Middle East, North Africa Face Emerging HIV Epidemics With Lagging Response

HIV prevalence is rising in the Middle East and North Africa (MENA) among 3 populations—men who have sex with men, people who inject drugs and female sex workers—suggesting the region has been neglected in the global HIV response.

A recent review, published in The Lancet HIV, noted that these populations accounted for an estimated 95% of new infections in the region in 2020.

“These epidemics emerged around the year 2003 and appear to be growing,” lead author Ghina Mumtaz, PhD, assistant professor at American University of Beirut, told Contagion. “Despite these epidemics, there are serious lags in the HIV response in terms of prevention, testing, and treatment with the region ranking lowest on all global HIV response indicators. Under-funding, poor surveillance, and stigma are longstanding challenges. They are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19.”

Lagging Behind Targets

The Joint United Nations Program on HIV/AIDS has focused on accelerating progress toward its goal of eliminating HIV by 2030, with new targets aiming to close gaps in intervention among key populations. Its “95-95-95” targets call for 95% of all HIV-positive people to be diagnosed, 95% to receive antiretroviral therapy, and 95% to reach viral suppression by 2030.

In 2020, the MENA region fell behind in all areas of HIV response, with only 61% of those living with HIV/AIDS aware of their status, 43% linked to care, and 37% reaching viral suppression.

“Contrary to popular opinions about the MENA region, there is a substantial volume of HIV-related data among key populations in the region,” Mumtaz said. “Our team has been compiling, since around 2007, the largest and most comprehensive database of all available HIV-related data from all 24 MENA countries. There is however a recent sharp decline in HIV surveillance funding, which has led to a stagnation in the number of studies being conducted in the region. There is also heterogeneity in the number and quality of studies between countries; and, until today, there almost no evidence to meaningfully characterize the status of the HIV epidemic among key populations in several MENA countries, which does not preclude the possibility of having hidden epidemics in these settings.”

HIV Incidence and Risk Behavior

Among people who inject drugs, the prevalence of HIV was 9% after 2010, but it reached as high as 87.1% in Tripoli, Libya, suggesting extremely high transmission among certain groups. Data was lacking for 9 countries, leaving the possibility of hidden epidemics unknown.

Risky behaviors, such as sharing needles, were reported widely. As many as 80% of people who inject drugs in Iran and Libya reported ever sharing a needle. Across all countries, 31% reported doing so in the past 12 months.

Risk factors also overlapped with other groups. On average, 12% of people who inject drugs reported having sex with other men in the past 12 months, and 40% reported having had sex with a female sex worker.

HIV has been rising among men who have sex with men (MSM) in the region since 2003, exceeding 5% in recent surveys. Epidemics among this group are emerging in Egypt, Morocco, and Pakistan and stabilizing in Lebanon, the review found.

Risky behavior among MSM is prevalent, with high numbers of sexual partners (ranging from 3 to 7 in the last week) and low condom use (about 30%) reported.

Prevalence of HIV varies widely among female sex workers, ranging from 0% in nearly half of the female sex worker populations in the region to 38% in South Sudan. Overall, HIV prevalence in this group remains low but has been rising at about 15% per year since 2000, the review found.

Meaningful Investment is Needed

“Our message to clinicians, health care providers, and importantly, public health experts, is that the only way for the MENA region to be on track towards the global target of eliminating HIV/AIDS by 2030 is to invest all possible efforts in addressing the needs of the populations most affected by the HIV epidemic in this part of the world: men who have sex with men, people who inject drugs, and female sex workers,” Mumtaz said. “The HIV situation in this region has been neglected and a meaningful investment is needed to be ahead of the emerging HIV epidemics.”

Barriers to HIV interventions include stigma and legal challenges, with laws against sex work in 21 of the countries in the region, and against possession of drugs in 9. There are laws prohibiting same-sex sexual acts in 19 countries, including the death penalty in 7.

These barriers contribute to reluctance to allocate resources to HIV programming for these populations. In 2020, dedicated funding for HIV programming was less than 20% of what is needed to reach targets, the study authors noted.

Sociopolitical and economic crises, including armed conflicts, forced displacements, and the COVID-19 pandemic also have affected HIV incidence, prevention, and treatment.

Only 17% of people who inject drugs, 42% of men who have sex with men, and 12% of female sex workers reported testing for HIV in the past 12 months. The review also estimated that only 43% of those with HIV in the region receive antiretroviral therapy and 37% reached viral suppression.

“Because the HIV epidemics we documented among key population are mostly nascent, there is a window of opportunity for countries to contain the growing epidemics and to control HIV transmission in high-risk sexual and injecting networks while still in relatively limited circulation,” Mumtaz said.

She highlighted three areas of focus:

1. A need for expanding surveillance to monitor HIV prevalence trends and to detect epidemics at their nascence.
2. A strong rationale for expanding the coverage of HIV combination prevention and treatment services among key populations, through adequate allocation of resources, providing enabling environments for key populations and abolishing legal barriers that impede access and delivery of services, and empowering non-governmental organizations to deliver a wide array of outreach programs.
3. An opportunity to integrate in HIV control programs some of the tools that were implemented during the COVID-19 pandemic to mitigate the resulting disruptions and that have proved successful such as telehealth, HIV self-testing, and multi-month drug dispensing.