shearer, R. L. Jacobson, et al. 1994. “Reduction of
Bailey, R. C., S. Moses, C. B. Parker, K. Agot, I. Maclean,
Maternal-Infant Transmission of Human Immuno-
J. N. Krieger, C. F. M. Williams, R. T. Campbell, and
deficiency Virus Type 1 with Zidovudine Treatment.”
J. O. Ndinya-Achola. 2007. “Male Circumcision for
Pediatric AIDS Clinical Trials Group Protocol 076
HIV Prevention in Young Men in Kisumu, Kenya:
Study Group. N Engl J Med 331: 1173–80.
A Randomised Controlled Trial.” Lancet 369: 643–56.
Constantine, N. T., M. F. Sheba, D. M. Watts, Z. Farid,
Bailey, R. C., S. Neema, and R. Othieno. 1999. “Sexual and M. Kamal. 1990. “HIV Infection in Egypt: A Two
Behaviors and Other HIV Risk Factors in Circumcised
and a Half Year Surveillance.” J Trop Med Hyg 93:
and Uncircumcised Men in Uganda.” J Acquir Immune
146–50.
Defic Syndr 22: 294–301.
Cote, A. M., F. Sobela, A. Dzokoto, K. Nzambi,
Baqi, S., N. Kayani, and J. A. Khan. 1999. “Epidemiology C. Asamoah-Adu, A. C. Labbe, B. Masse, J. Mensah,
and Clinical Profile of HIV/AIDS in Pakistan.” Trop E. Frost, and J. Pepin. 2004. “Transactional Sex Is the
Doct 29: 144–48. Driving Force in the Dynamics of HIV in Accra,
Bayoumi, A. 2005. Baseline Survey of Intravenous Drug Ghana.” AIDS 18: 917–25.
Users (IDUs) in Karthoum State (KS): Cross-Sectional and Coutsoudis, A., F. Dabis, W. Fawzi, P. Gaillard,
Case-Control Study. Assignment Report, Inter Agency G. Haverkamp, D. R. Harris, J. B. Jackson, V. Leroy,
Technical Committee, Sudan National AIDS N. Meda, P. Msellati, M. L. Newell, R. Nsuati, J. S.
Programme, Federal Ministry of Health, Khartoum, Read, and S. Wiktor. 2004. “Late Postnatal
Sudan. Transmission of HIV-1 in Breast-Fed Children: An
Biaya, T. K. 2001. “Les plaisirs de la ville: Masculinité, Individual Patient Data Meta-Analysis.” J Infect Dis
sexualité et féminité à Dakar (1997–2000).” African 189: 2154–66.
Studies Review: 71–85. Couzineau, B., J. Bouloumie, P. Hovette, and R. Laroche.
Blanchard, J. F., A. Khan, and A. Bokhari. 2008. 1991. “Prevalence of Infection by the Human
“Variations in the Population Size, Distribution and Immunodeficiency Virus (HIV) in a Target Population
Client Volume among Female Sex Workers in Seven in the Republic of Djibouti.” Med Trop (Mars) 51:
Cities of Pakistan.” Sex Transm Infect 84 Suppl 2: 485–86.
ii24–27. Dan, M., M. Rock, and S. Bar-Shany. 1989. “Prevalence
Boily, M. C., C. Lowndes, and M. Alary. 2002. “The of Antibodies to Human Immunodeficiency Virus
Impact of HIV Epidemic Phases on the Effectiveness of among Intravenous Drug Users in Israel—Association
Core Group Interventions: Insights from Mathematical with Travel Abroad.” Int J Epidemiol 18: 239–41.
Models.” Sex Transm Infect 78 Suppl 1: i78–90. Del Viso, N. 1997. “UNDP Supports HIV/AIDS/STD
Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan, Project for War-Torn South Sudan—A Special
M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, Report.” UNDP News 21.
192 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Demiroz, P., H. Irmak, A. Sengul, H. A. Ceviz, and Giasuddin, A. S., M. M. Ziu, A. Abusadra, and A. Gamati.
F. Kocabalkan. 1989. “HIV Infections among Turkish 1988. “Failure to Find Antibody to Human
Citizens Who Have Lived in Foreign Countries.” Immunodeficiency Virus Type I in Libya.” J Infect 17:
Mikrobiyol Bul 23: 203–9. 192–93.
Djibouti Ministère de La Santé, and Association Gibney, L., P. Choudhury, Z. Khawaja, M. Sarker, and
Internationale de Développement. 2002. Epidémie a S. H. Vermund. 1999. “Behavioural Risk Factors for
VIH/SIDA/IST en République de Djibouti; Tome I: Analyse HIV/AIDS in a Low-HIV Prevalence Muslim Nation:
de la Situation et Analyse de la Réponse Nationale. Bangladesh.” Int J STD AIDS 10: 186–94.
Décembre. Gilbert, S. S. 2008. “The Influence of Islam on AIDS
Drain, P. K., J. S. Smith, J. P. Hughes, D. T. Halperin, and Prevention among Senegalese University Students.”
K. K. Holmes. 2004. “Correlates of National HIV AIDS Educ Prev 20: 399–407.
Seroprevalence: An Ecologic Analysis of 122 “Global Update: Morocco.” 1993. AIDSlink (23): 14.
Developing Countries.” J Acquir Immune Defic Syndr Grassly, N. C., G. P. Garnett, B. Schwartlander,
35: 407–20. S. Gregson, and R. M. Anderson. 2001. “The
Egypt Ministry of Health and Population, and National Effectiveness of HIV Prevention and the Epidemio-
AIDS Program. 2006. HIV/AIDS Biological and logical Context.” Bull World Health Organ 79: 1121–32.
Behavioral Surveillance Survey. Summary report. Gray, P. B. 2004. “HIV and Islam: Is HIV Prevalence
El-Ghazzawi, E., G. Hunsmann, and J. Schneider. 1987. Lower among Muslims?” Soc Sci Med 58: 1751–56.
“Low Prevalence of Antibodies to HIV-1 and HTLV-I Gray, R. H., N. Kiwanuka, T. C. Quinn, N. K. Sewankambo,
in Alexandria, Egypt.” AIDS Forsch 2: 639. D. Serwadda, F. W. Mangen, T. Lutalo, F. Nalugoda,
Elharti, E., M. Alami, H. Khattabi, A. Bennani, A. R. Kelly, M. Meehan, M. Z. Chen, C. Li, and M. J.
Zidouh, A. Benjouad, and R. El Aouad. 2002. “Some Wawer. 2000. “Male Circumcision and HIV Acquisition
Characteristics of the HIV Epidemic in Morocco.” East and Transmission: Cohort Studies in Rakai, Uganda.
Mediterr Health J 8: 819–25. Rakai Project Team.” AIDS 14: 2371–81.
El-Hazmi, M. A., and S. Ramia. 1989. “Frequencies of Groterah, A. 2002. “Drug Abuse and HIV/AIDS in the
Hepatitis B, Delta and Human Immune Deficiency Middle East and North Africa: A Situation
Virus Markers in Multitransfused Saudi Patients with Assessment.” UNODC, internal document.
Thalassaemia and Sickle-Cell Disease.” J Trop Med Hyg Harfi, H. A., and B. M. Fakhry. 1986. “Acquired
92: 1–5. Immunodeficiency Syndrome in Saudi Arabia: The
Elrashied, S. 2006. “Prevalence, Knowledge and Related American-Saudi Connection.” JAMA 255: 383–84.
Risky Sexual Behaviours of HIV/AIDS among Hargrove, J. 2007. “Migration, Mines and Mores: The
Receptive Men Who Have Sex with Men (MSM) in HIV Epidemic in Southern Africa.” Inaugural Address,
Khartoum State, Sudan, 2005.” XVI International Stellenbosch University.
AIDS Conference, Toronto, August 13–18, abstract Hashim, M. S., M. A. Salih, A. A. el Hag, Z. A. Karrar,
TUPE0509. E. M. Osman, F. S. el-Shiekh, I. A. el Tilib, and N. E.
Etchepare, M. 2001. “Programme National de Lutte con- Attala. 1997. “AIDS and HIV Infection in Sudanese
tre le SIDA et les MST.” Draft report, World Bank Children: A Clinical and Epidemiological Study.”
Mission for Health Project Strategy Development, AIDS Patient Care STDS 11: 331–37.
Djibouti. Hawkes, S., G. J. Hart, A. M. Johnson, C. Shergold,
Fares, G., et al. 2004. Rapport sur l’enquête nationale de E. Ross, K. M. Herbert, P. Mortimer, J. V. Parry, and
sero-surveillance sentinelle du VIH et de la syphilis en D. Mabey. 1994. “Risk Behaviour and HIV Prevalence
Algérie en 2004. Ministère de la Santé de la population in International Travellers.” AIDS 8: 247–52.
et de la reforme hospitalière, Alger, Décembre. Huff, B. 2000. “Male Circumcision: Cutting the Risk?”
Farhoudi, B., A. Montevalian, M. Motamedi, M. M. American Foundation for AIDS Research, August.
Khameneh, M. Mohraz, M. Rassolinejad, S. Jafari, Iqbal, J., and N. Rehan. 1996. “Sero-Prevalence of HIV:
P. Afshar, I. Esmaili, and L. Mohseni. 2003. “Human Six Years’ Experience at Shaikh Zayed Hospital,
Immunodeficiency Virus and HIV-Associated Lahore.” J Pak Med Assoc 46: 255–58.
Tuberculosis Infection and Their Risk Factors in Iran Center for Disease Management. Unknown. Country
Injecting Drug Users in Prison in Iran.” Report on UNGASS Declaration of Commitment. Office of
Faris, R., and A. Shouman. 1994. “Study of the Deputy Minister of Health in Health Affairs, Islamic
Knowledge, Attitude of Egyptian Health Care Workers Republic of Iran, in cooperation with UNAIDS Iran
towards Occupational HIV Infection.” J Egypt Public and the Iranian Center for AIDS Research.
Health Assoc 69: 115–28. ———. 2004. HIV/AIDS and STIs Surveillance Report.
Fisher, J. C., H. Bang, and S. H. Kapiga. 2007. “The Ministry of Health and Medical Education, Tehran.
Association between HIV Infection and Alcohol Use: Isiugo-Abanihe, U. C. 1994. “Extramarital Relations and
A Systematic Review and Meta-Analysis of African Perceptions of HIV/AIDS in Nigeria.” Health Transit
Studies.” Sex Transm Dis 34: 856–63. Rev 4: 111–25.
Fox, E., J. P. Burans, M. A. Omar, A. H. Farah, A. Guled, Ismail, S. O., H. J. Ahmed, L. Grillner, B. Hederstedt, A.
S. Yusef, J. C. Morrill, and J. N. Woody. 1989. “AIDS: Issa, and S. M. Bygdeman. 1990. “Sexually Transmitted
The Situation in Mogadishu during Spring 1987.” Diseases in Men in Mogadishu, Somalia.” Int J STD
J Egypt Public Health Assoc 64: 135–43. AIDS 1: 102–6.
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 193
Jahani, M. R., S. M. Alavian, H. Shirzad, A. Kabir, and Immune Deficiency Syndrome in the Middle East
B. Hajarizadeh. 2005. “Distribution and Risk Factors from Imported Blood.” Transfusion 25: 317–18.
of Hepatitis B, Hepatitis C, and HIV Infection in a Kordy, F., S. Al-Hajjar, H. H. Frayha, R. Al-Khlaif,
Female Population with ‘Illegal Social Behaviour.’” D. Al-Shahrani, and J. Akthar. 2006. “Human
Sex Transm Infect 81: 185. Immunodeficiency Virus Infection in Saudi Arabian
Jama, H., L. Grillner, G. Biberfeld, S. Osman, A. Isse, Children: Transmission, Clinical Manifestations and
M. Abdirahman, and S. Bygdeman. 1987. “Sexually Outcome.” Ann Saudi Med 26: 92–99.
Transmitted Viral Infections in Various Population Leonard, G., A. Sangare, M. Verdier, E. Sassou-Guesseau,
Groups in Mogadishu, Somalia.” Genitourin Med 63: G. Petit, J. Milan, S. M’Boup, J. L. Rey, J. L. Dumas,
329–32. J. Hugon, et al. 1990. “Prevalence of HIV Infection
Jemni, L., S. Bahri, M. Saadi, A. Letaif, M. Dhidah, among Patients with Leprosy in African Countries
H. Lahdhiri, and S. Bouchoucha. 1991. “AIDS and and Yemen.” J Acquir Immune Defic Syndr 3: 1109–13.
Tuberculosis in Central Tunisia.” Tunis Med 69: 349–52. Lepers, J. P., C. Billon, J. L. Pesce, P. E. Rollin, and J. De
Jenkins, C., and D. A. Robalino. 2003. “HIV in the Saint-Martin. 1988. “Sero-Epidemiological Study in
Middle East and North Africa: The Cost of Inaction.” Mauritania (1985–1986): Incidence of Treponema-
Orientations in Development Series, World Bank. tosis, Hepatitis B Virus, HIV Virus and Viral Hemorrhagic
Jurjus, A. R., J. Kahhaleh, National AIDS Program, and Fevers.” Bull Soc Pathol Exot Filiales 81: 24–31.
WHO/EMRO (World Health Organization/Eastern Lerman, S. E., and J. C. Liao. 2001. “Neonatal
Mediterranean Regional Office). 2004. “Knowledge, Circumcision.” Pediatr Clin North Am 48: 1539–57.
Attitudes, Beliefs, and Practices of the Lebanese con-
Lowndes, C. M., M. Alary, A. C. Labbe, C. Gnintoungbe,
cerning HIV/AIDS.” Beirut, Lebanon.
M. Belleau, L. Mukenge, H. Meda, M. Ndour,
Kagee, A., Y. Toefy, L. Simbayi, and S. Kalichman. 2005. S. Anagonou, and A. Gbaguidi. 2007. “Interventions
“HIV Prevalence in Three Predominantly Muslim among Male Clients of Female Sex Workers in Benin,
Residential Areas in the Cape Town Metropole.” S Afr West Africa: An Essential Component of Targeted HIV
Med J 95: 512–16. Preventive Interventions.” Sex Transm Infect 83: 577–81.
Kagimu, M., E. Marum, F. Wabwire-Mangen, N. Nakyanjo, Maayan, S., E. Shinar, M. Aefani, M. Soughayer,
Y. Walakira, and J. Hogle. 1998. “Evaluation of the R. Alkhoudary, S. Barshany, and N. Manny. 1994.
Effectiveness of AIDS Health Education Interventions “HIV-1 Prevalence among Israeli and Palestinian
in the Muslim Community in Uganda.” AIDS Educ Prev Blood Donors.” AIDS 8: 133–34.
10: 215–28.
Maayan, S., E. Shinar, M. Aefani, M. Soughayer, R.
Kalaajieh, W. K. 2000. “Epidemiology of Human el Khoudary, G. Rahav, and N. Manny. 1993. “HIV/
Immunodeficiency Virus and Acquired Immuno- AIDS among Palestinian Arabs.” Isr J Med Sci 29: 7–10.
deficiency Syndrome in Lebanon from 1984 through
1998.” Int J Infect Dis 4: 209–13. Madani, T. A., Y. Y. Al-Mazrou, M. H. Al-Jeffri, and N. S.
Al Huzaim. 2004. “Epidemiology of the Human
Kaljee, L. M., B. L. Genberg, T. T. Minh, L. H. Tho, L. T. Immunodeficiency Virus in Saudi Arabia: 18-Year
Thoa, and B. Stanton. 2005. “Alcohol Use and HIV Surveillance Results and Prevention from an Islamic
Risk Behaviors among Rural Adolescents in Khanh Perspective.” BMC Infect Dis 4: 25.
Hoa Province Viet Nam.” Health Educ Res 20: 71–80.
Malamba, S. S., H. U. Wagner, G. Maude, M. Okongo,
Kandela, P. 1993. “Arab Nations: Attitudes to AIDS.” A. J. Nunn, J. F. Kengeya-Kayondo, and D. W.
Lancet 341: 884–85. Mulder. 1994. “Risk Factors for HIV-1 Infection in
Kayani, N., A. Sheikh, A. Khan, C. Mithani, and M. Adults in a Rural Ugandan Community: A Case-
Khurshid. 1994. “A View of HIV-I Infection in Control Study.” AIDS 8: 253–57.
Karachi.” J Pak Med Assoc 44: 8–11.
Mandal, M., S. Purdin, and T. McGinn. 2005. “A Study
Kengeya-Kayondo, J. F., A. Kamali, A. J. Nunn, A. of Health Facilities: Implications for Reproductive
Ruberantwari, H. U. Wagner, and D. W. Mulder. Health and HIV/AIDS Programs in Southern Sudan.”
1996. “Incidence of HIV-1 Infection in Adults and Int Q Community Health Educ 24: 175–90.
Socio-Demographic Characteristics of Seroconverters
Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck,
in a Rural Population in Uganda: 1990–1994.” Int J
M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M.
Epidemiol 25: 1077–82.
Huraux, and N. Dupin. 2001. “Comparative Study of
Khan, S., M. A. Rai, M. R. Khanani, M. N. Khan, and Heterosexual Transmission of HIV-1, HSV-2 and
S. H. Ali. 2006. “HIV-1 Subtype A Infection in a KSHV in Djibouti.” 8th Retrovir Oppor Infect (abstract
Community of Intravenous Drug Users in Pakistan.” no. 585).
BMC Infect Dis 6: 164.
Marcelin, A. G., M. Grandadam, P. Flandre, E. Nicand,
Khanani, R. M., A. Hafeez, S. M. Rab, and S. Rasheed. C. Milliancourt, J. L. Koeck, M. Philippon, R. Teyssou,
1988. “Human Immunodeficiency Virus-Associated H. Agut, N. Dupin, and V. Calvez. 2002. “Kaposi’s
Disorders in Pakistan.” AIDS Res Hum Retroviruses 4: Sarcoma Herpesvirus and HIV-1 Seroprevalences in
149–54. Prostitutes in Djibouti.” J Med Virol 68: 164–67.
Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. Maslin, J., C. Rogier, F. Berger, M. A. Khamil, D. Mattera,
Vermund. 1997. “HIV/AIDS and Its Risk Factors in M. Grandadam, M. Caron, and E. Nicand. 2005.
Pakistan.” AIDS 11: 843–48. “Epidemiology and Genetic Characterization of HIV-1
Kingston, M. E., E. J. Harder, M. M. Al-Jaberi, T. M. Isolates in the General Population of Djibouti (Horn
Bailey, G. T. Roberts, and K. V. Sheth. 1985. “Acquired of Africa).” J Acquir Immune Defic Syndr 39: 129–32.
194 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Mbulaiteye, S. M., A. Ruberantwari, J. S. Nakiyingi, Naman, R. E., J. E. Mokhbat, A. E. Farah, K. L. Zahar,
L. M. Carpenter, A. Kamali, and J. A. Whitworth. and F. S. Ghorra. 1989. “Seroepidemiology of the
2000. “Alcohol and HIV: A Study among Sexually Human Immunodeficiency Virus in Lebanon:
Active Adults in Rural Southwest Uganda.” Int J Preliminary Evaluation.” J Med Liban 38: 5–8.
Epidemiol 29: 911–15. Narenjiha, H., H. Rafiey, A. Baghestani, et al. 2005.
McCarthy, M. C., J. P. Burans, N. T. Constantine, A. A. “Rapid Situation Assessment of Drug Abuse and Drug
el-Hag, M. E. el-Tayeb, M. A. el-Dabi, J. G. Fahkry, J. Dependence in Iran, DARIUS Institute” (draft ver-
N. Woody, and K. C. Hyams. 1989. “Hepatitis B and sion, in Persian).
HIV in Sudan: A Serosurvey for Hepatitis B and Nguyen, L., D. J. Hu, K. Choopanya, S. Vanichseni,
Human Immunodeficiency Virus Antibodies among D. Kitayaporn, F. van Griensven, P. A. Mock, W.
Sexually Active Heterosexuals.” Am J Trop Med Hyg Kittikraisak, N. L. Young, T. D. Mastro, and S. Subbarao.
41: 726–31. 2002. “Genetic Analysis of Incident HIV-1 Strains
McCarthy, M. C., I. O. Khalid, and A. El Tigani. 1995. among Injection Drug Users in Bangkok: Evidence for
“HIV-1 Infection in Juba, Southern Sudan.” J Med Multiple Transmission Clusters during a Period of High
Virol 46: 18–20. Incidence.” J Acquir Immune Defic Syndr 30: 248–56.
McFarland, W., and C. F. Caceres. 2001. “HIV Surveillance Novelli, V. M., H. Mostafavipour, M. Abulaban, F. Ekteish,
among Men Who Have Sex with Men.” AIDS 15 J. Milder, and B. Azadeh. 1987. “High Prevalence of
Suppl 3: S23–32. Human Immunodeficiency Virus Infection in Children
with Thalassemia Exposed to Blood Imported from the
Meda, N., I. Ndoye, S. M’Boup, A. Wade, S. Ndiaye, United States.” Pediatr Infect Dis J 6: 765–66.
C. Niang, F. Sarr, I. Diop, and M. Carael. 1999. “Low
and Stable HIV Infection Rates in Senegal: Natural NSNAC (New Sudan AIDS Council), and UNAIDS (Joint
Course of the Epidemic or Evidence for Success of United Nations Programme on HIV/AIDS). 2006.
Prevention?” AIDS 13: 1397–405. HIV/AIDS Integrated Report South Sudan, 2004–2005.
With United Nations General Assembly Special
Mellors, J. W., C. R. Rinaldo, P. Gupta, R. M. White, J. A. Session on HIV/AIDS Declaration of Commitment.
Todd, and L. A. Kingsley. 1996. “Prognosis in HIV-1
Infection Predicted by the Quantity of Virus in Nunn, A. J., J. F. Kengeya-Kayondo, S. S. Malamba,
Plasma.” Science 272: 1167–70. J. A. Seeley, and D. W. Mulder. 1994. “Risk Factors
for HIV-1 Infection in Adults in a Rural Ugandan
Milder, J. E., and V. M. Novelli. 1992. “Clinical, Social Community: A Population Study.” AIDS 8: 81–86.
and Ethical Aspects of HIV-1 Infections in an Arab
O’Grady, M. 2004. “WFP Consultant Visit to Djibouti
Gulf State.” J Trop Med Hyg 95: 128–31.
Report.” July 30.
Ministry of Health and Medical Education of Iran. 2006. Oman MOH (Ministry of Health). 2006. “HIV Risk
“Treatment and Medical Education.” Islamic Republic among Heroin and Injecting Drug Users in Muscat,
of Iran HIV/AIDS situation and response analysis. Oman.” Quantitative survey, preliminary data.
Mishwar. 2008a. “An Integrated Bio-Behavioral Pakistan National AIDS Control Program. 2005. HIV
Surveillance Study among Four Vulnerable Groups in Second Generation Surveillance in Pakistan. National
Lebanon: Men Who Have Sex with Men; Prisoners; Report Round 1. Ministry of Health, Pakistan, and
Commercial Sex Workers and Intravenous Drug Canada-Pakistan HIV/AIDS Surveillance Project.
Users.” Mid-term report.
———. 2006–7. HIV Second Generation Surveillance in
———. 2008b. “An Integrated Bio-Behavioral Surveillance Pakistan. National Report Round II. Ministry of
Study among Four Vulnerable Groups in Lebanon: Men Health, Pakistan, and Canada-Pakistan HIV/AIDS
Who Have Sex with Men; Prisoners; Commercial Sex Surveillance Project.
Workers and Intravenous Drug Users.” Final report.
———. 2008. HIV Second Generation Surveillance in
Mokhbat, J. E., R. E. Naman, F. S. Rahme, A. E. Farah, Pakistan. National Report Round III. Ministry of
K. L. Zahar, and A. Maalouf. 1989. “Clinical and Health, Pakistan, Canada-Pakistan HIV/AIDS
Serological Study of the Human Immunodeficiency Surveillance Project.
Virus Infection in a Cohort of Multitransfused
Pickthall, M. 1930. The Meaning of the Glorious Qur’an.
Persons.” J Med Liban 38: 9–14.
Hyderabad, India. Chapters and Verses 17:32, 26:165–
Moses, A. E., S. Maayan, G. Rahav, M. Weinberger, 166, 5:90.
D. Engelhard, M. Schlesinger, B. Knishkowy, A. Morag, Pisani, E., S. Lazzari, N. Walker, and B. Schwartlander.
and M. Shapiro. 1996. “HIV Infection and AIDS in 2003. “HIV Surveillance: A Global Perspective.” J
Jerusalem: A Microcosm of Illness in Israel.” Isr J Med Acquir Immune Defic Syndr 32 Suppl 1: S3–11.
Sci 32: 716–21.
Piyasirisilp, S., F. E. McCutchan, J. K. Carr, E. Sanders-
Mostashari, G., UNODC (United Nations Office on Drugs Buell, W. Liu, J. Chen, R. Wagner, H. Wolf, Y. Shao,
and Crime), and M. Darabi. 2006. “Summary of the S. Lai, C. Beyrer, and X. F. Yu. 2000. “A Recent
Iranian Situation on HIV Epidemic.” NSP Situation Outbreak of Human Immunodeficiency Virus Type
Analysis. 1 Infection in Southern China Was Initiated by Two
Mujeeb, S. A., and A. Hafeez. 1993. “Prevalence and Pattern Highly Homogeneous, Geographically Separated
of HIV Infection in Karachi.” J Pak Med Assoc 43: 2–4. Strains, Circulating Recombinant Form AE and a
Mujeeb, S. A., M. R. Khanani, T. Khursheed, and A. Novel BC Recombinant.” J Virol 74: 11286–95.
Siddiqui. 1991. “Prevalence of HIV-Infection among Rakwar, J., L. Lavreys, M. L. Thompson, D. Jackson, J.
Blood Donors.” J Pak Med Assoc 41: 253–54. Bwayo, S. Hassanali, K. Mandaliya, J. Ndinya-Achola,
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 195
and J. Kreiss. 1999. “Cofactors for the Acquisition of Shirazi, K. K., and M. A. Morowatisharifabad. 2009.
HIV-1 among Heterosexual Men: Prospective Cohort “Religiosity and Determinants of Safe Sex in Iranian
Study of Trucking Company Workers in Kenya.” AIDS Non-Medical Male Students.” J Relig Health 48: 29–36.
13: 607–14. SNAP (Sudan National HIV/AIDS Control Program). 2004.
Ramezani, A., M. Mohraz, and L. Gachkar. 2006. HIV/AIDS/STIs Prevalence, Knowledge, Attitude, Practices
“Epidemiologic Situation of Human Immuno- and Risk Factors among University Students and Military
deficiency Virus (HIV/AIDS Patients) in a Private Personnel. Federal Ministry of Health, Khartoum.
Clinic in Tehran, Iran.” Arch Iran Med 9: 315–18. ———. 2008. “Update on the HIV Situation in Sudan.”
Rao, C. K. 1993. Strengthening of AIDS/HIV Surveillance in PowerPoint presentation.
the Islamic Republic of Iran. An Assignment Report, Tassie, J.-M. Unknown. “Assignment Report HIV/AIDS/
WHO/EMRO. STD Surveillance in I.R. of Iran.” UNAIDS, Mission
Razzaghi, E., A. Rahimi, and M. Hosseini. 1999. Rapid Internal Report.
Situation Assessment (RSA) of Drug Abuse in Iran. Tehran:
Tawilah, J., and O. Tawil. 2001. Visit to Sultane of Oman.
Prevention Department, State Welfare Organization,
Travel report summary, National AIDS Programme at
Ministry of Health, and United Nations International
the Ministry of Health in Muscat and Salalah, and
Drug Control Program.
WHO Representative Office and EMRO.
Ridanovic, Z. 1997. “AIDS and Islam.” Med Arh 51: 45–46.
Tehrani, F. R., and H. Malek-Afzalip. 2008. “Knowledge,
Rodier, G. R., B. Couzineau, G. C. Gray, C. S. Omar, Attitudes and Practices concerning HIV/AIDS among
E. Fox, J. Bouloumie, and D. Watts. 1993. “Trends of Iranian At-Risk Sub-Populations.” Eastern Mediter-
Human Immunodeficiency Virus Type-1 Infection in ranean Health Journal 14.
Female Prostitutes and Males Diagnosed with a
Tiouiri, H., B. Naddari, G. Khiari, S. Hajjem, and A. Zribi.
Sexually Transmitted Disease in Djibouti, East Africa.”
1999. “Study of Psychosocial Factors in HIV Infected
Am J Trop Med Hyg 48: 682–86.
Patients in Tunisia.” East Mediterr Health J 5: 903–11.
Rodier, G., B. Couzineau, S. Salah, J. Bouloumie,
J. P. Parra, E. Fox, N. Constantine, and D. Watts. Todd, C. S., A. M. Abed, S. A. Strathdee, P. T. Scott, B. A.
1993. “Infection by the Human Immunodeficiency Botros, N. Safi, and K. C. Earhart. 2007. “HIV,
Virus in the Republic of Djibouti: Literature Review Hepatitis C, and Hepatitis B Infections and Associated
and Regional Data.” Med Trop (Mars) 53: 61–67. Risk Behavior in Injection Drug Users, Kabul,
Afghanistan.” Emerg Infect Dis 13: 1327–31.
Rodier, G. R., J. J. Morand, J. S. Olson, D. M. Watts, and
S. Said. 1993. “HIV Infection among Secondary School Toukan, A. U., and C. A. Schable. 1987. “Human
Students in Djibouti, Horn of Africa: Knowledge, Immunodeficiency Virus (HIV) Infection in Jordan: A
Exposure and Prevalence.” East Afr Med J 70: Seroprevalence Study.” Int J Epidemiol 16: 462–65.
414–17. UNAIDS (Joint United Nations Programme on HIV/
Rota, S., A. Yildiz, H. Guner, and M. Erdem. 1989. “HIV AIDS). 2006. “Fact Sheet on Drug Use and HIV in the
Antibody Screening in a Gynecology and Obstetrics Middle East and North Africa.” MENA RST.
Clinic, Ankara, Turkey.” Int J Gynaecol Obstet 30: ———. 2007a. AIDS Epidemic Update 2007. Geneva.
395–96. ———. 2007b. Country Database, http://www.unaids
Ryan, S. 2006. “Travel Report Summary.” Kabul, .org/en/CountryResponses/Countries/default.asp.
Afghanistan, Joint United Nations Programme on ———. 2007c. “Key Findings on HIV Status in the West
HIV/AIDS, February 27 through March 7, 2006. Bank and Gaza.” Working document, UNAIDS Regional
Salahudeen, A. K., H. F. Woods, A. Pingle, M. Nur-El- Support Team for the Middle East and North Africa.
Huda Suleyman, K. Shakuntala, M. Nandakumar,
———. 2008. “Notes on AIDS in the Middle East and
T. M. Yahya, and A. S. Daar. 1990. “High Mortality
North Africa.” RST MENA.
among Recipients of Bought Living-Unrelated Donor
Kidneys.” Lancet 336: 725–28. UNAIDS, and WHO (World Health Organization). 2003.
AIDS Epidemic Update 2003. Geneva.
Salama, P., and T. J. Dondero. 2001. “HIV Surveillance in
Complex Emergencies.” AIDS 15 Suppl 3: S4–12. ———. 2006. AIDS Epidemic Update 2006. Geneva.
Sanders-Buell, E., M. D. Saad, A. M. Abed, M. Bose, Vandepitte, J., R. Lyerla, G. Dallabetta, F. Crabbe,
C. S. Todd, S. A. Strathdee, B. A. Botros, N. Safi, K. C. M. Alary, and A. Buve. 2006. “Estimates of the
Earhart, P. T. Scott, N. Michael, and F. E. McCutchan. Number of Female Sex Workers in Different Regions
2007. “A Nascent HIV Type 1 Epidemic among of the World.” Sex Transm Infect 82 Suppl 3: iii18–25.
Injecting Drug Users in Kabul, Afghanistan Is Watts, D. M., N. T. Constantine, M. F. Sheba, M. Kamal,
Dominated by Complex AD Recombinant Strain, J. D. Callahan, and M. E. Kilpatrick. 1993. “Prevalence
CRF35_AD.” AIDS Res Hum Retroviruses 23: 834–39. of HIV Infection and AIDS in Egypt over Four Years of
Shah, S. A., A. Altaf, S. A. Mujeeb, and A. Memon. 2004. Surveillance (1986–1990).” J Trop Med Hyg 96: 113–17.
“An Outbreak of HIV Infection among Injection Wawer, M. J., R. H. Gray, N. K. Sewankambo,
Drug Users in a Small Town in Pakistan: Potential for D. Serwadda, X. Li, O. Laeyendecker, N. Kiwanuka,
National Implications.” Int J STD AIDS 15: 209. G. Kigozi, M. Kiddugavu, T. Lutalo, F. Nalugoda,
Shah, S. A., O. A. Khan, S. Kristensen, and S. H. F. Wabwire-Mangen, M. P. Meehan, and T. C. Quinn.
Vermund. 1999. “HIV-Infected Workers Deported 2005. “Rates of HIV-1 Transmission per Coital Act, by
from the Gulf States: Impact on Southern Pakistan.” Stage of HIV-1 Infection, in Rakai, Uganda.” J Infect
Int J STD AIDS 10: 812–14. Dis 191: 1403–9.
196 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
WHO (World Health Organization). 2004. The 2004 First Sheets on HIV/AIDS and Sexually Transmitted
National Second Generation HIV/AIDS/STI Sentinel Infections.”
Surveillance Survey, Somalia, A Technical Report. Woodruff, P. W., J. C. Morrill, J. P. Burans, K. C. Hyams,
———. 2005. “Summary Country Profile for HIV/AIDS and J. N. Woody. 1988. “A Study of Viral and Rickettsial
Treatment Scale-Up.” Djibouti. Exposure and Causes of Fever in Juba, Southern
WHO/EMRO (Eastern Mediterranean Regional Office). Sudan.” Trans R Soc Trop Med Hyg 82: 761–66.
2005. “Progress Report on HIV/AIDS and ‘3 by 5.’” World Bank. 2008. “Mapping and Situation Assessment
Cairo, July. of Key Populations at High Risk of HIV in Three Cities
WHO, UNICEF (United Nations Children’s Fund), and of Afghanistan.” Human Development Sector, South
UNAIDS. 2006. “Yemen, Epidemiological Facts Asia Region (SAR) AIDS Team, World Bank.
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 197
Chapter 12
The epidemiological assessment detailed in the wide spectrum of interventions across MENA.
previous chapters highlights that the human This chapter discusses mainly the HIV response
immunodeficiency virus (HIV) disease burden through the lens of the epidemiological findings
in the Middle East and North Africa (MENA) is of this research work.
concentrated in priority populations, including
injecting drug users (IDUs), men who have sex
with men (MSM), and commercial sex net- HIV PREVENTION IN MENA
works, as well as the partners of these popula-
tions. There is very limited HIV spread in the Scaling up HIV prevention for people most at
general population. While HIV is likely to risk is the key to averting further spread of the
expand its spread in priority populations over HIV epidemic in MENA. As documented in the
the next decade, it is unlikely that MENA will previous chapters, the relatively limited magni-
experience substantial HIV epidemics in the tude and current potential for HIV transmission
general population such as those found in sub- across the region continue to provide a window
Saharan Africa. of opportunity for containing the epidemic.1
For any HIV response to be successful and Timing, however, is critical, and effective HIV
cost-effective, it must be tailored to the epide- prevention should be pursued with great vigor
miological reality of HIV transmission patterns. and unyielding intensity.
The analytical synthesis in this report provides While HIV prevention remains limited in
the strategic evidence necessary for determining scope and scale in MENA, based on a review of
the effectiveness of the HIV response in MENA, national strategic plans (NSPs), a few countries
and the appropriateness of current resource have made some advances, such as prevention
allocation to control HIV spread. efforts designed to engage female sex workers
This chapter provides a snapshot of HIV (FSWs), MSM, and IDUs in Morocco, and IDUs
efforts in the region from the perspective of in the Islamic Republic of Iran. Prevention efforts
assessing the extent to which the response is in in the region are impeded by generic and routine
alignment with HIV epidemiology. This chapter planning, competing priorities, limited human
is not an attempt to provide a comprehensive or capital, and lack of monitoring and evaluation,
exhaustive review of HIV efforts in MENA. A
detailed analysis of response and resource 1
Jenkins and Robalino, “HIV in the Middle East and North Africa”;
allocation is beyond the scope of this report. HIV World Bank, “Preventing HIV/AIDS in the Middle East and
efforts are highly heterogeneous and cover a North Africa.”
199
while national policies remain inadequate and It can be noted that where NGOs are strong, the
do not sufficiently reflect evidence-informed response is strong (for example, Algeria, the
approaches. Although there are noteworthy and Islamic Republic of Iran, Lebanon, Morocco, and
recent examples, still very few prevention pro- Pakistan).
grams in MENA have adopted a comprehensive While there is wider recognition in MENA
approach encompassing policy dimensions, stra- countries of the importance of implementing
tegic information, and an optimal mix of inter- targeted interventions for priority populations,
ventions developed with and implemented by there is concern over the coverage and the qual-
members of the concerned populations. ity of those services and whether the services
have the potential to avert the epidemic. Program
monitoring data are scarce and thus cannot con-
FOCUSED HIV PREVENTION PROGRAMS firm the appropriateness of the response in
terms of service coverage or specific services.
FOR PEOPLE EXPOSED TO RISK
Priority populations in MENA are either dispro-
Injecting drug users
portionately affected or more vulnerable to con-
tracting HIV compared to other populations. As With the emergence of IDU as an important
in all low prevalence and concentrated epidemic driver of the epidemic in MENA, and with the
settings in the world, it is expected that MENA wealth of evidence accumulated around the
countries strategically focus their response on world regarding the effectiveness of harm reduc-
key populations at risk, namely, IDUs, MSM, tion interventions in preventing, slowing, or even
and FSWs. However, a review of national strate- reversing HIV epidemics among IDUs,3 harm
gic plans revealed that only those of Lebanon, reduction is increasingly appropriate in MENA.
Morocco, and Pakistan aim to engage each of MENA countries, however, are at different
the three priority populations.2 Other countries stages of introducing the different components
have either included strategies for one or two of the harm reduction package. The Islamic
key populations only, or mentioned a lump of Republic of Iran is a model country in its
key populations at risk without including response to HIV among IDUs, with a rapidly
specific strategies to address their specific needs scaled-up plan to make available needles and
and risks. syringes, opioid substitution therapy (OST), HIV
It is worth noting that countries that have testing and counseling, and sexually transmitted
clearly stated objectives or strategies addressing infection (STI) services. Once stabilized on OST,
priority populations have been more successful eligible HIV-positive IDUs are provided with
in directing their response to effective inter- antiretroviral therapy (ART).
ventions. Morocco, for example, is the only After conducting an assessment of risk behav-
country in the region that was able to imple- iors among IDUs, Morocco developed its harm
ment and rapidly scale up comprehensive ser- reduction policies and integrated them into its
vices for MSM and FSWs, in spite of the cul- national AIDS strategic plan. Currently, pilot
tural sensitivity. Similarly, the Islamic Republic drop-in centers performing needle and syringe
of Iran and Pakistan have introduced harm exchange are in place, while preparations for
reduction services for IDUs (but these need to introducing OST are underway.4 Similarly, the
be at a larger scale), and Djibouti could intro- Lebanese Minister of Health has publicly an-
duce targeted interventions for FSWs. Promis- nounced his commitment to introducing OST
ing programs are currently developing in into the public health system as a national res-
Afghanistan for IDUs and in Lebanon and ponse, after a successful buprenorphine substi-
Tunisia for the three key populations at risk. tution program was introduced by the NGO
The role of civil society and nongovernmental
3
organizations (NGOs) in implementing activities Des Jarlais et al., “HIV Incidence”; Metzger et al., Human
addressing priority populations has been pivotal. Immunodeficiency Virus Seroconversion”; van Ameijden et al.,
“Interventions among Injecting Drug Users.”
4
G. Riedner, personal communication (2008), and site visits to drop-in
2
UNAIDS and ASAP, “Review of National AIDS Strategic Plan.” centers in Tangier and Tetouane.
200 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Skoun.5 Lebanon’s National AIDS Program is heightened by marginalizing sociocultural atti-
currently putting in place measures to expand tudes, as a study of MSM suggests in Lebanon.11
OST. Needle and syringe programs are also The majority of MSM in the study indicated that
being implemented by NGOs through outreach they face exclusion from their communities and
workers. Over the last few years Pakistan has families.12 As far as their own practices are con-
scaled up its outreach, needle and syringe cerned, they often engage in unprotected sex,
exchange, testing, and counseling services for with 74% of those surveyed identifying unpro-
IDUs.6 Multisectoral national consultation is tected sex as the main reason for seeking volun-
currently being held to initiate OST. Afghanistan tary counseling and testing (VCT).
has initiated drop-in centers providing harm In a study in Sudan, more than half (55.6%)
reduction services, except for OST, which is of MSM study participants had exchanged sex
expected to start in the near future.7 A few for money.13 Close to half of those who had com-
NGOs in the Arab Republic of Egypt are provid- mercial sexual partners did not use a condom in
ing sterile needles and syringes to IDUs through the last sexual contact, and 85.3% indicated
outreach.8 Oman is reviewing its national poli- nonavailability of condoms at the time of the
cies and regulations to assess the need for and sexual act as the reason for lack of use. High-risk
feasibility of OST.9 practices coupled with a significant HIV preva-
A regional civil society movement has formed lence rate (9.3%) for this group emphasize the
and is called the Middle East and North Africa need for immediate prevention services for MSM.
Harm Reduction Association (MENAHRA).10 In Tunisia, the qualitative and quantitative
MENHARA’s objective is to build the capacity of survey conducted among MSM documented sub-
civil society organizations for harm reduction stantive risk behaviors, limited access to services,
through training, sharing information, net- and that more than 92.2% of those surveyed had
working, and providing direct support to NGOs both male and female partners.14
to initiate or scale up harm reduction services. Customary claims that stringent legal and
MENAHRA includes three subregional knowl- social context deters implementation of preven-
edge hubs: Lebanon’s hub is hosted by an NGO tion programs should not be a reason to shy away
(SIDC [Soins Infirmiers et Developpement Commu- from adapting programs and denying services to
nautaire]), the Islamic Republic of Iran’s hub is MSM. A number of countries are now addressing
hosted by the Iranian National Center for this population directly, although this remains
Addiction Studies (INCAS), and Morocco’s hub particularly sensitive with the general public,
is hosted by the Ar-Razi psychiatric hospital. community leaders, and law enforcement agen-
The MENAHRA network connects over 350 cies. Examples include Lebanon, where NGOs
professionals in the field of drug use and HIV such as Helem and SIDC, along with the National
through its Web site, bimonthly newsletter, and AIDS Program, have implemented outreach and
ad hoc announcements. HIV prevention for MSM. In Algeria, the first
outreach HIV prevention program for people
most at risk has reached out to male sex workers
Men who have sex with men
(MSWs) with services and condoms. In Tunisia
Data on MSM have been the most difficult to and Morocco, MSM are the outreach workers
obtain, but have begun to emerge over the last informing their peers on HIV prevention services,
five years and are indicating the need for accompanying them to VCT, and providing con-
immediate action. Limited adoption of safe doms and lubricants (when available). The assess-
sexual practices and low access to services are ment undertaken in Sudan on better understanding
the needs of MSM and their vulnerabilities is
5
Skoun, “New Perspectives.”
6
Punjab Provincial AIDS Control Programme, “The Lethal Overdose”;
11
Nai Zindagi quarterly reports 2007 (www.naizindagi.com/Reports). Dewachi, “HIV/AIDS Prevention.”
7 12
WHO/EMRO, unpublished country information. Ibid.
8 13
Aziz et al., “The Impact of Harm Reduction.” Elrashied, “Prevalence, Knowledge and Related Risky Sexual
9
WHO/EMRO, unpublished country information. Behaviours.”
10 14
MENAHRA, http://www.menahra.org/. Hsairi and Ben Abdallah, “Analyse de la situation de vulnérabilité.”
Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 201
a stepping stone to establishing trust with the in programs for those people most at risk.
communities and tailoring HIV prevention pro- Subsequently, in 2008, AIDS Algerie provided
grams to their needs. In Pakistan, a special pro- more than 1,500 males and females involved in
gram is set for MSM, MSWs, and hijras.15 Through sex work in Oran and Alger with condoms and
NGOs, outreach peer education and condom dis- HIV prevention information and materials.
tribution are expected to reach over 56,000 mem- The first project for women in vulnerable
bers of these priority groups by 2013. situations, established in Cairo in 2006 and
implemented through Shehab NGOs, resulted in
awareness-raising services mainly for FSWs,
Commercial sex
reaching more than 900 FSWs in the first two
As demonstrated in the previous chapters, men years of implementation.18 The project, through
and women involved in sex work face an outreach work and a drop-in center, established
increased risk of HIV infection. In addition to trust with the concerned communities; ensured
the illegal status of FSWs in the majority of access to STI treatment, legal services, and train-
MENA countries, social taboos and lack of ing on negotiation skills and condom use; and
means to protect FSWs from exploitation cause generated crucial information on the structural
clandestine prostitution to thrive in all coun- vulnerabilities of those involved in sex work.
tries, as well as in Tunisia, where sex work is In the Islamic Republic of Iran, a promising
regulated by law. Consequently, those involved experience is currently unfolding. It includes
are secluded and often reluctant to seek health, the provision of services to FSWs through the
social, or legal services or to disclose their risk of establishment of drop-in centers for women in
HIV exposure.16 risky situations. Interventions include HIV test-
This is compounded by social exclusion and ing and counseling, harm reduction services for
the negative attitudes of communities and ser- women using drugs, condom distribution, and
vice providers, attitudes mainly due to sociocul- STI services. This is believed to be an adapted
tural conservative attitudes on sexual behavior. approach to engaging FSWs given sociocultural
Despite overall reluctance and the stringent sensitivity and their illegal status.
context, HIV prevention programs started in Starting in 2003, in Djibouti, programs designed
Morocco in the 1990s and have provided male to engage FSWs were implemented; they included
and female sex workers with prevention informa- awareness raising, STI services, HIV testing and
tion and prevention, condoms, testing, counsel- counseling, and condom promotion and distribu-
ing, and STI services. In Lebanon, one NGO, Dar tion. Other countries such as Afghanistan, Jordan,
el Amal (the House of Hope), which has provided Pakistan, and Sudan are reportedly conducting
health, social, and vocational services for female awareness raising for FSWs through outreach.
FSWs since the 1970s, has mainstreamed HIV The results generated and trust built with the
services into its activities. The first outreach peer- communities in some of these examples have led
educator FSWs were recruited from this NGO. to expansion of the programs through NGOs and
Similarly, an NGO in Tunisia (ATL MST/ community organizations. It has also led to initiat-
sida-section de Tunis [Association Tunisienne de ing partnerships with police and community lead-
Lutte contre les MST et le sida-Section de ers to facilitate implementation of programs and
Tunis]), through outreach work implemented to protect the well-being of concerned communi-
by FSWs and MSM, provides HIV information ties. Support mobilized from the Joint United
and prevention kits (including condoms and Nations Programme on HIV/AIDS (UNAIDS), the
lubricants) and conducts awareness-raising ser- Global Fund to Fight AIDS, Tuberculosis and
vices and referral for VCT or treatment services. Malaria (GFATM), HIV International Alliance,
A qualitative survey of FSWs17 in Algeria resulted and others has been instrumental in expanding
efforts in several countries.
15
Pakistan National AIDS Control Program, HIV Second Generation
Surveillance (Rounds II and III).
16
Karouaoui, “Report of Mission on HIV and Sex Work in Oman.”
17 18
AIDS Algérie, UNAIDS, and UNFPA, Travail du Sexe et VIH/SIDA en ONUSIDA, Rapport de fin de Mission Appui aux Programmes de
Algérie. Prévention SIDA.
202 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Young people components in evolving HIV prevention efforts,
encouraging and facilitating the engagement of
Peer influence can encourage risky behavior, but
civil society and national AIDS programs with
it can also be used to spread knowledge through
the concerned populations and communities.
peer educators.19 The Islamic Republic of Iran
HIV prevention efforts raise awareness and
has spearheaded a peer education program in
provide information, materials, and services (for
schools that has trained thousands of students to
example, condoms; interpersonal communica-
educate peers on HIV.20 A special course on
tion; referrals to VCT; and STI, ART, and other
AIDS was developed as an appendix to biology
health care and social support programs) includ-
books and 13,000 teachers and school physicians
ing risk or harm reduction. Prevention efforts
have been trained to educate 1.5 million stu-
focus on changing risky or maintaining safe
dents in high schools.21 Tunisia had a program to
behaviors through channels such as interper-
reach out to youth through appropriate educa-
sonal communication, peer education, and
tion, counseling and testing, condoms, and STI
outreach.
services that reached 10% of the youth.22 In
Sudan, an intervention for youth has provided
over 300,000 young people with health educa-
tion sessions covering various topics.23 ACCESS TO MEANS OF PREVENTION
While this shift over time from HIV prevention
Progress in HIV prevention based mainly on health promotion to a more
focused approach on behavior change is nota-
Progress made over the last four years in terms
ble, the coverage and quality of services and
of generating crucial information on HIV preva-
means of prevention in the region are still far
lence, risks, and vulnerabilities for priority pop-
from adequate. Access to HIV-related preven-
ulations and settings has been a breakthrough in
tion means and services remains sporadic, with
informing advocacy efforts and programmatic
very limited coverage, and is therefore unlikely
choices, contributing to policy change, and cre-
to lead to significant behavior change.
ating an enabling environment.
With regard to condom availability, some
With just a few exceptions, HIV prevention
progress has been made with some countries
programs have recently taken a qualitative step
(such as in Algeria, Jordan, Morocco, and Sudan)
forward by combining several communication
reporting an increase in condom availability and
and service-delivery approaches and focusing
distribution, mainly as part of indicators to
on behavior change in the form of risk and
monitor progress of GFATM-supported projects.
harm reduction. Enhancing the quality of inter-
These data are an important leap toward making
ventions, expanding coverage, and intensifying
means of prevention available; however, little is
implementation remain key challenges for HIV
known about whether condom distribution is
prevention programs that engage high-risk pop-
part of a behavior change approach reaching
ulations in the region.
people most at risk. However, stigma related to
One of the main obstacles that prevention
the very nature of HIV transmission, compounded
efforts had to overcome was the limited knowl-
by the social marginalization of those exposed,
edge on, contacts with, and participation of the
hampers efforts to include condoms and other
concerned populations. To overcome these
means of prevention as part of prevention pro-
obstacles, peer education and outreach strate-
grams in many countries. It is also noted that in
gies were introduced and are now essential
specific programs for people most at risk, the
19
messages delivered and means of prevention
Busulwa, “HIV/AIDS Situation Analysis Study”; Kocken et al., “Effects
have not been adapted to their needs; therefore,
of Peer-Led AIDS Education.”
20
Gheiratmand et al., “A Country Study.” they have little impact on behaviors, especially
21
Gheiratmand et al., “A Country Study”; Mohebbi and Navipour, while negotiation skills with their sexual part-
“Preventive Education.” ners are limited.
22
Jenkins and Robalino, “HIV in the Middle East and North Africa.”
23
SNAP and UNAIDS, “HIV/AIDS Integrated Report North Sudan, Information, education, and communication
2004–5.” (IEC) materials for refugees and mobile
Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 203
populations in the Republic of Yemen, for establishment of VCT services at a community
example, were not adapted to the languages of level across the region.
those concerned, nor were the messages explicit Morocco is one of the first countries to estab-
in terms of transmission modes and prevention lish VCT centers with broad, national coverage.
methods. Condoms were not included as part of Today, Algeria has expanded its VCT network
prevention activities, and referrals to VCT were across the country and more than 75 centers
lacking. The situation is compounded by the have been established in Sudan. In Lebanon, the
limited capacities and resources of implement- innovative model of establishing and managing
ing partners to provide prevention materials, VCTs through NGOs was adopted by the National
such as condoms and lubricants, and make them AIDS Program and partners.26
accessible as part of outreach activities.24 However, the recent increase in VCT services
In a review of programs for IDUs in Egypt, has not translated into enhanced prevention
provision of needles, syringes, condoms, and efforts or an increased number of those who
other HIV prevention commodities appeared to know their HIV status. A recent review revealed
be inconsistent at the three sites reviewed.25 The that VCT services are either not available or lim-
outreach program for MSM in Tunisia is in des- ited to major cities in most countries.27 Where
perate need of a robust and sustainable procure- they exist, these VCT services are underused.
ment system for water-based lubricants for dis- Different reasons may account for this, including
tribution with the prevention kit. the absence or low coverage of HIV prevention
The use of condoms in HIV prevention pro- programs among priority groups and vulnerable
tective strategies is reported to be generally low and other populations, as well as weak message
in the region (chapter 8). Condom use is also quality and lack of referrals to the VCT. Other
low and irregular among people who need them factors could be the general concern that confi-
the most, including those reporting multiple and dentiality may not be maintained and the nega-
casual unprotected sexual contacts, although tive attitudes of service providers in the VCT
utilization rates among such groups are still con- centers, which have been documented in some
siderably higher than in the general population countries.
(chapter 8). Despite the above evidence, con- The same review has demonstrated that HIV
dom promotion, access, and distribution are still rapid tests have not been fully adopted in
conspicuously missing from many HIV preven- MENA. Where they are used, laboratory confir-
tion programs being implemented in the region. mation of reactive tests requires the use of ELISA
Even when programs have included condoms, (enzyme-linked immunosorbent assay), and, in
access has remained difficult and limited to cer- many cases, Western blot assay. The resulting
tain distribution points. waiting time and cumbersome procedure for the
Continuing to ignore the sensitive but essential clients to get their HIV test results increase the
issue of condom accessibility and neglecting the promo- risk of losing the client before he or she is
tion of its protective role for everyone, particularly for informed of the test result.
people most at risk, are undoubtedly crippling effective Moreover, the review has shown that the
HIV prevention efforts, as is the case in many countries majority of people in MENA learn their HIV sta-
of the region. tus through mandatory testing. Out of tens of
millions of HIV tests conducted in the region
since 1995, only a little over 400,000 were
HIV TESTING AND COUNSELING administered through VCT. All countries of the
region (except Djibouti and Morocco, which do
Initially, most VCT centers across the region
mandatory testing only on military recruits to
were located only in the capital cities as part of
establish physical fitness) have mandated HIV
governmental health facilities, discouraging
testing for different purposes including preop-
those fearing stigma from checking their HIV
erative, pre-employment, in-migration, and
status. There was substantial delay in the
24 26
Semini, Njogou, and Mortagy, UNHCR/UNAIDS Joint Mission. Lebanon National AIDS Control Program, “A Case Study.”
25 27
UNAIDS/APMG, Recommendations for Interventions. WHO/EMRO, “Regional Review of HIV Testing.”
204 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
high-risk populations upon arrest or admission to adapt programs to the needs of people most at
to health care. The consequences of positive HIV risk and expand coverage and intensity to reach
test results can be deportation of migrant work- all of those in need. Adapted programmatic
ers, denial of visa, or denial of health care services. approaches are necessary to provide services to
Provider-initiated testing and counseling those in bars, residences, streets, and other high-
(PITC) is rarely adopted. Where it is reportedly risk areas. Biobehavior information disaggregat-
undertaken in health care settings (for example, ed on settings and specific geographical locations
in tuberculosis clinics, antenatal clinic services, at higher risk needs to take into account the geo-
surgical units, STI clinics, and others), PITC is graphical variations to determine the priority
often confused with mandatory screening, where settings and focus of expanded HIV prevention.
the requirement for consent is not respected. As an example, in Morocco, HIV prevalence
among sex workers is substantively higher in
Marrakesh and Agadir, while IDU is prevalent in
EXPANDING COVERAGE
Tangier and Tetouan, and this information
Currently, scaled-up and decentralized HIV pre- should be used in planning prevention programs
vention programs are the exception to the rule in each setting. In Algeria, Tamanrasset and
in MENA. Partially due to the fact that the cur- Tiaret are characterized by a considerably higher
rent HIV prevention programs for priority popu- HIV prevalence rate among FSWs compared to
lations are nascent in the region, current efforts other regions (9% in Tamanrasset, 3%–8% in
are mainly patchy projects providing access to some regions in 2004–07, and 11% in Tiaret28),
populations in selected areas of urban cities. The and the NSP for 2008–12 places a priority focus
programs that have expanded in various regions on programs for sex work in these selected areas.
of Morocco demonstrate the feasibility of scaled-
up programs for those involved in sex work,
even in a stringent context. In Morocco in 2007, CIVIL SOCIETY AND PEOPLE LIVING WITH
51.8% of FSWs were tested in VCT centers and HIV AS IMPLEMENTATION PARTNERS
received the result. Of the above, 53.2% declared
A wider proliferation of NGOs and community-
using a condom during the last sexual contact
based organizations to help implement HIV pre-
compared to 37.5% in 2003.
vention programs will improve HIV prevention
Massive efforts are needed to address the
services and programs and help focus these pro-
challenges impeding coverage expansion and
grams on priority populations that are harder to
the implementation of quality and focused HIV
reach. There is a limited presence of NGOs and
prevention programs. One of the challenges of
community organizations implementing HIV
scaling up programs for HIV prevention is the
prevention, particularly for people most at risk,
variety of contexts where risk behaviors take
and this significantly hinders the decentralization
place. People involved in sex work are not a
and expansion of service coverage. Pioneering
homogeneous group, existing networks relate
NGOs have initiated breakthrough projects on
to subpopulations (those working in the streets,
HIV prevention; however, their scope and cover-
hotels, and so forth), and various motivations
age remain limited.
and several underlying factors determine
Thus, it is essential that other NGOs and
involvement in sex work. The variations among
community-based organizations are identified
existing networks make it even more challeng-
in the priority areas and are trained to deliver
ing to inform an effective programmatic
HIV prevention services and information to
approach. In the MENA context, current pro-
people most in need. These NGOs can be devel-
grams reach only a few subpopulations of
opmental partners working on thematics other
FSWs, drug users, and MSM, mainly deter-
than AIDS that have community access and the
mined by the initial entry point of how these
trust of the populations, but not necessarily the
populations were reached.
required competence on HIV-related services.
Information generated by situation assess-
ments in terms of underlying vulnerability factors
28
and context variety needs to be effectively used Algeria National AIDS Council, “Algeria National Strategy.”
Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 205
Despite an environment of limited awareness, being inconsistent or nonexistent among the
apprehension, and stigma associated with HIV/ vast majority. In Afghanistan, more than 70% of
AIDS, associations of people living with HIV IDUs surveyed in Kabul had paid women for sex,
(PLHIV) have now emerged as partners in more while condom use is exceptionally low in the
than 10 countries of the region. Civil society orga- country.30 Conversely, in the Syrian Arab
nizations and, in some cases, the national AIDS Republic, 10% FSWs reported drug injection.31
programs have contributed to establishing sup- A study in Alexandria, Egypt, showed that
port groups and associations for PLHIV in recent 10.9% of MSM had injected drugs in the previous
years. In countries such as Algeria, Djibouti, 12 months.32 High-risk sexual practices were also
Morocco, and Sudan, socioeconomic support prevalent, with 53% of drug users interviewed in
mechanisms have also been put in place through Syria having engaged in sex work, and 40% of the
joint government and civil society initiatives, sexually experienced had never used a condom,
including for a sizable number of orphaned chil- while only 20% had done so consistently.33
dren in Djibouti. The role of people living with Likewise, among a sample of IDUs in treatment in
HIV and their association as equal partners is the Islamic Republic of Iran, most were sexually
essential to ensure access to HIV prevention, active and exchanging money for sex was not
treatment, care, and support services. uncommon, yet almost half of them had never
used a condom.34 However, few programs integrate
adapted approaches to address the multiple and
From evidence to programs overlapping risks. The NGOs providing HIV preven-
tion services to FSWs in Egypt, despite the holistic
Translating evidence generated through research, approach adopted and the willingness to address
biobehavior surveys, and surveillance into adapt- the needs of women who also inject drugs, do not
ed programming is essential to devise an optimal provide drug injection–related HIV prevention
combination of interventions tailored to the needs information and material as part of the prevention
of concerned populations. package, nor have they the capacity to do so. A few
Overlapping risks have been documented programs on drug use and HIV have included a
(chapters 2–4); however, few programs include focus on sexual risks, with limited integration of
a comprehensive package of interventions and education about sexual risks or condom provision.
referral to services to address the needs of people This lack of integration in adapted approach-
who are exposed to multiple risks. Such pack- es is also due to the focus and capacities of the
ages need to be an integral part of prevention NGOs implementing the HIV prevention pro-
programs and are crucial to averting an epidemic. grams. Involving the concerned communities in
Specific programming and focus are necessary to planning the prevention services and manage-
address the needs of these subpopulations. ment of implementation will help to redeem the
Strikingly, there appears to be considerable programming shortfalls.
multiplicity and overlap of risk factors in urban In almost all of the MENA countries, an
settings in MENA, including injecting drug use impediment to measuring progress and
and unprotected sexual contacts (chapter 2). The determining the priorities for prevention pro-
overlap of sexual and drug injecting risks, which grams is the absence of monitoring and evalua-
was featured in nearly all of the behavioral sur- tion (M&E) systems to assess program impact
veys among drug users,29 and was also docu- over time. Integrating data collection from the
mented among FSWs and MSM, could spark inception of the program, using the data to
more serious HIV outbreaks across populations inform the program and national M&E system,
at a time when consistent condom use is strik-
ingly low. Over 40% of drug users in Algeria,
30
36% in Cairo, and 33% in Lebanon had engaged Todd et al., “Prevalence of Human Immunodeficiency Virus.”
31
Syria National AIDS Programme, “HIV/AIDS Female Sex Workers.”
in sex work contacts in the month preceding the 32
Egypt Ministry of Health and Population, and National AIDS Program,
interview, with the reported use of condoms HIV/AIDS Biological and Behavioral Surveillance Survey.
33
Syria Ministry of Health, UNODC, and UNAIDS, “Assessment on Drug
Use and HIV in Syria.”
29 34
UNAIDS, UNODC, and WHO, “Fact Sheet on Drug Use.” Zamani et al., “Prevalence.”
206 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
and the participation of concerned populations in health care settings are generally on the dec-
will yield much-needed information on service line, although this mode of transmission contin-
delivery and prevention progress. ues to be present in a small number of countries.
Overall, the percentage of reported HIV and AIDS
cases attributed to contaminated blood has fallen
Scope, quality, and outreach are essential for
from 12.1% in 1993 to 0.4% for the entire
sustainable HIV prevention programs
MENA region in 2003.35
Because HIV prevention efforts need to focus on According to countries’ universal access indi-
the people who are likely to be reluctant to cator reports for 2007, the screening of donated
approach facility-based services, outreach and blood was fully operational at 100% in all facili-
peer education are the keys to providing these ties in Djibouti, the Islamic Republic of Iran,
hard-to-reach people with information and Iraq, Jordan, Lebanon, Oman, Saudi Arabia,
services. Somalia, Sudan, Syria, Tunisia, and the United
Experience confirms that it is essential that Arab Emirates.36 Afghanistan and Pakistan
outreach workers come from the concerned com- report that 39% and 87%, respectively, of
munities; this helps to ensure behavior change donated blood units were screened for HIV in a
and empowers the communities themselves. quality assured manner.37 No data were avail-
Health and social workers, and NGO volunteers able for Sudan, the West Bank and Gaza, and
face increasing challenges to establish regular the Republic of Yemen.38
contacts and deliver HIV prevention messages to
IDUs in Egypt, while ex- and active IDUs have
proven to be very efficient and trusted by the
HIV CARE AND TREATMENT
communities, leading to increased adoption of
safe methods. By 2005, in the majority of MENA countries,
Outreach is an efficient technique for getting ART was available at least at one central health
information and services to people who need facility. During the following years, access to
them most. However, high rotation and change ART was expanded to include low-income coun-
of personnel over time hampers effective and tries that had succeeded in mobilizing donor
quality behavior change interventions, because support through the GFATM.
there is limited incremental experience in the The introduction of ART had an almost imme-
implementing partner institutions. The complexi- diate and visible impact on the quality of life of
ties and challenges are magnified as the programs PLHIV, which was also evident in the reduced
try to expand coverage. In addition to manage- mortality rates. In Tunisia, the mortality of AIDS
ment challenges, maintaining a core mass of patients fell from 45% to 7.8% between 2000
outreach workers with adequate, updated skills is and 2003. However, the gap between PLHIV
proving difficult. receiving treatment and the overall estimated
Education and referral for large HIV prevention need for treatment has remained substantial.
programs demand significant resources, and con- Based on the most recent UNAIDS and World
tinuous training quality may be affected over time. Health Organization (WHO) estimates, at the
While recognizing the necessity of ensuring that end of 2008, approximately 151,000 PLHIV
outreach workers are peers of the populations were in need of ART in MENA39; two-thirds of
being engaged, programs in MENA should try to them are living in Pakistan and Sudan. Only
institutionalize outreach work to ensure their sus- 9,622 PLHIV in need of ART were reportedly
tainability and long-term impact on HIV prevention. receiving treatment.40 Accordingly, in 2007, the
35
UNAIDS, “Notes on AIDS in the Middle East and North Africa.”
36
BLOOD SAFETY AND UNIVERSAL 37
WHO/EMRO, “Progress towards Universal Access” (2007).
Ibid.
PRECAUTIONS 38
WHO/EMRO, Progress towards Universal Access” (2006); WHO and
EMRO, “Progress towards Universal Access” (2007).
Infections as a result of blood products, blood 39
WHO, UNAIDS, and UNICEF, “Towards Universal Access.”
transfusion, and lack of infection control measures 40
WHO/EMRO, “Progress towards Universal Access” (2007).
Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 207
Figure 12.1 ART Scale Up in Somalia and Southern Sudan between 2005 and 2008
1,000
800
400
200
0
Jun. 05 Dec. 05 Jun. 06 Dec. 06 Jun. 07 Dec. 07 Jun. 08 Dec. 08
time
Source: WHO/EMRO. Country data reported to the WHO Office of the Eastern Mediterranean Region.
Table 12.1 Number of PLHIV on ART in Selected Somalia started in June 2005, and by the end of
Countries, 2006–08 2008, more than 500 of the PLHIV were receiv-
ing ART (figure 12.1).43
Country 2006 2007 2008
A main reason for the low ART coverage in
Djibouti 578 705 816 MENA is that a very small proportion of PLHIV
Iran, Islamic Rep. of 522 827 921 know their HIV status, and approximately 80%
Morocco 1,370 1,648 2,207 of PLHIV known to the health care system to be
Pakistan 164 523 907 in need of ART are actually receiving treat-
Somalia 111 211 413 ment.44 At local and regional meetings of sup-
port groups, PLHIV frequently voice their fear of
Sudan 986 1,198 2,317
nonconfidentiality if they disclose their HIV sta-
Yemen, Republic of 0 107 189
tus to health service providers and the resulting
Source: WHO/EMRO Regional Database on HIV/AIDS; WHO/EMRO stigma and discrimination they could face with-
2008a.
in the health system, their workplaces, and
communities. Accordingly, there is reason to
regional ART coverage of the estimated need assume that a considerable proportion of PLHIV
was 6%, the lowest among all regions. By 2008, who know their HIV status try to avoid contact
all countries in MENA, except for Afghanistan, with the public health system and attempt to
Iraq, and the West Bank and Gaza, had estab- find access to treatment in the private sector or
lished HIV care and treatment services and were outside their countries. The limited ability of
steadily expanding access to ART (table 12.1).41 most countries to implement interventions for
Experience with establishing and expanding reaching high-risk populations is likely to con-
access to HIV care and treatment in Southern siderably affect access to and use of HIV VCT,
Sudan and Somalia shows that providing ART is and therefore impact treatment.
possible, even in very difficult contexts. Southern Large gaps in geographical coverage of ART
Sudan initiated its HIV care and treatment pro- services are another reason for the low treat-
gram by mid-2007, and by December 2008, ment coverage in MENA countries with the
almost 1,000 of the PLHIV received ART.42 highest burden of HIV. In 2007, per 1,000
PLHIV in need of ART, 1.5 health facilities
41
WHO/EMRO Regional Database on HIV/AIDS.
42 43
WHO/EMRO, data reported to the WHO Office of the Eastern Ibid.
44
Mediterranean Region. WHO/EMRO, “Survey on Status.”
208 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
offered ART in Pakistan, 0.9 in Somalia, 0.4 in mother-to-child transmission (PMTCT), com-
Sudan, and 0.6 in the Republic of Yemen.45 pared to one-third in 2006.54 However, major
Treatment outcomes reported by country ART challenges remain to ensure the effectiveness of
programs in low-income countries in the region PMTCT programs, including low antenatal care
are comparable to globally reported outcomes. In attendance rates in some countries, geographical
2008, the reported survival rate of PLHIV on availability of PMTCT services, provision of HIV
ART during one year was 92% in Pakistan and testing and counseling in antenatal care clinics
ranged between 72% and 91% in Djibouti, the (opt-out approach), antiretroviral (ARV) prophy-
Islamic Republic of Iran, Morocco, Somalia, and laxis regimen efficacy, and retention of women
the Republic of Yemen.46 and children in PMTCT services. According to
Despite rather newly established national ART reports on universal access indicators in 2008
programs and low ART coverage, some countries, from Jordan, Morocco, Somalia, Sudan, and the
such as the Islamic Republic of Iran and Pakistan, Republic of Yemen, less than 1% of the estimat-
already report a high proportion (greater than ed total number of pregnant women underwent
10%) of patients receiving second line ART, indi- an HIV test. Based on the same reports, between
cating the emergence of HIV drug resistance. less than 1% and 24% of the estimated number
Good adherence to ART has been observed in of HIV-positive pregnant women received anti-
Morocco,47 though noncompliance and treatment retroviral prophylaxis to reduce the risk of
interruptions have been observed, for example, in mother-to-child HIV transmission in the Islamic
Oman.48 Some of the identified challenges to Republic of Iran (23.6%), Morocco (14.3%),
adherence are the difficulty in following the admi- North Sudan (0.2%), Pakistan (0.02%), Somalia
nistration schedule, long distances between home (0.3%), and the Republic of Yemen (0.4%).55
and ART services, or the presence of adverse
effects.49 This suggests the need for education and
PREVENTION AND CONTROL OF STIS:
counseling programs to ensure that patients
understand ART and thereby improve adher-
CURRENT RESPONSE AND CHALLENGES
ence.50 There is also evidence of obtaining drugs According to information on the status of STI sur-
with no prescription and no clinical and psychoso- veillance and control obtained from focal points
cial support.51 Some countries report problems in the ministries of health, surveillance is limited
such as drug stock outs, lack of second line drugs, or not established in most MENA countries. Only
over-centralization of services, and lack of com- one country (Morocco) reported establishing a
prehensive care and psychosocial support.52 surveillance system that makes it possible to chart
Few countries are implementing HIV drug trends, quantify the situation, guide program
resistance monitoring and surveillance activities, planning, and assess the impact of interventions
according to the WHO global strategy. In 2008, (chapter 10). Thus, reliable data on STIs are not
only Djibouti published an annual report on HIV often available in the region.
drug resistance early warning indicators.53 The degree to which MENA countries have
already established STI control programs and
HIV MOTHER-TO-CHILD TRANSMISSION their ability to implement recommended STI pre-
vention and control interventions, in terms of
In 2008, half of the MENA countries had estab- available political support, resources, and sys-
lished national programs for prevention of tems, vary widely. Most STI programs are not
appropriately equipped with human and finan-
45
WHO/EMRO, “Progress towards Universal Access” (2007). cial resources. According to an unpublished
46
WHO/EMRO, “Progress towards Universal Access” (2007); WHO/ review of the STI response conducted by the
EMRO, “Progress towards Universal Access” (2008).
47
Benjaber, Rey, and Himmich, “A Study on Antiretroviral Treatment.” World Health Organization Eastern Mediterranean
48
Al Dhahry et al., “Human Immunodeficiency Virus.” Regional Office (WHO/EMRO), 12 countries
49
Benjaber, Rey, and Himmich, “A Study on Antiretroviral Treatment.” (Afghanistan, Bahrain, Djibouti, Egypt, the
50
Ibid.
51
Shah et al., “Antiretroviral Drugs.”
52 54
UNAIDS, “Notes on AIDS in the Middle East and North Africa.” WHO/EMRO, “Progress towards Universal Access” (2007).
53 55
Djibouti National AIDS Programme, “Programme de lutte contre le sida.” WHO/EMRO, “Progress towards Universal Access” (2008).
Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 209
Islamic Republic of Iran, Iraq, Morocco, Oman, focused on the general population despite the
Pakistan, Saudi Arabia, Somalia, and the West limited HIV prevalence in this population.
Bank and Gaza) reported having a national strat- Coverage of and access to HIV prevention ser-
egy for STIs. Only five countries (Bahrain, the vices among priority populations continue to be
Islamic Republic of Iran, Morocco, Pakistan, and far below the needs. Access to HIV treatment
Saudi Arabia) have a national action plan to varies and is among the lowest globally.
implement these strategies and have allocated A key structural problem in MENA is the
more than 50% of the funds required for the poor mapping of risk, vulnerabilities, and HIV
response from the national health budget. infection in the population. Most HIV infections
STI interventions currently being implemented are not diagnosed until years after infection.
in several countries often do not build on evi- There is an urgent need for all MENA countries
dence-based, effective public health approaches, to develop robust surveillance systems for HIV
as recommended in the global strategy for the and STIs and to base their policies on the epide-
prevention and control of STIs. According to a miological outcome of this surveillance. Due to
survey carried out by WHO/EMRO in 2008, the absence of such surveillance, resources are
13 countries have implemented the syndromic not being allocated according to need.
approach for STI case management, but only Essential to transforming social attitudes in
6 (Djibouti, Egypt, Jordan, Morocco, Pakistan, MENA is the growing participation of PLHIV in
and Somalia) have carried out etiological studies the national response. Prevailing stigma and
to validate the WHO flowcharts relating to the discrimination in relation to HIV/AIDS have
syndromic approach.56 been a serious impediment to the proliferation
The same survey found that most countries in and visibility of the HIV engagement of civil
the region do not provide any special STI services society and other nongovernmental partners.
for priority populations. Only six countries However, MENA has witnessed a growing
(Djibouti, Egypt, Jordan, Morocco, Pakistan, and movement of PLHIV over the past few years.
Sudan) have implemented an outreach peer Walking the fine line between law enforce-
education program among sex workers. Egypt, ment and public health will necessitate strong
Morocco, and Pakistan also provide special con- political commitment and a solid and effective
sultation and treatment services for this group. partnership between different sectors, such as
Any response that does not address priority the police, national AIDS programs, NGOs, and
populations, such as FSWs, MSM, and IDUs, will communities. Without a multisectoral approach
fall short of having any significant impact on the and partnerships with civil society, key popula-
spread of STIs in MENA. As in other regions, STI tions, and PLHIV, the HIV response in MENA
and HIV transmission are concentrated among will be severely limited in its ability to control
groups that have higher rates of partner change HIV spread.
and higher-risk behaviors than the general pop-
ulation. Although these groups are socially mar-
ginalized, the infection spreads to the general BIBLIOGRAPHY
public via other population subgroups, known as
AIDS Algérie/UNAIDS/UNFPA. 2005. Travail du Sexe et
bridging populations, which connect the higher- VIH/SIDA en Algérie; Enquête qualitative sur le travail du
risk groups (such as clients of sex workers) and sexe et le VIH/SIDA. AIDS Algeria/UNAIDS/UNFPA.
the general population. 2005.
Al Dhahry, S. H., E. M. Scrimgeour, A. R. Al Suwaid,
M. R. Al Lawati, H. S. El Khatim, M. F. Al Kobaisi,
CONCLUDING REMARKS AND SUMMARY and T. C. Merigan. 2004. “Human Immunodeficiency
Virus Type 1 Infection in Oman: Antiretroviral
OF FINDINGS Therapy and Frequencies of Drug Resistance
Mutations.” AIDS Res Hum Retroviruses 20: 1166–72.
HIV prevention and treatment efforts in MENA
Algeria National AIDS Council. 2009. “Algeria National
continue to be rather limited despite recent Strategy of the HIV/AIDS Response for 2009–2012.”
improvements. Ample efforts continue to be Aziz, A., A. Malek, S. Kozman, D. Rezk, A. Sawy, and
Y. Shafei. 2007. “The Impact of Harm Reduction
56
WHO/EMRO, “Technical Paper.” Program on IDUs Knowledge and Preventive Practice:
210 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
A Pilot Experience.” International Conference on the Metzger, D. S., G. E. Woody, A. T. McLellan, C. P. O’Brien,
Reduction of Drug Related Harm, Warsaw, abstract. P. Druley, H. Navaline, D. DePhilippis, P. Stolley, and
Benjaber, K., J. L. Rey, and H. Himmich. 2005. “A Study E. Abrutyn. 1993. “Human Immunodeficiency Virus
on Antiretroviral Treatment Compliance in Casa- Seroconversion among Intravenous Drug Users in-
blanca (Morocco).” Med Mal Infect 35: 390–95. and out-of-Treatment: An 18-Month Prospective
Follow-Up.” J Acquir Immune Defic Syndr 6: 1049–56.
Busulwa, R. 2003. “HIV/AIDS Situation Analysis Study.”
Conducted in Hodeidah, Taiz and Hadhramut, Mohebbi, M. R., and R. Navipour. 2004. “Preventive
Republic of Yemen. Education against HIV/AIDS in the Schools of Iran.”
Indian Pediatr 41: 966–67.
Des Jarlais, D. C., M. Marmor, D. Paone, S. Titus, Q. Shi,
T. Perlis, B. Jose, and S. R. Friedman. 1996. “HIV Morocco National STI/AIDS Programme. 2007. “National
Incidence among Injecting Drug Users in New York Strategic Plan to Fight AIDS 2007–2011.” Ministry of
City Syringe—Exchange Programmes.” Lancet 348: Public Health/Department of Epidemiology and
987–91. Disease Response, Kingdom of Morocco.
Dewachi, O. 2001. “HIV/AIDS Prevention through ONUSIDA/El Karaouaoui A. 2008. Rapport de fin de
Outreach to Vulnerable Populations in Beirut, Mission Appui aux Programmes de Prévention SIDA auprès
Lebanon: Men Who Have Sex with Other Men and des Professionnelles du Sexe. Caire-Egypte-2008.
HIV AIDS; A Situation Analysis in Beirut, Lebanon.” Pakistan National AIDS Control Program. 2006–7. HIV
Final report, April 29. Second Generation Surveillance in Pakistan. National
Djibouti National AIDS Programme. 2008. “Programme Report Round II. Ministry of Health, Pakistan, and
de lutte contre le sida: Suivi des indicateurs d’alerte Canada-Pakistan HIV/AIDS Surveillance Project.
rapide à la résistance aux médicaments antirétroviraux ———. 2008. HIV Second Generation Surveillance in Pakistan.
en République de Djibouti.” République de Djibouti, National Report Round III. Ministry of Health, Pakistan,
Ministère de la Sante, document de référence. Canada-Pakistan HIV/AIDS Surveillance Project.
Egypt Ministry of Health and Population, and National Punjab Provincial AIDS Control Programme. 2005. “The
AIDS Program. 2006. HIV/AIDS Biological and Behavioral Lethal Overdose: Injecting Drug Use and HIV/AIDS.”
Surveillance Survey. Summary report, Cairo, Egypt.
Semini, I., P. Njogou, and I. Mortagy. 2004. UNHCR/
Elrashied, S. 2006. “Prevalence, Knowledge and Related UNAIDS Joint Mission; HIV/AIDS Assessment Mission in
Risky Sexual Behaviours of HIV/AIDS among Refugee Setting in Yemen. September.
Receptive Men Who Have Sex with Men (MSM) in
Khartoum State, Sudan, 2005.” XVI International Shah, S. A., A. Altaf, R. Khanani, and S. H. Vermund.
AIDS Conference, Toronto, August 13–18, abstract 2005. “Antiretroviral Drugs Obtained without
TUPE0509. Prescription for Treatment of HIV/AIDS in Pakistan:
Patient Mismanagement as a Serious Threat for Drug
Gheiratmand, R., R. Navipour, M. Mohebbi, K. Hosseini, Resistance.” J Coll Physicians Surg Pak 15: 378.
M. Motaghian-Monazzam, A. Mallik, et al. 2004. “A
Country Study to Review Existing Capacity Building Skoun. 2009. “New Perspectives for the Prevention and
and Management of the Training of Teachers on Treatment of Addictions.” Conference proceedings,
Preventive Education against HIV/AIDS in the October 7–9, 2009.
Schools in I.R. Iran.” SNAP (Sudan National AIDS Programme), and UNAIDS
Hsairi, M., and S. Ben Abdallah. 2007. “Analyse de la (Joint United Nations Programme on HIV/AIDS).
situation de vulnérabilité vis-à-vis de l’infection à VIH 2006. “HIV/AIDS Integrated Report North Sudan,
des hommes ayant des relations sexuelles avec des 2004–2005 (Draft).” With United Nations General
hommes.” For ATL MST sida NGO–Tunis Section, Assembly Special Session on HIV/AIDS Declaration of
National AIDS Programme/DSSB, UNAIDS. Final Commitment.
report, abridged version. Syria Ministry of Health, UNODC (United Nations Office
Jenkins, C., and D. A. Robalino. 2003. “HIV in the on Drugs and Crime), and UNAIDS. 2007. “Assessment
Middle East and North Africa: The Cost of Inaction.” on Drug Use and HIV in Syria.” Draft report, July.
Orientations in Development Series, World Bank. Syria National AIDS Programme. 2004. “HIV/AIDS
Karouaoui, A. 2008. “Report of Mission on HIV and Sex Female Sex Workers KABP Survey in Syria.”
Work in Oman.” UNAIDS, RST, Cairo, Egypt. Todd, C. S., Y. Barbera-Lainez, S. C. Doocy, A. Ahmadzai,
Kocken, P., T. Voorham, J. Brandsma, and W. Swart. F. M. Delawar, and G. M. Burnham. 2007. “Prevalence
2001. “Effects of Peer-Led AIDS Education Aimed at of Human Immunodeficiency Virus Infection, Risk
Turkish and Moroccan Male Immigrants in the Behavior, and HIV Knowledge among Tuberculosis
Netherlands: A Randomised Controlled Evaluation Patients in Afghanistan.” Sex Transm Dis 34: 878–82.
Study.” Eur J Public Health 11: 153–59. UNAIDS (Joint United Nations Programme on HIV/
Lebanon National AIDS Control Program. 2008. “A Case AIDS). 2008. “Notes on AIDS in the Middle East and
Study of the First Legal, Above-Ground LGBT North Africa.” RST MENA.
Organization in the Mena Region.” Helem, Beirut, UNAIDS/AIDS Project Management Group (APMG)
Lebanon. (2007). Recommendations for Interventions Addressing
———. 2004. “AIDS/HIV National Strategic Plan: Injecting Drug Use and Related HIV Infection in Egypt;
Lebanon 2004–2009.” Ministry of Public Health, Egypt HIV and Injecting Drug Use Supplementary Report.
United Nations Theme Group on HIV/AIDS. UNAIDS. October 2007.
Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 211
UNAIDS, and ASAP. 2008. “Review of National AIDS Report on an indicator survey for the year 2007 in
Strategic Plan in the Middle East and North Africa.” the WHO Eastern Mediterranean Region.
RST MENA, December. ———. 2008a. “Progress towards Universal Access to
UNAIDS, UNODC (United Nations Office on Drugs and HIV Prevention, Treatment and Care in the Health
Crime), and WHO (World Health Organization). Sector. Report on an indicator survey for the year
2006. “Fact Sheet on Drug Use and HIV in MENA.” 2007 in the WHO Eastern Mediterranean Region.”
November. ———. 2008b. “Regional Review of HIV Testing and
van Ameijden, E. J., J. K. Watters, J. A. van den Hoek, Counseling Policies and Practices in the EMR.” WHO/
and R. A. Coutinho. 1995. “Interventions among EMRO, FHI, unpublished.
Injecting Drug Users: Do They Work?” AIDS 9 Suppl WHO, UNAIDS, and UNICEF (United Nations Children’s
A: S75–84. Fund). 2008. “Towards Universal Access: Scaling Up
WHO/EMRO (Eastern Mediterranean Regional Office). Priority HIV/AIDS Interventions in the Health Sector.”
“Technical Paper on the Regional Strategy for STI Progress report, WHO/UNAIDS/UNICEF, Geneva.
Prevention and Control in the Eastern Mediterranean World Bank. 2005. “Preventing HIV/AIDS in the Middle
Region of WHO presented at the Regional East and North Africa: A Window of Opportunity to
Committee 55. Act.” Orientations in Development Series, World Bank.
———. 2005. “Survey on Status of National AIDS Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian,
Programme Implementation in the Health Sector.” M. Ono-Kihara, E. M. Razzaghi, and S. Ichikawa.
——— . 2006 “Progress towards Universal Access to HIV 2005. “Prevalence of and Factors Associated with
Prevention, Treatment and Care in the Health Sector.” HIV-1 Infection among Drug Users Visiting Treatment
Report on a baseline survey for the year 2005 in the Centers in Tehran, Iran.” AIDS 19: 709–16.
WHO Eastern Mediterranean Region. Draft.
———. 2007. “Progress towards Universal Access to HIV
Prevention, Treatment and Care in the Health Sector.”
212 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Chapter 13
Summary of Recommendations
This chapter focuses on key strategic recom- nonrepresentative populations at low risk of
mendations related to the human immunodefi- infection, such as blood donors, is feeding a
ciency virus (HIV) epidemiology in the Middle culture of complacency toward the epidemic
East and North Africa (MENA) presented in this that is blind to the reality of nascent HIV epi-
report. The following recommendations are demics in hard-to-reach and stigmatized popu-
based on the identification of the HIV epidemic lations. The low HIV prevalence in the general
status in MENA, through this synthesis, as a low population may mask a much higher preva-
HIV prevalence setting, but with rising concen- lence in priority populations.
trated epidemics among priority populations. HIV is not spreading evenly among the
General directions for prevention interventions different subpopulations within each MENA
as warranted by the outcome of this synthesis country. Finding the subpopulations where HIV
are also briefly discussed, but detailed recom- is currently spreading is a key challenge.1
mendations are beyond the realm of this report. Inadequate surveillance continues to be one of
It is not part of the scope of this report to pro- the most pervasive problems in the region.2
vide intervention recommendations for each Despite recent progress in several countries
MENA country. such as Morocco and Sudan, epidemiological
and methodological surveillance remains
limited.3 Although surveillance has been
expanded to include sentinel surveillance of
pregnant women in a few countries, efforts
RECOMMENDATION 1: INCREASE AND need to be expanded and focused on surveil-
EXPAND BASELINE AND CONTINUED lance of priority and vulnerable populations,
SURVEILLANCE including the mapping of risk and vulnerability
factors, risk behavior measures, population size
The data synthesis and HIV transmission con-
estimations, and, importantly, measurements of
centration in priority populations, as described
HIV prevalence and biomarkers of risk such as
in this report, highlight the need for HIV sur-
sexually transmitted infections (STIs) and hepa-
veillance of these at-risk groups. However,
titis C virus (HCV) prevalence levels. Mapping of
resistance to acknowledging the existence of
priority populations is a necessary prerequisite
priority populations including injecting drug
to prevention efforts among these groups. The
users (IDUs), men who have sex with men
(MSM), and female sex workers (FSWs) can 1
El Feki, “Middle-Eastern AIDS Efforts.”
still be found among stakeholders in MENA. 2
UNAIDS and WHO, AIDS Epidemic Update 2006.
The low HIV prevalence found in sporadic and 3
Obermeyer, “HIV in the Middle East.”
213
surveillance system must be tailored to the epi- RECOMMENDATION 2: EXPAND
demic state of each country.4 SCIENTIFIC RESEARCH AND FORMULATE
Integrated biobehavioral surveillance surveys EVIDENCE-INFORMED POLICIES
(IBBSS) of representative priority populations
should be the main component of surveillance This data synthesis highlights a large gap in
efforts,5 rather than relying on facility-based methodological, scientific research in relation to
surveillance using convenient population sam- HIV and other STI epidemiology in MENA.
ples. This is particularly true in settings of low Although scientific research is often recognized
prevalence or concentrated HIV epidemics, as is in HIV national policies,12 limited human and
the case in MENA.6 Resources should not be financial resources are key challenges. In turn,
wasted on surveillance of low-risk populations this is preventing the region from formulating
while overlooking HIV spread in priority pop- effective and evidence-informed policies.13
ulations. Surveillance systems in the former MENA also has a poor record in utilizing
Soviet republics focused on pregnant women existing sources of data. Valuable data sources
and tested millions of them, but found very lim- are often ignored even though they can provide
ited HIV spread.7 At the time, HIV was raging useful insights into HIV dynamics and trends.
among IDUs.8 For instance, methodological analyses of the
Repeated IBBSS monitors trends over time by millions of HIV tests that are conducted yearly
combining HIV sero-surveillance with biomarker may provide hints about populations where HIV
surveillance and risk behavior surveillance.9 incidence is increasing. The depth and breadth
This allows pinpointing of windows of opportu- of these analyses would significantly increase if
nity for early intervention when necessary.10 HIV tests were supplemented with the collection
Biomarker surveillance, such as that of herpes of basic demographic and behavioral data and if
simplex virus 2 (HSV-2) and HCV, is an indis- additional serological tests, such as for HSV-2,
pensable component of HIV surveillance. This were conducted on subsamples of these tests.
facilitates the collection and analysis of essential In terms of research priorities, the first prior-
data needed for programming interventions and ity is conducting repeated multicenter IBBSS
evaluating impact. studies of priority groups to monitor trends over
The surveillance should be appropriate for time, combining HIV sero-surveillance with STI,
the phase of the epidemic and focus resources HCV, and risk behavior surveillance. These stud-
where they can provide the most useful data. ies also need to explore the network structures
Biological and behavioral data should be used among these risk groups, including both sexual
to validate one another, and information from and injecting drug networks.
other sources as well should be integrated within The second priority is research on mapping
the surveillance system. Programmatic data and size estimation of hard-to-reach priority
from voluntary counseling and testing (VCT) populations because this will be essential for the
and antiretroviral therapy (ART) clinics can also quantitative assessments of HIV epidemiology
inform epidemic patterns. This allows a deeper and trends and would help in planning more
understanding of the factors involved in emerg- effective prevention strategies and programs.
ing epidemics. In other words, “know your epi- The third priority is conducting multicenter
demic,” and at a local level.11 cohort or cross-sectional studies of the vulnera-
ble populations, particularly the youth, to assess
HIV and other STIs’ incidence, other infectious
4
Pisani et al., “HIV Surveillance.”
disease incidence such as HCV, sexual and
5
UNAIDS and WHO, Guidelines; Reider and Dehne, “HIV/AIDS injecting drug use risk behaviors, and drivers of
Surveillance”; Sun et al., “The Development of HIV/AIDS Surveillance risky behavior. With the high rates of popula-
in China.”
6 tion mobility in MENA, it is also informative to
Ghys, Jenkins, and Pisani, “HIV Surveillance.”
7
Pisani et al., “HIV Surveillance.” assess the levels of risky behavior and infection
8
Ibid.
9
Reintjes and Wiessing, “2nd-Generation HIV Surveillance.”
10 12
Pisani et al., “HIV Surveillance.” SNAP, National Policy on HIV/AIDS.
11 13
Wilson and Halperin, “Know Your Epidemic.” Khan and Hyder, “Responses to an Emerging Threat.”
214 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
among migrants because data on this population problem. In Libya, restrictions imposed on the sale
remain rather limited, and the socioeconomic of needles and syringes at pharmacies in the late
context of migration in this region may predis- 1990s contributed to an increase in the use of
pose this population to risk behavior practices. nonsterile injecting equipment and led conse-
The fourth priority is conducting mathematical quently to a rapid growth of HIV infections
modeling and cost-effectiveness studies to explore among IDUs since 2000.16 Following this policy
the full range of the complex HIV dynamics and failure, Libya has made progress in moving to
intervention impacts in MENA. These studies harm reduction policies.17 The Islamic Republic
would build inferences and suggest policy recom- of Iran passed through a similar path of policy
mendations by utilizing the individual and popu- failure only to become a world leader in a much
lation-level data that will become increasingly celebrated harm reduction approach.18 Use of
available over the next few years from surveil- nonsterile equipment decreased by half in the
lance studies on priority populations.14 Islamic Republic of Iran after making needles and
syringes easily available in pharmacies.19
Policy, programs, and resources continue to
RECOMMENDATION 3: FOCUS ON RISK be diverted from where they are needed. The
AND VULNERABILITY, NOT ON LAW mandatory testing of many population groups at
ENFORCEMENT low risk of HIV infection is disconnected from
the epidemiological reality of HIV infection in
MENA has a history of approaching challenges
the region. Some of this testing may also violate
through a “security” prism and often stakehold-
basic human rights and is likely not effective
ers believe that the HIV question is a question of
from a public health perspective. Efforts need to
law enforcement to prevent risk practices. This
be prioritized to the contours of risk and vulner-
is at odds with the reality gleaned from this syn-
ability and focus on priority groups. Recognizing
thesis. HIV is merely a reflection of existing
the settings of risks and targeting them with
contours of risk and vulnerability in the societies
effective interventions is the only available path
in which it is spreading and cannot be addressed
for controlling HIV spread in MENA.
fundamentally except by addressing the under-
lying causes of these risks and vulnerabilities.
Sex work, for example, is a reflection of demand RECOMMENDATION 4: STRENGTHEN CIVIL
and supply mechanisms where the existence of SOCIETY CONTRIBUTIONS TO HIV EFFORTS
a massive bulge of single and often unemployed
youth, and omnipresent pockets of wealth, are The contribution of civil society to HIV preven-
creating strong demand for sex work, and on tion efforts remains limited in MENA despite
the supply side, the large income disparity, pov- recent progress. One of the structural weak-
erty, and complex emergencies are fueling an nesses of the HIV response is the meager contri-
ample supply of sex workers. Repressive mea- bution of nongovernmental organizations
sures on priority populations will only compli- (NGOs), community organizations, and people
cate efforts, increase hidden risky behaviors, and living with HIV (PLHIV) groups in the formula-
discourage the these populations from seeking tion, planning, and implementation of the
aid and information. This would not change the response. Strengthening civil society contribu-
vulnerability settings, but would deprive us of tions to HIV efforts is essential due to the
the ability to control the epidemic and admin- epidemiological reality of HIV transmission
ister prevention interventions as needed.
The failure of the “security” approach is mani- 16
Tawilah and Ball, “WHO/EMRO & WHO/HQ Mission.”
fest in the case of injecting drug use. For a long 17
Razzaghi et al., “HIV/AIDS Harm Reduction in Iran”; Butler, “Libya
time the region depended on failed supply- Progresses on HIV.”
18
reduction policies that focused on criminalizing Zamani et al., “Prevalence”; Razzaghi et al., “HIV/AIDS Harm
Reduction in Iran”; Ministry of Health and Medical Education of Iran,
drug use.15 This only acted to exacerbate the “Treatment and Medical Education”; Afshar, “From the Assessment to
the Implementation”; Afshar and Kasraee, “HIV Prevention
14
American University, “Reaching ‘Hard to Reach’ Population.” Experiences”; WHO/EMRO, “Best Practice.”
15 19
Razzaghi et al., “HIV/AIDS Harm Reduction in Iran.” UNAIDS and WHO, AIDS Epidemic Update 2004.
216 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
There is a need to invest in comprehensive impede the transmission chains driven by the
analysis of the current gaps of as well as inter- short primary stage of infection following HIV
vention opportunities for the HIV response. This infection.45 Molecular epidemiology studies and
can be started by combining implementation of quantitative assessments of priority populations
the transmission modes analysis for each coun- have shown high levels of genetic clustering
try with the mapping of current interventions, where at least 25% of HIV infections originate
including the taxonomy of prevention. from HIV-positive persons in their primary
To maximize intervention impact, emphasis infection.46 It is believed that the large disparity
should be on using existing resources, such as in HIV testing and diagnosis between Caucasian
integrating STI prevention into the reproductive and African American MSM in the United States
health programs. Blood banks and facilities can is a key determinant of the striking difference in
also help in communicating blood-borne virus HIV incidence among these two racial groups.47
prevention messages.38 Anonymous testing needs to be expanded, and
Interventions need to capitalize on the it has already proved its utility in attracting hid-
strengths represented by cultural traditions, and den populations.48
yet be culturally sensitive while fostering effec- Although countries need to address the struc-
tive responses to the epidemic.39 Interventions tural factors that drive risk behavior practices, the
among IDUs, including those in prison, such as priority in the public health sector should be on
needle and syringe exchange, opioid substitution addressing the direct factors that put individuals
therapies, and HIV testing and counseling, have at risk of HIV exposure, because tackling struc-
shown effectiveness against HIV infection40 and tural factors takes time and is beyond the control
need to be expanded. Lessons also need to be of the public health community.49 Because almost
learned from other successful experiences in the all infections occur when an infected individual
control of sexually transmitted diseases, particu- shares body fluids with an uninfected individual,
larly from resource-limited settings.41 prevention programs must focus on addressing
Intervention methodology should emphasize the situations in which this is happening.50
identifying places, rather than individuals, Careful analysis of the transmission patterns
where high-risk sexual or injecting activities are must be conducted to inform policy decisions.51
present.42 In this fashion, the central and key Beyond doubt, harm reduction should be at the
nodes of risk networks, instead of the peripheral core of intervention policy, and targeted preven-
ones, can be reached and used as a springboard tion should go further than harm reduction. The
for interventions such as condom distribution.43 concept of harm reduction should be applied not
This would also help targeting the “cut points” only to IDUs, but should also be considered for
and the “bridges” between subcomponents in MSM and FSWs as well. Harm reduction is a direct
sexual and injecting networks where interven- and effective strategy to stem the tide of HIV, con-
tions are most needed and effective.44 sidering that addressing the root causes of risks and
Access to testing, care, and treatment services vulnerabilities might be a much more challenging
should be expanded substantially. It is impera- task. The Islamic Republic of Iran has already
tive to remove all barriers to HIV testing and paved the way by showing how harm reduction
diagnosis, particularly among priority groups, to can be implemented within the cultural fabric of
MENA and in consonance with religious values.
38
Razzaghi et al., “Profiles of Risk.”
39
Obermeyer, “HIV in the Middle East”; Lazarus et al., “HIV/AIDS
45
Knowledge and Condom Use”; Aden, Dahlgren, and Guerra, Pilcher, et al., “Brief but Efficient.”
46
“Experiences against HIV/AIDS/STDS.” Abu-Raddad et al., “Genital Herpes”; Brenner et al., “High Rates of
40
Des Jarlais et al., “HIV Incidence”; Metzger et al., “Human Forward Transmission”; Pao et al., “Transmission of HIV-1”; Yerly
Immunodeficiency Virus Seroconversion”; van Ameijden et al., et al., “Acute HIV Infection”; Lewis et al., “Episodic Sexual
“Interventions among Injecting Drug Users”; Jurgens, Ball, and Verster, Transmission.”
47
“Interventions to Reduce HIV Transmission.” MacKellar et al., “Unrecognized HIV Infection.”
41 48
Cohen et al., “Successful Eradication of Sexually Transmitted Levi et al., “Characteristics of Clients.”
49
Diseases.” Pisani et al., “Back to Basics in HIV Prevention.”
42 50
Weir et al., “From People to Places.” Pisani et al., “Back to Basics in HIV Prevention”; Ainsworth and Teokul,
43
Doherty et al., “Determinants and Consequences of Sexual Networks.” “Breaking the Silence.”
44 51
Wasserman and Faust, Social Network Analysis. Ainsworth and Teokul, “Breaking the Silence.”
218 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Immunodeficiency Virus Seroconversion among 1999. “HIV Prevention among Vulnerable Populations:
Intravenous Drug Users in- and out-of-Treatment: An Outreach in the Developing World.” AIDS 13 Suppl A:
18-Month Prospective Follow-Up.” J Acquir Immune S239–47.
Defic Syndr 6: 1049–56. Tawilah, J., and A. Ball. 2003. “WHO/EMRO & WHO/
Ministry of Health and Medical Education of Iran. 2006. HQ Mission to Libyan Arab Jamahiriya to Undertake
“Treatment and Medical Education.” Islamic Republic an Initial Assessment of the HIV/AIDS and STI
of Iran HIV/AIDS situation and response analysis. Situation and National AIDS Programme.” Tripoli,
Mishwar. 2008. “An Integrated Bio-Behavioral June 15–19.
Surveillance Study among Four Vulnerable Groups in UNAIDS (Joint United Nations Programme on HIV/
Lebanon: Men Who Have Sex with Men; Prisoners; AIDS). 2008. “Notes on AIDS in the Middle East and
Commercial Sex Workers and Intravenous Drug North Africa.” RST MENA.
Users.” Final report. UNAIDS, and WHO (World Health Organization). 2000.
O’Grady, M. 2004. “WFP Consultant Visit to Djibouti Guidelines for Second Generation HIV Surveillance: The
Report.” July 30. Next Decade. Geneva: WHO.
Obermeyer, C. M. 2006. “HIV in the Middle East.” BMJ ———. 2004. AIDS Epidemic Update 2004. Geneva.
333: 851–54. ———. 2006. AIDS Epidemic Update 2006. Geneva.
Ohiri, K., M. Claeson, E. Razzaghi, B. Nassirimanesh, van Ameijden, E. J., J. K. Watters, J. A. van den Hoek,
P. Afshar, and R. Power. 2006. “HIV/AIDS Prevention and R. A. Coutinho. 1995. “Interventions among
among Injecting Drug Users Learning from Harm Injecting Drug Users: Do They Work?” AIDS 9 Suppl A:
Reduction in Iran.” Iranian National Center for S75–84.
Addiction Studies, Persepolis NGO, Iran Prison
Organization, and the World Bank Vazirian, M., B. Nassirimanesh, S. Zamani, M. Ono-
Kihara, M. Kihara, S. M. Ravari, and M. M. Gouya.
Pao, D., M. Fisher, S. Hue, G. Dean, G. Murphy, P. A. 2005. “Needle and Syringe Sharing Practices of
Cane, C. A. Sabin, and D. Pillay. 2005. “Transmission Injecting Drug Users Participating in an Outreach HIV
of HIV-1 during Primary Infection: Relationship to Prevention Program in Tehran, Iran: A Cross-
Sexual Risk and Sexually Transmitted Infections.” Sectional Study.” Harm Reduct J 2: 19.
AIDS 19: 85–90.
Wahdan, M. H. 1995. “The Middle East: Past, Present,
Pilcher, C. D., H. C. Tien, J. J. Eron, Jr., P. L. Vernazza, S. and Future.” AIDS Asia 2: 21–23.
Y. Leu, P. W. Stewart, L. E. Goh, and M. S. Cohen.
2004. “Brief but Efficient: Acute HIV Infection and the Wasserman, S., and K. Faust. 1994. Social Network
Sexual Transmission of HIV.” J Infect Dis 189: 1785–92. Analysis: Methods and Applications. New York:
Cambridge University Press.
Pisani, E., G. P. Garnett, N. C. Grassly, T. Brown,
Weir, S. S., C. Pailman, X. Mahlalela, N. Coetzee,
J. Stover, C. Hankins, N. Walker, and P. D. Ghys.
F. Meidany, and J. T. Boerma. 2003. “From People to
2003. “Back to Basics in HIV Prevention: Focus on
Places: Focusing AIDS Prevention Efforts Where It
Exposure.” BMJ 326: 1384–87.
Matters Most.” AIDS 17: 895–903.
Pisani, E., S. Lazzari, N. Walker, and B. Schwartlander.
WHO/EMRO (World Health Organization/Eastern
2003. “HIV Surveillance: A Global Perspective.”
Mediterranean Regional Office). 2004. “Best Practice
J Acquir Immune Defic Syndr 32 Suppl 1: S3–11.
in HIV/AIDS Prevention and Care for Injecting Drug
Razzaghi, E. M., A. R. Movaghar, T. C. Green, and Abusers: The Triangular Clinic in Kermanshah,
K. Khoshnood. 2006. “Profiles of Risk: A Qualitative Islamic Republic of Iran.”
Study of Injecting Drug Users in Tehran, Iran.” Harm
Wilson, D., and D. T. Halperin. 2008. “’Know Your
Reduct J 3: 12.
Epidemic, Know Your Response’: A Useful Approach,
Razzaghi, E., B. Nassirimanesh, P. Afshar, K. Ohiri, If We Get It Right.” Lancet 372: 423–26.
M. Claeson, and R. Power. 2006. “HIV/AIDS Harm World Bank. 2005. “Preventing HIV/AIDS in the Middle
Reduction in Iran.” Lancet 368: 434–35. East and North Africa: A Window of Opportunity to
Reider, G., and K. L. Dehne. 1999. “HIV/AIDS Act.” Orientations in Development Series, World
Surveillance in Developing Countries: Experiences Bank.
and Issues.” Eschborn, Germany, Deutsche Yerly, S., S. Vora, P. Rizzardi, J. P. Chave, P. L. Vernazza,
Gesellschaft für Technische Zusammenarbeit (GTZ). M. Flepp, A. Telenti, M. Battegay, A. L. Veuthey, J. P.
Reintjes, R., and L. Wiessing. 2007. “2nd-generation HIV Bru, M. Rickenbach, B. Hirschel, and L. Perrin. 2001.
Surveillance and Injecting Drug Use: Uncovering the “Acute HIV Infection: Impact on the Spread of HIV
Epidemiological Ice-Berg.” Int J Public Health 52: and Transmission of Drug Resistance.” AIDS 15:
166–72. 2287–92.
SNAP (Sudan National AIDS Control Programme). 2005. Zaheer, H. A., S. Hawkes, K. Buse, and M. O’Dwyer.
National Policy on HIV/AIDS. Ministry of Health. 2009. “STIs and HIV in Pakistan: From Analysis to
Sun, X. N. Wang, D. Li, X. Zheng, S. Qu, L. Wang, F. Lu, Action.” Sex Transm Infect 85 Suppl 2: ii1–2.
and K. Poundstone. 2007. “The Development of Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian,
HIV/AIDS Surveillance in China.” AIDS 21 Suppl 8: M. Ono-Kihara, E. M. Razzaghi, and S. Ichikawa.
S33–38. 2005. “Prevalence of and Factors Associated with
HIV-1 Infection among Drug Users Visiting Treatment
Tawil, O., K. O’Reilly, I. M. Coulibaly, A. Tiemele,
Centers in Tehran, Iran.” AIDS 19: 709–16.
H. Himmich, A. Boushaba, K. Pradeep, and M. Carael.
Table A.1 Estimated Number of People Living with HIV in MENA Countries
221
Appendix B
Table B.1 shows key differences in the epide- CRITERIA FOR SCIENTIFIC LITERATURE
miologic characteristics of several sexually trans- REVIEW
mitted infections (STIs). These characteristics
play a leading role in determining the nature of We used the following criteria for the scien-
the infectious spread of these STIs. The effective tific literature searches in peer-reviewed
sexual partner acquisition rate determines the publications using the Medline (PubMed)
size of the population where the STI transmis- database:
sion chains are sustainable (group of sustainable 1. Studies of HIV infectious spread in its differ-
transmission, GST).1 The size of the GST in any ent transmission modes under the strategy of
community determines the potential size of the “HIV Seropositivity” OR “HIV” OR “HIV
STI epidemic. Different STIs have different GST Infections” AND “Middle East” OR “Islam”
sizes.
Table B.1 Threshold for Sustainable Transmission and Transmission Probability per Partnership for Key STIs
1
Abu-Raddad et al., “Genital Herpes”; Boily and Masse, “Mathematical
Models”; Brunham and Plummer, “A General Model.”
222
OR “Arabs” OR “Arab World” OR “Africa, “Djibouti” OR “Pakistan.” As of July 30,
Northern” OR “Mauritania” OR “Sudan” OR 2009, 27 publications were identified.
“Somalia” OR “Djibouti” OR “Pakistan.” As of
4. Studies of human papillomavirus and cervical
July 30, 2009, 1,036 publications were iden-
cancer under the strategy of “HPV” OR
tified, covering studies from the early days of
“Human Papillomavirus” OR “Human
the HIV epidemic in MENA up to today. The
Papilloma Virus” OR “Cervical Cancer” AND
number of studies has increased substantially
“Middle East” OR “Islam” OR “Arabs”
in the last few years.
OR “Arab World” OR “Africa, Northern” OR
2. Studies of sexual behavior and levels of risk “Mauritania” OR “Sudan” OR “Somalia” OR
behavior under the strategy of “Sexual “Djibouti” OR “Pakistan.” As of July 30,
Behavior” OR “Sexual Partners” OR “Sexual 2009, 188 publications were identified.
Abstinence” OR “Unsafe Sex” OR “Sexology”
5. Studies of bacterial STIs under the strategy of
OR “Reproductive Behavior” OR “Safe
“Chlamydia” OR “Chlamydia Infections” OR
Sex” OR “Condoms” OR “Sex” AND “Middle
“Chlamydia Trachomatis” OR “Gonorrhea”
East” OR “Islam” OR “Arabs” OR “Arab World”
OR “Neisseria Gonorrhoeae” OR “Syphilis” OR
OR “Africa, Northern” OR “Mauritania” OR
“Vaginosis, Bacterial” OR “Pelvic Inflammatory
“Sudan” OR “Somalia” OR “Djibouti” OR
Disease” AND “Middle East” OR “Arabs” OR
“Pakistan.” As of July 30, 2009, 1,393 publica-
“Islam” OR “Arab World” OR “Africa,
tions were identified, covering diverse issues
Northern” OR “Mauritania” OR “Sudan” OR
in sexual and reproductive behavior. Most of
“Somalia” OR “Djibouti” OR “Pakistan”. As of
these articles are focused on demographic and
July 30, 2009, 523 publications were identified.
reproductive issues such as fertility, but still
hundreds of articles study or discuss sexual 6. Studies of hepatitis C virus under the strategy of
behavior in MENA. “Hepatitis C” OR “Hepatitis C Antibodies” OR
“Hepatitis C Antigens” AND “Middle East” OR
3. Studies of herpes simplex virus type 2
“Islam” OR “Iran” OR “Arabs” OR “Arab
seroprevalence under the strategy of “Herpes-
World” OR “Africa, Northern” OR “Mauritania”
virus 2, Human” OR “Herpes Genitalis”
OR “Sudan” OR “Somalia” OR “Djibouti” OR
AND “Middle East” OR “Islam” OR “Arabs”
“Pakistan”. As of July 30, 2009, 788 publica-
OR “Arab World” OR “Africa, Northern” OR
tions were identified.
“Mauritania” OR “Sudan” OR “Somalia” OR
Appendix B 223
Appendix C
Table C.1 summarizes the results of HIV point- groups within the general population in MENA,
prevalence surveys in different population in addition to the data shown in chapter 6.
224
Table C.1 (Continued)
Pakistan 0.23% (15,000 individuals with various characteristics including people suspected of living with HIV;
Kayani et al. 1994)
0.06% (STD attendees, IDUs, hemodialysis patients, suspected people living with HIV, blood donors, ANC
attendees, TB patients, travelers abroad, and multitransfused patients; Iqbal and Rehan 1996)
0.064% (general population; Hyder and Khan 1998)
5.4% (men reporting extramarital contacts; Hyder and Khan 1998)
0.0% (health care workers; Aziz et al. 2002)
0.97% (blood donors and recipients, IDUs, and suspected AIDS cases; Khanani et al. 1990)
0.06% (blood donors and deported Pakistanis from Persian Gulf countries; Tariq et al. 1993)
0.0% (IDUs in rehabilitation centers and drug-related arrestees; Khawaja et al. 1997)
0.1% (high-risk and low-risk populations; Raziq, Alam, and Ali 1993)
0.007% (general population; Khattak et al. 2002)
0.0% (two surveys; earthquake victims; Khan et al. 2008)
Saudi Arabia 0% (controls in a study; Bakir et al. 1995)
Somalia 0.0% (military cadets; Corwin et al. 1991)
0.0% (blood donors and hospitalized children and adults; Nur et al. 2000)
0.0% (women and neonates; Jama et al. 1987)
0.0% (hospitalized persons; Scott et al. 1991)
1.0% (hospitalized persons; Kulane et al. 2000)
Sudan 1.1% (general population; Southern Sudan; Arbesser, Mose, and Sixl 1987)
2.7% (general population; Southern Sudan; NSNAC and UNAIDS 2006)
4.3% (women; Southern Sudan; NSNAC and UNAIDS 2006)
1.0% (general population; Malakal, Southern Sudan; IGAD 2006)
7.2% (general population; Yambio, Southern Sudan; IGAD 2006)
12.0% (tea sellers; Southern Sudan; NSNAC and UNAIDS 2006)
3.0% (female outpatients; Southern Sudan; McCarthy, Khalid, and El Tigani 1995)
3.0% (outpatients; Juba; Southern Sudan; UNAIDS 2007b ; UNAIDS 2007a)
4.0% (outpatients; Juba; Southern Sudan; UNAIDS 2007b; UNAIDS 2007a)
0.8% (pregnant women and STI patients; Komo and Ardi Kanan; Southern Sudan; NSNAC
and UNAIDS 2006)
1.1% (university students; North Sudan; Ahmed 2004l),
1.2% (women in a suburban community in Khartoum; North Sudan; Kafi, Mohamed, and Musa 2000)
2.5% (tea sellers; North Sudan; UNAIDS 2008; Ahmed 2004j)
0.4% (tea sellers; North Sudan; Anonymous 2007)
0.2% (patients with various malignancies and normal subjects; North Sudan; Fahal et al. 1995)
0.12% (hospital attendees; North Sudan; Ati 2005)
1.0% (police officers in Khartoum; North Sudan; Abdelwahab 2006)
Turkey 0.1% (engaged couples; Alim et al. 2009)
Yemen, Republic of 0.0%, 0.17%, 1.26%, and 1.19% (travelers seeking visas to work abroad in different years, respectively;
WHO, UNICEF, and UNAIDS 2006s)
Note: ANC = antenatal clinic; IDU = injecting drug use/user; STD = sexually transmitted disease; TB = tuberculosis.
Appendix C 225
Appendix D
Table D.1 HIV Prevalence among STD Clinic Attendees, VCT Attendees, and People Suspected of
Living with HIV
HIV prevalence among STD clinic attendees, VCT attendees, and people
Country suspected of living with HIV
226
Table D.1 (Continued)
HIV prevalence among STD clinic attendees, VCT attendees, and people
Country suspected of living with HIV
Appendix D 227
Table D.2 HIV Prevalence of Tuberculosis (TB) Patients
228 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table D.2 (Continued)
3.6% (North Kurdofan; North Sudan; Sudan National AIDS Control Program 2005)
5.1% (North Kurdofan; North Sudan; SNAP and UNAIDS 2006)
0.33% (Kassala; North Sudan; SNAP and UNAIDS 2006)
2.8% (Khartoum; North Sudan; Sudan National AIDS Control Program 2005)
1.89%–5.65% (four Khartoum sites; North Sudan; SNAP and UNAIDS 2006)
3.6% (North Sudan origin; El-Sony et al. 2002)
Tunisia 0.0% (Jemni et al. 1991)
Yemen, Republic of 3.3% (WHO/EMRO 2007)
2.1% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006s)
6.9% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006s)
1.9% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006s)
0.7% (Yemen National TB Programme 2006)
(continued)
Appendix D 229
Table D.3 (Continued)
230 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table D.3 (Continued)
(continued)
Appendix D 231
Table D.3 (Continued)
Note: This table is a summary of all point–prevalence surveys as extracted from UNAIDS epidemiological facts sheets on each MENA
country over the years. STI = sexually transmitted infection.
a k
WHO, UNICEF, and UNAIDS 2006a. WHO, UNICEF, and UNAIDS 2006k.
b l
WHO, UNICEF, and UNAIDS 2006b. WHO, UNICEF, and UNAIDS 2006l.
c m
WHO, UNICEF, and UNAIDS 2006c. WHO, UNICEF, and UNAIDS 2006m.
d n
WHO, UNICEF, and UNAIDS 2006d. WHO, UNICEF, and UNAIDS 2006n.
e o
WHO, UNICEF, and UNAIDS 2006e. WHO, UNICEF, and UNAIDS 2006o.
f p
WHO, UNICEF, and UNAIDS 2006f. WHO, UNICEF, and UNAIDS 2006p.
g q
WHO, UNICEF, and UNAIDS 2006g. WHO, UNICEF, and UNAIDS 2006q.
h r
WHO, UNICEF, and UNAIDS 2006h. WHO, UNICEF, and UNAIDS 2006r.
i s
WHO, UNICEF, and UNAIDS 2006i. WHO, UNICEF, and UNAIDS 2006s.
j
WHO, UNICEF, and UNAIDS 2006j.
232 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table D.4 (Continued)
(continued)
Appendix D 233
Table D.4 (Continued)
Iran, Islamic Republic of 0.5% (blood donors; Ansar and Kooloobandi 2002)
0.59% (blood donors; Karimi and Ghavanini 2001; Ghavanini and Sabri 2000)
0.3% (blood donors; Rezvan et al. 1994)
0.1% (blood donors; Rahbar, Rooholamini, and Khoshnood 2004)
0.4% (blood donors; Pourshams et al. 2005)
0.4% (blood donors; Taziki and Espahbodi 2008)
0.8% (blood donors; Taziki and Espahbodi 2008)
2.07% (blood donors; Khedmat et al. 2007)
0.12% (general population; Alavian, Gholami and Masarrat 2002)
3.1% (general population; gypsy; Hosseini Asl, Avijgan, and Mohamadnejad 2004)
12.3% (adult population; Gholamreza et al. 2007)
0.0% (street children; Vahdani et al. 2006)
0.59% (healthy children; Karimi and Ghavanini 2001)
2.7% (FSWs; Jahani et al. 2005)
52.0% (IDUs; Zamani et al. 2007)
59.4% (IDUs; Rahbar, Rooholamini, and Khoshnood 2004)
78.0% (IDUs; local prison; Nassirimanesh 2002)
47.4% (IDUs; Khani and Vakili 2003)
45.3% (IDUs; Zali et al. 2001)
30.0% (injecting and noninjecting drug users; Alizadeh et al. 2005)
11.2% (IDUs; Imani et al. 2008)
80.0% (incarcerated IDUs; Kheirandish et al. 2009)
7.35% (injecting and noninjecting drug users; Mohammad Alizadeh et al. 2003)
14.4% (noninjecting drug users; Talaie et al. 2007)
30.0% (prisoners; Alizadeh et al. 2005)
45.4% (prisoners; Mutter, Grimes, and Labarthe 1994)
47.0% (prisoners; Khani and Vakili 2003)
78.0% (prisoners; Nassirimanesh 2002)
35.8% (prisoners; Javadi, Avijgan, and Hafizi 2006)
1.33% (household contacts of HCV positive patients; Hajiani et al. 2006)
12.3% (HBV positive patients; Semnani et al. 2007)
11.5% (HIV-infected patients; Sharifi-Mood et al. 2006)
5.5% (hemodialysis patients; Rais-Jalali and Khajehdehi 1999)
21.0% (hemodialysis patients; Nobakht, Zali, and Nowroozi 2001)
2.9% (hemodialysis patients; Khamispoor and Tahmasebi 1999)
13.2% (hemodialysis patients; Mohammad et al. 2003)
24.8% (hemodialysis patients; Amiri, Shakib, and Toorchi 2005)
55.9% (hemodialysis patients; Ansar and Kooloobandi 2002)
42.6% (hemodialysis patients; Hosseini-Moghaddam et al. 2006)
60.2% (hemophiliac patients; Alavian, Ardeshiri, and Hajarizadeh 2001)
16.0% (hemophiliac patients; Karimi, Yarmohammadi, and Ardeshiri 2002)
51.0% (hemophiliac patients; Torabi et al. 2006)
48.6% (hemophiliac patients; Javadzadeh, Attar, and Taher Yavari 2006)
41.9% (hemophiliac patients; Khamispoor and Tahmasebi 1999)
43.4% (hemophiliac patients; Samimi-Rad and Shahbaz 2007)
29.6% (hemophiliac patients; Sharifi-Mood et al. 2007)
71.3% (hemophiliac patients; Mansour-Ghanaei et al. 2002)
15.65% (hemophiliac patients; Karimi and Ghavanini 2001)
24.2% (thalassemia patients; Alavian, Gholami and Masarrat 2002)
9.4% (thalassemia patients; Javadzadeh, Attar, and Taher Yavari 2006)
13.0% (thalassemia patients; Khamispoor and Tahmasebi 1999)
24.0% (thalassemia patients; Nakhaie and Talachian 2003)
27.2% (thalassemia patients; Kadivar et al., 2001)
23.0% (thalassemia patients; Basiratnia, HosseiniAsl, and Avijegan 1999)
25.0% (thalassemia patients; Jafroodi and Asadi 2006)
21.0% (thalassemia patients; Rezvan, Abolghassemi, and Kafiabad 2007)
234 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table D.4 (Continued)
(continued)
Appendix D 235
Table D.4 (Continued)
236 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table D.4 (Continued)
(continued)
Appendix D 237
Table D.4 (Continued)
Note: ANC ⫽ antenatal clinic; FSW ⫽ female sex worker; IDU ⫽ injecting drug user; STD ⫽ sexually transmitted disease.
238 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Appendix E
(continued)
239
Table E.1 (Continued)
240 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table E.1 (Continued)
(continued)
Appendix E 241
Table E.1 (Continued)
Table E.2 MENA Populations with Low Levels of Comprehensive HIV/AIDS Knowledge
242 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table E.2 (Continued)
Note: ANC ⫽ antenatal clinic; FSW ⫽ female sex worker; HCW ⫽ health care worker; IDU ⫽ injecting drug user; MSM ⫽ men who have
sex with men; STD ⫽ sexually transmitted disease; TB ⫽ tuberculosis.
Appendix E 243
Table E.3 MENA Populations with High Levels of HIV/AIDS Misinformation
244 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table E.3 (Continued)
Note: ANC ⫽ antenatal clinic; FSW ⫽ female sex worker; IDU ⫽ injecting drug user; MSM ⫽ men who have sex with men;
PLHIV ⫽ people living with HIV; STD ⫽ sexually transmitted disease; TB ⫽ tuberculosis.
Table E.4 Nature of Attitudes toward People Living with HIV/AIDS by Different Population Groups
(continued)
Appendix E 245
Table E.4 (Continued)
246 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Table E.4 (Continued)
Note: ANC ⫽ antenatal clinic; FSW ⫽ female sex worker; MSM ⫽ men who have sex with men; STD ⫽ sexually transmitted disease;
TB ⫽ tuberculosis.
Table E.5 Television as the Main Source of HIV/AIDS Knowledge, by MENA Population Groups
Country Populations that identified television as the main source of HIV/AIDS knowledge
Egypt, Arab Republic of Street children (Egypt MOH and Population National AIDS Program 2006)
University students (Refaat 2004)
General population women (Measure DHS 2004)
General population women (Measure DHS 2006)
Squatter populations (Shama, Fiala, and Abbas 2002)
HCWs (Faris and Shouman 1994)
IDUs (Egypt MOH and Population National AIDS Program 2006)
FSWs (Egypt MOH and Population National AIDS Program 2006)
MSM (Egypt MOH and Population National AIDS Program 2006)
Iran, Islamic Republic of Adolescents (Yazdi et al. 2006)
Youth (Tehrani and Malek-Afzalip 2008)
High school students (Tavoosi et al. 2004)
High school students (Karimi and Ataei 2007)
Teachers (Mazloomy and Baghianimoghadam 2008)
General population (Montazeri 2005)
General population (Ministry of Health and Medical Education of Iran 2006)
Truck drivers (Tehrani and Malek-Afzalip 2008)
FSWs (Tehrani and Malek-Afzalip 2008)
Pakistan Female college students (Khan et al. 2005)
Male prisoners (Khawaja et al. 1997)
IDUs (Khawaja et al. 1997)
FSWs (Jamal, Khushk, and Naeem 2006)
Sudan Youth (SNAP, UNICEF, and UNAIDS 2005)
University students (Ahmed 2004l)
University students (Sudan National HIV/AIDS Control Program 2004)
Military personnel (Sudan National HIV/AIDS Control Program 2004)
Turkey High school students (Savaser 2003)
College students (Ungan and Yaman 2003)
West Bank and Gaza General population women (Husseini and Abu-Rmeileh 2007)
Yemen, Republic of Youth (Al-Serouri 2005)
High school students (Raja and Farhan 2005)
General population (Al-Serouri et al. 2002)
General population (Busulwa 2003)
Marginalized minority (Al-Akhdam) (Busulwa 2003)
Returnee families from abroad (Busulwa 2003)
Note: FSW ⫽ female sex worker; HCW ⫽ health care worker; IDU ⫽ injecting drug user; MSM ⫽ men who have sex with men.
Appendix E 247
BIBLIOGRAPHY FOR APPENDIXES A–E HIV/AIDS Prevention among Informal Sex Workers.”
Agency for Co-operation and Research in
Aaraj, E. Unknown. “Report on the Situation Analysis Development, Federal Ministry of Health, Sudan
on Vulnerable Groups in Beirut, Lebanon.” IVDU National AIDS Control Program, and the World
Group. Health Organization.
Abbas, Z., N. L. Jeswani, G. N. Kakepoto, M. Islam, K. ———. 2006. “Qualitative Socio Economic Research on
Mehdi, and W. Jafri. 2008. “Prevalence and Mode of Female Sex Workers and Their Vulnerability to HIV/
Spread of Hepatitis B and C in Rural Sindh, Pakistan.” AIDS in Khartoum State.” Agency for Co-operation
Trop Gastroenterol 29: 210–16. and Research in Development.
Abdelaal, M., D. Rowbottom, T. Zawawi, T. Scott, and Aceti, A., G. Taliani, R. Bruni, O. S. Sharif, K. A. Moallin,
C. Gilpin. 1994. “Epidemiology of Hepatitis C Virus: A D. Celestino, G. Quaranta, and A. Sebastiani. 1993.
Study of Male Blood Donors in Saudi Arabia.” “Hepatitis C Virus Infection in Chronic Liver Disease
Transfusion 34: 135–37. in Somalia.” Am J Trop Med Hyg 48: 581–84.
Abdel-Aziz, F., M. Habib, M. K. Mohamed, M. Abdel- Achakzai, M., M. Kassi, and P. M. Kasi. 2007.
Hamid, F. Gamil, S. Madkour, N. N. Mikhail, D. “Seroprevalences and Co-Infections of HIV,
Thomas, A. D. Fix, G. T. Strickland, W. Anwar, and Hepatitis C Virus and Hepatitis B Virus in Injecting
I. Sallam. 2000. “Hepatitis C Virus (HCV) Infection in Drug Users in Quetta, Pakistan.” Trop Doct 37:
a Community in the Nile Delta: Population Description 43–45.
and HCV Prevalence.” Hepatology 32: 111–15. Action Aid Afghanistan. 2006. “HIV AIDS in Afghanistan:
Abdelmoneim, I., M. Y. Khan, A. Daffalla, S. Al-Ghamdi, A Study on Knowledge, Attitude, Behavior, and
and M. Al-Gamal. 2002. “Knowledge and Attitudes Practice in High Risk and Vulnerable Groups in
towards AIDS among Saudi and Non-Saudi Bus Afghanistan.”
Drivers.” East Mediterr Health J 8: 716–24. Afghanistan Central Blood Bank. 2006. Report of Testing of
Abdel-Wahab, M. F., S. Zakaria, M. Kamel, M. K. Abdel- Blood Donors from March–December, 2006. Ministry of
Khaliq, M. A. Mabrouk, H. Salama, G. Esmat, D. L. Public Health, Kabul, Afghanistan.
Thomas, and G. T. Strickland. 1994. “High Afsar, I., S. Gungor, A. G. Sener, and S. G. Yurtsever.
Seroprevalence of Hepatitis C Infection among Risk 2008. “The Prevalence of HBV, HCV and HIV
Groups in Egypt.” Am J Trop Med Hyg 51: 563–67. Infections among Blood Donors in Izmir, Turkey.”
Abdelwahab, O. 2006. “Prevalence, Knowledge of AIDS Indian J Med Microbiol 26: 288–89.
and HIV Risk-Related Sexual Behaviour among Police Afshar, P., and F. Kasrace. 2005. “HIV Prevention
Personnel in Khartoum State, Sudan 2005.” XVI Experiences and Programs in Iranian Prisons”
International AIDS Conference, Toronto, August [MoPC0057]. Presented at the Seventh International
13–18, abstract CDC0792. Congress on AIDS in Asia and the Pacific, July 1–5,
Abdul Mujeeb, S., K. Aamir, and K. Mehmood. 2000. Kobe, Japan.
“Seroprevalence of HBV, HCV and HIV Infections Afshar, P. Unknown (a). “From the Assessment to the
among College Going First Time Voluntary Blood Implementation of Services Available for Drug
Donors.” J Pak Med Assoc 50: 269–70. Abuse and HIV/AIDS Prevention and Care in Prison
Abdul Mujeeb, S., Q. Jamal, R. Khanani, N. Iqbal, and S. Setting: The Experience of Iran.” PowerPoint
Kaher. 1997. “Prevalence of Hepatitis B Surface presentation
Antigen and HCV Antibodies in Hepatocellular ———. Unknown (b). “Health and Prison.” Director
Carcinoma Cases in Karachi, Pakistan.” Trop Doct 27: General of Health, Office of Iran Prisons Organization.
45–46.
Agboatwalla, M., S. Isomura, K. Miyake, T. Yamashita, T.
Abdul Mujeeb, S., D. Nanan, S. Sabir, A. Altaf, and Morishita, and D. S. Akram. 1994. “Hepatitis A, B and
M. Kadir. 2006. “Hepatitis B and C Infection in First- C Seroprevalence in Pakistan.” Indian J Pediatr 61:
Time Blood Donors in Karachi—A Possible Subgroup 545–49.
for Sentinel Surveillance.” East Mediterr Health J 12:
735–41. Ahmad, N., M. Asgher, M. Shafique, and J. A. Qureshi.
2007. “An Evidence of High Prevalence of Hepatitis
Abdul-Abbas, A. J., A. M. al-Delami, and T. K. Yousif. C Virus in Faisalabad, Pakistan.” Saudi Med J 28:
2000. “HIV Infection in Patients with Tuberculosis in 390–95.
Baghdad (1996–98).” East Mediterr Health J 6: 1103–6.
Ahmed, S. M. 2004a. AIDS Patients: Situation Analysis-
Abolfotouh, M. A. 1995. “The Impact of a Lecture on Behavioral Survey Results & Discussions. Report, Sudan
AIDS on Knowledge, Attitudes and Beliefs of Male National AIDS Control Program.
School-Age Adolescents in the Asir Region of
Southwestern Saudi Arabia.” J Community Health 20: ———. 2004b. Antenatal: Situation Analysis-Behavioral
271–81. Survey Results & Discussions. Report. Sudan National
AIDS Control Program.
Abu-Raddad, L. J., A. S. Magaret, C. Celum, A. Wald, I.
M. Longini, S. G. Self, and L. Corey. 2008. “Genital ———. 2004c. Internally Displaced People: Situation
Herpes Has Played a More Important Role Than Any Analysis-Behavioral Survey Results & Discussions. Report,
Other Sexually Transmitted Infection in Driving HIV Sudan National AIDS Control Program.
Prevalence in Africa.” PLoS ONE 3: e2230. ———. 2004d. Military Situation: Analysis-Behavioral
ACORD (Agency for Co-operation and Research Survey Results & Discussions. Report. Sudan National
Development). 2005. “Socio Economic Research on AIDS Control Program.
248 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
———. 2004e. Prisoners: Situation Analysis-Behavioral of Antibodies to Hepatitis C Virus among Omani
Survey Results & Discussions. Report. Sudan National Patients with Renal Disease.” Infection 21: 164–67.
AIDS Control Program. Al-Faleh, F. Z., E. A. Ayoola, M. Al-Jeffry, R. Al-Rashed,
———. 2004f. Sex Sellers: Situation Analysis-Behavioral M. Al-Mofarreh, M. Arif, S. Ramia, M. Al-Karawi,
Survey Results & Discussions Report. Sudan National and M. Al-Shabrawy. 1991. “Prevalence of Antibody
AIDS Control Program. to Hepatitis C Virus among Saudi Arabian Children: A
———. 2004g. STDs: Situation Analysis-Behavioral Survey Community-Based Study.” Hepatology 14: 215–18.
Results & Discussions. Report, Sudan National AIDS Al-Fouzan, A., and N. Al-Mutairi. 2004. “Overview of
Control Program. Incidence of Sexually Transmitted Diseases in
———. 2004h. Street Children: Situation Analysis-Behavioral Kuwait.” Clin Dermatol 22: 509–12.
Survey Results & Discussions. Report, Sudan National Al-Fuzae, L., K. C. Aboolbacker, and Q. Al-Saleh. 1998.
AIDS Control Program. “Beta-Thalassaemia Major in Kuwait.” J Trop Pediatr
———. 2004i. TB Patients: Situation Analysis-Behavioral 44: 311–12.
Survey Results & Discussions. Report, Sudan National Al-Ghanim, S. A. 2005. “Exploring Public Knowledge
AIDS Control Program. and Attitudes towards HIV/AIDS in Saudi Arabia: A
———. 2004j. Tea Sellers: Situation Analysis-Behavioral Survey of Primary Health Care Users.” Saudi Med J 26:
Survey Results & Discussions. Report. Sudan National 812–18.
AIDS Control Program. Ali, F., A. Abdel-Aziz, M. F. Helmy, A. Abdel-Mobdy,
———. 2004k. Truck Drivers: Situation Analysis-Behavioral and M. Darwish. 1998. “Prevalence of Certain
Survey Results & Discussions. Report. Sudan National Sexually Transmitted Viruses in Egypt.” J Egypt Public
AIDS Control Program. Health Assoc 73: 181–92.
———. 2004l. University Students: Situation Analysis- Ali, G., R. Khanani, M. A. Shaikh, A. R. Memon, and
Behavioral Survey, Results & Discussions. Report, Sudan H. N. Naqvi. 1996. “Knowledge and Attitudes of
National AIDS Control Program. Medical Students to People with HIV and AIDS.” J
Coll Physicians Surg Pak 6: 58–61.
Aidaoui, M., S. Bouzbid, and M. Laouar. 2008.
“Seroprevalence of HIV Infection in Pregnant Women Ali, M., M. A. Bhatti, and H. Ushijima. 2004.
in the Annaba Region (Algeria).” Rev Epidemiol Sante “Reproductive Health Needs of Adolescent Males in
Publique 56: 261–66. Rural Pakistan: An Exploratory Study.” Tohoku J Exp
Med 204: 17–25.
Akcam, F. Z., E. Uskun, K. Avsar, and Y. Songur. 2009.
“Hepatitis B Virus and Hepatitis C Virus Seroprevalence Ali, S. A., R. M. Donahue, H. Qureshi, and S. H. Vermund.
in Rural Areas of the Southwestern Region of 2009. “Hepatitis B and Hepatitis C in Pakistan:
Turkey.” Int J Infect Dis 13: 274–84. Prevalence and Risk Factors.” Int J Infect Dis 13: 9–19.
Akhtar, S., and T. Moatter. 2004. “Hepatitis C Virus Ali, S. S., I. S. Ali, A. H. Aamir, Z. Jadoon, and S. Inayatullah.
Infection in Polytransfused Thalassemic Children in 2007. “Frequency of Hepatitis C Infection in Diabetic
Pakistan.” Indian Pediatr 41: 1072–73. Patients.” J Ayub Med Coll Abbottabad 19: 46–49.
Akhtar, S., T. Moatter, S. I. Azam, M. H. Rahbar, and Alim, A., M. O. Artan, Z. Baykan, and B. A. Alim. 2009.
S. Adil. 2002. “Prevalence and Risk Factors for “Seroprevalence of Hepatitis B and C Viruses, HIV,
Intrafamilial Transmission of Hepatitis C Virus in and Syphilis Infections among Engaged Couples.”
Karachi, Pakistan.” J Viral Hepat 9: 309–14. Saudi Med J 30: 541–45.
Akhtar, S., M. Younus, S. Adil, S. H. Jafri, and F. Hassan. Alizadeh, A. H., S. M. Alavian, K. Jafari, and N. Yazdi.
2004. “Hepatitis C Virus Infection in Asymptomatic 2005. “Prevalence of Hepatitis C Virus Infection
Male Volunteer Blood Donors in Karachi, Pakistan.” and Its Related Risk Factors in Drug Abuser
J Viral Hepat 11: 527–35. Prisoners in Hamedan—Iran.” World J Gastroenterol
11: 4085–89.
Al Nasser, M. N. 1992. “Intrafamilial Transmission of
Hepatitis C Virus (HCV): A Major Mode of Spread in Al-Jabri, A. A., and J. H. Al-Abri. 2003. “Knowledge and
the Saudi Arabia Population.” Ann Trop Paediatr 12: Attitudes of Undergraduate Medical and Non-Medical
211–15. Students in Sultan Qaboos University toward
Alami, K. 2009. “Tendances récentes de l’épidémie à Acquired Immune Deficiency Syndrome.” Saudi Med
VIH/SIDA en Afrique du nord.” Presentation, J 24: 273–77.
Research and AIDS Workshop in North Africa/ Al-Kubaisy, W. A., K. T. Al-Naib, and M. A. Habib.
Marrakech, Morocco. 2006a. “Prevalence of HCV/HIV Co-Infection among
Alavian, S. M., A. Ardeshiri, and B. Hajarizadeh. 2001. Haemophilia Patients in Baghdad.” East Mediterr
“Prevalence of HCV, HBV and HIV Infections among Health J 12: 264–69.
Hemophiliacs.” Transfusion Today 49: 4–5. ———. 2006b. “Seroprevalence of Hepatitis C Virus
Alavian, S. M., B. Gholami, and S. Masarrat. 2002. Specific Antibodies among Iraqi Children with
“Hepatitis C Risk Factors in Iranian Volunteer Blood Thalassaemia.” East Mediterr Health J 12: 204–10.
Donors: A Case-Control Study.” J Gastroenterol Hepatol Al-Kubaisy, W. A., A. D. Niazi, and K. Kubba. 2002.
17: 1092–97. “History of Miscarriage as a Risk Factor for Hepatitis C
Al-Dhahry, S. H. S., M. R. Buhl, A. S. Daar, P. N. Virus Infection in Pregnant Iraqi Women.” East
Aganashinikar, and M. K. Al-Hasani. 1993. “Prevalence Mediterr Health J 8: 239–44.
250 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Ayed, Z., D. Houinato, M. Hocine, S. Ranger-Rogez, and Programme, Federal Ministry of Health, Khartoum,
F. Denis. 1995. “Prevalence of Serum Markers of Sudan.
Hepatitis B and C in Blood Donors and Pregnant Ben, Othman S., N. Bouzgarrou, A. Achour, T. Bourlet,
Women in Algeria.” Bull Soc Pathol Exot 88: 225–28. B. Pozzetto, and A. Trabelsi. 2004. “High Prevalence
Ayoola, E. A., I. A. al-Mofleh, F. Z. al-Faleh, R. al- and Incidence of Hepatitis C Virus Infections among
Rashed, M. A. Arif, S. Ramia, and I. Mayet. 1992. Dialysis Patients in the East-Centre of Tunisia.” Pathol
“Prevalence of Antibodies to Hepatitis C Virus among Biol (Paris) 52: 323–27.
Saudi Patients with Chronic Liver Diseases.” Benjelloun, S., B. Bahbouhi, S. Sekkat, A. Bennani,
Hepatogastroenterology 39: 337–39. N. Hda, and A. Benslimane. 1996. “Anti-HCV
Ayoola, E. A., S. Huraib, M. Arif, F. Z. al-Faleh, R. al- Seroprevalence and Risk Factors of Hepatitis C Virus
Rashed, S. Ramia, I. A. al-Mofleh, and H. Abu-Aisha. Infection in Moroccan Population Groups.” Res Virol
1991. “Prevalence and Significance of Antibodies to 147: 247–55.
Hepatitis C Virus among Saudi Haemodialysis Bennani, A., and K. Alami. 2006. “Surveillance sentinelle
Patients.” J Med Virol 35: 155–59. VIH, résultats 2005 et tendances de la séroprévalence
Ayranci, U. 2005. “AIDS Knowledge and Attitudes in a du VIH.” Morocco Ministry of Health, UNAIDS.
Turkish Population: An Epidemiological Study.” BMC Bhatti, F. A., M. Amin, and M. Saleem. 1995. “Prevalence
Public Health 5: 95. of Antibody to Hepatitis C Virus in Pakistani
Aziz, S., A. Memon, H. I. Tily, K. Rasheed, K. Jehangir, Thalassaemics by Particle Agglutination Test Utilizing
and M. S. Quraishy. 2002. “Prevalence of HIV, C 200 and C 22-3 Viral Antigen Coated Particles.”
Hepatitis B and C amongst Health Workers of Civil J Pak Med Assoc 45: 269–71.
Hospital Karachi.” J Pak Med Assoc 52: 92–94. Bile, K., C. Aden, H. Norder, L. Magnius, G. Lindberg,
Badahdah, A. 2005. “Saudi Attitudes towards People and L. Nilsson. 1993. “Important Role of Hepatitis C
Living with HIV/AIDS.” Int J STD AIDS 16: 837–38. Virus Infection as a Cause of Chronic Liver Disease in
Baddoura, R., C. Haddad, and M. Germanos. 2002. Somalia.” Scand J Infect Dis 25: 559–64.
“Hepatitis B and C Seroprevalence in the Lebanese Bile, K., O. Mohamud, C. Aden, A. Isse, H. Norder, L.
Population.” East Mediterr Health J 8: 150–56. Nilsson, and L. Magnius. 1992. “The Risk for Hepatitis
Baidy, Lo B., M. Adimorty, C. Fatimata, and S. Amadou. A, B, and C at Two Institutions for Children in
1993. “Surveillance of HIV Seroprevalence in Somalia with Different Socioeconomic Conditions.”
Mauritania.” Bull Soc Pathol Exot 86: 133–35. Am J Trop Med Hyg 47: 357–64.
Bakir, T. M., K. M. Kurbaan, I. al Fawaz, and S. Ramia. Boily, M. C., and B. Masse. 1997. “Mathematical Models
1995. “Infection with Hepatitis Viruses (B and C) and of Disease Transmission: A Precious Tool for the
Human Retroviruses (HTLV-1 and HIV) in Saudi Study of Sexually Transmitted Diseases.” Can J Public
Children Receiving Cycled Cancer Chemotherapy.” J Health 88: 255–65.
Trop Pediatr 41: 206–9. Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan,
Baqi, S., S. A. Shah, M. A. Baig, S. A. Mujeeb, and A. M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, K.
Memon. 1999. “Seroprevalence of HIV, HBV, and Qayum, P. Girault, E. Pisani, and I. Thaver. 2007.
Syphilis and Associated Risk Behaviours in Male “HIV Risk in Karachi and Lahore, Pakistan: An
Transvestites (Hijras) in Karachi, Pakistan.” Int J STD Emerging Epidemic in Injecting and Commercial Sex
AIDS 10: 300–4. Networks.” Int J STD AIDS 18: 486–92.
Basha, H. M. 2006. “Vulnerable Population Research in Boulaajaj, K., Y. Elomari, B. Elmaliki, B. Madkouri, D.
Darfur.” Grey Report. Zaid, and N. Benchemsi. 2005. “Prevalence of
Hepatitis C, Hepatitis B and HIV Infection among
Bashawri, L. A., N. A. Fawaz, M. S. Ahmad, A. A. Qadi, Haemodialysis Patients in Ibn-Rochd University
and W. Y. Almawi. 2004. “Prevalence of Seromarkers Hospital, Casablanca.” Nephrol Ther 1: 274–84.
of HBV and HCV among Blood Donors in Eastern
Saudi Arabia, 1998–2001.” Clin Lab Haematol 26: Boutayeb, H., A. Aamoum, and N. Benchemsi. 2006.
225–28. “Knowledge about Hepatitis B and C Viruses and HIV
among Blood Donors in Casablanca.” East Mediterr
Basiratnia, M., S. M. K. HosseiniAsl, and M. Avijegan. Health J 12: 538–47.
1999. “Hepatitis C Prevalence in Thalassemia Patients
Bozdayi, G., S. Rota, H. Verdi, U. Derici, S. Sindel, M.
in Sharkord, Iran (Farsi).” Shahrkord University Medical
Bali, and T. Basay. 2002. “The Presence of Hepatitis C
Science Journal 4: 13–18.
Virus (HCV) Infection in Hemodialysis Patients and
Bassily, S., K. C. Hyams, R. A. Fouad, M. D. Samaan, and Determination of HCV Genotype Distribution.”
R. G. Hibbs. 1995. “A High Risk of Hepatitis C Infection Mikrobiyol Bul 36: 291–300.
among Egyptian Blood Donors: The Role of Parenteral
Bozkurt, H., M. G. Kurtoglu, Y. Bayram, R. Kesli, and
Drug Abuse.” Am J Trop Med Hyg 52: 503–5.
M. Berktas. 2008. “Distribution of Hepatitis C
Baybuga, M. S., and S. S. Celik. 2004. “The Level of Prevalence in Individuals according to Their Age
Knowledge and Views of the Street Children/Youth Level in Eastern Turkey.” Eur J Gastroenterol Hepatol
about AIDS in Turkey.” Int J Nurs Stud 41: 591–97. 20: 1249.
Bayoumi, A. 2005. Baseline Survey of Intravenous Drug Brunham, R. C., and F. A. Plummer. 1990. “A General
Users (IDUs) in Karthoum State (KS): Cross-Sectional and Model of Sexually Transmitted Disease Epidemiology
Case-Control Study. Assignment Report, Inter Agency and Its Implications for Control.” Med Clin North Am
Technical Committee, Sudan National AIDS 74: 1339–52.
252 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
“Prevalence of Hepatitis-C Antibody Seropositivity in Farah, M. S., and S. Hussein. 2006. “HIV Prevalence,
Healthy Egyptian Children and Four High Risk Knowledge, Attitude, Practices and Risk Factors
Groups.” J Trop Pediatr 41: 341–43. among Truck Drivers in Karthoum State.”
Elrashied, S. M. 2006. “Generating Strategic Information Farghaly, A. G., and M. M. Kamal. 1991. “Study of the
and Assessing HIV/AIDS Knowledge, Attitude and Opinion and Level of Knowledge about AIDS Problem
Behaviour and Practices as well as Prevalence of HIV1 among Secondary School Students and Teachers in
among MSM in Khartoum State, 2005.” A draft Alexandria.” J Egypt Public Health Assoc 66: 209–25.
report submitted to Sudan National AIDS Control Farid, R., and A. J. Choudhry. 2003. “Knowledge about
Programme, Together Against AIDS Organization AIDS/HIV Infection among Female College Students.”
(TAG), Khartoum, Sudan. J Coll Physicians Surg Pak 13: 135–37.
El-Raziky, M. S., M. El-Hawary, G. Esmat, A. M. Abouzied, Faris, R., and A. Shouman. 1994. “Study of the
N. El-Koofy, N. Mohsen, S. Mansour, A. Shaheen, Knowledge, Attitude of Egyptian Health Care
M. Abdel Hamid, and H. El-Karaksy. 2007. “Prevalence Workers towards Occupational HIV Infection.” J
and Risk Factors of Asymptomatic Hepatitis C Virus Egypt Public Health Assoc 69: 115–28.
Infection in Egyptian Children.” World J Gastroenterol
13: 1828–32. Fido, A., and R. Al Kazemi. 2002. “Survey of HIV/AIDS
Knowledge and Attitudes of Kuwaiti Family
El-Sayed, H. F., S. M. Abaza, S. Mehanna, and P. J.
Physicians.” Fam Pract 19: 682–84.
Winch. 1997. “The Prevalence of Hepatitis B and C
Infections among Immigrants to a Newly Reclaimed Fox, E., R. L. Haberberger, E. A. Abbatte, S. Said, D.
Area Endemic for Schistosoma Mansoni in Sinai, Polycarpe, and N. T. Constantine. 1989. “Observations
Egypt.” Acta Trop 68: 229–37. on Sexually Transmitted Diseases in Promiscuous
Males in Djibouti.” J Egypt Public Health Assoc 64:
El-Sayed, N. M., P. J. Gomatos, G. R. Rodier, T. F.
561–69.
Wierzba, A. Darwish, S. Khashaba, and R. R. Arthur.
1996. “Seroprevalence Survey of Egyptian Tourism Ganczak, M., P. Barss, F. Alfaresi, S. Almazrouei, A.
Workers for Hepatitis B Virus, Hepatitis C Virus, Muraddad, and F. Al-Maskari. 2007. “Break the
Human Immunodeficiency Virus, and Treponema Silence: HIV/AIDS Knowledge, Attitudes, and
Pallidum Infections: Association of Hepatitis C Virus Educational Needs among Arab University Students
Infections with Specific Regions of Egypt.” Am J Trop in United Arab Emirates.” J Adolesc Health 40: 572
Med Hyg 55: 179–84. e571–78.
El-Sayyed, N., I. A. Kabbash, and M. El-Gueniedy. 2008. Ghannad, M. S., S. M. Arab, M. Mirzaei, and A.
“Risk Behaviours for HIV/AIDS Infection among Men Moinipur. 2009. “Epidemiologic Study of Human
Who Have Sex with Men in Cairo, Egypt.” East Immunodeficiency Virus (HIV) Infection in the
Mediterr Health J 14: 905–15. Patients Referred to Health Centers in Hamadan
Elsheikh, R. M., A. A. Daak, M. A. Elsheikh, M. S. Province, Iran.” AIDS Res Hum Retroviruses 25: 277–83.
Karsany, and I. Adam. 2007. “Hepatitis B Virus and Gharamah, F. A., and N. A. Baktayan. 2006. “Exploring
Hepatitis C Virus in Pregnant Sudanese Women.” HIV/AIDS Knowledge and Attitudes of Secondary
Virol J 4: 104. School Students (10th &11th Grade) in Al-Tahreer
El-Sony, A. I., A. H. Khamis, D. A. Enarson, O. Baraka, District Sana’a City.” Republic of Yemen, March–April.
S. A. Mustafa, and G. Bjune. 2002. “Treatment Ghavanini, A. A., and M. R. Sabri. 2000. “Hepatitis B
Results of DOTS in 1797 Sudanese Tuberculosis Surface Antigen and Anti-Hepatitis C Antibodies
Patients with or without HIV Co-Infection.” Int J among Blood Donors in the Islamic Republic of Iran.”
Tuberc Lung Dis 6: 1058–66. East Mediterr Health J 6: 1114–16.
El-Tawila, S., O. El-Gibaly, B. Ibrahim, et al. 1999. Gheith, O. A., M. A. Saad, A. A. Hassan, A. E. Agroudy,
Transitions to Adulthood: A National Survey of Adolescents H. Sheashaa, and M. A. Ghoneim. 2007. “Hepatic
in Egypt. Cairo, Egypt: Population Council. Dysfunction in Kidney Transplant Recipients:
Elzubier, A. G., M. H. el Nour, and E. H. Ansari. 1996. Prevalence and Impact on Graft and Patient Survival.”
“AIDS-Related Knowledge and Misconceptions Clin Exp Nephrol 11: 309–15.
among High Secondary School Teachers and Students Gholamreza, R., S. Shahryar, K. Abbasali, J. Hamidreza,
in Kassala, Sudan.” East Afr Med J 73: 295–97. M. Abdolvahab, K. Khodaberdi, R. Danyal, and A.
Fahal, A. H., S. A. el Razig, S. H. Suliman, S. Z. Ibrahim, Nafiseh. 2007. “Seroprevalence of Hepatitis B Virus
and A. E. Tigani. 1995. “Gastrointestinal Tract Cancer and Its Co-Infection with Hepatitis D Virus and
in Association with Hepatitis and HIV Infection.” East Hepatitis C Virus in Iranian Adult Population.” Indian
Afr Med J 72: 424–26. J Med Sci 61: 263–68.
Faisel, A., and J. Cleland. 2006. “Study of the Sexual Gohar, S. A., R. Y. Khalil, N. M. Elaish, E. M. Khedr, and
Behaviours and Prevalence of STIs among Migrant M. S. Ahmed. 1995. “Prevalence of Antibodies to
Men in Lahore, Pakistan.” Arjumand and Associates, Hepatitis C Virus in Hemodialysis Patients and Renal
Centre for Population Studies, London School of Transplant Recipients.” J Egypt Public Health Assoc 70:
Hygiene and Tropical Medicine. 465–84.
Fakeeh, M., and A. M. Zaki. 1999. “Hepatitis C: Gorgi, Y., S. Yalaoui, H. L. Ben Nejma, M. M. Azzouz, M.
Prevalence and Common Genotypes among Ethnic Hsairi, H. Ben Khelifa, and K. Ayed. 1998. “Detection
Groups in Jeddah, Saudi Arabia.” Am J Trop Med Hyg of Hepatitis C Virus in the General Population of
61: 889–92. Tunisia.” Bull Soc Pathol Exot 91: 177.
254 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Iqbal, J., and N. Rehan. 1996. “Sero-Prevalence of HIV: Jordan National AIDS Control Programme. 2005. Report
Six Years’ Experience at Shaikh Zayed Hospital, on the National KABP Survey on HIV/AIDS among
Lahore.” J Pak Med Assoc 46: 255–58. Jordanian Youth. NAP Jordan. Amman, Jordan:
Irani-Hakime, N., J. Aoun, S. Khoury, H. R. Samaha, Ministry of Health.
H. Tamim, and W. Y. Almawi. 2001a. “Seroprevalence Jordan National TB Programme. 2006. “TB Facts and
of Hepatitis C Infection among Health Care Personnel Figures of Jordan.” Directorate of Chest Diseases and
in Beirut, Lebanon.” Am J Infect Control 29: 20–23. Foreigner’s Health, Ministry of Health.
Irani-Hakime, N., H. Tamim, H. Samaha, and W. Y. Jurjus, A. R., J. Kahhaleh, National AIDS Program, and
Almawi. 2001b. “Prevalence of Antibodies against WHO/EMRO. 2004. “Knowledge, Attitudes, Beliefs,
Hepatitis C Virus among Blood Donors in Lebanon, and Practices of the Lebanese concerning HIV/AIDS.”
1997–2000.” Clin Lab Haematol 23: 317–23. Beirut, Lebanon.
Irani-Hakime, N., U. Musharrafieh, H. Samaha, and Kabbash, I. A., N. M. El-Sayed, A. N. Al-Nawawy, I. K.
W. Y. Almawi. 2006. “Prevalence of Antibodies Shady, and M. S. Abou Zeid. 2007. “Condom Use
against Hepatitis B Virus and Hepatitis C Virus among among Males (15–49 Years) in Lower Egypt:
Blood Donors in Lebanon, 1997–2003.” Am J Infect Knowledge, Attitudes and Patterns of Use.” East
Control 34: 241–43. Mediterr Health J 13: 1405–16.
Iraq National TB Programme. 2006. “TB Facts and Kadivar, M. R., A. R. Mirahmadizadeh, A. Karimi, and
Figures of Iraq.” Directorate of General Health & A. Hemmati. 2001. “The Prevalence of HCV and HIV
Primary Health Care. Ministry of Health. in Thalassemia Patients in Shiraz, Iran.” Medical
IRIB (Islamic Republic of Iran Broadcasting). 2006. “Poll Journal of Iranian Hospital 4: 18–20.
of Teharan Public on AIDS.” Unpublished. Kafi, S. K., A. O. Mohamed, and H. A. Musa. 2000.
Jafri, W., N. Jafri, J. Yakoob, M. Islam, S. F. Tirmizi, “Prevalence of Sexually Transmitted Diseases (STD)
T. Jafar, S. Akhtar, S. Hamid, H. A. Shah, and S. Q. among Women in a Suburban Sudanese Community.”
Nizami. 2006. “Hepatitis B and C: Prevalence and Ups J Med Sci 105: 249–53.
Risk Factors Associated with Seropositivity among Kakepoto, G. N., H. S. Bhally, G. Khaliq, N. Kayani, I. A.
Children in Karachi, Pakistan.” BMC Infect Dis 6: 101. Burney, T. Siddiqui, and M. Khurshid. 1996.
Jafroodi, M., and R. Asadi. 2006. “Prevalence of HCV in “Epidemiology of Blood-Borne Viruses: A Study of
Thalassemia Major Patients in Guilan Province, Iran.” Healthy Blood Donors in Southern Pakistan.”
The 4th Congress of Iranian Pediatric Hematology, Southeast Asian J Trop Med Public Health 27: 703–6.
Oncology Society. Kerman, Iran. September. Karimi, I, and B. Ataei. 2007. “The Assessment of
Jahani, M. R., S. M. Alavian, H. Shirzad, A. Kabir, and Knowledge about AIDS and Its Prevention on Isfahan
B. Hajarizadeh. 2005. “Distribution and Risk Factors High School Students.” European Society of Clinical
of Hepatitis B, Hepatitis C, and HIV Infection in a Microbiology and Infectious Diseases, Munich,
Female Population with ‘Illegal Social Behaviour.’” Germany.
Sex Transm Infect 81: 185. Karimi, M., and A. A. Ghavanini. 2001. “Seroprevalence
Jama, H., L. Grillner, G. Biberfeld, S. Osman, A. Isse, of Hepatitis B, Hepatitis C and Human Immuno-
M. Abdirahman, and S. Bygdeman. 1987. “Sexually deficiency Virus Antibodies among Multitransfused
Transmitted Viral Infections in Various Population Thalassaemic Children in Shiraz, Iran.” J Paediatr
Groups in Mogadishu, Somalia.” Genitourin Med 63: Child Health 37: 564–66.
329–32. Karimi, M., H. Yarmohammadi, and R. Ardeshiri. 2002.
Jamal, N., I. A. Khushk, and Z. Naeem. 2006. “Knowledge “Inherited Coagulation Disorders in Southern Iran.”
and Attitudes regarding AIDS among Female Haemophilia 8: 740–44.
Commercial Sex Workers at Hyderabad City, Pakistan. Karkar, A. 2007. “Hepatitis C in Dialysis Units: The Saudi
J Coll Physicians Surg Pak 16: 91–93. Experience.” Hemodial Int 11: 354–67.
Javadi, A. A., M. Avijgan, and M. Hafizi. 2006. Kashef, S., M. Karimi, Z. Amirghofran, M. Ayatollahi,
“Prevalence of HBV and HCV Infections and M. Pasalar, M. M. Ghaedian, and M. A. Kashef. 2008.
Associated Risk Factors in Addict Prisoners.” Iranian J “Antiphospholipid Antibodies and Hepatitis C Virus
Publ Health 35: 33–36. Infection in Iranian Thalassemia Major Patients.” Int J
Javadzadeh, H., M. Attar, and M. Taher Yavari. 2006. Lab Hematol 30: 11–16.
“Study of the Prevalence of HBV, HCV, and HIV Kassem, A. S., A. A. el-Nawawy, M. N. Massoud, S. Y.
Infection in Hemophilia and Thalassemia Population el-Nazar, and E. M. Sobhi. 2000. “Prevalence of
of Yazd (Farsi).” Khoon (Blood) 2: 315–22. Hepatitis C Virus (HCV) Infection and Its Vertical
Jemni, L., S. Bahri, M. Saadi, A. Letaif, M. Dhidah, Transmission in Egyptian Pregnant Women and
H. Lahdhiri, and S. Bouchoucha. 1991. “AIDS Their Newborns.” J Trop Pediatr 46: 231–33.
and Tuberculosis in Central Tunisia.” Tunis Med 69: Kayani, N., A. Sheikh, A. Khan, C. Mithani, and M.
349–52. Khurshid. 1994. “A View of HIV-I Infection in
Jemni, S., K. Ikbel, M. Kortas, J. Mahjoub, L. Ghachem, Karachi.” J Pak Med Assoc 44: 8–11.
J. M. Bidet, and K. Boukef. 1994. “Seropositivity to Kebudi, R., I. Ayan, G. Yilmaz, F. Akici, O. Gorgun, and
Hepatitis C Virus in Tunisian Haemodialysis Patients.” S. Badur. 2000. “Seroprevalence of Hepatitis B,
Nouv Rev Fr Hematol 36: 349–51. Hepatitis C, and Human Immunodeficiency Virus
256 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Lazarus, J. V., H. M. Himedan, L. R. Ostergaard, and Marcelin, A. G., M. Grandadam, P. Flandre, E. Nicand, C.
J. Liljestrand. 2006. “HIV/AIDS Knowledge and Milliancourt, J. L. Koeck, M. Philippon, R. Teyssou,
Condom Use among Somali and Sudanese Immigrants H. Agut, N. Dupin, and V. Calvez. 2002. “Kaposi’s
in Denmark.” Scand J Public Health 34: 92–99. Sarcoma Herpesvirus and HIV-1 Seroprevalences in
Lebanon National AIDS Control Program. 1996. “General Prostitutes in Djibouti.” J Med Virol 68: 164–67.
Population Evaluation Survey Assessing Knowledge, Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck,
Attitudes, Beliefs and Practices Related to HIV/AIDS M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M.
in Lebanon.” Ministry of Public Health. Huraux, and N. Dupin. 2001. “Comparative Study of
———. 2003. “Soins Infirmiers et Développement Heterosexual Transmission of HIV-1, HSV-2 and KSHV
Communautaire (SIDC) (2003) Rapid Appraisal in Djibouti.” 8th Retrovir Oppor Infect (abstract no. 585).
Study on Stigma and Discrimination in Lebanon.” Marzouk, D., J. Sass, I. Bakr, M. El Hosseiny, M. Abdel-
Ministry of Public Health, Beirut, Lebanon. Hamid, C. Rekacewicz, N. Chaturvedi, M. K.
Mohamed, and A. Fontanet. 2007. “Metabolic and
Lebanon National TB Programme. 2006. “TB Facts and
Cardiovascular Risk Profiles and Hepatitis C Virus
Figures of Lebanon.” Ministry of Public Health,
Infection in Rural Egypt.” Gut 56: 1105–10.
Karantina, Beirut, Lebanon.
Mazloomy, S. S., and M. H. Baghianimoghadam. 2008.
Lehman, E. M., and M. L. Wilson. 2009. “Epidemiology
“Knowledge and Attitude about HIV/AIDS of
of Hepatitis Viruses among Hepatocellular Carcinoma
Schoolteachers in Yazd, Islamic Republic of Iran.” East
Cases and Healthy People in Egypt: A Systematic
Mediterr Health J 14: 292–97.
Review and Meta-Analysis.” Int J Cancer 124: 690–97.
McCarthy, M. C., A. el-Tigani, I. O. Khalid, and K. C.
Libya National Center for the Prevention of and Control
Hyams. 1994. “Hepatitis B and C in Juba, Southern
of Infectious Diseases. 2005. “Results of the National
Sudan: Results of a Serosurvey.” Trans R Soc Trop Med
Seroprevalence Survey.”
Hyg 88: 534–36.
Lycke, E., G. B. Lowhagen, G. Hallhagen, G. Johannisson, McCarthy, M. C., I. O. Khalid, and A. El Tigani. 1995.
and K. Ramstedt. 1980. “The Risk of Transmission of “HIV-1 Infection in Juba, Southern Sudan.” J Med
Genital Chlamydia Trachomatis Infection Is Less Than Virol 46: 18–20.
That of Genital Neisseria Gonorrhoeae Infection.” Sex
Transm Dis 7: 6–10. Measure DHS. 1998. “Jordan: Demographic and Health
Survey 1997.”
Mabrouk, G. M. 1997. “Prevalence of Hepatitis C
Infection and Schistosomiasis in Egyptian Patients ———. 2003. “Jordan: Demographic and Health Survey
with Hepatocellular Carcinoma.” Dis Markers 13: 2002.”
177–82. ———. 2004. “Egypt: Demographic and Health Survey
Madwar, M. A., I. El-Gindy, H. M. Fahmy, N. M. Shoeb, 2003.”
and B. A. Massoud. 1999. “Hepatitis C Virus ———. 2006. “Egypt: Demographic and Health Survey
Transmission in Family Members of Egyptian Patients 2005.”
with HCV Related Chronic Liver Disease.” J Egypt ———. 2007. “Pakistan Demographic and Health Survey
Public Health Assoc 74: 313–32. 2006–7.” Preliminary report, National Institute for
Mahaba, H., K. el-Tayeb Ael, and H. Elbaz. 1999. “The Population Studies, Measure DHS, and Macro
Prevalence of Antibodies to Hepatitis C Virus in Hail International.
Region, Saudi Arabia.” J Egypt Public Health Assoc 74: Mejri, S., A. B. Salah, H. Triki, N. B. Alaya, A. Djebbi, and
69–80. K. Dellagi. 2005. “Contrasting Patterns of Hepatitis C
Mahfouz, A. A., W. Alakija, A. A. al-Khozayem, and R. A. Virus Infection in Two Regions from Tunisia.” J Med
al-Erian. 1995. “Knowledge and Attitudes towards Virol 76: 185–93.
AIDS among Primary Health Care Physicians in the Ministry of Health and Medical Education of Iran. 2006.
Asir Region, Saudi Arabia.” J R Soc Health 115: 23–25. “Treatment and Medical Education.” Islamic Republic
Mahmoud, M. M., A. M. Nasr, D. E. Gassmelseed, M. A. of Iran HIV/AIDS situation and response analysis.
Abdalelhafiz, M. A. Elsheikh, and I. Adam. 2007. Mirmomen, S., S. M. Alavian, S. M., B. Hajarizadeh,
“Knowledge and Attitude toward HIV Voluntary J. Kafaee, B. Yektaparast, M. J. Zahedi, A. A. Azami,
Counseling and Testing Services among Pregnant M. M. Hosseini, A. R. Faridi, K. Davari, and B.
Women Attending an Antenatal Clinic in Sudan.” Hajibeigi. 2006. “Epidemiology of Hepatitis B,
J Med Virol 79: 469–73. Hepatitis C, and Human Immunodeficiency Virus
Mansoor, A. B., W. Fungladda, J. Kaewkungwal, and W. Infections in Patients with Beta-Thalassemia in Iran:
Wongwit. 2008. “Gender Differences in KAP Related A Multicenter Study.” Arch Iran Med 9: 319–23.
to HIV/AIDS among Freshmen in Afghan Mishwar. 2008. “An Integrated Bio-Behavioral
Universities.” Southeast Asian J Trop Med Public Health Surveillance Study among Four Vulnerable Groups in
39: 404–418. Lebanon: Men Who Have Sex with Men; Prisoners;
Mansour-Ghanaei, F., M. S. Fallah, A. Shafaghi, M. Commercial Sex Workers and Intravenous Drug
Yousefi-Mashhoor, N. Ramezani, F. Farzaneh, and Users.” Final report.
R. Nassiri. 2002. “Prevalence of Hepatitis B and C Mohamed, M. K., M. Abdel-Hamid, M. N. Mikhail,
Seromarkers and Abnormal Liver Function Tests F. Abdel-Aziz, A. Medhat, L. S. Magder, A. D. Fix,
among Hemophiliacs in Guilan (Northern Province of and G. T. Strickland. 2005. “Intrafamilial Transmission
Iran).” Med Sci Monit 8: CR797–800. of Hepatitis C in Egypt.” Hepatology 42: 683–87.
258 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Pakistan National AIDS Control Program. 2005a. HIV Quinti, I., E. Renganathan, E. El Ghazzawi, M. Divizia,
Second Generation Surveillance in Pakistan. National G. Sawaf, S. Awad, A. Pana, and G. Rocchi. 1995.
Report Round 1. Ministry of Health, Pakistan, and “Seroprevalence of HIV and HCV Infections in
Canada-Pakistan HIV/AIDS Surveillance Project. Alexandria, Egypt.” Zentralbl Bakteriol 283: 239–44.
———. 2005b. National Study of Reproductive Tract and Rady, A. 2005. “Knowledge, Attitudes and Prevalence of
Sexually Transmitted Infections. Survey of High Risk Condom Use among Female Sex Workers in Lebanon:
Groups in Lahore and Karachi. Ministry of Health, Behavioral Surveillance Study.” UNFPA.
Pakistan. Rahbar, A. R., S. Rooholamini, and K. Khoshnood. 2004.
———. 2005c. “Report of the Pilot Study in Karachi & “Prevalence of HIV Infection and Other Blood-Borne
Rawalpindi.” Ministry of Health Canada-Pakistan Infections in Incarcerated and Non-Incarcerated
HIV/AIDS Surveillance Project, Integrated Biological Injection Drug Users (IDUs) in Mashhad, Iran.”
& Behavioral Surveillance 2004–5. International Journal of Drug Policy 15: 151–55.
———. 2006–7. HIV Second Generation Surveillance in Raheel, H., F. White, M. M. Kadir, and Z. Fatmi. 2007.
Pakistan. National Report Round II. Ministry of “Knowledge and Beliefs of Adolescents regarding
Health, Pakistan, and Canada-Pakistan HIV/AIDS Sexually Transmitted Infections and HIV/AIDS in a
Surveillance Project. Rural District in Pakistan.” J Pak Med Assoc 57: 8–11.
———. 2008. HIV Second Generation Surveillance in Rais-Jalali, G., and P. Khajehdehi. 1999. “Anti-HCV
Pakistan. National Report Round III. Ministry of Seropositivity among Haemodialysis Patients of
Health, Pakistan, Canada-Pakistan HIV/AIDS Iranian Origin.” Nephrol Dial Transplant (European
Surveillance Project. Renal Association–European Dialysis and Transplant
Parker, S. P., H. I. Khan, and W. D. Cubitt. 1999. Association; ERA-EDTA): 2055–56.
“Detection of Antibodies to Hepatitis C Virus in Dried Raja, N. S., and K. A. Janjua. 2008. “Epidemiology of
Blood Spot Samples from Mothers and Their Offspring Hepatitis C Virus Infection in Pakistan.” J Microbiol
in Lahore, Pakistan.” J Clin Microbiol 37: 2061–63. Immunol Infect 41: 4–8.
Petro-Nustas, W. 2000. “University Students’ Knowledge Raja, Y., and A. Farhan. 2005. “Knowledge and Attitude
of AIDS.” Int J Nurs Stud 37: 423–33. of 10th and 11th Grade Students towards HIV/AIDS
Petro-Nustas, W., A. Kulwicki, and A. F. Zumout. 2002. in Aden Governorate.” Republic of Yemen.
“Students’ Knowledge, Attitudes, and Beliefs about Ramia, S., J. Mokhbat, A. Sibai, S. Klayme, and R.
AIDS: A Cross-Cultural Study.” J Transcult Nurs 13: Naman. 2004. “Exposure Rates to Hepatitis C and G
118–25. Virus Infections among HIV-Infected Patients:
PFPPA (Palestinian Family Planning and Protection Evidence of Efficient Transmission of HGV by the
Association). 2005. “Assessment of Palestinian Sexual Route.” Int J STD AIDS 15: 463–66.
Students’ Knowledge about AIDS and Their Attitudes Raza, M. I., A. Afifi, A. J. Choudhry, and H. I. Khan.
toward the AIDS Patient.” Jerusalem, Palestine. 1998. “Knowledge, Attitude and Behaviour towards
Plummer, F. A., L. J. D’Costa, H. Nsanze, J. Dylewski, P. AIDS among Educated Youth in Lahore, Pakistan.”
Karasira, and A. R. Ronald. 1983. “Epidemiology of J Pak Med Assoc 48: 179–82.
Chancroid and Haemophilus Ducreyi in Nairobi, Raziq, F., N. Alam, and L. Ali. 1993. “Serosurveillance of
Kenya.” Lancet 2: 1293–95. HIV Infection.” Pakistan Journal of Pathology.
Pourshams, A., R. Malekzadeh, A. Monavvari, M. R. Razzaghi, E. M., A. R. Movaghar, T. C. Green, and
Akbari, A. Mohamadkhani, S. Yarahmadi, N. Seddighi, K. Khoshnood. 2006. “Profiles of Risk: A Qualitative
M. Mohamadnejad, M. Sotoudeh, and A. Madjlessi. Study of Injecting Drug Users in Tehran, Iran.” Harm
2005. “Prevalence and Etiology of Persistently Reduct J 3: 12.
Elevated Alanine Aminotransferase Levels in Healthy
Refaat, A. 2004. “Practice and Awareness of Health Risk
Iranian Blood Donors.” Journal of Gastroenterology and
Behaviour among Egyptian University Students.”
Hepatology 20: 229–33.
East Mediterr Health J 10: 72–81.
Qadi, A. A., H. Tamim, G. Ameen, A. Bu-Ali, S.
Rehan, N. 2006. “Profile of Men Suffering from Sexually
Al-Arrayed, N. A. Fawaz, and W. Y. Almawi. 2004.
Transmitted Infections in Pakistan.” J Pak Med Assoc
“Hepatitis B and Hepatitis C Virus Prevalence among
56: S60–65.
Dialysis Patients in Bahrain and Saudi Arabia: A
Survey by Serologic and Molecular Methods.” Am J Renganathan, E., I. Quinti, E. El Ghazzawi, O. Kader,
Infect Control 32: 493–95. I. El Sherbini, F. Gamil, and G. Rocchi. 1995.
“Absence of HIV-1 and HIV-2 Infection in Different
Qatar National TB Programme. 2006. “TB Facts and
Populations from Alexandria, Egypt.” Eur J Epidemiol
Figures of Qatar.” Hamad Medical Corporation.
11: 711–12.
Quadan, A. 2002. “Prevalence of Anti Hepatitis C Virus
Rezvan, H., H. Abolghassemi, and S. A. Kafiabad. 2007.
among the Hospital Populations in Jordan.” New
“Transfusion-Transmitted Infections among Multi-
Microbiol 25: 269–73.
transfused Patients in Iran: A Review.” Transfus Med
Quinti, I., D. el-Salman, M. K. Monier, B. G. Hackbart, 17: 425–33.
M. S. Darwish, D. el-Zamiaty, R. Paganelli, F.
Rezvan, H., J. Ahmadi, M. Farhadi, and S. Taroyan.
Pandolfi, and R. R. Arthur. 1997. “HCV Infection in
1994. “A Preliminary Study on the Prevalence of
Egyptian Patients with Acute Hepatitis.” Dig Dis Sci
Anti-HCV amongst Healthy Blood Donors in Iran.”
42: 2017–23.
Vox Sang 67: 100.
260 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Shidrawi, R., M. Ali Al-Huraibi, M. Ahmad Al-Haimi, Users and Non-Drug Users Attending an HIV Testing
R. Dayton, and I. M. Murray-Lyon. 2004. Clinic in Israel.” Isr J Psychiatry Relat Sci 35: 307–17.
“Seroprevalence of Markers of Viral Hepatitis in Stoszek, S. K., M. Abdel-Hamid, S. Narooz, M. El Daly,
Yemeni Healthcare Workers.” J Med Virol 73: 562–65. D. A. Saleh, N. Mikhail, E. Kassem, Y. Hawash, S. El
Shobokshi, O. A., F. E. Serebour, A. Z. Al-Drees, A. H. Kafrawy, A. Said, M. El Batanony, F. M. Shebl,
Mitwalli, A. Qahtani, and L. I. Skakni. 2003. “Hepatitis M. Sayed, S. Sharaf, A. D. Fix, and G. T. Strickland.
C Virus Seroprevalence Rate among Saudis.” Saudi 2006. “Prevalence of and Risk Factors for Hepatitis C
Med J 24 Suppl 2: S81–86. in Rural Pregnant Egyptian Women.” Trans R Soc Trop
Shrestha, P. N. 1996. “HIV/AIDS Surveillance in the Med Hyg 100: 102–7.
Eastern Mediterranean Region.” Eastern Mediterranean Sudan Government of National Unity. 2007. United
Health Journal 2: 82–89. Nations National Integrated Annual Action Plan 2007.
Siddiqi, S., S. A. Majeed, and M. Saeed Khan. 1995. United Nations.
“Knowledge, Attitude and Practice Survey of Acquired Sudan MOH (Ministry of Health). 2005. Sudan National
Immune Deficiency Syndrome (AIDS) among HIV/AIDS Surveillance Unit, Annual Report. Khartoum.
Paramedicals in a Tertiary Care Hospital in Pakistan.” Sudan National AIDS Control Program. 1999. 1999
J Pak Med Assoc 45: 200–2. report. Khartoum: Federal Ministry of Health.
Sit, D., A. K. Kadiroglu, H. Kayabasi, M. E. Yilmaz, and ———. 2005. Sentinel Sero-Survailance—2005 Data.
V. Goral. 2007. “Seroprevalence of Hepatitis B and C Annual Newsletter.
Viruses in Patients with Chronic Kidney Disease in Sudan National HIV/AIDS Control Program. 2004. HIV/
the Predialysis Stage at a University Hospital in AIDS/STIs Prevalence, Knowledge, Attitude, Practices and
Turkey.” Intervirology 50: 133–37. Risk Factors among University Students and Military
Slama, H., N. Mojaat, R. Dahri, and K. Boukef. 1991. Personnel. Federal Ministry of Health, Khartoum.
“Epidemiologic Study of Anti-HCV Antibodies in Sultan, F., T. Mehmood, and M. T. Mahmood. 2007.
Tunisian Blood Donors.” Rev Fr Transfus Hemobiol 34: “Infectious Pathogens in Volunteer and Replacement
459–64. Blood Donors in Pakistan: A Ten-Year Experience.”
SNAP (Sudan National AIDS Programme). 2006. “HIV Int J Infect Dis 11: 407–12.
Sentinel Surveillance among Tuberculosis Patients in Syria Mental Health Directorate. 2008. “Assessment of
Sudan.” Federal Ministry of Health, General HIV Risk and Sero-Prevalence among Drug Users in
Directorate of Preventive Medicine, SNAP. Greater Damascus.” Programme SNA, Syrian Ministry
———. 2008. “Update on the HIV Situation in Sudan.” of Health, UNODC, UNAIDS.
PowerPoint presenation. Syria National AIDS Programme. 2004. “HIV/AIDS
SNAP (Sudan National AIDS Programme), NSNAC Female Sex Workers KABP Survey in Syria.”
(New Sudan National AIDS Council), and UNAIDS Tabarsi, P., S. M. Mirsaeidi, M. Amiri, S. D. Mansouri,
(United Nations Joint Progamme on HIV/AIDS). M. R. Masjedi, and A. A. Velayati. 2008. “Clinical and
2006. “Scaling-up HIV/AIDS Response in Sudan.” Laboratory Profile of Patients with Tuberculosis/HIV
“National Consultation on the Road towards Universal Coinfection at a National Referral Centre: A Case
Access to Prevention, Treatment, Care and Support.” Series.” East Mediterr Health J 14: 283–91.
February. Tahan, V., C. Karaca, B. Yildirim, A. Bozbas, R. Ozaras,
SNAP (Sudan National AIDS Programme), and UNAIDS. K. Demir, E. Avsar, A. Mert, F. Besisik, S. Kaymakoglu,
2006. “HIV/AIDS Integrated Report North Sudan, H. Senturk, Y. Cakaloglu, C. Kalayci, A. Okten, and
2004–2005 (Draft).” With United Nations General N. Tozun. 2005. “Sexual Transmission of HCV
Assembly Special Session on HIV/AIDS Declaration of between Spouses.” Am J Gastroenterol 100: 821–24.
Commitment. Talaie, H., S. H. Shadnia, A. Okazi, A. Pajouhmand,
SNAP (Sudan National AIDS Programme), UNICEF H. Hasanian, and H. Arianpoor. 2007. “The Prevalence
(United Nations Children’s Fund), and UNAIDS. of Hepatitis B, Hepatitis C and HIV Infections in Non-
2005. “Baseline Study on Knowledge, Attitudes, and IV Drug Opioid Poisoned Patients in Tehran, Iran.”
Practices on Sexual Behaviors and HIV/AIDS Pak J Biol Sci 10: 220–24.
Prevention amongst Young People in Selected States Tamim, H., N. Irani-Hakime, J. P. Aoun, S. Khoury,
in Sudan.” HIV/AIDS KAPB Report. Projects and H. Samaha, and W. Y. Almawi. 2001. “Seroprevalence of
Research Department (AFROCENTER Group). Hepatitis C Virus (HCV) Infection among Blood Donors:
Somaliland Ministry of Health and Labour. 2007. A Hospital-Based Study.” Transfus Apher Sci 24: 29–5.
Somaliland 2007 HIV/Syphilis Seroprevalence Survey, Tanaka, Y., S. Agha, N. Saudy, F. Kurbanov, E. Orito,
A Technical Report. Ministry of Health and Labour in T. Kato, M. Abo-Zeid, M. Khalaf, Y. Miyakawa, and
collaboration with the WHO, UNAIDS, UNICEF/ M. Mizokami. 2004. “Exponential Spread of Hepatitis
GFATM, and SOLNAC. C Virus Genotype 4a in Egypt.” J Mol Evol 58: 191–95.
Sonmez, M., O. Bektas, M. Yilmaz, A. Durmus, E. Tariq, W. U. Z., I. A. Malik, Z. U. Hassan, A. Hannan, and
Akdogan, M. Topbas, M. Erturk, E. Ovali, and S. B. M. Ahmen. 1993. “Epidemiology of HIV Infection in
Omay. 2007. “The Relation of Lymphoma and Northern Pakistan.” Pakistan J Path 4: 111–14.
Hepatitis B Virus/Hepatitis C Virus Infections in the Tavoosi, A., A. Zaferani, A. Enzevaei, P. Tajik, and
Region of East Black Sea, Turkey.” Tumori 93: 536–39. Z. Ahmadinezhad. 2004. “Knowledge and Attitude
Soskolne, V., and S. Maayan. 1998. “HIV Knowledge, towards HIV/AIDS among Iranian Students.” BMC
Beliefs and Sexual Behavior of Male Heterosexual Drug Public Health 4: 17.
262 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
———. 2007. “HIV/AIDS Surveillance in Low Level and World Bank. 2008. “Mapping and Situation Assessment
Concentrated HIV Epidemics: A Technical Guide for of Key Populations at High Risk of HIV in Three Cities
Countries in the WHO Eastern Mediterranean of Afghanistan.” Human Development Sector, South
Region.” Asia Region (SAR) AIDS Team, World Bank.
WHO (World Health Organization), UNICEF (United Yakaryilmaz, F., O. A. Gurbuz, S. Guliter, A. Mert,
Nations Children’s Fund), and UNAIDS (United Y. Songur, T. Karakan, and H. Keles. 2006.
Nations Joint Programe on HIV/AIDS). 2006a. “Prevalence of Occult Hepatitis B and Hepatitis C
“Epidemiological Facts Sheets on HIV/AIDS and Virus Infections in Turkish Hemodialysis Patients.”
Sexually Transmitted Infections.” Algeria. Ren Fail 28: 729–35.
———. 2006b. “Epidemiological Facts Sheets on HIV/ Yazdi, C. A., K. Aschbacher, A. Arvantaj, H. M. Naser,
AIDS and Sexually Transmitted Infections.” Bahrain. E. Abdollahi, A. Asadi, M. Mousavi, M. R. Narmani,
———. 2006c. “Epidemiological Facts Sheets on HIV/ M. Kianpishe, F. Nicfallah, and A. K. Moghadam.
AIDS and Sexually Transmitted Infections.” Djibouti. 2006. “Knowledge, Attitudes and Sources of
Information regarding HIV/AIDS in Iranian
———. 2006d. “Epidemiological Facts Sheets on HIV/ Adolescents.” AIDS Care 18: 1004–10.
AIDS and Sexually Transmitted Infections.” Egypt.
Yemen National TB Programme. 2006. “TB Facts and
———. 2006e. “Epidemiological Facts Sheets on HIV/ Figures of Yemen.” NTCP, Ministry of Health.
AIDS and Sexually Transmitted Infections.” Iraq.
Yildirim, B., S. Barut, Y. Bulut, G. Yenisehirli, M. Ozdemir,
———. 2006f. “Epidemiological Facts Sheets on HIV/ I. Cetin, I. Etikan, A. Akbas, O. Atis, H. Ozyurt, and
AIDS and Sexually Transmitted Infections.” Iran. S. Sahin. 2009. “Seroprevalence of Hepatitis B and C
———. 2006g. “Epidemiological Facts Sheets on HIV/ Viruses in the Province of Tokat in the Black Sea
AIDS and Sexually Transmitted Infections.” Jordan. Region of Turkey: A Population-Based Study.” Turk
———. 2006h. “Epidemiological Facts Sheets on HIV/ J Gastroenterol 20: 27–30.
AIDS and Sexually Transmitted Infections.” Kuwait. Yorke, J. A., H. W. Hethcote, and A. Nold. 1978.
———. 2006i. “Epidemiological Facts Sheets on HIV/ “Dynamics and Control of the Transmission of
AIDS and Sexually Transmitted Infections.” Lebanon. Gonorrhea.” Sex Transm Dis 5: 51–56.
———. 2006j. “Epidemiological Facts Sheets on HIV/ Yousif, M. E. A. 2006. Health Education Programme among
AIDS and Sexually Transmitted Infections.” Libya, Female Sex Workers in Wad Medani Town-Gezira State.
Arab Jamahiriya. Final report.
———. 2006k. “Epidemiological Facts Sheets on HIV/ Zafar, T., H. Brahmbhatt, G. Imam, S. ul Hassan, and S.
AIDS and Sexually Transmitted Infections.” A. Strathdee. 2003. “HIV Knowledge and Risk
Morocco. Behaviors among Pakistani and Afghani Drug Users
in Quetta, Pakistan.” J Acquir Immune Defic Syndr 32:
———. 2006l. “Epidemiological Facts Sheets on HIV/ 394–98.
AIDS and Sexually Transmitted Infections.” Oman.
Zahraoui-Mehadji, M., M. Z. Baakrim, S. Laraqui,
———. 2006m. “Epidemiological Facts Sheets on HIV/ O. Laraqui, Y. El Kabouss, C. Verger, A. Caubet, and
AIDS and Sexually Transmitted Infections.” Pakistan. C. H. Laraqui. 2004. “Infectious Risks Associated with
———. 2006n. “Epidemiological Facts Sheets on HIV/ Blood Exposure for Traditional Barbers and Their
AIDS and Sexually Transmitted Infections.” Qatar. Customers in Morocco.” Sante 14: 211–16.
———. 2006o. “Epidemiological Facts Sheets on HIV/ Zali, M. R., R. Aghazadeh, A. Nowroozi, and H. Amir-
AIDS and Sexually Transmitted Infections.” Somalia. Rasouly. 2001. “Anti-HCV Antibody among Iranian
———. 2006p. “Epidemiological Facts Sheets on HIV/ IV Drug Users: Is It a Serious Problem?” Arch Iranian
AIDS and Sexually Transmitted Infections.” Sudan. Med 4: 115–19.
———. 2006q. “Epidemiological Facts Sheets on HIV/ Zamani, S., M. Kihara, M. M. Gouya, M. Vazirian,
AIDS and Sexually Transmitted Infections.” Syrian M. Ono-Kihara, E. M. Razzaghi, and S. Ichikawa.
Arab Republic. 2005. “Prevalence of and Factors Associated with
HIV-1 Infection among Drug Users Visiting Treatment
———. 2006r. “Epidemiological Facts Sheets on HIV/ Centers in Tehran, Iran.” AIDS 19: 709–16.
AIDS and Sexually Transmitted Infections.” Tunisia.
Zamani, S., G. M. Mehdi, M. Ono-Kihara, S. Ichikawa,
———. 2006s. “Epidemiological Facts Sheets on HIV/ and M. Kuhara. 2007. “Shared Drug Injection Inside
AIDS and Sexually Transmitted Infections.” Yemen. Prison as a Potent Associated Factor for Acquisition
Winer, R. L., S. K. Lee, J. P. Hughes, D. E. Adam, N. B. of HIV Infection: Implication for Harm Reduction
Kiviat, and L. A. Koutsky. 2003. “Genital Human Interventions in Correctional Settings.” Journal of
Papillomavirus Infection: Incidence and Risk Factors AIDS Research 9: 217–22.
in a Cohort of Female University Students.” Am Zidouh, A. Unknown. “VIH/SIDA et infections sexuelle-
J Epidemiol 157: 218–26. ment transmissibles: connaissance et attitudes.”
Winter, J. 1996. “Where the Imams Play Their Part.”
AIDS Anal Afr 6: 1–2.
265
antenatal clinic (ANC) attendees and other pregnant migrant population, 134, 136
women. See also mother-to-child transmission MSM in, 34
bacterial STIs, 168 banthas, 33
case notification surveillance reports, 82–84, 83f barbers, HCV prevalence among, 91
FSWs, 47 behavioral surveillance, increasing and expanding,
general population, prevalence of HIV in, 65, 213–14
66–67t, 71, 72 bibliographies, 8–10
HSV-2 incidence, 152, 154 condom use, 113–18
migrants, 134 current status and future potential, 191–97
point-prevalence surveys, 229–32t epidemiological factors, 94–100
refugees and IDPs, 138 FSWs, 54–58
studies and surveys, 181 general population and HIV, 75–80
antiretroviral therapy (ART), 200, 203, 207–9, 208f, IDUs, 25–29
208t, 214 knowledge of HIV/AIDS, 113–18
antischistosomal therapy, 89 MSM, 39–41
Ar-Razi psychiatric hospital, Morocco, 201 potential bridging populations, 62–63
Arab Republic of Egypt. See Egypt, Arab Republic of proxy markers of risk behavior, 170–78
armed forces, as potential bridging population. See responses to HIV in MENA, 210–12
potential bridging populations strategic recommendations, 218–19
ART (antiretroviral therapy), 200, 203, 207–9, 208f, vulnerable populations, 141–49
208t, 214 blood and blood products
Asia. See also East Asia and Pacific; Eastern Europe case notification surveillance reports, 82–84, 83f
and Central Asia; South Asia general population, prevalence of HIV in, 65,
FSWs, 52 68–69t
HSV-2 in, 155t IDUs providing, 21
parenteral transmission in, 91 MSM providing, 35
priority and bridging populations, HIV origins of HIV in MENA and, 179–81
concentrated in, 5 parenteral transmission other than IDU,
youth and HIV in, 132 88–92, 90t
Association Tunisienne de Lutte contre le SIDA safety and screening programs, 180, 207
(ATLS), 202 STIs/STDs, 165
attitudes toward PLHIV, 110–11, 113, 245–47t as transmission mode, 86–87t
Azerbaijan, HPV and cervical cancer in, 157 blood letting, traditional practices of, 89
Brazil, HPV and cervical cancer in, 161
B bridging populations. See potential bridging
Bahrain populations
as covered country, 6
FSWs in, 229t C
HCV in different population groups, 232t Cameroon, molecular epidemiology of
HPV and cervical cancer in, 157t, 159t HIV/AIDS in, 93
IDUs in, 11, 12t, 15t, 229t care and treatment of HIV/AIDS patients, 206f,
knowledge of HIV/AIDS in, 232t 207–9, 208t
MSM in, 229t Caribbean. See Latin America and Caribbean
origins and evolution of HIV in, 179 case notification surveillance reports, 82–84,
parenteral transmission other than IDU, 90t 83f, 186
PLHIV, estimated numbers of, 221t casual sex
prevalence of HIV, 224t in general population, 70
prevention efforts, 209, 210 of refugees and IDPs, 137
prisoners in, 121t in youth populations, 129–31
status of current epidemic in, 184t Central America. See Latin America and Caribbean
STIs/STDs, 209, 210, 229t Central Asia. See Eastern Europe and Central Asia
TB and HIV in, 229t cervical cancer and HPV, 69–70, 72, 132, 156–62,
Bangladesh 157t, 158f, 159t, 160f, 161f, 222t
civil society organizations and NGOs in, 216 cervical lesions, noncancerous, in young women, 132
HSV-2 in, 153t chancroid, 168, 222t
266 Index
chastity houses, 71 status of current epidemic, 184t
chavas, 33 typology of disease in different regions, 182–83
China, truck driver network in, 61 vulnerable populations, 188–89
chlamydia, 162–69, 167–68t, 169f, 222t. See also
sexually transmitted infections (STIs) and
D
Dar el Amal, 202
diseases (STDs) other than HIV
Demographic and Health Survey (DHS) reports, 7
circumcision
desirability bias, 5–6
female genital mutilation, 74
divorced women, sexual risk behaviors of, 70, 71
male, 4, 54, 62, 73–75, 160, 187, 190
Djibouti
civil society organizations, 201, 205–7, 215–16
ART in, 208t, 209
clean needle programs, 201, 215
attitudes toward PLHIV in, 245t
clinic attendees. See antenatal clinic (ANC) attendees and
civil society organizations and NGOs in, 216
other pregnant women; sexually transmitted
condom use in, 103t
disease (STD) clinic attendees; voluntary
as covered country, 6
counseling and testing (VCT) attendees
female circumcision/genital mutilation in, 74
commercial sex. See sex workers
FSWs in, 43, 44t, 47, 53, 54, 129, 202, 229t
conceptual framework of HIV/AIDS in MENA
general population and HIV in, 65t, 66t, 68t, 69,
region, 3–6, 4–6f, 182–85, 185f
70, 74
condom use, 101–9
HCV in different population groups, 232t
accessibility of condoms, 101–8, 203–4
HPV and cervical cancer in, 157t
actual condom use, 101, 103–8t, 108
HSV-2 in, 153t
bibliography, 113–18
IDUs in, 185, 229t
conclusions regarding, 108–9
knowledge of HIV/AIDS in, 109–10, 131, 239t, 244t
by FSWs, 50–51, 101, 108
molecular epidemiology in, 92, 93
general knowledge regarding, 101–9, 102–3t
MSM in, 229t
in general population, 70
origins and evolution of HIV in, 181
by IDUs, 21, 22–24t
PLHIV, associations of, 206
by MSM, 36–37, 101, 108
PLHIV, estimated numbers of, 221t
prevention programs, 202, 203–4
potential bridging populations in, 59, 60, 62
prisoners, 125
pregnant women, prevalence of HIV among, 229t
refugees and IDPs, 137
prevalence of HIV in, 180, 187, 224t
by street children, 139
prevention efforts in, 202, 207, 209, 210
youth and HIV, 130–31
prisoners in, 121t
conflicts and postconflict situations, 133
status of current epidemic in, 184t
crisis situations, 133
STIs/STDs, 81, 163t, 166t, 167t, 168, 209, 210,
cultural issues
226t, 229t
desirability bias, 5–6
TB and HIV in, 228t, 229t
as protective factors, 187–88
typology of disease in, 183
status of HIV in MENA and, 2–3
unsafe abortions in, 169
vulnerability due to cultural change, 2
VCT clinics and attendees, 81, 204, 226t
cupping, 89
youth and HIV in, 129–30, 131
current status and future potential, 179–97
domestic violence. See abuse
bibliography, 191–97
drug resistance monitoring, 209
dynamics of current disease in conceptual
framework, 185f E
expansion of HIV in MENA, 189–91, 190f East Asia and Pacific. See also Asia
knowledge of HIV and, 189 IDUs in, 16
number of current infections, 186 MSM, 31
origins and evolution of epidemic in MENA, 179–82 unsafe abortions in, 170f
overlap among priority groups, 188f Eastern Europe and Central Asia. See also Asia
prevalence of HIV, 186–87 HSV-2 in, 155t
progress in controlling, 186 IDUs, prevalence of, 14
protective factors, 187–88 truck driver network, 61
response to epidemic, 199–212. See also responses unsafe abortions in, 170f
to HIV in MENA youth and HIV in, 126
Index 267
Eastern Mediterranean Regional Office of WHO. extramarital sex
See World Health Organization, Eastern in general population, 69, 70–71
Mediterranean Regional Office refugees and IDPs, 137
Egypt, Arab Republic of
attitudes toward PLHIV in, 245t F
civil society organizations and NGOs in, 216 Family Health International (FHI), 7
condom use in, 101, 102t, 103t female circumcision/genital mutilation, 74
as covered country, 6 female prisoners having sex with guards, 125
DHS reports, 7 female sex workers (FSWs), 43–58
female circumcision/genital mutilation in, 74 abuse of, 43, 46
FSWs in, 44t, 47, 51, 52, 53, 202, 229–30t anal and oral sex, 48, 50, 52, 54
general population and HIV in, 68t, 71–72, bibliography, 54–58
73, 74 case notification surveillance reports, 82–84, 83f
HCV in different population groups, 232–33t clients of, 47–48, 61, 62
HPV and cervical cancer in, 157t, 158, 159t, 160 conclusions regarding, 53–54
HSV-2 in, 152, 153t condom use, 50–51, 101, 108
IDUs in, 12t, 14t, 15–16, 15t, 17, 18t, 20, 21, 22t, dynamics of current epidemic and, 185f
52, 111, 124, 201, 204, 229–30t frequency of sexual contact/number of partners,
intergenerational marriage in, 127 48–49, 61, 62
knowledge of HIV/AIDS in, 109, 110, 111, 112, future expansion of HIV among, 190–91
113, 131, 239t, 242t, 244t, 247t general population’s contact with, 69, 70
migrant population, 133, 136 heterogeneity of risk and, 4, 5
MSM in, 32t, 33, 34, 36, 37, 128, 229–30t HPV and cervical cancer, 69, 70, 159, 160f
nontraditional marriages in, 71–72 HSV-2 incidence, 152, 155
origins and evolution of HIV in, 179 IDUs and, 20–21, 22–24t, 25, 49, 53–53, 54, 188f, 206
overlapping risks in, 206 knowledge of HIV/AIDS among, 53, 109
parenteral transmission other than IDU, 88, 89, migrants and, 48, 50, 134, 135
90, 90t, 91 MSM having sex with, 37, 188f, 206
PLHIV, estimated numbers of, 221t MSWs hosted by, 36
pregnant women, prevalence of HIV among, networks among, 49–50
229–30t pimps, 45, 47
prevalence of HIV in, 180, 224t potential bridging populations and, 59–62
prevention efforts in, 201, 202, 204, 209, 210 practices of, 46–47
prisoners in, 121t, 124 prevalence of, 47
status of current epidemic in, 184t prevalence of HIV among, 43, 44–45t, 181, 187,
STIs/STDs, 129, 163t, 166t, 167t, 169, 209, 210, 229–32t
226t, 229–30t prevention programs for, 202
street children in, 139 refugees and IDPs, 48, 141b
TB and HIV in, 229–30t risk behaviors of, 48–53
transmission modes in, 86t sexual trafficking in, 46
youth and HIV in, 126, 127, 128, 129, social, economic, and political factors affecting,
130, 131 43–46
emergency situations, 133 status of current epidemic, 184t
EMRO. See World Health Organization, Eastern stigmatization in MENA, 2, 189, 202
Mediterranean Regional Office STIs/STDs, 48, 50, 51–52, 53, 81, 165, 168, 202
enzyme-linked immunosorbent assay (ELISA), 204 studies and surveys, 181
Ethiopia truck drivers and, 46, 47, 48, 51, 53, 216
FSWs in, 48 VCT/STD clinic attendees and, 48, 81, 202
migrant population, 134 youth and HIV, 126, 129
molecular epidemiology in, 93 female sexual partners of MSM, 37
potential bridging populations in, 59, 60 FHI (Family Health International), 7
refugees and IDPs, 138 France, Tunisian IDUs deported from, 180
Europe, Eastern. See Eastern Europe and FSWs. See female sex workers
Central Asia future of HIV/AIDS in MENA region. See current
exogenous HIV exposures, 85–87, 180, 182 status and future potential
268 Index
G H
gay men. See men who have sex with men harm reduction as aim for priority populations, 217
gender issues HBV (Hepatitis B), 88, 89, 90, 91, 179
female genital mutilation, 74 HCV. See Hepatitis C
FSWs. See female sex workers health care in MENA, vulnerability factors arising
HPV and cervical cancer rates, male sexual from, 2
behavior mainly affecting, 159 health care workers (HCWs)
IDUs, female, 16, 52–53, 54 hemodialysis, universal blood precautions in, 89
intergenerational sex, 61, 73 PLHIV, attitudes toward, 110
knowledge of HIV/AIDS, gender differentials in, Helem (NGO), 201, 216
111–12 hemodialysis patients, 88, 89, 90t, 91
migrant populations, 134, 135 hemolytic anemia, 179
MSM. See men who have sex with men Hepatitis B (HBV), 88, 89, 90, 91, 179
premarital sex as leading cause of suicide for Hepatitis C (HCV)
women, 73 IDUs
prevalence of HIV by gender, 84–85 MSM and, 38
prisoners, female, having sex with guards, 125 as proxy marker of HIV risk among, 13, 14t
risk behavior, men more likely to engage in, 61, need to study, 3
73, 84–85 parenteral transmission other than IDU,
transgender individuals, 31, 33, 35, 36, 37, 88–92, 179
38, 61, 202 prevalence in MENA, 14t, 232–38t
vulnerability factors exacerbated by, 2, 61 in prison population, 120
vulnerability of sexual partners/spouses, 188–89 research priorities, 214
widowed and divorced women, sexual risk surveillance practices, 213, 214
behaviors of, 70, 71 herpes simplex virus type 1 (HSV-1), 154
young single women, large cohort of, 127–28 herpes simplex virus type 2 (HSV-2), or genital
general population, 65–80 herpes, 132, 152–56, 153t, 154f, 155t,
bibliography, 75–80 214, 222t
casual sex, 70 heterogeneity of risk, 3–4, 4f, 5f
in conceptual framework, 3–4, 4f, 5f heterosexual sex, as transmission mode, 85, 86–87t
conclusions regarding, 74–75 High Risk Corridor Initiative, 216
condom use, 70 hijamah (traditional medical practices), 89
extramarital sex, 69, 70–71 hijras, 31, 33, 35, 36, 37, 38, 60, 168, 202
female genital mutilation in, 74 HIV/AIDS in MENA region, 1–10
FSWs, contact with, 69, 70 bibliographies. See bibliographies
male circumcision in, 73–75 as bloodborne pathogen. See entries at blood
nontraditional marriages, 71–72 case notification surveillance reports, 82–84,
polygamy, 69–70, 71, 72–73 83f, 186
premarital sex, 70, 71, 73 conceptual framework, 3–6, 4–6f, 182–85, 185f
prevalence of HIV among, 65–69t, 187 condom use, 101–9. See also condom use
risk behavior of, 69–73, 74 countries covered, 6. See also specific countries
status of current epidemic, 184t current status and future potential, 179–97.
STIs/STDs, 69–74 See also current status and future potential
genital herpes (herpes simplex virus type 2 or epidemiological data for, 1, 7–8
HSV-2), 132, 152–56, 153t, 154f, 155t exogenous HIV exposures, 85–87, 180, 182
glass cupping, 89 FSWs, 43–58. See also female sex workers
Global Fund to Fight AIDS, Tuberculosis and Malaria gender issues related to. See gender issues
(GFATM), 202, 203, 207 in general population, 65–80. See also general
gonorrhea, 162–69, 166t, 169f, 222t. See also sexually population
transmitted infections (STIs) and diseases IDUs, 15–29. See also injecting drug users
(STDs) other than HIV knowledge about HIV/AIDS, 109–13
government organized NGOs (GONGOs), 216 knowledge of HIV/AIDS. See also knowledge about
group of sustainable transmission (GST), 4 HIV/AIDS
guest workers. See migrants limitations of study, 8
gurus (pimps) for hijras, 35 literature review, 6–7, 222–23
Index 269
HIV/AIDS in MENA region (continued) IDPs (internally displaced persons). See refugees
molecular epidemiology/subtypes, 92–94 and IDPs
MSM, 31–41. See also men who have sex IDUs. See injecting drug users
with men INCAS (Iranian National Center for Addiction
objectives and scope of study, 3 Studies), 201
origins and evolution of epidemic, 179–82 India
point-prevalence surveys, 7–8, 82, 224–38t IDUs in, 15
potential bridging populations, 59–63. See also migrant population, 134
potential bridging populations molecular epidemiology in, 93
priority populations. See female sex workers; MSM in, 32, 34
injecting drug users; men who have sex with Indonesia
men; priority populations FSWs in, 47
proxy markers, 151–78. See also proxy markers of migrant population, 134, 136
risk behavior MSM in, 31
research methodology, 6–8 injecting drug users (IDUs), 15–29
response to, 199–212. See also responses to HIV in availability of drugs in MENA, 2, 16
MENA bibliography, 25–29
STDs/STIs. See sexually transmitted disease blood, commercial sale of, 21
(STD) clinic attendees; sexually transmitted case notification surveillance reports, 82–84, 83f
infections (STIs) and diseases (STDs) other conclusions regarding, 24–25
than HIV dynamics of current epidemic and, 185f
strategic recommendations regarding, 213–19. female, 16, 52–53, 54
See also strategic recommendations frequency of injection, 17–19
sustainable transmission period and transmission FSWs and, 20–21, 22–24t, 25, 49, 53–53, 54,
probability, 222t 188f, 206
TB patients. See tuberculosis (TB) patients, future expansion of HIV among, 190
HIV/AIDS among HCV
transmission modes, 85, 86–87t MSM and, 38
VCT attendees. See voluntary counseling and as proxy marker of HIV risk, 13, 14t
testing (VCT) attendees heterogeneity of risk and, 4, 5
vulnerability factors, 2–3 “jerking,” 21
vulnerable populations, 119–49. See also knowledge of HIV/AIDS among, 21–24, 109
vulnerable populations law enforcement approach to HIV control,
HIV International Alliance, 202 avoiding, 215
homophobia in MENA, 31–32 migrants as, 135
homosexuality. See men who have sex with men MSM and, 21, 22–24t, 25, 38, 188f, 206
HPV (human papillomavirus) and cervical cancer, networks of, 19–20
69–70, 72, 132, 156–62, 157t, 158f, 159t, nonsterile equipment, use of, 17, 18t
160f, 161f, 222t number and frequency of sexual partners, 20–21, 61
HPV (human papillomavirus) vaccination, 161–62 OST, 200–201
HSV-1 (herpes simplex virus type 1), 154 potential bridging populations and, 59, 61
HSV-2 (herpes simplex virus type 2), or genital prevalence in MENA, 13–16, 15t, 186–87
herpes, 132, 152–56, 153t, 154f, 155t, prevalence of HIV infection among, 11, 12–13t,
214, 222t 229–32t
human papillomavirus (HPV) and cervical cancer, prevention programs for, 200–201
69–70, 72, 132, 156–62, 157t, 158f, 159t, prisoners as, 91, 119–20, 123, 128
160f, 161f, 222t refugees and IDPs, 137
human papillomavirus (HPV) vaccination, 161–62 risk behaviors of, 16–21, 18t, 22–24t
status of current epidemic, 184t
I sterile needle programs, 201, 215
IARC (International Agency for Research on stigmatization of, 2, 189
Cancer), 7 STIs/STDs, 168
IBBSS (integrated biobehavioral surveillance studies and surveys, 181
surveys), 214 transmission mode, drug injection as, 85, 86–87t
ICPS (International Centre for Prison Studies), 7 youth and HIV, 126, 128, 140b
270 Index
integrated biobehavioral surveillance surveys Iranian National Center for Addiction Studies
(IBBSS), 214 (INCAS), 201
intergenerational sex, 61, 73 Iraq
internally displaced persons (IDPs). See refugees ART in, 208
and IDPs as covered country, 6
International Agency for Research on Cancer emergency situations in, 133
(IARC), 7 FSWs in, 230t
International Centre for Prison Studies (ICPS), 7 HCV in different population groups, 235t
International Organization for Migration (IOM), HPV and cervical cancer in, 157t, 158
7, 133 IDUs in, 12t, 15t, 230t
Iran, Islamic Republic of knowledge of HIV/AIDS in, 239t
ART in, 208t, 209 MSM in, 230t
attitudes toward PLHIV in, 245t PLHIV, estimated numbers of, 221t
availability of drugs in, 16 pregnant women, prevalence of HIV
case notification surveillance reports, 83–84 among, 230t
civil society organizations and NGOs in, 216 prevention efforts in, 207, 210
condom use in, 102t, 104t, 108 prisoners in, 121t
as covered country, 6 refugees and IDPs, 136, 141b
FSWs in, 44t, 47, 48–49, 50, 51, 52, 53, 182, sexual trafficking, 46
202, 230t status of current epidemic in, 184t
general population and HIV in, 65t, 66t, 68t, 70, 71 STIs/STDs, 210, 230t
harm reduction approach in, 215, 217 TB and HIV in, 228t, 230t
HCV in different population groups, 234–35t vulnerable populations in, 189
HPV and cervical cancer in, 157t, 159t, 161 Islam and HIV/AIDS, 110, 111, 113, 187–88, 217
HSV-2 in, 152, 153t Islamic Republic of Iran. See Iran, Islamic Republic of
IDUs in, 11, 12t, 14t, 15t, 16, 17, 18t, 19, 20, 21, Israel. See also West Bank and Gaza
22t, 38, 52, 123, 124, 125, 135, 182, 185, as covered country, 6
199, 200, 201, 214, 230t exogenous exposures of West Bank and Gaza
knowledge of HIV/AIDS in, 109, 110, 111, 112, residents in, 180
113, 131, 239t, 242t, 244t, 247t HPV and cervical cancer in, 157t, 158f
marriage, age at, 127 HSV-2 in, 153t
migrant population, 135 PLHIV, estimated numbers of, 221t
molecular epidemiology in, 92–93
MSM in, 33, 34, 36, 37, 38, 182, 188, 230t J
nontraditional marriage in, 71, 72 jawaz al misyar, 72
origins and evolution of HIV in, 179, 182 “jerking,” 21
overlapping risks in, 206 Joint United Nations Programme on HIV/AIDS.
parenteral transmission other than IDU, 88, 90t, 91 See UNAIDS
PLHIV, estimated numbers of, 221t Jordan
PMTCT services, 209 attitudes toward PLHIV in, 245t
potential bridging populations in, 60, 60t civil society organizations and NGOs in, 216
pregnant women, prevalence of HIV among, 230t condom use in, 102t, 104t, 108, 203
prevalence of HIV in, 180, 224t as covered country, 6
prevention efforts in, 199, 200, 201, 202, 203, DHS reports, 7
207, 209, 210 exogenous HIV exposures, 85, 180
prisoners in, 120, 121t, 123, 124, 125, 126, 128 FSWs in, 48, 202, 230t
refugees and IDPs, 136, 137, 138 general population and HIV in, 68t, 72
STIs/STDs, 81, 129, 163t, 165, 166t, 167t, 168, HCV in different population groups, 235t
210, 226t, 230t HPV and cervical cancer in, 157t, 158, 159t
street children in, 139 HSV-2 in, 152–54
tattooing by prisoners, 125 IDUs in, 12t, 15t, 230t
TB and HIV in, 228t, 230t knowledge of HIV/AIDS in, 110, 111, 112, 239t,
transmission modes in, 85, 86t 242t, 244t
VCT clinic attendees, 81, 226t marriage in, 72, 127, 128
youth and HIV in, 128, 129, 130, 131, 132, 203 migrant population, 133, 134, 135
Index 271
Jordan (continued) marriage in, 72, 128
origins and evolution of HIV in, 180 migrant population, 135, 136
parenteral transmission other than IDU, 89, 90t MSM in, 230t
PLHIV, estimated numbers of, 221t PLHIV, estimated numbers of, 221t
polygamy in, 72 polygamy in, 72
potential bridging populations in, 60t pregnant women, prevalence of HIV among, 230t
pregnant women, prevalence of HIV among, 230t prisoners in, 121t
prevalence of HIV in, 180, 224t status of current epidemic in, 184t
prevention efforts in, 202, 207, 210 STIs/STDs, 81, 129, 136, 163t, 166t, 167t, 168,
prisoners in, 121t 226t, 230t
status of current epidemic in, 184t TB and HIV in, 228t, 230t
STIs/STDs, 163t, 166t, 167t, 210, 230t transmission modes in, 86t
TB and HIV in, 228t, 230t VCT clinic attendees, 81, 226t
transmission modes in, 86t youth and HIV, 129
youth and HIV in, 126
L
K Latin America and Caribbean
Kenya HSV-2 in, 155t
molecular epidemiology in, 92, 93 parenteral transmission in, 91
refugees and IDPs, 71, 138 prisoners in, 120
khotkis, 33 unsafe abortions in, 170f
khusras, 33 youth and HIV in, 132
knowledge about condoms. See condom use law enforcement approach to HIV control,
knowledge about HIV/AIDS, 109–13 avoiding, 215
basic knowledge levels, 109, 239–42t Lebanon
bibliography, 113–18 attitudes toward PLHIV in, 246t
comprehensive knowledge levels, 109, 242–43t civil society organizations and NGOs in, 216
conclusions regarding, 112–13 condom use in, 102t, 104t
current status and future potential, 189 as covered country, 6
among different population groups, by country, emergency situations in, 133
239–45t exogenous HIV exposures, 85, 180
differentials in, 111–12 FSWs in, 44t, 49, 50, 51, 53, 129, 230t
among FSWs, 53 general population and HIV in, 71, 72
among IDUs, 21–24 HCV in different population groups, 235t
misinformation levels, 109, 244–45 HPV and cervical cancer in, 157t, 158, 159t, 160
mother-to-child transmission, 112–13 HSV-2 in, 153t
among MSM, 38–39 IDUs in, 12t, 14t, 15t, 18t, 19, 20, 22t, 24, 123,
perception of risk, 109–10, 131 124, 140b, 200–201, 230t
PLHIV, attitudes toward, 110–11, 113, 245–47t knowledge of HIV/AIDS in, 109, 240t, 242t, 244t
prevention efforts, 199–204 marriage in, 71, 72, 127, 128
refugees and IDPs, 112, 137 migrant population, 133, 136
sources of, 111, 247t molecular epidemiology in, 93
youth populations, 131 MSM in, 32t, 33, 34, 36, 37, 38, 128, 201, 230t
knowledge about HIV status, 208 origins and evolution of HIV in, 179, 180
knowledge about STIs/STDs, 112 overlapping risks in, 206
Kuwait parenteral transmission other than IDU, 90t
condom use in, 104t PLHIV, estimated numbers of, 221t
as covered country, 6 polygamy in, 72
FSWs in, 51, 230t pregnant women, prevalence of HIV among, 230t
general population and HIV in, 68t, 72, 73 prevalence of HIV in, 180
HCV in different population groups, 235t prevention efforts in, 200–201, 207
HPV and cervical cancer in, 157t, 158, 158f, prisoners in, 121t, 123, 124
160, 161 refugees and IDPs, 136
IDUs in, 11, 12t, 15t, 230t status of current epidemic in, 184t
knowledge of HIV/AIDS in, 110, 239t, 242t, 244t STIs/STDs, 163t, 165–68, 166t, 167t, 169, 230t
272 Index
TB and HIV in, 228t, 230t men who have sex with men (MSM), 31–41
transmission modes in, 86t anal sex, 32, 33, 34, 35, 37, 39
VCT services in, 204 bibliography, 39–41
vulnerable populations in, 189 case notification surveillance reports, 82–84, 83f
youth and HIV in, 127, 128, 129, 130, 131, conclusions regarding, 39
132, 140b condom use, 36, 101, 108
Libya dynamics of current epidemic and, 185f
attitudes toward PLHIV in, 246t frequency of sexual contact/number of partners,
as covered country, 6 34, 61
FSWs in, 230t FSWs and, 36, 37, 188f, 206
general population and HIV in, 65t future expansion of HIV among, 190
HCV in different population groups, 235t heterogeneity of risk, 4, 5
HPV and cervical cancer in, 157t heterosexual risk behavior, engagement in, 37
IDUs in, 11, 12t, 15t, 18t, 20, 214, 230t HSV-2 incidence, 152, 154, 155
knowledge of HIV/AIDS in, 110, 112 IDUs and, 21, 22–24t, 25, 38, 188f, 206
marriage in, 128 knowledge of HIV/AIDS among, 38–39, 109
mobile populations in, 133 migrants and, 33, 135
molecular epidemiology in, 93 MSWs, 34–36, 60, 128–29, 202
MSM in, 230t oral sex, 34, 35, 36
parenteral transmission other than IDU, 89 potential bridging populations and, 59–61
PLHIV, estimated numbers of, 221t prevalence of HIV among, 31, 32t, 187, 229–32t
pregnant women, prevalence of HIV among, 230t prevalence of homosexuality in MENA and, 31–32
prevalence of HIV in, 181 prevention programs for, 201–2
prisoners in, 121t prisoners, 33, 125
status of current epidemic in, 184t risk behaviors of, 33–38
STIs/STDs, 230t simulated epidemic among MSM community,
TB and HIV in, 230t 189, 190f
status of current epidemic, 184t
M stigmatization of, 2, 31, 189
maalishias, 33 STIs/STDs, 31, 33, 39, 168
Maghreb countries of MENA, 135, 158, 162, 169, street children, 33, 139
170, 180 transgender individuals (hijras), 31, 33, 35, 36, 37,
Malaysia 38, 60, 202
FSWs in, 47 transmission mode, homosexual sex as, 85, 86–87t
HPV and cervical cancer in, 157t truck drivers, 33, 60–61
male circumcision, 4, 54, 62, 73–75, 160, 187, 190 youth and HIV, 128–29
male sex workers (MSWs), 34–36, 60, 128–29, 202 youth as, 126
malishi, 36 Middle East and North Africa (MENA), HIV/AIDS in.
mandatory testing programs, 214 See HIV/AIDS in MENA region
M&E (monitoring and evaluation) systems, 206–7 Middle East and North Africa Harm Reduction
marriage. See also extramarital sex; premarital sex Association (MENAHRA), 201
early/intergenerational, 61, 73, 127, 128 migrants, 133–36
nontraditional, 71–72 case notification surveillance reports, 82–84, 83f
polygamy, 69–70, 71, 72–73 exogenous HIV exposures, 85–87
youth and HIV, 127–28 FSWs and, 48, 50, 134, 135
marriage squeeze, 127 IDUs, 135
Mashriq countries of MENA, 159, 162, 169, 170 MSM, 33, 135
Mauritania potential bridging populations, 59, 61
as covered country, 6 prevalence of, 133
DHS reports, 7 prevalence of HIV among, 135–36
general population and HIV in, 66t, 68t research priorities regarding, 214–15
HCV in different population groups, 235t risk behaviors, 135
prevalence of HIV in, 181, 224t STIs/STDs, 133, 136
TB and HIV in, 228t structural factors, 133–35
youth and HIV in, 130 youth and HIV, 128, 131
Index 273
military, as potential bridging population. See N
potential bridging populations national strategic plans (NSPs), 199, 200
mobile populations, 133–38. See also migrants; NGOs (nongovernmental organizations), 200–202,
refugees and IDPs 204–7, 210, 215–16
molecular epidemiology of HIV, 92–94, 217 Niger, molecular epidemiology of HIV/AIDS in, 92
monitoring and evaluation (M&E) systems, 206–7 nikah al misyar, 72
Morocco nongovernmental organizations (NGOs), 200–202,
ART in, 208t, 209 204–7, 210, 215–16
attitudes toward PLHIV in, 246t nonsterile equipment, IDU use of, 17, 18t
civil society organizations and NGOs in, 216 nontraditional marriages, 71–72
condom use in, 102t, 104–5t, 203 nosocomial transmissions, 89
as covered country, 6 NSPs (national strategic plans), 199, 200
DHS reports, 7
FSWs in, 44t, 47, 199, 200, 205, 231t O
general population and HIV in, 66t, 68t, 69, 70, Office of the UN High Commissioner for Refugees
72, 73 (UNHCR), 7
HCV in different population groups, 235t Oman
HPV and cervical cancer in, 157t, 158, 159t ART in, 209
HSV-2 in, 153t, 154f condom use in, 105t
IDUs in, 11, 12t, 15t, 16, 18t, 20, 123, 199, 200, as covered country, 6
201, 231t FSWs in, 231t
knowledge of HIV/AIDS in, 110, 112, 240t, general population and HIV in, 71
242t, 244t HCV in different population groups, 235t
marriage in, 72, 128 HPV and cervical cancer in, 157t, 158f
molecular epidemiology in, 93 IDUs in, 11, 12t, 14t, 15t, 16, 18t, 20, 21, 22t, 34,
MSM in, 32t, 191, 200, 201, 231t 123, 124, 128, 231t
parenteral transmission other than IDU, 88, 89, knowledge of HIV/AIDS in, 240t, 244t
90t, 91 migrant population, 135
PLHIV, associations of, 206 MSM in, 34, 36, 231t
PLHIV, estimated numbers of, 221t origins and evolution of HIV in, 180
PMTCT services, 209 PLHIV, estimated numbers of, 221t
polygamy in, 72 prevention efforts in, 207, 210
potential bridging populations in, 60t prisoners in, 122t, 123, 124
pregnant women, prevalence of HIV among, 231t status of current epidemic in, 184t
prevalence of HIV, 224t STIs/STDs, 210, 231t
prevention efforts in, 199, 200, 201, 205, 209, 210 TB and HIV in, 228t, 231t
prisoners in, 122t, 123 youth and HIV in, 128
status of current epidemic in, 184t opioid substitution therapy (OST), 200, 201
STIs/STDs, 129, 163–64t, 166t, 167t, 168, 169f, oral sex
209, 210, 226t, 231t FSWs, 48, 50, 52, 54
street children in, 139 MSM, 34, 35, 36
surveillance in, 213 organ transplants, 180, 181
TB and HIV in, 228t, 231t OST (opioid substitution therapy), 200, 201
transmission modes in, 86t
VCT services in, 204, 205, 226t P
youth and HIV in, 126, 129 Pacific region. See East Asia and Pacific
mother-to-child transmission. See also antenatal clinic Pakistan
(ANC) attendees and other pregnant women ART in, 207, 208t, 209
frequency of transmission by country, 86–87t availability of drugs in, 16
knowledge about, 112–13 civil society organizations and NGOs in, 216
nosocomial outbreaks, 89 condom use in, 102t, 105–6t, 108
PMTCT services, 138, 209 as covered country, 6
via priority populations, 181, 190 exogenous HIV exposures, 87
MSM. See men who have sex with men FSWs in, 45t, 46, 47, 48, 49, 50, 51, 52, 53, 129,
MSWs (male sex workers), 34–36, 60, 128–29, 202 135, 180, 202, 231t
274 Index
future expansion of HIV in, 189 pimps
general population and HIV in, 68t, 70 FSWs, 45, 47
HCV in different population groups, 235–36t hijras, 35
HPV and cervical cancer in, 157t, 158f, 159t, PITC (provider-initiated testing and counseling), 205
160, 161 PLHIV. See people living with HIV
HSV-2 in, 153t PMTCT (prevention of mother-to-child
IDUs in, 11, 12–13t, 13, 14t, 15t, 16, 17–21, transmission) services, 138, 209
18t, 23t, 24, 38, 52, 87, 123, 185, 186–87, point-prevalence surveys, 7–8, 82, 224–38t
201, 232t polygamy, 69–70, 71, 72–73
knowledge of HIV/AIDS in, 109, 111, 240t, 242t, Population Reference Bureau (PRB), 7
244t, 247t postconflict situations, 133
migrant population, 134–35, 136 potential bridging populations, 59–63
molecular epidemiology in, 93 bibliography, 62–63
MSM in, 31, 32t, 33, 34–35, 36, 37, 38, 128–29, in conceptual framework, 3–4, 4f, 5f
188, 202, 231t conclusions regarding, 62
origins and evolution of HIV in, 180 defined, 59
parenteral transmission other than IDU, 88, 90, prevalence of HIV among, 59–60, 60t
90t, 91 research on, 59–63
PLHIV, estimated numbers of, 221t risk behavior of, 60–61
PMTCT services, 209 sexual partners, 61–62
potential bridging populations in, 59, 60–61, 60t case notification surveillance reports, 82–84, 83f
pregnant women, prevalence of HIV among, 231t of FSWs, 47–49
prevalence of HIV in, 181, 186–87, 225t of IDUs, 20–21
prevention efforts in, 200, 201, 202, 207, of MSM, 34, 37
209, 210 STIs/STDs, 60, 62
prisoners in, 122t, 123 studies and surveys, 181
refugees and IDPs, 136, 137 surveillance of, 213–14
status of current epidemic in, 184t youth as, 126
STIs/STDs, 81, 164t, 166t, 167t, 168, 210, PRB (Population Reference Bureau), 7
227t, 231t pregnancy. See antenatal clinic (ANC) attendees and
street children in, 139 other pregnant women
TB and HIV in, 228t, 231t premarital sex
transmission modes in, 86t in general population, 70, 71, 73
VCT clinic attendees, 81, 227t migrants and, 135
youth and HIV in, 128–29 refugees and IDPs, 137
Palestinian refugees, 127, 136. See also Israel; West youth involvement in, 127, 129–31
Bank and Gaza prevention of HIV. See responses to HIV in MENA
Pap smears, 132, 160–61 prevention of mother-to-child transmission
parenteral transmission other than IDU, 88–92, 90t. (PMTCT) services, 138, 209
See also entries at blood primary stage of infection, 217
people living with HIV (PLHIV) priority populations. See also female sex workers; injecting
attitudes toward, 110–11, 113, 245–47t drug users; men who have sex with men
care and treatment, 206f, 207–9, 208t behavioral surveillance, increasing and expanding,
estimated numbers by country, 221t 213–14
knowledge of HIV status, 208 case notification surveillance reports, 82
migrants, 136 in conceptual framework, 5
response efforts, involvement in, 205–7 current status and future potential, 182–83, 185f,
sexual partners of. See under potential bridging 186, 188f
populations focused prevention programs for, 200–203
stigma and discrimination against, 210 harm reduction as aim for, 217
strategic recommendation to rely on, 215–16 law enforcement approach to HIV control,
Persepolis (NGO), 216 avoiding, 215
Philippines, migrant workers from, 134, 136 overlapping risks, 188f, 206
phlebotomy, traditional practices of, 89 STI/STD prevention programs, importance of, 210
physical abuse. See abuse weak surveillance systems for, 87
Index 275
prisoners, 119–26 refugees and IDPs, 136–38
case notification surveillance reports, 82–84, 83f conclusions regarding, 138
conclusions regarding, 125–26 data sets covering, 7
condom use, 125 FSWs and, 48, 141b
female prisoners having sex with guards, 125 high numbers in MENA, 2
IDUs and drug use generally, 91, 119–20, 123–25, 128 IDUs, 137
imprisonment as risk factor, 123 knowledge of HIV/AIDS, 112, 137
knowledge of HIV/AIDS, 109, 112, 113 numbers of, 136
as migrants, 134 Palestinian refugees, 127, 136
MSM, 33, 125 in polygamous marriages, 71, 72
parenteral transmission other than IDU, 91 prevalence of HIV among, 138
prevalence of HIV among, 120, 121–22t risk behavior, 137–38
rates of imprisonment in MENA, 120, 121–22t studies and surveys, 181
risk behaviors, 120–25 typology of disease in southern Sudan and, 183
sexually risky behavior in and out of prison, 125 vulnerability of, 137
studies and surveys, 181 religion and HIV/AIDS, 110, 111, 113, 187–88, 217
tattooing, 125 remittances from migrant populations, 133
as vulnerable population, 119–20 renal dialysis, 89
youth and HIV, 128 Republic of Yemen. See Yemen, Republic of
prostitution. See sex workers research for evidence-based policy, 214–15
protective factors, 187–88 responses to HIV in MENA, 199–212
provider-initiated testing and counseling (PITC), 205 access to prevention programs, 203–4
proxy markers of risk behavior, 151–78 bibliography, 210–12
bacterial STIs (syphilis, gonorrhea, and blood safety and screening efforts, 180, 207
chlamydia), 162–69, 163–68t, 169f care and treatment, 206f, 207–9, 208t
bibliography, 170–78 civil society organizations, involvement of, 201,
conclusions regarding, 169–70 205–7, 215–16
HPV and cervical cancer, 69–70, 72, 132, 156–62, conclusions regarding, 210
157t, 158f, 159t, 160f, 161f expanding coverage for, 205
HSV-2, 132, 152–56, 153t, 154f, 155t FSWs and MSWs, prevention programs for, 202
unsafe abortions, 169, 170f IDUs, prevention programs for, 200–201
validity of reported risk behavior, verifying, 151–52 M&E systems, 206–7
MSM, prevention programs for, 201–2
Q NGOs, involvement of, 200–202, 204–7, 210,
Qatar 215–16
as covered country, 6 outreach efforts, 207
general population and HIV in, 68t PLHIV, involvement of, 205–7, 215–16
HPV and cervical cancer in, 157t PMTCT services, 138, 209
IDUs in, 15t, 231t progress in prevention programs, 203
marriage in, 128 scope and scale of prevention programs, 199–200
migrant population, 135 STIs/STDs, 209–10
origins and evolution of HIV in, 179 strategic focus on prevention, 216–17
parenteral transmission other than IDU, 90t testing and counseling, 204–5, 214. See also
PLHIV, estimated numbers of, 221t voluntary counseling and testing (VCT)
prisoners in, 122t attendees
status of current epidemic in, 184t translating evidence into programs, 206–7
STIs/STDs, 164t, 231t youth, prevention programs for, 203
TB and HIV in, 228t, 231t risk and risk behavior
transmission modes in, 86t of FSWs, 48–53
of general population, 69–73, 74
R heterogeneity and sustainability of, 3–5, 4–6f
R0, concept of, 4–5, 5f of IDUs, 16–21, 18t, 22–24t
rape. See abuse law enforcement approach to HIV control,
recommendations regarding HIV in MENA. See avoiding, 215
strategic recommendations men more likely to engage in, 61, 73, 84–85
276 Index
of migrants, 135 security approach to HIV control, avoiding, 215
of MSM, 33–38 sex workers
perception of risk from HIV, 109–10, 131 female. See female sex workers
of potential bridging populations, 60–61 hijras, 31, 33, 35, 36, 37, 38, 60, 168
priority populations, overlapping risks among, MSWs, 34–36, 60, 128–29, 202
188f, 206 prevention programs for, 202
of prisoners, 120–25 street children as, 33, 46, 138–39
proxy markers of, 151–78. See also proxy markers sexual abuse. See abuse
of risk behavior sexual identity in MENA, fluidity of, 32–33
of refugees and IDPs, 137–38 sexual issues. See gender issues
research priorities, 214 sexual partners
of street children, 139 HPV and cervical cancer rates, 159, 160f
VCT and STD clinic attendees, 81 of potential bridging populations. See under
of youth, 128–32 potential bridging populations
rural/urban vulnerability of, 188–89
knowledge of HIV/AIDS, 112 sexual trafficking, 46, 134
migration between, 134 sexually risky behavior. See risk and risk behavior
Russian Federation/former Soviet Union sexually transmitted disease (STD) clinic attendees
IDUs in, 17, 214 case notification surveillance reports, 82–84, 83f
migrant FSWs in United Arab Emirates, 135 chancroid, 168
surveillance efforts in, 214 FSWs, 51–52, 202
truck driver network, 61 general population, 71, 72, 73
HSV-2 incidence, 155
S as migrants, 134, 135
sailors, as potential bridging population. See potential bridging populations, 60
potential bridging populations prevalence of HIV among, 81–82, 181, 226–27t,
Saudi Arabia 229–32t
attitudes toward PLHIV in, 246t prevention efforts, 202, 203
as covered country, 6 studies and surveys, 181
FSWs in, 43, 52 sexually transmitted infections (STIs) and diseases
general population and HIV in, 68t (STDs) other than HIV
HCV in different population groups, 236–37t bacterial STIs, 162–69, 163–68t, 169f
HPV and cervical cancer in, 157t, 158, 159t, 160 chancroid, 168, 222t
HSV-2 in, 154 chlamydia, 162–69, 167–68t, 169f, 222t
IDUs in, 13t, 14t, 15t epidemiological characteristics of different STIs/
knowledge of HIV/AIDS in, 109, 113, 240t, STDs, 222t
242t, 244t FSWs and, 48, 50, 51–52, 53, 81
marriage, age at, 127 in general population, 69–74
migrant population, 133, 135 gonorrhea, 162–69, 166t, 169f, 222t
molecular epidemiology in, 93 heterogeneity of risk, 4
origins and evolution of HIV in, 179, 180 HPV and cervical cancer, 69–70, 72, 132, 156–62,
parenteral transmission other than IDU, 89, 90t 157t, 158f, 159t, 160f, 161f, 222t
PLHIV, estimated numbers of, 221t HSV-2, 132, 152–56, 153t, 154f, 155t, 214, 222t
prevalence of HIV in, 181, 225t IDUs, sexually risky behavior of, 21
prevention efforts in, 207, 210 intergenerational sex and, 73
spouses, vulnerability of, 188–89 knowledge of, 112
status of current epidemic in, 184t literature review, criteria for, 222–23
STIs/STDs, 167t, 168, 210 migrants, 133, 136
TB and HIV in, 228t MSM and, 31, 33, 39
transmission modes in, 85, 87t need to study, 3, 7
vulnerability of women to HIV infection in, 61 nontraditional marriage, associated with, 72
youth and HIV in, 132 polygamy and, 72–73
scientific research for evidence-based policy, 214–15 potential bridging populations and, 60, 62
seafarers, as potential bridging population. See prevention efforts, 209–10
potential bridging populations research priorities, 214
Index 277
sexually transmitted infections (STIs) and diseases spouses. See sexual partners
(STDs) other than HIV (continued) Sri Lanka, migration from, 134, 136
surveillance practices, 213 STDs. See sexually transmitted disease (STD) clinic
syphilis, 162–69, 163–65t, 169f, 222t attendees; sexually transmitted infections
trichomonas, 168 (STIs) and diseases (STDs) other than HIV
youth and HIV, 129, 132 sterile needle programs, 201, 215
Shehab NGOs, 202 STIs. See sexually transmitted disease (STD) clinic
sickle cell disease, 180 attendees; sexually transmitted infections
SIDC (Soins Infirmiers et Developpement (STIs) and diseases (STDs) other than HIV
Communautaire), 201 strategic recommendations, 213–19
sigheh (temporary marriage), 71 behavioral surveillance, increasing and expanding,
Singapore, HPV and cervical cancer in, 157t 213–14
skin scarification, 2, 89 bibliography, 218–19
Skoun, 201 civil society organizations and PLHIV, involvement
Soins Infirmiers et Developpement Communautaire of, 215–16
(SIDC), 201 law enforcement approach, avoiding, 215
Somalia prevention, focus on, 216–17
ART in, 208, 208f, 208t, 209 scientific research for evidence-based policy,
attitudes toward PLHIV in, 246t 214–15
condom use in, 102t, 106t street children
as covered country, 6 as migrants, 134
emergency situations in, 133 in polygamous marriages, 72
female circumcision/genital mutilation in, 74 prevalence of HIV among, 139
FSWs in, 43, 45t, 48, 52, 53, 231t as sex workers, 33, 46, 138–39
general population and HIV in, 65, 66–67t, 68t, as vulnerable population, 138–39
69, 71, 75 sub-Saharan Africa
HCV in different population groups, 237t FSWs in, 43, 53
HPV and cervical cancer in, 157t, 158 gender gap in HIV prevalence in, 73
IDUs, minor role of, 185 in general population, 69, 75
knowledge of HIV/AIDS in, 109, 240t, 243t HCV in, 90
parenteral transmission other than IDU, 88 HPV and cervical cancer in, 158
PLHIV, estimated numbers of, 221t HSV-2 in, 155t
PMTCT services, 209 hyperendemic HIV in, 4, 5, 69, 74
potential bridging populations in, 61, 62 migrant population, 135
pregnant women, prevalence of HIV among, 231t parenteral transmission in, 92
prevalence of HIV in, 181, 187, 225t polygamy in, 72
prevention efforts in, 207, 209, 210 prisoners in, 120
prisoners in, 122t refugees and IDPs, 137
refugees and IDPs, 136, 137, 138 typology of disease in, 183
status of current epidemic in, 184t youth and HIV in, 126
STIs/STDs, 81, 129, 164–65t, 166t, 168t, 210, 227t, 231t subtypes of HIV, 92–94
TB and HIV in, 228t, 231t Sudan
typology of disease in, 183 ART in, 208, 208f, 208t, 209
unsafe abortions in, 169 attitudes toward PLHIV in, 246t
VCT clinic attendees, 81, 227t civil society organizations and NGOs in, 216
vulnerable populations in, 189 condom use in, 102–3t, 106–7t
youth and HIV, 129, 130 condoms, access to, 203
South America. See Latin America and Caribbean as covered country, 6
South Asia. See also Asia DHS reports, 7
IDUs in, 14 female circumcision/genital mutilation in, 74
MSM, 34 FSWs in, 43, 45t, 47, 48, 49, 50, 51, 52, 53, 54,
prisoners in, 120 129, 134, 202, 231t
unsafe abortions in, 170f general population and HIV in, 65t, 67t, 68t, 69,
Soviet Union, former. See Russian Federation/former 70, 72, 73–74, 75, 185, 187
Soviet Union HCV in different population groups, 237t
278 Index
HPV and cervical cancer in, 157t prisoners in, 122t, 123, 124
HSV-2 in, 153t refugees and IDPs, 136, 141b
IDUs in, 13t, 15t, 38, 123, 124, 185 status of current epidemic in, 184t
knowledge of HIV/AIDS in, 109, 111, 112, 113, STIs/STDs, 231–32t
241t, 243t, 244–45t, 247t TB and HIV in, 231–32t
male circumcision in, 73–74 transmission modes in, 87t
migrant population, 134, 136 youth and HIV in, 127, 129
molecular epidemiology in, 93
MSM in, 32t, 33, 34, 36, 37, 38, 128, 201–2 T
number of current infections in, 186 tattooing in prisons, 125
parenteral transmission other than IDU, 88 TB. See tuberculosis (TB) patients, HIV/AIDS among
PLHIV, associations of, 206 testing
PLHIV, estimated numbers of, 221t incidence of HIV and, 217
PMTCT services, 209 mandatory testing programs, 214
polygamy in, 72 PITC, 205
potential bridging populations in, 60t, 61, 62 voluntary. See voluntary counseling and testing
pregnant women, prevalence of HIV among, 231t (VCT) attendees
prevalence of HIV in, 181, 187, 225t Thailand
prevention efforts in, 201–2, 203, 207, 209, 210 IDUs in, 17
prisoners in, 122t, 123, 124, 125 migrant population, 134
refugees and IDPs, 136, 137, 138 thalassemia patients, 91, 180
status of current epidemic in, 184t traditional medical practices (hijamah), 89
STIs/STDs, 81, 129, 165t, 168t, 210, 227t, 231t transgender individuals, 31, 33, 35, 36, 37,
street children in, 139 38, 60, 202
surveillance in, 213 transmission modes, 85, 86–87t
TB and HIV in, 228–29t, 231t travelers’ marriage, 72
transmission modes in, 85, 87t treatment and care of HIV/AIDS patients, 206f,
typology of disease in southern region with higher 207–9, 208t
prevalence, 183 trichomonas, 168
VCT clinic attendees and services, 81, 204, 227t truck drivers
youth and HIV in, 127, 128, 129, 130–31, 203 FSWs and, 46, 47, 48, 51, 53, 216
summer marriages, 72 High Risk Corridor Initiative, 216
surveillance, behavioral, increasing and expanding, IDUs engaging in sexually risky behavior, 20
213–14 mobile populations, vulnerability of, 133, 134
syphilis, 162–69, 163–65t, 169f, 222t. See also MSM, 33, 60–61
sexually transmitted infections (STIs) and nontraditional marriage among, 71
diseases (STDs) other than HIV as potential bridging population, 59, 60, 61
Syrian Arab Republic STIs/STDs, 165
attitudes toward PLHIV in, 246t studies and surveys, 181
condom use in, 103t, 107t tuberculosis (TB) patients, HIV/AIDS among, 82
as covered country, 6 case notification surveillance reports, 82–84, 83f
FSWs in, 49, 50, 51, 129, 141b, 231–32t general population, 71, 72
HCV in different population groups, 237t imprisonment as risk factor, 123
HPV and cervical cancer in, 157t migrant populations, 134
HSV-2 in, 153t prevalence of, 228–32t
IDUs in, 13t, 14t, 15t, 16, 18t, 19, 21, 24t, 53, 123, Tunisia
124, 231–32t condom use in, 103t, 107–8t
knowledge of HIV/AIDS in, 110, 241t, 243t, 245t as covered country, 6
marriage in, 128 DHS reports, 7
MSM in, 231–32t FSWs in, 45t, 50, 202, 232t
overlapping risks in, 206 HCV in different population groups, 237t
PLHIV, estimated numbers of, 221t HPV and cervical cancer in, 157t, 158, 159t
polygamy in, 72 IDUs in, 11, 13t, 14t, 15t, 38, 128, 180, 232t
pregnant women, prevalence of HIV among, 231t knowledge of HIV/AIDS in, 131, 241t, 245t
prevention efforts in, 207 marriage in, 127, 128
Index 279
Tunisia (continued) unemployment rates
mobile populations in, 133 migration fueled by, 134
molecular epidemiology in, 93 youth in MENA, 127
MSM in, 34, 36, 37, 38, 201, 204 UNHCR (Office of the UN High Commissioner for
origins and evolution of HIV in, 180 Refugees), 7
parenteral transmission other than IDU, 90t UNICEF (United Nations Children’s Fund), 7
PLHIV, estimated numbers of, 221t uniformed personnel, as potential bridging
pregnant women, prevalence of HIV among, 232t population. See potential bridging populations
prevention efforts in, 200, 201, 202, 203, 204, 207 United Arab Emirates
prisoners in, 122t attitudes toward PLHIV in, 246t
status of current epidemic in, 184t as covered country, 6
STIs/STDs, 129, 226t, 232t FSWs, 135
TB and HIV in, 229t, 232t HPV and cervical cancer in, 157t
transmission modes in, 87t HSV-2 in, 153t
youth and HIV in, 127, 128, 129, 131, 203 IDUs in, 15t
Turkey knowledge of HIV/AIDS in, 241t, 243t, 245t
attitudes toward PLHIV in, 246t migrant population, 135, 136
condom use in, 108t origins and evolution of HIV in, 180
as covered country, 6 PLHIV, estimated numbers of, 221t
FSWs in, 45t polygamy in, 72
general population and HIV in, 69t prevention efforts in, 207
HCV in different population groups, 237–38t prisoners in, 122t
HPV and cervical cancer in, 157t, 159t status of current epidemic in, 184t
HSV-2 in, 153t, 154 STIs/STDs, 168t
IDUs in, 13t, 15t United Kingdom, availability of drugs in, 16
knowledge of HIV/AIDS in, 111, 241t, 243t, United Nations Children’s Fund (UNICEF), 7
245t, 247t United Nations High Commissioner for Refugees
parenteral transmission other than IDU, 91 (UNHCR), 136, 141b
PLHIV, estimated numbers of, 221t United Nations Joint Programme on HIV/AIDS.
prevalence of HIV, 225t See UNAIDS
prevalence of HIV in, 181 United Nations Office on Drugs and Crime
STIs/STDs, 132, 165t, 166t, 168t (UNODC), 7, 16
women, premarital sex as leading cause of United Nations Relief and Works Agency for Palestine
suicide of, 73 Refugees in the Near East (UNRWA), 136
youth and HIV in, 131, 132 United States
typology availability of drugs in, 16
in core MENA region, 182–83 bacterial STIs in, 168
in subregion with considerable prevalence IDUs in, 15, 16, 17
(Djibouti, Somalia, and Southern Sudan), 183 prison population in, 120
UNODC (United Nations Office on Drugs and Crime), 16
U UNRWA (United Nations Relief and Works Agency
Uganda for Palestine Refugees in the Near East), 136
molecular epidemiology in, 92, 93 unsafe abortions, 169, 170f
refugees and IDPs, 138 urban/rural
youth and HIV in, 126 knowledge of HIV/AIDS, 112
UNAIDS (Joint United Nations Programme on migration between, 134
HIV/AIDS) ‘urfi marriage (clandestine marriage), 71–72
ART, use of, 207
covered countries, 6 V
data limitations, 8 vaccination against HPV, 161–62
epidemiological fact sheets, 82 voluntary counseling and testing (VCT) attendees,
on epidemiology of AIDS in MENA, 1 204–5
literature review, 7 case notification surveillance reports, 82–84, 83f
prevention programs for FSWs, 202 FSWs and, 48, 81, 202
280 Index
prevalence of HIV among, 81–82, 226–27t covered countries, 6
prevention efforts, 202, 203 data limitations, 8
surveillance practices, 214 on epidemiology of AIDS in MENA, 1
vulnerable populations, 119–49 literature review, 7
bibliography, 141–49 STI/STD response, 209
conclusions regarding, 139–41
defined, 119 Y
emergency situations, 133 Yemen, Republic of
mobile populations, 133–38. See also migrants; ART in, 208t, 209
refugees and IDPs attitudes toward PLHIV in, 247t
prisoners, 119–26. See also prisoners condom use in, 103t, 108t
research on, 214–15 as covered country, 6
sexual partners, 188–89 DHS reports, 7
situations contributing to, 189 exogenous HIV exposures, 85
street children, 138–39. See also street children female circumcision/genital mutilation in, 74
surveillance of, 213–14 FSWs in, 45t, 47, 50, 51, 53, 232t
youth, 126–32. See also youth and HIV general population and HIV in, 69t, 75
HCV in different population groups, 238t
W HPV and cervical cancer in, 157t, 158
WBA (Western blot assays), 156, 204 IDUs in, 15t, 53
West Bank and Gaza. See also Israel knowledge of HIV/AIDS in, 110, 111, 112, 204,
ART in, 208 242t, 243t, 245t, 247t
attitudes toward PLHIV in, 246t marriage in, 128
condom use in, 103t migrant population, 133, 136
as covered country, 6 molecular epidemiology in, 93
emergency situations in, 133 MSM in, 33
general population and HIV in, 69t origins and evolution of HIV in, 180
HCV in different population groups, 238t parenteral transmission other than IDU, 88
HPV and cervical cancer in, 159t PLHIV, estimated numbers of, 221t
IDUs in, 16, 128 PMTCT services, 209
knowledge of HIV/AIDS in, 245t, 247t pregnant women, prevalence of HIV
marriage in, 127, 128 among, 232t
molecular epidemiology in, 93 prevalence of HIV in, 181, 225t
origins and evolution of HIV in, 179, 180 prevention efforts in, 204, 207, 209
Palestinian refugees, 127, 136 prisoners in, 122t
prevalence of HIV in, 181 refugees and IDPs, 137
prevention efforts in, 207, 210 status of current epidemic in, 184t
status of current epidemic in, 184t STIs/STDs, 165t, 168, 227t, 232t
STIs/STDs, 129, 168t, 210 TB and HIV in, 229t, 232t
transmission modes in, 87t transmission modes in, 87t
vulnerability of women to HIV infection in, 61 youth and HIV in, 126
vulnerable populations in, 189 youth and HIV, 126–32
youth and HIV in, 126, 127, 128, 129 conclusions regarding, 132
Western blot assays (WBA), 156, 204 condom use, 130–31
widows, sexual risk behaviors of, 70 demographics of youth in MENA, 2, 126
women. See female sex workers; gender issues FSWs, 126, 128, 140b
World Bank HPV and cervical cancer, 132, 160
covered countries, 6 HSV-2 incidence, 155
data limitations, 8 IDUs and drug users generally, 128, 140b
literature review, 7 knowledge of HIV/AIDS, 131
World Health Organization, Eastern Mediterranean limitations of behavioral evidence, 131–32
Regional Office (EMRO) marriage phenomena, 127–28
ART, 207, 209 migrants, 128, 131
case notification surveillance reports, 82 MSM, 128–29
Index 281
youth and HIV (continued) unemployment rates, 127
prevalence of HIV among youth, 126 Western cultural influence, 131
prevention efforts, 203
in priority and potential bridging populations, Z
126, 128–29 zawaj al-muta’a (temporary marriage), 71
sexually risky behavior, 129–32 zenanas, 33
STIs/STDs, 129, 132, 165
282 Index
Eco-Audit
Environmental Benefits Statement
This report aims to fill the knowledge gap by providing the first-ever comprehen-
sive scientific assessment and data-driven epidemiological synthesis of HIV’s
spread in MENA. It is based on a literature review and analysis of thousands of
largely unrecognized publications, reports, and data sources extracted from
scientific literature or collected from sources at the local, national, and regional
levels. The resulting collection of data provides a solid foundation on which
efforts to stem the spread of HIV/AIDS can be based.
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa will
be of particular interest to policy makers, researchers, development practitioners,
and specialists in public health and epidemiology. It builds on two prior publica-
tions: HIV/AIDS in the Middle East and North Africa: The Cost of Inaction (pub-
lished in 2003) and Preventing HIV/AIDS in the Middle East and North Africa:
A Window of Opportunity to Act (published in 2005).
ISBN 978-0-8213-8137-3
SKU 18137