Acquired immuno-deficiency syndrome (AIDS) in the Eastern Mediterranean Region

WHO-EMlRC/INF.DOC. Acquired immuno-deficiency syndrome (AIDS) in the Eastern Mediterranean Region. Introduction By the end of 00, an estimated 0 million people in the world were living with HIV/AIDS, million of whom were infected in 00. Three million people died as a result of HIV/AIDS during 00. It is estimated that of the million HIV I AIDS patients who need treatment with antiretroviral drug therapy, % live in developing countries and have no access to antiretroviral drugs. Recognizing these challenges, in 00 WHO launched the by Initiative which aims at providing million people with ARV treatment by the end of 00. To achieve this goal, 0 priority countries were identified to start implementing the initiative, based on the number of existing AIDS cases. Guided by the strategic framework developed for the by Initiative, in 00 the Regional Office reviewed the regional strategic plan for 00-00 on improving health sector response to HIV I AIDS and STD in light of the aims of the Initiative. The five major targets of the regional strategic plan constitute important foundations for scaling up access to antiretroviral treatment, mainly through facilitating the identification of people living with HIV I AIDS, strengthening management of AIDS cases and enhancing surveillance and monitoring of the epidemic. The regional strategic plan also includes prevention as a crucial element of the response.. Overview of the epidemiological situation in the Region The HIV I AIDS epidemic is advancing in the Eastern Mediterranean Region at an alarming rate. In 00, the adult prevalence rate in the Region reached 0.%, equal to that of western Europe. However, while an estimated 000 new cases occurred in western Europe in 00, 000 new cases were estimated to have occurred in the Region during the same period. Similarly, the estimated number of deaths resulting from AIDS in 00 was 000 in the Eastern Mediterranean Region, compared to only 000 in western Europe. These figures show the relative containment of the epidemic in western Europe, while the same epidemic is rapidly expanding in the Eastern Mediterranean Region. An estimated 00 000 people in the Region are currently living with HIV/AIDS. The total number of reported AIDS cases since is, a number which is far lower than the estimated figure (Table ).. Heterosexual transmission of HIV remains the leading mode of transmission in!be Region, accounting for.% of the cumulative total AIDS cases reported to date. However, its prominence as a mode of transmission varies by subregion. Heterosexual transmission accounts for.% of reported AIDS cases in the Hom of Africa. In countries of the Maghreb Union and Near East it accounts for. % and. % of reported cases, respectively. Marked differences in mode of transmission can also occur among countries within one subregion. Injecting drug use is the leading mode of transmission in the Islamic Republic of Iran, accounting for % of reported cases. In Pakistan, however, heterosexual transmission accounts for.% of AIDS cases. Over the past decade, the number of AIDS cases attributed to blood and blood product transfusion has steadily decreased, indicating improvement in blood safety measures in countries of the Region. In, AIDS cases attributed to blood and blood product transfusion represented.% of all the AIDS cases reported in the Region. In 00, this percentage was 0.%. (Figure ). Efforts to minimize transmission through blood and blood product transfusion should be continued and strengthened. The proportion of AIDS cases attributable to injecting drug use in the Region has increased, from.% of all reported AIDS cases in to approximately 0% in 00. This increase reflects a shifting trend from heterosexual transmission to transmission by injecting drug use (Figure ). Moreover, the spread of HIV among drug users has accelerated over the years. In less than 0.%

Table. Reported AIDS cases by year and by country Country 0 000 00 00 00 Total Bahrain Cyprus Djibouti Egypt Iran, Islamic Republic of Iraq Jordan Kuwait Lebanon 0 0 0. 0 0 0 0 0 0 Libyan Arab Jamahiriya '" Morocco Oman Pakistan Palestine Oatar Saudi Arabia 0 0 0 0 0 00 0 0 0 0 0 0 0 0 Somalia Sudan Syrian Arab Republic Tunisia 0 0 0 0 0 0 0 0 United Arab Emirates UNRWA Yemen Total : information not available 0 0 o 0 0 0 0

WHO-EMlRCSMNF.DOC. of the injecting drug users tested for HIV in the Region were positive. In 00, the rate of HIV positive tests among injecting drug users reached.%. These trends are clearly visible in some countries of the Gulf Cooperation Council (GCC), such as Bahrain and Oman, and in the Islamic Republic of Iran. Women represent around 0% of the total reported AIDS cases, a proportion which has remained relatively stable over the past years. This proportion varies at subregional level In the Islamic Republic of Iran, for example, where 0% of the AIDS cases reported in 00 are among male injecting drug users, the proportion of women with AIDS is as low as % of the cumulative total. In contrast, in subregions where the prevailing mode of transmission is heterosexual, the proportion of women with AIDS is much higher. In countries of the Maghreb Union, for example, the proportion of women reported with AIDS in 00 is % of the cumulative total. Men and women are infected at different ages. The highest numher of men is diagnosed with AIDS at between and years of age_ Women seem to acquire the infection at a much younger age, with the highest number of reported AIDS cases at the age of - years (Figure )_ Around two thirds of the total reported AIDS cases are among patients in the age group of 0-- years; however, vulnerability starts at a younger age_ AIDS patients in the age group of 0-- years represent 0.% of the total cumulative number. This percentage more than doubles in the age group of - years (,%), and then surges up to.% in the age group of 0-- years. In light of the fact that sexual transmission (heterosexual and homosexual) is responsible for more than % of the cumulative total reported AIDS cases in the Region, vulnerability among youth can be attributed to the beginnings of sexual activity and to risky sexual behaviour. It must be noted that the reported AIDS cases reflect advanced stages of HIV infection, indicating that the virus was acquired at a younger age. An estimated 00 OOO--ll 0 000 AIDS patients in the Region are currently in need of antiretroviral therapy. Of these, less than % are actually receiving it. There are several reasons for this. Countries with the highest burden (Djibouti, Sudan, Somalia) often have weak health systems and scarce fmancial resources, and are incapable of providing antiretroviral therapy to AIDS patients_ In addition, because of stigma associated with HIV/AIDS, low rates of voluntary testing and unavailability of services, the majority of people living with HIV I AIDS remain unidentified... 00% 0% :! 0% '" c <i 0% ii : 0% &. I!!.... c " 0% c 0% '0 at 0% J! i 0% ~ "- 0% 0% --...- ~ \ \ \ - --- =- / / / 000 00 00 Year Blood/Blood product Heterosexual -..-Homosexual Injecting drug use Mother to child Figure _ Trends In mode of transmission of reported AIDS cases in the Region, -00

EMlRCS/INF.DOC. 00 000 00-00 - - 00 f- f- ;- r--- - em ~ 00 - r- f- f- I=- - o n.n..... r. L r Age group (years) Figure. Distribution of total reported AIDS cases In the Region by age group and sex, -00 Some countries of the Region provide antiretroviral therapy free of charge to their AIDS patients. Lebanon, Morocco, Syrian Arab Republic, Tunisia and acc countries are providing full coverage for AIDS patients. The Libyan Arab Jamahiriya (paediatric care) and Islamic Republic of Iran provide free therapy to some patients. Other countries are providing a small percentage of patients with antiretroviral therapy, such as Djibouti (00 patients) and Sudan (00 patients). To finance provision, countries are using either regular country budget resources or resources made available through the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) or other major agencies such as the World Bank. Some countries, such as Lebanon, Morocco and Tunisia, have successfully negotiated siguificant price reductions with pharmaceutical companies, bringing the cost of antiretroviral therapy down to around US$ 00-0 per patient per month. In the Islamic Republic of Iran, negotiations have reduced costs to approximately US$ 00 per patient per month. Despite these achievements, however, the cost of antiretroviral therapy in the Region remains unaffordably high. In other regions, negotiations have resulted in prices as low as US$ 0 per patient per year. Closing the gap in access to antiretroviral therapy in the Region requires, in addition to available and affordable drugs, active entry points to people living with lllv/aids. Data from the Region show that, compared to the overall 0.% prevalence oflllv/aids in the general population in 00, tuberculosis patients, prisoners and injecting drug users have higher infection rates of %, 0.% and.% respectively, with some variation at subregional level. In addition, reported lllv/aids prevalence in voluntary counselling and testing services was 0.% in 00. These data are useful for strategic guidance in the identification of people living with lllv I AIDS, suggesting that the introduction of voluntary counselling and testing units in tuberculosis centres, in service facilities for injecting drug users and in prisons, in addition to the establishment of voluntary counselling and testing centres targeting other risk groups, can create efficient entry points to people living with lllv/aids. Countries of the Region are at different stages of adoption and implementation of second generation surveillance and its methods and the ability to draw relevant indicators. In a very few countries, such as Morocco, the system has made satisfactory progress. The majority of countries are only in early

EMlRCS/INF.DOC. stages of adopting the system. Various components of second-generation surveillance are covered by most countries, but on an ad hoc basis rather than systematically. Behavioural surveillance, mainly among vulnerable groups, and STD surveillance are the weakest areas, and in many instances suffer from incompleteness, inconsistency, un-representativeness and low coverage.. Progress in implementation of the regional targets. Target : By the year 00, all countries of the Region will have a declared political commitment to, and sustained public Information activities about, Hlv/ AIDS and STD In 00, advocacy activities for HIV/AIDS prevention and care focused on two main areas: reducing stigma and discrimination related to HIV/AIDS, the theme of the World AIDS Campaign 00; and scaling up the provision of antiretroviral therapy in countries, in line with the by Initiative. The AIDS Information Exchange Centre (AIEC) provided the national AIDS programmes in the Region with adapted materials and publications. An advocacy package was produced by the Centre for the World AIDS Campaign 00, carrying the global slogan 'Live and let live' and a regional slogan 'AIDS is treatable... for a better future act now!' All countries of the Region celebrated the World AIDS Campaign 00, and regional media coverage in 00 was more extensive tban in previous years. The website of the HIV I AIDS and Sexually Transmitted Diseases unit is updated and maintained as source for information about the World AIDS Campaign and for regional information about HIV/AIDS. Another advocacy strategy is widescale documentation and dissemination of successful experiences of countries of the Region. The Regional Office, in collaboration with the Islamic Republic of Iran, has developed a good practice study from Kermanshah province, where a comprehensive HIV I AIDS prevention and care programme is being implemented with a focus on intravenous drug users and prisoners. The HIV/AIDS and STD Regional Advisory Group for the Eastern Mediterranean (ARAG) convened for the third time in July 00 to formulate recommendations for further implementation of the five targets of the regional strategic plan. The ARAG recommended that the Regional Office encourage countries to exchange HIV/AIDS related experience and to participate more actively and effectively in international conferences. The ARAG also suggested that the Ministry of Public Health in Kuwait consider reviving the successful experience of the Kuwait International AIDS Conference. The Regional Office continues to assist national AIDS programmes in mobilizing available resources, a main source of which is the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). WHO is actively supporting countries in developing GFATM proposals. In 00, HIV/AIDS proposals from the Islamic Republic of Iran and Sudan were approved by the GFATM, with total -year support of US$ million and US$. million, respectively. A joint meeting was organized in collaboration with the GFATM secretariat in June 00 to brief country representatives on Global Fund operational policies and procedures, including the role of the principal recipient, and to facilitate the development of country-specific plans. The Regional Office provides up-t<hlate information about the Global Fund through the EMRO website and through direct correspondence with countries, and will continue to assist countries in developing new proposals and in implementation and monitoring of successful ones. The Regional Office also supports countries in planning and managing other funds. For example, Djibouti has received a World Bank grant amounting US$ million through the Bank's Multicountry AIDS Project, phase (MAP-). Staff members of the Regional Office conducted a mission to Djibouti and assisted with the consensus building exercise for the national strategic plan for HIV I AIDS. WHO is supporting the country in implementation of the strategic plan in the areas of monitoring, surveillance and evaluation, access to care and STD control.

EMlRCSMNF.DOC.. Target : By the year 00, all countries of the Region will have developed institutional mechanisms for human resource development and capacity-building in all fields related to HIV/AIDS and STD prevention and care In 00, the Regional Office supported several important activities intended for human resource development and capacity building. A course on hot-line counselling was organized jointly by EMRO, UIDS, UNICEF and the national AIDS programme of Egypt. The course was attended by counselling and health education specialists from Oman, Palestine and the Syrian Arab Republic. Two training workshops on IllY/AIDS peer education were conducted in Cyprus in November 00. The workshops aimed at addressing school health personnel and members of youth organizations to improve their knowledge on IllY/AIDS and STDs, develop negotiation skills and improve interpersonal communication, mainly around intimate and sensitive issues. The Regional Office provided technical support to two workshops organized by the Ministry of Health of Saudi Arabia on AIDS health education for AIDS care coordinators and primary health care physicians in October 00. The objective of the workshops was to enable participants to educate the public on aspects of IllY/AIDS. The workshops included a meeting with media organizations to discuss raising awareness on IllY/AIDS issues in a positive way in line with Ministry of Health policy. WHO coordinated with Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ) to establish a "Knowledge Hub" in Sudan for capacity building on IllY/AIDS prograrnnting, which includes the development of an HIV/AIDS programme management training course. In preparation, an initial country assessment for capacity building needs was made by WHO in November 00. The Regional Office collaborated with the WHO Mediterranean Centre for Reducing Vulnerability and headquarters in developing training curricula for WHO national professional officers on IllY/AIDS, tuberculosis and malaria. The training is intended to enhance country support at the level of WHO country offices.. Target : By the year 00, all countries of the Region will have sustained and comprehensive HIV/AIDS and STD prevention and care packages integrated Into the health care delivery system A regional meeting on expanded access to IllY/AIDS treatment in the countries of the Region, held in Cairo in February 00, focused on planning IllY/AIDS care at national level. Participants recommended that Member States commit to achieving a regional target of 0 000 people with AIDS receiving antiretroviral (ARV) therapy by 00, with the long-term goal of 00% coverage with ARV therapy at national level. They recommended that WHO explore ways by which the International IllY Treatment Access Coalition network could support implementation of national HIV/AIDS care plans, mainly in the areas of training and accreditation on IllY care, and facilitate subregional negotiations for reduced ARV drug prices and procurement schemes similar to that of the GeC. Participants also recommended that countries develop national guidelines for the use of antiretroviral drugs, and that they include in the national essential drug list and national register an optimal number of ARV drugs in accordance with the national guidelines. Within the context of the by Initiative, Djibouti and Sudan were among a number of countries selected as focus countries at global level. The Regional Office identified five additional priority countries for scaling up access to ARV therapy: Egypt, Islamic Republic of Iran, Pakistan, Somalia and Yemen. These countries were selected on the basis of large population size, the existence of concentrated epidemics in special population groups or the prevalence of high-risk behaviour. A WHO mission visited Sudan to assess the needs for rapid scaling up of access to care. Country support tearns from headquarters, the Regional Office and country offices will work together to ensure timely technical support to countries wishing to scale up. The Regional Office has developed a workplan for the biennium 00-00 and established a regional taskforce to follow up the implementation of the workplan and advise on different activities.

EMlRC/INF.DOC. In support of the above, the Regional Office adapted and translated the guidelines Scaling up antiretroviral therapy in resource-limited settings, developed initially by headquarters. Other tools for national AIDS programme managers are currently being adapted and produced. Technical support to develop country-specific care guidelines and interventions was also provided to Djibouti and Sudan. EMRO organized a series of subregional meetings to countries in developing and implementing plans for assessment, monitoring and control of sexually transmitted diseases. The first of these meetings was held in Oman in March 00 for GeC countries and Yemen. The second and third were held in May and June 00, respectively. The meetings focused on fostering SID activities and laying out practical steps to sttengthen national lllv and STD control programmes. Hann reduction interventions are in place in a few countries of the Region, notably the Islamic Republic of Iran and Pakistan. In the Islamic Republic of Iran, interventions are focusing on lllv prevention among injecting drug users. Technical support to assess lllv issues with special consideration to injecting drug use was provided to the Libyan Arab Jamahiriya and Oman. In December 00, the Regional Advisory Panel on the Impact of Drug Abuse (RAPID) met to review the situation in the Region regarding substance abuse, with particular emphasis on injecting drug use and its consequences including lllv/aids. The Regional Office continues to collaborate closely with other UN agencies for the prevention of lllv/aids among injecting drug users. In 00, Regional Office staff participated in a meeting on lllv I AIDS prevention among injecting drug users in the Middle East and North Africa, organized by the United Nations Office on Drugs and Crime (UNODC), and provided UNODC with updated epidemiological information on the links between lllv and injecting drug use in the Region.. Target : By the year 00, all countries will have capacity to generate relevant Information and apply operational research In various aspects related to HIV/AIDS and STD health response National lllv/aids and STD surveillance systems continue to be generally weak in the Region. The data reported to the Regional Office are often delayed and incomplete. Consequently a wide gap exists between reported and estimated figures for lllv I AIDS cases. To address this issue, a regional meeting on lllv/aids and STD surveillance and monitoring was held in July 00. The objectives of the meeting were to review existing lllv I AIDS and SID surveillance systems in the countries of the Region, agree on strategies to strengthen the lllvl AIDS and SID surveillance systems, gnided by the second generation surveillance guidelines, and discuss the feasibility of various approaches for implementation of behavioural surveys in countries of the Region. The regional lllv/aids and STD database is updated continually according to the data reported from countries. Data are reviewed on an ongoing basis, and reporting problems are discussed with the countries to improve reporting. In Afghanistan, a consultant was recruited by EMRO to help in developing a surveillance protocol. The Regional Office, in collaboration with headquarters and UIDS, organized a training workshop on methods for lllv/aids estimations and projections for the countries of the Middle East and North Africa in September 00. The workshop was one of a series of subregional workshops held worldwide to train national epidemiologists and data analysts involved in producing national lllv I AIDS estimates and the use of methods and software for estimations and projections.. Target : By the year 00, all countries In situations of complex emergency, such as embargo, population displacement and conflict, will have developed national strategies that Incorporate HIVlAlDS and STD prevention and care Into the national response to emergencies and related International assistance plans The Regional Office continues to support one full-time medical officer to reinforce technical capacity in the WHO Somalia office. Special attention and technical support is being given to countries in situations of complex emergency such as Afghanistan, Somalia and Sudan.

EMlRCS/INF.DOC.l. Challenges and future directions Challenges remain as follows: Ensuring access to low-price antiretroviral drugs. Currently, the lowest international price is around US$ 0 per patient per year. Securing extra-budgetary funding for mv / AIDS related activities in the Regional Office, mainly in relation to scaling up delivery of antiretroviral therapy. Reducing the harm associated with drug abuse. Promoting responsible sexual behaviour. Promoting early and effective treatment of sexually transmitted infections. To address these challenges, the Regional Office will continue to support the implementation of both the regional strategic plan 00-00 for improving health sector response to mv/aids and STD, and the by Initiative, at regional and country levels. Efforts will focus on the following areas during the 00-00 biennium. Supporting the development of care services for mv/ AIDS/STD in the national health systems. This will be done in line with the by Initiative with focus on the priority countries: Djibouti, Egypt, Islamic Republic of Iran, Libyan Arab Jamahiriya, Pakistan, Somalia, Sudan and Yemen. Strengthening mv / AIDS/SID surveillance. Establishing STD services and control programmes. Supporting countries in the development of Global Fund proposals and in the implementation of approved proposals. Supporting mv / AIDS/SID national strategic planning Supporting mv / AIDS/SID operational research.