21 February 2019
World AIDS Day: Alarming trends in the Arab world
Published online 1 December 2015
HIV and AIDS infections are rising sharply in the Middle East and North Africa.
On World AIDS Day red ribbons on lapels, dresses, T-shirts, lab coats and hoodies stand out as powerful symbols of solidarity with people affected by HIV and living with AIDS.
These visible reminders of support for affected communities, along with determined efforts of organizations working hard to eradicate the disease, whether through research, public health programs, community outreach, social activism or government policy initiatives, are crucial but much is still lacking.
HIV is the most researched virus to have emerged, but there is still no cure.
The epidemic has plateaued or is decreasing in many regions of the world today, including Sub-Saharan Africa, but in the Middle East, HIV is an expanding epidemic.
In marked contrast to the rest of the world, recent reports by the joint United Nations program for HIV/AIDS (UNAIDS) and the World Health Organization (WHO) suggest that the Middle East and North Africa (MENA) region is experiencing a rise in infections.
The total number of adults and children in the region who are living with HIV was estimated in 2014 to be 270,000, with roughly 34,000 new infections and an average of 16,500 deaths annually. These numbers suggest that overall incidence of HIV has increased by almost 79% from 2001 to 2010. Deaths due to AIDS have increased 176% in the region — yet many countries have still not established their own national strategic plans.
The key reason for the rise is depressingly simple: HIV stigma.
HIV: Stigma and denial
Stigma stops people from finding out their HIV status. It prevents patients from seeking effective early treatment for the disease. It thwarts community discussion and the sharing critical of educational information, especially among young people.
Women in particular are severely discriminated against when it comes to HIV treatment.
The MENA region has not adequately addressed the stigma associated with HIV infection. Yet the region’s people, particularly the large cohort of young adults and adolescents, must be empowered through education to be able to evade the disease.
The dynamics of the epidemic itself have not been sufficiently addressed. In theory, Muslim and Christian religious tenets condemn the use of illicit drugs and alcohol, and prohibit extra-marital sex, but the reality is that the major causes of the epidemic in the MENA region are intravenous drug use and prostitution.
And few are talking about this paradox out loud.
Sociocultural factors that determine gender norms also affect the modes of transmission of sexually transmitted diseases, including HIV. Stigma and discrimination are key reasons for insufficient treatment options for people infected with HIV or diagnosed with AIDS.
Women in particular are severely discriminated against when it comes to accessing testing and HIV treatment.
In some places, women are not allowed to visit testing and counseling centers.
For these reasons many women do not know their own HIV status and are equally unlikely to know their husbands’ status. Thus, husband-to-wife transmission is increasing; the male to female ratio of new adult HIV infection has been reduced from one female per eight males diagnosed, to one female per three males in the past 10 years.
Many countries of the region either ignore or are utterly intolerant to men who have sex with men (MSM). These countries impose legal measures — that often include harsh penalty and prison — for homosexual acts. Naturally, such measures block the access of these men to HIV-related services.
The Arab Spring disrupts HIV treatments
The last five years have been an extremely tumultuous period for the region. The Arab Spring of 2011 triggered a sequence of events that is having a major impact on the course of the HIV epidemic.
The epidemic among intravenous drug users is still rising in Egypt and Morocco.
Numerous conflicts in MENA that have lead to a large number of people being either internally displaced or seeking refuge in neighboring countries. Health systems have been disrupted, and many people living with HIV had to stop their treatment, while vulnerable minorities are facing higher levels of stigma and violence.
Healthcare infrastructures experience other challenges that hinder efforts to expedite the scaling up of HIV treatment. Programs for publicizing HIV information are weak in many countries. Laboratory capacity remains short, so testing is expensive and inefficient.
A concentrated effort, therefore, is still needed to strengthen each country’s existing public health response to their HIV epidemics.
This could happen through a two-pronged approach of a health-driven education, which can target misguided taboos and stigma, as well as a biochemical approach of enhanced laboratory-based viral load detection and increased testing.
It is clear that strong educational efforts to fight stigma are needed to stem the tide of HIV infection. Some examples:
- Regional epidemiology shows that HIV incidence is increasing most rapidly among women and children, as heterosexual and perinatal contact become more common points of transmission. Removing barriers to testing, treatment, and medical care for women is a crucial first step.
- The epidemic among intravenous drug users is still rising in Egypt and Morocco. Evidence of concentrated epidemics has also been reported among MSM in Egypt (5.7%), Tunisia (5%), and Morocco (5.6%). Educating the public about the need to use sterile needles and offering access to drug treatment and HIV testing could have a significant impact on HIV spread through drug use.
- Evidence of alarming prevalence of HIV among female sex workers in Egypt (2–3%) and Morocco (2%) has also been observed. There is no data from Qatar and Jordan, but migrant workers who spread the virus to their spouses are a major concern, and the regional dynamics raise concerns about the emerging epidemics among at-risk populations in these countries as well. Educating the public, and particularly sex workers, on condom use and safe-sex practices offers an opportunity to limit these impacts.
Despite the trends, there is some positive news coming out of different countries.
For example, Morocco is in an excellent position to reverse the course, with positive consequences for the entire region. The movement of the civil society in addressing HIV-related risk behaviours in the country in recent years has made great strides for harm reduction.
Even so, there is a great deal of work yet to do: Although the availability of HIV test kits and antiretroviral medications has increased in Morocco, there’s a huge gap between known and estimated numbers of people living with HIV, with almost 72% of them being unknown — and therefore untreated.
The red ribbon is an expression of compassion for people living with, and affected by HIV.
On December 1 this year, it should also represent our continued efforts to find better preventive measures, and a vaccine–antiviral combination that will move us towards a possible cure for HIV. Let the symbol inspire us and remind us that we need to educate MENA society, teach our young people, inform our religious and political leaders, and elect policy makers and leaders, both at the national and international levels, committed to advancing health and education in order to combat this terrible epidemic.
Madani is a Senior Scientist in the Department of Cancer Immunology and Virology at Dana-Farber Cancer Institute and the Department of Global Health and Social Medicine at Harvard Medical School.