What is the MENA face of HIV/AIDS?

Transcription

1 What is the MENA face of HIV/AIDS? Laith J. Abu-Raddad Weill Cornell Medical College - Qatar, Cornell University, Doha, Qatar Fred Hutchinson Cancer Research Center, Seattle, Washington, U.S.A The MENA HIV/AIDS Epidemiology and Response Synthesis Project is financed as a joint activity by the World Bank (MENA Region); GAMET; UNAIDS MENA RST; and WHO/EMRO

2 The MENA region falls into a real hole in terms of HIV epidemiological data Mark Kline, International Pediatric AIDS Initiative Baylor College of Medicine

3 Epidemiologic evidence in MENA Substantial increase in HIV epidemiological evidence in recent years Plenty of epidemiological data exist but are not widely known

4 Nature of epidemiologic data in MENA No systematic reviews of thousands of HIV-related scientific publications Large sums of data are not published in scientific publications and mostly distributed in closed circuits Large sums of data are not normally or easily available or accessible Large sums of data have never been methodologically studied or analyzed (such as HIV testing data)

5 Problems with existing data Available data are not necessarily representative Data are not necessarily collected using standard accepted surveillance methodologies and procedures Data are highly fragmented, lack integration, and amorphous

6 Nature of epidemiologic data in MENA: Shattered glass

7 Putting the pieces together

8 MENA HIV/AIDS Epidemiology and Response Synthesis Project Goal: To conduct an evidence-based and data-driven synthesis and review to produce a coherent and well-integrated picture of HIV transmission trends and dynamics in MENA

9 MENA HIV/AIDS Epidemiology and Response Synthesis Project Context: Project is taking place within the framework of the regional working group on strengthening strategic information in MENA consisting of World Bank, WHO and UNAIDS

10 A three-prong approach 1. Synthesis of biological measures of HIV/AIDS such as prevalence 2. Synthesis of behavioral measures to probe levels of risk behavior 3. Synthesis of epidemiological evidence of proxies of biomarkers

11 Proxy measures: Pathways of infection in the population

12 Review of proxy measures Parenteral transmission of HIV: Hepatitis C virus (HCV) infection Sexual transmission of HIV: Herpes simplex virus type 2 (HSV-2) infection Human papillomavirus (HPV) infection and cervical cancer Bacterial sexually transmitted infections Unsafe abortions

13 Hepatitis C virus (HCV): the tour guide of parenteral transmission of HIV About 10 times as infectious as HIV HCV epidemiology is to an extent a fastforward HIV epidemiology HCV is a proxy of the potential for parenteral transmission of HIV

14 Herpes simplex virus 2 (HSV-2): tour guide of sexual transmission of HIV About 10 times as infectious as HIV HSV-2 epidemiology is to an extent a fastforward HIV epidemiology HSV-2 as a proxy for sexual risk behavior

15 Human papillomavirus (HPV) and cervical cancer: the flashlight of sexual network connectivity About a 100 times as infectious as HIV Spreads to most sexual partnerships except the ones disconnected Probe of connectivity of sexual networks and different risk groups

16 Middle East and North Africa HIV/AIDS Epidemiology Synthesis Project Sources of data Medline (PubMed) literature search of HIV, sexual behavior, and proxy measures Literature search of local journals, other academic publications, and DHS reports International organizations reports (UNAIDS, WHO, World Bank, UNICEF, UNODC etc) Country-level reports, government publications, institutional reports (National AIDS Programs, Ministries of Health etc) Consultations with key experts, public health officials, researchers, and academics in the region and beyond

17 List of MENA countries Afghanistan Algeria Bahrain Djibouti Egypt Iran Iraq Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Qatar Saudi Arabia Somalia Sudan Syria Tunisia United Arab Emirates West Bank and Gaza Yemen

18 A conceptual framework for HIV epidemiology General Population Core Group Bridging Population

19 An example of the synthesis approach: Injecting drug users (IDUs)

20 Injecting drug users: HIV prevalence Pattern: High HIV prevalence (>20%) Very low HIV prevalence (around 0%) Country HIV prevalence among IDUs Afghanistan 0.0% [63], 3% [53,64] Algeria 11% (self-reported) [65] Bahrain 0-2.3% [62], 21.1% [66] Egypt 0.15% (drug addicts) [67], 0.0% [68], 0.0% [69], 0.0% [62], 0.0% [70,71], 0.6% [72] Iran Iraq 0.0% (prior to occupation) [62] Jordan 4.2% [62] Kuwait 0.0% [62] Lebanon 7.8% [62] 1.2% [73], 4% [74], 0.9% (injecting and non-injecting drug users) [75], 7% (incarcerated IDUs) [76], 0.0% (treatment center) [76], as high as 63% in prisons [60], 30% (local prison) [77], 6.9% (incarcerated IDUs) [76], 22.0% (incarcerated IDUs) [78], 24.0% (incarcerated IDUs) [78], 15.2% [79], 23.2% [80], 5.4% (noninjecting drug users) [79] Libya 0.5% [81], 59.4% [82], up to 49% [60] Oman 5.0% [62,83], 12% [84], 18% [84], 27% [84] Pakistan 0.0% [85], 0.0% [86], 0.0% [13], 0.63 [87], 1.77% [13], 0.4% [88], 9.7% [56], 9.3% [89,90], 26.3% [91], 24% [92], 0.5% [59], 23.1% [55,58,59] Saudi Arabia 0.15% [93] Syria 0.3% [62] Tunisia 0.3% [62]

21 Injecting drug users: Behavioral data; sharing of injection equipment Pattern About half of IDUs share injecting utensils (needle or syringe) Documented evidence for the potential HIV infectious spread Country Sharing of injecting equipment Afghanistan 50% [11], one third [79], 50.4% [53], 46% [63] Algeria 41% [555] Egypt 32.2% [72], 11% [556], 59% [11], 55% [557] Iran 67% [558], 49.8% [537], 24.8% [537], 48.3% [80], 11% [80], 30.6% [79], % [538], 21.0% [559], 39.9% [559], % [78] Lebanon 33% [560], 42% [455], 40% [138], 64.7% [561,562,563], 34.2% [106], 17% [106], 34.2% [106] Libya 44% [11] Morocco 47% [11] Oman 44-70% (different groups of IDUs) [84] Pakistan 56.8% [564], 56% [565], 76% [565], 52% [69], 47% [88], 48.2% [566], 58.7% [554], 82% [567], 23% [567], 78.1% [568], 18% [59], 48% [108], 82% [108], 72.2% (Afghanis refugees) [566] Syria 47% [11]

22 Injecting drug users: HCV prevalence as a proxy Pattern Documented evidence for HCV spread in IDU networks Very high HCV prevalence in some settings (Pakistan) Intermediate HCV prevalence in other settings Country Afghanistan 36.6% [53] Egypt 63% [70,71] HCV prevalence among IDUs Iran 30% (injecting and non-injecting drug users) [75], 60% [76], 52.0% [101], 59.4% (incarcerated IDUs) [76], 78% (local prison) [77], 47.4% [102], 45.3% [103] Lebanon below 20% [104], 25% (HIV infected) [105], 49% [106] Oman 11-53% [84] Pakistan 88% [86], 89% [107], 60% [92], 87% [108], 91% [108] Saudi Arabia 69% [109], 75% [93] Syria 60.5% [110] Tunisia 39.7% (HIV infected) [111]

23 Injecting drug users: Conclusions of synthesis Documented evidence for substantial potential of HIV spread HIV did not penetrate many of IDU risk networks The region is flooded with inexpensive drugs originating from Afghanistan. The prevalence of IDUs is in the intermediate to high range compared to other regions Both drug use and injection drug use are rising in the region contrary to global trends

24 A potential prototype story: Iran s IDU epidemic Started in the early nineties by a subtype A virus of an Ugandan/Kenyan isolate in the city of Mashhad Started to grow among IDUs around 1995 First reported outbreak was in 1996 in prisons of Kerman and Kermanshah By 2000, the prevalence grew to about 1-2% in all studies Since 2003 the prevalence started growing rapidly and was consistently above 5% in all point-prevalence surveys

25 A potential prototype story: Iran s IDU epidemic HIV infection among spouses of infected persons rose from 0.5% of all cases in 2001 to 2% of all cases in Most HIV infected women in Iran are spouses of IDUs The viral sequences were found strongly related with confined variability and form a single cluster suggesting the recency of the epidemic This epidemic is distinct from an epidemic among hemophiliacs of subtype B; two parallel epidemics in Iran The HIV epidemic among IDUs in Kabul, Afghanistan at 3% HIV prevalence has also been linked through molecular epidemiology to the Iranian epidemic

26 A story to be continued: A question of time scales? Is Afghanistan s IDU epidemic at 3% prevalence an Iranian epidemic delayed by 10 years? Will we see increased HIV disease burden among spouses of IDUs in Iran? Will we see an increase in mother to child transmissions in Iran? Considering the overlapping risks, will we see an epidemic among MSM in Iran? Considering the overlapping risks, will we see an epidemic among FSWs in Iran? Then, will we see an epidemic among clients of FSWs in Iran? Here where the HIV epidemic is likely to saturate. It is not likely that we will see a massive epidemic in the general population in Iran

27 A similar story in Pakistan? HIV prevalence was 0.63% among IDUs at a site in Karachi at the end of 2003, but the prevalence increased to 23% at this site by mid 2004.

28 The story continues but for the rest of the risk groups in the populations

29 Men who have sex with men: HIV prevalence Pattern Documented evidence of HIV prevalence among MSM in MENA Country HIV prevalence among men who have sex with men Egypt 1% [60,140,142], 6.2% [72] Lebanon 3.6% [106] Pakistan 3.9% (MSWs) [59], 0.0% (MSWs) [59], 1.5% (hijras) [59], 0.5% (hijras) [59], 0.0% (hijras), 4% (MSWs) [59] Sudan 9.3% [144]

30 Men who have sex with men: Behavioral measures and proxy measures It is a highly hidden group with relatively limited data Considerable evidence of risk behavior among MSM such as low condom use, multiple sexual partnerships of different kinds, and prevalence of sex work among MSM Some evidence of considerable prevalence of STIs among some MSM groups Substantial overlap with IDU and heterosexual sex

31 Men who have sex with men: Conclusions of synthesis The epidemic appears to be spreading in this group in different countries of the region There is an environment of high risk behavior and overlapping risk behavior with injection drug use and heterosexual sex In terms of speed of spread, this is the epidemic that is likely to be the first to materialize or second after IDU epidemics

32 Female sex workers: HIV prevalence Pattern: Apart from the three notable exceptions of Sudan, Djibouti, and possibly Somalia, HIV prevalence continues to be at relatively low level Country Afghanistan 0.0% [63] HIV prevalence among female sex workers Algeria 1.7% [114,115], 2% [114], 9% [114] Djibouti Egypt 0.8% [72], 0.0% [67] 3.9% (street based) [116], 9.0% (street based) [116], 41.4% (street based) [116], 39.5% (street based) [116], 51.3% (street based) [116], 55.8% (street based) [116], >50% (street based) [116], 2% [117], 4.6% (street based) [118], 41.7% (street based) [118], 41% (street based) [118], 36% (street based) [118], 70% (street based) [119], 1.4% (bar-based) [116], 2.7% (bar-based) [116], 5.0% (bar-based) [116], 7% (bar-based) [119], 14.2% (bar-based) [116], 15.3% (barbased) [118,120], 21.7% (bar-based) [116], 25.6% (bar-based) [116], about 50% [121] Iran 0.0% [122], 0.0% [123], 2.67% [48] Lebanon 0.0% [106] Morocco 1.4% [48], 2.3 % [124,125] Pakistan 0.0% [85], 0.0% [69], 0.0% [59], 0.5% [59] Somalia 0.0% [126], 0.0% [127], 2.1% [128], 2.4% [129], 8.3% [129], 0.0% [129], 0.0%, 0.6% [130] Sudan Tunisia 2.3% [9] Turkey 0.0% (1991) [134] 0.0% [127], 16% (Southern Sudan) [113], 4.4% [131], 1.55% (FSWs and tea sellers) [132], 1.7% [133] Yemen 4.5% [135,136], 2.7% [135,136], 7% [135,136,137]

33 Female sex workers: Behavioral measures and proxy measures Considerable evidence of risk behavior among FSWs such as low condom use, intermediate number of clients, variable kinds of partnerships Considerable evidence on clients of FSWs and STI transmission between them and FSWs Prevalence of STIs among FSWs but still it appears at lower prevalence (apart from the three notable exceptions) than FSWs in other regions including HSV-2 and bacterial STI prevalence

34 Female sex workers: Conclusions of synthesis The epidemic appears to be still at a relatively early stage with the exception of Djibouti, Southern Sudan, and possibly Somalia It appears that the level of risk is at a level that could lead to substantial HIV epidemics though possibly at lower prevalence than FSWs in other regions HIV so far does not appear to be spreading at a relatively rapid level compared to FSWs in other regions

35 Overlap of risk factors: Conclusions of synthesis Pattern A major highlight in the data in the region is that of overlapping risks IDUs are sexually active with regular and non-regular sexual partnerships; contact frequently FSWs, MSWs, hijras (in Pakistan), and other males; exchange sex for money or drugs; infrequently use condoms; sell their blood for money; perceive low risk of HIV acquisition; and have limited comprehensive knowledge of HIV/AIDS FSWs, MSWs, MSM and hijras report frequent intermixing among themselves, frequent drug abuse including injecting drug use, and frequently having partners and clients who are IDUs

36 Bridge populations: Conclusions of synthesis Evidence suggests generally low HIV prevalence among bridge populations such as truck drivers, fishermen, sailors, military personnel, and migrant workers Considerable evidence of substantial risk behavior such as contacts with FSWs, MSWs, hijras, and males; very infrequent condom use; multiple kinds of sexual partnerships; but (surprisingly) low levels of IDU HIV does not appear to have penetrated the sexual networks of bridge populations; probably because of still low HIV levels among FSWs

37 Prisoner population: Conclusions of synthesis Pattern Substantial evidence of high risk behaviors among prisoners such as IDU and homosexual contacts Considerable HIV prevalence rates have been documented in some prisons Imprisonment rates in the region tend to be in the low to intermediate side though with several exceptions Will prisons serve as a social petri dish for amplification of the HIV epidemic? Country Imprisonment (per ) Afghanistan 30 [810] Algeria 158 [810] Bahrain 95 [810] Djibouti 61 [804,810] 6.1% [811] HIV prevalence in prisons Egypt About 121 [804,810] 0% [68], 0% [812], 1.6% [222] Iran 191 [804,810], 185 [813] 2% [814,815], 1.4% [52], 2.3% [52], 12% [50], 2.1% (mostly IDUs) [160], 2.3% (mostly IDUs) [160], 3.3% (mostly IDUs) [160], 0.9% (injecting and non-injecting drug users) [75], 7% (IDUs) [76], 22.0% (IDUs) [78], 24.0% (IDUs) [78], 12% [50] to 63% [816], 22-24% [807], 6% [807] Iraq About 60 [804,810] 0% [811], 0% [817] Jordan 104 [810] 0% [152] Kuwait 130 [810] Lebanon 145 [804,810] 0.7% [811], 0.16% [106] Libya 207 [804,810] 18% [818], 60% (detention for treatment) [804] Morocco 174 [804,810] 0.8% [124], 0.7% [819], 0 (women) [819], 2% (women) [719] Oman 81 [804,810] 0.2% [811], 0.14% [9] Pakistan 55 [810] 0.3% [69], 1.1% (women) [69], 1.64% [151] Qatar 55 [810] Somalia 0.0% [820] Sudan About 36 [810] 0.0% [127] and 2% [9], 8.63% [607], 27.1% (women) [607] Syria 93 [804,810] 0-0.2% [811] Tunisia 253 [804,810] 0 [811] United Arab Emirates 288 [810] Yemen 83 [804,810] 26.5% [811]

38 General population: HIV prevalence among pregnant women Pattern Consistently very low HIV prevalence over the years apart from Sudan, Djibouti, and Somalia Country Afghanistan 0.0% [206] HIV prevalence among ANC attendees Algeria 1% (Southern Algeria) [115], 0.53% (Annaba) [207] Iran 0.02% [208], around 0.1% [158] Mauritania 0.4% [167] Morocco 0.0% [48], 0.13% [55] Somalia 0.0% [126], 0.9% [175], 0.9% [175] (Somaliland) [175], 1.4% (Somaliland) [175], 1.3% (Somaliland) [175], 1.0% (Puntland) [209], 0.6% (Central Somalia) [210] Sudan 1% (national) [176,211], 1% [212], 0.58% (national) [211], 0.5% [213], 1.57% (IDPs) [178], 0.26% (refugees) [211], 0.27% (IDPs) [211], 6-8% (Southern Sudan) [60], 3.0 (Juba, Southern Sudan) [132], 4.0 (Juba, Southern Sudan) [132], 2.3% (Yei town; Southern Sudan) [149,205], 2.3% (Rumbek town; Southern Sudan) [149,205], 0.19% (North Sudan) [211], 0.14% (urban; North Sudan) [211], 0.14% (rural; North Sudan) [211], 2% (West Nile) [204], 1.5% (Red Sea) [176], 0% (Algadarif) [176], 0.0% (Kassala) [176], 0.0% (Upper Nile) [176], 0.98% (Algazira) [176], 0.0% (Algazira) [178], 0.0% (Blue Nile) [178], 0.0% (West Kurdufan) [178], 0.0% (North Darfur) [178], 2.2% (White Nile) [176,178], 0.0% (Upper Nile) [178], 1-5% (Khartoum) [214], 0.25% (Khartoum) [178], 0.5% (Khartoum 1) [176,178], 0.25% (Khartoum 2) [176,178], 0.25% (Khartoum 3) [176,178], 0.8% (Khartoum) [215], 1.38% (Khartoum) [216]

39 General population: HIV prevalence among blood donors Pattern Consistently very low HIV prevalence over the years apart from Sudan, Djibouti, and Somalia Country Afghanistan 0.0% [217] HIV prevalence among blood donors Djibouti 0.0% [119], 1.9% [218], 3.4% [219] Egypt 0% [220], 0% [68], 0.0% [221], 0.02% [67], 0.0% (Alexandria) [222] Iran % [223], 0.009% [223], 0.005% [223], 0.005% [223], 0% [224] Jordan 0.004% [225], 0.0% [152] Kuwait 0.01% (Kuwaitis) [226], 0.00% (non-kuwaiti Arabs) [226] Mauritania 0.6% [167], 0.8% [167] Morocco 0.02% [191] Palestinian territories 0.006% [227], 0.0% (Gaza) [228] Pakistan 0.15% [229], 0% [230], 0.003% [231], 0.052% [232], 0.064% [233], 0.02% [234], 0.0% [85], % [235] Qatar 0.03% [236] Saudi Arabia 0.02% [237], 0.0% [238], 0.0% [239] Somalia 1% [173], 0.8% [240] Sudan 0.05% [241], 0.9% [242],0.8% to 1.8% [158] Yemen 0.1 % to 0.3% [158], 0.04% [243], 0.29% [244], 0.02% [48]

40 General population: HIV prevalence in population surveys Pattern Consistently very low HIV prevalence over the years apart from Sudan, Djibouti, and Somalia Country Djibouti HIV prevalence in population-based surveys 2.9% (national) [198], 3.4% in (Djibouti-ville) [9], and 1.1% (out of Djibouti-ville) [9], 2.0% [199], 2.2% [199] Iran 0.0% (Hamadan province) [200], 0.01% [201] Libya 0.13% [202] Sudan 2.6% (national) [203], 2% (national) [60], 1.6% (national) [204], 0.4% (Rumbek town, Southern Sudan) [205], 4.4% (Yei town, Southern Sudan) [205], 2.7% in (overall in Yei area) [149]

41 General population: HIV prevalence in different population groups Pattern Consistently very low HIV prevalence over the years apart from Sudan, Djibouti, and Somalia Country HIV prevalence among other different population groups Bahrain 0.0% (outpatient pediatric clinic) [247] Djibouti 0% (women) [119], 5% (women) [248], 5% (men) [248] Egypt 0% (different population groups) [220], 0% (tourism workers) [249], 0.18% (fever patients) [67], 1.9% (HIV contacts) [67], 0.07% (international travelers) [67], 0.97% (non-egyptian residents) [67], 0.0% (hospital patients) [68], 0.0% (control group in a study) [71], 0% (fire brigade personnel) [222,250], 0.0% (university students) [251] Iran 0.34% (healthy children) [252], 1.8% (gypsy population) [253], 0.0% (runaways and other women seeking safe haven) [41] Jordan 0% (public employees) [152], 0% (military personnel) [152], 0% (prisoners) [152], 0.64% (at risk populations) [254]. Mauritania 0.28% (general population) [255], 0.3% (general population) [256], 0.6% (general population) [256] Morocco Pakistan Saudi Arabia 0% (controls in a study) [265] Somalia Sudan Yemen 0.0% (traditional barbers and their customers) [257], 0.10% (STD clinic attendees, pregnant women and patients with pulmonary tuberculosis), 0.10% (STD clinic attendees, pregnant women and patients with pulmonary tuberculosis) [168], 0.0% (women at family planning clinics) [48] 0.0% (low risk population), 0.23% (15,000 individuals with various characteristics including suspected HIV patients) [231], 0.06% (STD attendees, IDUs, haemodialysis patients, suspected AIDS patients, blood donors, ANC attendees, TB patients, travelers abroad, and multiple-transfused patients) [85], 0.064% (general population) [258], 5.4% (men reporting extramarital contacts) [258], 0.0% (health care workers) [259], 0.97% (blood donors and recipients, IDU, and suspected AIDS cases) [260], 0.06% (blood donors and deported Pakistanis from Persian Gulf countries) [261], 0.0% (IDUs in rehabilitation centers and drug-related arrestees) [13], 0.1% (high risk and low risk population) [262], 0.007% (general population) [263], 0.0% (two surveys; earthquake victims) [264] 0.0% (military cadets) [129], 0% (blood donors and hospitalized children and adults) [266], 0.0% (women and neonates) [126], 0% (hospitalized persons) [172], 1% (hospitalized persons) [173] 1% (police officers in Khartoum) [267], 1% (university students) [268], 0.2% (patients with various malignancies and normal subjects) [269], 1.2% (women in a suburban community in Khartoum) [270], 1.1% (university students) [271], 0.12% (hospital attendees) [272], 1.1% (general population; Southern Sudan) [273], 1.0% (general population; Malakal, Southern Sudan) [274], 7.2% (general population; Yambio, Southern Sudan) [274], 3% (female outpatients; Southern Sudan) [113], 3% (outpatients; Juba, Southern Sudan) [275,276], 4% (outpatients; Juba, Southern Sudan) [275,276] 0%, 0.17%, 1.26%, and 1.19% (travelers seeking visas to work abroad in different years) respectively [136]

42 General population: Sexual risk behavior measures Levels of reported sexual risk behavior tend to be generally on the low side Most of the high risk behavior appears to be concentrated, though not confined, between puberty and marriage Youth are a main concern

43 General population: Proxy measures: HSV-2 prevalence Pattern: Lower HSV-2 prevalence in the general population than other regions HSV-2 prevalence in high risk groups is high and comparable to other regions Country HSV-2 prevalence Bangladesh 12% (women attending basic health care clinic) [918] Djibouti 2% (general population women), 5% (male blood donors) [119], 49% (luxury bar FSWs), 81% (street-based FSWs) Egypt 6.2% (STD clinic attendees) [70] Israel 9% (Arab and Jewish non-soviet immigrants; pregnant women) [910], 2.4% (Arabs; STD clinic attendees) [911] Lebanon 0.027% (general population women) [913] Morocco 12.9% (ANC attendees) [908], 16.2% (ANC attendees) [48], 13% (general population women) [48], 10% (general population men) [48], 26% (urban women with a median age of 40 years) [909], 9.2% (male HIV sentinel surveillance attendees) [908], 6.5% (military personnel) [908], 6.7% (STD clinic attendees) [48] Sudan 5.5% (household cluster survey; South Sudan) [205], 27% (male Sudanese refugees in Ethiopia) [610], 26% (female Sudanese refugees in Ethiopia) [610] Syria 0% (pregnant women) [912], 0% (general population women) [912], 0.3% (general population men) [912], 0% (neonates) [912], 9.5% (STD clinic attendees) [912], 8.0% (women with cervical cancer) [912], 20% ( bar girls ) [912], 34% FSWs [912] Turkey United Arab Emirates [919] 5.0% (pregnant women) [914], 8% (women with pregnancy complications) [917], 5.5% (blood donors) [914], 4.8% (sexually active adults) [914], 8.3% (hotel staff) [914], 17.3% (patients with genital warts) [914], 60% (FSWs) [914], 26% (MSM) [915,916]

44 General population: Proxy measures: HPV prevalence and cervical cancer Pattern: MENA has the lowest cervical cancer incidence rate of all regions (5.6 per 100,000). The global rates vary from 3 to 61 per 100,000. The list of the lowest seven cervical cancer rates in the world include five MENA countries There is substantial variability in the region; highest in countries closest to sub- Saharan Africa, intermediate in Maghreb (Western) countries, and lowest in Mashriq countries (Eastern) Country/Region Incidence Mortality ASR(W) ASR(W) Afghanistan Algeria Bahrain Djibouti Egypt Iraq Iran Israel Jordan Kuwait Lebanon Libya Morocco Oman Pakistan Qatar Saudi Arabia Somalia Sudan Syrian Arab Republic 2 1 Tunisia Turkey United Arab Emirates Yemen 8 4.6

45 General population: Proxy measures: HPV prevalence and cervical cancer Country ASR Algeria Setif 11.6 Egypt Gharbiah 2.1 Tunis Centre, Sousse 7.1 Bahrain Bahraini 6 Israel Non-Jews 2.4 Kuwait Kuwaitis 4.5 Non-Kuwaitis 5.3 Malaysia Penang 17.9 Sarawak 15.9 Oman Omani 6.5 Pakistan South Karachi 7.5 Singapore Malay 7.3 Turkey Antalya 4.4 Izmir 5.4 (per person-years) Age *Algeria, Algiers Algeria, Setif Wilaya Israel: Non-Jew s *Kuw ait: Kuw aitis *Oman: Omani *Pakistan, South Karachi Global Average

46 General population: Conclusions of synthesis Pattern: The levels of risk behavior among the general population appear so far to be lower than that in other regions No evidence of a sustainable general population HIV epidemic in MENA We do have generalized epidemics in MENA (>1% prevalence) in Southern Sudan, Djibouti, and parts of Somalia, but these epidemics appear to be concentrated among FSWs, their clients, and spouses of these clients

47 Analytical view of HIV Epidemiology in MENA

48 Summary of 53 million HIV tests from country reports provided to the WHO HIV prevalence of 0.1% 10% 9% 8% 7% 6% 5% 4% 3% Prevalence 2% 1% 0% IDUs Blood donors Pregnant women Premarital testing Blood recipients Out-Migrants In-Migrants Suspected AIDS Cases Prisoners TB patients Voluntary counseling and testing STD clinic attendees Contacts of AIDS patients Bar Girls FSWs MSMs

49 Directions for scientific research

50 Surveillance is the Golden Word Surveillance of most at risk and hidden groups, bridge populations, and vulnerability settings for representative data Size estimation of high risk groups and bridge populations

51 Risk networks: A hypothesis A B Females Males Female Sex Workers

52 Increases in risk behavior particularly among youth? Increases in incidence of STIs (such as in Iran and Kuwait) Increases in reported sexual behavior among youth (such as in Lebanon and Turkey) Structural factors leading to increases in risk behavior: Socio-cultural transition leading to more tolerance and acceptance of premarital and extramarital sex Increased exposure to outside influences such as satellite TV Economic hardships and social changes that delay the age at marriage Prevalence of non-conventional forms of marriage

53 An opportunity for prevention! Generally speaking HIV transmission appears to be focused in most at risk groups and their partners with limited inroads into the general population Though we already have concentrated epidemics in some most at risk groups, most epidemics appear to be still at low prevalence or early concentrated epidemic stages

54 Risk and vulnerability There are most at risk groups in every country of the region There are substantial levels of risk behavior among most at risk groups suggesting the potential for further spread of HIV There are various settings of vulnerabilities such as prisons, migration and mobility, youth, and gender We need to focus the programmatic response where the risks and vulnerabilities are

55 Sudan: A strategic reorientation Sudan has made impressive progress on surveillance in recent years among FSWs, MSM, IDUs, STD clinic attendees, prisoners, military personnel, truck drivers, refugees, internally displaced persons, tea sellers, ANC attendees, university students, and general population Programmatic response reorientation: Generalized epidemic type response Focus on most-at-risk and vulnerable populations

56 The human face of AIDS in MENA In Sum: HIV travels along, and defines the contours of, the map of vulnerability and risk that already exists in the MENA region

57 MENA is not the anomaly of the HIV/AIDS world map

58 Acknowledgement Collaborators World Bank: F. Ayodeji Akala (MENA Region) and David Wilson (GAMET) Iris Semini and Oussama Tawil (UNAIDS MENA RST) Gabriele Riedner (WHO/EMRO)