54889 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa TIME FOR STRATEGIC ACTION Laith J. Abu-Raddad, Francisca Ayodeji Akala, Iris Semini, Gabriele Riedner, David Wilson, and Ousama Tawil Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa TIME FOR STRATEGIC ACTION Laith J. Abu-Raddad, Francisca Ayodeji Akala, Iris Semini, Gabriele Riedner, David Wilson, and Ousama Tawil 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 All rights reserved 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. 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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 1 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Why and How?................................. 1 Background and Rationale for This Report ............................................................................................... 1 Conceptual Framework and Research Methodology ................................................................................ 3 Bibliography ............................................................................................................................................... 8 Chapter 2 Injecting Drug Users and HIV ..............................................................11 HIV Prevalence among IDUs .................................................................................................................... 11 Hepatitis C Prevalence as a Proxy Marker of Risky Behavior among IDUs ........................................... 13 Prevalence of Drug Injection ................................................................................................................... 13 Female Injecting Drug Users ................................................................................................................... 16 Injecting Drug Users and Risky Behavior ................................................................................................ 16 Knowledge of HIV/AIDS ......................................................................................................................... 21 Bibliography ............................................................................................................................................. 25 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 Chapter 4 Commercial Sex and HIV .......................................................................43 HIV Prevalence among FSWs .................................................................................................................. 43 Context of Commercial Sex in MENA ..................................................................................................... 43 Forms of Commercial Sex ........................................................................................................................ 46 Prevalence of Commercial Sex ................................................................................................................ 47 Commercial Sex and Risk Behavior......................................................................................................... 48 Knowledge of HIV/AIDS .......................................................................................................................... 53 Analytical Summary ................................................................................................................................. 53 Bibliography ............................................................................................................................................. 54 v Chapter 5 Potential Bridging Populations and HIV .................................59 Context of Bridging Populations in MENA........................................................................................ 59 HIV Prevalence in Potential Bridging Populations ........................................................................... 59 Potential Bridging Populations and Risk Behavior............................................................................ 60 Vulnerability of Sexual Partners of Priority Populations .................................................................. 61 Analytical Summary ........................................................................................................................... 62 Bibliography ....................................................................................................................................... 62 Chapter 6 General Population and HIV ...........................................................65 HIV Prevalence in the General Population ........................................................................................ 65 General Population and Risk Behavior .............................................................................................. 69 Male Circumcision ............................................................................................................................. 73 Analytical Summary ........................................................................................................................... 74 Bibliography ....................................................................................................................................... 75 Chapter 7 Further Evidence Related to HIV Epidemiology in MENA......................................................................81 HIV and Sexually Transmitted Disease Clinic Attendees, Voluntary Counseling and Testing Attendees, and Suspected AIDS Patients .................................................................... 81 HIV/AIDS among Tuberculosis Patients............................................................................................ 82 Further Point-Prevalence Surveys...................................................................................................... 82 HIV-Positive Results Extracted from HIV/AIDS Case Notification Surveillance Reports ............... 82 Distribution by Sex of Reported HIV Cases ..................................................................................... 84 Transmission Modes ........................................................................................................................ 85 Pattern of Exogenous HIV Exposures in MENA ............................................................................... 85 Parenteral HIV Transmissions Other Than Injecting Drug Use ....................................................... 88 HIV Molecular Epidemiology ............................................................................................................ 92 Bibliography ...................................................................................................................................... 94 Chapter 8 Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes ..................................... 101 Knowledge of Condom as a Prevention Method and Its Use ....................................................... 101 HIV/AIDS Knowledge and Attitudes .............................................................................................. 109 Bibliography .................................................................................................................................... 113 Chapter 9 HIV/AIDS and Vulnerability Settings..................................... 119 Prisoners and HIV............................................................................................................................. 119 Youth and HIV .................................................................................................................................. 126 Population Mobility and HIV............................................................................................................ 133 Street Children ................................................................................................................................. 138 Vulnerability Settings: Analytical Summary ................................................................................... 139 Bibliography ..................................................................................................................................... 141 Chapter 10 Proxy Biological Markers of Sexual Risk Behavior ........ 151 HSV-2 as a Marker of Sexual Risk Behavior .................................................................................. 152 HPV and Cervical Cancer Levels as Markers of Sexual Risk Behavior .......................................... 156 Bacterial STIs as Markers of Sexual Risk Behavior ....................................................................... 162 Unsafe Abortions as Markers of Sexual Risk Behavior ................................................................. 169 Biological Evidence on Proxy Measures of Sexual Risk Behaviors: Analytical Summary ............ 169 Bibliography ..................................................................................................................................... 170 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 Chapter 12 Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic .......................................................... 199 HIV Prevention in MENA ....................................................................................................................... 199 Focused HIV Prevention Programs for People Exposed to Risk............................................................ 200 Access to Means of Prevention ............................................................................................................ 203 HIV Testing and Counseling .................................................................................................................. 204 Expanding Coverage .............................................................................................................................. 205 Civil Society and People Living with HIV as Implementation Partners................................................ 205 Blood Safety and Universal Precautions ............................................................................................... 207 HIV Care and Treatment ........................................................................................................................ 207 HIV Mother-to-Child Transmission ........................................................................................................ 209 Prevention and Control of STIs: Current Response and Challenges .................................................... 209 Concluding Remarks and Summary of Findings.................................................................................... 210 Bibliography ........................................................................................................................................... 210 Chapter 13 Summary of Recommendations...................................................... 213 Recommendation 1: Increase and Expand Baseline and Continued Surveillance ............................. 213 Recommendation 2: Expand Scientific Research and Formulate Evidence-Informed Policies ........... 214 Recommendation 3: Focus on Risk and Vulnerability, Not on Law Enforcement .............................. 215 Recommendation 4: Strengthen Civil Society Contributions to HIV Efforts ....................................... 215 Recommendation 5: An Opportunity for Prevention ............................................................................. 216 Bibliography ........................................................................................................................................... 218 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, 1992­2006...................................................169 10.6 Estimated Annual Incidence of Unsafe Abortions per 1,000 Women Aged 15­44 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, 2006­08 .......................................... 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 xiv Executive Summary populations. Levels of HIV prevalence among MSM report high levels of sexual risk behav- populations where the infection is already ior, such as multiple sexual partnerships of dif- established are comparable to those observed in ferent kinds, low condom use, and high preva- other regions. lence of sex work. MSM risk behaviors overlap Levels of risk behavior practices, such as considerably with heterosexual sex and inject- using nonsterile injecting equipment, are gen- ing drug risk behaviors. Prevalence levels of erally high, confirming the potential for fur- sexually transmitted infections (STIs) other than ther HIV spread among IDUs. Levels of hepati- HIV are substantial, suggesting epidemic poten- tis C virus (HCV), a marker of using nonsterile tial for HIV. Levels of comprehensive HIV injecting equipment, are in the intermediate to knowledge among MSM vary across the region high range, also confirming the potential for with, both high and low levels being reported in further HIV spread. IDUs are sexually active different settings. and report high levels of sexual risk behavior, The MSM risk context suggests the possibility indicating substantial overlap of risks among of concentrated HIV epidemics among MSM in the three priority groups of IDUs, MSM, and MENA over the next decade. Indeed, MENA FSWs. Levels of comprehensive HIV knowl- may already be in a stage of concentrated HIV edge among IDUs vary across the region, with epidemics among MSM in several countries, but both high and low levels being reported in dif- definitive and conclusive data are lacking to ferent settings. support this possibility. The IDU risk context suggests the possibility There is urgent need for HIV surveillance to of further concentrated HIV epidemics among better understand the transmission dynamics IDUs in MENA over the next decade. The low or among MSM so that this information can be nil HIV prevalence in a number of IDU popula- used to plan and implement more effective pre- tions appears to reflect lack of HIV introduction vention and care services for this population into these populations, or that is has only group in MENA. Expansion of prevention and recently been introduced, or the nature inject- treatment efforts for MSM, such as condom dis- ing network structure among the IDUs. tribution, counseling, HIV testing, HIV and STI There is an urgent need for HIV surveillance treatment, and social and medical services, is to better understand transmission dynamics, key to preventing considerable HIV epidemics risk behavior practices, and population esti- among MSM. mates so that this information can be used to plan and implement more effective prevention Commercial sex networks and care services for IDUs. There is an opportu- Commercial sex is prevalent all over MENA, nity to prevent IDU epidemics in MENA through although levels are rather low in comparison to needle exchange programs, access to frequent other regions. Economic pressure, family dis- testing, prevention of heroin uptake, safe sex ruption or dysfunction, and political conflicts messages, and condom distribution. are major pressures for commercial sex in this region. Roughly 0.1% to 1% of women appear Men who have sex with men to exchange sex for money or other commodi- MSM are the most hidden and stigmatized risk ties, and a few percentage points of men report group of all HIV risk groups in MENA. sexual contacts with FSWs. Accordingly, com- Nevertheless, homosexuality is prevalent at lev- mercial sex networks are the largest of the three els comparable to those in other regions, with a priority group networks in MENA. few percentage points of the male population HIV prevalence continues to be at low levels engaging in homosexual contacts. among FSWs in most countries, although at lev- HIV is spreading among MSM, with appar- els much higher than those in the general popu- ently a rapidly rising epidemic in at least one lation. HIV spread does not appear to be well country (Pakistan). HIV prevalence among established in many commercial sex networks in MSM is already at considerable levels in several the region. In three countries, however, namely other countries, but data are still too limited to Djibouti, Somalia, and Sudan, HIV prevalence confirm the trend. among some FSW groups has reached high 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 xvi Executive Summary low levels in MENA compared to other regions. miology in MENA as a whole. The recommen- These proxy measures of sexual risk behavior dations are based on identifying the status of the imply low levels of risk behavior in the general HIV epidemic in MENA, through this synthesis, population and further indicate limited potential as a low HIV prevalence setting with rising for a sustainable HIV epidemic in this part of the concentrated epidemics among priority population. populations. General directions for prevention Male circumcision is almost universal in interventions as warranted by the outcome of MENA and is associated with a strong biological this synthesis are also discussed briefly, but are efficacy against HIV infection. This further indi- not delineated because they are beyond the cates limited potential for a sustainable HIV scope of this report. This report was not intend- epidemic in the general population. ed to provide intervention recommendations for In the other regions around the world, there each MENA country. is no evidence for a sustainable general popula- tion HIV epidemic apart from parts of sub- Recommendation 1: Increase and expand Saharan Africa. It is inconceivable that the baseline and continued surveillance MENA region will be the exception to this pat- tern after consistently very low HIV prevalence The analytical insights drawn here from a syn- in the general population for over two decades thesis of thousands of studies and data sources since the virus' introduction into MENA in the indicate that there is no escape from the neces- 1980s. Considering all the evidence reviewed sity of developing robust surveillance systems to for this report, it is unlikely that the HIV epi- monitor HIV spread among priority popula- demic in MENA will take a course similar to that tions. Inadequate and limited HIV epidemio- in sub-Saharan Africa if the existing social and logical and methodological surveillance contin- epidemiological context in the region remains ue to be one of the most pervasive problems in largely the same. At most, the region may face this region. Effective and repeated surveillance up to a few percentage points prevalence in the of IDUs, MSM, and FSWs is key in MENA coun- population of several of its countries. Still, this tries to definitively conclude whether HIV would be an immense disease burden and spread is indeed limited in priority populations, subsequent economic burden in a region and to detect epidemics among these groups at that is mostly unprepared for such an an early stage. epidemic. Surveillance work should include the mapping A major unknown in the understanding of of risk and vulnerability factors, risk behavior the HIV epidemiology in the general population measures, population size estimations, and, in MENA is that of the levels of recent increases, importantly, measurements of HIV prevalence and future trends, in risk behaviors, particularly and risk biomarkers, such as STI and HCV preva- among youth. If the increases in risk behavior lence levels. This would offer a window of oppor- are substantial, this could put some aspects of tunity to target prevention at an early phase of an the analytical view of the dynamics in question. epidemic. Monitoring recent infections and The trajectory of the HIV epidemic may be dif- examining the nature of exposures could also be ferent and possibly result in substantial HIV useful in detecting emerging endemic transmis- epidemics in MENA populations. Studying the sion chains within MENA populations. levels of risk behaviors and STI incidence among An approach of integrated biobehavioral sur- youth should be a priority for scientific research veillance surveys (IBBSS) among representative in MENA. priority populations should be the main compo- nent of surveillance efforts, rather than reliance on facility-based surveillance using convenient population samples that are not capturing the RECOMMENDATIONS dynamics of HIV transmission in MENA. The recommendations provided here focus on Resources should not be wasted on surveillance key strategies related to the scope of this report among low-risk populations while overlooking and its emphasis on understanding HIV epide- HIV spread in priority populations. Executive Summary xvii Recommendation 2: Expand scientific research tion of existing contours of risk and vulnerabil- and formulate evidence-informed policies ity in the societies in which it is spreading. HIV cannot be addressed fundamentally except by The data synthesis in this report highlights the addressing the underlying causes of these risks large gap in methodological scientific research in and vulnerabilities. HIV spread is not a question relation to HIV and other STI epidemiology in of law enforcement to prevent risky behavior. MENA. The limited human and financial resourc- Repressive measures will only complicate pre- es are key challenges in most countries, and these vention efforts and push risky behavior further constraints are preventing the region from formu- underground, making it even more difficult to lating effective and evidence- informed policies. reach these groups with programs. This would The first research priority should be to con- not change the vulnerability settings but would duct repeated, multicenter IBBSS studies on deprive MENA governments and their partners priority groups to monitor trends, combining from the ability to prevent the epidemic and HIV sero-surveillance with STI, HCV, and risk administer prevention interventions as needed. behavior surveillance. These studies also need to The "security" approach to HIV policy has explore the network structures among these risk already led to documented failures in control- groups, including both sexual and injecting drug ling HIV spread in MENA countries. networks. Policies, programs, and resources continue to The second priority is research on mapping be diverted from where they are needed. The and size estimation of hard-to-reach priority mandatory testing of many population groups at populations, which are essential for the quantita- low risk of HIV infection, such as the general tive assessments of HIV epidemiology and trends, population, which is the practice in the region, and would help in planning sufficient and more is disconnected from the epidemiological reality effective prevention strategies and programs. of HIV infection in the region. Some of this test- The third priority is to conduct multicenter ing may also violate basic human rights and is cohort or cross-sectional studies among vulner- likely not effective from a public health perspec- able populations, such as the youth, to assess tive. Efforts need to be prioritized to the con- trends of HIV and other STI incidence, other tours of risk and vulnerability and focus on pri- infectious disease incidence such as HCV, sexual ority groups. Recognizing the settings of risks, and injecting drug use risk behaviors, and driv- and implementing effective, evidence- informed ers of risky behavior. With the high rates of interventions, is the only available path for con- population mobility in MENA, it is also a prior- trolling HIV spread in MENA. ity to assess levels of risk behavior and infection among migrants because data on this population remain limited, although the socioeconomic Recommendation 4: Strengthen civil society context of migration in this region may predis- contributions to HIV efforts pose this population to risky behavior practices. A structural weakness of the HIV response in The fourth priority is to conduct mathematical MENA is the meager contribution of nongovern- modeling and cost-effectiveness studies to explore mental organizations (NGOs), community orga- the full range of the complex HIV dynamics and nizations, and people living with HIV (PLHIV) predict intervention impacts in MENA. These groups in the formulation, planning, and imple- studies would build inferences and suggest policy mentation of the response. Strengthening civil recommendations by using the individual and society contributions to HIV efforts is essential population level data that will become increas- given the epidemiological reality of HIV transmis- ingly available over the next few years from sur- sion being concentrated among largely hidden veillance studies on priority populations. and stigmatized priority populations, as docu- mented by this synthesis. Recommendation 3: Focus on risk and There is no escaping the fact that grassroots vulnerability, not on law enforcement NGOs need to be developed within the MENA The HIV transmission patterns delineated in this region to support the HIV response. NGOs may report show that HIV spread is merely a reflec- be able to help governments deal with priority xviii Executive Summary groups indirectly, thereby avoiding cultural sen- practices, the priority in the public health sitivities in explicit outreach efforts for stigma- sector should be on addressing the direct fac- tized populations. Discreet interventions for HIV tors that put individuals at risk of HIV expo- prevention have already proven effective in a sure. Since almost all infections occur when an number of MENA countries. infected individual shares body fluids with an uninfected individual, prevention programs must focus on addressing the situations in Recommendation 5: An opportunity for prevention which this is happening. Careful analysis of There is still an open window of opportunity for transmission patterns must be conducted to MENA to control the HIV epidemic. HIV pro- inform policy decisions. grams involving the general population should Beyond doubt, harm reduction should be at stress stigma reduction, while prevention efforts the core of intervention policy, although tar- should be focused on priority populations that geted prevention should go further than harm are at increased risk of HIV infection. Interventions reduction. The concept of harm reduction need to capitalize on the strengths represented should be applied not only to IDUs, but should by cultural traditions, as well as be culturally also be considered for MSM and FSWs. Harm sensitive, while fostering effective responses to reduction is the most direct and effective strat- the epidemic. Access to testing, care, and treat- egy to stem the tide of HIV, considering that ment services must be expanded substantially. addressing the root causes of risks and vulnera- To impede future HIV transmission, it is impera- bilities might be a much more challenging task. tive to remove all barriers to HIV testing and The Islamic Republic of Iran has already paved diagnosis, particularly among priority groups. the way by showing how harm reduction can be There is a need to invest in a comprehensive implemented within the cultural fabric of MENA analysis of the current gaps in the HIV response and in consonance with religious values. as well as the promising opportunities. This can be accomplished by combining transmission mode analysis in each country with the map- BIBLIOGRAPHY ping of current interventions, including a tax- onomy of prevention. Bohannon, J. 2005. "Science in Libya: From Pariah to Science Powerhouse?" Science 308: 182­84. Although countries need to address the structural factors that drive risky behavior Executive Summary xix Key Definitions and Abbreviations KEY DEFINITIONS Priority populations Bridging populations Priority populations are populations that expe- rience the highest probability of being exposed Bridging populations are populations at interme- to HIV infection. Priority populations include diate risk of exposure to HIV and provide links IDUs, MSM (including MSWs), and FSWs. between the high-risk priority populations and the low-risk general population. Conventionally, Vulnerable populations bridging populations include groups such as truck drivers, military personnel, sailors, and Vulnerable populations form a subset of the sexual partners of IDUs, FSWs, and MSM. general population and generally are at low risk of HIV exposure but are vulnerable to practices General population that may put them at a higher risk of HIV infec- tion. Vulnerable populations include prisoners, The general population is the part of the popula- youth, and mobile populations. Once these vul- tion that is at relatively low risk of HIV exposure nerable populations adopt higher-risk practices, and encompasses most of the population in any they become part of the priority or bridging community. It is strictly defined here as the total populations. population not belonging to priority or bridging populations. 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 xxii Key Definitions and Abbreviations Chapter 1 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Why and How? 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 (24,000­46,000) 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 (250,000­380,000).3 It is also estimated that in the Middle East and North Africa: The Cost of 20,000 (15,000­25,000) 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 15­24 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 core and bridging populations, as is the case in Asia.30 HIV infection Transmission could not then be endemic in the general population and would die out if all sexual contacts with core and bridging populations are pro- tected or stopped. Figure 1.3 shows Infectious a schematic diagram contrasting a general population HIV epidemic Susceptible versus a concentrated HIV epidemic (a) in the core populations. As shown below in our discus- sion of HIV spread in the different T(0) T(1) T(2) risk groups in MENA, the role of the general population in the HIV epidemics in MENA is very limited. R 0 = 0.5 HIV dynamics are mostly concen- trated in the core populations of IDUs, MSM, and FSWs; therefore, Transmission these core populations are labeled in this report as priority populations to signify that these are the groups where curtailing HIV spread to below sustainability (R0 1) would Infectious control the HIV epidemic in the whole population. Priority popula- Susceptible tions are the key populations for (b) focusing HIV prevention efforts. The conceptual framework delin- Source: Reproduced with permission from Dr. Ruanne Barnabas, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA. eated above will be adapted to help understand the dynamics of HIV Note: If R0 1, the infection's transmission chains in the population are sustainable and the infection would spread. If R0 1, the infection's transmission chains are not sustainable and the infection does not have infectious spread in MENA and the the "critical mass" to spread in the population. T(i) denotes the generation number of infection transmission. prospects for HIV infection expan- sion in different populations. The priority (core), bridging, and general populations and the degree of HIV penetration in the popula- will be defined within the context of MENA and tions where it is self-sustainable. the levels of risk will be delineated by the syn- One of the challenges of behavioral research thesis approach. This assessment will help facili- in MENA is desirability bias.31 Although such tate a qualitative determination of the epidemic bias is documented in all regions for both sexual potential for each risk group and the potential behavior32 and injecting drug use,33 the higher for sustainable transmission in the general popu- lation. The synthesis also facilitates a determina- 31 Lee and Renzetti, "The Problems of Researching Sensitive Topics." 32 tion of the phases of the HIV epidemics in MENA Lee and Renzetti, "The Problems of Researching Sensitive Topics"; Caldwell and Quiggin, "The Social Context of AIDS"; Wadsworth et al., "Methodology of the National Survey." 30 33 Commission on AIDS in Asia, Redefining AIDS in Asia. Latkin and Vlahov, "Socially Desirable Response Tendency." 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: 91­104. 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: 1603­6. 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: 643­56. 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: 182­84. 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: 255­65. Vermund. 1997. "HIV/AIDS and Its Risk Factors in Brunham, R. C., and F. A. Plummer. 1990. "A General Pakistan." AIDS 11: 843­48. 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: 1339­52. Self-Reported HIV Serostatus for HIV Seropositive Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Injection Drug Users." Addiction 93: 1191­97. 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: 510­28. Groups in Port Sudan, Sudan." East Afr Med J 67: Lenton, C. 1997. "Will Egypt Escape the AIDS Epidemic?" 650­55. 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 2001­16. of AIDS in Sub-Saharan Africa." Population and Mohammad, K., F. K. Farahani, M. R. Mohammadi, S. Development Review 15: 185­234. 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 15­18 Years in AIDS 5 Suppl 1: S65­74. Tehran." J Adolesc Health 41: 407­14. 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: 851­54. 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: S3­11. Lower among Muslims?" Soc Sci Med 58: 1751­56. 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: 657­66. 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: 519­30. 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: 315­21. 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: 407­21. 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: 42­48. 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: 1403­9. Perform Qual Health Care 6: 79­83. 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: 369­72. Tertiary Care Hospital in Pakistan." J Pak Med Assoc 58: Yorke, J. A., H. W. Hethcote, and A. Nold. 1978. 57­60. "Dynamics and Control of the Transmission of Gonorrhea." Sex Transm Dis 5: 51­56. 10 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Chapter 2 Injecting Drug Users and HIV 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 Country Surveys' results for HIV prevalence among IDUs Afghanistan 0.0% (World Bank 2008) 3.0% (Todd et al. 2007; Sanders-Buell et al. 2007) 3.4% (Mathers et al. 2008) Algeria 11.0% (self-reported; Mimouni and Remaoun 2006; Algeria MOH [unknown]) Bahrain 0.0%­2.3% (Aceijas et al. 2004) 21.1% (Al-Haddad et al. 1994) 0.3% (Mathers et al. 2008) Egypt, Arab Republic of 0.15% (drug addicts; Watts et al. 1993) 0.0% (El-Ghazzawi, Hunsmann, and Schneider 1987) 0.0% (Baqi et al. 1998) 0.0% (Aceijas et al. 2004) 0.0% (Saleh et al. 2000; El-Ghazzawi et al. 1995) 0.6% (Egypt MOH and Population National AIDS Program 2006) 2.55% (Mathers et al. 2008) Iran, Islamic Republic of 1.2% (Khani and Vakili 2003) 4.0% (Ministry of Health and Medical Education of Iran 2004) 0.9% (injecting and noninjecting drug users; Alizadeh et al. 2005) 7.0% (incarcerated IDUs; Rahbar, Rooholamini, and Khoshnood 2004) 0.0% (treatment center; Rahbar, Rooholamini, and Khoshnood 2004) 63.0% (up to, in prisons; UNAIDS and WHO 2003) 30.0% (local prison; Nassirimanesh 2002) 6.9% (incarcerated IDUs; Rahbar, Rooholamini, and Khoshnood 2004) 22.0% (newly admitted IDUs to prison; Farhoudi et al. 2003) 24.0% (resident incarcerated IDUs in prison; Farhoudi et al. 2003) 24.4% (incarcerated IDUs; Jahani et al. 2009) 0.8% (Khani and Vakili 2003) 15.2% (Zamani et al. 2005) 23.2% (Zamani et al. 2006) 5.4% (noninjecting drug users; Zamani et al. 2005) 72.0% (a rural population of highly selected IDUs; Mojtahedzadeh et al. 2008) 1.4% (mainly noninjecting drug users; Talaie et al. 2007) 15.0% (Mathers et al. 2008) Iraq 0.0% (prior to occupation; Aceijas et al. 2004) Jordan 4.2% (Aceijas et al. 2004) Kuwait 0.0% (Aceijas et al. 2004) Lebanon 7.8% (Aceijas et al. 2004) 0.0% (Mishwar 2008) Libya 0.5% (UNAIDS 2002b) 59.4% (Groterah 2002) 49.0% (up to; UNAIDS and WHO 2003) 22.0% (Mathers et al. 2008) Oman 5.0% (Aceijas et al. 2004; Tawilah and Tawil 2001) 12.0% (IDUs under treatment; Oman MOH 2006) 18.0% (IDUs outside of prison and not under treatment; Oman MOH 2006) 27.0% (incarcerated IDUs; Oman MOH 2006) 11.8% (Mathers et al. 2008) Morocco 6.5% (self-reported; Mathers et al. 2008) 1.6% (Alami 2009) 0.0% (Morocco MOH 2007) Pakistan 0.0% (Iqbal and Rehan 1996) 0.0% (Kuo et al. 2006) 0.0% (Khawaja et al. 1997) 0.63% (Altaf et al. 2004) 12 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 2.1 (Continued) Country Surveys' results for HIV prevalence among IDUs 1.77% (Khawaja et al. 1997) 0.4% (Parviz et al. 2006) 9.7% (Shah et al. 2004) 9.3% (Sindh AIDS Control Program 2004; Ur Rehman, Emmanuel, and Akhtar 2007) 26.3% (Pakistan National AIDS Control Program 2005b) 24.0% (Achakzai, Kassi, and Kasi 2007) 0.5% (Bokhari et al. 2007) 23.1% (UNAIDS and WHO 2005; Rai et al. 2007; Bokhari et al. 2007) 10.8% (average of different cities with a range of 0.3%­25.4%; Pakistan National AIDS Control Program 2005a) 15.8% (average of different cities with a range of 0%­51.8%; Pakistan National AIDS Control Program (2006­07) 20.8% (average of different cities with a range of 12.3%­28.5%; Pakistan National AIDS Control Program 2008) 2.6% (Platt et al. 2009) 0.0% (Platt et al. 2009) 10.8% (Mathers et al. 2008) Saudi Arabia 0.15% (Njoh and Zimmo 1997b) 0.14% (Mathers et al. 2008) Sudan 0.0% (Mathers et al. 2008) Syrian Arab Republic 0.3% (Aceijas et al. 2004) 0.5% (51% of sample are IDUs; Syria Mental Health Directorate 2008) Tunisia 0.3% (Aceijas et al. 2004; Mathers et al. 2008) Turkey 2.65% (Mathers et al. 2008) HEPATITIS C PREVALENCE AS A PROXY mediate to high range compared to those MARKER OF RISKY BEHAVIOR AMONG reported in other regions.20 This confirms the IDUS potential for HIV to spread if HIV enters IDU networks and suggests that the use of nonsterile HIV is only one of several blood-borne infections injecting equipment is a common practice. that can be transmitted through IDU. Hepatitis C Recent and rapidly growing HIV epidemics doc- virus (HCV) is a classical infection transmitted pre- umented among IDUs in Pakistan,21 following dominantly through percutaneous exposures and many years of low HIV prevalence,22 validate therefore can be used as a proxy of risky drug- this conjecture. It bears notice that there is low injecting practices. IDUs form the leading risk awareness of HCV infection in MENA despite its group for HCV infection.18 HCV, however, is about seriousness. Only 20% of IDUs in Pakistan were six times as infectious as HIV through the paren- aware of the existence of HCV, but 85% knew teral route.19 Substantial presence of HCV infec- of the existence of HIV.23 tion in an IDU population does not necessarily imply that HIV is destined to have substantial prevalence in this population. Nevertheless, a high PREVALENCE OF DRUG INJECTION HCV prevalence in an IDU population suggests the potential for HIV transmission along the same The prevalence of IDU in MENA, at 0.2% of the route that HCV has traveled because both infec- population, is in the intermediate range compared tions share the same transmission mode. Table 2.2 describes the results of the available 20 Sy and Jamal, "Epidemiology of Hepatitis C Virus (HCV) Infection." 21 HCV point-prevalence surveys of IDUs in MENA. Shah et al., "An Outbreak of HIV Infection"; UNAIDS and WHO, AIDS Epidemic Update 2005; Rai et al., "HIV/AIDS in Pakistan"; Bokhari et al., HCV prevalence levels are generally in the inter- "HIV Risk in Karachi and Lahore, Pakistan." 22 Baqi et al., "HIV Antibody Seroprevalence"; Altaf et al., "Harm Reduction"; Parviz et al., "Background Demographics and Risk 18 Ray Kim, "Global Epidemiology." Behaviors"; UNODCP, "Baseline Study"; Agha et al., "Socio-Economic 19 Goldmann, "Blood-Borne Pathogens and Nosocomial Infections"; and Demographic Factors." 23 Gerberding, "Management of Occupational Exposures." Kuo et al., "High HCV Seroprevalence." Injecting Drug Users and HIV 13 Table 2.2 HCV Prevalence among IDUs in MENA Country Survey results for HCV prevalence among IDUs Afghanistan 36.6% (Todd et al. 2007) Egypt, Arab Republic of 63.0% (Saleh et al. 2000; El-Ghazzawi et al. 1995) Iran, Islamic Republic of 30.0% (injecting and noninjecting drug users; Alizadeh et al. 2005) 60.0% (Rahbar, Rooholamini, and Khoshnood 2004) 52.0% (Zamani et al. 2007) 59.4% (incarcerated IDUs; Rahbar, Rooholamini, and Khoshnood 2004) 78.0% (local prison; Nassirimanesh 2002) 47.4% (Khani and Vakili 2003) 45.3% (Zali et al. 2001) 11.2% (Imani et al. 2008) 14.48% (mainly noninjecting drug users; Talaie et al. 2007) 25.4% (Altaf et al. 2009) 19.2% (Altaf et al. 2009) Lebanon < 20.0% (Aceijas and Rhodes 2007) 25.0% (HIV infected; Ramia et al. 2004) 49.0% (Mishwar 2008) 80.0% (incarcerated IDUs; Kheirandish et al. 2009) 7.35% (injecting and noninjecting drug users; Mohammad et al. 2003) Oman 11%­53% (Oman MOH 2006) Pakistan 88.0% (Kuo et al. 2006) 89.0% (UNODCP and UNAIDS 1999) 60.0% (Achakzai, Kassi, and Kasi 2007) 87.0% (Pakistan National AIDS Control Program 2005c) 91.0% (Pakistan National AIDS Control Program 2005c) 17.3% (Platt et al. 2009) 8.0% (Platt et al. 2009) Saudi Arabia 69.0% (Iqbal 2000) 75.0% (Njoh and Zimmo 1997a) Syrian Arab Republic 60.5% (Othman and Monem 2002) 21.0% (self-reported; 51% of sample are IDUs; Syria Mental Health Directorate 2008) Tunisia 39.7% (HIV infected; Kilani et al. 2007) 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 IDU estimates IDU prevalence (%) Country Low Middle High Low Middle High Afghanistan 22,720 34,080 45,440 0.16 0.24 0.32 6,870 6,900 6,930 0.05 0.05 0.05 Algeria 26,333 40,961 55,590 0.14 0.22 0.29 Bahrain 337 674 1,011 0.08 0.16 0.24 Egypt, Arab Republic of 56,970 88,618 120,265 0.13 0.21 0.28 Iran, Islamic Republic of 70,000 185,000 300,000 0.17 0.46 0.74 180,000 0.4 Iraq 23,115 34,673 46,230 0.19 0.28 0.37 Jordan 3,200 4,850 6,500 0.11 0.16 0.22 Kuwait 2,700 4,100 5,500 0.2 0.3 0.41 Lebanon 2,200 3,300 4,400 0.09 0.14 0.19 Libya 4,633 7,206 9,779 0.15 0.23 0.32 1,685 0.05 Morocco 18,500 0.1 Oman 2,800 4,250 5,700 0.2 0.3 0.4 Pakistan 54,000 462,000 870,000 0.07 0.5 1.12 0.13 0.14 0.16 Qatar 780 1,190 1,600 0.15 0.22 0.3 Saudi Arabia 15,172 23,600 32,028 0.13 0.2 0.27 Sudan 24,319 37,828 51,337 0.13 0.2 0.28 Syrian Arab Republic 4,000 6,000 8,000 0.04 0.07 0.09 Tunisia 8,462 13,163 17,864 0.14 0.21 0.29 Turkey 66,591 99,887 133,182 0.16 0.23 0.31 United Arab Emirates 3,200 4,800 6,400 0.2 0.3 0.4 Yemen, Republic of 12,710 19,770 26,830 0.15 0.23 0.31 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 2000­01, 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. Injecting Drug Users and HIV 15 that 6% of respondents reported that they had Afghanistan, the epicenter of opiate production, ever used drugs.50 Prevalence of drug use in the has very limited resources to deal with the IDU West Bank and Gaza was estimated at 0.86%­ problem among its population.60 1.21%, with a total of 35,000­45,000 drug users51 (including 900­1,400 heroin users52). MENA is flooded with inexpensive drugs due FEMALE INJECTING DRUG USERS to record levels of heroin production in Afghanistan.53 Around 92% of the world's sup- The hardest-to-reach population of IDUs in MENA ply of heroin in 2006 came from Afghanistan,54 is that of the female IDUs; therefore, knowledge of where it is estimated that 2.9% of all arable land this risk group is limited.61 There is a prevailing is devoted to opium cultivation.55 According to perception that the IDU problem in MENA is the United Nations Office on Drugs and Crime heavily concentrated among men. A study in the (UNODC),56 the area under illicit opium poppy Islamic Republic of Iran among nursing students cultivation worldwide increased by 33% in found that males were much more likely to use 2006, mainly due to the 59% increase in drugs than females.62 A study mapping IDU in Afghanistan. Afghan opium is increasingly being Pakistan found that only 0.2% of IDUs were processed into morphine and heroin before females.63 However, there is also evidence suggest- exportation. In 2006, 53% of the opiates that ing a considerable injection drug problem among left Afghanistan went via the Islamic Republic of women. Although all IDUs in one study in Oman Iran, and 33% left via Pakistan. These are the were males, 25%­58% of them knew of at least main routes for drug trafficking in the region. one female IDU.64 Similarly in the Syrian Arab In 2006, 67% of opiate seizures worldwide Republic, 48% of IDUs were familiar with at least occurred in the countries neighboring one female IDU.65 In the 1999 rapid situation Afghanistan. Almost 30% of the global seizures assessment (RSA) in the Islamic Republic of Iran, occurred in the Islamic Republic of Iran alone, 6.6% of drug users were women.66 Another RSA compared to 1.8% in the United Kingdom and of prisoners estimated that 10%­50% of female 1.4% in the United States. MENA is a drug- inmates had a history of drug use.67 The number trafficking destination as well as a route for drug of female IDUs in the Islamic Republic of Iran has traffic to Africa, Europe, and North America. been estimated at 14,000.68 There is a perception The countries surrounding Afghanistan, such that drug dependence among Iranian women has as the Islamic Republic of Iran and Pakistan, are been increasing in recent years.69 Lastly, in a study experiencing increases in heroin usage with the of IDUs in Morocco, 16% were females.70 increased supply. IDU and HIV are known to follow drug-trafficking routes.57 Opiate con- sumption is rising in MENA, though it is stable INJECTING DRUG USERS AND RISKY or declining in most other regions including BEHAVIOR North America, Western Europe, Oceania, and East and Southeast Asia.58 Increases in drug use This section examines risky behaviors and prac- have been cited in the West Bank and Gaza tices in relation to HIV among IDUs, including since 1994, despite its severe isolation.59 the use of nonsterile injecting equipment, 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. Injecting Drug Users and HIV 17 Table 2.4 Levels of Nonsterile Needle or Syringe Use among IDUs in Several MENA Countries Country Survey results for use of nonsterile needles or syringes Afghanistan 50.0% (UNAIDS 2008) 50.4% (Todd et al. 2007) 46.0% (World Bank 2008) Algeria 41.0% (Mimouni and Remaoun 2006) Egypt, Arab Republic of 32.2% (Egypt MOH and Population National AIDS Program 2006) 11.0% (Salama et al. 1998) 59.0% (UNAIDS 2008) 55.0% (Elshimi, Warner-Smith, and Aon 2004) Iran, Islamic Republic of 67.0% (Day et al. 2006) 49.8% (Razzaghi, Rahimi, and Hosseini 1999) 24.8% (Razzaghi, Rahimi, and Hosseini 1999) 48.3% (Zamani et al. 2006) 11.0% (Zamani et al. 2006) 30.6% (Zamani et al. 2005) 30%­100% (Razzaghi et al. 2006) 21.0% (Zamani et al. 2008) 39.9% (Zamani et al. 2008) 35.2%­48.6% (Farhoudi et al. 2003) 73.0% (Mojtahedzadeh et al. 2008) 26.6% (Kheirandish et al. 2009) Lebanon 33.0% (Ingold 1994) 42.0% (Aaraj [unknown]) 40.0% (Jenkins and Robalino 2003) 64.7% (Hermez [unknown]) (Aaraj [unknown]) 34.2% (Mishwar 2008) 17.0% (Mishwar 2008) 34.2% (Mishwar 2008) Libya 44.0% (UNAIDS 2008) Morocco 47.0% (UNAIDS 2008) 72.6% (Asouab 2005; Morocco MOH 2007) Oman 44%­70% (different groups of IDUs; Oman MOH 2006) Pakistan 56.8% (Ahmed et al. 2003) 56.0% (Ahmed et al. 2003) 76.0% (Strathdee et al. 2003) 52.0% (Baqi et al. 1998) 47.0% (Parviz et al. 2006) 48.2% (Zafar et al. 2003) 58.7% (Emmanuel et al. 2004) 82.0% (Pakistan National AIDS Control Program 2005b) 23.0% (Pakistan National AIDS Control Program 2005c) 78.1% (Emmanuel and Fatima 2008) 18.0% (Bokhari et al. 2007) 48.0% (Pakistan National AIDS Control Program 2005c) 82.0% (Pakistan National AIDS Control Program 2005c) 72.2% (Afghan refugees; Zafar et al. 2003) 25.2% (Saleem, Adrien, and Razaque 2008) 47.1% (Pakistan National AIDS Control Program 2005a) 21.9% (Pakistan National AIDS Control Program 2006­07) 17.6% (Pakistan National AIDS Control Program 2008) 8.5% (Altaf et al. 2009) 33.6% (Altaf et al. 2009) 41.0% (Platt et al. 2009) 14.0% (Platt et al. 2009) Syrian Arab Republic 47.0% (UNAIDS 2008) 28.0% (Syria Mental Health Directorate 2008) 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). Injecting Drug Users and HIV 19 doctor at least once in the last month was different studies reported current marriage. reported by 42.1%,121 27.1%,122 and 60.6%123 Multiple sexual partnerships were reported by of IDUs in Pakistan. According to a study con- 73% of IDUs in Egypt,136 and 24% in Pakistan.137 ducted in Afghanistan, a large fraction of IDUs In Afghanistan, IDUs reported multiple,138 reported injecting drugs in open spaces such as regular, and casual sexual partnerships and con- in streets or parks.124 tacts with female sex workers (FSWs), and 75% By reusing injection equipment, street doc- of them at some point had sex with a female.139 tors may connect different IDU subnetworks In Egypt, 70.5% of IDUs had sex in the last together. Well-connected injecting drug net- year.140 In the Islamic Republic of Iran, one-third works are most conducive to HIV spread. This is of married IDUs had extramarital sex, over half of manifested in the high HIV and HCV prevalence those divorced or separated had sex after separa- levels among different IDU communities in the tion, and over 70% of unmarried IDUs reported Islamic Republic of Iran, Libya, and Pakistan, as premarital sex.141 Also in the Islamic Republic of delineated above. The social environment and Iran, 54% of IDUs reported two or more sexual injecting network structure need to be consid- partners in their lifetime,142 and 57.1% of HIV- ered in any prevention interventions among positive and 39.4% of uninfected incarcerated IDUs in MENA. Network-level interventions can IDUs reported more than three lifetime sexual reinforce individual-level interventions.125 partners.143 In yet another study in the Islamic Republic of Iran, drug use was associated with Engagement of IDUs in risky sexual behavior premarital and extramarital sex among truck drivers and youth.144 A recent RSA in the Islamic Various studies indicated that the majority of IDUs Republic of Iran has also indicated that 44% of in MENA are sexually active and engage in risky married drug users engage in extramarital sex.145 sexual behavior.126 Being married (currently or at In Lebanon, the average number of sex part- some point) was reported by 55.5% of IDUs127 in ners among IDUs in the last year was 2.85, and Egypt; 57%,128 52%,129 and 59%130 in different 34.1% of IDUs reported a casual sexual partner studies in the Islamic Republic of Iran; 50%131 in in the past month.146 Another study reported Pakistan; and 3%­28%132 in Oman. In Pakistan, that 66% of IDUs had one to five sexual part- 44.7%,133 45.24%,134 and 41.1%135 of IDUs in ners and 3% had more than five partners.147 In Morocco, 48.1% of males and 70.1% of females 121 Pakistan National AIDS Control Program, HIV Second Generation of a group of mainly IDUs reported multiple 122 Surveillance (Round I). sexual partners in the last 12 months.148 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II). In Oman, 91%­100% of IDUs reported they 123 Pakistan National AIDS Control Program, HIV Second Generation had sex with two to eight sexual partners in the Surveillance (Round III). past month.149 In Pakistan, 58%­79% of IDUs 124 World Bank, "Mapping and Situation Assessment." 125 had sex in the last six months with a nonpaid Neaigus, "The Network Approach." 126 Egypt MOH and Population National AIDS Program, HIV/AIDS Biological and Behavioral Surveillance Survey; Kuo et al., "High HCV 136 Seroprevalence"; Elshimi, Warner-Smith, and Aon, "Blood-Borne Virus El-Sayed et al., "Evaluation of Selected Reproductive Health Infections." 137 Risks." Emmanuel et al., "HIV Risk Behavior." 127 138 Egypt MOH and Population National AIDS Program, HIV/AIDS Sanders-Buell et al., "A Nascent HIV Type 1 Epidemic." 139 Biological and Behavioral Surveillance Survey. World Bank, "Mapping and Situation Assessment." 128 140 Zamani et al., "High Prevalence of HIV Infection." Egypt MOH and Population National AIDS Program, HIV/AIDS 129 Zamani et al., "Prevalence of and Factors Associated with HIV-1 Biological and Behavioral Surveillance Survey. 141 Infection." Razzaghi, Rahimi, and Hosseini, Rapid Situation Assessment. 130 142 Zamani et al., "Prevalence and Correlates of Hepatitis C Virus." Zamani et al., "High Prevalence of HIV Infection." 131 143 Haque et al., "High-Risk Sexual Behaviours"; Pakistan National AIDS Rahbar, Rooholamini, and Khoshnood, "Prevalence of HIV Infection." 144 Control Program, "Pilot Study in Karachi & Rawalpindi." Tehrani and Malek-Afzalip, "Knowledge, Attitudes and Practices." 132 145 Oman MOH, "HIV Risk." Narenjiha et al., "Rapid Situation Assessment." 133 146 Pakistan National AIDS Control Program, HIV Second Generation Aaraj, "Report on the Situation Analysis"; Hermez et al., "HIV/AIDS Surveillance (Round I). Prevention among Vulnerable Groups." 134 147 Pakistan National AIDS Control Program, HIV Second Generation Mishwar, "An Integrated Bio-Behavioral Surveillance Study." 148 Surveillance (Round II). Asouab, "Risques VIH/SIDA chez UDI"; Morocco MOH, "Situation 135 Pakistan National AIDS Control Program, HIV Second Generation épidémiologique actuelle du VIH/SIDA au Maroc." 149 Surveillance (Round III). Oman MOH, "HIV Risk." 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." Injecting Drug Users and HIV 21 Table 2.5 Measures 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 Afghanistan 69.0% (World Bank 2006) 32.0% (World Bank 2006) 0.0% (ever use; Sanders-Buell 76.2% (Todd et al. 2007) 8.3% (Todd et al. 2007) et al. 2007) 48.0% (World Bank 2008) 21.0% (World Bank 2008) 17.0% (ever use; commercial sex; World Bank 2008) Algeria 40.0% (Mimouni and Remaoun 2006) 44.0% (Algeria MOH [unknown]) Egypt, Arab 13.3% (Egypt MOH and 9.4% (Egypt MOH and 34.1% (ever use; regular partners; Republic of Population National AIDS Population National AIDS Egypt MOH and Population Program 2006) Program 2006) National AIDS Program 2006) 12.8% (ever use; nonregular non- commercial partners; Egypt MOH and Population National AIDS Program 2006) 11.8% (ever use; with CSWs; Egypt MOH and Population National AIDS Program 2006) 66.0% (ever use; Elshimi, Warner- Smith, and Aon. 2004) 20.0% (ever use; El-Sayed et al. 2002) 9.0% (always; El-Sayed et al. 2002) Iran, Islamic 23.0% (Narenjiha et al. 28.6% (last month; 30.0% (Razzaghi, Rahimi, 53.0% (ever use; Zamani et al. Republic of 2005) Eftekhar et al. 2008) and Hosseini 1999) 2005) 9.2%­14.9% (IDU prison- 13.3% (Narenjiha et al. 2005) 52.0% (ever use; Narenjiha et al. ers; Farhoudi et al. 2003) 1.6% (IDU prisoners; 2005) 23.3% (Kheirandish et al. Farhoudi et al. 2003) 37.0% (last sex; Zamani et al. 2009) 5%­17% (Ministry of Health 2005) and Medical Education of 11.3%­12.4% (ever use; IDU pris- Iran 2006; Mostashari, oners; Farhoudi et al. 2003) UNODC, and Darabi 2006) 5.0% (Kheirandish et al. 2009) Lebanon 47.1% (Mishwar 2008) 33.0% (UNAIDS 2008) 24.7 (Aaraj [unknown]) 88.0% (ever use; Aaraj [unknown]) 32.9% (last month; Hermez 27.1% (Hermez 59.0% (ever use; Ingold 1994) [unknown]; Aaraj [unknown]; Aaraj 5.8% (last sex; regular; Hermez [unknown]) [unknown]) [unknown]; Aaraj [unknown]) 17.0% (Mishwar 2008) 34.6% (last sex; casual sex; Aaraj [unknown]; Hermez et al. [unknown]) 39.3% (last sex; commercial sex; Aaraj [unknown]; Hermez et al. [unknown]) Oman 60%­97% (Oman MOH 12%­25% (always; Oman 53%­69% (ever use; Oman MOH 2006) MOH 2006) 2006) 12%­25% (always; Oman MOH 2006) 22 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa (Continued) Table 2.5 Measures 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 2006­07) 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 2006­07) 12.6% (Pakistan National 33.5% (last sex; regular partner; AIDS Control Program Pakistan National AIDS Control 2006­07) 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) 2006­07) 14.7% (with MSW or hijra; 31.0% (last sex; FSW; Pakistan Pakistan National AIDS National AIDS Control Program Control Program 2006­07) 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 2006­07) 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) Table 2.5 Measures 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 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. several misconceptions.179 The knowledge level Analytical summary was very high in Lebanon and almost all IDUs Injecting drug use is a persistent and a growing were aware of the risk of infection through problem in MENA, with close to a million peo- reuse of nonsterile injecting equipment (95.5%) ple injecting drugs: a population prevalence of and unprotected sex (100%).180 However, 0.2%. MENA is a major source, route, and des- despite HIV/AIDS knowledge, a large fraction of tination for the global trade in illicit drugs. IDUs do not feel at risk of HIV infection. There is considerable evidence on HIV preva- According to individual studies, only 33.9%,181 lence and risky behavior practices among IDUs 31.1%,182 and 35.9%183 of IDUs in Pakistan and in MENA. There is also evidence of rapidly rising 27% of IDUs in Syria184 reported feeling at risk HIV epidemics among IDUs in a few MENA of HIV infection. A more comprehensive study countries. Earlier evidence suffered from meth- of HIV/AIDS knowledge in MENA can be found odological limitations, but the quality of evi- in chapter 7. dence has increased significantly in recent years. Regardless, all evidence consistently indicates 179 Egypt MOH and Population National AIDS Program, HIV/AIDS that HIV has already established itself among a Biological and Behavioral Surveillance Survey. number of IDU populations in MENA, while it is 180 Aaraj, "Report on the Situation Analysis"; Hermez et al., "HIV/AIDS still at low or nil prevalence in other popula- Prevention among Vulnerable Groups." 181 tions. Levels of HIV prevalence among popula- Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). tions where the infection is already established 182 Pakistan National AIDS Control Program, HIV Second Generation are comparable to those observed in other Surveillance (Round II). regions. 183 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round III). The levels of risky behavior practices, such as 184 Syria Mental Health Directorate, "Assessment of HIV Risk. the use of nonsterile injecting equipment, have 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: 511­16. 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: 60­64. 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: 321­29. 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 2004­2005. 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: 321­28. 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: 127­32. 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: 4085­89. 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: 136­40. 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 2006­2010." 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. iii10­17. 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 2295­303. 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: 73­79. Users." Int J Drug Policy 18: 352­58. 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: 43­45. X. F. Yu. 2000. "Overland Heroin Trafficking Routes Injecting Drug Users and HIV 25 and HIV-1 Spread in South and South-East Asia." HIV/AIDS Patients: Our Experience in Iran." Sex AIDS 14: 75­83. Transm Infect 81: 279­80. Bokhari, A., N. M. Nizamani, D. J. Jackson, N. E. Rehan, Ghys, P. D., W. Bazant, M. G. Monteiro, S. Calvani, M. Rahman, R. Muzaffar, S. Mansoor, H. Raza, K. and S. Lazzari. 2001. "The Epidemics of Injecting Qayum, P. Girault, E. Pisani, and I. Thaver. 2007. Drug Use and HIV in Asia." AIDS 15 Suppl 5: "HIV Risk in Karachi and Lahore, Pakistan: An S91­99. Emerging Epidemic in Injecting and Commercial Sex Goldmann, D. A. 2002. "Blood-Borne Pathogens and Networks." Int J STD AIDS 18: 486­92. Nosocomial Infections." J Allergy Clin Immunol 110: Bolhari, J., M. Alvandi, P. Afshar, A. Bayanzadeh, M. S21­26. Rezaii, and A. Rahimi Movaghar. 2002. "Assessment Groterah, A. 2002. "Drug Abuse and HIV/AIDS in the of Drug Abuse in Iranian Prisons." United National Middle East and North Africa: A Situation Drug Control Programme (UNDCP). Assessment." UNODC, internal document. Day, C., B. Nassirimanesh, A. Shakeshaft, and K. Dolan. Hafeiz, H. B. 1995. "Socio-Demographic Correlates and 2006. "Patterns of Drug Use among a Sample of Drug Pattern of Drug Abuse in Eastern Saudi Arabia." Drug Users and Injecting Drug Users Attending a General Alcohol Depend 38: 255­59. Practice in Iran." Harm Reduct J 3: 2. Eftekhar, M., M.-M. Gouya, A. Feizzadeh, N. Moshtagh, Haque, N., T. Zafar, H. Brahmbhatt, G. Imam, S. ul H. Setayesh, K. Azadmanesh, and A.-R. Vassigh. Hassan, and S. A. Strathdee. 2004. "High-Risk Sexual 2008. "Bio-Behavioural Survey on HIV and Its Risk Behaviours among Drug Users in Pakistan: Factors among Homeless Men Who Have Sex with Implications for Prevention of STDs and HIV/AIDS." Men in Tehran, 2006­07." Int J STD AIDS 15: 601­7. 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: 127­50. Kord, Islamic Republic of Iran." East Mediterr Health J 14: 1136­41. 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: 255­58. 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: 51­57. 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: 940­48. 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 S59­64. among Injection Drug Users in Detention, Tehran, Iran." AIDS 23: 538­40. 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 2­18, 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 444­51. 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: 1­4. 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: 843­48. 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: 121­23. 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: 140­50. 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: 67­78. Behaviours among Voluntary Blood Donors in Hong Neaigus, A., M. Miller, S. R. Friedman, D. L. Hagen, S. J. Kong." AIDS Care 14: 481­92. 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 847­60. People Who Inject Drugs: A Systematic Review." Njoh, J., and S. Zimmo. 1997a. "Prevalence of Antibodies Lancet 372: 1733­45. 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: 89­91. 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: 487­88. ii31­36. 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 2004­2005." 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: 393­95. 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 2004­5. 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. 311­13. ------. 2006­7. 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: S7­12. 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: 364­71. Injecting Drug Users and HIV 27 Platt, L, P. Vickerman, M. Collumbien, S. Hasan, N. Lalji, Sanders-Buell, E., M. D. Saad, A. M. Abed, M. Bose, C. S. Mayhew, R. Muzaffar, A. Andreasen, and S. S. Todd, S. A. Strathdee, B. A. Botros, N. Safi, K. C. Hawkes. 2009. "Prevalence of HIV, HCV and Sexually Earhart, P. T. Scott, N. Michael, and F. E. McCutchan. Transmitted Infections among Injecting Drug Users 2007. "A Nascent HIV Type 1 Epidemic among in Rawalpindi and Abbottabad, Pakistan: Evidence Injecting Drug Users in Kabul, Afghanistan Is for an Emerging Injection-Related HIV Epidemic." Sex Dominated by Complex AD Recombinant Strain, Transm Infect 85 Suppl 2: ii17­22. CRF35_AD." AIDS Res Hum Retroviruses 23: 834­39. Rahbar, A. R., S. Rooholamini, and K. Khoshnood. 2004. Sarkar, K., S. Panda, N. Das, and S. Sarkar. 1997. "Prevalence of HIV Infection and Other Blood-Borne "Relationship of National Highway with Injecting Infections in Incarcerated and Non-Incarcerated Drug Abuse and HIV in Rural Manipur, India." Indian Injection Drug Users (IDUs) in Mashhad, Iran." J Public Health 41: 49­51. International Journal of Drug Policy 15: 151­55. Schmitt, A., and J. Sofer. 1992. Sexuality and Eroticism Rai, M. A., H. J. Warraich, S. H. Ali, and V. R. Nerurkar. among Males in Moslem Countries. New York: Harrington 2007. "HIV/AIDS in Pakistan: The Battle Begins." Park Press. Retrovirology 4: 22. Shah, S. A., and A. Altaf. 2004. "Prevention and Control Ramia, S., J. Mokhbat, A. Sibai, S. Klayme, and R. of HIV/AIDS among Injection Drug Users in Pakistan: Naman. 2004. "Exposure Rates to Hepatitis C and G A Great Challenge." J Pak Med Assoc 54: 290­91. Virus Infections among HIV-Infected Patients: Shah, S. A., A. Altaf, S. A. Mujeeb, and A. Memon. 2004. Evidence of Efficient Transmission of HGV by the "An Outbreak of HIV Infection among Injection Drug Sexual Route." Int J STD AIDS 15: 463­66. Users in a Small Town in Pakistan: Potential for Ray Kim, W. 2002. "Global Epidemiology and Burden of National Implications." Int J STD AIDS 15: 209. Hepatitis C." Microbes Infect 4: 1219­25. Shakeshaft, A., B. Nassirimanesh, C. Day, and K. A. Razzaghi, E. M., A. R. Movaghar, T. C. Green, and K. Dolan. 2005. "Perceptions of Substance Use, Khoshnood. 2006. "Profiles of Risk: A Qualitative Treatment Options and Training Needs among Iranian Study of Injecting Drug Users in Tehran, Iran." Harm Primary Care Physicians." Int J Equity Health 4: 7. Reduct J 3: 12. Shareef, A., A. J. Burqan, A. Abed, E. Kalloub, and A. Razzaghi, E., B. Nassirimanesh, P. Afshar, K. Ohiri, M. Alaiwi. 2006. "Drug Abuse Situation and ANGA Claeson, and R. Power. 2006. "HIV/AIDS Harm Needs Study." PowerPoint presentation. Reduction in Iran." Lancet 368: 434­35. Shareef, A., I. Abu AlAjeen, A. Ailaiwi, Z. Mezeh, M. Razzaghi, E., A. Rahimi, and M. Hosseini. 1999. Rapid Shaheen, A. Helles, and A. Abed. 2006. "Assessment Situation Assessment (RSA) of Drug Abuse in Iran. Tehran: Study of the Drug Demand and Supply Status in Prevention Department, State Welfare Organization, Palestine, and the Urgent Needs of the Anti-Narcotic Ministry of Health, I.R. of Iran and United Nations General Administration (ANGA)." Palestine International Drug Control Program. Authority, Ministry of Interior, Police Headquarter Reid, G., and G. Costigan. 2002. "Revisiting the Hidden Anti-Narcotic General Administration. UNODC Epidemic: A Situation Assessment of Drug Use in Asia PAL-06 Project supporting Palestinian ANGA. in the Context of HIV/AIDS." Centre for Harm Sindh AIDS Control Program. 2004. Surveillance data, Reduction, the Burnet Institute, Melbourne. government of Sindh, Pakistan. Rhodes, T., C. Lowndes, A. Judd, L. A. Mikhailova, A. Strathdee, S. A., T. Zafar, H. Brahmbhatt, A. Baksh, and Sarang, A. Rylkov, M. Tichonov, K. Lewis, N. S. ul Hassan. 2003. "Rise in Needle Sharing among Ulyanova, T. Alpatova, V. Karavashkin, M. Injection Drug Users in Pakistan during the Khutorskoy, M. Hickman, J. V. Parry, and A. Renton. Afghanistan War." Drug Alcohol Depend 71: 17­24. 2002. "Explosive Spread and High Prevalence of HIV Sy, T., and M. M. Jamal. 2006. "Epidemiology of Infection among Injecting Drug Users in Togliatti Hepatitis C Virus (HCV) Infection." Int J Med Sci 3: City, Russia." AIDS 16: F25­31. 41­46. Ryan, S. 2006. "Travel Report Summary." UNAIDS, Syria Mental Health Directorate. 2008. "Assessment of Kabul, Afghanistan, February 27­March 7, 2006. HIV Risk and Sero-Prevalence among Drug Users in Salama, I. I., N. K. Kotb, S. A. Hemeda, and F. Zaki. Greater Damascus." Programme SNA, Syrian Ministry 1998. "HIV/AIDS Knowledge and Attitudes among of Health, UNODC, UNAIDS. Alcohol and Drug Abusers in Egypt." J Egypt Public Talaie, H., S. H. Shadnia, A. Okazi, A. Pajouhmand, H. Health Assoc 73: 479­500. Hasanian, and H. Arianpoor. 2007. "The Prevalence Saleem, N. H., A. Adrien, and A. Razaque. 2008. "Risky of Hepatitis B, Hepatitis C and HIV Infections in Non- Sexual Behavior, Knowledge of Sexually Transmitted IV Drug Opioid Poisoned Patients in Tehran, Iran." Infections and Treatment Utilization among a Pak J Biol Sci 10: 220­24. Vulnerable Population in Rawalpindi, Pakistan." Tawilah, J., and O. Tawil. 2001. "Visit to Sultane of Southeast Asian J Trop Med Public Health 39: 642­48. Oman." Travel Report Summary, National AIDS Saleh, E., W. McFarland, G. Rutherford, J. Mandel, M. Programme at the Ministry of Health in Muscat and El-Shazaly, and T. Coates. 2000. "Sentinel Surveillance Salalah, WHO Representative Office, WHO/EMRO. for HIV and Markers for High Risk Behaviors among Tehrani, F. R., and H. Malek-Afzalip. 2008. "Knowledge, STD Clinic Attendees in Alexandria, Egypt." XIII Attitudes and Practices concerning HIV/AIDS among International AIDS Conference, Durban, South Iranian At-Risk Sub-Populations." Eastern Africa, Poster MoPeC2398. Mediterranean Health Journal 14. 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: 1135­39. 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: 1327­31. 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: 665­75. ------. 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. 394­98. ------. 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: 115­19. 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. 359­63. ------. 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: 342­46. 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: 709­16. Transmission among Drug Users in Larkana, Zamani, S., M. Vazirian, B. Nassirimanesh, E. M. Pakistan." Trop Doct 37: 58­59. 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 (1986­1990)." J Trop Med with and One without a Needle and Syringe Program." Hyg 96: 113­17. AIDS Behav DOI 10.1007/s10461-008-9404-2. Injecting Drug Users and HIV 29 Chapter 3 Men Who Have Sex with Men and HIV 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 HIV PREVALENCE AMONG MSM PREVALENCE OF HOMOSEXUALITY HIV transmission between men who have sex Men who have sex with men form the most with men has been reported in most MENA hidden and stigmatized risk group of all HIV risk countries.1 Table 3.1 describes the results of groups in MENA. They are often subjected to available point-prevalence surveys for MSM, harassment and even brutality.7 Homosexual including male sex workers (MSWs), hijras2 identities existed throughout Arab and Islamic (transgender individuals3), and hijra sex work- history and are well described, including cele- ers (HSWs). The available prevalence levels brated historical figures.8 Arab and Islamic cul- indicate a considerable HIV spread among MSM tures treated homosexuals for much of history in MENA. Although some prevalence levels are largely with indifference.9 Despite homophobic low, this should not be interpreted as limited inclinations at the individual level, there was no potential for future spread. HIV prevalence presence historically of an ideology of homopho- among hijras in one study in Pakistan was 0% in bia similar to that which existed in the West.10 In 1998, but syphilis prevalence was at 37%.4 This suggests substantial levels of sexual risk behav- 5 ior and potential for HIV infectious spread if HIV Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Rounds I, II, and III). is introduced into sexual networks involving 6 Commission on AIDS in Asia, Redefining AIDS in Asia; Pisani et al., "HIV, Syphilis Infection, and Sexual Practices." 7 Yuzgun, "Homosexuality and Police Terror in Turkey"; Symington, 1 WHO/EMRO Regional Database on HIV/AIDS; Jenkins and Robalino, "Egypt"; Moszynski, "Egyptian Doctors." 8 "HIV in the Middle East and North Africa"; Schmitt and Sofer, Sexuality Al-Jahiz, Letters of Al-Jahiz, Volume 2; Abu-Nuwwas, Poetry Collection and Eroticism. of Abu-Nuwwas; As-Siyuti, History of the Caliphs. 2 9 Mainly in Pakistan and Afghanistan. Boswell, Christianity, Social Tolerance, and Homosexuality. 3 10 Bokhari et al., "HIV Risk in Karachi and Lahore, Pakistan." Abukhalil, "Gender Boundaries and Sexual Categories in the Arab 4 Baqi et al., "Seroprevalence of HIV" (1999; 2006). World." 31 Table 3.1 HIV Prevalence among MSM in MENA Country HIV prevalence among MSM Egypt, Arab Republic of 1.4% (UNAIDS and WHO 2003; El-Rahman 2004; Family Health International 2007; El-Sayyed et al. 2008) 6.2% (Egypt MOH and Population National AIDS Program 2006) Lebanon 3.6% (Mishwar 2008)) Morocco 4.4% (Alami 2009) Pakistan 3.9% (MSWs; Bokhari et al. 2007) 0.0% (MSWs; Bokhari et al. 2007) 4.0% (MSWs; Bokhari et al. 2007) 0.4% (average of different cities with a range of 0­4.0; MSWs; Pakistan National AIDS Control Program 2005) 1.5% (average of different cities with a range of 0­7.5; MSWs; Pakistan National AIDS Control Program 2006­07) 0.9% (average of different cities with a range of 0­3.1; MSWs; Pakistan National AIDS Control Program 2008) 0.8% (average of different cities with a range of 0­1.6; HSWs; Pakistan National AIDS Control Program 2005) 1.8% (average of different cities with a range of 0­14.0; HSWs; Pakistan National AIDS Control Program 2006­07) 6.4% (average of different cities with a range of 0­27.6; HSWs; Pakistan National AIDS Control Program 2008) 1.5% (hijras; Bokhari et al. 2007) 0.5% (hijras; Bokhari et al. 2007) 0.0% (hijras; Baqi et al. 1999) 1.0% (hijras; Khan, A. A. et al. 2008) 0.5% (MSWs; banthas a; Hawkes et al. 2009) 0.0% (MSWs; banthas; Hawkes et al. 2009) 0.0% (MSWs; khotkis b; Rawalpindi; Hawkes et al. 2009) 0.0% (MSWs; khotkis; Abbottabad; Hawkes et al. 2009) 2.5% (MSWs; khusras c; Hawkes et al. 2009) 0.0% (MSWs; khusras; Hawkes et al. 2009) Sudan 9.3% (Elrashied 2006) a. Biological males with a male gender identity. b. Biological males who dress as men but have "female soul" and feminized traits. c. Transgenders who dress as women; they are often known as hijras. 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." Men Who Have Sex with Men and HIV 33 Sexual behavior and partnerships Sudan, 97.2% of MSM reported more than one concurrent partner,51 and receptive MSM Evidence on sexual partnership formation among reported a mean of eight noncommercial part- MSM indicates substantial risk behavior. In ners in the last six months.52 In addition to anal Egypt, 90% of MSM reported more than one sex, 57.2% of MSM in Sudan reported engaging sexual partner,37 with 82% of MSM being insertive in oral sex, with virtually all doing so without and 51% being receptive.38 In another study, condoms.53 In Tunisia, 90.1% of MSM reported 65.8% of MSM took both receptive and insertive multiple anal sex partners in the last six months sexual roles, 24.8% had only receptive roles, and and 12% paid for sex with MSWs.54 Among 8.2% were exclusively insertive.39 Sixty-seven South Asian men from Bangladesh, India, and percent of MSM reported having five concurrent Pakistan, MSM aged 14­16, 17­20, 21­35, and sexual partners,40 and 80.8% had ever had sex 36­45 years averaged 2, 5, 42, and 35 sex part- with multiple partners per act.41 Being forced by ners per year, respectively.55 their partners to practice anal sex in the last year was reported by 6.3% of MSM.42 In the Islamic Republic of Iran, 81.9% of Male sex work MSM reported different kinds of sexual partner- Sex work appears to be common among MSM ships in the last six months including steady, in MENA who possibly use it to support their casual, commercial, and female partnerships.43 living in an environment of stigma and poor Forty-six percent reported six or more sexual support networks.56 Commercial sex among partnerships in the last six months, and 9.93% MSM was reported by various studies as 42%57 reported only one kind of sexual partnership.44 and 20%58 in Egypt, 36% in Lebanon,59 and The partners were described as steady in 61.2% 67%60 and 75.5%61 in Sudan. of the cases, sex workers in 53.8%, and casual in The practice of MSW in MENA reflects an 82.2%.45 Being victimized in coercive sex was environment of high risk and of considerable reported by 47.8% of MSM.46 Also among these overlap with female commercial sex networks MSM, 43% had ever tested for HIV, 82.3% (see section on overlap below). In Afghanistan, reported being imprisoned at least once (mainly male sex work is secretive and occurs in small for drug use), and 64% reported a history of sui- networks in the homes of clients at a frequency cide attempts.47 of three clients per day.62 In studies in Pakistan, In Lebanon, 74.3% of MSM reported having MSWs reported an average of 2.3,63 2.1,64 and a regular sexual partner, 51.8% a casual part- 1.965 clients per working day, and an average of ner, and 54.5% a commercial sex partner dur- ing the last month.48 On average, MSM reported 9.47 partners in the past 12 months.49 In Oman, MSM injecting drug users (IDUs) reported a mean number of two sexual partners.50 In 51 Anonymous, "Improving HIV/AIDS Response." 52 Elrashied, "Generating Strategic Information." 53 Ibid. 37 54 El-Sayed et al., "Evaluation of Selected Reproductive Health Hsairi and Ben Abdallah, "Analyse de la situation de vulnérabilité." 55 Infections." Khan and Hyder, "HIV/AIDS among Men Who Have Sex with Men." 38 56 Egypt MOH and Population National AIDS Program, HIV/AIDS International HIV/AIDS Alliance, "Spreading the Word." 57 Biological and Behavioral Surveillance Survey. Egypt MOH and Population National AIDS Program, HIV/AIDS 39 El-Sayyed, Kabbash, and El-Gueniedy, "Risk Behaviours." Biological and Behavioral Surveillance Survey. 40 58 El-Sayed et al., "Knowledge, Attitude, and Practice." El-Sayed et al., "Knowledge, Attitude, and Practice." 41 59 El-Sayyed, Kabbash, and El-Gueniedy, "Risk Behaviours." Mishwar, "An Integrated Bio-Behavioral Surveillance Study." 42 60 El-Sayed et al., "Knowledge, Attitude, and Practice." Elrashied, "Prevalence, Knowledge and Related Risky Sexual 43 Eftekhar et al., "Bio-Behavioural Survey." Behaviours." 44 61 Ibid. Anonymous, "Improving HIV/AIDS Response." 45 62 Ibid. World Bank, "Mapping and Situation Assessment." 46 63 Ibid. Pakistan National AIDS Control Program, HIV Second Generation 47 Ibid. Surveillance (Round I). 48 64 Hermez et al., "HIV/AIDS Prevention among Vulnerable Groups"; Pakistan National AIDS Control Program, HIV Second Generation Dewachi, "Men Who Have Sex with Other Men." Surveillance (Round II). 49 65 Hermez et al., "HIV/AIDS Prevention among Vulnerable Groups." Pakistan National AIDS Control Program, HIV Second Generation 50 Oman MOH, "HIV Risk." Surveillance (Round III). 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). Men Who Have Sex with Men and HIV 35 In Sudan, 63.7% of MSM reported being difficulty in obtaining condoms and 38% reported forced to have anal sex; that anal sex was neces- difficulty using them,116 but three quarters of sary to secure employment, alcohol, or drugs; or MSM had heard of male condoms.117 In studies in that sex work was practiced for financial rea- the Islamic Republic of Iran, 19.4%, 59.5%, and sons.103 About 25% of receptive MSM had at least 59.9% of MSM used condoms during last anal sex 1 commercial sex partner per day with a mean with steady partners, commercial sex partners, of 10 insertive partners in the last six months.104 and casual partners, respectively.118 In Lebanon, Seventy-one percent of MSM reported a com- two studies found that 47.1% and 54.5% of MSM mercial sex partner in the last six months.105 A always used condoms with regular partners and study among female sex workers (FSWs) in noncommercial casual partners, respectively.119 In Sudan reported that FSWs host young MSWs in Oman, 68%­100% of different groups of MSM their houses to offer both heterosexual and IDUs used condoms in the last year.120 homosexual sex to clients who wish to engage In Pakistan, condom use during last anal sex in both activities.106 with a client was reported by 24% of MSWs and MSWs and HSWs report other sources of 21% of HSWs.121 Condom use during last oral sex income. The majority of MSWs and HSWs in with a client was reported by 13% of MSWs and Pakistan reported working as laborers, factory 15% of HSWs.122 Among MSWs, 34.7% reported workers, bus/van conductors, tailors, shopkeep- condom use at last sex with a paying client and ers, beggars, dancers, and malishi (masseurs).107 32.5% with a nonpaying partner.123 For HSWs, Close to half of MSWs and HSWs were illiter- the percentages were 32.3 and 26, respectively.124 ate.108 High levels of sexual abuse were reported Studies reported consistent condom use in the among hijras in Pakistan. Between 12% and 27% last month by 7.2%125 and 8%126 of MSWs, and of different MSW and HSW groups reported 5.6%127 and 7.5%128 of HSWs. In further stud- being sexually violated by police in the last year, ies, 4% of hijras and 3.1% of MSWs used con- and between 24% and 39% reported providing doms consistently,129 and 17% of MSWs used a free sex to police in the last year.109 Between condom with a nonpaying female in the last 10% and 18% of these MSWs and HSWs report- month.130 Among the reasons cited for not using ed that their first sex was forced.110 condoms among MSM in Pakistan are not liking them, partners' objection, lack of availability, Condom use and not thinking of them as necessary.131 Reported condom use among MSM varies sub- 116 El-Sayed et al., "Evaluation of Selected Reproductive Health Infections." stantially, although overall it is more on the low 117 Egypt MOH and Population National AIDS Program, HIV/AIDS side. In different studies in Egypt, 19% of MSM Biological and Behavioral Surveillance Survey. 118 regularly used condoms111; 2%,112 19%,113 and 119 Eftekhar et al., "Bio-Behavioural Survey." Hermez et al., "HIV/AIDS Prevention among Vulnerable Groups"; 19.2%114 used condoms consistently; and 9.2% Dewachi, "Men Who Have Sex with Other Men." used condoms during last commercial sex.115 120 Oman MOH, "HIV Risk." 121 Twenty-two percent of MSM in Egypt reported Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). 122 Pakistan National AIDS Control Program, HIV Second Generation 103 Elrashied, "Generating Strategic Information." Surveillance (Round I). 104 123 Ibid. Pakistan National AIDS Control Program, HIV Second Generation 105 Ibid. Surveillance (Round III). 106 124 Yousif, "Health Education Programme." Ibid. 107 125 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Rounds I, II, and III). Surveillance (Round I). 108 126 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Rounds I and II). Surveillance (Round II). 109 127 Hawkes et al., "HIV and Other Sexually Transmitted Infections." Pakistan National AIDS Control Program, HIV Second Generation 110 Ibid. Surveillance (Round I). 111 128 El-Rahman, "Risky Behaviours for HIV/AIDS Infection." Pakistan National AIDS Control Program, HIV Second Generation 112 El-Sayed et al., "Knowledge, Attitude, and Practice." Surveillance (Round II). 113 129 El-Sayed et al., "Evaluation of Selected Reproductive Health Infections." Saleem, Adrien, and Razaque, "Risky Sexual Behavior." 114 130 El-Sayyed, Kabbash, and El-Gueniedy, "Risk Behaviours." Bokhari et al., "HIV Risk in Karachi and Lahore, Pakistan." 115 131 Egypt MOH and Population National AIDS Program, HIV/AIDS Pakistan National AIDS Control Program, HIV Second Generation Biological and Behavioral Surveillance Survey. Surveillance (Round 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." Men Who Have Sex with Men and HIV 37 Engagement of MSM in injecting 19% and 25% reported IDU sex partners in the drug risk behavior last year, and between 0% and 2% had a hus- band or lover who is an IDU.181 In Sudan, 24.4% MSM report considerable levels of drug use, of MSM used drugs.182 In Tunisia, 14.7% of MSM both in injecting and noninjecting forms. In reported IDU within the last year.183 Egypt, 10.9% of MSM injected drugs in the pre- vious 12 months and 79.3% reported ever using noninjecting drugs.163 In the Islamic Republic of KNOWLEDGE OF HIV/AIDS Iran, 53% of MSM injected drugs in the last Levels of HIV knowledge among MSM in MENA month and hepatitis C virus (HCV) prevalence appear to vary, probably reflecting the socioeco- was high at 48.8%, attesting to the overlap nomic status of each MSM group. In Egypt, almost between MSM and IDU risk factors.164 Studies in all MSM in one study have heard of HIV/AIDS and Pakistan reported that 4%­17%165 and the majority were able to identify several transmis- 1%­2%166 of hijras and 7%­9%167 and 4%168 of sion modes, but about one-quarter of MSM had MSWs injected drugs. Also in Pakistan, studies misconceptions.184 In the Islamic Republic of Iran, reported that 5%,169 5.2%,170 and 4.2%171 of 82.4% of MSM were aware of HIV/AIDS and MSWs and 5.3%,172 6.3%,173 and 4.6%174 of 50.6% knew of someone who was living with HSWs injected drugs in the last six months. HIV.185 Seventy-five percent also knew that they Further reported by these studies, 10.1%,175 can protect themselves by using condoms, and 9.5%,176 and 4.2%177 of MSWs and 8.4%,178 87.4% knew of the risk of infection from using 6.4,179 and 6.3%180 of HSWs had sex with IDUs nonsterile injecting equipment.186 In Lebanon, in the last six months. In yet another study in almost all MSM were aware of HIV/AIDS, its trans- Pakistan, between 0% and 3% of different groups mission modes, the condom's role in prevention, of MSWs reported IDU in the last year, between and other prevention measures, but 43.3% per- ceived no chance of becoming infected with HIV.187 163 Separate studies in Pakistan found that 72.1%,188 Egypt MOH and Population National AIDS Program, HIV/AIDS Biological and Behavioral Surveillance Survey. 63.5%,189 and 62.1%190 of MSWs perceived no risk 164 Eftekhar et al., "Bio-Behavioural Survey." of HIV infection. Among HSWs, the percentages 165 Pakistan National AIDS Control Program, "Pilot Study in Karachi & were 83.7,191 77.8,192 and 59.2.193 In Sudan, 98.3% Rawalpindi." 166 Bokhari et al., "HIV Risk in Karachi and Lahore, Pakistan." of MSM have heard of HIV/AIDS,194 but miscon- 167 Pakistan National AIDS Control Program, "Pilot Study in Karachi & ceptions were prevalent.195 Some MSM harbored Rawalpindi." the belief that keeping to an insertive role 168 Bokhari et al., "HIV Risk in Karachi and Lahore, Pakistan." 169 Pakistan National AIDS Control Program, HIV Second Generation 181 Surveillance (Round I). Hawkes et al., "HIV and Other Sexually Transmitted Infections." 170 182 Pakistan National AIDS Control Program, HIV Second Generation Elrashied, "Generating Strategic Information." 183 Surveillance (Round II). Hsairi and Ben Abdallah, "Analyse de la situation de vulnérabilité." 171 184 Pakistan National AIDS Control Program, HIV Second Generation Egypt MOH and Population National AIDS Program, HIV/AIDS Surveillance (Round III). Biological and Behavioral Surveillance Survey. 172 185 Pakistan National AIDS Control Program, HIV Second Generation Eftekhar et al., "Bio-Behavioural Survey." 186 Surveillance (Round I). Ibid. 173 187 Pakistan National AIDS Control Program, HIV Second Generation Hermez et al., "HIV/AIDS Prevention among Vulnerable Groups"; Surveillance (Round II). Dewachi, "Men Who Have Sex with Other Men." 174 188 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round III). Surveillance (Round I). 175 189 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). Surveillance (Round II). 176 190 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II). Surveillance (Round III). 177 191 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round III). Surveillance (Round I). 178 192 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). Surveillance (Round II). 179 193 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II). Surveillance (Round III). 180 194 Pakistan National AIDS Control Program, HIV Second Generation Anonymous, "Improving HIV/AIDS Response." 195 Surveillance (Round III). Elrashied, "Generating Strategic Information." 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: 91­104. 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: 2404­6. 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: 776­86. 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: 73­79. 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: 300­04. 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 S17­21. 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: 486­92. Men Who Have Sex with Men and HIV 39 Boswell, J. 1980. Christianity, Social Tolerance, and Faisel, A., and J. Cleland. 2006. "Study of the Sexual Homosexuality. University of Chicago Press. Behaviours and Prevalence of STIs among Migrant Busulwa, R. 2003. "HIV/AIDS Situation Analysis Study." Men in Lahore, Pakistan." Arjumand and Associates, Conducted in Hodeidah, Taiz and Hadhramut, Centre for Population Studies, London School of Republic of Yemen. Hygiene and Tropical Medicine. Collumbien, M., A. A. Qureshi, S. H. Mayhew, N. Rizvi, Family Health International. 2007. "USAID's A. Rabbani, B. Rolfe, R. K. Verma, H. Rehman, and R. Implementing AIDS Prevention and Care (IMPACT) Naveed i. 2009. "Understanding the Context of Male Project, Middle East and North Africa Region Final and Transgender Sex Work Using Peer Ethnography." Report." March 2005­June 2007. Sex Transm Infect 85 Suppl 2: ii3­7. Farah, M. S., and S. Hussein. 2006. "HIV Prevalence, Commission on AIDS in Asia. 2008. Redefining AIDS in Knowledge, Attitude, Practices and Risk Factors Asia: Crafting an Effective Response. New Delhi, India: among Truck Drivers in Khartoum State." Grey Oxford University Press. Presented to Ban Ki-moon, Report. Sudan National AIDS Program. UN Secretary General, on March 26, 2008. Oxford Hawkes, S., M. Collumbien, L. Platt, N. Lalji, N. Rizvi, A. University Press. Andreasen, J. Chow, R. Muzaffar, H. ur-Rehman, N. Dewachi, O. 2001. "Men Who Have Sex with Other Men Siddiqui, S. Hasan, and A. Bokhari. 2009. "HIV and and HIV AIDS: A Situation Analysis in Beirut, Other Sexually Transmitted Infections among Men, Lebanon; HIV/AIDS Prevention through Outreach to Transgenders and Women Selling Sex in Two Cities Vulnerable Populations." Final report, April 29. in Pakistan: A Cross-Sectional Prevalence Survey." Sex Transm Infect 85 Suppl 2: ii8­16. Eftekhar, M., A. Feizzadeh, N. Moshtagh, H. Setayesh, K. Azadmanesh, and A.-R. Vassigh. 2009. "HIV and HCV Hermez, J., E. Aaraj, O. Dewachi, and N. Chemaly. "HIV/ Prevalence and Related Risk Factors among Street- AIDS Prevention among Vulnerable Groups in Beirut, Based Men Who Have Sex with Men." Lebanon." PowerPoint presentation, Lebanon National AIDS Program. Eftekhar, M., M.-M. Gouya, A. Feizzadeh, N. Moshtagh, H. Setayesh, K. Azadmanesh, and A.-R. Vassigh. Hsairi, M., and S. Ben Abdallah. 2007. "Analyse de la 2008. "Bio-Behavioural Survey on HIV and Its Risk situation de vulnérabilité vis-à-vis de l'infection à VIH Factors among Homeless Men Who Have Sex with des hommes ayant des relations sexuelles avec des Men in Tehran, 2006­07." hommes." For ATL MST sida NGO­Tunis Section, National AIDS Programme/DSSB, UNAIDS. Final Egypt MOH (Ministry of Health), and Population report abridged version. National AIDS Program. 2006. HIV/AIDS Biological and Behavioral Surveillance Survey. Summary report. International HIV/AIDS Alliance. 2007. "Spreading the El-Rahman, A. 2004. "Risky Behaviours for HIV/AIDS Word," http://www.aidsalliance.org/sw50794.asp, Infection among a Sample of Homosexuals in Cairo accessed on January 12. City, Egypt." XV International AIDS Conference, Jenkins, C. 2004. "Male Sexual Diversity and Culture: Bangkok, July 11­16, Abstract WePeC6146. Implications for HIV Prevention and Care." Prepared for UNAIDS. Elrashied, S. M. 2006a. "Generating Strategic Information and Assessing HIV/AIDS Knowledge, Attitude and Jenkins, C., and D. A. Robalino. 2003. HIV in the Middle East Behaviour and Practices as well as Prevalence of HIV1 and North Africa: The Cost of Inaction. Orientations in among MSM in Khartoum State, 2005." A draft Development Series. Washington, D.C.: World Bank. report submitted to Sudan National AIDS Control Khan, A. A., N. Rehan, K. Qayyum, and A. Khan. 2008. Programme. Together Against AIDS Organization "Correlates and Prevalence of HIV and Sexually (TAG). Khartoum, Sudan. Transmitted Infections among Hijras (Male ------. 2006b. "Prevalence, Knowledge and Related Transgenders) in Pakistan." Int J STD AIDS 19: Risky Sexual Behaviours of HIV/AIDS among 817­20. Receptive Men Who Have Sex with Men (MSM) in Khan, O. A., and A. A. Hyder. 1998. "HIV/AIDS among Khartoum State, Sudan, 2005." XVI International Men Who Have Sex with Men in Pakistan." Sex Health AIDS Conference, Toronto, August 13­18, Abstract Exch 12­13, 15. TUPE0509. Khan, S., and T. Khilji. 2002. "Pakistan Enhanced HIV/ El-Sayed, N., M. Abdallah, A. Abdel Mobdy, A. Abdel AIDS Program: Social Assessment and Mapping of Sattar, E. Aoun, F. Beths, G. Dallabetta, M. Rakha, C. Men Who Have Sex with Men (MSM) in Lahore, Soliman, and N. Wasef. 2002. "Evaluation of Selected Pakistan." Naz Foundation International, Luknow. Reproductive Health Infections in Various Egyptian Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. Population Groups in Greater Cairo." MOHP, Vermund. 1997. "HIV/AIDS and Its Risk Factors in IMPACT/FHI/USAID. Pakistan." AIDS 11: 843­48. El-Sayed, N., A. Darwish, M. El-Geneidy, and M. Mehrez. Khilji, N. K. 2004. "Combating HIV/AIDS amongst 1994. "Knowledge, Attitude, and Practice of Zenana Youth in Lahore Pakistan." XV International Homosexuals Regarding HIV in Egypt." National AIDS AIDS Conference, Bangkok, Thailand, July 11. Int Program, Ministry of Health and Population, Egypt. Conf AIDS 15, Abstract WePeD6350. El-Sayyed, N., I. A. Kabbash, and M. El-Gueniedy. 2008. McFarland, W., and C. F. Caceres. 2001. "HIV Surveillance "Risk Behaviours for HIV/AIDS Infection among Men among Men Who Have Sex with Men." AIDS 15 Who Have Sex with Men in Cairo, Egypt." East Suppl 3: S23­32. Mediterr Health J 14: 905­15. 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: 4­17. 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: 87­94. 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: 536­40. 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: 511­15. 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: 642­48. 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: 63­64. ------. 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. ------. 2006­7. 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: 159­69. Men Who Have Sex with Men and HIV 41 Chapter 4 Commercial Sex and HIV 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"; Stulhofer and Bozicevic, 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 Country HIV prevalence among FSWs Afghanistan 0.0% (World Bank 2008) Algeria 1.7% (Fares et al. 2004; Institut de Formation Paramédicale de Parnet 2004) 2.0% (Fares et al. 2004) 9.0% (Fares et al. 2004) 10.0% (Unknown, "Statut de la réponse nationale") 3.0% (Algeria MOH [unknown]) 4.0% (Algeria MOH [unknown]) 2.8% (Alami 2009) 3.7% (Alami 2009) 3.9% (Alami 2009) 6.9% (Alami 2009) 10.7% (Alami 2009) 10.0% (Alami 2009) Djibouti 3.9% (street-based; Etchepare 2001) 9.0% (street-based; Etchepare 2001) 41.4% (street-based; Etchepare 2001) 39.5% (street-based; Etchepare 2001) 51.3% (street-based; Etchepare 2001) 55.8% (street-based; Etchepare 2001) 50.0% (street-based; Etchepare 2001) 2.0% (Fox et al. 1989) 4.6% (street-based; Rodier et al. 1993) 41.7% (street-based; Rodier et al. 1993) 41.0% (street-based; Rodier et al. 1993) 36.0% (street-based; Rodier et al. 1993) 70.0% (street-based; Marcelin et al. 2001; Marcelin et al. 2002) 1.4% (bar-based; Etchepare 2001) 2.7% (bar-based; Etchepare 2001) 5.0% (bar-based; Etchepare 2001) 7.0% (bar-based; Marcelin et al. 2001; Marcelin et al. 2002) 14.2% (bar-based; Etchepare 2001) 15.3% (bar-based; Rodier et al. 1993) 21.7% (bar-based; Etchepare 2001) 25.6% (bar-based; Etchepare 2001) 50% (Philippon et al. 1997) Egypt, Arab Republic of 0.8% (Egypt MOH and Population National AIDS Program 2006) 0.0% (Watts et al. 1993) Iran, Islamic Republic of 0.0% (Jahani et al. 2005) 0.0% (Tassie [unknown]) 2.67% (WHO/EMRO Regional Database on HIV/AIDS) Lebanon 0.0% (Mishwar 2008) Morocco 1.4% (WHO/EMRO Regional Database on HIV/AIDS) 2.3% (Morocco MOH 2003­04, 2005; Khattabi and Alami 2005) 3.14% (Khattabi and Alami 2005) 2.03% (Khattabi and Alami 2005) 2.95% (Khattabi and Alami 2005) 2.52% (Khattabi and Alami 2005) 2.36% (Khattabi and Alami 2005) 0.9% (female prisoners imprisoned for sex work; Khattabi and Alami 2005) 0.0% (female prisoners imprisoned for sex work; Morocco MOH 2007) 4.41% (Khattabi and Alami 2005) 0.0% (Khattabi and Alami 2005) 1.95% (Khattabi and Alami 2005) 2.1% (Alami 2009) 0.33% (Morocco MOH 2007) 0.0% (Morocco MOH 2007) 44 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 4.1 (Continued ) Country HIV prevalence among FSWs Pakistan 0.0% (Iqbal and Rehan 1996) 0.0% (Baqi et al. 1998) 0.0% (Bokhari et al. 2007) 0.5% (Bokhari et al. 2007) 0.2% (Pakistan National AIDS Control Program 2005) 0.02% (Pakistan National AIDS Control Program 2006­07) 0.2% (UNFPA 2009) 0.0% (Rawalpindi; Hawkes et al. 2009) 0.0% (Abbottabad; Hawkes et al. 2009) Somalia 0.0% (Jama et al. 1987) 0.0% (Burans et al. 1990) 2.1% (Watts et al. 1994) 2.4% (Corwin et al. 1991) 8.3% (Corwin et al. 1991) 0.0% (Corwin et al. 1991) 0.6% (Ahmed et al. 1991) 5.2% (Testa and Kriitmaa 2009) Sudan 0.0% (Burans et al. 1990) 16.0% (Southern Sudan; McCarthy, Khalid, and El Tigani 1995) 4.4% (Ahmed 2004d) 1.55% (FSWs and tea sellers; Basha 2006) 1.7% (Anonymous 2007) Tunisia 2.3% (UNAIDS 2008) Turkey 0.0% (Orak, Dalkilic, and Ozbal 1991) 0.0% (Gul et al. 2008) 0.0% (Tiras et al. 1998) Yemen, Republic of 4.5% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006) 2.7% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006) 7.0% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006; Al-Qadhi 2001) 1.3% (Stulhofer and Bozicevic 2008) 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." Commercial Sex and HIV 45 FSWs in MENA often report high levels of themselves trapped or tricked into sex work by sexual violence and abuse.16 The abuse takes friends and colleagues already involved in sex different forms including verbal, physical, sex- work, either as a cover-up of their activities or ual, or being pimped against their will.17 The as a silencing tactic.26 perpetrators of the abuse are often clients, hus- bands, lovers, and neighbors as well as the police and other state actors.18 Eight percent of FORMS OF COMMERCIAL SEX FSWs in Pakistan in one study reported being Sex work is prevalent all over MENA and its sexually violated by police in the last year and forms are changing rapidly due to the changes in 35% reported providing free sex to police in the the socioeconomic conditions and the use of last year.19 Five percent of these FSWs reported modern communications, such as mobile phones. that their first sex was forced.20 Commercial sex, long an invisible trade in this Political conflicts and social and economic part of the world, is now becoming visible in inequalities also fuel sexual exploitation and large cities, even in once very conservative and trafficking of women across national boundar- traditional societies.27 It is taking place at different ies.21 Several countries in MENA are source or venues including homes, hotels, nightclubs, transit countries for women and children traf- streets, brothels, Kothikhana ("grand houses"),28 ficked for the purpose of sexual exploitation at client homes,29 massage parlors, "pimp"-run or destination countries within MENA.22 The occu- individually run permanent houses,30 "red flats,"31 pation of Iraq in 2003 has led to abductions of beaches,32 rental houses near army bases and women and girls to be sold for prostitution, or market places,33 truck stops,34 and in bazaars.35 being violently forced to engage in sex work for As in other regions, commercial sex has a survival or because of economic necessity, both complex tapestry and it is difficult to provide a inside Iraq and in neighboring countries.23 clear-cut definition of this practice as it involves Though the vast majority of sex work in contacts with sex workers, other forms of trans- MENA is driven by economic necessity, there is actional sex, and other nonregular sexual con- evidence of "means-to-an-end" or lifestyle sex tacts.36 It takes a variety of forms, including that work involving middle class young women who of street children and runaway adolescents con- use commercial sex to pay for education fees trolled by older adults37; high-class mobile while attending universities, or to attain social FSWs38; mobile-phone networks39; "call girls"40; prestige by purchasing luxury goods to maintain a higher lifestyle.24 The recent rapid increase in 26 Ibid. the age at marriage among women creates a 27 Busulwa, "HIV/AIDS Situation Analysis Study"; Jenkins, "Report on window of vulnerability where women may Sex Worker Consultation in Iran." 28 succumb to sex work with the lure of incentives Kothikhana are generally small premises that are rented by a madam and/or broker where a small number of FSWs engage in sex work and presents.25 Young women sometimes find (Pakistan National AIDS Control Program, HIV Second Generation Surveillance [Rounds I, II, and III]); Blanchard, Khan, and Bokhari, "Variations in the Population Size." 16 29 Pakistan National AIDS Control Program, HIV Second Generation ACORD, "Socio Economic Research." 30 Surveillance (Round I and II); Mayhew et al., "Protecting the Ati, "HIV/AIDS/STIs Social and Geographical Mapping." 31 Unprotected"; Stulhofer and Bozicevic, "HIV Bio-Behavioural Survey"; El-Gawhary, Sex Tourism in Cairo. 32 Syria National AIDS Programme, "HIV/AIDS Female Sex Workers." Stulhofer and Bozicevic, "HIV Bio-Behavioural Survey." 17 33 Mayhew et al., "Protecting the Unprotected." ACORD, "Socio Economic Research"; ACORD, "Qualitative Socio 18 Ibid. Economic Research." 19 34 Hawkes et al., "HIV and Other Sexually Transmitted." Stulhofer and Bozicevic, "HIV Bio-Behavioural Survey." 20 35 Ibid. World Bank, "Mapping and Situation Assessment." 21 36 Huda, "Sex Trafficking in South Asia." Morison et al., "Commercial Sex"; Carael et al., "Clients of Sex 22 Ibid. Workers"; Lowndes et al., "Role of Core and Bridging Groups"; Aral 23 Al-Ali, "Reconstructing Gender"; Al-Ali, "Iraqi Women: Untold Stories"; and St. Lawrence, "The Ecology of Sex Work and Drug Use"; Aral Hassan, "Iraqi Women under Occupation." et al., "The Social Organization of Commercial Sex." 24 37 Busulwa, "HIV/AIDS Situation Analysis Study"; Algeria MOH, Rapport Ati, "HIV/AIDS/STIs Social and Geographical Mapping." 38 de l'enquête nationale de séro-surveillance; Jenkins, "Report on Sex Ibid. 39 Worker Consultation in Iran"; Ati, "HIV/AIDS/STIs Social and Busulwa, "HIV/AIDS Situation Analysis Study." 40 Geographical Mapping." Pakistan National AIDS Control Program, HIV Second Generation 25 Ati, "HIV/AIDS/STIs Social and Geographical Mapping." Surveillance (Round II). 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." Commercial Sex and HIV 47 public officials, youth, truck drivers, sailors, and 31% reported a sexual contact with an FSW migrant workers, traders, rich business people, within the last three months.81 single men with well-paying jobs, men with The number of clients of sex workers is much frequent travel, and Persian Gulf country tour- bigger than that of the number of FSWs. In ists.65 Several studies assessed the prevalence of Pakistan, for example, the average number of sexual contacts with sex workers. Broadly clients per sex worker per month was 33.7.82 speaking, levels of contacts appear comparable Therefore, the size of commercial sex networks to those in other regions, but on the low side.66 is substantially bigger than that of IDUs and In Afghanistan, 39% of truck drivers reported MSM risk networks, implying a substantially having access to FSWs and 7% have had sex larger potential bridging population. The number with FSWs in the last 12 months.67 In Jordan, of clients of sex workers in one study in Pakistan most voluntary counseling and testing (VCT) was found to be much larger than that of spouses attendees reported contacts with sex workers as of IDUs.83 the reason for attending VCT services (Jordan National AIDS Program, personal communica- tion). In Pakistan, 34% of truck drivers68 and COMMERCIAL SEX AND RISK BEHAVIOR 34.7% of migrant workers69 reported contacts with FSWs.70 This section reviews evidence on different In Somalia, 48% of a group of healthy men aspects of sexual risk behavior among FSWs, reported contacts with FSWs.71 Also in Somalia, a including frequency of contacts with clients, group of predominantly soldiers attending sexu- nature of commercial sex networks, condom ally transmitted disease (STD) clinics reported use, STI (sexually transmitted infection) trans- contacts with sex workers at a frequency of 1.51 mission, anal and oral sex, and engagement of contacts per week.72 In Sudan, 3.1% of mainly FSWs in injecting drug risk behavior. rural populations in six states,73 7.6% of prison- ers,74 71% of a group of truck drivers and pris- Frequency of contacts with clients oners,75 and 57% of a group of soldiers, truck drivers, outpatients, and Ethiopian refugees The higher the frequency of sexual contacts with reported contacts with FSWs.76 Also in Sudan, clients, the larger the potential for HIV to spread in 11.7% of military personnel,77 8.1% of truck commercial sex networks. Data suggest that FSWs drivers,78 and 8.6% of prisoners79 reported pay- in MENA have an average of about one client or ing for sex. Among STD clinic attendees, 49.3% less per calendar day, but a higher number per acquired their STD from sex workers.80 Among work day, broadly consistent with, but on the low mostly Sudanese refugees in Ethiopia, 46% of side of, global trends.84 In Afghanistan, FSWs males reported having ever had sex with an FSW, reported an average of 13.1 clients per month in one study,85 and in another study, 84% of them reported having one or two clients per working 65 Busulwa, "HIV/AIDS Situation Analysis Study"; Action Aid day, with 14% reporting three clients daily.86 In Afghanistan, "HIV AIDS in Afghanistan"; Ati, "HIV/AIDS/STIs Social the Islamic Republic of Iran, it is estimated that and Geographical Mapping"; ACORD, "Socio Economic Research." 66 Carael et al., "Clients of Sex Workers." FSWs have five to nine customers per week,87 67 Action Aid Afghanistan, "HIV AIDS in Afghanistan." 68 Agha, "Potential for HIV Transmission." 69 Faisel and Cleland, "Study of the Sexual Behaviours." 70 81 Agha, "Potential for HIV Transmission." Holt et al., "Planning STI/HIV Prevention." 71 82 Ismail et al., "Sexually Transmitted Diseases in Men." Blanchard, Khan, and Bokhari, "Variations in the Population Size." 72 83 Burans et al., "HIV Infection Surveillance in Mogadishu, Somalia." Ibid. 73 84 SNAP, UNICEF, and UNAIDS, "Baseline Study." Morison et al., "Commercial Sex"; Lau et al., "A Study on Female Sex 74 Assal, "HIV Prevalence." Workers"; Strathdee et al., "Characteristics of Female Sex Workers"; 75 Burans et al., "Serosurvey of Prevalence." Elmore-Meegan, Conroy, and Agala, "Sex Workers in Kenya"; Wilson 76 McCarthy et al., "Hepatitis B and HIV in Sudan." et al., "Sex Worker." 77 85 Ahmed, Military. World Bank, "Mapping and Situation Assessment." 78 86 Ahmed, Truck Drivers. Action Aid Afghanistan, "HIV AIDS in Afghanistan." 79 87 Ahmed, Prisoners. Mostashari, UNODC, and Darabi, "Summary of the Iranian Situation on 80 Taha et al., "Study of STDs." HIV Epidemic." 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." Commercial Sex and HIV 49 and other STIs in commercial sex networks.119 In Pakistan, 17%­18% of FSWs in different Clustering of commercial sex networks into settings always used condoms and 19%­26% smaller subnetworks can reduce the overall STI did not use condoms during the last month.129 prevalence among FSWs.120 Given the limita- In another study, 29%­49% of FSWs used a tions of the data, it is not possible to infer the condom with a one-time client during last sex, connectivity of commercial sex networks in 26%­47% used a condom with a regular client MENA. during last sex, and 21% used a condom with a nonpaying male during last sex.130 Condom use during anal or oral sex was found to be more Condom use limited than its use in vaginal sex; only 7.9% of Reported condom use among FSWs varies sub- FSWs used a condom during last anal sex and stantially in MENA, although it appears to have 32.4% during last oral sex.131 Also in Pakistan, been increasing in recent years. And while con- 10% of migrant workers who had sex with dom use is already at intermediate to high levels FSWs used condoms.132 in several settings in MENA, it is still overall at In Sudan, 13% of FSWs used condoms low levels, particularly in the parts of MENA regularly,133 and as reported in different studies, that are experiencing concentrated HIV epidem- 10.3%,134 24.6%,135 57.8%,136 and 23%137 had ics among commercial sex workers, such as in ever used condoms. In yet another study, only Southern Sudan. This suggests that the majority 2% of clients of FSWs used condoms during last of at-risk commercial sex acts in MENA are sex.138 According to studies in Syria, 13.2%, unprotected against HIV. 20.6%, 51%, and 15.2% always used condoms, A number of studies documented condom often used condoms, sometimes used condoms, use among FSWs in MENA. In Afghanistan, and never used condoms, respectively.139 In 36% of FSWs had ever used condoms.121 In Tunisia, only 37% of FSWs always used con- Egypt, 6% of FSWs always used condoms,122 doms, and 65% had ever used condoms, even 56% had ever used condoms,123 and 6.8% used though these FSWs are legal sex workers with condoms with noncommercial partners during free access to primary care centers.140 In the last sex.124 In the Islamic Republic of Iran, 24% Republic of Yemen, 57.1% of FSWs used a con- and 83.2% of two FSW groups used condoms dom during last paid sex, 28.8% used a condom with the most recent client.125 In studies in during last nonpaid sex, 50% used condoms Lebanon, 28.1%, 34.8%, and 11.9% of FSWs consistently with nonregular clients, and 58% reported that they always used condoms with used condoms consistently with regular cli- nonregular clients, regular clients, and regular ents.141 Further data on condom use among partners, respectively.126 Almost 21% of these FSWs can be found in table 8.2. FSWs have never used condoms.127 In a more Knowledge of condoms for HIV prevention, recent study, 98%, 94%, and 43% of FSWs used or as a birth control measure, appears to be condoms during last sex with a nonregular part- rather high among FSWs, but still low in some ner, a regular partner, and a regular client, respectively.128 129 Pakistan National AIDS Control Program, "Pilot Study in Karachi & Rawalpindi." 130 Bokhari et al., "HIV Risk in Karachi and Lahore, Pakistan." 119 131 Ghani and Aral, "Patterns of Sex Worker-Client Contacts." Pakistan National AIDS Control Program, HIV Second Generation 120 Ibid. Surveillance (Round II). 121 132 World Bank, "Mapping and Situation Assessment." Faisel and Cleland, "Study of the Sexual Behaviours"; Faisel and 122 El-Sayed et al., "Evaluation of Selected Reproductive Health Cleland, "Migrant Men." 133 Infections." Ati, "HIV/AIDS/STIs Social and Geographical Mapping." 123 134 Ibid. Ahmed, Sex Sellers. 124 135 Egypt MOH and Population National AIDS Program, HIV/AIDS ACORD, "Qualitative Socio Economic Research." 136 Biological and Behavioral Surveillance Survey. Ati, "HIV/AIDS/STIs Social and Geographical Mapping." 125 137 Jahani et al., "Distribution and Risk Factors."; Ardalan et al., "Sex for Anonymous, "Improving HIV/AIDS Response." 138 Survival." SNAP, UNICEF, and UNAIDS, "Baseline Study." 126 139 Hermez et al., "HIV/AIDS Prevention among Vulnerable Groups." Syria National AIDS Programme, "HIV/AIDS Female Sex Workers." 127 140 Hermez, "HIV/AIDS Prevention through Outreach." Hassen et al., "Cervical Human Papillomavirus Infection." 128 141 Mishwar, "An Integrated Bio-Behavioral Surveillance Study." Stulhofer and Bozicevic, "HIV Bio-Behavioural Survey." 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 Stulhofer and Bozicevic, "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." Commercial Sex and HIV 51 worker.170 In Saudi Arabia, 90% of men who Engagement of FSWs in injecting drug risk were infected with HIV heterosexually acquired behavior it from FSWs.171 In Somalia, two studies reported FSWs report considerable levels of drug use both that 40%172 and 54%173 of STD clinic attendees in injecting and noninjecting forms, and also reported contacts with FSWs. In Sudan, 49.3% report having sex with IDUs. These facts high- of STD patients reported acquiring their infec- light the ease by which HIV can move between tion from FSWs.174 HIV prevalence in Southern IDUs and FSWs. In particular, FSWs who inject Sudan was 14% among men who reported con- drugs, or female IDUs who exchange sex for tacts with FSWs, but 0% among men who money or drugs, form subgroups at a height- denied such contacts.175 ened risk of HIV exposure, as has been seen in Asia.184 These FSWs are highly marginalized Anal sex, oral sex, and STIs as cofactors and in urgent need of prevention and care programs. Several studies have documented anal and oral Several studies have documented drug use sex practices in MENA. In Pakistan, FSWs in dif- among FSWs and sexual contacts with IDUs, but ferent cities reported having anal sex with a the data on female IDUs exchanging sex for range of 0.6­4.1 clients last month.176 In Sudan, money are limited. In Egypt, 9.3% of FSWs about 55% of FSWs reported engaging in anal injected drugs and 78.8% used drugs.185 In the sex and 40% did so regularly.177 Most often this Islamic Republic of Iran, 2% of a group of mainly was demanded or imposed by clients, but on FSWs injected drugs and 15.3% reported nonin- occasion FSWs opted for anal sex to avoid preg- jecting drug use.186 In another study, 2.5% of nancy or to avoid having vaginal sex during FSWs injected drugs and 60% used drugs.187 In menstruation.178 The HIV transmission probabil- Pakistan, 20% of FSWs reported that they had ity per coital act in unprotected receptive anal clients whom they knew to inject drugs and intercourse (0.0082)179 is much higher than that 1%­2% of FSWs reported injecting drugs.188 Also, of vaginal intercourse (0.0015).180 in two studies in Pakistan, 3.3%189 and 2.3%190 of Oral sex appears to be common and was FSWs reported injecting drugs in the last six reported by 40% of FSWs in a study in Sudan.181 months and 13.5%191 and 9.9%192 had sex with In Pakistan, FSWs in different cities reported IDUs. In yet more studies from Pakistan, 3% of oral sex with a range of 0.6­3.8 clients last FSWs reported injecting drugs in the last year,193 month.182 36% reported having sex with an IDU in the last Only 3% of FSWs in a study in Sudan reported year,194 20.3% reported IDUs as clients,195 22.4% refraining from sex while suffering from a reported lovers who inject drugs,196 and 26% reproductive tract infection, a practice of con- reported having a husband who injects drugs.197 cern considering the biological association of HIV transmission and STI coinfections.183 184 Commission on AIDS in Asia, Redefining AIDS in Asia. 185 Egypt MOH and Population National AIDS Program, HIV/AIDS Biological and Behavioral Surveillance Survey. 170 186 Rehan, "Profile of Men." Jahani et al., "Distribution and Risk Factors." 171 187 Alrajhi, Halim, and Al-Abdely, "Mode of Transmission of HIV-1." Tehrani and Malek-Afzalip, "Knowledge, Attitudes and Practices." 172 188 Burans et al., "HIV Infection Surveillance in Mogadishu, Somalia." Bokhari et al., "HIV Risk in Karachi and Lahore, Pakistan." 173 189 Ismail et al., "Sexually Transmitted Diseases in Men." Pakistan National AIDS Control Program, HIV Second Generation 174 Omer et al., "Sexually Transmitted Diseases in Sudanese Males." Surveillance (Round I). 175 190 McCarthy, Khalid, and El Tigani, "HIV-1 Infection in Juba, Southern Pakistan National AIDS Control Program, HIV Second Generation Sudan." Surveillance (Round II). 176 191 Pakistan National AIDS Control Program, HIV Second Generation Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). Surveillance (Round I). 177 192 Ati, "HIV/AIDS/STIs Social and Geographical Mapping." Pakistan National AIDS Control Program, HIV Second Generation 178 Ibid. Surveillance (Round II). 179 193 Vittinghoff et al., "Per-Contact Risk." Mayhew et al., "Protecting the Unprotected"; Hawkes et al., "HIV and 180 Wawer et al., "Rates of HIV-1 Transmission." Other Sexually Transmitted Infections." 181 194 Ati, "HIV/AIDS/STIs Social and Geographical Mapping." Hawkes et al., "HIV and Other Sexually Transmitted Infections." 182 195 Pakistan National AIDS Control Program, HIV Second Generation Mayhew et al., "Protecting the Unprotected." 196 Surveillance (Round I). Ibid. 183 197 Korenromp et al., "Estimating the Magnitude." Hawkes et al., "HIV and Other Sexually Transmitted Infections." 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 Stulhofer and Bozicevic, "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 Stulhofer and Bozicevic, "HIV Bio-Behavioural Survey." Zargooshi, "Characteristics of Gonorrhoea." Commercial Sex and HIV 53 FSWs; anal and oral sex in addition to vaginal Control Program, and the World Health sex; having clients or sexual partners who inject Organization. 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: 2404­6. 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: 119­23. 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: 776­86. 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: 739­58. 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: 509­12. 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: 594­99. 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: 852­59. Networks." Int J STD AIDS 18: 486­92. 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: 466­72. "Mode of Transmission of HIV-1 in Saudi Arabia." Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani, AIDS 18: 1478­80. 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: 650­55. 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 iii26­33. 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: 798­805. Cancer in Rabat, Morocco." Int J Cancer 75: 546­54. 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: 39­45. 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: 187­219. D. M. Watts. 1991. "HIV-1 in Somalia: Prevalence Assal, M. 2006. "HIV Prevalence, Knowledge, Attitude, and Knowledge among Prostitutes." AIDS 5: 902­4. 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: 144­48. 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: 73­79. Report (September­October). 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: 50­57. Setting: Implications for HIV Prevention Strategies." El-Sayed, N., M. Abdallah, A. Abdel Mobdy, A. Abdel Sex Transm Infect 83 Suppl 1: i30­36. 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. ii24­27. 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. Commercial Sex and HIV 55 Faisel, A., and J. Cleland. 2006a. "Migrant Men: A Huda, S. 2006. "Sex Trafficking in South Asia." Int J Priority for HIV Control in Pakistan?" Sex Transm Infect Gynaecol Obstet 94: 374­81. 82: 307­10. Indonesia MOH (Ministry of Health). 2002. National ------. 2006b. "Study of the Sexual Behaviours and Estimates of Adult HIV Infection, Indonesia. Workshop Prevalence of STIs among Migrant Men in Lahore, report. Pakistan." Arjumand and Associates, Centre for Institut de Formation Paramédicale de Parnet. 2004. Population Studies, London School of Hygiene and Rapport de la réunion d'évaluation a mis-parcours de Tropical Medicine. l'enquête de sero-surveillance du VIH. Juin. Family Health International. 2007. "Implementing AIDS Iqbal, J., and N. Rehan. 1996. "Sero-Prevalence of HIV: Prevention and Care (IMPACT) Project." USAID, Six Years' Experience at Shaikh Zayed Hospital, Egypt Final Report, April 1999­September 2007. Lahore." J Pak Med Assoc 46: 255­58. Farah, M. S., and S. Hussein. 2006. "HIV Prevalence, Ismail, S. O., H. J. Ahmed, L. Grillner, B. Hederstedt, A. Knowledge, Attitude, Practices and Risk Factors Issa, and S. M. Bygdeman. 1990. "Sexually among Truck Drivers in Khartoum State." Grey Transmitted Diseases in Men in Mogadishu, Somalia." Report. Sudan National AIDS Program. Int J STD AIDS 1: 102­6. Fares, G., et al. 2004. Rapport sur l'enquête nationale de Jahani, M. R., S. M. Alavian, H. Shirzad, A. Kabir, and B. sero-surveillance sentinelle du VIH et de la syphilis en Hajarizadeh. 2005. "Distribution and Risk Factors of Algérie en 2004. Ministère de la Santé de la population Hepatitis B, Hepatitis C, and HIV Infection in a et de la reforme hospitalière, Alger, Décembre. Female Population with `Illegal Social Behaviour.'" Fisher, J. C., H. Bang, and S. H. Kapiga. 2007. "The Sex Transm Infect 81: 185. Association between HIV Infection and Alcohol Use: Jama, H., L. Grillner, G. Biberfeld, S. Osman, A. Isse, M. A Systematic Review and Meta-Analysis of African Abdirahman, and S. Bygdeman. 1987. "Sexually Studies." Sex Transm Dis 34: 856­63. Transmitted Viral Infections in Various Population Fox, E., R. L. Haberberger, E. A. Abbatte, S. Said, D. Groups in Mogadishu, Somalia." Genitourin Med 63: Polycarpe, and N. T. Constantine. 1989. "Observations 329­32. on Sexually Transmitted Diseases in Promiscuous Jenkins, C., and D. A. Robalino. 2003. "HIV in the Males in Djibouti." J Egypt Public Health Assoc 64: Middle East and North Africa: The Cost of Inaction." 561­69. Orientations in Development Series. Washington, Ghani, A. C., and S. O. Aral. 2005. "Patterns of Sex DC: World Bank. Worker-Client Contacts and Their Implications for Kaljee, L. M., B. L. Genberg, T. T. Minh, L. H. Tho, L. the Persistence of Sexually Transmitted Infections." J T. Thoa, and B. Stanton. 2005. "Alcohol Use and Infect Dis 191 Suppl 1: S34­41. HIV Risk Behaviors among Rural Adolescents in Gul, U., A. Kilic, B. Sakizligil, S. Aksaray, S. Bilgili, O. Khanh Hoa Province Viet Nam." Health Educ Res 20: Demirel, and C. Erinckan. 2008. "Magnitude of 71­80. Sexually Transmitted Infections among Female Sex Khan, S., M. A. Rai, M. R. Khanani, M. N. Khan, and S. Workers in Turkey." J Eur Acad Dermatol Venereol 22: H. Ali. 2006. "HIV-1 Subtype A Infection in a 1123­24. Community of Intravenous Drug Users in Pakistan." BMC Infect Dis 6: 164. Hassan, G. 2005. "Iraqi Women under Occupation." Brussells Tribunal (www.brusselstribunal.org), May. Khattabi, H., and K. Alami. 2005. "Surveillance sentinelle du VIH, Résultats 2004 et tendance de la séropréva- Hassen, E., A. Chaieb, M. Letaief, H. Khairi, A. Zakhama, lence du VIH." Morocco Ministry of Health, S. Remadi, and L. Chouchane. 2003. "Cervical Human UNAIDS. Papillomavirus Infection in Tunisian Women." Infection 31: 143­48. Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. Vermund. 1997. "HIV/AIDS and Its Risk Factors in Hawkes, S., M. Collumbien, L. Platt, N. Lalji, N. Rizvi, A. Pakistan." AIDS 11: 843­48. Andreasen, J. Chow, R. Muzaffar, H. ur-Rehman, N. Siddiqui, S. Hasan, and A. Bokhari. 2009. "HIV and Korenromp, E. L., S. J. de Vlass, N. J. Nagelkerke, and J. Other Sexually Transmitted Infections among Men, D. Habbema. 2001. "Estimating the Magnitude of Transgenders and Women Selling Sex in Two Cities STD Cofactor Effects on HIV Transmission: How Well in Pakistan: A Cross-Sectional Prevalence Survey." Can It Be Done?" Sex Transm Dis 28: 613­21. Sex Transm Infect 85 Suppl 2: ii8­16. Lambert, L. 2007. "HIV and Development Challenges in Hermez, J. Unknown. "HIV/AIDS Prevention through Yemen: Which Grows Fastest?" Health Policy and Outreach to Vulnerable Populations in Beirut, Planning 22: 60. Lebanon." Grey Report, Beirut, Lebanon. Lau, J. T., H. Y. Tsui, P. C. Siah, and K. L. Zhang. 2002. Hermez, J., E. Aaraj, O. Dewachi, and N. Chemaly. "A Study on Female Sex Workers in Southern China Unknown. "HIV/AIDS Prevention among Vulnerable (Shenzhen): HIV-Related Knowledge, Condom Use Groups in Beirut, Lebanon." PowerPoint presenta- and STD History." AIDS Care 14: 219­33. tion, Lebanon National AIDS Program, Beirut. Lowndes, C. M., M. Alary, H. Meda, C. A. Gnintoungbe, L. Mukenge-Tshibaka, C. Adjovi, A. Buve, L. Morison, Holt, B. Y., P. Effler, W. Brady, J. Friday, E. Belay, K. M. Laourou, L. Kanhonou, and S. Anagonou. 2002. Parker, and M. Toole. 2003. "Planning STI/HIV "Role of Core and Bridging Groups in the Transmission Prevention among Refugees and Mobile Populations: Dynamics of HIV and STIs in Cotonou, Benin, West Situation Assessment of Sudanese Refugees." Disasters Africa." Sex Transm Infect 78 Suppl 1: i69­77. 27: 1­15. 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: 51­56. 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: 164­67. Behavioral Surveillance 2004­5. Mayhew, S., M. Collumbien, A. Qureshi, L. Platt, N. Rafiq, ------. 2006­7. 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: ii31­36. ------. 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: 911­15. 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: 5­10. 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: 726­31. Lebanon." Emerg Infect Dis 4: 649­56. 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: 18­20. 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: S60­65. 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: 180­81. 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: 682­86. "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: S61­69. Sexual Behavior, Knowledge of Sexually Transmitted Morocco MOH (Ministry of Health, Ministère de la Infections and Treatment Utilization among a Santé). 2003­4. 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: 642­48. 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: 812­14. 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: 208­10. 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: iii18­25. 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: 263­68. 306­11. Stulhofer, A., and I. Bozicevic. 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 (1986­1990)." J Trop Med Hyg 96: Female Sex Workers KABP Survey in Syria." Grey 113­17. 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: 55­56. Vener Dis 55: 313­15. 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: 1403­9. 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: 157­58. in Harare, Zimbabwe." AIDS Care 1: 269­80. 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: 460­61. Algeria. 58 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Chapter 5 Potential Bridging Populations and HIV 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 Country HIV prevalence in potential bridging populations 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." Potential Bridging Populations and HIV 61 behaviors), and probably rarely spread the Ahmed, A. J., N. Hassan, O. Pasha, S. Fisher-Hoch, J. B. infection further. In this sense, they are not a McCormick, and S. P. Luby. 1995. "Prevalence of STDs among Long-Distance Truck Drivers in bridging population that would pass the infec- Pakistan." Proceedings of the Conference on HIV tion into the general population. This aspect of Surveillance, Karachi, Pakistan. HIV epidemiology in MENA could be one of the Ahmed, S. M. 2004a. Military: Situation Analysis-Behavioral factors behind the consistently very low HIV Survey Results & Discussions. Report. Sudan National AIDS Control Program. prevalence found in the general population ------. 2004b. Truck Drivers: Situation Analysis-Behavioral (chapter 6). Survey Results & Discussions. Report. Sudan National AIDS Control Program. Aidaoui, M., S. Bouzbid, and M. Laouar. 2008. ANALYTICAL SUMMARY "Seroprevalence of HIV Infection in Pregnant Women in the Annaba Region (Algeria)." Rev Epidemiol Sante A sizable fraction of the MENA population Publique 56: 261­66. 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: 1478­80. 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: 486­92. 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: 466­72. 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: 307­10. 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: 2404­6. 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: 843­48. 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: 725­29. 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: 18­20. 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: 279­80. 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: 2­4. 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 30­Nov 2. deficiency Virus (HIV/AIDS Patients) in a Private ------. 2007. "Prevention and Control of Sexually Clinic in Tehran, Iran." Arch Iran Med 9: 315­18. Transmitted Infections in the WHO Eastern Ryan, S. 2006. "Travel Report Summary." Kabul, Mediterranean Region." Intercountry meeting, Afghanistan. UNAIDS, February 27­March 7, 2006. PowerPoint presentation. Potential Bridging Populations and HIV 63 Chapter 6 General Population and HIV This chapter focuses on the biological evidence with the exception Djibouti, Somalia, and for the extent of human immunodeficiency Sudan. Tables 6.1­6.3 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 Table 6.1 HIV Prevalence in Population-Based Surveys in MENA Country HIV prevalence 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 Country HIV prevalence Afghanistan 0.0% (Todd et al. 2007; Todd et al. 2008) Algeria 1.0% (Institut de Formation Paramédicale de Parnet 2004) 0.53% (Aidaoui, Bouzbid, and Laouar 2008) 0.7% (Algeria MOH [unknown]) 0.9% (Algeria MOH [unknown]) 0.2% (Alami 2009) 0.14% (Alami 2009) 0.09 (Alami 2009) 0.5% (Alami 2009) 0.23% (Alami 2009) Djibouti 2.5% (Unknown 2002) Iran, Islamic Republic of 0.02% (Ministry of Health and Medical Education of Iran 2006) 0.1% (WHO/EMRO 2007a) 0.5% (SeyedAlinaghi 2009) 0.05% (Sharifi-Mood and Keikha 2008) Mauritania 0.4% (WHO 2002) Morocco 0.03% (Khattabi and Alami 2005) 0.0025% (Khattabi and Alami 2005) 0.014% (Khattabi and Alami 2005) 0.0% (WHO/EMRO Regional Database on HIV/AIDS) 0.12% (Khattabi and Alami 2005; Morocco MOH 2006) 0.13% (UNAIDS/WHO 2005; Morocco MOH 2006) 0.04% (Elharti et al. 2002) 0.02% (Elharti et al. 2002) 0.01% (Elharti et al. 2002) 0.07% (Elharti et al. 2002) 0.15% (Khattabi and Alami 2005) 0.10% (Khattabi and Alami 2005) 0.08% (Alami 2009) 0.06% (Bennani and Alami 2006) Somalia 0.0% (Jama et al. 1987) 0.9% (WHO 2004c) 0.9% (Somaliland; WHO 2004c) 1.4% (Somaliland; WHO 2004c) 1.3% (Somaliland; WHO 2004c; Somaliland Ministry of Health and Labour 2007) 0.7% (Somaliland Ministry of Health and Labour 2007) 1.6% (Somaliland Ministry of Health and Labour 2007) 0.0% (Somaliland Ministry of Health and Labour 2007) 2.3% (Somaliland Ministry of Health and Labour 2007) 0.6% (Somaliland Ministry of Health and Labour 2007) 1.1% (Somaliland Ministry of Health and Labour 2007) 1.6% (Somaliland Ministry of Health and Labour 2007) 2.7% (Somaliland Ministry of Health and Labour 2007) 0.0% (Somaliland Ministry of Health and Labour 2007) 1.3% (Somaliland Ministry of Health and Labour 2007) 2.2% (Somaliland Ministry of Health and Labour 2007) 0.8% (Somaliland Ministry of Health and Labour 2007) 1.0% (Puntland; WHO 2004b) 0.6% (central Somalia; WHO 2004c) 0.7% (refugees; UNHCR 2003) 1.4% (refugees; UNHCR 2005) 1.0% (refugees; UNHCR 2006­07a) 1.5% (refugees; UNHCR 2006­07a) 1.6% (refugees; UNHCR 2006­07a) 1.2% (refugees; UNHCR 2006­07a) 66 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 6.2 (Continued) Country HIV prevalence 0.6% (refugees; UNHCR 2006­07a) 0.7% (refugees; UNHCR 2006­07a) 1.9% (refugees; UNHCR 2006­07a) 0.1% (refugees; PMTCT attendees; UNHCR 2006­07a) Sudan 1.0% (national; Sudan National AIDS/STIs Program 2008; Sudan National HIV/AIDS Control Program 2005b) 1.0% (Ahmed 2004b) 0.58% (national; Sudan National AIDS/STIs Program 2008) 0.5% (Gutbi and Eldin 2006) 1.57% (IDPs; SNAP and UNAIDS 2006) 0.26% (refugees; Sudan National AIDS/STIs Program 2008) 0.27% (IDPs; Sudan National AIDS/STIs Program 2008) 6­8% (Southern Sudan; UNAIDS and WHO 2003) 3.4% (Southern Sudan; Southern Sudan AIDS Commission 2007) 2.3% (Southern Sudan; NSNAC and UNAIDS 2006) 0­11.1% (various locations; Southern Sudan; Southern Sudan AIDS Commission 2007) 3.0% (Juba, Southern Sudan; Basha 2006) 4.0% (Juba, Southern Sudan; Basha 2006) 2.3% (Yei town; Southern Sudan; SNAP, NSNAC, and UNAIDS 2006; Kaiser et al. 2006) 2.3% (Rumbek town; Southern Sudan; SNAP, NSNAC, and UNAIDS 2006; Kaiser et al. 2006) 1.6% (Tambura; Southern Sudan; NSNAC and UNAIDS 2006) 2.0% (Ezo; Southern Sudan; NSNAC and UNAIDS 2006) 7.2% (Yambio; Southern Sudan; NSNAC and UNAIDS 2006) 8.7% (Yambio; villages near main road; Southern Sudan; NSNAC and UNAIDS 2006) 3.0% (Yambio; villages away from main road; Southern Sudan; NSNAC and UNAIDS 2006) 0.19% (North Sudan; Sudan National AIDS/STIs Program 2008) 0.66% (PMTCT attendees; North Sudan; SNAP 2008; NSNAC and UNAIDS 2006) 0.14% (urban; North Sudan; Sudan National AIDS/STIs Program 2008) 0.33% (rural; North Sudan; Sudan National AIDS/STIs Program 2008) 2.0% (West Nile; North Sudan; Sudan MOH 2006) 1.5% (Red Sea; North Sudan; Sudan National HIV/AIDS Control Program 2005b) 0.0% (Algadarif; North Sudan; Sudan National HIV/AIDS Control Program 2005b) 0.0% (Kassala; North Sudan; Sudan National HIV/AIDS Control Program 2005b) 0.0% (Upper Nile; North Sudan; Sudan National HIV/AIDS Control Program 2005b) 0.98% (Algazira; North Sudan; Sudan National HIV/AIDS Control Program 2005b) 0.0% (Algazira; North Sudan; SNAP and UNAIDS 2006) 0.0% (Blue Nile; North Sudan; SNAP and UNAIDS 2006) 0.0% (West Kurdufan; North Sudan; SNAP and UNAIDS 2006) 0.0% (North Darfur; North Sudan; SNAP and UNAIDS 2006) 2.2% (White Nile; North Sudan; Sudan National HIV/AIDS Control Program 2005b; SNAP and UNAIDS 2006) 0.0% (Upper Nile; North Sudan; SNAP and UNAIDS 2006) 1­5% (Khartoum; North Sudan; UNAIDS 2000) 0.25% (Khartoum; North Sudan; Gutbi and Eldin 2006) 0.5% (Khartoum 1; North Sudan; Sudan National HIV/AIDS Control Program 2005b; Gutbi and Eldin 2006) 0.25% (Khartoum 2; North Sudan; Sudan National HIV/AIDS Control Program 2005b; Gutbi and Eldin 2006) 0.25% (Khartoum 3; North Sudan; Sudan National AIDS Control Program 2005b; Gutbi and Eldin 2006) 0.8% (Khartoum; North Sudan; Ahmed 2004b) 1.38% (Khartoum; North Sudan; Gassmelseed et al. 2006) 5.0% (refugees; IRC 2002) 1.2% (refugees; UNHCR 2006­07b) 0.8% (PMTCT attendees; UNHCR 2006­07b) Note: IDP internally displaced person; PMTCT prevention of mother-to-child transmission. General Population and HIV 67 Table 6.3 HIV Prevalence among Blood Donors in MENA Country HIV prevalence Afghanistan 0.0% (Dupire et al. 1999) 0.0006% (Afghanistan Central Blood Bank 2006) Algeria 0.01% (Unknown 2002) 0.02% (Unknown 2002) 0.08% (Unknown 2002) 0.01% (Unknown 2002) Djibouti 0.0% (Marcelin et al. 2001) 1.9% (Dray et al. 2005) 3.4% (Massenet and Bouh 1997) Egypt, Arab Republic of 0.0% (Constantine et al. 1990) 0.0% (El-Ghazzawi, Hunsmann, and Schneider 1987) 0.0% (Kandela 1993) 0.02% (Watts et al. 1993) 0.0% (Quinti et al. 1995) Iran, Islamic Republic of 0.0018% (Rezvan, Abolghassemi, and Kafiabad 2007) 0.009% (Rezvan, Abolghassemi, and Kafiabad 2007) 0.005% (Rezvan, Abolghassemi, and Kafiabad 2007) 0.005% (Rezvan, Abolghassemi, and Kafiabad 2007) 0.0% (Pourshams et al. 2005) 0.003% (Khedmat et al. 2007) Jordan 0.004% (Al Katheeb, Tarawneh, and Awidi 1988) 0.0% (Jordan National AIDS Program, personal communication) Kuwait 0.01% (Kuwaitis; Ameen et al. 2005) 0.00% (non-Kuwaiti Arabs; Ameen et al. 2005) Mauritania 0.6% (WHO 2002) 0.8% (WHO 2002) Morocco 0.02% (Elmir et al. 2002; Elharti 2002) Pakistan 0.15% (Abdul Mujeeb and Hashmi 1988) 0.0% (Mujeeb et al. 1991) 0.003% (Kayani et al. 1994) 0.052% (Pakistan National Institute of Health 1992) 0.064% (Pakistan National Institute of Health 1995) 0.02% (Kakepoto et al. 1996) 0.0% (Iqbal and Rehan 1996) 0­0.06% (Sultan, Mehmood, and Mahmood 2007) 0.0% (college students; Mujeeb, Aamir, and Mehmood 2006; Abdul Mujeeb, Aamir, and Mehmood 2000) Qatar 0.03% (Qatar 2008) Saudi Arabia 0.02% (Al Rasheed et al. 1988) 0.0% (El-Hazmi 2004) 0.0% (Alamawi et al. 2003) Somalia 1.0% (Kulane et al. 2000) 0.8% (WHO 2003) Sudan 0­11% (various locations; Southern Sudan; NSNAC and UNAIDS 2006) 7.0% (Labone; Southern Sudan; NSNAC and UNAIDS 2006) 13.5% (Chukudum; Southern Sudan; NSNAC and UNAIDS 2006) 12.7% (Yei; Southern Sudan; NSNAC and UNAIDS 2006) 0.05% (Hashim et al. 1997) 0.9% (Winsbury 1996) 0.8­1.8% (WHO/EMRO 2007a) 1.25% (SNAP 2008) 68 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 6.3 (Continued) Country HIV prevalence Turkey 0.005% (Afsar et al. 2008) 0.0% (Afsar et al. 2008) 0.0% (Afsar et al. 2008) 0.015% (Coskun et al. 2008) 0­0.66% (Arabaci et al. 2003) West Bank and Gaza 0.006% (Maayan et al. 1994) 0.0% (Yassin et al. 2001) Yemen, Republic of 0.1­0.3% (WHO/EMRO 2007a) 0.04% (Yemen National AIDS Control Programme 1998) 0.29% (Yemen National AIDS Control Programme 2001) 0.02% (WHO/EMRO Regional Database on HIV/AIDS) 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." General Population and HIV 69 behavior than monogamy. Widowed and women reported exchanging sex for money.14 divorced women were also at higher risk of cer- Three percent of women, but no men, reported vical cancer, also suggesting higher levels of ever being forced to have sex.15 sexual risk behavior. The pattern of apparently Other studies have provided further data on higher levels of risky behavior among widowed sexual behavior. In Afghanistan, studies found or divorced women was also seen in Djibouti, that 0.2% and 0.7% of spouses reported that where single, divorced, separated, or widowed their husbands engaged in extramarital sexual women were found to have significantly higher contacts with men or boys, and other women, HIV prevalence (8.2%) compared to married respectively.16 In the Islamic Republic of Iran, women (2.3%).4 among runaways and other women seeking safe In the Morocco study, almost 20% of women haven, 40% of those sexually active reported reported more than one lifetime sexual partner, that their first sexual contact was with someone with 2% reporting more than three partners.5 other than their husband, and 6% reported a Six percent reported having more than one history of rape.17 In another study, 38% of cli- partner before reaching 20 years of age, and 2% ents of FSWs were married, suggesting that reported having nonspousal sexual partner- marriage does not preclude contact with FSWs.18 ships. One woman out of 203 women reported In Lebanon, 62.8% of the general population engaging in sex work. The study also reported a in one study had their first sexual intercourse mean of 1.3 lifetime sexual partners, a median prior to age 20, 32.1% had multiple sexual part- of 1, and a range of 1­4, and that the median ners, 22.4% had casual sex, and 36% had paid age at first sex was 18 years. Condom use was for sex.19 In another study, 52% of men were limited with only 16% of women having ever sexually active before age 20, and 22% of used condoms. Polygamous unions were reported unmarried men had sexual relations with non- by 12% of women and polygamy was associated regular partners.20 In a third study, 30.8% of the with cervical cancer, although not with statisti- general population was sexually active but cal significance as in the Algeria study.6 unmarried, and 13% of them had nonspousal A behavioral surveillance study among the regular partners.21 Of those who reported non- general population in Juba, Southern Sudan, also spousal regular partners, almost 20% had more provided valuable data.7 Thirty-one percent of than one partner. Of the respondents, 33.3% unmarried men 15­24 years of age and 62% of had their sexual debut between the ages of unmarried men 25­49 years of age had ever had 15 and 20 years, and 42.9% were sexually sex.8 Among women, the corresponding per- active by age 25.22 Among the sexually active centages were 8 and also 8, respectively.9 Casual population, 16.8% had nonregular sexual part- sex in the last year was reported by 11.7% of ners and 31.4% paid money or gifts for sex.23 men and 1.5% of women.10 The mean number In Pakistan, 6% of general population respon- of casual partners in the last year among those dents had extramarital affairs and only 5% had who had casual sex was two for both men and ever used condoms.24 In another study, the women.11 Casual sex was found to be much average frequency of coital acts, whether mari- more common among unmarried men (19%) tal or extramarital, was 3.5 per week.25 In than married men (4%).12 In the last year, 1.7% of men13 reported paying for sex and 0.2% of 14 Ibid. 15 Ibid. 16 Todd et al., "Seroprevalence and Correlates of HIV" (2008). 17 Hajiabdolbaghi et al., "Insights from a Survey." 4 18 Unknown, "Surveillance des infections à VIH." Zargooshi, "Characteristics of Gonorrhoea." 5 19 Chaouki et al., "The Viral Origin of Cervical Cancer." Lebanon National AIDS Control Program, "General Population 6 Hammouda et al., "Cervical Carcinoma in Algiers." Evaluation Survey." 7 20 UNHCR, "HIV Behavioural Surveillance Survey." WHO/EMRO, "Prevention and Control of Sexually Transmitted 8 Ibid. Infections." 9 21 Ibid. Jurjus et al., "Knowledge, Attitudes, Beliefs, and Practices." 10 22 Ibid. Ibid. 11 23 Ibid. Ibid. 12 24 Ibid. Raza et al., "Knowledge, Attitude and Behaviour." 13 25 Ibid. Naim and Bhutto, "Sexuality during Pregnancy." 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." General Population and HIV 71 `urfi marriages, there were nearly 10,000 cases wife was 0% among university students,67 7% of contested paternity due to `urfi marriages in among military personnel,68 24.2% among mar- Egyptian courts in 1998.54 ried military personnel,69 14.5% among A third type of nonconventional marriage is prisoners,70 12.6% among truck drivers,71 13% "travelers' marriage," including "summer mar- among internally displaced persons,72 14.2% riages" and jawaz (or nikah) al misyar. Summer among tea sellers,73 1.8% among street marriages typically occur between wealthy tourists children,74 11.8% among ANC women from rich MENA countries and poor women or attendees,75 14.1% among FSWs,76 13.3% girls from poor MENA countries, and last only for among TB patients,77 15.7% among STD clinic the duration of the summer, after which the mar- attendees,78 and 15.7% among suspected AIDS riage is often dissolved.55 Jawaz al misyar is com- patients.79 There was no definition given to dis- mon mainly in the Persian Gulf region and is an tinguish whether these percentages represent arrangement by which a man marries without the sequential or polygamous marriages or whether housing and financial responsibilities that are these marriages include spousal relationships expected from him in a conventional marriage.56 not necessarily sanctioned by religion or state. The couples continue to live separately from each These measures, however, suggest the preva- other and see each other when they please. Jawaz lence of multiple marriages in Sudan. al misyar is generally sanctioned among Sunnis, Concurrency of sexual partnerships and het- but is forbidden among Shiites. erogeneity in sexual risk behavior are conducive There is very limited evidence on the levels of to the spread of HIV in the population.80 sexual risk behavior implied by these kinds of Polygamy has been associated with higher risk marriages and whether they are effectively a of exposure to STIs in sub-Saharan Africa.81 The "legitimization" of premarital and extramarital permissive attitudes toward polygamy have sex. One study in the Islamic Republic of Iran been suggested as an explanation of higher HIV reported that temporary marriages appear to be rates among a minority of Muslim communities associated with exposure to STIs. Twenty-four in sub-Saharan Africa.82 Polygamy was found to percent of male gonorrhea patients reported be associated with cervical cancer in two studies acquiring the infection from temporary wives.57 in Algeria83 and Morocco.84 Nevertheless, lower Although polygamy is common in MENA, it STI prevalence was reported among women in appears to be in decline.58 The percentage of polygamous marriages compared to women in women in polygamous unions is estimated (not nonpolygamous marriages in the United Arab necessarily from representative populations) at Emirates.85 The association between polygamy 6% in Algeria,59 6.8% in Jordan,60 12.5% in Kuwait,61 3% in Lebanon,62 12% in Morocco,63 67 Ahmed, University Students. 68 5% in the Syrian Arab Republic,64 and 26% in 69 Ahmed, Military. Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence. the United Arab Emirates.65 Among Somali ref- 70 Ahmed, Prisoners. ugees in Kenya, 18.7% of married women were 71 Ahmed, Truck Drivers. in polygamous unions.66 In Sudan, the percent- 72 Ahmed, Internally Displaced People. 73 age of people of different population groups Ahmed, Tea Sellers. 74 Ahmed, Street Children. who reported having more than one husband/ 75 Ahmed, Antenatal. 76 Ahmed, Sex Sellers. 54 77 Rashad et al., "Marriage in the Arab World." Ahmed, TB Patients. 55 78 DeJong et al., "The Sexual and Reproductive Health of Young People." Ahmed, STDs. 56 79 Rashad et al., "Marriage in the Arab World." Ahmed, AIDS Patients. 57 80 Zargooshi, "Characteristics of Gonorrhoea." Kretzschmar and Morris, "Measures of Concurrency in Networks"; 58 Foster, "Young Women's Sexuality in Tunisia." Morris, "Sexual Networks and HIV"; Watts and May, "The Influence of 59 Hammouda et al., "Cervical Carcinoma in Algiers." Concurrent Partnerships"; May and Anderson, "The Transmission 60 Naffa, "Jordanian Women: Past and Present." Dynamics." 61 81 Chaleby, "Women of Polygamous Marriages." Obasi et al., "Antibody to Herpes Simplex Virus Type 2." 62 82 Jurjus et al., "Knowledge, Attitudes, Beliefs, and Practices." Kapiga, "Determinants of Multiple Sexual Partners"; Kapiga and 63 Chaouki et al., "The Viral Origin of Cervical Cancer." Lugalla, "Sexual Behaviour Patterns." 64 83 Roudi-Fahimi and Ashford, "Sexual & Reproductive Health." Hammouda et al., "Cervical Carcinoma in Algiers." 65 84 Ghazal-Aswad et al., "Prevalence of Chlamydia Trachomatis Infection." Chaouki et al., "The Viral Origin of Cervical Cancer." 66 85 UNHCR, HIV Sentinel Surveillance among Antenatal Clients. Ghazal-Aswad et al., "Prevalence of Chlamydia Trachomatis Infection." 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 20­30 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 21­30 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." General Population and HIV 73 probably lower in the rural areas in Southern of Somalia is technically already generalized, the Sudan, out of Juba. Male circumcision should be epidemiology of HIV infection in these nations considered as a prevention intervention for HIV suggests that there is no sustainable general in Southern Sudan. It must be stressed, however, population epidemic. The dynamics of HIV that male circumcision is only partially protec- infection in these nations are focused mainly tive and does not fully prevent HIV infection. around concentrated epidemics in commercial Female "circumcision," more appropriately sex networks in the context of special circum- labeled as female genital mutilation, is also stances of risk and vulnerability largely not pres- prevalent in several MENA countries and is not ent in the rest of the MENA countries. HIV associated with any protective effects against prevalence in these countries is still at levels HIV.104 The prevalence of female genital mutila- much lower than those found in the hyperen- tion is estimated at 98% in Djibouti,105 97.3% in demic HIV epidemics in sub-Saharan Africa. Egypt,106 94% in southern Somalia,107 89% in Sexual behavior data in the general popula- Sudan,108 and 22.6% in the Republic of Yemen.109 tion in MENA remain rather limited. Existing Although three-quarters of girls in Egypt undergo evidence suggests that sexual risk behaviors in this procedure by medically trained personnel,110 the general population are present, but at rather this may not be the case in other countries. low levels in comparison to other regions. Female genital mutilation is associated with Spousal sexual partnerships in MENA seem to infections and other health complications that be in a state of change with nonconventional may potentially put females, biologically speak- forms of marriage increasing in prevalence. ing, at higher risk of HIV infection.111 Levels of sexual risk behavior appear to be increasing, particularly among youth, though probably not to a level that can support an HIV ANALYTICAL SUMMARY epidemic in the general population. Available sexual risk behavior measures suggest limited There is considerable evidence on the levels of potential for a sustainable HIV epidemic in the HIV prevalence among the general population general population in at least the foreseeable in MENA. HIV prevalence is very low in all future, if ever. countries, except Djibouti, Somalia, and Sudan. STI prevalence data, including herpes simplex There is no evidence for a substantial HIV epi- virus type 2 (HSV-2), HPV, syphilis, gonorrhea, demic in the general population in any of the and chlamydia, indicate low prevalence of these MENA countries. infections among the general population in Apart from Djibouti, Somalia, and Sudan, MENA in comparison to other regions (chap- there appears to be very limited HIV transmis- ter 10). Unsafe abortions are also at low levels in sion within the general population. Southern MENA compared to other regions (chapter 10). Sudan is of particular concern and could be These proxy measures of sexual risk behavior already in a state of general population HIV epi- imply low levels of risky behavior in MENA. This demic, but conclusive evidence is still lacking. further indicates limited potential for a sustain- Though the HIV epidemic in Djibouti and parts able HIV epidemic in the general population. Male circumcision is almost universal in 104 DeJong et al., "The Sexual and Reproductive Health of Young People." MENA,112 and is associated with a biological effi- 105 Roudi-Fahimi and Ashford, "Sexual & Reproductive Health." cacy against HIV infection.113 Male circumcision 106 El-Zanaty and Way, Egypt Demographic and Health Survey. 107 Scott et al., "Low Prevalence of Human Immunodeficiency Virus-1." is associated with lower HIV prevalence at the 108 Sudan Department of Statistics, Sudan Demographic and Health population level,114 and its role in HIV dynamics Survey 1989/1990. appears to be "quarantining" HIV sustainable 109 Roudi-Fahimi and Ashford, "Sexual & Reproductive Health"; Yemen Central Statistical Organization, Yemen Demographic, Maternal and transmission to within higher risk groups with Child Health Survey 1997. 110 112 Roudi-Fahimi and Ashford, "Sexual & Reproductive Health." Weiss et al., "Male Circumcision." 111 113 Obermeyer, "The Consequences of Female Circumcision"; Obermeyer, Auvert et al., "Randomized, Controlled Intervention Trial"; Bailey "The Health Consequences of Female Circumcision"; Bailey, Neema, et al., "Male Circumcision"; Gray et al., "Male Circumcision." 114 and Othieno, "Sexual Behaviors." Weiss et al., "Male Circumcision"; Drain et al., "Male Circumcision." 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: 261­66. 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: 269­70. 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: 221­22. 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 March­December, 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: 288­89. Banks: Results from Saudi Arabia." Br J Biomed Sci 60: Aghajanian, A. 2001. Family and Family Change in Iran. 102­4. 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 2004­2005." 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 General Population and HIV 75 Practices in the Farwaniya Region of Kuwait." Int J and a Half Year Surveillance." J Trop Med Hyg 93: Dermatol 46: 594­99. 146­50. Alsallaq, R. A., B. Cash, H. A. Weiss, I. M. Longini, S. B. Coskun, O., C. Gul, H. Erdem, O. Bedir, and C. P. Omer, M. J. Wawer, R. H. Gray, and L. J. Abu- Eyigun. 2008. "Prevalence of HIV and Syphilis among Raddad. Forthcoming. "Quantitative Assessment of Turkish Blood Donors." Ann Saudi Med 28: 470. the Role of Male Circumcision in HIV Epidemiology DeJong, J., R. Jawad, and I. Mortagy, and B. Shepard. at the Population Level." Epidemics. 2005. "The Sexual and Reproductive Health of Young Ameen, R., N. Sanad, S. Al-Shemmari, I. Siddique, R. I. People in the Arab Countries and Iran." Reprod Health Chowdhury, S. Al-Hamdan, and A. Al-Bashir. 2005. Matters 13: 49­59. "Prevalence of Viral Markers among First-Time Arab Djibouti (Ministère de La Santé) and Association Blood Donors in Kuwait." Transfusion 45: 1973­80. Internationale de Développement. 2002. Epidémie a Amini, S., M. F. Mahmoodi, S. Andalibi, and A. A. Solati. VIH/SIDA/IST en République de Djibouti; Tome I: Analyse 1993. "Seroepidemiology of Hepatitis B, Delta and de la Situation et Analyse de la Réponse Nationale. Human Immunodeficiency Virus Infections in Décembre. Hamadan Province, Iran: A Population Based Study." Drain, P. K., D. T. Halperin, J. P. Hughes, J. D. Klausner, J Trop Med Hyg 96: 277­87. and R. C. Bailey. 2006. "Male Circumcision, Religion, Arabaci, F., H. A. Sahin, I. Sahin, and S. Kartal. 2003. and Infectious Diseases: An Ecologic Analysis of 118 "Kan donörlerinde HBV, HCV, HIV ve VDRL seropoz- Developing Countries." BMC Infect Dis 6: 172. itifligi." Klimik Derg 16: 18­20. Dray, X., R. Dray-Spira, J. A. Bronstein, and D. Mattera. Auvert, B., D. Taljaard, E. Lagarde, J. Sobngwi- 2005. "Prevalences of HIV, Hepatitis B and Hepatitis Tambekou, R. Sitta, and A. Puren. 2005. "Randomized, C in Blood Donors in the Republic of Djibouti." Med Controlled Intervention Trial of Male Circumcision Trop (Mars) 65: 39­42. for Reduction of HIV Infection Risk: The ANRS 1265 Dupire, B., A. K. Abawi, C. Ganteaume, T. Lam, P. Truze, Trial." PLoS Med 2: e298. and G. Martet. 1999. "Establishment of a Blood Bailey, R. C., S. Moses, C. B. Parker, K. Agot, I. Maclean, Transfusion Center at Kabul (Afghanistan)." Sante 9: J. N. Krieger, C. F. M. Williams, R. T. Campbell, and 18­22. J. O. Ndinya-Achola. 2007. "Male Circumcision for Durex. 2005. "Durex Global Sex Survey 2005." HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial." Lancet 369: 643­56. El-Gadi, S., A. Abudher, and M. Sammud. 2008. "HIV- Related Knowledge and Stigma among High School Bailey, R. C., S. Neema, and R. Othieno. 1999. "Sexual Students in Libya." Int J STD AIDS 19: 178­83. Behaviors and Other HIV Risk Factors in Circumcised and Uncircumcised Men in Uganda." J Acquir Immune El-Ghazzawi, E., G. Hunsmann, and J. Schneider. 1987. Defic Syndr 22: 294­301. "Low Prevalence of Antibodies to HIV-1 and HTLV-I in Alexandria, Egypt." AIDS Forsch 2: 639. Basha, H. M. 2006. "Vulnerable Population Research in Darfur." Elharti, E., A. Zidouh, R. Mengad, O. Bennani, and R. Elaouad. 2002. "Monitoring HIV through Sentinel Beamish, J. 2003. "Adolescent Reproductive Health in Surveillance in Morocco." East Mediterr Health J 8: Egypt: Status, Policies, Programs, and Issues Policy 141­49. Project." Unpublished memo. El-Hazmi, M. M. 2004. "Prevalence of HBV, HCV, HIV-1, Bennani, A., and K. Alami. 2006. "Surveillance senti- 2 and HTLV-I/II Infections among Blood Donors in a nelle VIH, résultats 2005 et tendances de la séro- Teaching Hospital in the Central Region of Saudi prévalence du VIH." Morocco Ministry of Health, Arabia." Saudi Med J 25: 26­33. UNAIDS. Elmir, E., S. Nadia, B. Ouafae, M. Rajae, S. Amina, and Burchell, A. N., R. L. Winer, S. de Sanjose, and E. L. A. Rajae el. 2002. "HIV Epidemiology in Morocco: A Franco. 2006. "Chapter 6: Epidemiology and Nine-Year Survey (1991­1999)." Int J STD AIDS 13: Transmission Dynamics of Genital HPV Infection." 839­42. Vaccine 24 Suppl 3: S52­61. El-Zanaty, F., and A. Way. 2001. Egypt Demographic and Busulwa, R. 2003. "HIV/AIDS Situation Analysis Study." Health Survey. Calverton, MD: Ministry of Health Conducted in Hodeidah, Taiz and Hadhramut, and Population Egypt, National Population Council Republic of Yemen. and ORC Macro. Chaleby, K. 1985. "Women of Polygamous Marriages in Foster, A. 2002. "Young Women's Sexuality in Tunisia: an Inpatient Psychiatric Service in Kuwait." J Nerv The Health Consequences of Misinformation among Ment Dis 173: 56­58. University Students." In Everyday Life in the Muslim Chaouki, N., F. X. Bosch, N. Munoz, C. J. Meijer, B. El Middle East, ed. D. L. Bowen and E. A. Early, 98­110. Gueddari, A. El Ghazi, J. Deacon, X. Castellsague, and Bloomington: Indiana University Press. J. M. Walboomers. 1998. "The Viral Origin of Cervical Gassmelseed, D. E., A. M. Nasr, S. M. Homeida, M. A. Cancer in Rabat, Morocco." Int J Cancer 75: 546­54. Elsheikh, and I. Adam. 2006. "Prevalence of HIV Chemtob, D., and S. F. Srour. 2005. "Epidemiology of Infection among Pregnant Women of the Central HIV Infection among Israeli Arabs." Public Health 119: Sudan." J Med Virol 78: 1269­70. 138­43. Ghazal-Aswad, S., P. Badrinath, N. Osman, S. Abdul- Constantine, N. T., M. F. Sheba, D. M. Watts, Z. Farid, Khaliq, S. Mc Ilvenny, and I. Sidky. 2004. "Prevalence and M. Kamal. 1990. "HIV Infection in Egypt: A Two of Chlamydia Trachomatis Infection among Women 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: 255­58. 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: 657­66. Groups in Mogadishu, Somalia." Genitourin Med 63: Gregson, S., C. A. Nyamukapa, G. P. Garnett, P. R. 329­32. 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: 485­96. 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, 98­114. New York, NY: Tauris Sudan." AIDS 20: 942­44. 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: 703­6. At-Risk Women in Tehran, Iran, 2006." AIDS Educ Kandela, P. 1993. "Arab Nations: Attitudes to AIDS." Prev 19: 519­30. Lancet 341: 884­85. 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: 435­42. Generational Sex and Delaying Age at Sexual Debut." Sex Transm Infect 83 Suppl 1: i50­54. 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: 455­69. 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: 483­89. 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: 331­37. 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: 8­11. Women." Infection 31: 143­48. 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: 4461­66. General Population and HIV 77 Kretzschmar, M., and M. Morris. 1996. "Measures of Mujeeb, S. A., M. R. Khanani, T. Khursheed, and A. Concurrency in Networks and the Spread of Infectious Siddiqui. 1991. "Prevalence of HIV-Infection among Disease." Mathematical Biosciences 133: 165­95. Blood Donors." J Pak Med Assoc 41: 253­54. Kulane, A., A. A. Hilowle, A. A. Hassan, and R. Naffa, S. 2004. "Jordanian Women: Past and Present." Thorstensson. 2000. "Prevalence of HIV, HTLV I/II Grey Report. and HBV Infections during Long Lasting Civil Conflicts Naim, M., and E. Bhutto. 2000. "Sexuality during in Somalia." Int Conf AIDS: 13. Pregnancy in Pakistani Women." J Pak Med Assoc 50: Lebanon National AIDS Control Program. 1996. "General 38­44. Population Evaluation Survey Assessing Knowledge, NSNAC (New Sudan National AIDS Council), and Attitudes, Beliefs and Practices Related to HIV/AIDS UNAIDS (United Nations Joint Programme on HIV/ in Lebanon." Ministry of Public Health. AIDS). 2006. HIV/AIDS Integrated Report South Sudan, Libya National Center for the Prevention of and Control 2004­2005. With United Nations General Assembly of Infectious Diseases. 2005. "Results of the National Special Session on HIV/AIDS Declaration of Seroprevalence Survey." Summary document. Commitment. Maayan, S., E. Shinar, M. Aefani, M. Soughayer, R. Obasi, A., F. Mosha, M. Quigley, Z. Sekirassa, T. Gibbs, Alkhoudary, S. Barshany, and N. Manny. 1994. K. Munguti, J. Todd, H. Grosskurth, P. Mayaud, J. "HIV-1 Prevalence among Israeli and Palestinian Changalucha, D. Brown, D. Mabey, and R. Hayes. Blood Donors." AIDS 8: 133­34. 1999. "Antibody to Herpes Simplex Virus Type 2 as a Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck, Marker of Sexual Risk Behavior in Rural Tanzania." J M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M. Infect Dis 179: 16­24. Huraux, and N. Dupin. 2001. "Comparative Study of Obermeyer, C. M. 2003. "The Health Consequences of Heterosexual Transmission of HIV-1, HSV-2 and Female Circumcision: Science, Advocacy, and KSHV in Djibouti." 8th Retrovir Oppor Infect (abstract Standards of Evidence." Med Anthropol Q 17: 394­ no. 585). 412. Maslin, J., C. Rogier, F. Berger, M. A. Khamil, D. ------. 2005. "The Consequences of Female Circumcision Mattera, M. Grandadam, M. Caron, and E. Nicand. for Health and Sexuality: An Update on the Evidence." 2005. "Epidemiology and Genetic Characterization of Cult Health Sex 7: 443­61. HIV-1 Isolates in the General Population of Djibouti Pakistan National Institute of Health. 1992. National (Horn of Africa)." J Acquir Immune Defic Syndr 39: AIDS Control Program Report. Islamabad: Government 129­32. of Pakistan. Massarrat, M. S., and S. Tahaghoghi-Mehrizi. 2002. ------. 1995. National AIDS Control Program Report. "Iranian National Health Survey: A Brief Report." Islamabad: Government of Pakistan. Archives of Iranian Medicine 2: 73­79. Pisani, E., S. Lazzari, N. Walker, and B. Schwartlander. Massenet, D., and A. Bouh. 1997. "Aspects of Blood 2003. "HIV Surveillance: A Global Perspective." J Transfusion in Djibouti." Med Trop (Mars) 57: 202­5. Acquir Immune Defic Syndr 32 Suppl 1: S3­11. May, R. M., and R. M. Anderson. 1988. "The Transmission Pourshams, A., R. Malekzadeh, A. Monavvari, M. R. Dynamics of Human Immunodeficiency Virus (HIV)." Akbari, A. Mohamadkhani, S. Yarahmadi, N. Philosophical Transactions of the Royal Society of London Seddighi, M. Mohamadnejad, M. Sotoudeh, and A. Series B-Biological Sciences 321: 565­607. Madjlessi. 2005. "Prevalence and Etiology of Ministry of Health and Medical Education of Iran. 2006. Persistently Elevated Alanine Aminotransferase "Treatment and Medical Education." Islamic Republic Levels in Healthy Iranian Blood Donors." Journal of of Iran HIV/AIDS situation and response analysis. Gastroenterology and Hepatology 20: 229­33. Mohammad, K., F. K. Farahani, M. R. Mohammadi, S. Qatar, state of. 2008. Report on the Country Progress Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani, Indicators towards Implementing the Declaration of A. Hasanzadeh, and H. Ghanbari. 2007. "Sexual Risk- Commitment on HIV. National Health Authority. Taking Behaviors among Boys Aged 15­18 Years in Quinti, I., E. Renganathan, E. El Ghazzawi, M. Divizia, Tehran." J Adolesc Health 41: 407­14. G. Sawaf, S. Awad, A. Pana, and G. Rocchi. 1995. Morocco MOH (Ministry of Health). 2006. Implementation "Seroprevalence of HIV and HCV Infections in of the Declaration of Commitment on HIV/AIDS. 2006 Alexandria, Egypt." Zentralbl Bakteriol 283: 239­ National Report, Kingdom of Morocco. 44. Morris, M. 1997. "Sexual Networks and HIV." AIDS 11: Rashad, H. 2000. "Demographic Transition in Arab S209­16. Countries: A New Perspective." Journal of Population Mostafa, S. R., and O. H. Roshdy. 1999. "Risk Profiles for Research 17: 83­101. Sexually Transmitted Diseases among Patients Rashad, H., and M. Osman. 2003. "Nuptiality in Arab Attending the Venereal Disease Clinic at Alexandria Countries: Changes and Implications." In The New Main University Hospital." East Mediterr Health J 5: Arab Family, Cairo Papers in Social Science, Vol. 24, 740­54. Nos. 1­2, ed. N. Hopkins, 20­50. Cairo: American Mujeeb, S. A., K. Aamir, and K. Mehmood. 2006. University in Cairo Press. "Seroprevalence of HBV, HCV and HIV Infections Rashad, H., M. I. Osman, F. Roudi-Fahimi, and among College Going First Time Voluntary Blood Population Reference Bureau. 2005. "Marriage in the Donors." J Pak Med Assoc 56: S24­25. Arab World." Population Reference Bureau. 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, 2004­2005 (Draft)." With United AIDS among Educated Youth in Lahore, Pakistan." Nations General Assembly Special Session on HIV/ J Pak Med Assoc 48: 179­82. 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: 425­33. 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: S95­105. 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: 296­302. 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: 407­12. 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: 186­88. "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 General Population and HIV 79 Control Programme. HIV sentinel surveillance, Dadaab ------. 2004b. The 2004 First National Second Generation Refugee Camps, Nairobi, Kenya. HIV/AIDS/STI Sentinel Surveillance Survey, Puntland, ------. 2005. National AIDS and Sexually Transmitted Somalia, A Technical Report. Control Programme. Sentinel surveillance report, ------. 2004c. The 2004 First National Second Generation Dadaab Refugee Camps, Nairobi, Kenya, January­ HIV/AIDS/STI Sentinel Surveillance Survey, Somalia, A May 2005. Technical Report. ------. 2006­7a. HIV Sentinel Surveillance among Antenatal WHO/EMRO (World Health Organization, Eastern Clients and STI Patients. Dadaab Refugee Camps, Kenya. Mediterranean Region). 2000. "Presentation of WHO ------. 2006­7b. HIV Sentinel Surveillance among Conflict Somalia's Experience in Supporting the National Affected Populations. Kakuma Refugee Camp-- Response." Regional Consultation towards Improving Refugees and Host Nationals, Great Lakes Initiative HIV/AIDS & STD Surveillance in the Countries of on HIV/AIDS. EMRO, Beirut, Lebanon, October 30­November 2. ------. 2007. "HIV Behavioural Surveillance Survey ------. 2007a. "HIV/AIDS Surveillance in Low Level Juba Municipality, South Sudan." United Nations and Concentrated HIV Epidemics. A Technical Guide High Commissioner for Refugees. for Countries in the WHO Eastern Mediterranean Region." Grey Report. Unknown. Unknown. "Statut de la réponse nationale: Caractéristiques de l'épidémie des IST/VIH/SIDA." ------. 2007b. "Prevention and Control of Sexually Algeria, Grey Report. Transmitted Infections in the WHO Eastern Mediterranean Region." Intercountry meeting, Unknown. 2002. "Surveillance des infections à VIH et de PowerPoint presentation. la syphilis chez les femmes enceintes vues dans 8 centres de consultations prénatales dans le district de Winsbury, R. 1996. "Aiding Refugees in the Aftermath of Djibouti." Grey Report. Civil War." AIDS Anal Afr 6 (5): 3. Watts, C. H., and R. M. May. 1992. "The Influence of Yamazhan, T., D. Gokengin, E. Ertem, R. Sertoz, S. Concurrent Partnerships on the Dynamics of HIV/ Atalay, and D. Serter. 2007. "Attitudes towards HIV/ AIDS." Math Biosci 108: 89­104. AIDS and Other Sexually Transmitted Diseases in Secondary School Students in Izmir, Turkey: Changes Watts, D. M., N. T. Constantine, M. F. Sheba, M. Kamal, in Time." Trop Doct 37: 10­12. J. D. Callahan, and M. E. Kilpatrick. 1993. "Prevalence of HIV Infection and AIDS in Egypt over Four Years of Yassin, K., R. Awad, A. J. Tebi, A. Queder, and U. Laaser. Surveillance (1986­1990)." J Trop Med Hyg 96: 113­17. 2001. "A Zero Prevalence of Anti-HIV in Blood Donors in Gaza: How Can It Be Sustained?" AIDS 15: Weiss, H. A., D. Halperin, R. C. Bailey, R. J. Hayes, G. 936­37. Schmid, and C. A. Hankins. 2008. "Male Circumcision for HIV Prevention: From Evidence to Action?" AIDS Yemen Central Statistical Organization. 1998. Yemen 22: 567­74. Demographic, Maternal and Child Health Survey 1997. Macro International. Calverton, MD: Central Wellings, K., M. Collumbien, E. Slaymaker, S. Singh, Z. Statistical Organization and Macro International. Hodges, D. Patel, and N. Bajos. 2006. "Sexual Behaviour in Context: A Global Perspective." Lancet Yemen National AIDS Control Programme. 1998. AIDS/ 368: 1706­28. HIV Surveillance Report, Fourth Quarter 1998. Ministry of Public Health. WHO (World Health Organization). 2002. "HIV/AIDS Epidemiological Surveillance Report for the WHO ------. 2001. AIDS/HIV Surveillance Report, Fourth Quarter African Region 2002 Update." 2001. Ministry of Public Health. ------. 2003. WHO Somalia Statistic Report 2003. Zargooshi, J. 2002. "Characteristics of Gonorrhoea in Kermanshah, Iran." Sex Transm Infect 78: 460­61. ------. 2004a. The 2004 First National Second Generation HIV/AIDS/STI Sentinel Surveillance Survey, Central South, Somalia, A Technical Report. 80 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Chapter 7 Further Evidence Related to HIV Epidemiology in MENA 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 HIV prevalence among sexually transmitted dis- ease (STD) clinic attendees, voluntary counsel- Analytical summary ing and testing (VCT) attendees, and suspected These results suggest that apart from Djibouti, AIDS (acquired immune deficiency syndrome) Somalia, and Sudan, HIV prevalence among patients has been reported for several MENA STD clinic and VCT attendees is generally low. countries. Table D.1 (appendix D) lists the results HIV has clearly made inroads into the hetero- of available point-prevalence surveys among sexual high-risk networks in Djibouti, Somalia, these populations. Since STD clinic and VCT and Sudan. The limited prevalence in the rest of attendees are more likely to represent people the countries is likely a consequence of the low who visited these centers because of perceived levels of HIV prevalence in the priority groups, risks, the level of HIV prevalence among these FSWs in particular, since the main reason for populations hints at the risk of HIV exposure in attending an STD clinic in the region is sexual a part of the population with specific identifiable contact with FSWs. risk behaviors. There are also few measures of risky behavior among these population groups. A study on STD 2 Ahmed, STDs. 3 clinic attendees in Pakistan found that 55% Ahmed, AIDS Patients. 4 Zargooshi, "Characteristics of Gonorrhoea." acquired the STD heterosexually, 11.6% homo- 5 Al-Mutairi et al., "Clinical Patterns"; Al-Fouzan and Al-Mutairi, "Overview." sexually, and 18.4% bisexually.1 Among STD 6 Rehan, "Profile of Men." 7 Burans et al., "HIV Infection Surveillance in Mogadishu, Somalia"; Ismail et al., "Sexually Transmitted Diseases in Men." 1 8 Rehan, "Profile of Men." Omer et al., "Sexually Transmitted Diseases in Sudanese Males." 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 may be subject to different kinds of 4 selection bias, such as reflecting 3 measurements from a few countries as 2 opposed to others. There is also 1 substantial intercountry and inter- 0 population variability in HIV prev- d) s rs en g nts mig s ts nts Ws ers s g ts M " ses ts ee irls t IDU stin stin ifie an ran no (no gran en MS om ipie tie nd son FS alence across these measures, suggesting ca rg igr do ec ati l te 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 TB in- a blo ou od AID dA gn ma lini ling 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 Further Evidence Related to HIV Epidemiology in MENA 83 due to two testing campaigns in prisons in these Sudan,20 respectively. The percentages of HIV respective years.13 infections that are among men are 81% in the Arab Republic of Egypt,21 94% in the Islamic Republic of Iran,22 81.75% in Lebanon,23 70% Analytical summary in Oman,24 88.4% (up to 1997) in Pakistan,25 HIV prevalence in HIV testing surveys is gener- and 79.4% in the West Bank and Gaza.26 In ally consistent with the levels reported in the Lebanon, the disease burden among men has previous chapters and follows a similar pat- even increased. The ratio of males versus females tern. There is very limited HIV prevalence in was 3.6 to 1 in the years 1984 to 1998,27 but it the general population. Most HIV infections increased to 8.5 to 1 by 2004.28 are found among priority and vulnerable pop- Nevertheless, the overall pattern in MENA ulations, their sexual partners, or in popula- appears to include an increasing proportion of tions with suspected infection or identifiable females among HIV cases, such as in Algeria, risks. Djibouti, Morocco, Pakistan, Sudan, and the Resources are not prioritized to testing high- Republic of Yemen.29 In Algeria, the ratio of risk priority groups. HIV testing appears to be men to women decreased from 5.1 at the disconnected with the reality of HIV epidemiol- beginning of the epidemic to 1.1 in 2004.30 The ogy in MENA. proportion of infections in women in Morocco The fluctuations in the testing results sug- has steadily increased to reach almost 50%, gest a lack of representation and nonsustained compared to 20% only five years earlier.31 The and sporadic HIV testing. There is no consis- ratio of men to women in the Republic of tent, standard, and effective methodological Yemen decreased from 4 to 1 in 1995, to 2 to surveillance in the countries of the region. 1 in 1999, and to 1 to 1 in 2000.32 In Djibouti, Surveillance capacity needs to be enhanced the country with the highest HIV prevalence and HIV testing procedures need to be stan- in MENA, women are already more affected by dardized to generate interpretable data on HIV the disease than men. The prevalence is 3.6% epidemiology. Tens of millions of HIV tests are among women and 3.1% among men in routinely conducted every year in MENA, but Djibouti-ville, and 1.7% among women and these valuable data sources are not being uti- 0.3% among men in the rest of the country.33 lized because of a lack of scientific capacity and methodological rigor. Analytical summary Most HIV infections in most MENA countries DISTRIBUTION BY SEX OF REPORTED continue to be among men. This reflects the HIV CASES reality that most risk behaviors are practiced by Until recently, the vast majority of HIV infec- 20 Sudan National HIV/AIDS Control Program, Annual Report. tions in most countries in MENA were found 21 WHO/EMRO Regional Database on HIV/AIDS. 22 among men. Men were 10, 4.4, 8.5, 1.6, 7, 3, Iran Center for Disease Management, AIDS/HIV Surveillance Report. 23 Kassak et al., "Final Working Protocol." and 2 times as likely as women to be infected in 24 Tawilah and Tawil, Visit to Sultane of Oman. Bahrain,14 Israel (Arab Israelis),15 Lebanon,16 25 Khan and Hyder, "HIV/AIDS among Men." 26 Morocco,17 Pakistan,18 Saudi Arabia,19 and 27 UNAIDS, "Key Findings." Kalaajieh, "Epidemiology of Human Immunodeficiency Virus." 28 Jurjus et al., "Knowledge, Attitudes, Beliefs, and Practices." 29 UNAIDS, "Notes on AIDS in the Middle East and North Africa"; Iqbal and Rehan, "Sero-Prevalence of HIV"; Kayani et al., "A View of HIV-I 13 Gheiratmand et al., "Uncertainty on the Number of HIV/AIDS Patients." Infection in Karachi." 14 30 Al-Haddad et al., "HIV Antibodies." Algeria MOH, "Rapport de l'enquête nationale de séro-surveillance." 15 31 Chemtob and Srour, "Epidemiology of HIV Infection." UNAIDS, "Notes on AIDS in the Middle East and North Africa"; 16 Jurjus et al., "Knowledge, Attitudes, Beliefs, and Practices." Morocco MOH, "Situation épidémiologique"; Elharti et al., "Some 17 Elharti et al., "Some Characteristics of the HIV Epidemic in Morocco." Characteristics of the HIV Epidemic in Morocco." 18 32 Rajabali et al., "HIV and Homosexuality in Pakistan"; UNAIDS and WHO, Lambert, "HIV and Development Challenges"; Al-Serouri, HIV/AIDS AIDS Epidemic Update 2006. Situation and Response Analysis Report. 19 33 UNAIDS and WHO, AIDS Epidemic Update 2006. WHO, "Summary Country Profile." 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 TRANSMISSION MODES HIV epidemiology in MENA exhibits one key aspect not captured in the conceptual framework All transmission modes reported globally have used to understand HIV epidemiology (chapter 1). been documented in MENA. There is consider- In a few MENA countries, there appears to be able variability in which transmission mode is very limited endemic transmission of HIV in all most common across MENA countries (table 7.1). of the population groups within the country, Of the total number of reported HIV infections including priority populations. The number of in the WHO/EMRO database of HIV/AIDS case newly diagnosed HIV infections continues to be notification surveillance reports,35 the main rather stable, at low frequency with the majority transmission mode is unprotected vaginal and reflecting sexual and injecting exposures abroad anal sex, followed by drug injection.36 In a sub- among the nationals of these countries, or HIV stantial percentage of HIV infections, the trans- transmissions to their sexual partners upon their mission mode continues to be characterized as return.38 The high mobility and migration levels unknown, such as in Saudi Arabia, where 26% are the drivers of this pattern, which has been of HIV infections appear to be with no reported persistent since the discovery of the epidemic, identifiable risk factors. 37 Table 7.1 lists the and continues to be seen even among recent HIV transmission modes for a number of MENA infections. In Jordan, in 450 out of 501 notified countries. HIV/AIDS cases by 2006, HIV infections were acquired abroad.39 In Lebanon, 45.36% of noti- fied HIV/AIDS cases up to 2004 were linked to Analytical summary travel abroad.40 Half of reported AIDS cases in The MENA region is experiencing the same HIV the Republic of Yemen were linked to a travel transmission modes that exist in the rest of the history abroad.41 It bears notice that some of regions. There is variability in the dominant these exposures, though exogenous to the coun- transmission modes across MENA countries, try of the national, may still reflect exposures in reflecting the status of HIV dynamics in these another MENA country. countries. In countries with apparently no significant endemic transmission of HIV, the dominant mode is that of heterosexual sex, Analytical summary apparently reflecting mainly exogenous HIV HIV epidemiology in a few MENA countries infections related to exposures abroad among appears to be dominated by the pattern of the nationals of these countries, or HIV exogenous HIV exposures among the nationals transmissions to their sexual partners upon their 38 WHO/EMRO Regional Database on HIV/AIDS; L. J. Abu-Raddad, per- sonal discussions with members of National AIDS Programs in MENA 34 Aidaoui, Bouzbid, and Laouar, "Seroprevalence of HIV Infection." during 2006­9. 35 39 WHO/EMRO Regional Database on HIV/AIDS. Jordan National AIDS Program, personal communication. 36 40 UNAIDS, "Notes on AIDS in the Middle East and North Africa." Jurjus et al., "Knowledge, Attitudes, Beliefs, and Practices." 37 41 UNAIDS and WHO, AIDS Epidemic Update 2006. WHO, UNICEF, and UNAIDS, "Yemen, Epidemiological Facts Sheets." Further Evidence Related to HIV Epidemiology in MENA 85 Table 7.1 HIV Transmission Modes for a Number of MENA Countries Heterosexual Homosexual Injecting drug Blood or blood prod- Mother-to-child Country transmission transmission transmission ucts transmission transmission Algeria 45.71% Algeria MOH [unknown]) Egypt, Arab 50.0% (UNAIDS 20.0% (UNAIDS Republic of and WHO 2005) and WHO 2005) Iran, Islamic 87.0% (Iran 1.8% (Ministry of 0.5% (Ministry Republic of Center for Health and Medical of Health and Disease Education of Iran 2006) Medical Management 0.35% (Hamadan prov- Education of 2004) ince; Ghannad Iran 2006) 82.0% et al. 2009) 1.0% (Hamadan (Gouya 2006) province; 78.0% Ghannad et al. (Hamadan prov- 2009) ince; Ghannad et al. 2009) Jordan 52.0% (Jordan 4.3% 31.0% (Jordan National 1.7% National AIDS (Anonymous AIDS Program, personal (Anonymous Program, personal 2006) communication) 2006) communication) 19.0% (UNAIDS 2006b) Kuwait 48.0% (Al-Fouzan and Al-Mutairi 2004) Lebanon 53.0% (Lebanon 16.0% (Lebanon 6.0% (Lebanon 7.0% (Lebanon 3.0% (Lebanon National AIDS National AIDS National AIDS National AIDS Control National AIDS Control Program Control Program Control Program Program 2008) Control 2008) 2008) 2008) 8.5% (up to 1998; Program 2008) 53.9% (up to 1998; 15.68% (Jurjus Kalaajieh 2000) 4.3% (Kalaajieh Kalaajieh 2000) et al. 2004) 2000) 56.0% (Kassak et al. 2008) Morocco 77.0% (Elharti 7.0% (Elharti 11.0% (Elharti 0.62% (Elharti et al. 4.63% (Elharti et al. 2002) et al. 2002) et al. 2002) 2002) et al. 2002) 72.0% (Elharti 4.0% (Alami 2009) 4.0% (Alami 1.0% (Alami 2009) 3.0% (Alami et al. 2002) 2009) 2009) 80.0% (Alami 2009) 83.0% (Morocco MOH [unknown]) Pakistan 3.2% (Khan and Hyder 1998) 7.0% (Rajabali et al. 2008; UNAIDS and WHO 2006) Qatar Main transmission mode (Qatar 2008) 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). Further Evidence Related to HIV Epidemiology in MENA 87 PARENTERAL HIV TRANSMISSIONS of the participants of a study.52 Financial limita- OTHER THAN INJECTING DRUG USE tions contribute to the reuse of syringes.53 Blood transfusions are performed even when Transmission of blood-borne pathogens occurs not medically indicated54; a considerable share routinely in resource-limited settings and is con- of the population reported such procedures. sidered a major public health problem in the From 6.7% to 14.2% of diverse population developing world.43 MENA is no exception to groups in Sudan reported receiving a blood this rule, and there appears to be a lack of suf- transfusion at least once in their lifetime.55 ficient resources for screening blood and steril- Reuse of nonsterile blades and needles is not izing medical equipment in several countries, uncommon. Five percent of university students including Afghanistan, Pakistan, Somalia, and in Afghanistan used the nonsterile injecting the Republic of Yemen.44 MENA as a whole suf- needles of others and 20.8% used the nonsterile fers from high prevalence of unnecessary medi- shaving sets of another person.56 Thirty-one cal injections and transfusions, reuse of needles percent of university students and 19.4% of and syringes, needlestick injuries among health military personnel in Sudan used the nonsterile care workers (HCWs), and scarifications.45 Public blades of others, and 4.8% and 8.6% used non- health systems are overstretched, leading to sterile needles with others, respectively.57 some careless attitudes toward safety measures.46 Occupational injuries among HCWs are com- Standard precautions are not routinely imple- mon, such as in Morocco where they were mented in public health care, and even less so in found to be at high frequency, although they private practices such as among dentists47 and in were rarely declared.58 Forty-nine percent of hemodialysis centers.48 Injections are the pre- HCWs in Egypt,59 58.9% in Morocco,60 and 45% ferred mode of therapy even when alternative in Pakistan61 reported a needlestick injury in the modes are equally effective,49 and some health previous year.62 Percutaneous injuries among practitioners see this as an opportunity for HCWs in MENA are caused by needle recapping, charging additional fees.50 Injections by non- handling of trash bags or linens, collision with medical providers are rampant,51 such as in sharps, concealed sharps, restless patients, han- Afghanistan, where they were reported by 38% dling and passing of devices, and invasive inter- ventions such as surgery.63 The incidence of occupational exposures to infected blood and other fluids in the Islamic Republic of Iran, including exposures to fluids 43 Kane et al., "Transmission of Hepatitis"; Simonsen et al., "Unsafe infected with HIV, hepatitis C virus (HCV), and Injections." hepatitis B virus (HBV), was documented at a 44 Khawaja et al., "HIV/AIDS and Its Risk Factors in Pakistan"; World rate of 53% exposures per person per year.64 The Bank Group, "World Bank Update 2005"; World Bank, HIV/AIDS in Afghanistan; WHO/EMRO, "Progress Report on HIV/AIDS and `3 by 5'"; 52 UNAIDS, "Country Alignment and Harmonisation Support"; WHO/EMRO, Todd et al., "Prevalence of Human Immunodeficiency Virus Infection." 53 Progress towards Universal Access to HIV Prevention; Luby et al., Janjua, "Injection Practices." 54 "Evaluation of Blood Bank Practices." Abdul Mujeeb, "Blood Transfusion." 45 55 Khawaja et al., "HIV/AIDS and Its Risk Factors in Pakistan"; World Ahmed, Sex Sellers; Ahmed, Antenatal; Ahmed, Tea Sellers; Ahmed, Bank Group, "World Bank Update 2005"; Yerly et al., "Nosocomial Military; Ahmed, Truck Drivers; Ahmed, University Students; Ahmed, Outbreak"; Khattab et al., "Report on a Study of Women Living with TB Patients; Ahmed, Internally Displaced People; Ahmed, Street HIV"; Burans et al., "Serosurvey of Prevalence"; Zafar et al., Children. 56 "Knowledge, Attitudes and Practices"; Hossini et al., "Knowledge and Mansoor et al., "Gender Differences in KAP." 57 Attitudes"; Yemen MOH, National Strategic Framework; Kennedy, Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence; O'Reilly, and Mah, "The Use of a Quality-Improvement Approach." Ahmed, STDs; Ahmed, AIDS Patients. 46 58 Zafar et al., "Knowledge, Attitudes and Practices." Hossini et al., "Knowledge and Attitudes"; Laraqui et al., "Assessing 47 Askarian, Mirzaei, and McLaws, "Attitudes, Beliefs, and Infection Knowledge, Attitude, and Practice." 59 Control"; Askarian, Mirzaei, and Cookson, "Knowledge, Attitudes, and Kabbash et al., "Risk Perception and Precautions." 60 Practice." Laraqui et al., "Assessing Knowledge." 48 61 Kabbash et al., "Risk Perception and Precautions." Zafar et al., "Knowledge, Attitudes and Practices." 49 62 Janjua et al., "Population Beliefs"; Altaf et al., "Determinants of Ibid. 63 Therapeutic Injection Overuse." Kuruuzum et al., "Risk of Infection"; Jahan, "Epidemiology of 50 Janjua, Akhtar, and Hutin, "Injection Use." Needlestick Injuries." 51 64 Janjua, Akhtar, and Hutin, "Injection Use"; Janjua, "Injection Practices." Hadadi et al., "Occupational Exposure." 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." Further Evidence Related to HIV Epidemiology in MENA 89 Table 7.2 HIV Prevalence among Populations at Risk of Parenteral HIV Infection (excluding IDUs) Country HIV prevalence among populations at risk of parenteral HIV infection 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." Further Evidence Related to HIV Epidemiology in MENA 91 Analytical summary suggested the transmission pathways in the population. There have been steady improvements in recent In Algeria, despite substantial HIV subtype years in MENA in safety measures related to HIV diversity,114 subtype B was found to be the domi- parenteral transmission modes, but a few coun- nant strain, particularly in the north of the coun- tries are still lagging in achieving acceptable stan- try, accounting for 56% of the samples studied.115 dards. In line with this progress, HIV parenteral There is, however, a high diversity in the recom- transmissions, other than IDU, have been in binant subtypes in the southern part of Algeria decline in most MENA countries and have bordering sub-Saharan Africa, with origins found reached very low levels. Despite this progress, in the vicinity of Algeria, such as in Niger.116 isolated HIV outbreaks, particularly in health care In Djibouti, an analysis of 34 isolates found facilities, could still occur as they have in the past. that 73% were of subtype C, 18% of recombi- Some HIV infectious spread may be present nants forms including CRF02_AG, 6% of subtype along the same pathways that HCV is using to D, and 3% of subtype A.117 Another study in spread in MENA. The parenteral transmission Djibouti found subtype C to be the most preva- modes other than IDU, however, are unlikely to lent, with the presence of subtypes A and D along be large enough to sustain an HIV epidemic con- with recombinant types.118 Among French mili- sidering that HIV transmission probability per tary personnel who served in Djibouti, mostly exposure is much lower than that of HCV.108 subtype C infections were found, though sub- Despite the presence of exposures to blood and types A and B were also found.119 bodily fluids, the low endemicity of HIV, as well An analysis of viral sequences among IDUs as HCV and HBV, in most of the region limits in the Islamic Republic of Iran found confined the infection risk to these pathogens.109 Earlier variability, suggesting the epidemic in the speculation that the sub-Saharan Africa HIV Islamic Republic of Iran is recent.120 The viral epidemic was driven by unsafe injections110 sequences were found to be strongly related proved to be incorrect.111 Yet, more precautions, and formed a single cluster within subtype A, including educational programs,112 need to be related, though not necessarily directly, to implemented to avoid the unnecessary spread of Ugandan and Kenyan isolates.121 Interestingly, HIV and other blood-borne pathogens along the there was a lack of strong phylogenetic cor- parenteral transmission modes. relation between the sequences from the Islamic Republic of Iran and other Middle HIV MOLECULAR EPIDEMIOLOGY Eastern countries.122 The virus may have been introduced to Iranian IDUs by a pilgrim Molecular epidemiology research in MENA is visiting Mashhad, the Islamic Republic of still limited, though such research could be Iran's holiest city.123 Meanwhile, the analyses valuable in tracking the evolution of the epi- indicated that all hemophiliacs infected with demic among different risk groups, understand- HIV in the Islamic Republic of Iran are infected ing sexual and injecting risk networks of priority with HIV subtype B.124 This suggests that groups, and identifying transmission pathways there have been two parallel epidemics in among the populations of the region.113 Several studies in MENA have examined the nature of 114 HIV subtypes present in the region and have Bouzeghoub et al., "First Observation." 115 Bouzeghoub et al., "High Diversity of HIV Type 1 in Algeria." 116 Ibid. 108 117 Goldmann, "Blood-Borne Pathogens and Nosocomial Infections"; Maslin et al., "Epidemiology and Genetic Characterization." 118 Gerberding, "Management of Occupational Exposures to Blood-Borne Ibid. 119 Viruses." Lasky et al., "Presence of Multiple Non-B Subtypes." 109 120 Kuruuzum et al., "Risk of Infection." Tagliamonte et al., "HIV Type 1 Subtype A"; Naderi et al., "Molecular 110 Gisselquist et al., "Let It Be Sexual"; Gisselquist et al., "HIV Infections." and Phylogenetic Analysis." 111 121 Schmid et al., "Transmission of HIV-1." Tagliamonte et al., "HIV Type 1 Subtype A." 112 122 Mishal et al., "Risk of Transmission." Tagliamonte et al., "HIV Type 1 Subtype A"; Naderi et al., "Molecular 113 Sanders-Buell et al., "A Nascent HIV Type 1 Epidemic"; Piyasirisilp and Phylogenetic Analysis." 123 et al., "A Recent Outbreak"; McCutchan et al., "HIV-1 and Drug Tagliamonte et al., "HIV Type 1 Subtype A." 124 Trafficking." Sarrami-Forooshani et al., "Molecular Analysis." 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." Further Evidence Related to HIV Epidemiology in MENA 93 Needless to say, the above data show that HIV Alavian, S. M., A. Ardeshiri, and B. Hajarizadeh. 2001. has no borders and is entering the region from "Prevalence of HCV, HBV and HIV Infections among Hemophiliacs." Transfusion Today 49: 4­5. multiple sources through nationals of MENA Alavian, S. M., K. Bagheri-Lankarani, M. Mahdavi- countries. Mazdeh, and S. Nourozi. 2008. "Hepatitis B and C in Dialysis Units in Iran: Changing the Epidemiology." Hemodial Int 12: 378­82. Alavian, S. M., B. Gholami, and S. Masarrat. 2002. BIBLIOGRAPHY "Hepatitis C Risk Factors in Iranian Volunteer Blood Donors: A Case-Control Study." J Gastroenterol Hepatol Abbas, Z., N. L. Jeswani, G. N. Kakepoto, M. Islam, 17: 1092­97. K. Mehdi, and W. Jafri. 2008. "Prevalence and Mode of Spread of Hepatitis B and C in Rural Sindh, Al-Fouzan, A., and N. Al-Mutairi. 2004. "Overview of Pakistan." Trop Gastroenterol 29: 210­16. Incidence of Sexually Transmitted Diseases in Kuwait." Clin Dermatol 22: 509­12. Abdul Mujeeb, S. 1993. "Blood Transfusion--A Potential Algeria MOH (Ministry of Health). Unknown. "Rapport Source of HIV/AIDS Spread." J Pakistan Med Assoc 43: 1. de l'enquête nationale de séro-surveillance sentinelle Ahmed, S. M. 2004a. AIDS Patients: Situation Analysis- du VIH et de la syphilis en Algérie 2004­2005." Grey Behavioral Survey Results & Discussions. Report. Sudan Report. National AIDS Control Program. Al-Haddad, M. K., A. S. Khashaba, B. Z. Baig, and S. ------. 2004b. Antenatal: Situation Analysis-Behavioral Khalfan. 1994. "HIV Antibodies among Intravenous Survey Results & Discussions. Report. Sudan National Drug Users in Bahrain." J Commun Dis 26: 127­32. AIDS Control Program. Ali, S. A., R. M. Donahue, H. Qureshi, and S. H. Vermund. ------. 2004c. Internally Displaced People: Situation 2009. "Hepatitis B and Hepatitis C in Pakistan: Analysis-Behavioral Survey Results & Discussions. Report, Prevalence and Risk Factors." Int J Infect Dis 13: 9­19. Sudan National AIDS Control Program. Al-Mahroos, F. T., and A. Ebrahim. 1995. "Prevalence of ------. 2004d. Military Situation: Analysis-Behavioral Survey Hepatitis B, Hepatitis C and Human Immune Results & Discussions. Report. Sudan National AIDS Deficiency Virus Markers among Patients with Control Program. Hereditary Haemolytic Anaemias." Ann Trop Paediatr ------. 2004e. Sex Sellers: Situation Analysis-Behavioral 15: 121­28. Survey Results & Discussions. Report. Sudan National Al-Mazrou, Y. Y., M. H. Al-Jeffri, A. I. Fidail, N. AIDS Control Program. Al-Huzaim, and S. E. El-Gizouli. 2005. "HIV/AIDS ------. 2004f. STDs: Situation Analysis-Behavioral Survey Epidemic Features and Trends in Saudi Arabia." Ann Results & Discussions. Report. Sudan National AIDS Saudi Med 25: 100­04. Control Program. Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, ------. 2004g. Street Children: Situation Analysis-Behavioral I. El-Adawy, and M. Rijhwani. 2007. "Clinical Survey Results & Discussions. Report. Sudan National Patterns of Sexually Transmitted Diseases, Associated AIDS Control Program. Sociodemographic Characteristics, and Sexual Practices in the Farwaniya Region of Kuwait." ------. 2004h. TB Patients: Situation Analysis-Behavioral Int J Dermatol 46: 594­99. Survey Results & Discussions. Report, Sudan National AIDS Control Program. Alrajhi, A. A., M. A. Halim, and H. M. Al-Abdely. 2004. "Mode of Transmission of HIV-1 in Saudi Arabia." ------. 2004i. Tea Sellers: Situation Analysis-Behavioral AIDS 18: 1478­80. Survey Results & Discussions. Report. Sudan National Al-Serouri, A. W. 2000. HIV/AIDS Situation and Response AIDS Control Program. Analysis Report. National AIDS Program, Ministry of ------. 2004j. Truck Drivers: Situation: Analysis-Behavioral Health, Yemen Republic. Survey Results & Discussions. Report. Sudan National Al-Sheyyab, M., A. Batieha, and M. El-Khateeb. 2001. AIDS Control Program. "The Prevalence of Hepatitis B, Hepatitis C and ------. 2004k. University Students: Situation Analysis- Human Immune Deficiency Virus Markers in Multi- Behavioral Survey, Results & Discussions. Report. Sudan Transfused Patients." J Trop Pediatr 47: 239­42. National AIDS Control Program. Altaf, A., Z. Fatmi, A. Ajmal, T. Hussain, H. Qahir, and Aidaoui, M., S. Bouzbid, and M. Laouar. 2008. "Sero- M. Agboatwalla. 2004. "Determinants of Therapeutic prevalence of HIV Infection in Pregnant Women in Injection Overuse among Communities in Sindh, the Annaba Region (Algeria)." Rev Epidemiol Sante Pakistan." J Ayub Med Coll Abbottabad 16: 35­38. Publique 56: 261­66. Anonymous. 2006. Scaling Up the HIV Response toward Al Hijazat, M., and Y. M. Ajlouni. 2008. "Hepatitis B Universal Access to Prevention, Treatment, Care and Support Infection among Patients Receiving Chronic Hemo- in Jordan. Summary report of the national consultation. dialysis at the Royal Medical Services in Jordan." Ansar, M. M., and A. Kooloobandi. 2002. "Prevalence of Saudi J Kidney Dis Transpl 19: 260­67. Hepatitis C Virus Infection in Thalassemia and Alami, K. 2009. "Tendances récentes de l'épidémie à Haemodialysis Patients in North Iran-Rasht." J Viral VIH/SIDA en Afrique du nord." Presentation, Hepat 9: 390­92. Research and AIDS Workshop in North Africa, Askarian, M., K. Mirzaei, and B. Cookson. 2007. Marrakech, Morocco. "Knowledge, Attitudes, and Practice of Iranian 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: 83­87. "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: 31­34. Iranian Dentists Associated with HIV-Positive Chemtob, D., and S. F. Srour. 2005. "Epidemiology of Patients." Am J Infect Control 34: 530­33. HIV Infection among Israeli Arabs." Public Health 119: Aslam, M., J. Aslam, B. D. Mitchell, and K. M. Munir. 138­43. 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: 243­46. J Hepatobiliary Pancreat Surg 10: 168­71. 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: 667­74. 444: 836­37. 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: 206­9. 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: 91­97. Turkey." Mikrobiyol Bul 42: 675­80. 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: 819­25. Science Journal 4: 13­18. 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: 1781­83. 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: 21­27. 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: 1­5. "First Molecular Characterization of HIV-1 Tunisian Farah, M. S., and S. Hussein. 2006. "HIV Prevalence, Strains." J Acquir Immune Defic Syndr 28: 94­96. 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: 274­84. 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: 887­91. Type 1 Drug Resistance Mutations in Algeria." AIDS Gehring, S., S. Maayan, H. Ruppach, P. Balfe, Res Hum Retroviruses 24: 1467­73. 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: 367­72. Retrovirol 15: 296­303. 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 444­51. in Mogadishu, Somalia." East Afr Med J 67: 466­72. 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: 650­55. 277­83. Further Evidence Related to HIV Epidemiology in MENA 95 Gheiratmand, R., R. Navipour, M. R. Mohebbi, and A. K. Idrees, M., and S. Riazuddin. 2008. "Frequency Distribution Mallik. 2005. "Uncertainty on the Number of HIV/ of Hepatitis C Virus Genotypes in Dif ferent AIDS Patients: Our Experience in Iran." Sex Transm Geographical Regions of Pakistan and Their Possible Infect 81: 279­80. Routes of Transmission." BMC Infect Dis 8: 69. Gisselquist, D., J. J. Potterat, S. Brody, and F. Vachon. Iqbal, J., and N. Rehan. 1996. "Sero-Prevalence of HIV: 2003. "Let It Be Sexual: How Health Care Six Years' Experience at Shaikh Zayed Hospital, Transmission of AIDS in Africa Was Ignored." Int J Lahore." J Pak Med Assoc 46: 255­58. STD AIDS 14: 148­61. Iran Center for Disease Management. 2004. AIDS/HIV Gisselquist, D., R. Rothenberg, J. Potterat, and E. Surveillance Report (April). Tehran: Ministry of Health Drucker. 2002. "HIV Infections in Sub-Saharan Africa and Medical Education. Not Explained by Sexual or Vertical Transmission." Ismail, S. O., H. J. Ahmed, L. Grillner, B. Hederstedt, A. Issa, Int J STD AIDS 13: 657­66. and S. M. Bygdeman. 1990. "Sexually Transmitted Goldmann, D. A. 2002. "Blood-Borne Pathogens and Diseases in Men in Mogadishu, Somalia." Int J STD AIDS Nosocomial Infections." J Allergy Clin Immunol 110: 1: 102­6. S21­26. Jahan, S. 2005. "Epidemiology of Needlestick Injuries Gouya, M. M. 2006. National Report on HIV and AIDS among Health Care Workers in a Secondary Cases. Disease Management Center, Ministry of Care Hospital in Saudi Arabia." Ann Saudi Med 25: Health and Medical Education. Tehran: Islamic 233­38. Republic of Iran. Janjua, N. Z. 2003. "Injection Practices and Sharp Waste Gulcan, A., E. Gulcan, A. Toker, I. Bulut, and Y. Akcan. Disposal by General Practitioners of Murree, 2008. "Evaluation of Risk Factors and Seroprevalence Pakistan." J Pak Med Assoc 53: 107­11. of Hepatitis B and C in Diabetic Patients in Kutahya, Janjua, N. Z., S. Akhtar, and Y. J. Hutin. 2005. "Injection Turkey." J Investig Med 56: 858­63. Use in Two Districts of Pakistan: Implications for Hadadi, A., S. Afhami, M. Karbakhsh, and N. Esmailpour. Disease Prevention." Int J Qual Health Care 17: 401­8. 2008. "Occupational Exposure to Body Fluids among Healthcare Workers: A Report from Iran." Singapore Janjua, N. Z., Y. J. Hutin, S. Akhtar, and K. Ahmad. Med J 49: 492­96. 2006. "Population Beliefs about the Efficacy of Injections in Pakistan's Sindh Province." Public Health Hassan, N. F., N. M. el Ghorab, M. S. Abdel Rehim, M. S. 120: 824­33. el Sharkawy, N. M. el Sayed, K. Emara, Y. Soltant, M. Sanad, R. G. Hibbs, and R. R. Arthur. 1994. Janjua, N. Z., and M. A. Nizamy. 2004. "Knowledge and "HIV Infection in Renal Dialysis Patients in Egypt." Practices of Barbers about Hepatitis B and C AIDS 8: 853. Transmission in Rawalpindi and Islamabad." J Pak Med Assoc 54: 116­19. Hauri, A. M., G. L. Armstrong, and Y. J. Hutin. 2004. "The Global Burden of Disease Attributable to Contaminated Javadzadeh, H., M. Attar, and M. Taher Yavari. 2006. Injections Given in Health Care Settings." Int J STD "Study of the Prevalence of HBV, HCV, and HIV AIDS 15: 7­16. Infection in Hemophilia and Thalassemia Population of Yazd (Farsi)." Khoon (Blood) 2: 315­22. Hierholzer, M., R. R. Graham, I. El Khidir, S. Tasker, M. Darwish, G. D. Chapman, A. H. Fagbami, A. Soliman, Jurjus, A. R., J. Kahhaleh, National AIDS Program, and D. L. Birx, F. McCutchan, and J. K. Carr. 2002. "HIV WHO/EMRO (World Health Organization, Eastern Type 1 Strains from East and West Africa Are Mediterranean Regional Office). 2004. "Knowledge, Intermixed in Sudan." AIDS Res Hum Retroviruses 18: Attitudes, Beliefs, and Practices of the Lebanese con- 1163­66. cerning HIV/AIDS." Beirut, Lebanon. Hmida, S., N. Mojaat, E. Chaouchi, T. Mahjoub, B. Khlass, Kabbash, I. A., N. M. El-Sayed, A. N. Al-Nawawy, S. S. Abid, and K. Boukef. 1995. "HCV Antibodies in Abou Salem Mel, B. El-Deek, and N. M. Hassan. Hemodialyzed Patients in Tunisia." Pathol Biol (Paris) 2007. "Risk Perception and Precautions Taken by 43: 581­83. Health Care Workers for HIV Infection in Haemodialysis Units in Egypt." East Mediterr Health J Hosseini Asl, S. K., M. Avijgan, and M. Mohamadnejad. 13: 392­407. 2004. "High Prevalence of HBV, HCV, and HIV Infections: In Gypsy Population Residing in Shar-e- Kadivar, M. R., A. R. Mirahmadizadeh, A. Karimi, and A. kord." Arch Iranian Med 7: 22­24. Hemmati. 2001. "The Prevalence of HCV and HIV in Thalassemia Patients in Shiraz, Iran." Medical Journal Hossini, C. H., D. Tripodi, A. E. Rahhali, M. Bichara, of Iranian Hospital 4: 18­20. D. Betito, J. P. Curtes, and C. Verger. 2000. "Knowledge and Attitudes of Health Care Professionals Kalaajieh, W. K. 2000. "Epidemiology of Human with Respect to AIDS and the Risk of Occupational Immunodeficiency Virus and Acquired Transmission of HIV in 2 Moroccan Hospitals." Sante Immunodeficiency Syndrome in Lebanon from 1984 10: 315­21. through 1998." Int J Infect Dis 4: 209­13. Hsairi, M., and S. Ben Abdallah. 2007. "Analyse de la Kane, A., J. Lloyd, M. Zaffran, L. Simonsen, and M. Kane. situation de vulnérabilité vis-à-vis de l'infection à VIH 1999. "Transmission of Hepatitis B, Hepatitis C des hommes ayant des relations sexuelles avec des and Human Immunodeficiency Viruses through hommes." For ATL MST sida NGO­Tunis Section, Unsafe Injections in the Developing World: Model- National AIDS Programme/DSSB, UNAIDS. Final Based Regional Estimates." Bull World Health Organ 77: report, abridged version. 801­7. 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: 564­66. Istanbul, Turkey." J Int Med Res 32: 671­75. ------. 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: 251­55. 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: e27­31. "Inherited Coagulation Disorders in Southern Iran." Haemophilia 8: 740­44. 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 301­5. 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: 8­11. Blood Exposure in Caregiving Facilities, in Morocco." Med Mal Infect 38: 658­66. 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: 79­83. 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: 43­51. Bushehr Province (Farsi)." Iranian South Medical Lebanon National AIDS Control Program. 2008. "A Case Journal 1: 53­59. 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: 82­84. 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: 217­22. Exch 12­13, 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: 869­74. 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: 160­65. 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: 207­25. 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: 404­18. Vermund. 1997. "HIV/AIDS and Its Risk Factors in Mansour-Ghanaei, F., M. S. Fallah, A. Shafaghi, Pakistan." AIDS 11: 843­48. 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 534­36. Iran)." Med Sci Monit 8: CR797­800. 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 121­23. in Djibouti." 8th Retrovir Oppor Infect (abstract no. 585). Further Evidence Related to HIV Epidemiology in MENA 97 Maslin, J., C. Rogier, F. Berger, M. A. Khamil, D. Nakhaie, S., and E. Talachian. 2003. "Prevalence and Mattera, M. Grandadam, M. Caron, and E. Nicand. Characteristic of Liver Involvement in Thalassemia 2005. "Epidemiology and Genetic Characterization of Patients with HCV in Ali-Asghar Children Hospital, HIV-1 Isolates in the General Population of Djibouti Tehran, Iran (Farsi)." Journal of Iranian University (Horn of Africa)." J Acquir Immune Defic Syndr 39: Medical Science 37: 799­806. 129­32. Nemati, E., S. M. Alavian, S. Taheri, M. Moradi, McCutchan, F., J. Carr, S. Tovanabutra, X.-F. Yu, C. Beyrer, V. Pourfarziani, and B. Einollahi. 2009. "Hepatitis and D. Birx. 2002. "HIV-1 and Drug Trafficking: Viral C Virus Infection among Patients on Hemodialysis: A Strains Illuminate Networks and Provide Focus for Report from a Single Center in Iran." Saudi J Kidney Interventions." NIDA-Sponsored Satellite Sessions, Dis Transpl 20: 147­53. XIV International AIDS Conference, Barcelona, Spain. Novelli, V. M., H. Mostafavipour, M. Abulaban, Measure DHS. 2006. "Egypt: Demographic and Health F. Ekteish, J. Milder, and B. Azadeh. 1987. "High Survey 2005." Grey Report. Prevalence of Human Immunodeficiency Virus Ministry of Health and Medical Education of Iran. 2006. Infection in Children with Thalassemia Exposed to "Treatment and Medical Education." Islamic Republic Blood Imported from the United States." Pediatr Infect of Iran HIV/AIDS situation and response analysis. Dis J 6: 765­66. Mirmomen, S., S. M. Alavian, B. Hajarizadeh, J. Kafaee, Omer, E. E., M. H. Ali, O. M. Taha, M. A. Ahmed, and S. B. Yektaparast, M. J. Zahedi, A. A. Azami, M. M. A. Abbaro. 1982. "Sexually Transmitted Diseases in Hosseini, A. R. Faridi, K. Davari, and B. Hajibeigi. Sudanese Males." Trop Doct 12: 208­10. 2006. "Epidemiology of Hepatitis B, Hepatitis C, and Pakistan National AIDS Control Program. 2005. HIV Human Immunodeficiency Virus Infections in Second Generation Surveillance in Pakistan. National Patients with Beta-Thalassemia in Iran: A Multicenter Report Round 1. Ministry of Health, Pakistan, and Study." Arch Iran Med 9: 319­23. Canada-Pakistan HIV/AIDS Surveillance Project. Mishal, Y., C. Yosefy, E. Hay, D. Catz, E. Ambon, and ------. 2006­7. HIV Second Generation Surveillance in R. Schneider. 1998. "Risk of Transmission of Viral Pakistan. National Report Round II. Ministry of Disease by Needle Punctures and Cuts in Hospital Health, Pakistan, and Canada-Pakistan HIV/AIDS Health Care Workers." Harefuah 135: 337­39, 408. Surveillance Project. Moghimi, M., S. A. Marashi, A. Kabir, H. R. Taghipour, ------. 2008. HIV Second Generation Surveillance in A. H. Faghihi-Kashani, I. Ghoddoosi, and S. M. Pakistan. National Report Round III. Ministry of Alavian. 2009. "Knowledge, Attitude, and Practice of Health, Pakistan, Canada-Pakistan HIV/AIDS Iranian Surgeons about Blood-Borne Diseases." J Surg Surveillance Project. Res 151: 80­84. Pieniazek, D., J. Baggs, D. J. Hu, G. M. Matar, A. M. Mohamed, M. K., M. Abdel-Hamid, M. N. Mikhail, Abdelnoor, J. E. Mokhbat, M. Uwaydah, A. R. Bizri, A. F. Abdel-Aziz, A. Medhat, L. S. Magder, A. D. Fix, Ramos, L. M. Janini, A. Tanuri, C. Fridlund, C. Schable, and G. T. Strickland. 2005. "Intrafamilial Transmission L. Heyndrickx, M. A. Rayfield, and W. Heneine. 1998. of Hepatitis C in Egypt." Hepatology 42: 683­87. "Introduction of HIV-2 and Multiple HIV-1 Subtypes to Mohamed, M. K., L. S. Magder, M. Abdel-Hamid, Lebanon." Emerg Infect Dis 4: 649­56. M. El-Daly, N. N. Mikhail, F. Abdel-Aziz, A. Medhat, Piyasirisilp, S., F. E. McCutchan, J. K. Carr, E. Sanders- V. Thiers, and G. T. Strickland. 2006. "Transmission Buell, W. Liu, J. Chen, R. Wagner, H. Wolf, Y. Shao, of Hepatitis C Virus between Parents and Children." S. Lai, C. Beyrer, and X. F. Yu. 2000. "A Recent Am J Trop Med Hyg 75: 16­20. Outbreak of Human Immunodeficiency Virus Type 1 Mokhbat, J. E., R. E. Naman, F. S. Rahme, A. E. Farah, Infection in Southern China Was Initiated by Two K. L. Zahar, and A. Maalouf. 1989. "Clinical and Highly Homogeneous, Geographically Separated Serological Study of the Human Immunodeficiency Strains, Circulating Recombinant Form AE and a Virus Infection in a Cohort of Multi-Transfused Novel BC Recombinant." J Virol 74: 11286­95. Persons." J Med Liban 38: 9­14. Qatar, State of. 2008. Report on the Country Progress Indicators towards Implementing the Declaration of Morocco MOH (Ministry of Health). Unknown. Commitment on HIV. National Health Authority. "Situation épidémiologique actuelle du VIH/SIDA au Maroc." Raja, N. S., and K. A. Janjua. 2008. "Epidemiology of Hepatitis C Virus Infection in Pakistan." J Microbiol Mujeeb, S. A., and A. Hafeez. 1993. "Prevalence and Immunol Infect 41: 4­8. Pattern of HIV Infection in Karachi." J Pak Med Assoc 43: 2­4. Rajabali, A., S. Khan, H. J. Warraich, M. R. Khanani, and S. H. Ali. 2008. "HIV and Homosexuality in Pakistan." Mujeeb, S. A., and M. S. Pearce. 2008. "Temporal Trends Lancet Infect Dis 8: 511­15. in Hepatitis B and C Infection in Family Blood Donors from Interior Sindh, Pakistan." BMC Infect Dis 8: 43. Rehan, N. 2006. "Profile of Men Suffering from Sexually Transmitted Infections in Pakistan." J Pak Med Assoc Naderi, H. R., M. Tagliamonte, M. L. Tornesello, M. 56: S60­65. Ciccozzi, G. Rezza, R. Farid, F. M. Buonaguro, and L. Buonaguro. 2006. "Molecular and Phylogenetic Rezvan, H., H. Abolghassemi, and S. A. Kafiabad. 2007. Analysis of HIV-1 Variants Circulating among "Transfusion-Transmitted Infections among Multi- Injecting Drug Users in Mashhad-Iran." Infect Agent Transfused Patients in Iran: A Review." Transfus Med Cancer 1: 4. 17: 425­33. 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: 644­48. Hepatitis C Virus (HCV) Infection." Int J Med Sci 3: Saleh, D. A., F. Shebl, M. Abdel-Hamid, S. Narooz, N. 41­46. 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: 921­28. 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: 1569­74. 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: 834­39. 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: 475­78. terization of HIV in Iran." J Med Virol 78: 853­63. 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: 878­82. Africa and Effect of Elimination of Unsafe Injections." Torabi, S. A., K. Abed-Ashtiani, R. Dehkhoda, A. N. Lancet 363: 482­88. 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: 291­99. Seroconversion Incidence in Five Haemodialysis UNAIDS (United Nations Joint Programme on HIV/ Units in Morocco." Nephrol Ther 4: 105­10. 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: 789­800. 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: 123­24. 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: 727­32. "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: 102­7. Prevalence of Hepatitis C in Egyptian Patients with Sudan National HIV/AIDS Control Program. 2004a. Chronic Liver Disease." Gut 37: 105­7. 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. Further Evidence Related to HIV Epidemiology in MENA 99 Watts, D. M., N. T. Constantine, M. F. Sheba, M. Kamal, Yemen MOH (Ministry of Health). Unknown. National J. D. Callahan, and M. E. Kilpatrick. 1993. "Prevalence Strategic Framework for the Control and Prevention of HIV/ of HIV Infection and AIDS in Egypt over Four Years AIDS in the Republic of Yemen. Grey Report. of Surveillance (1986­1990)." J Trop Med Hyg 96: Yerly, S., R. Quadri, F. Negro, K. P. Barbe, J. J. Cheseaux, 113­17. P. Burgisser, C. A. Siegrist, and L. Perrin. 2001. WHO (World Health Organization). 1999a. "Global "Nosocomial Outbreak of Multiple Bloodborne Viral Surveillance and Control of Hepatitis C." Report of a Infections." J Infect Dis 184: 369­72. WHO consultation organized in collaboration with Younus, M., A. E. Siddiqi, and S. Akhtar. 2009. the Viral Hepatitis Prevention Board, Antwerp, "Reassessment of Selected Healthcare Associated Risk Belgium. J Viral Hepat 6: 35­47. Factors for HBV and HCV Infections among Volunteer ------. 1999b. Weekly Epidemiological Record. No. 49. Blood Donors, Karachi, Pakistan." Cent Eur J Public ------. 2005. "Summary Country Profile for HIV/AIDS Health 17: 31­35. Treatment Scale-Up." Djibouti. Zafar, A., N. Aslam, N. Nasir, R. Meraj, and V. Mehraj. WHO/EMRO (Eastern Mediterranean Regional Office). 2008. "Knowledge, Attitudes and Practices of Health 2005. "Progress Report on HIV/AIDS and `3 by 5.'" Care Workers regarding Needle Stick Injuries at a July, Cairo. Tertiary Care Hospital in Pakistan." J Pak Med Assoc ------. 2006. Progress towards Universal Access to HIV 58: 57­60. Prevention, Treatment and Care in the Health Sector. Zahraoui-Mehadji, M., M. Z. Baakrim, S. Laraqui, O. Report on a baseline survey for the year 2005 in the Laraqui, Y. El Kabouss, C. Verger, A. Caubet, and C. WHO Eastern Mediterranean Region. Draft. H. Laraqui. 2004. "Infectious Risks Associated with WHO, UNICEF (United Nations Children's Fund), and Blood Exposure for Traditional Barbers and Their UNAIDS (United Nations Joint Programme on HIV/ Customers in Morocco." Sante 14: 211­16. AIDS). 2006. "Yemen, Epidemiological Facts Sheets Zali, M. R., R. Aghazadeh, A. Nowroozi, and H. Amir- on HIV/AIDS and Sexually Transmitted Infections." Rasouly. 2001. "Anti-HCV Antibody among Iranian World Bank. 2006. HIV/AIDS in Afghanistan. South Asia IV Drug Users: Is It a Serious Problem?" Arch Iranian Region, World Bank. Med 4: 115­19. World Bank Group. 2005. "World Bank Update 2005: Zargooshi, J. 2002. "Characteristics of Gonorrhoea in HIV/AIDS in Pakistan." Washington, DC. Kermanshah, Iran." Sex Transm Infect 78: 460­61. Yamaguchi, J., S. Badreddine, P. Swanson, P. Bodelle, S. G. Zouiten, F., A. Ben Said, L. Ammari, A. Slim, F. Kanoun, Devare, and C. A. Brennan. 2008. "Identification of and T. Ben Chaabane. 2002. "AIDS in Tunisian New CRF43_02G and CRF25_cpx in Saudi Arabia Women: Study of 92 Cases." Tunis Med 80: 402­6. Based on Full Genome Sequence Analysis of Six HIV Type 1 Isolates." AIDS Res Hum Retroviruses 24: 1327­35. 100 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Chapter 8 Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 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 Country Knowledge of condoms Knowledge of condom use for HIV prevention Afghanistan 25.0% (TB patients; Todd et al. 2007) 41.0% (FSWs; World Bank 2008) Egypt, Arab 10.0% (adolescents; El-Tawila et al. 1999) 60.0% (general population; Kabbash et al. 2007) Republic of 49.3% (MSM; El-Sayyed, Kabbash, and El-Gueniedy 2008) Iran, Islamic Majority (adolescents; Mohammadi et al. 2006) Majority (adolescents; Mohammadi et al. 2006) Republic of 53.0% (adolescents; Yazdi et al. 2006) 42.0% (adolescents; prevent STIs; Mohammadi et al. 2006) 49.0% (university students; Simbar, Tehrani, and Hashemi 2005) 62.0% (male university students; Simbar, Tehrani, and Hashemi 2005) 39.0% (female university students; Simbar, Tehrani, and Hashemi 2005) 10.0% (prisoners; Khawaja et al. 1997) Nearly all (FSWs; Ministry of Health and Medical Education of Iran 2004) Jordan 84.4% (general population women; Measure 33.0% (general population women; Measure DHS 2003) DHS 1998) Lebanon 84.1% (general population; Jurjus et al. 2004) Morocco 37.5% (general population women; Morocco MOH 2004) 37.5% (general population women; Zidouh [unknown]) 53.8% (youth; Morocco MOH, with GTZ, 2007) 53% (youth; Morocco MOH, with GTZ, 2007) 73.4% (FSWs; Morocco MOH 2007) 53% (FSWs; Morocco MOH 2007) Pakistan 94.0% hijras (Khan et al. 2008) 58.7% (obstetrics and gynecology clinic attendees; Haider et al. 2009) 19.5% (ever-married women; Measure DHS 2007) Minority (truck drivers; Agha 2000) 37%­77% (FSWs; Bokhari et al. 2007) 60.4% (FSWs; Pakistan National AIDS Control Program 2005) 64.0% (FSWs; Pakistan National AIDS Control Program 2006­07) 46.6% (IDUs; Pakistan National AIDS Control Program 2005) 44.3% (IDUs; Pakistan National AIDS Control Program 2006­07) 44.0% (IDUs; Pakistan National AIDS Control Program 2008) 63.7% (MSWs; Pakistan National AIDS Control Program 2005) 54.0% (MSWs; Pakistan National AIDS Control Program 2006­07) 61.7% (MSWs; Pakistan National AIDS Control Program 2008) 57.0% (HSWs; Pakistan National AIDS Control Program 2005) 50.2% (HSWs; Pakistan National AIDS Control Program 2006­07) 66.5% (HSWs; Pakistan National AIDS Control Program 2008) 69.0% hijras (Khan et al. 2008) Somalia 23.0% (women under age 24; Population Studies Research Institute 2000) Sudan 71.9% (university students; Sudan National 18.5% (street children; Ahmed 2004h) HIV/AIDS Control Program 2004) 27.4% (university students; Ahmed 2004l) One-third (general population; Ahmed 2004b) 4.0% (rural populations; SNAP, UNICEF, and UNAIDS 2005) 21.1% (general population; Southern Sudan; NSNAC 5.2% (ANC women attendees; Ahmed 2004b) and UNAIDS 2006) 10.2% (general population; Southern Sudan; NSNAC and UNAIDS 2006) 89.0% (general population; men; Southern Sudan; 78.0% (general population; men; Southern Sudan; UNHCR 2007) UNHCR 2007) 58.0% (general population; women; Southern Sudan; UNHCR 2007) 71.0% (general population; women; Southern Sudan; 5.0% (tea sellers; Ahmed 2004j) UNHCR 2007) 11.3% (internally displaced persons; Ahmed 2004c) 31.6% (rural populations; SNAP, UNICEF, and 2.0% (police officers; Abdelwahab 2006) UNAIDS 2005) 5.7% (military personnel; Ahmed 2004d) 72.1% (truck drivers; Farah and Hussein 2006) 9.1% (prisoners; Ahmed 2004e) 63.9% (prisoners; Assal 2006) 7.5% (truck drivers; Ahmed 2004k) 65.2% (military personnel; Sudan National HIV/ 12.8% (TB patients; Ahmed 2004i) AIDS Control Program 2004) 8.5% (STD clinic attendees; Ahmed 2004g) 45.0% (FSWs; Sudan National HIV/AIDS Control 4.3% (suspected AIDS patients; Ahmed 2004a) Program 2004) 5.3% (truck drivers; Farah and Hussein 2006) 60.9% (FSWs; Yousif 2006) 17.0% (FSWs; Sudan National HIV/AIDS Control Program 2004) 17.2% (FSWs; ACORD 2006) 17.3% (FSWs; Ahmed 2004f) 28.0% (FSWs; Ati 2005) Table 8.1 (Continued) Country Knowledge of condoms Knowledge of condom use for HIV prevention 45.0% (FSWs; Sudan National HIV/AIDS Control Program 2004) 45.1% (FSWs; Anonymous 2007) Syrian Arab 38.0% (IDUs; Syria Mental Health Directorate 2008) Republic Tunisia 89.2% (MSM; Hsairi and Ben Abdallah 2007) West Bank 67.0% (youth; PFPPA 2005) and Gaza Yemen, 48.3% (general population, marginalized minority, 28.5% (youth; Al-Serouri 2005) Republic of and returnees from extended work abroad; 49.4% (high school students; Raja and Farhan 2005) Busulwa 2003) 51.9% (high school students; Gharamah and Baktayan 2006) 20.7% (general population, marginalized minority, and returnees from extended work abroad; Busulwa 2003) Note: ANC antenatal clinic; HSW hijra sex worker; IDU injecting drug user; STD sexually transmitted disease; TB tuberculosis. Table 8.2 Condom Use among Different Population Groups in MENA Country Condom use Afghanistan 0.0% (ever use; IDUs; Sanders-Buell et al. 2007) 17.0% (ever use; commercial sex; IDUs; World Bank 2008) 36.0% (ever use; FSWs; World Bank 2008) Djibouti 48.4% (ever use; sexually active high school students; Rodier et al. 1993) 24.2% (always; sexually active high school students; Rodier et al. 1993) Rare (STD clinic attendees; Wassef et al. 1989) Not common (unlicensed FSWs; Wassef et al. 1989) Common (bar hostesses; Wassef et al. 1989) Egypt, Arab Republic of 90.0% (casual sex; tourism workers; El-Sayed et al. 1996) 23.9% (contraceptive method; general population; Kabbash et al. 2007) Low (regular use; university students; Refaat 2004) 34.1% (ever use; regular partners; IDUs; Egypt MOH and Population National AIDS Program 2006) 12.8% (ever use; nonregular noncommercial partners; IDUs; Egypt MOH and Population National AIDS Program 2006) 11.8% (ever use; with CSWs; IDUs; Egypt MOH and Population National AIDS Program 2006) 66.0% (ever use; IDUs; Elshimi, Warner-Smith, and Aon 2004) 20.0% (ever use; IDUs; El-Sayed et al. 2002) 9.0% (always; IDUs; El-Sayed et al. 2002) 44.0% (ever use; FSWs; El-Sayed et al. 2002) 6.8% (last sex act with a noncommercial partner; FSWs; Egypt MOH and Population National AIDS Program 2006) 6.0% (always; FSWs; El-Sayed et al. 2002) 56.0% (ever use; FSWs; El-Sayed et al. 2002) 6.8% (last sex; noncommercial partners; IDUs; Egypt MOH and Population National AIDS Program 2006) 47.0% (ever use; MSM; El-Sayed et al. 2002) 19.0% (regularly; MSM; El-Rahman 2004) 2.0% (consistent; MSM; El-Sayed 1994) 19.0% (consistent; MSM; El-Sayed et al. 2002) 19.2% (consistent; MSM; El-Sayyed, Kabbash, and El-Gueniedy 2008) 9.2% (last commercial sex; MSM; Egypt MOH and Population National AIDS Program 2006) 12.7% (last noncommercial sex; MSM; Egypt MOH and Population National AIDS Program 2006) 21.0% (ever use; MSM; El-Sayed 1994) 47.9% (ever use; MSM; El-Sayyed, Kabbash, and El-Gueniedy 2008) (continued) Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 103 Table 8.2 (Continued) Country Condom use 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) Country Condom use 4.9% (usually; females; mainly IDUs; Asouab 2005) 29.3% (rarely; females; mainly IDUs; Asouab 2005) 43.9% (never; females; mainly IDUs; Asouab 2005) 59.0% (consistent; vaginal sex; FSWs; Alami 2009) 9.7% (almost always; vaginal sex; FSWs; Alami 2009) 22.2% (sometimes; vaginal sex; FSWs; Alami 2009) 26.1% (consistent; anal sex; FSWs; Alami 2009) 10.9% (almost always; anal sex; FSWs; Alami 2009) 13.0% (sometimes; anal sex; FSWs; Alami 2009) Oman 53%­69% (ever use; IDUs; Oman MOH 2006) 12%­25% (always; IDUs; Oman MOH 2006) 68%­100% (last year; MSM; IDUs; Oman MOH 2006) Pakistan 7.0% (contraceptive method; general population; Measure DHS 2007) 6.0% (ever use; general population; Raza et al. 1998) 10.0% (commercial sex; migrant workers; Faisel and Cleland 2006) 25.0% (sex with a female friend; migrant workers; Faisel and Cleland 2006) 3%­6% (last sex with a nonspousal partner; truck drivers; Agha 2000) 1.7% (last sex with FSW; truck drivers; Bokhari et al. 2007) 0.0% (last sex with male or hijra; truck drivers; Bokhari et al. 2007) 40.0% (ever use; IDUs; Emmanuel and Fatima 2008) 37.5% (ever use; IDUs; Lahore; Kuo et al. 2006) 14.2% (ever use; IDUs; Quetta; Kuo et al. 2006) 7.0% (ever use; IDUs; Parviz et al. 2006) 34.0% (ever use; IDUs; Altaf et al. 2007) 10.0% (ever use; IDUs; Haque et al. 2004) 17%­34% (last commercial sex; IDUs; Bokhari et al. 2007) 10%­25% (last anal sex sold to a man; IDUs; Bokhari et al. 2007) 22%­39% (last vaginal or anal sex sold to a woman; IDUs; Bokhari et al. 2007) 7%­13% (last anal sex paid to a man or hijra; IDUs; Bokhari et al. 2007) 46%­66% (not used last 6 months; nonpaid partners; IDUs; Pakistan National AIDS Control Program 2005) 49%­86% (not used last 6 months; commercial sex; IDUs; Pakistan National AIDS Control Program 2005) 45.0% (last sex; IDUs; Platt et al. 2009) 32.0% (last sex; IDUs; Platt et al. 2009) 17%­18% (always; FSWs; Pakistan National AIDS Control Program 2005) 74%­81% (last month; FSWs; Pakistan National AIDS Control Program 2005) 29%­49% (last sex; one-time client; FSWs; Bokhari et al. 2007) 26%­47% (last sex; regular client; FSWs; Bokhari et al. 2007) 21.0% (last sex; noncommercial partners; FSWs; Bokhari et al. 2007) 17.0% (consistent last month; FSWs; Saleem, Adrien, and Razaque 2008) 68.0% (ever use; FSWs; Pakistan National AIDS Control Program 2005) 34.0% (last sex; noncommercial partners; FSWs; Pakistan National AIDS Control Program 2005) 18.0% (consistent last month; FSWs; Pakistan National AIDS Control Program 2005) 23.0% (consistent last month; FSWs; Pakistan National AIDS Control Program 2006­07) 34.0% (last vaginal sex; FSWs; Blanchard, Khan, and Bokhari 2008) 45.0% (last vaginal sex; FSWs; Pakistan National AIDS Control Program 2006­07) 38.0% (last commercial vaginal sex; FSWs; Hawkes et al. 2009) 12.0% (consistent last month during commercial vaginal sex; FSWs; Hawkes et al. 2009) 61.0% (last commercial anal sex; FSWs; Hawkes et al. 2009) 54.0% (last commercial oral sex; FSWs; Hawkes et al. 2009) 46.0% (last sex with husband; FSWs; Hawkes et al. 2009) 15.0% (consistent last month with husband; FSWs; Hawkes et al. 2009) 7.9% (last anal sex; FSWs; Pakistan National AIDS Control Program 2006­07) 32.4% (last oral sex; FSWs; Pakistan National AIDS Control Program 2006­07) 3.1% (consistent; MSWs; Saleem, Adrien, and Razaque 2008) (continued) Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 105 Table 8.2 (Continued) Country Condom use 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 2006­07) 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 2006­07) 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) Country Condom use 2.7% (ever use; ANC women attendees; Ahmed 2004b) 5.0% (last sex with spouse; men; Southern Sudan; UNHCR 2007) 1.0% (last sex with spouse; women; Southern Sudan; UNHCR 2007) 31.0% (last sex with spouse; refugees; men; Southern Sudan; UNHCR 2007) 5.0% (last sex with spouse; refugees; women; Southern Sudan; UNHCR 2007) 46.3% (last sex with casual partner; men; Southern Sudan; UNHCR 2007) 0.0% (last sex with casual partner; women; Southern Sudan; UNHCR 2007) 22.5% (consistent with casual partner; men; Southern Sudan; UNHCR 2007) 0.0% (consistent with casual partner; women; Southern Sudan; UNHCR 2007) 0.0% (last sex with commercial partner; men; Southern Sudan; UNHCR 2007) 0.0% (last sex with commercial partner; women; Southern Sudan; UNHCR 2007) 16.0% (ever use among sexually active; men; Southern Sudan; UNHCR 2007) 3.0% (ever use among sexually active; women; Southern Sudan; UNHCR 2007) 1.0% (ever use; tea sellers; Ahmed 2004j) 3.0% (ever use; internally displaced persons; IGAD 2006) 5.0% (ever use; internally displaced persons; Ahmed 2004c) 0.0% (ever use; Sudanese women refugees; Holt et al. 2003) 8.9% (ever use; truck drivers; Farah and Hussein 2006) 2.4% (ever use; truck drivers; Ahmed 2004k) 2.7% (ever use; military personnel; Ahmed 2004d) 4.0% (ever use; prisoners; Ahmed 2004e) 15.8% (ever use; prisoners; Assal 2006) 1.7% (ever use; TB patients; Ahmed 2004i) 5.4% (ever use; STD clinic attendees; Ahmed 2004g) 0.0% (ever use; suspected AIDS patients; Ahmed 2004a) 10.4% (ever used; military personnel; Sudan National HIV/AIDS Control Program 2004) 1.7% (consistent; military personnel; Sudan National HIV/AIDS Control Program 2004) 2.0% (last sex; clients of FSWs; SNAP, UNICEF, and UNAIDS 2005) 2.1% (regularly; FSWs and tea sellers; Basha 2006) 10.3% (ever use; FSWs; Ahmed 2004f) 16.7% (ever use; FSWs; Yousif 2006) 13.0% (regularly; FSWs; Ati 2005) 24.6% (ever use; FSWs; ACORD 2006) 57.8% (ever use; FSWs; Ati 2005) 23.0% (ever use; FSWs; Anonymous 2007) 86.2% (ever use; MSM; Elrashied 2006) 50.9% (every time or almost every time; MSM; Elrashied 2006) 58.5% (last commercial sex; MSM; Elrashied 2006) 48.5% (last noncommercial sex; MSM; Elrashied 2006) 72.9% (ever use; MSM; Elrashied 2006) 89.4% (last six months; female partners; MSM; Elrashied 2006) Syrian Arab Republic 13.2% (always; FSWs; Syria MOH 2004) 20.6% (often; FSWs; Syria MOH 2004) 51.0% (sometimes; FSWs; Syria MOH 2004) 15.2% (never; FSWs; Syria MOH 2004) 39.0% (less than half the time; Syria Mental Health Directorate 2008) 21.0% (more than half the time; Syria Mental Health Directorate 2008) 19.0% (consistent; Syria Mental Health Directorate 2008) 27.0% (less than half the time; commercial sex; Syria Mental Health Directorate 2008) 5.0% (more than half the time; commercial sex; Syria Mental Health Directorate 2008) 17.0% (consistent; commercial sex; Syria Mental Health Directorate 2008) Tunisia 65.0% (ever use; FSWs; Hassen et al. 2003) 37.0% (always; FSWs; Hassen et al. 2003) 27.0% (sometimes; FSWs; Hassen et al. 2003) 46.4% (last nonpaid sex; MSM; Hsairi and Ben Abdallah 2007) (continued) Condom Knowledge and Use and HIV/AIDS Knowledge and Attitudes 107 Table 8.2 (Continued) Country Condom use 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; Stulhofer and Bozicevic 2008) 28.8% (last nonpaid sex; FSWs; Stulhofer and Bozicevic 2008) 50.0% (consistent; nonregular clients; FSWs; Stulhofer and Bozicevic 2008) 58.0% (consistent; regular clients; FSWs; Stulhofer and Bozicevic 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- 13­18, 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. 271­81. 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: 2404­6. 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: 837­38. ------. 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: 300­4. 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: ii24­27. 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: 486­92. 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: 277­85. 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: 546­54. 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: 594­99. from a National Knowledge, Attitudes and Practices Al-Serouri, A. W. 2005. "Assessment of Knowledge, Survey." Isr Med Assoc J 8: 610­14. 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: 49­59. 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 243­50. 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: 187­219. Men in Teharan, 2006­07." 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: 48­53. El-Bakly, S., and R. W. Hess. 1994. "Mass Media Makes Asouab, F. 2005. "Risques VIH/SIDA chez UDI et plan a Difference." Integration 13­15. d'action 2006­2010." 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: 774­79. 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: 178­83. 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: 209­25. and Perceived Needs Related to Sexual and Farhoudi, B., A. Montevalian, M. Motamedi, M. M. Reproductive Health." J Adolesc Health 29: 153­55. 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 11­16. 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: 682­84. 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: 161­64. 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, March­April. 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: 1123­24. 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: 95­98. Infections with Specific Regions of Egypt." Am J Trop Med Hyg 55: 179­84. 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: 1126­35. Prev 19: 519­30. 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: 601­7. 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: 143­48. Where Most Needed." Int J Drug Policy 19 Suppl 1: Hawkes, S., M. Collumbien, L. Platt, N. Lalji, N. Rizvi, S59­64. 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: 268­78. Survey." Sex Transm Infect 85 Suppl 2: ii8­16. 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: 1321­32. 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: 817­20. 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: 1­15. Female College Students of Karachi." J Pak Med Assoc Hsairi, M., and S. Ben Abdallah. 2007. "Analyse de la 55: 195­98. 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 7­8. hommes." For ATL MST sida NGO­Tunis 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: 843­48. 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: 246­60. 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: 92­99. 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: 407­9. 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 1­2. 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: 23­25. 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: 1369­83. 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: 404­18. 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: 1308­20. Mediterr Health J 14: 292­97. 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 (15­49 Years) in Lower Egypt: ------. 2003. "Jordan: Demographic and Health Survey Knowledge, Attitudes and Patterns of Use." East 2002." Mediterr Health J 13: 1405­16. ------. 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 21­25. 2006­7." 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: 352­61. 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: 510­15. 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: 364­71. Ethics 34: 225­29. 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 15­18 Years in S. Mayhew, R. Muzaffar, A. Andreasen, and S. Tehran." J Adolesc Health 41: 407­14. 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: ii17­22. Tehran, Iran." Int Fam Plan Perspect 32: 35­44. 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: 199­203. 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: 4­8. 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: 511­15. 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: 725­31. Pak Med Assoc 48: 179­82. 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: 72­81. 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, 2004­2005. With Exposure and Prevalence." East Afr Med J 70: 414­17. 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: 4­5. 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: 479­500. ------. 2006­7. 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: 642­48. 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: 1068­75. 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: 834­39. 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: 71­79. 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: 549­53. 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: 25­35. 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: 888­97. Lebanon, Oct. 30­Nov. 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: 1004­10. and SOLNAC. Yemen Central Statistical Organization. 1998. Yemen Stulhofer, A., and I. Bozicevic. 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: 709­16. 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: 460­61. 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 HIV/AIDS and Vulnerability Settings 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 2004­5 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 Country Imprisonment (per 100,000) HIV prevalence in prisons Afghanistan 30 (International Centre for Prison Studies 2006) Algeria 158 (International Centre for Prison Studies 2006) Bahrain 95 (International Centre for Prison Studies 2006) Djibouti 61 (Dolan et al. 2007; International 6.1% (Shrestha 1999) Centre for Prison Studies 2006) Egypt, Arab About 121 (Dolan et al. 2007; 0.0% (El-Ghazzawi, Hunsmann, and Schneider 1987) Republic of International Centre for Prison Studies 0.0% (Egypt Ministry of Health and Population 2001) 2006) 1.6% (Quinti et al. 1995) Iran, Islamic 191 (Dolan et al. 2007; International 2% (UNAIDS and WHO 2002; UNAIDS 2002) Republic of Centre for Prison Studies 2006) 1.4% (UNAIDS and WHO 2001) 185 (Burrows, Wodak, and WHO 2005) 2.3% (UNAIDS and WHO 2001) 12% (UNAIDS and WHO 2002) 2.1% (mostly IDUs; Afshar [unknown (a)]) 2.3% (mostly IDUs; Afshar [unknown (a)]) 3.3% (mostly IDUs; Afshar [unknown (a)]) 0.9% (injecting and noninjecting drug users; Alizadeh et al. 2005) 24.4% (IDUs; Jahani et al. 2009) 7.0% (IDUs; Rahbar, Rooholamini, and Khoshnood 2004) 22.0% (IDUs; Farhoudi et al. 2003) 24.0% (IDUs; Farhoudi et al. 2003) 12.0% (UNAIDS and WHO 2002) Up to 63.0% (UNAIDS 2002) 22­24% (Spaulding et al. 2002) 6% (Spaulding et al. 2002) 2.5% (Ghannad et al. 2009) 2.4% (Ghannad et al. 2009) 1.9% (Ghannad et al. 2009) 2.3% (Ghannad et al. 2009) Iraq About 60 (Dolan et al. 2007; 0.0% (Shrestha 1999) International Centre for Prison Studies 0.0% (Jordan National AIDS Program, personal communication) 2006) Jordan 104 (International Centre for Prison 0.0% (Jordan National AIDS Program, personal communication) Studies 2006) Kuwait 130 (International Centre for Prison Studies 2006) Lebanon 145 (Dolan et al. 2007; International 0.7% (Shrestha 1999) Centre for Prison Studies 2006) 0.16% (Mishwar 2008) Libya 207 (Dolan et al. 2007; International 18.0% (Sammud 2005) Centre for Prison Studies 2006) 60.0% (detention for treatment; Dolan et al. 2007) (continued) HIV/AIDS and Vulnerability Settings 121 Table 9.1 (Continued) Country Imprisonment (per 100,000) HIV prevalence in prisons Morocco 174 (Dolan et al. 2007; International 0.8% (Ministère de la Santé Maroc 2003­04) Centre for Prison Studies 2006) 0.7% (Elharti et al. 2002) 0.0% (women; Elharti et al. 2002) 2.0% (women; El Ghrari et al. 2007) 0.0% (women; Khattabi and Alami 2005) 0.72% (women; Khattabi and Alami 2005) 0.0% (women; Khattabi and Alami 2005) 1.2% (women; Khattabi and Alami 2005) 2.11% (women; Morocco MOH 2007) 0.9% (female prisoners imprisoned for sex work; Khattabi and Alami 2005) 0.70% (men; Khattabi and Alami 2005) 1.18% (men; Khattabi and Alami 2005) 0.80% (men; Khattabi and Alami 2005) 0.61% (men; Khattabi and Alami 2005) 0.53% (men; Morocco MOH 2007) Oman 81 (Dolan et al. 2007; International 0.2% (Shrestha 1999) Centre for Prison Studies 2006) 0.14% (UNAIDS 2008) Pakistan 55 (International Centre for Prison 0.3% (Baqi et al. 1998) Studies 2006) 1.1% (women; Baqi et al. 1998) 1.64% (Mujeeb and Hafeez 1993) 2.8% (Safdar, Mehmood, and Abbas 2009) 0.7% (Safdar, Mehmood, and Abbas 2009) 10% (Safdar, Mehmood, and Abbas 2009) 0.5% (Safdar, Mehmood, and Abbas 2009) 0.4% (Safdar, Mehmood, and Abbas 2009) 0.5% (Safdar, Mehmood, and Abbas 2009) 0.3% (Safdar, Mehmood, and Abbas 2009) 2.1% (Safdar, Mehmood, and Abbas 2009) 0.7% (Safdar, Mehmood, and Abbas 2009) 1.0% (Safdar, Mehmood, and Abbas 2009) Qatar 55 (International Centre for Prison Studies 2006) Somalia 0.0% (Ahmed 1997) Sudan About 36 (International Centre for 0.0% (Burans et al. 1990) Prison Studies 2006) 2.0% (UNAIDS 2008) 8.63% (Assal 2006) 27.1% (women; Assal 2006) Syrian Arab 93 (Dolan et al. 2007; International 0­0.2% (Shrestha 1999) Republic Centre for Prison Studies 2006) Tunisia 253 (Dolan et al. 2007; International 0.0% (Shrestha 1999) Centre for Prison Studies 2006) United Arab 288 (International Centre for Prison Emirates Studies 2006) Yemen, Republic 83 (Dolan et al. 2007; International 26.5% (Shrestha 1999) of Centre for Prison Studies 2006) Note: Table adapted from Dolan et al. (2007). Data not available for empty cells. 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." HIV/AIDS and Vulnerability Settings 123 continue their drug use in prison,52 while another prison due to the difficulty of clandestine reported that 85% of IDUs used drugs in prison.53 smoking and scarcity of raw opium.66 The A study found that 28% of community-based higher cost of obtaining drugs in prison has IDUs with a history of incarceration have injected also been cited as a reason for injecting drugs drugs in prisons,54 and another reported that because it is the most cost-effective method of 9.7% of drug-using inmates continued to use using drugs.67 Inmates find multiple ways of drugs, mostly heroin, while in prison.55 paying for drugs in prison, such as through Also in the Islamic Republic of Iran, opioid use family financial support, drug dealing, prison prevalence while in prison was found to be work, sex work, forcing their wives to do sex 30.7%, though 54.3% of inmates used drugs work, selling food and personal effects, gam- before incarceration, indicating a reduction in bling, credit, and extortion.68 drug use during incarceration.56 About 25%­ Use of nonsterile injecting equipment 30% of prisoners used drugs in prison in one in prisons study,57 with another study indicating that about Although predominantly from the Islamic 30% of prisoners attempt to use drugs in prison Republic of Iran, evidence indicates the use of and 17%­23% of prisoners use drugs by injec- nonsterile injecting equipment in prisons. Studies tion.58 In further studies, 91% of IDUs and non- in the Islamic Republic of Iran found, respec- injecting drug users ever imprisoned reported tively, that 19%,69 29.9%,70 and 37.1%71 of IDUs using drugs while in prison,59 and 18.9% and reported using nonsterile injection equipment in 6.1% reported using opioid and injecting drugs prison. In further studies in the Islamic Republic while in prison, respectively.60 of Iran, 82% of those with a history of IDU in Other studies have also observed IDU in pris- prison have injected drugs using nonsterile ons in other MENA countries. In Algeria, 67% of utensils,72 and 23% of community-based IDUs those incarcerated reported using drugs in reported using nonsterile drug injection utensils prison.61 In the Arab Republic of Egypt, about in prison.73 Twenty-three percent of prisoners in 25% of IDUs who had been incarcerated reported another study used drugs mostly with nonsterile injecting drugs in prison.62 In Lebanon, only and handmade utensils.74 0.16% of prisoners, including IDUs, reported There is also evidence from other countries of injecting while in prison.63 In Oman, 26%­44% using nonsterile injecting equipment in prisons. of IDUs reported drug use in prison and 5%­11% In Afghanistan, 30% of IDUs in prison reported reported injecting drugs in prison.64 In Syria, 11% using nonsterile needles or injection equip- of imprisoned IDUs injected drugs in prison.65 ment.75 In Oman, 3%­11% reported using non- The prison environment is possibly compel- sterile needles in prison.76 In Sudan, 3.2% of ling noninjecting drug users to inject while in prisoners reported using nonsterile syringes while in prison.77 In Syria, the majority of IDUs 52 Ibid. 53 who injected in prison did so by using a nonster- Day et al., "Patterns of Drug Use." 54 Zamani et al., "High Prevalence of HIV"; Zamani et al., "Shared Drug ile syringe or a needle.78 Injection inside Prison." 55 66 Bolhari and Mirzamani, "Assessment of Substance Abuse in Iran's Day et al., "Patterns of Drug Use"; Kheirandish et al., "Prevalence and Prisons." Correlates of Hepatitis C." 56 67 Ibid. Zamani et al., "Shared Drug Injection inside Prison"; Zamani, 57 Mostashari, UNODC, and Darabi, "Summary of the Iranian Situation on "Methadone Maintenance Treatment (MMT)." 68 HIV Epidemic." S. Zamani, personal communication (2008); Bolhari and Mirzamani, 58 Afshar, "From the Assessment to the Implementation of Services"; "Assessment of Substance Abuse in Iran's Prisons." 69 Afshar, "Health and Prison." Day et al., "Patterns of Drug Use." 59 70 Day et al., "Patterns of Drug Use"; Zamani et al., "Needle and Syringe Zamani et al., "Needle and Syringe Sharing." 71 Sharing." Ibid. 60 72 Zamani et al., "Needle and Syringe Sharing." Zamani et al., "High Prevalence of HIV." 61 73 Mimouni and Remaoun, "Etude du Lien Potentiel entre l'Usage Zamani et al., "Shared Drug Injection inside Prison." 74 Problématique de Drogues et le VIH/SIDA." Afshar, "Health and Prison." 62 75 Elshimi, Warner-Smith, and Aon, "Blood-Borne Virus Risks." UNAIDS, "Notes on AIDS in the Middle East and North Africa." 63 76 Mishwar, "An Integrated Bio-Behavioral Surveillance Study." Oman MOH, "HIV Risk among Heroin and Injecting Drug Users." 64 77 Oman MOH, "HIV Risk among Heroin and Injecting Drug Users." Assal, "HIV Prevalence." 65 78 Syria Mental Health Directorate, "Assessment of HIV Risk and Syria Mental Health Directorate, "Assessment of HIV Risk and Sero-Prevalence." Sero-Prevalence." 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." HIV/AIDS and Vulnerability Settings 125 drug and sexual risk behaviors have also been a young age.111 Young people bridge HIV infec- observed in MENA prisons. tion between different population groups, such Prevention efforts are needed to combat HIV as young, sexually active IDUs exchanging sex infection in prisons; the Islamic Republic of Iran for money with MSM and exchanging money provides an example of what can be achieved in for sex with FSWs.112 Young people are also the the MENA context by incorporating effective best vehicle for change if they can be reached harm reduction in prisons.102 with appropriate interventions.113 The countries that reported the largest declines in risky behav- ior and HIV prevalence, such as Uganda, YOUTH AND HIV observed the biggest changes among youth.114 MENA is distinctively characterized by a "tidal Demography wave" of youth; one-fifth of the population, 95 million people,103 are in the 15­24 years age The share of youth 15­24 years of age ranges group,104 the average age range of initiation of between 15% and 25% among the countries of sexual activities.105 This is the largest youth the region.115 In Egypt and Morocco, about one- cohort in the region's history and the largest third of the population is between 15 and 29 years vulnerable population in MENA.106 of age.116 In Jordan, 70% of the population is Youth are experiencing high rates of unem- below the age of 25.117 In the West Bank and ployment, delayed marital age, increased pre- Gaza, 52% of the population is below the age of marital sex, conflict morbidity and mortality, 18.118 In Sudan, 45% of the population is under increased mobility, peer pressure to engage in the age of 15.119 In the Republic of Yemen, 46.2% risky behavior, and changing lifestyle norms.107 of the population is below age 15 and 58.3% is The increasing high educational attainment of below age 19.120 youth, coupled with high unemployment, is Though the demographic transition is pro- leading to a structural vulnerability of rising gressing rapidly and fertility has been in sharp expectations but declining opportunities.108 decline in much of the region in recent years, There is a widening generation gap between with several countries being even below the young people on one hand, and their parents replacement level,121 youth will continue to be and decision makers on the other hand.109 the largest vulnerable population as well as the Youth play a central role in the HIV epidemic. population that has the greatest potential to About half of all HIV infections in sub-Saharan drive the socioeconomic dynamics in the Africa, Eastern Europe, and Central Asia are region.122 Regrettably, this region as a whole is among those younger than 25 years of age.110 In largely failing to take advantage of this "demo- most regions, most IDUs, men who have sex graphic bonus" by using this window of oppor- with men (MSM), and female sex workers tunity for economic growth. MENA youth today (FSWs) and their clients are young, or if older, are the first generation of young people in they would have started at-risk behavior at recent history that are unlikely to fare better than their parents, despite having higher educa- 102 Zamani et al., "Prevalence of and Factors Associated with HIV-1 tional levels than their parents.123 Infection"; Ministry of Health and Medical Education of Iran, 111 "Treatment and Medical Education"; Afshar, "From the Assessment Ibid. 112 to the Implementation of Services"; Afshar and Kasraee, "HIV Michael, Ahmed, and Lemma, "HIV/AIDS Behavioral Surveillance Prevention Experiences." Survey." 103 113 Assaad and Roudi-Fahimi, "Youth in the Middle East and North Africa." Monasch and Mahy, "Young People." 104 114 UNAIDS, "Notes on AIDS in the Middle East and North Africa"; Roudi- Ibid. 115 Fahimi and Ashford, "Sexual & Reproductive Health." Assaad and Roudi-Fahimi, "Youth in the Middle East and North Africa." 105 116 Roudi-Fahimi and Ashford, "Sexual & Reproductive Health"; UNAIDS, Jenkins and Robalino, "HIV in the Middle East and North Africa." 117 Report on the Global AIDS Epidemic. UNAIDS, "HIV Prevention in Jordan." 106 118 Assaad and Roudi-Fahimi, "Youth in the Middle East and North Africa." UNAIDS, "Key Findings on HIV Status." 107 119 Busulwa, "HIV/AIDS Situation Analysis Study"; UNAIDS, "Notes on Gutbi and Eldin, "Women Tea-Sellers in Khartoum and HIV/AIDS." 120 AIDS in the Middle East and North Africa." Lambert, "HIV and Development Challenges in Yemen." 108 121 Jenkins and Robalino, "HIV in the Middle East and North Africa." Rashad, "Demographic Transition in Arab Countries." 109 122 Assaad and Roudi-Fahimi, "Youth in the Middle East and North Africa." Assaad and Roudi-Fahimi, "Youth in the Middle East and North Africa." 110 123 Monasch and Mahy, "Young People." Rashad, Osman, and Roudi-Fahimi, Marriage in the Arab World. 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 15­49 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." HIV/AIDS and Vulnerability Settings 127 21% of women in MENA are not married by age youth.162 Among high school students, mari- 30­39.150 In nearly half of the countries, women juana was used by 2%­2.9% of males and spend about one-third of their sexual activity 0.7%­1% of females, and heroin was used by lifespan (15­49 years of age) in an unmarried 0.8%­1% of males and 0.4%­0.6% of females.163 state.151 In Lebanon, about one out of five men The average age at first use of different forms of and women aged 35­39 years was still single in drugs ranged between 12.8 and 14.75 years for 1996.152 In Algeria, Jordan, Kuwait, Lebanon, males and 12 and 16 years for females.164 Peer Libya, Morocco, Qatar, Syria, Tunisia, and the pressure was found to be a key determinant of West Bank and Gaza, between 10% and 25% of starting drug use among these adolescents.165 women are never married.153 Even in a highly The knowledge of harm was generally poor and traditional and underdeveloped country such as multiple use of different drugs was reported by the Republic of Yemen, marriage among women a considerable share of these users.166 15­19 years old declined from 27% to 17% The lack of engagement in meaningful activi- between 1997 and 2003.154 ties is conducive to risky behavior in MENA. Of Early and near universal marriage, where high school students in the West Bank and almost all adults spend most of their sexual Gaza, 38.2% of males and 5.2% of females activity lifetime being married, was once the spend evenings hanging in streets, and among highlight of this region. Yet, it will soon become heroin users, these percentages were 66.7% for the exception rather than the norm.155 In large males and 42.9% for females.167 part, the demographic transition in MENA is For MSM, more than half of the participants driven by stark changes in nuptiality.156 in a study in Sudan (60.1%) were between 15 and 24 years of age, and 85.5% of them had Youth and priority populations their first anal experience between the ages of Youth contribute disproportionately to the priority 15 and 25.168 MSM tend to start having sex at a populations in MENA, attesting to the vulnerabil- younger age compared to males who have sex ity of this population group. Being an unemployed with females.169 In Lebanon, 54% of MSM youth is a frequent characteristic of IDUs.157 Drug reported having their first anal sex at under the use in different forms appears to be considerable age of 18 years.170 In Egypt, young MSM were and probably increasing among youth in MENA.158 the group that changed their sexual partners The profile of IDUs in a Tunisian study was that of most often among MSM.171 Also in Egypt, young men raised in large families shattered by young MSM were found to be the most sexually urban-rural migration.159 Among young prisoners active, with a frequency of sexual acts greater in the Islamic Republic of Iran, 33.9% of inmates than one per day.172 In studies in Pakistan, male used opioid while in prison.160 IDUs in Oman sex workers (MSWs) had an average age of reported hashish as their first drug at a mean age 22.3,173 21.3,174 and 21.7175 years, and started of 18, and then IDU of heroin at age 22.161 The largest burden of drug use in the West 162 Shareef et al., "Drug Abuse Situation." Bank and Gaza is in the 31­40 years age group, 163 Afifi and El-Sousi, "Drug Abuse and Related Behaviors." with a notable increase in drug use among 164 Ibid. 165 Ibid. 166 Ibid. 150 167 Ibid. Ibid. 151 168 Ibid. Elrashied, "Generating Strategic Information." 152 169 Saxena, Kulczycki, and Jurdi, "Nuptiality Transition." Monasch and Mahy, "Young People." 153 170 Roudi-Fahimi and Ashford, "Sexual & Reproductive Health." Mishwar, "An Integrated Bio-Behavioral Surveillance Study." 154 171 Ibid. El-Rahman, "Risky Behaviours for HIV/AIDS Infection." 155 172 Rashad, "Demographic Transition in Arab Countries." El-Sayyed, Kabbash, and El-Gueniedy, "Risk Behaviours for HIV/AIDS 156 Ibid. Infection." 157 173 Zamani et al., "High Prevalence of HIV." Pakistan National AIDS Control Program, HIV Second Generation 158 Ibid. Surveillance (Round I). 159 174 Tiouiri et al., "Study of Psychosocial Factors." Pakistan National AIDS Control Program, HIV Second Generation 160 Bolhari and Mirzamani, "Assessment of Substance Abuse in Iran's Surveillance (Round II). 175 Prisons." Pakistan National AIDS Control Program, HIV Second Generation 161 Oman MOH, "HIV Risk among Heroin and Injecting Drug Users." Surveillance (Round III). 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 21­30 years.192 The age group most affected by Sudan were below 30 years of age, including HIV in Jordan is the 15­35 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 20­40 years found that the majority are under 30 years of age group, with 31% among the 20­29 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 15­29 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 15­24 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 20­24 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 25­34 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 20­29 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." HIV/AIDS and Vulnerability Settings 129 being sexually active (40.8% of males and In Jordan, a survey of youth found casual sex 2.7% of females).203 Another study in Djibouti to be rare and condom use to be moderately reported that 71% of young males and females high among those who engaged in nonmarital reported sexual relations without defining the sex.217 Another study reported that 7% of col- kind of relations, and 39% reported ever using lege students and 4% of the general population condoms.204 in the 15­30 years age range admitted to In Egypt, 26% of male and 3% of female uni- engaging in nonmarital sex.218 About 90% of versity students reported having sexual inter- the youth who reported sexual partnerships course.205 In another study, 16.5% of university reported opposite sex partners only, while 10% students engaged in sexual intercourse,206 and reported sex with the same sex or both sexes.219 in a third, 18% of the students reported engag- About 10% of the youth reported nonmarital ing in risky sexual behavior.207 Low condom use sexual contacts in the last year.220 was reported among university students.208 In Lebanon, behavioral surveys suggest In the Islamic Republic of Iran, 12.4% of increased risky behavior among youth.221 young males reported premarital or extramarital About 50% of young conscripts reported any sex in one study,209 and in a second study, 28% lifetime heterosexual experience and about of males aged 15­18 years reported sexual experi- 50% reported consistent condom use.222 In ence, with 73% of them having more than one Mauritania, 40% of male school students lifetime sexual partner.210 Condom nonuse was reported sexual activity, with 41% of them associated with poor access to the Internet (reflect- reporting multiple sexual partnerships and 38% ing poorer knowledge), feeling regretful at first reporting unprotected sexual intercourse.223 In sex, and one lifetime sexual partner.211 Meanwhile, Pakistan, 80% of young men masturbated and multiple sexual partnerships were associated with 94% had experienced nocturnal emissions.224 alcohol consumption, older ages, and poor knowl- In Somalia, 7% of youth acknowledged sex- edge of reproductive physiology.212 Close to half ual activity in the last year, 17.8% reported that of the adolescents in this sample were unfamiliar they had ever had sex, and only 6.5% of them with condoms and their protective effect against used a condom during the most recent sexual STIs, including HIV.213 Eight percent of college activity.225 About 23% of women under age 24 students (16% of males and 0.6% of females) had knowledge of condoms.226 reported having sexual intercourse before mar- In Sudan, 6.9% of university students riage and 48% had used condoms.214 Yet another reported having sex and 5.5% engaged in pre- study of adolescents found that 47% were not marital sex.227 Almost half (48.6%) of sexually aware that condoms protect against HIV infec- active students had one sexual partner, 14.5% tion.215 Finally, from the Islamic Republic of Iran, had two partners, 10.9% had three partners, a study of college students reported that 20% of and 23.2% had more than three partners.228 In the respondents had a history of sexual contact.216 another study of university students, 6.2% reported ever using a condom, and 14.4% 203 Rodier et al., "HIV Infection among Secondary School Students." reported extramarital sex.229 In a study of 204 Ministére de la Santé-PNLS et al., "Etude des connaissances youth, 0.6% reported condom use, 2% reported attitudes-practiques des jeunes." 205 El-Zanaty and El-Daw, "Behavior Research." 206 217 NAMRU-3, "Young People and HIV/AIDS." UNAIDS and WHO, AIDS Epidemic Update 2005. 207 218 Refaat, "Practice and Awareness of Health Risk Behaviour." Johns Hopkins University, "Youth Survey." 208 219 Ibid. Jenkins and Robalino, "HIV in the Middle East and North Africa." 209 220 Tehrani and Malek-Afzalip, "Knowledge, Attitudes and Practices Jordan National AIDS Control Programme, Report on the National concerning HIV/AIDS." KABP Survey (2005). 210 221 Mohammad et al., "Sexual Risk-Taking Behaviors"; Mohammadi et al., Kassak et al., "Final Working Protocol." 222 "Reproductive Knowledge, Attitudes and Behavior." Adib et al., "Heterosexual Awareness and Practices." 211 223 Mohammad et al., "Sexual Risk-Taking Behaviors." Ndiaye et al., "Evaluation of Condom Use." 212 224 Ibid. Qidwai, "Sexual Knowledge." 213 225 Mohammadi et al., "Reproductive Knowledge, Attitudes and Behavior." WHO/EMRO, "Presentation of WHO Somalia's Experience." 214 226 Simbar, Tehrani, and Hashemi, "Reproductive Health Knowledge." Population Studies Research Institute, "Baseline Survey." 215 227 Yazdi et al., "Knowledge, Attitudes and Sources of Information." Sudan National HIV/AIDS Control Program, HIV/AIDS/STIs Prevalence. 216 228 Shirazi and Morowatisharifabad, "Religiosity and Determinants of Ibid. 229 Safe Sex." Ahmed, University Students. 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 20­25 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." HIV/AIDS and Vulnerability Settings 131 may include nonpenetrative sexual activities, the cases occurring in the 20­29 years age which are less of a concern in relation to HIV.253 group.262 Though 28% of males aged 15­18 years reported In Kuwait, STI incidence has been steadily sexual experiences in the Islamic Republic of increasing,263 and there appears to be an increase Iran,254 this sexual activity may not have included in precancerous cervical lesions in women, with sexual intercourse. The definition of sexual activ- appearance of these lesions at a younger age.264 ity is broad enough in many studies to encompass In Lebanon, a similar trend of increases in pre- even kissing or touching.255 This limitation in cancerous lesions has been reported over the behavioral data, in addition to the need to moni- years from 2002 to 2006, also at younger tor changes in sexual risk behavior among youth, ages.265 Also in Lebanon, repeated behavioral suggests the utility of using biomarkers such as surveys have indicated increased risky behavior herpes simplex virus type 2 (HSV-2) prevalence among youth.266 In Saudi Arabia, the percentage and incidence to monitor levels and trends of of abnormal Pap smears appears to be increas- sexual activity among youth in MENA. ing.267 In Turkey, the share of high school stu- dents who reported having sexual experiences Recent increases in risky behavior increased from 11.3% in 1997 to 22.8% in One of the concerning trends in MENA is that of 2004.268 Also in Turkey, the prevalence of syph- increases in risky behavior, particularly among ilis among blood donors, though still at low the youth. Attention needs to focus on identify- levels, has increased fivefold between 1987 and ing trends in risky behavior among this popula- 2002 in one study,269 and tenfold in another tion group.256 Increases in sexual risk behavior study between 1998 and 2007.270 have been observed in other regions, such in Latin America and Asia, due to the changes in Analytical summary the socioeconomic conditions.257 Youth form the largest vulnerable population in Anecdotal observations suggest that risky MENA and are facing enormous challenges that behaviors and sexual activity are increasing could expose them to HIV infection. Traditional among both male and female youth in MENA.258 forms of managing youth sexuality are in decline These observations are supported by a trend of and are not of much use with the rapidly chang- increasing HIV incidence in the younger age ing socioeconomic realities. Because youth do groups.259 Other trends also seem to suggest not appreciate the importance of safe sex, and recent increases in risky behavior. In Afghanistan, they have no other sexual outlets, they are risky behavior in terms of injecting drug use and increasingly engaging in risky sexual behavior commercial sex appears to have considerably to dissipate their sexual energy. increased since the Afghanistan war in 2001.260 Youth disproportionately contribute to the In the Islamic Republic of Iran, reported STD HIV epidemic in MENA and behavioral data sug- cases have grown by 38% annually since 1998, gest considerable and increasing levels of sexual and the number of cases has quadrupled between and injecting drug risk behaviors among them. 1992 and 2004.261 Genital ulcers have grown by Much research is needed to track the trends of a factor of 6.2 over the same period, with 45% of risky behavior and STIs of the youth population. Effective HIV prevention interventions for youth 253 Mohammad et al., "Sexual Risk-Taking Behaviors." that focus specifically on the behaviors that can 254 Mohammad et al., "Sexual Risk-Taking Behaviors"; Mohammadi et al., "Reproductive Knowledge, Attitudes and Behavior." lead to HIV exposure need to be formulated. 255 Mohammadi et al., "Reproductive Knowledge, Attitudes and Behavior." 256 262 Pisani et al., "HIV Surveillance." Iran Center for Disease Management, Three Month Statistics of the 257 Curtis and Sutherland, "Measuring Sexual Behaviour in the Era of HIV/ MoH AIDS Office. 263 AIDS"; Gammeltoft, "Seeking Trust and Transcendence"; Ono-Kihara Al-Fouzan and Al-Mutairi, "Overview." 264 and Kihara, "The First Nationwide Sexual Behavior Survey in Japan." Kapila et al., "Changing Spectrum of Squamous Cell Abnormalities." 258 265 Busulwa, "HIV/AIDS Situation Analysis Study." Karam et al., "Prevalence of Sexually Transmitted Infections." 259 266 UNAIDS, and WHO, AIDS Epidemic Update 2005. Kassak et al., "Final Working Protocol." 260 267 World Bank, "Mapping and Situation Assessment." Altaf, "Cervical Cancer Screening." 261 268 Iran Center for Disease Management, Three Month Statistics of the Yamazhan et al., "Attitudes towards HIV/AIDS." 269 MoH AIDS Office; Iran Center for Disease Management, HIV/AIDS Kocak et al., "Trends in Major Transfusion-Transmissible Infections." 270 and STIs Surveillance Report. Coskun et al., "Prevalence of HIV and Syphilis." 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." HIV/AIDS and Vulnerability Settings 133 Middle East has the highest unemployment rate The segmentation of the labor market is one in the world at an average of 15%,291 three of the key structural trends that are contributing times the global average.292 There are currently to heavy dependence on migrant workers. 6 million new entrants to the labor market every Indigenous populations are reluctant to work in year in a flow that is proportionately greater than certain sectors of the economy, relegating those that of any other region in the world.293 Economic sectors to migrant workers. Some countries are hardship and poor economic development are both exporters and importers of migrant work- forcing many to emigrate in search of employ- ers. Migrant workers constitute about 20% of ment. The industrial labor productivity per the resident labor force in Jordan, even though worker has been in decline since the 1980s, with millions of Jordanians are working abroad and the level in 1990 comparable to that in 1970.294 over 400,000 net emigrants have left the country The large gap in income across countries and between 1999 and 2003.301 The growth of the the pockets of wealth created by oil and gas rev- Qualifying Industrial Zones in Jordan has also enues are also major drivers of migration. Rapid created more demand for migrant workers.302 an economic development in oil-rich states, in The rural-urban and urban-urban migrations addition to rising personal wealth, has created are also structural challenges in MENA.303 In an enormous demand for migrant labor in the Sudan, large percentages of different popula- construction and services sectors. tion groups reported living in a place other than Although women's share of employment is their place of birth, including 59.3% of univer- only 29% of the regional labor force, women sity students,304 91.7% of military personnel,305 from countries outside the region, principally 76.9% of prisoners,306 78.2% of truck drivers,307 from Bangladesh, Ethiopia, India, Indonesia, 58.4% of tea sellers,308 66.5% of street children,309 Pakistan, the Philippines, Sri Lanka, and 51.4% of ANC attendees,310 62.6% of FSWs,311 Thailand, are recruited to fill positions not filled 56.3% of TB patients,312 55.9% of STD clinic by indigenous women.295 These women are fill- attendees,313 and 78.3% of suspected AIDS ing positions as domestic workers or in the ser- patients.314 The main reported causes of move- vice sector in a trend that has contributed to ment were work, marriage, war, education, increasing the percentage of women among treatment, and drought. Women are especially migrants in recent years.296 vulnerable in this kind of migration because it Domestic workers in MENA are vulnerable to exposes them to the risk of being trapped into marginalization, gender-based discrimination, sex work.315 Among FSWs in the Red Sea State and exploitation297 and some are experiencing in Sudan, 59% were migrants from outside of sexual abuse or are being forced into sex this state316; and among FSWs in Khartoum work.298 Abundant articles in the media docu- State, only about one-quarter were born in this ment cases of harassment, sexual abuse, and state.317 In Pakistan, 40%­70% of different pri- violence against domestic workers, who on ority populations reported having emigrated occasion can find no escape from their employ- ers and jump out of windows or off of balconies 301 to their death or injury.299 Trafficking in persons Ibid. 302 Ibid. is another aspect of migration in MENA.300 303 Ibid. 304 Ahmed, University Students. 291 305 Fergany, Aspects of Labor Migration. Ahmed, Military. 292 306 UNDP, The Arab Human Development Report 2002. Ahmed, Prisoners. 293 307 IOM, "World Migration." Ahmed, Truck Drivers. 294 308 Fergany, Aspects of Labor Migration. Ahmed, Tea Sellers. 295 309 IOM, "World Migration." Ahmed, Street Children. 296 310 Ibid. Ahmed, Antenatal. 297 311 Ibid. Ahmed, Sex Sellers. 298 312 Jenkins and Robalino, "HIV in the Middle East and North Africa"; Ahmed, TB Patients. 313 Al-Najjar, "Women Migrant Domestic Workers in Bahrain"; Sabban, Ahmed, STDs. 314 "United Arab Emirates: Migrant Women"; UNDP, "HIV Vulnerabilities Ahmed, AIDS Patients. 315 of Migrant Women." Taha, "Sudanese Women Carry a Double Burden." 299 316 IOM, "World Migration." Ati, "HIV/AIDS/STIs Social and Geographical Mapping." 300 317 Ibid. ACORD, "Qualitative Socio Economic Research." 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). HIV/AIDS and Vulnerability Settings 135 0.06% in the United Arab Emirates.344 Many of Due to the hostile environment endured by the migrant workers who tested positive and HIV-positive migrant workers, including the were then deported had negative serology threat of immediate deportation, there is a con- results for HIV when their residencies were ini- stant fear of persecution that creates challenges in tially granted. This suggests an ongoing HIV supporting HIV efforts to aid migrants in MENA.360 transmission within the Persian Gulf region and is confirmed by HIV case reports among migrants Refugees and internally displaced persons from countries that send their migrants This section discusses population displacement primarily to the Arab world. There is evidence as a vulnerability for HIV infection. of HIV infection in the Persian Gulf region among migrants from Afghanistan,345 Egypt,346 Numbers of refugees and internally Indonesia,347 Lebanon,348 the Philippines,349 Sri displaced persons Lanka,350 Sudan,351 and the Republic of Yemen.352 There were some 42 million forcibly displaced Most exposures to STDs among migrant STD clinic people worldwide at the end of 2008.361 This attendees in Kuwait (92%) occurred in Kuwait.353 includes 15.2 million refugees, 827,000 asylum In Bangladesh, 51% of the reported cumula- seekers, and 26 million IDPs.362 Pakistan is host tive HIV cases in 2002 were among returning to the largest number of refugees worldwide migrant workers and 47 out of 259 HIV infec- (1.8 million), followed by Syria (1.1. million), tions between 2002 and 2004 occurred while and the Islamic Republic of Iran (980,000).363 being away as migrants.354 Among the newly Afghan and Iraqi refugees account for almost identified infections in 2004, 56% were among half of all refugees under the United Nations returning migrants.355 Most diagnosed HIV High Commissioner for Refugees (UNHCR) infections among Pakistanis for the first two responsibility worldwide.364 In addition, there decades following discovery of HIV/AIDS were are 4.7 million Palestinian refugees under the attributed to deported HIV-positive migrants responsibility of the United Nations Relief and from the Persian Gulf states.356 These workers Works Agency for Palestine Refugees in the Near represented 61% to 86% of reported cases every East (UNRWA).365 year in Pakistan during the 1996­98 period.357 MENA continues to have high numbers of In the Philippines, 34% of PLHIV were overseas internally displaced persons in Afghanistan, Filipino workers and 17% of them were domes- Iraq, Somalia, and Sudan. There are 2.6 million tic workers, while only 8% were entertainers.358 IDPs in Iraq.366 The Iraqi diaspora involves more In Sri Lanka, about 40% of identified HIV infec- than 4 million people who are living abroad as tions among women have been linked to work- refugees, asylum seekers, illegal migrants, ing in the Persian Gulf region, mostly as domestic migrant workers, or naturalized citizens of other workers.359 countries.367 Sudan is ranked among the leading countries in the world in terms of the number of 344 U.A.E. MOH, "United Arab Emirates: Migrant Women." IDPs.368 There are about 4 million IDPs living in 345 Ryan, "Travel Report Summary"; Todd et al., "Seroprevalence and Khartoum and other states.369 During the civil Correlates of HIV." war in Lebanon, almost a third of the popula- 346 Jenkins and Robalino, "HIV in the Middle East and North Africa." 347 tion was displaced.370 UNDP, "HIV Vulnerabilities of Migrant Women." 348 Pieniazek et al., "Introduction of HIV-2." 349 360 UNDP, "HIV Vulnerabilities of Migrant Women." AIDS Policy Law, "Fear of Persecution." 350 361 Ibid. UNHCR, "2008 Global Trends." 351 362 Hierholzer et al., "HIV Type 1 Strains from East and West Africa." Ibid. 352 363 Saad et al., "HIV Type 1 Strains." Ibid. 353 364 Al-Mutairi et al., "Clinical Patterns." Ibid. 354 365 UNDP, "HIV Vulnerabilities of Migrant Women." Ibid. 355 366 Ibid. Ibid. 356 367 Khawaja et al., "HIV/AIDS and Its Risk Factors in Pakistan"; Rai et al., IOM, "World Migration." 368 "HIV/AIDS in Pakistan"; Shah et al., "HIV-Infected Workers Deported"; IGAD, IGAD/World Bank Cross Border Mobile Population Mapping Kayani et al., "A View of HIV-I Infection in Karachi." Exercise. 357 369 UNDP, "HIV Vulnerabilities of Migrant Women." Sudan Government of National Unity, United Nations National Integrated 358 Ibid. Annual Action Plan 2007; Hampton, "Internally Displaced People." 359 370 Jenkins and Robalino, "HIV in the Middle East and North Africa." IOM, "World Migration." 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." HIV/AIDS and Vulnerability Settings 137 women in the general population.386 In Southern location, studies found that HIV prevalence was Sudan, HIV prevalence was 4.4% in Yei town, 0.1% among Somali refugees attending ANCs where half of the respondents were internally who were offered PMTCT services, and 2.0% displaced, but only 0.4% in Rumbek town, (2003), 1.7% (2005), and 0.9% (2006) among where the level of displacement is considerably Somali refugees attending STI clinics.403 lower.387 In North Sudan, the prevalence among ANC women who were internally displaced Analytical summary (1.6%) was much higher than that of other preg- nant women (0.3%).388 Population mobility is a key HIV risk factor in No evidence has been found in MENA to sup- MENA due to the sheer size of the mobile popu- port the claim that refugees spread HIV infection lations and the extensive presence of this vul- in host communities.389 nerability across MENA countries. The complex emergencies that continue to be present in the HIV spread among refugees and internally region lead to increased vulnerability to HIV. It displaced persons is therefore important that forcibly displaced Several other point-prevalence surveys docu- populations are included in national HIV pro- mented the level of HIV spread among displaced grams and have universal access to prevention, populations in MENA. Among Afghani refugees treatment, and care programs. in the Islamic Republic of Iran, HIV prevalence was 0.2%.390 Among Sudanese refugees, sepa- rate studies reported that HIV prevalence was STREET CHILDREN 5.0% and 1.2% for ANC attendees and 0.8% for prevention of mother-to-child transmission Though prisoners, youth, and mobile popula- (PMTCT) attendees in Kenya391; 5% for men and tions are the key vulnerable populations in 2% for women in Ethiopia392; and 1% and 2.7% MENA, another important vulnerable popula- in Uganda.393 In several studies in Sudan, HIV tion is that of "street children." prevalence among IDPs or refugees was 1.57%,394 The presence of street children is an increas- 1%,395 4%,396 1%,397 0.26%,398 and 0.27%.399 ingly emerging phenomenon in several MENA Among Somali refugees attending ANCs in countries, as well as globally.404 Causes of this Kenya, HIV prevalence was 0.7% in 2003,400 phenomenon in MENA include poverty, family 1.4% in 2005,401 and 1% in 2006.402 Also at this disruption, natural and manmade disasters, fol- lowing friends, and desiring drugs.405 There are 386 two types of street children: "home-based," Somaliland Ministry of Health and Labour, Somaliland 2007 HIV/ Syphilis Seroprevalence Survey. where children spend most of the day on the 387 Kaiser et al., "HIV, Syphilis, Herpes Simplex Virus 2, and Behavioral street but still return home at night and may Surveillance." have some family support; and "street-based," 388 Sudan Ministry of Health, Sudan National HIV/AIDS Surveillance Unit. 389 UNHCR, "HIV Behavioural Surveillance Survey"; Spiegel et al., where children spend most of day and night on "Prevalence of HIV." the street and are functionally without family.406 390 SeyedAlinaghi, "Assessing the Prevalence of HIV." Boys often engage in odd jobs, begging, theft, 391 UNHCR, HIV Sentinel Surveillance among Conflict Affected Populations. and sex work.407 Girls, who have fewer work 392 Holt et al., "Planning STI/HIV Prevention." opportunities, obtain money primarily through 393 UNHCR, HIV Sentinel Surveillance Report; Uganda MOH, STD/HIV/ begging and sex work.408 Street girls in Sudan AIDS Surveillance Report. 394 reported being frequently raped by street boys, SNAP and UNAIDS, "HIV/AIDS Integrated Report North Sudan, 2004­5." 395 Ahmed, Internally Displaced People. 396 SNAP, "HIV Sentinel Surveillance." 397 403 Ahmed, Internally Displaced People. Ibid. 398 404 Sudan National AIDS/STIs Program, 2007 ANC HIV Sentinel Sero-Survey. Dallape, "Urban Children"; UNICEF, The State of the World's Children 399 Ibid. 2006. 400 405 UNHCR, "HIV Sentinel Surveillance in Dadaab Refugee Camps" (2003). Khalil, Street Children and HIV/AIDS; Kudrati et al., "Sexual Health 401 UNHCR, "Sentinel Surveillance Report Dadaab Refugee Camps" and Risk Behaviour." 406 (2005). Khalil, Street Children and HIV/AIDS. 402 407 UNHCR, HIV Sentinel Surveillance among Antenatal Clients and STI Kudrati, Plummer, and Yousif, "Children of the Sug." 408 Patients. Ibid. 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 5,000­7,000 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 12­17 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. HIV/AIDS and Vulnerability Settings 139 BOX 9.1 Youth, Drug Use, and Marginalization in Lebanon "The drug user is exposed to HIV/AIDS, suicide, and death most of the times . . . there should be someone giving him support." --Ramy 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 Iraqi Women Refugees and Commercial Sex in Syria Human rights organizations, UNHCR, and jobs. With the economic conditions declin- the international press have documented ing over the extended period in exile or anecdotes of a thriving industry of Iraqi girls inside Iraq, aid workers and authorities as young as age 12 working in night clubs in attested to a marked increase in the num- Damascus following the invasion of Iraq in bers of Iraqi women and young girls engaged 2003. Reliable statistics of Iraqi girls engaged in sex work. in sex work are not available. A United Nations report found that "Nada, 16, was dumped by her father at many women-headed families in "severe the Iraq-Syria border after her cousin had need" turned to sex work, in secret or with raped her. Five Iraqi men took her from the the knowledge or involvement of family border to Damascus, where they raped her members. and sold her to a woman who forced her to "I met three sisters-in-law recently who work in night clubs and private villas." were living together and all prostituting Women picked up by the police are themselves. They would go out on alternate taken to government protection centers from nights--each woman took her turn--and where they frequently escape, are bailed out, then divide the money to feed all children" or are sent to prison. Those deported to Iraq (Sister Marie-Claude, Good Shepherd often make their way back to Syria. Convent, Damascus). In 2007, UNHCR reported 1.2 million The influx of Iraqi refugees to Syria over- Iraqi refugees in Syria. Despite the country's whelmed the host country's infrastructure relaxed entry policy for its Arab neighbors, and restrained access to services, particularly refugees, with the exception of Palestinian to health services, for the vulnerable women refugees, are not officially allowed to hold and young girls. Sources: BBC News report, December 2007; New York Times, May 2007. 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 765­75. MENA. Afifi, M., and S. El-Sousi. 2004. "Drug Abuse and Related Behaviors among High School Student Children in Palestine Authority (2002­2004)." 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 HIV/AIDS and Vulnerability Settings 141 Medical Microbiology, University of Gothenburg, Its Related Risk Factors in Drug Abuser Prisoners in Gothenburg. Hamedan--Iran." World J Gastroenterol 11: 4085­89. Ahmed, S. M. 2004a. AIDS Patients: Situation Analysis- Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, I. Behavioral Survey Results & Discussions. Report, Sudan El-Adawy, and M. Rijhwani. 2007. "Clinical Patterns National AIDS Control Program. of Sexually Transmitted Diseases, Associated ------. 2004b. Antenatal: Situation Analysis-Behavioral Sociodemographic Characteristics, and Sexual Survey Results & Discussions. Report, Sudan National Practices in the Farwaniya Region of Kuwait." Int J AIDS Control Program. Dermatol 46: 594­99. ------. 2004c. Internally Displaced People: Situation Al-Najjar, S. 2002. "Women Migrant Domestic Workers Analysis-Behavioral Survey Results & Discussions. Report, in Bahrain." International Labour Office, International Sudan National AIDS Control Program. Migration Branch. ------. 2004d. Military: Situation Analysis-Behavioral Al-Serouri, A. W. 2005. "Assessment of Knowledge, Survey Results & Discussions. Report, Sudan National Attitudes and Beliefs about HIV/AIDS among Young AIDS Control Program. People Residing in High Risk Communities in Aden Governatore, Republic of Yemen." Society for the ------. 2004e. Prisoners: Situation Analysis-Behavioral Development of Women & Children (SOUL), Survey Results & Discussions. Report, Sudan National Education, Health, Welfare. United Nations Children's AIDS Control Program. Fund, Yemen Country Office, HIV/AIDS Project. ------. 2004f. Sex Sellers: Situation Analysis-Behavioral Altaf, F. J. 2006. "Cervical Cancer Screening with Survey Results & Discussions. Report, Sudan National Pattern of Pap Smear: Review of Multicenter Studies." AIDS Control Program. Saudi Med J 27: 1498­502. ------. 2004g. STDs: Situation Analysis-Behavioral Survey Anonymous. 2006. Scaling Up the HIV Response toward Results & Discussions. Report, Sudan National AIDS Universal Access to Prevention, Treatment, Care and Control Program. Support in Jordan. Summary report of the national ------. 2004h. Street Children: Situation Analysis-Behavioral consultation. Survey Results & Discussions. Report, Sudan National Aras, S., E. Orcin, S. Ozan, and S. Semin. 2007. "Sexual AIDS Control Program. Behaviours and Contraception among University ------. 2004i. TB Patients: Situation Analysis-Behavioral Students in Turkey." J Biosoc Sci 39: 121­35. Survey Results & Discussions. Report, Sudan National Aras, S., S. Semin, T. Gunay, E. Orcin, and S. Ozan. AIDS Control Program. 2007. "Sexual Attitudes and Risk-Taking Behaviors of ------. 2004j. Tea Sellers: Situation Analysis-Behavioral High School Students in Turkey." J Sch Health 77: Survey Results & Discussions. Report, Sudan National 359­66; quiz 379­81. AIDS Control Program. Assaad, R., and F. Roudi-Fahimi. 2007. "Youth in the ------. 2004k. Truck Drivers: Situation Analysis-Behavioral Middle East and North Africa: Demographic Opportunity Survey Results & Discussions. Report, Sudan National Or Challenge?" Population Reference Bureau. AIDS Control Program. Assal, M. 2006. "HIV Prevalence, Knowledge, Attitude, ------. 2004l. University Students: Situation Analysis- Practices, and Risk Factors among Prisoners in Behavioral Survey, Results & Discussions. Report, Sudan Khartoum State, Sudan." National AIDS Control Program. Ati, H. A. 2005. "HIV/AIDS/STIs Social and Geographical AIDS Policy Law. 2005. "Immigration: Fear of Persecution Mapping of Prisoners, Tea Sellers and Commercial for Being HIV-Positive in Lebanon Is Valid." AIDS Sex Workers in Port Sudan Town, Red Sea State." Policy Law 20: 7. Draft 2, Ockenden International, Sudan. Akers, D. S. 1967. "On Measuring the Marriage Squeeze." Awad, S. S. 2003. "Sudanese Street Children Narrating Demography 4: 907­24. Their Life Experiences." Journal of Psychology in Africa Akhtar, S., and H. G. Mohammad. 2008. "Spectral 13: 133­47. Analysis of HIV Sero-Positivity among Migrant Babay, Z. A., M. H. Addar, K. Shahid, and N. Meriki. 2004. Workers Entering Kuwait." BMC Infect Dis 8: 37. "Age at Menarche and the Reproductive Performance Al Ahmadi, A., and S. Beatty. 1997. "Participatory-Socio of Saudi Women." Ann Saudi Med 24: 354­56. Economic Needs Survey of the Sana'a Urban Baqi, S., N. Kayani, and J. A. Khan. 1999. "Epidemiology Settlements Dwellers with Special Reference to and Clinical Profile of HIV/AIDS in Pakistan." Trop Women." Oxfam, Yemen. Doct 29: 144­48. Al-Fouzan, A., and N. Al-Mutairi. 2004. "Overview of Baqi, S., N. Nabi, S. N. Hasan, A. J. Khan, O. Pasha, N. Incidence of Sexually Transmitted Diseases in Kayani, R. A. Haque, I. U. Haq, M. Khurshid, S. Kuwait." Clin Dermatol 22: 509­12. Fisher-Hoch, S. P. Luby, and J. B. McCormick. 1998. Ali, F., A. A. Aziz, M. F. Helmy, A. A. Mobdy, and M. "HIV Antibody Seroprevalence and Associated Risk Darwish. 1996. "Prevalence of Certain Sexually Factors in Sex Workers, Drug Users, and Prisoners in Transmitted Diseases in Egypt." J Egypt Public Health Sindh, Pakistan." J Acquir Immune Defic Syndr Hum Assoc 71: 553­75. Retrovirol 18: 73­79. Alizadeh, A. H., S. M. Alavian, K. Jafari, and N. Yazdi. Basha, H. M. 2006. "Vulnerable Population Research in 2005. "Prevalence of Hepatitis C Virus Infection and Darfur." 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 32­41. Public Health Policy 26: 30­59. 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: 14­17. 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: 774­79. in Port Sudan, Sudan." East Afr Med J 67: 650­55. 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: 153­55. Migration in the Era of AIDS, ed. G. Herdt, 107­26. 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, 2003­2007. and Selected Findings of Sexual Behaviour Surveys." Sudan National AIDS Control Program, Federal Ministry AIDS 5 Suppl 1: S65­74. 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 11­16, abstract WePeC6146. Cairo, Egypt, March 3­6. 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: ii22­27. 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: 905­15. 431­39. 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): 283­94. 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: 49­59. 307­10. 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 HIV/AIDS and Vulnerability Settings 143 Nos.1­2, ed. N. Hopkins, 247­73. Cairo: American Iran Center for Disease Management. Unknown. Country University in Cairo Press. Report on UNGASS Declaration of Commitment. Office of Farhoudi, B., A. Montevalian, M. Motamedi, M. M. Deputy Minister of Health in Health Affairs, Islamic Khameneh, M. Mohraz, M. Rassolinejad, S. Jafari, P. Republic of Iran, in cooperation with UNAIDS Iran Afshar, I. Esmaili, and L. Mohseni. 2003. "Human and the Iranian Center for AIDS Research. Immunodeficiency Virus and HIV-Associated ------. 2004. HIV/AIDS and STIs Surveillance Report. Tuberculosis Infection and Their Risk Factors in Center for Disease Management, Ministry of Health Injecting Drug Users in Prison in Iran." and Medical Education, Tehran. Fergany, N. 2001. Aspects of Labor Migration and ------. 2005. Three Month Statistics of the MoH AIDS Unemployment in the Arab Region. Cairo, Egypt: Office. Unpublished. Almishkat Center for Research. Iran Prison Organization. 2006. "Health and Treatment Gammeltoft, T. 2002. "Seeking Trust and Transcendence: Headquarter: An Overview on HIV/AIDS in Prisons of Sexual Risk-Taking among Vietnamese Youth." Soc Islamic Republic of Iran" (in Persian). Sci Med 55: 483­96. Iranian Statistics Center. 2005. "Iran as Reflected by Gaughwin, M., R. Douglas, and A. Wodak. 1991. Statistics: 2004." "Behind Bars--Risk Behaviours for HIV Transmission Jaber, H., F. Métral, and M. Doraï. 2000. "Migration in in Prisons: A Review." In HIV/AIDS and Prisons the Arab Middle East: Policies, Networks and Conference Proceedings, ed. J. Norberry, S. A. Gerull, Communities in the Context of Globalisation." and M. D. Gaughwin, 89­108. Canberra: Australian Research Programme, CERMOC, Beirut/Amman, Institute of Criminology. Konrad Adenauer Foundation. Ghannad, M. S., S. M. Arab, M. Mirzaei, and A. Jahani, M. R., P. Kheirandish, M. Hosseini, H. Shirzad, S. Moinipur. 2009. "Epidemiologic Study of Human A. Seyedalinaghi, N. Karami, P. Valiollahi, M. Mohraz, Immunodeficiency Virus (HIV) Infection in the and W. McFarland. 2009. "HIV Seroconversion Patients Referred to Health Centers in Hamadan among Injection Drug Users in Detention, Tehran, Province, Iran." AIDS Res Hum Retroviruses 25: 277­83. Iran." AIDS 23: 538­40. Gokengin, D., T. Yamazhan, D. Ozkaya, S. Aytug, E. Javadi, A. A., M. Avijgan, and M. Hafizi. 2006. Ertem, B. Arda, and D. Serter. 2003. "Sexual "Prevalence of HBV and HCV Infections and Knowledge, Attitudes, and Risk Behaviors of Students Associated Risk Factors in Addict Prisoners." Iranian J in Turkey." J Sch Health 73: 258­63. Publ Health 35: 33­36. Gutbi, O. S.-A., and A. M. G. Eldin. 2006. "Women Tea- Jenkins, C., and D. A. Robalino. 2003. "HIV in the Sellers in Khartoum and HIV/AIDS: Surviving Against Middle East and North Africa: The Cost of Inaction." the Odds." Khartoum, Sudan. Orientations in Development Series. Washington, Haeri, S. 1994. "Temporary Marriage: An Islamic Discourse DC: World Bank. on Female Sexuality in Iran." In The Eye of the Storm: Johns Hopkins University. 2001. "Youth Survey: Women in Post-Revolutionary Iran, ed. M. Afkhami and Knowledge, Attitudes and Practices on Reproductive E. Friedl, 98­114. New York, NY: Tauris Publishers. Health and Life Planning." Center for Communication Hampton, J. 1998. "Internally Displaced People: A Programs, National Population Commission, Jordan, Global Survey." Earthscan/James & James. Johns Hopkins University. Hierholzer, M., R. R. Graham, I. El Khidir, S. Tasker, M. Jordan National AIDS Control Programme. 2005. Report Darwish, G. D. Chapman, A. H. Fagbami, A. Soliman, on the National KABP Survey on HIV/AIDS among D. L. Birx, F. McCutchan, and J. K. Carr. 2002. "HIV Jordanian Youth. NAP Jordan. Type 1 Strains from East and West Africa Are Kaiser, R., T. Kedamo, J. Lane, G. Kessia, R. Downing, T. Intermixed in Sudan." AIDS Res Hum Retroviruses 18: Handzel, E. Marum, P. Salama, J. Mermin, W. Brady, 1163­66. and P. Spiegel. 2006. "HIV, Syphilis, Herpes Simplex Virus 2, and Behavioral Surveillance among Conflict- HOAP (Horn of Africa Project). 2006. "Regional Affected Populations in Yei and Rumbek, Southern Partnership on HIV Vulnerability and Cross-Border Sudan." AIDS 20: 942­44. Mobility in the Horn of Africa. Meeting Report." Hargeisa, Somaliland, November 13­15. Kandela, P. 2000. "Child Prostitution and the Spread of AIDS." Lancet 356: 1991. Holt, B. Y., P. Effler, W. Brady, J. Friday, E. Belay, K. Parker, and M. Toole. 2003. "Planning STI/HIV Kapila, K., S. S. George, A. Al-Shaheen, M. S. Al-Ottibi, Prevention among Refugees and Mobile Populations: S. K. Pathan, Z. A. Sheikh, B. E. Haji, M. K. Mallik, D. Situation Assessment of Sudanese Refugees." Disasters K. Das, and I. M. Francis. 2006. "Changing Spectrum 27: 1­15. of Squamous Cell Abnormalities Observed on Papanicolaou Smears in Mubarak Al-Kabeer Hospital, IGAD (Intergovernmental Authority on Development). Kuwait, over a 13-year Period." Med Princ Pract 15: 2006. "IGAD/World Bank Cross Border Mobile 253­59. Population Mapping Exercise." Sudan, draft report. Karam, W., G. Aftimos, A. Jurjus, S. Khairallah, and N. International Centre for Prison Studies. 2006. World Bedrossian. 2007. "Prevalence of Sexually Transmitted Prison Brief Country Profiles, www.prisonstudies.org. Infections in Lebanese Women as Revealed by Pap IOM (International Organization for Migration). 2005. Smear Cytology: A Cross Sectional Study from 2002­ "World Migration: Costs and Benefits of International 2006." WHO/EMRO. Migration." IOM. Geneva. 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: 404­18. Karachi." J Pak Med Assoc 44: 8­11. 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: 327­31. 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: 1­4. 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 2004­2005." 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. 2003­4. Bulletin épidemi- Pakistan." AIDS 11: 843­48. 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: 671­75. 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: 439­48. A. Hasanzadeh, and H. Ghanbari. 2007. "Sexual Risk- Kudrati, M., M. Plummer, N. Dafaalla El Hag Yousif, A. Taking Behaviors among Boys Aged 15­18 Years in Mohamed Adam Adham, W. Mohamed Osman Tehran." J Adolesc Health 41: 407­14. 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: 35­44. July 7­12; 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: 250­56. Control, ed. A. Frate, U. Zvekic, and J. Dijk, 343­49. 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: 15­41. HIV/AIDS and Vulnerability Settings 145 Morocco MOH (Ministry of Health). 2007. Surveillance HIV/AIDS Surveillance Project, Integrated Biological sentinelle du VIH, résultats 2006 et tendances de la séro- & Behavioral Surveillance 2004­5. prévalence du VIH. ------. 2006­7. HIV Second Generation Surveillance in Morton, J. 2003. "Conceptualising the Links between HIV/ Pakistan. National Report Round II. Ministry of AIDS and Pastoralist Livelihoods." Paper presented to Health, Pakistan, and Canada-Pakistan HIV/AIDS the Annual Conference of the Development Studies Surveillance Project. Association, 10-12.09. 03, amended draft 31.10. 03, ------. 2008. HIV Second Generation Surveillance in Natural Resources Institute, University of Greenwich. Pakistan. National Report Round III. Ministry of Mostashari, G., UNODC (United Nations Office on Drugs Health, Pakistan, Canada-Pakistan HIV/AIDS and Crime), and M. Darabi. 2006. "Summary of the Surveillance Project. Iranian Situation on HIV Epidemic." NSP Situation Parker, R. G., D. Easton, and C. H. Klein. 2000. Analysis. "Structural Barriers and Facilitators in HIV Prevention: Mujeeb, S. A., and A. Hafeez. 1993. "Prevalence and A Review of International Research." AIDS 14 Suppl Pattern of HIV Infection in Karachi." J Pak Med Assoc 1: S22­32. 43: 2­4. Pieniazek, D., J. Baggs, D. J. Hu, G. M. Matar, A. M. Mutter, R. C., R. M. Grimes, and D. Labarthe. 1994. Abdelnoor, J. E. Mokhbat, M. Uwaydah, A. R. Bizri, A. "Evidence of Intraprison Spread of HIV Infection." Ramos, L. M. Janini, A. Tanuri, C. Fridlund, C. Schable, Arch Intern Med 154: 793­95. L. Heyndrickx, M. A. Rayfield, and W. Heneine. 1998. Naffa, S. 2004. "Jordanian Women: Past and Present." "Introduction of HIV-2 and Multiple HIV-1 Subtypes to Lebanon." Emerg Infect Dis 4: 649­56. NAMRU-3 (Naval Medical Research Unit). 2004. "Young People and HIV/AIDS." A Qualitative Study in Cairo Pisani, E., S. Lazzari, N. Walker, and B. Schwartlander. and Qena, Egypt. UNAIDS Secretariat and the 2003. "HIV Surveillance: A Global Perspective." J National AIDS Programme, with Ford Foundation Acquir Immune Defic Syndr 32 Suppl 1: S3­11. Funding. Platt, L. P. Vickerman, M. Collumbien, S. Hasan, N. Lalji, Nassirimanesh, B. 2002. "Proceedings of the Abstract for S. Mayhew, R. Muzaffar, A. Andreasen, and S. the Fourth National Harm Reduction Conference." Hawkes. 2009. "Prevalence of HIV, HCV and Sexually Harm Reduction Coalition, Seattle, USA. Transmitted Infections among Injecting Drug Users in Nassirimanesh, B., M. Trace, and M. Roberts. 2005. "The Rawalpindi and Abbottabad, Pakistan: Evidence for Rise of Harm Reduction in the Islamic Republic of an Emerging Injection-Related HIV Epidemic." Sex Iran." Briefing Paper Eight, for the Beckley Transm Infect 85 Suppl 2: ii17­22. Foundation, Drug Policy Program. Plummer, M. L., M. Kudrati, and N. Dafalla El Hag Navipour, R,, and M. R. Mohebbi. 2004. "Street Children Yousif. 2007. "Beginning Street Life: Factors and Runaway Adolescents in Iran." Indian Pediatr 41: Contributing to Children Working and Living on the 1283­84. Streets of Khartoum, Sudan." Children and Youth Services Review 29: 1520­36. Ndiaye, P., H. O. Abdallahi el, A. Diedhiou, A. Tal-Dia, and J. P. Lemort. 2005. "Evaluation of Condom Use Pont, J., H. Strutz, W. Kahl, and G. Salzner. 1994. "HIV among Students of the El Mina Middle School in Epidemiology and Risk Behavior Promoting HIV Nouakchott in the Islamic Republic of Mauritania." Transmission in Austrian Prisons." Eur J Epidemiol 10: Sante 15: 189­94. 285­89. Obasi, A., F. Mosha, M. Quigley, Z. Sekirassa, T. Gibbs, Population Studies Research Institute. 2000. "Baseline K. Munguti, J. Todd, H. Grosskurth, P. Mayaud, J. Survey on Reproductive Health and Family Planning Changalucha, D. Brown, D. Mabey, and R. Hayes. in Northeast and Northwest Regions of Somalia." 1999. "Antibody to Herpes Simplex Virus Type 2 as a University of Nairobi, WHO. Marker of Sexual Risk Behavior in Rural Tanzania." J Qidwai, W. 1999. "Sexual Knowledge and Practice in Infect Dis 179: 16­24. Pakistani Young Men." J Pak Med Assoc 49: 251­54. Oman MOH (Ministry of Health). 2006. "HIV Risk Quinti, I., E. Renganathan, E. El Ghazzawi, M. Divizia, among Heroin and Injecting Drug Users in Muscat, G. Sawaf, S. Awad, A. Pana, and G. Rocchi. 1995. Oman." Quantitative survey, preliminary data. "Seroprevalence of HIV and HCV Infections in Ono-Kihara, M., and M. Kihara. 2001. "The First Alexandria, Egypt." Zentralbl Bakteriol 283: 239­44. Nationwide Sexual Behavior Survey in Japan--The Rahbar, A. R., S. Rooholamini, and K. Khoshnood. 2004. Results of `HIV & Sex in Japan 1999' Survey." J Asian "Prevalence of HIV Infection and Other Blood-Borne Sexol 2. Infections in Incarcerated and Non-Incarcerated Pakistan National AIDS Control Program. 2005a. HIV Injection Drug Users (IDUs) in Mashhad, Iran." Second Generation Surveillance in Pakistan. National International Journal of Drug Policy 15: 151­55. Report Round 1. Ministry of Health, Pakistan, and Rai, M. A., H. J. Warraich, S. H. Ali, and V. R. Nerurkar. Canada-Pakistan HIV/AIDS Surveillance Project. 2007. "HIV/AIDS in Pakistan: The Battle Begins." ------. 2005b. National Study of Reproductive Tract and Retrovirology 4: 22. Sexually Transmitted Infections: Survey of High Risk Groups Ramezani, A., M. Mohraz, and L. Gachkar. 2006. in Lahore and Karachi. Ministry of Health, Pakistan. "Epidemiologic Situation of Human Immuno- ------. 2005c. "Report of the Pilot Study in Karachi & deficiency Virus (HIV/AIDS Patients) in a Private Rawalpindi." Ministry of Health Canada-Pakistan Clinic in Tehran, Iran." Arch Iran Med 9: 315­18. 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: 83­101. 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: 162­66. Arab Family, Cairo Papers in Social Science, Vol. 24, SeyedAlinaghi, S. 2009. "Assessing the Prevalence of Nos. 1­2, ed. N. Hopkins, 20­50. 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: 812­14. 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: 72­81. Non-Medical Male Students." J Relig Health 48: 29­36. 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: 369­76. Sigusch, V. 1998. "The Neosexual Revolution." Archives Rodier, G. R., J. J. Morand, J. S. Olson, D. M. Watts, and of Sexual Behavior 27: 331­59. 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: 414­17. Practices of Iranian College Students." East Mediterr Roudi-Fahimi, F., and L. Ashford. 2008. "Sexual & Health J 11: 888­97. 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, 2004­2005 (draft)." With United Cocirculate in Yemen." AIDS Res Hum Retroviruses 21: Nations General Assembly Special Session on HIV/ 644­48. 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: 111­12. 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: S4­12. 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: 305­12. 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: 2187­95. HIV/AIDS and Vulnerability Settings 147 Sudan Government of National Unity. 2007. United U.A.E. MOH (United Arab Emirates/Ministry of Health). Nations National Integrated Annual Action Plan 2007. 2006. "United Arab Emirates: Migrant Women in the United Nations. United Arab Emirates." Sudan Ministry of Health. 2005. Sudan National HIV/AIDS Uganda MOH (Ministry of Health). 2003. STD/HIV/AIDS Surveillance Unit, Annual Report. Khartoum. Surveillance Report. Kampala. Sudan National AIDS/STIs Program. 2008. 2007 ANC UNAIDS (Joint United Nations Programme on HIV/ HIV Sentinel Sero-survey, Technical Report. Federal AIDS). 2002. "Factsheet 2002: The Middle East and Ministry of Health, Preventive Medicine Directorate, North Africa." UNAIDS, Geneva. Draft. ------. 2004. Report on the Global AIDS Epidemic: 4th Sudan National HIV/AIDS Control Program. 2002. Global Report. Geneva, Switzerland. Situation Analysis: Behavioral & Epidemiological Surveys & ------. 2006. "HIV Prevention in Jordan: Common Response Analysis. HIV/AIDS Strategic Planning Process Country Assessment; Key Challenges in Health." Report, Federal Ministry of Health, Khartoum. ------. 2007. "Key Findings on HIV Status in the West ------. 2004. HIV/AIDS/STIs Prevalence, Knowledge, Bank and Gaza." Working document, UNAIDS Attitude, Practices and Risk Factors among University Regional Support Team (RST) for the Middle East and Students and Military Personnel. Federal Ministry of North Africa. Health, Khartoum. ------. 2008. "Notes on AIDS in the Middle East and Syria Mental Health Directorate. 2008. "Assessment of North Africa." RST MENA. HIV Risk and Sero-Prevalence among Drug Users in Greater Damascus." Programme SNA, Syrian Ministry UNAIDS, and UNHCR (United Nations High of Health, UNODC, UNAIDS. Commissioner on Refugees). 2005. "Strategies to Support the HIV Related Needs of Refugees and Host Syria National AIDS Programme. 2004. "HIV/AIDS Populations." Geneva. Female Sex Workers KABP Survey in Syria." UNAIDS, and WHO (World Health Organization). 2001. Tabarsi, P., S. M. Mirsaeidi, M. Amiri, S. D. Mansouri, M. AIDS Epidemic Update 2001. Geneva. R. Masjedi, and A. A. Velayati. 2008. "Clinical and Laboratory Profile of Patients with Tuberculosis/HIV ------. 2002. AIDS Epidemic Update 2002. Geneva. Coinfection at a National Referral Centre: A Case ------. 2003. AIDS Epidemic Update 2003. Geneva. Series." East Mediterr Health J 14: 283­91. ------. 2005. AIDS Epidemic Update 2005. Geneva. Taha, S. I. 1995. "Sudanese Women Carry a Double Burden: Special Report; Women and HIV." AIDS Anal UNDP (United Nations Development Programme). 2002. Afr 5: 12. The Arab Human Development Report 2002: Creating Opportunities for Future Generations. United Nations Taylor, A., D. Goldberg, J. Emslie, J. Wrench, L. Gruer, Development Programme, Regional Bureau for Arab S. Cameron, J. Black, B. Davis, J. McGregor, E. States. Follett, et al. 1995. "Outbreak of HIV Infection in a Scottish Prison." BMJ 310: 289­92. ------. 2008. "HIV Vulnerabilities of Migrant Women: From Asia to the Arab States; Shifting from Silence, Tchupo, J. P. 1998. Les maladies sexuellement transmissibles Stigma and Shame to Safe Mobility with Dignity, en République de Djibouti: Evaluation de la situation et Equity and Justice." Regional Centre in Colombo. recommandations pour une prise en charge optimale. Report de mission, UNAIDS. Ungan, M., and H. Yaman. 2003. "AIDS Knowledge and Tehrani, F. R., and H. Malek-Afzalip. 2008. "Knowledge, Educational Needs of Technical University Students Attitudes and Practices concerning HIV/AIDS in Turkey." Patient Educ Couns 51: 163­67. among Iranian At-Risk Sub-Populations." Eastern UNHCR (United Nations High Commissioner on Mediterranean Health Journal 14. Refugees). 2003. "HIV Sentinel Surveillance in Tiouiri, H., B. Naddari, G. Khiari, S. Hajjem, and A. Zribi. Dadaab Refugee Camps." 1999. "Study of Psychosocial Factors in HIV Infected ------. 2005. "Sentinel Surveillance Report Dadaab Patients in Tunisia." East Mediterr Health J 5: 903­11. Refugee Camps." Todd, C. S., A. M. Abed, S. A. Strathdee, P. T. Scott, B. ------. 2006. HIV Sentinel Surveillance Report in Two A. Botros, N. Safi, and K. C. Earhart. 2007. "HIV, Refugee Settlements in Uganda, 2004. Kampala: UNHCR. Hepatitis C, and Hepatitis B Infections and Associated ------. 2006­7a. HIV Sentinel Surveillance among Antenatal Risk Behavior in Injection Drug Users, Kabul, Clients and STI Patients. Dadaab Refugee Camps, Kenya. Afghanistan." Emerg Infect Dis 13: 1327­31. Todd, C. S., M. Ahmadzai, F. Atiqzai, S. Miller, J. M. ------. 2006­7b. HIV Sentinel Surveillance among Conflict Smith, S. A. Ghazanfar, and S. A. Strathdee. 2008. Affected Populations. Kakuma Refugee Camp-- "Seroprevalence and Correlates of HIV, Syphilis, and Refugees and Host Nationals, Great Lakes Initiative Hepatitis B and C Virus among Intrapartum Patients on HIV/AIDS. in Kabul, Afghanistan." BMC Infect Dis 8: 119. ------. 2007. "HIV Behavioural Surveillance Survey Towe, V. L., S. ul Hasan, S. T. Zafar, and S. G. Sherman. Juba Municipality, South Sudan." UNHCR. 2009. "Street Life and Drug Risk Behaviors Associated ------. 2009. "2008 Global Trends: Refugees, Asylum- with Exchanging Sex among Male Street Children in Seekers, Returnees, Internally Displaced Persons and Lahore, Pakistan." J Adolesc Health 44: 222­28. Stateless Persons." 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, 394­98. 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: 153­55. IV Drug Users: Is It a Serious Problem?" Arch Iranian Med 4: 115­19. 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. 30­Nov. 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: 342­46. 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: 709­16. Secondary School Students in Izmir, Turkey: Changes in Time." Trop Doct 37: 10­12. 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: 217­22. regarding HIV/AIDS in Iranian Adolescents." AIDS Care 18: 1004­10. 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. HIV/AIDS and Vulnerability Settings 149 Chapter 10 Proxy Biological Markers of Sexual Risk Behavior 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 Country HSV-2 prevalence 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]) Proxy Biological Markers of Sexual Risk Behavior 153 Figure 10.1 HSV-2 Prevalence for Selected Populations, by Age Group in The type of tests conducted for Morocco HSV-2 serology in these studies was 25 not able to be confirmed or clari- fied, despite repeated attempts. 20 Some of these studies also tended to convey limited knowledge of HSV-2 epidemiology. prevalence (%) 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 18­24 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." Proxy Biological Markers of Sexual Risk Behavior 155 by Western blot assays (WBA), which provide cancers of the vagina, vulva, and penis.48 HPV the golden reference standard for measuring infection is the most common STI worldwide HSV-2 serology.43 This validation appears to and most sexually active individuals, even with have been done only once in MENA on a low sexual risk behavior, are likely to be exposed Moroccan sample using centralized study proto- to HPV during their lifetime.49 cols and laboratory testing.44 This further high- Rates of HPV acquisition among women and lights the need for research expansion and sur- men are very high following sexual debut as veillance work on HSV-2 in MENA. well as with the acquisition of new sexual part- ners.50 Numerous studies have demonstrated the association between the number of lifetime Analytical summary sex partners and genital HPV infection,51 includ- HSV-2 prevalence levels in the general population ing studies in MENA.52 HPV, cervical cancer, in MENA are low, but are considerable among and genital warts incidence and prevalence can priority groups. The prevalence level in the gen- be used as proxies of the levels of sexual risk eral population is among the lowest globally, sug- behavior in the population.53 HPV infection is gesting that levels of sexual risk behavior in this not only associated with sexual intercourse, but population are low. HIV infection is unlikely to also with other sexual contacts such as penile- have substantial inroads into this population, con- vulvar, oral-penile, or finger-vulvar contacts.54 firming the results of HIV prevalence and behav- HPV prevalence and cervical cancer levels appear ioral measures (chapter 7). The substantial levels to be particularly sensitive to the sexual behav- in priority groups suggest a potential for HIV ior of the male population and, in particular, to spread among these groups. contacts with FSWs.55 HSV-2 serological measurements are under- used in MENA despite their utility in indicat- Cervical cancer levels ing the levels of sexual risk behavior and HIV epidemic potential in different population A number of studies and international data- groups. HSV-2 serology can also be used to bases56 have documented cervical cancer lev- track the trends of sexual risk behavior among els in MENA. Table 10.3 shows the rates of youth. HSV-2 research in MENA needs to be cervical cancer incidence for each of the expanded and HSV-2 serology should be MENA countries.57 These numbers represent included as a standard component of every national reports and are not necessarily surveillance effort. derived using robust methodology. Table 10.4 displays the rates at select surveillance sites derived using sound methodology.58 Figure HPV AND CERVICAL CANCER LEVELS AS 10.2 depicts the age-stratified cervical cancer MARKERS OF SEXUAL RISK BEHAVIOR 48 Munoz et al., "Chapter 1." Why HPV and cervical cancer? 49 Trottier and Franco, "The Epidemiology of Genital Human Papillomavirus Infection." HPV is one of the most infectious sexually trans- 50 Collins et al., "Proximity of First Intercourse to Menarche"; Winer mitted viruses.45 It is the leading cause of over et al., "Genital Human Papillomavirus Infection"; Partridge et al., 99% of all cervical cancer cases worldwide.46 51 "Genital Human Papillomavirus Infection in Men." Baseman and Koutsky, "The Epidemiology of Human Papillomavirus HPV is also the causative agent of anogenital Infections"; Lu et al., "Factors Associated with Acquisition and warts, which cause substantial health care costs Clearance." 52 globally,47 and HPV is a major cause of the Chaouki et al., "The Viral Origin of Cervical Cancer"; Hassen et al., "Cervical Human Papillomavirus Infection"; Hammouda et al., "Cervical Carcinoma in Algiers." 53 Trottier and Franco, "The Epidemiology of Genital Human 43 Ashley and Wald, "Genital Herpes." Papillomavirus Infection"; Chuang et al., "Condyloma Acuminatum." 44 54 Patnaik et al., "Type-Specific Seroprevalence." Burchell et al., "Chapter 6." 45 55 Burchell et al., "Modeling the Sexual Transmissibility." Skegg et al., "Importance of the Male Factor." 46 56 Bosch et al., "Prevalence of Human Papillomavirus in Cervical Cancer"; IARC and WHO, http://www.iarc.fr/. 57 Walboomers et al., "Human Papillomavirus." Ferlay et al., "GLOBOCAN 2002." 47 58 Lacey, Lowndes, and Shah, "Chapter 4." Curado et al., Cancer Incidence in Five Continents, Volume IX. 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." Proxy Biological Markers of Sexual Risk Behavior 157 Figure 10.2 Age-Stratified Cervical Cancer Incidence in Select MENA prevalence levels are considerable Populations Compared to the Global Average and suggest significant HPV infec- 90 tion transmission in MENA. 75 80 Some studies found high levels of HPV infection, such as in Saudi 70 Arabia,76 despite low levels of cervi- per 100,000 person-years 60 cal cancer in this country.77 There is 50 a question as to whether some of 40 these studies are representative of women in the general population 30 and whether they reflect preva- 20 lence of cancerous HPV types or 10 not.78 Well over a hundred HPV 0 types have been identified, with only a minority of them being sex- 0­4 5­9 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 Country HPV prevalence Algeria 12.4% (controls in a hospital-based, case control study; Hammouda et al. 2005) Bahrain 11.0% (women attending health facilities; Hajjaj et al. 2006) Egypt, Arab Republic of 3.0% (community-based household survey; El-All, Refaat, and Dandash 2007) 15.0% (general population women; Abdel Aziz et al. 2006) Iran, Islamic Republic of 13.0% (gynecology clinic attendees; Ghaffari et al. 2006) 9.0% (general population women; Hamkar et al. 2002) 3.0% (general population women; Farhadi 2005) Jordan 0.0% (hospital attendees; Malkawi et al. 2004) Lebanon 4.9% (gynecological clinic attendees; Mroueh et al. 2002) Morocco 21.0% (controls in a hospital-based case control study; Chaouki et al. 1998) Pakistan 33.0% (unspecified cervical specimens; Anwar et al. 1991) Saudi Arabia 32.0% (family medical clinic attendees; Al-Muammar et al. 2007) Tunisia 14.0% (national family population office attendees; Hassen, Remadi, and Chouchane 1999) Turkey 8.0% (adolescent pregnant women; Yildirim, Inal, and Tinar 2005) 6.0% (low-risk hospital attendees; Ozcelik et al. 2003) 2.0% (general population women; Inal et al. 2007) 2.0% (controls in a clinic-based case control study; Cirpan et al. 2007) West Bank and Gaza 13.0% (pregnant women; Lubbad and Al-Hindi 2007) 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." Proxy Biological Markers of Sexual Risk Behavior 159 Figure 10.3 A Schematic Diagram of Two Different Kinds of Sexual Networks sexual risk behavior among youth with Different Connectivity in MENA. Another potential limitation to the use of HPV as a proxy measure is the role of male circumcision, which has been shown to reduce the risk of penile HPV90 and genital warts91 and improve clearance of HPV infection among men,92 thereby reducing the transmission to women. This suggests that HPV prevalence in MENA could be low despite higher levels of risk behavior. HPV levels can be used to measure recent changes in sexual risk behavior (a) by examining increases in incidence of low-grade and high-grade precancer- ous lesions and cervical cancer levels among young females 20­30 years of age. HPV prevalence, as measured by direct HPV virus DNA detection, can also be an alternative powerful mea- sure of changes in risky behavior over time. Though low, our study suggests that levels of cervical cancer are con- siderable enough to warrant inter- ventions for this health challenge. There are severe limitations in the (b) screening programs and treatment Females Males Female sex workers facilities in much of the region; therefore, expansion of screening Source: Author. programs is recommended.93 Pap smear screening appears to be at low levels, such as at 2% in Egypt94 and of precancerous lesions as well HPV prevalence 2.6% in Pakistan.95 Cervical cancer diagnosis levels may provide, when well established, appears to occur in advanced stages where it is better proxies of recent changes in risky behav- associated with a high mortality rate.96 Despite ior. There appears to be an increase in precan- the availability of screening infrastructure and cerous lesions due to HPV among Kuwaiti its free cost in some resource-rich settings, such women over the years, as well as the appear- as in the United Arab Emirates, only 15.4% of ance of these lesions at a younger age.87 A women reported ever having a Pap smear test.97 similar apparent trend has been reported among women in Lebanon, particularly at 90 Castellsague et al., "Male Circumcision." 91 younger ages.88 The percentage of abnormal 92 Bailey, "Scaling Up Circumcision Programmes." Lu et al., "Factors Associated with Acquisition and Clearance." Pap smears also appears to be increasing in 93 Bennis et al., "Role of Cervical Smear." Saudi Arabia.89 This may suggest an increase in 94 El-All, Refaat, and Dandash, "Prevalence of Cervical Neoplastic Lesions." 95 Imam et al., "Perceptions and Practices." 87 96 Kapila et al., "Changing Spectrum of Squamous Cell Abnormalities." Chaouki et al., "The Viral Origin of Cervical Cancer"; Hammouda et al., 88 Karam et al., "Prevalence of Sexually Transmitted Infections." "Cervical Carcinoma in Algiers." 89 97 Altaf, "Cervical Cancer Screening." Bener, Denic, and Alwash, "Screening for Cervical Cancer." 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 Due to the intrusive nature of the test, in conservative societies many women prefer for such a test to be administered by females.99 In Kuwait, 78.7% of women in one study pre- ferred that a female doctor conduct Precancer Cancer the test.100 On the other hand, it appears that a 15 years 30 years 45 years rather significant proportion of women report having at least one Pap smear in their lifetime in a few countries.101 In Pap tests a study in the Islamic Republic of Iran, HPV vaccination HPV test 1 HPV test 2 68.5% of women reported having undergone at least one Pap test.102 In a Source: Schiffman and Castle 2005. study in Kuwait, 52.3% of women Note: Reproduced with permission. Copyright © 2005 Massachusetts Medical Society. All rights reserved. knew of screening, 30.6% had a posi- tive attitude toward it, and 23.8% had types 16 and 18).106 It also appears that there is 103 the test on a fairly routine basis. There is a need a positive attitude toward HPV vaccination in at to develop national policies for screening, train least a few Muslim societies.107 female nurses to conduct the screening, and Vaccination can reduce the need for Pap increase awareness of the benefits of screening smear screening by reducing the age of initiation and the dangers of cervical cancer, despite the of screening or its frequency.108 Considering relatively low rates in MENA. Once-in-a-lifetime that screening is limited in MENA, vaccination screening of women 30­50 years of age using Pap may offer a cost-effective method to reduce cer- smears, direct visual inspection, and/or HPV DNA vical cancer mortality. In Brazil, a middle- testing may be cost-effective in reducing the mor- income country similar to many countries in tality of cervical cancer.104 MENA, it was estimated that vaccination can HPV vaccination should be considered as a reduce cervical cancer incidence by 43%.109 prevention intervention for girls as well as Combining vaccination with three screening women in MENA, and there is no need to screen events per lifetime can reduce the incidence by for HPV before offering the vaccine because only 61%.110 Several countries in MENA can easily very few women would have been infected by afford such vaccination programs, while other all four leading cancerous HPV types.105 The countries should pursue arrangements with vac- available vaccines protect against the dominant cine providers to reduce the cost of vaccination types that cause cervical cancer in MENA (mainly and make it affordable to them. In addition to 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. Proxy Biological Markers of Sexual Risk Behavior 161 protection against cervical cancer, the vaccines, risky behavior followed by the Maghreb coun- especially the quadrivalent one, may partially tries in the western part of MENA. The lowest protect against genital warts, cancers of the levels of risk behavior appear to be in the neck, head, anus, vagina, and vulva as well as Mashriq countries in the eastern part of the recurrent respiratory papillomatosis. Even in region. These differences may merely reflect dif- settings with low HPV prevalence, HPV vaccina- ferences in the sizes of commercial sex networks tion has been shown to be cost-effective, very and the fraction of men who have sexual con- cost-effective, and cost saving, provided the cost tact with FSWs. per dose can be reduced to $96.85, $50.42, and Low-grade and high-grade precancerous cer- $27.20, respectively.111 However, a detailed vical lesions and HPV prevalence levels can be cost-effectiveness analysis that takes into used in MENA to monitor trends of sexual risk account the diversity of settings in this region behavior, particularly among youth. needs to be conducted. There are severe limitations in HPV screening Increasing the level of awareness of cervical programs in MENA, and HPV vaccination is vir- cancer and screening may pose challenging tually nonexistent. Public health authorities ethical issues in conservative cultures.112 Though need to consider expansion of screening and women are likely to welcome the possible intro- vaccination programs and the formulation of duction of HPV testing, they may not be fully national screening and vaccination policies. aware of the sexually transmitted nature of cer- vical cancer. This may cause anxiety, confusion, and stigma about HPV as an STI and may raise BACTERIAL STIs AS MARKERS OF concerns about women's sexual relationships in SEXUAL RISK BEHAVIOR terms of trust, fidelity, blame, and protection.113 Participation in HPV testing may communicate In a fashion similar to the use of HSV-2 and HPV messages of distrust, infidelity, and promiscuity to map levels of sexual risk behavior, prevalence to women's partners, family, and community. levels of bacterial STIs, including syphilis, gonor- These issues should be dealt with in any expan- rhea, and chlamydia, were used to map the sion of HPV testing and awareness in the region. presence of sexual risk behaviors. Bacterial STIs Any anxieties concerning screening should not are mainly prevalent among populations with cause women to forgo screenings.114 high-risk practices, or their partners, and are not common among general population groups.115 Bacterial STI prevalence levels are specifically Analytical summary indicative of the presence of high-risk behaviors Cervical cancer and HPV prevalence levels in in a small part of the population, compared to MENA are generally lower than those in other HPV and HSV-2 infections, which may propa- regions, suggesting lower levels of sexual risk gate in populations with intermediate or even behavior and limited connectivity of sexual net- relatively low-risk behaviors. works. HIV infection is unlikely to have major Different studies have documented bacterial inroads into the general population in MENA, STI prevalence in different population groups. confirming the results of HIV prevalence and Tables 10.6, 10.7, and 10.8 list summaries of behavioral measures (chapter 6). these prevalence levels. These measures suggest Nevertheless, there is substantial heterogene- that bacterial STIs are present in MENA and are ity of cervical cancer and HPV prevalence levels common among priority populations. indicating variability of sexual risk behavior Nevertheless, prevalence levels outside of prior- within MENA. It appears that countries closest ity populations are generally low, and possibly to sub-Saharan Africa have the highest levels of reflect exposures among sexual partners of pri- ority or bridging populations. 111 Ginsberg et al., "Cost-Utility Analysis." In addition to the data in the tables, further 112 Matin and LeBaron, "Attitudes toward Cervical Cancer"; Shafiq and data suggest that bacterial STIs are present in Ali, "Sexually Transmitted Infections in Pakistan." 113 McCaffery et al., "Attitudes towards HPV Testing." 114 115 Azaiza and Cohen, "Between Traditional and Modern Perceptions." Brunham and Plummer, "A General Model." 162 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 10.6 Syphilis Prevalence in Different Population Groups Country Syphilis prevalence 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) Proxy Biological Markers of Sexual Risk Behavior 163 Table 10.6 (Continued) Country Syphilis prevalence 1.9% (sailors; Khattabi and Alami 2005) 3.37% (sailors; Bennani and Alami 2006) 2.3% (TB patients; Khattabi and Alami 2005) 4.0% (TB patients; Bennani and Alami 2006) 23.0% (female prisoners; El Ghrari et al. 2007) 7.8% (female prisoners; Khattabi and Alami 2005) 16.39% (female prisoners; Bennani and Alami 2006) 4.8% (male prisoners; Khattabi and Alami 2005) 4.03% (male prisoners; Khattabi and Alami 2005) 2.7% (female STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS) 13.2% (STD clinic attendees; Heikel et al. 1999) 18.4% (STD clinic attendees; Ryan et al. 1998) 4.0% (STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS) 3.8% (STD clinic attendees; Khattabi and Alami 2005) 4.92% (STD clinic attendees; Bennani and Alami 2006) 9.6% (female prisoners imprisoned for sex work; Khattabi and Alami 2005) 11.76% (female prisoners imprisoned for sex work; Bennani and Alami 2006) 12.1% (FSWs; Khattabi and Alami 2005) 9.0% (FSWs; Khattabi and Alami 2005) 13.29% (FSWs; Bennani and Alami 2006) 17% (FSWs; WHO/EMRO Regional Database on HIV/AIDS) Pakistan 0.4% (ANC attendees; WHO/EMRO 2007) 0.4% (general population; WHO/EMRO Regional Database on HIV/AIDS) 0.19%­0.57% (blood donors; Sultan, Mehmood, and Mahmood 2007) 9.4% (truck drivers; WHO/EMRO 2007) 1%­4% (truck drivers; Pakistan National AIDS Control Program 2005a) 7.0% (persons arrested for drug-related crimes; Baqi 1995) 4%­18% (IDUs; Pakistan National AIDS Control Program 2005a) 11.0% (IDUs; WHO/EMRO Regional Database on HIV/AIDS) 7.6% (IDUs; Platt et al. 2009) 3.9% (IDUs; Platt et al. 2009) 23.5% (FSWs; WHO/EMRO 2007) 4­7% (FSWs; Pakistan National AIDS Control Program 2005a) 1.2% (FSWs; Hawkes et al. 2009) 2.8% (FSWs; Hawkes et al. 2009) 6­36% (MSWs; Pakistan National AIDS Control Program 2005a) 21% (MSWs; WHO/EMRO Regional Database on HIV/AIDS) 11%­60% (hijras; Pakistan National AIDS Control Program 2005a) 50.0% (hijras; Khan et al. 2008) 36.0% (hijras; WHO/EMRO Regional Database on HIV/AIDS) 4.7% (MSWs; banthas; Hawkes et al. 2009) 4.9% (MSWs; banthas; Hawkes et al. 2009) 9.6% (MSWs; khotkis; Hawkes et al. 2009) 0.0% (MSWs; khotkis; Hawkes et al. 2009) 48.8% (MSWs; khusras; Hawkes et al. 2009) 37.5% (MSWs; khusras; Hawkes et al. 2009) Qatar 1.1% (blood donors; WHO/EMRO 1998) Somalia 2.0% (ANC attendees; Somaliland Ministry of Health and Labour 2007) 1.4% (ANC attendees; Somaliland Ministry of Health and Labour 2007) 3.6% (ANC attendees; Somaliland Ministry of Health and Labour 2007) 0.0% (ANC attendees; Somaliland Ministry of Health and Labour 2007) 2.4% (ANC attendees; Somaliland Ministry of Health and Labour 2007) 1.8% (ANC attendees; Somaliland Ministry of Health and Labour 2007) 164 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 10.6 (Continued) Country Syphilis prevalence 3.0% (general population; Ismail et al. 1990) 5.2% (miscellaneous individuals; Scott et al. 1991) 1.0% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 4.4% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 1.6% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 2.4% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 3.3% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 3.8% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 0.9% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 2.7% (active syphilis; Somali ANC refugee attendees in Kenya; UNHCR 2006­07) 1.0% (active syphilis; Somali refugees attending STI clinic in Kenya; UNHCR 2006­07) 4.7% (active syphilis; Somali refugees attending STI clinic in Kenya; UNHCR 2006­07) 1.3% (active syphilis; Somali refugees attending STI clinic in Kenya; UNHCR 2006­07) 2.3% (active syphilis; Somali refugees attending STI clinic in Kenya; UNHCR 2006­07) 2.0% (female STD clinic attendees; WHO 2004) 0.0% (male STD clinic attendees; WHO 2004) 1.4% (STD clinic attendees; Somaliland Ministry of Health and Labour 2007) 10.0% (STD clinic attendees; Ismail et al. 1990) 12.6% (STD clinic attendees; Scott et al. 1991) 18.0% (a group of FSWs, STD clinic attendees, male soldiers, and tuberculosis patients; Watts et al. 1994) 69.0% (FSWs; Ahmed et al. 1991) 10.0% (FSWs; Corwin et al. 1991) 5.6% (FSWs; Corwin et al. 1991) 50.8% (FSWs; Scott et al. 1991) 3.1% (Testa and Kriitmaa 2009) Sudan 0.9% (randomly sampled women in a suburban community; Kafi, Mohamed, and Musa 2000) 2.4% (pregnant women; WHO/EMRO 1998) 2.0% (ANC attendees; Sudan National AIDS/STIs Program 2008) 11.2% (ANC attendees; Southern Sudan; Southern Sudan AIDS Commission 2007) 0%­27% (various locations; ANC attendees; Southern Sudan; Southern Sudan AIDS Commission 2007) 4.4% (active syphilis; Sudanese ANC refugee attendees in Kenya; UNHCR 2006­07) 5.6% (blood donors; Sudan National AIDS Program 2008) 1.8% (refugees; Sudan National AIDS/STIs Program 2008) 11.0% (female Sudanese refugees in Ethiopia; Holt et al. 2003) 26.0% (male Sudanese refugees in Ethiopia; Holt et al. 2003) 6.3% (active syphilis; Sudanese refugees attending STI clinic in Kenya; UNHCR 2006­07) 17.0% (a population of FSWs, soldiers, truck drivers, outpatients, and Ethiopian refugees; McCarthy et al. 1989) Turkey 0.1% (engaged couples; Alim et al. 2009) 0.168% (blood donors; Coskun et al. 2008) 5.38% (FSWs; Gul et al. 2008) Yemen, Republic of 2.0% (general population; WHO/EMRO Regional Database on HIV/AIDS) 4.9% (FSWs; Stulhofer and Bozicevic 2008) 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. Proxy Biological Markers of Sexual Risk Behavior 165 Table 10.7 Gonorrhea Prevalence in Different Population Groups Country Gonorrhea prevalence Djibouti 32.4% (promiscuous males; Fox et al. 1989) Egypt, Arab Republic of 2.8% (family planning attendees; El-Sayed et al. 2002) 2.0% (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 0.4% (a group of pregnant and nonpregnant women; Dezfulimanesh and Tehranian 2005) 1.0% (female prison inmates; Zangeneh 1999) 6.4% (obstetrics and gynecology clinics attendees; Chamani-Tabriz et al. 2007) Jordan 0.7% (symptomatic hospital attendees; Jordan Ministry of Health 2004) 0.5% (asymptomatic hospital attendees; Jordan Ministry of Health 2004) 1.2% (symptomatic hospital attendees; As'ad 2004) 0.0% (asymptomatic hospital attendees; As'ad 2004) 0.6% (symptomatic hospital attendees; Mahafzah et al. 2008) 0.9% (asymptomatic hospital attendees; Mahafzah et al. 2008) Kuwait 31.5% (STD clinic attendees; Al-Mutairi et al. 2007) Lebanon 0.0% (rural population; Deeb et al. 2003) Morocco 3.2% (family planning center attendees; Ryan et al. 1998) 5.4% (symptomatic primary health care center attendees; Ryan et al. 1998) 0.9% (ANC attendees; WHO/EMRO Regional Database on HIV/AIDS) 1.74% (female STD clinic attendees; Heikel et al. 1999) 0.8% (female STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS) 7.07% (male STD clinic attendees; Heikel et al. 1999) 10.0% (STD clinic attendees; Ryan et al. 1998) 42.0% (STD clinic attendees; WHO/EMRO Regional Database on HIV/AIDS) 52.4% (STD clinic attendees; Alami et al. 2002) 3.5% (FSWs; WHO/EMRO Regional Database on HIV/AIDS) Pakistan 1%­4% (truck drivers; Pakistan National AIDS Control Program 2005a) 1%­2% (IDUs; Pakistan National AIDS Control Program 2005a) 1.3% (IDUs; Platt et al. 2009) 0.0% (IDUs; Platt et al. 2009) 10%­12% (FSWs; Pakistan National AIDS Control Program 2005a) 0%­18% (anal; MSWs; Pakistan National AIDS Control Program 2005a) 3%­6% (genital; MSWs; Pakistan National AIDS Control Program 2005a) 3%­4% (anal; hijras; Pakistan National AIDS Control Program 2005a) 15.0% (anal; hijras; Khan et al. 2008) 4.0% (urethral; hijras; Khan et al. 2008) 12.6% (anal; MSWs; banthas; Hawkes et al. 2009) 11.1% (anal; MSWs; banthas; Hawkes et al. 2009) 4.7% (anal; MSWs; khotkis; Hawkes et al. 2009) 0.0% (anal; MSWs; khotkis; Hawkes et al. 2009) 20.2% (anal; MSWs; khusras; Hawkes et al. 2009) 6.3% (anal; MSWs; khusras; Hawkes et al. 2009) Somalia 0.8% (ANC attendees; WHO 2004) 0.5% (STD clinic attendees; WHO 2004) 6.7% (STD clinic attendees; Burans et al. 1990) 11.2% (FSWs; Burans et al. 1990) Turkey 0.0% (family planning clinic attendees; Ortayli, Bulut, and Nalbant 2001; Ortayli et al. 2001) 166 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table 10.8 Chlamydia Prevalence in Different Population Groups Country Chlamydia prevalence 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) Country Chlamydia prevalence Somalia 1.1% (ANC attendees; WHO 2004) 0.8% (STD clinic attendees; WHO 2004) 14.0% (STD clinic attendees; Ismail et al. 1990) Sudan 1.2% (randomly sampled women in a suburban community; Kafi, Mohamed, and Musa 2000) Turkey 1.9% (family planning clinic attendees; Ortayli et al. 2001) 1.9% (family planning clinic attendees; Ortayli, Bulut, and Nalbant 2001) 12.0% (registered FSWs; Agacfidan et al. 1997) 14.4% (unregistered FSWs; Agacfidan et al. 1997) 12.9% (FSWs; Agacfidan et al. 1997) United Arab Emirates 2.6% (female primary and secondary care attendees; Ghazal-Aswad et al. 2004) West Bank and Gaza 8.0% (pregnant women; Lubbad and Al-Hindi 2007) 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 15­44 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, 1992­2006 needs to be exercised when inter- 400 preting STD data with no con- no. of new cases per year (1,000) firmed etiology. In a rural com- 300 munity in eastern Lebanon, STD prevalence was 1.2%, but there were no etiologically confirmed 200 cases of syphilis, gonorrhea, or chlamydia.140 Among general 100 population women in Egypt, 19.7% of women self-reported STI symptoms in the previous 0 141 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 12 months, but given the epide- year miological context of sexual risk behavior highlighted in this syn- Source: WHO/EMRO data reported to the WHO office of the Eastern Mediterranean Region. thesis, it seems unlikely that the majority of these symptoms are STI related. It is estimated that about 1.5 million unsafe Facilities with etiologic diagnostic methods are abortions occurred in MENA in 2003,144 out of a not widely available in MENA.142 world total of about 19 million.145 Unsafe abor- tions account for 11% of maternal deaths in Analytical summary MENA,146 compared to 30% of all maternal Prevalence levels of bacterial STIs among the deaths globally.147 general population in MENA are low compared to other regions, but prevalence levels among Analytical summary priority populations are considerable, suggesting higher levels of sexual risk behavior. HIV infec- The fact that MENA has one of the lowest rates tion is unlikely to have major inroads into the of unsafe abortions in the developing world sug- general population in MENA, confirming the gests that levels of risk behavior are lower than results of HIV prevalence and behavioral mea- those in other regions. HIV infection is unlikely sures (chapter 6). The considerable prevalence to have major inroads into the general popula- levels in priority groups suggest that there is tion in MENA, confirming the results of HIV potential for HIV spread among these groups. prevalence and behavioral measures (chapter 6). Nevertheless, there is substantial heterogeneity UNSAFE ABORTIONS AS MARKERS in unsafe abortion rates across MENA. Countries OF SEXUAL RISK BEHAVIOR closest to sub-Saharan Africa have the highest levels followed by the Maghreb countries. Lower Levels of unsafe abortions can be used as proxies of levels are found in the rest of MENA. sexual risk behavior and may reflect levels of unprotected sexual intercourse in nonspousal part- nerships. Figure 10.5 displays the rates of unsafe BIOLOGICAL EVIDENCE ON PROXY abortion in MENA compared to the rest of the MEASURES OF SEXUAL RISK BEHAVIORS: regions.143 Apart from Djibouti and Somalia, MENA ANALYTICAL SUMMARY has one of the lowest rates of unsafe abortions in the developing world. The rates are higher in the The above sections presented data on several Maghreb than in the Mashriq parts of MENA, con- proxy biomarkers for sexual risk behavior in sistent with the results of STI measures. different population groups in MENA. The 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." Proxy Biological Markers of Sexual Risk Behavior 169 Figure 10.6 Estimated Annual Incidence of Unsafe Abortions per 1,000 Women Aged 15­44 Years, by United Nations Subregions in 2000 unsafe abortions per 1,000 women aged 15­44 30+ 25­29 20­24 15­19 10­14 5­9 0­4 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. Source: Reproduced with permission from WHO (2004). data derived from these different proxy BIBLIOGRAPHY biomarkers converge to the same conclusion: Abdel, Aziz M. T., M. Z. Abdel Aziz, H. M. Atta, O. G. sexual risk behaviors are present in MENA; Shaker, M. M. Abdel Fattah, G. A. Mohsen, H. H. there are existing local sexual risk networks Ahmed, and D. A. El Derwi. 2006. "Screening for where STIs are propagating; and levels of Human Papillomavirus (HPV) in Egyptian Women by the Second-Generation Hybrid Capture (HC II) Test." sexual risk behavior appear to be considerable Med Sci Monit 12: MT43­49. among priority groups. However, levels of Abuharfeil, N., and M. M. Meqdam. 2000. "Seroepide- risky behavior are low among the general miologic Study of Herpes Simplex Virus Type 2 and population and overall they are among the Cytomegalovirus among Young Adults in Northern lowest of all regions. Jordan." New Microbiol 23: 235­39. Sexual risk behaviors vary across MENA, Abu-Raddad, L. J., A. S. Magaret, C. Celum, A. Wald, I. M. Longini, S. G. Self, and L. Corey. 2008. "Genital with the highest levels found in countries closest Herpes Has Played a More Important Role Than Any to sub-Saharan Africa, followed by the Maghreb Other Sexually Transmitted Infection in Driving HIV countries in the western part of MENA. The Prevalence in Africa." PLoS ONE 3: e2230. lowest levels appear to be in the Mashriq coun- Abu-Raddad, L. J., J. T Schiffer, R. Ashley, R. A. Alsallaq, tries in the eastern part of MENA. F. A. Akala, I. Semini, G. Riedner, and D. Wilson. Forthcoming. "HSV-2 Serology Can Be Predictive of The evidence on the different proxy biomark- HIV Epidemic Potential and Hidden Sexual Risk ers suggests that it is unlikely that HIV infection Behavior in the Middle East and North Africa." will make major inroads into the general popu- Afghanistan Central Blood Bank. 2006. Report of Testing of lation in MENA, confirming the results of HIV Blood Donors from March­December, 2006. Ministry of prevalence and behavioral measures (chap- Public Health, Kabul, Afghanistan. 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: 573­75. 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: 13­17. Cancer 47: 675­80. 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: 114­19. 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: 520­26. 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: 119­23. Specific Serology." Clin Microbiol Rev 12: 1­8. 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: 261­66. Int J Infect Dis 7: 206­9. 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: 35­42. Women in Israel." Psychooncology 17: 34­41. 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 22­25, 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: S16­24. East Mediterr Health J 8: 794­804. 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: 541­45. 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: 76­79. Papanicolaou Smear Screening Programs for Women Bener, A., S. Denic, and R. Alwash. 2001. "Screening for in Iran." Women Health 47: 23­37. Cervical Cancer among Arab Women." Int J Gynaecol Al-Muammar, T., M. N. Al-Ahdal, A. Hassan, G. Kessie, Obstet 74: 305­7. 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: 1­5. 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: 1153­59. 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: 594­99. "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: 114­19. in Jordan." East Mediterr Health J 14: 1148­54. 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: 92­96. 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: 796­802. Med J 27: 1498­502. 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 Proxy Biological Markers of Sexual Risk Behavior 171 Endemicity in the Incidence of Cervical Cancer: An Chamani-Tabriz, L., M. J. Tehrani, M. M. Akhondi, Extension of the Hypothesis on Sexual Behavior." A. Mosavi-Jarrahi, H. Zeraati, J. Ghasemi, S. Asgari, Cancer Epidemiol Biomarkers Prev 3: 375­79. A. Kokab, and A. R. Eley. 2007. "Chlamydia Boudghene-Stambouli, O., and A. Merad-Boudia. 1997. Trachomatis Prevalence in Iranian Women "Chancroid in Algeria: The Status of This Sexually Attending Obstetrics and Gynaecology Clinics." Pak Transmitted Disease in 1995." Bull Soc Pathol Exot 90: J Biol Sci 10: 4490­94. 78­80. Chaouki, N., F. X. Bosch, N. Munoz, C. J. Meijer, B. El Brown, Z. A., S. Selke, J. Zeh, J. Kopelman, A. Maslow, Gueddari, A. El Ghazi, J. Deacon, X. Castellsague, R. L. Ashley, D. H. Watts, S. Berry, M. Herd, and and J. M. Walboomers. 1998. "The Viral Origin of L. Corey. 1997. "The Acquisition of Herpes Simplex Cervical Cancer in Rabat, Morocco." Int J Cancer 75: Virus during Pregnancy." N Engl J Med 337: 509­15. 546­54. Brunham, R. C., and F. A. Plummer. 1990. "A General Chuang, T. Y., H. O. Perry, L. T. Kurland, and D. M. Model of Sexually Transmitted Disease Epidemiology Ilstrup. 1984. "Condyloma Acuminatum in Rochester, and Its Implications for Control." Med Clin North Am Minn., 1950­78: I. Epidemiology and Clinical Features." 74: 1339­52. Arch Dermatol 120: 469­75. Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani, Cirpan, T., A. Guliyeva, G. Onder, M. C. Terek, A. J. George, R. Abu-Elyazeed, and J. N. Woody. 1990. Ozsaran, Y. Kabasakal, O. Zekioglu, and S. Yucebilgin. "Serosurvey of Prevalence of Human Immuno- 2007. "Comparison of Human Papillomavirus Testing deficiency Virus amongst High Risk Groups in Port and Cervical Cytology with Colposcopic Examination Sudan, Sudan." East Afr Med J 67: 650­55. and Biopsy in Cervical Cancer Screening in a Cohort of Patients with Sjogren's Syndrome." Eur J Gynaecol Burchell, A. N., H. Richardson, S. M. Mahmud, H. Oncol 28: 302­6. Trottier, P. P. Tellier, J. Hanley, F. Coutlee, and E. L. Franco. 2006. "Modeling the Sexual Transmissibility Cleland, J., J. T. Boerma, M. Carael, and S. S. Weir. of Human Papillomavirus Infection Using Stochastic 2004. "Measurement of Sexual Behaviour." Sexually Computer Simulation and Empirical Data from a Transmitted Infections 80: ii1­i90. Cohort Study of Young Women in Montreal, Canada." Collins, S. I., S. Mazloomzadeh, H. Winter, T. P. Rollason, Am J Epidemiol 163: 534­43. P. Blomfield, L. S. Young, and C. B. Woodman. 2005. Burchell, A. N., R. L. Winer, S. de Sanjose, and E. L. "Proximity of First Intercourse to Menarche and Franco. 2006. "Chapter 6: Epidemiology and the Risk of Human Papillomavirus Infection: A Transmission Dynamics of Genital HPV Infection." Longitudinal Study." Int J Cancer 114: 498­500. Vaccine 24 Suppl 3: S52­61. Corey, L., and H. H. Handsfield. 2000. "Genital Herpes Caldwell, C., and P. Quiggin. 1989. "The Social Context and Public Health: Addressing a Global Problem." of AIDS in Sub-Saharan Africa." Population and JAMA 283: 791­94. Development Review 15: 185­234. Corey, L., A. Wald, C. L. Celum, and T. C. Quinn. 2004. Castellsague, X., F. X. Bosch, N. Munoz, C. J. Meijer, "The Effects of Herpes Simplex Virus-2 on HIV-1 K. V. Shah, S. de Sanjose, J. Eluf-Neto, C. A. Ngelangel, Acquisition and Transmission: A Review of Two S. Chichareon, J. S. Smith, R. Herrero, V. Moreno, and Overlapping Epidemics." J Acquir Immune Defic Syndr S. Franceschi. 2002. "Male Circumcision, Penile Human 35: 435­45. Papillomavirus Infection, and Cervical Cancer in Female Corwin, A. L., J. G. Olson, M. A. Omar, A. Razaki, and Partners." N Engl J Med 346: 1105­12. D. M. Watts. 1991. "HIV-1 in Somalia: Prevalence Catania, J. A., D. R. Gibson, D. D. Chitwood, and T. J. and Knowledge among Prostitutes." AIDS 5: 902­4. Coates. 1990. "Methodological Problems in AIDS Coskun, O., C. Gul, H. Erdem, O. Bedir, and C. P. Behavioral Research: Influences on Measurement Eyigun. 2008. "Prevalence of HIV and Syphilis among Error and Participation Bias in Studies of Sexual Turkish Blood Donors." Ann Saudi Med 28: 470. Behavior." Psychol Bull 108: 339­62. Cowan, F. M., R. S. French, P. Mayaud, R. Gopal, N. J. CDC (Centers for Disease Control and Prevention). 2000. Robinson, S. A. de Oliveira, T. Faillace, A. Uuskula, "Tracking the Hidden Epidemics." Trends in STDs in M. Nygard-Kibur, S. Ramalingam, G. Sridharan, R. El the United States, Atlanta, Georgia. Aouad, K. Alami, M. Rbai, N. P. Sunil-Chandra, and Cengiz, A. T., O. Kendi, M. Kiyan, Y. Bilge, S. Ugurel, D. W. Brown. 2003. "Seroepidemiological Study of and A. R. Tumer. 1992. "Detection of Herpes Simplex Herpes Simplex Virus Types 1 and 2 in Brazil, Estonia, Virus 2 (HSV) IgG and IgM Using ELISA in India, Morocco, and Sri Lanka." Sex Transm Infect 79: Transsexuals and Homosexuals." Mikrobiyol Bul 26: 286­90. 41­49. Cowan, F. M., A. M. Johnson, R. Ashley, L. Corey, and ------. 1993. "Demonstration of Herpes Simplex Virus A. Mindel. 1994. "Antibody to Herpes Simplex Virus (HSV)-2 IgG and IgM Using ELISA in Transsexuals Type 2 as Serological Marker of Sexual Lifestyle in and Homosexuals." Mikrobiyol Bul 27: 46­51. Populations." BMJ 309: 1325­29. Cengiz, L., M. Kiyan, A. T. Cengiz, F. Kara, and M. S. Cunningham, A. L., F. K. Lee, D. W. Ho, P. R. Field, C. L. Ugurel. 1993. "Detection of Herpes Simplex Virus 1 Law, D. R. Packham, I. D. McCrossin, E. Sjogren- and 2 (HSV-1 And HSV-2) Igg and Igm by ELISA in Jansson, S. Jeansson, and A. J. Nahmias. 1993. "Herpes Cord Blood and Sera of Mothers with Pregnancy Simplex Virus Type 2 Antibody in Patients Attending Complications." Mikrobiyol Bul 27: 299­307. Antenatal or STD Clinics." Med J Aust 158: 525­28. 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: 835­38. Med Hyg 55: 179­84. 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: 53­55. 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: 956­60. 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: 374­76. 307­10. 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: 639­45. J Gastroenterol 11: 1200­203. 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 July­September 21: 313­17. Clinic in Israel." Isr Med Assoc J 5: 626­28. 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. 1232­36. 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: 1105­11. 199­205. 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: 106­10. 561­69. 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: 73­83. 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: 742­48. 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, 529­32. 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: 774­79. 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: 1333­37. 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: 45­56. 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. Proxy Biological Markers of Sexual Risk Behavior 173 Ghazi, H. O., A. M. Telmesani, and M. F. Mahomed. Holt, B. Y., P. Effler, W. Brady, J. Friday, E. Belay, K. Parker, 2002. "TORCH Agents in Pregnant Saudi Women." and M. Toole. 2003. "Planning STI/HIV Prevention Med Princ Pract 11: 180­82. among Refugees and Mobile Populations: Situation Ginsberg, G. M., M. Fisher, I. Ben-Shahar, and Assessment of Sudanese Refugees." Disasters 27: 1­15. J. Bornstein. 2007. "Cost-Utility Analysis of Vaccination IARC (International Agency for Research on Cancer). against HPV in Israel." Vaccine 25: 6677­91. WHO http://www.iarc.fr/. Glasier, A., A. M. Gulmezoglu, G. P. Schmid, C. G. Ibrahim, A. I., K. M. Kouwatli, and M. T. Obeid. 2000. Moreno, and P. F. Van Look. 2006. "Sexual and "Frequency of Herpes Simplex Virus in Syria Based Reproductive Health: A Matter of Life and Death." on Type-Specific Serological Assay." Saudi Med J 21: Lancet 368: 1595­607. 355­60. Goldie, S. J., L. Kuhn, L. Denny, A. Pollack, and T. C. Imam, S. Z., F. Rehman, M. M. Zeeshan, B. Maqsood, Wright. 2001. "Policy Analysis of Cervical Cancer S. Asrar, N. Fatima, F. Aslam, and M. R. Khawaja. 2008. Screening Strategies in Low-Resource Settings: Clinical "Perceptions and Practices of a Pakistani Population Benefits and Cost-Effectiveness." JAMA 285: 3107­15. regarding Cervical Cancer Screening." Asian Pac J Cancer Prev 9: 42­44. Gul, U., A. Kilic, B. Sakizligil, S. Aksaray, S. Bilgili, O. Demirel, and C. Erinckan. 2008. "Magnitude of Inal, M. M., S. Kose, Y. Yildirim, Y. Ozdemir, E. Toz, Sexually Transmitted Infections among Female Sex K. Ertopcu, I. Ozelmas, and S. Tinar. 2007. "The Workers in Turkey." J Eur Acad Dermatol Venereol 22: Relationship between Human Papillomavirus 1123­24. Infection and Cervical Intraepithelial Neoplasia in Turkish Women." Int J Gynecol Cancer 17: 1266­70. Hajiabdolbaghi, M., N. Razani, N. Karami, P. Kheirandish, M. Mohraz, M. Rasoolinejad, K. Arefnia, Z. Kourorian, Iran Center for Disease Management. 2005. Three G. Rutherford, and W. McFarland. 2007. "Insights Month Statistics of the MoH AIDS Office. Unpublished. from a Survey of Sexual Behavior among a Group of Ismail, S. O., H. J. Ahmed, L. Grillner, B. Hederstedt, At-Risk Women in Tehran, Iran, 2006." AIDS Educ A. Issa, and S. M. Bygdeman. 1990. "Sexually Prev 19: 519­30. Transmitted Diseases in Men in Mogadishu, Somalia." Hajjaj, A. A., A. C. Senok, A. E. Al-Mahmeed, A. A. Issa, Int J STD AIDS 1: 102­6. A. R. Arzese, and G. A. Botta. 2006. "Human Jamal, A., and J. A. Al-Maghrabi. 2003. "Profile of Pap Papillomavirus Infection among Women Attending Smear Cytology in the Western Region of Saudi Health Facilities in the Kingdom of Bahrain." Saudi Arabia." Saudi Med J 24: 1225­29. Med J 27: 487­91. Jordan Ministry of Health. 2004. "Prevalence of Hamkar, R., T. M. Azad, M. Mahmoodi, S. Seyedirashti, Reproductive Tract Infections in Women Attending A. Severini, and R. Nategh. 2002. "Prevalence of Human Selected Urban OB/GYN Clinics in Jordan." Amman, Papillomavirus in Mazandaran Province, Islamic Republic Jordan. of Iran." East Mediterr Health J 8: 805­11. Jordan National Cancer Registry. 2008. Cancer Incidence Hammad, M. M., H. W. Jones, and M. Zayed. 1987. in Jordan. Annual reports, 2000­2004. Cancer "Low Prevalence of Cervical Intraepithelial Neoplasia Prevention Directorate, National Cancer Registry, among Egyptian Females." Gynecol Oncol 28: 300­4. Ministry of Health, Amman, Jordan. Hammouda, D., N. Munoz, R. Herrero, A. Arslan, Kadi, Z., A. Bouguermouh, N. Ait-Mokhtar, A. Allouache, A. Bouhadef, M. Oublil, B. Djedeat, B. Fontaniere, A. Ziat, and J. Orfilla. 1989. "Genital Chlamydia P. Snijders, C. Meijer, and S. Franceschi. 2005. "Cervical Infections: A Seroepidemiologic Study in Algiers." Carcinoma in Algiers, Algeria: Human Papillomavirus Arch Inst Pasteur Alger 57: 73­82. and Lifestyle Risk Factors." Int J Cancer 113: 483­89. Kafi, S. K., A. O. Mohamed, and H. A. Musa. 2000. Hassen, E., A. Chaieb, M. Letaief, H. Khairi, A. Zakhama, "Prevalence of Sexually Transmitted Diseases (STD) S. Remadi, and L. Chouchane. 2003. "Cervical Human among Women in a Suburban Sudanese Community." Papillomavirus Infection in Tunisian Women." Infection Ups J Med Sci 105: 249­53. 31: 143­48. Kaiser, R., T. Kedamo, J. Lane, G. Kessia, R. Downing, T. Hassen, E., S. Remadi, and L. Chouchane. 1999. Handzel, E. Marum, P. Salama, J. Mermin, W. Brady, "Detection and Molecular Typing of Human and P. Spiegel. 2006. "HIV, Syphilis, Herpes Simplex Papillomaviruses: Prevalence of Cervical Infection in Virus 2, and Behavioral Surveillance among Conflict- the Tunisian Central Region." Tunis Med 77: 497­502. Affected Populations in Yei and Rumbek, Southern Sudan." AIDS 20: 942­44. Hawkes, S., M. Collumbien, L. Platt, N. Lalji, N. Rizvi, A. Andreasen, J. Chow, R. Muzaffar, H. ur-Rehman, N. Kapila, K., S. S. George, A. Al-Shaheen, M. S. Al-Ottibi, S. Siddiqui, S. Hasan, and A. Bokhari. 2009. "HIV and K. Pathan, Z. A. Sheikh, B. E. Haji, M. K. Mallik, D. K. Other Sexually Transmitted Infections among Men, Das, and I. M. Francis. 2006. "Changing Spectrum of Transgenders and Women Selling Sex in Two Cities Squamous Cell Abnormalities Observed on Papanicolaou in Pakistan: A Cross-Sectional Prevalence Survey." Smears in Mubarak Al-Kabeer Hospital, Kuwait, over a Sex Transm Infect 85 Suppl 2: ii8­16. 13-Year Period." Med Princ Pract 15: 253­59. Heikel, J., S. Sekkat, F. Bouqdir, H. Rich, B. Takourt, Karam, W., G. Aftimos, A. Jurjus, S. Khairallah, and N. F. Radouani, N. Hda, S. Ibrahimy, and A. Benslimane. Bedrossian. 2007. "Prevalence of Sexually Transmitted 1999. "The Prevalence of Sexually Transmitted Path- Infections in Lebanese Women as Revealed by Pap ogens in Patients Presenting to a Casablanca STD Smear Cytology: A Cross Sectional Study from 2002­ Clinic." Eur J Epidemiol 15: 711­15. 2006." WHO/EMRO. 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 362­71. 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: 138­42. 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: 678­84. 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: 607­10. Transmitted Infections among Hijras (Male Transgenders) in Pakistan." Int J STD AIDS 19: 817­20. 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: 676­79. 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: 739­43. 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: 4461­66. 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: 202­5. L. S. Freedman, B. K. Edwards, L. A. Ries, and J. L. Massoud, M., A. Noweir, M. Salah, and W. A. Saleh. Young, 83­90. Bethesda, MD: National Cancer Institute, 1991. "Chlamydial Infection in Riyadh, Saudi Arabia." NIH Pub. No. 06­5873. J Egypt Public Health Assoc 66: 411­19. 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: 165­95. Pilot Study." Women Health 39: 63­77. 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: S35­41. 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: 42­46. 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: 144­48. 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: 726­31. 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: 1432­38. 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: 510­28. Contacts." Sex Transm Dis 12: 33­39. 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: 805­12, 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: 1795­98. Proxy Biological Markers of Sexual Risk Behavior 175 Morocco MOH (Ministry of Health). Unknown. ------. 2005b. "Report of the Pilot Study in Karachi & "Situation épidémiologique actuelle du VIH/SIDA au Rawalpindi." Ministry of Health Canada-Pakistan Maroc." HIV/AIDS Surveillance Project, Integrated Biological & Morris, M. 1993. "Telling Tails Explain the Discrepancy Behavioral Surveillance 2004­5. in Sexual Partner Reports." Nature 365: 437­40. Parkin, D. M., S. L. Whelan, J. Ferlay, L. Teppo, and D. B. ------. 1997. "Sexual Networks and HIV." AIDS 11: Thomas, eds. 2002. Cancer Incidence in Five Continents S209­16. Vol. VIII, IARC Scientific Publications No. 155, ------. 2004. Network Epidemiology: A Handbook for Survey International Agency for Research on Cancer. Design and Data Collection. Oxford University Press. Partridge, J. M., J. P. Hughes, Q. Feng, R. L. Winer, B. A. Morse, S. A. 1999. "Etiology of Genital Ulcer Disease and Weaver, L. F. Xi, M. E. Stern, S. K. Lee, S. F. O'Reilly, Its Relationship to HIV Infection." Sex Transm Dis 26: S. E. Hawes, N. B. Kiviat, and L. A. Koutsky. 2007. 63­65. "Genital Human Papillomavirus Infection in Men: Incidence and Risk Factors in a Cohort of University Mroueh, A. M., M. A. Seoud, H. G. Kaspar, and P. A. Students." J Infect Dis 196: 1128­36. Zalloua. 2002. "Prevalence of Genital Human Papillomavirus among Lebanese Women." Eur J Patnaik, P., R. Herrero, R. A. Morrow, N. Munoz, F. X. Gynaecol Oncol 23: 429­32. Bosch, S. Bayo, B. El Gueddari, E. Caceres, S. B. Munoz, N., X. Castellsague, A. B. de Gonzalez, and Chichareon, X. Castellsague, C. J. Meijer, P. J. L. Gissmann. 2006. "Chapter 1: HPV in the Etiology Snijders, and J. S. Smith. 2007. "Type-Specific of Human Cancer." Vaccine 24S3: S1­S10. Seroprevalence of Herpes Simplex Virus Type 2 and Associated Risk Factors in Middle-Aged Women from Nagelkerke, N. J., R. M. Bernsen, S. K. Sgaier, and P. Jha. 6 Countries: The IARC Multicentric Study." Sex 2006. "Body Mass Index, Sexual Behaviour, and Transm Dis 34: 1019­24. Sexually Transmitted Infections: An Analysis Using the NHANES 1999­2000 Data." BMC Public Health 6: Paz-Bailey, G., M. Ramaswamy, S. J. Hawkes, and A. M. 199. Geretti. 2007. "Herpes Simplex Virus Type 2: Epidemiology and Management Options in Nahmias, A. J., F. K. Lee, and S. Beckman-Nahmias. Developing Countries." Sex Transm Infect 83: 16­22. 1990. "Sero-Epidemiological and Sociological Patterns Pebody, R. G., N. Andrews, D. Brown, R. Gopal, H. De of Herpes Simplex Virus Infection in the World." Melker, G. Francois, N. Gatcheva, W. Hellenbrand, Scand J Infect Dis Suppl 69: 19­36. S. Jokinen, I. Klavs, M. Kojouharova, T. Kortbeek, Obasi, A., F. Mosha, M. Quigley, Z. Sekirassa, T. Gibbs, B. Kriz, K. Prosenc, K. Roubalova, P. Teocharov, K. Munguti, J. Todd, H. Grosskurth, P. Mayaud, W. Thierfelder, M. Valle, P. Van Damme, and J. Changalucha, D. Brown, D. Mabey, and R. Hayes. R. Vranckx. 2004. "The Seroepidemiology of Herpes 1999. "Antibody to Herpes Simplex Virus Type 2 as a Simplex Virus Type 1 and 2 in Europe." Sex Transm Marker of Sexual Risk Behavior in Rural Tanzania." Infect 80: 185­91. J Infect Dis 179: 16­24. Pisani, E., S. Lazzari, N. Walker, and B. Schwartlander. O'Farrell, N. 1999. "Increasing Prevalence of Genital 2003. "HIV Surveillance: A Global Perspective." Herpes in Developing Countries: Implications for J Acquir Immune Defic Syndr 32 Suppl 1: S3­11. Heterosexual HIV Transmission and STI Control Platt, L., P. Vickerman, M. Collumbien, S. Hasan, N. Lalji, Programmes." Sex Transm Infect 75: 377­84. S. Mayhew, R. Muzaffar, A. Andreasen, and S. Hawkes. Ortashi, O. M., I. El Khidir, and E. Herieka. 2004. 2009. "Prevalence of HIV, HCV and Sexually Transmitted "Prevalence of HIV, Syphilis, Chlamydia Trachomatis, Infections among Injecting Drug Users in Rawalpindi Neisseria Gonorrhoea, Trichomonas Vaginalis and and Abbottabad, Pakistan: Evidence for an Emerging Candidiasis among Pregnant Women Attending an Injection-Related HIV Epidemic." Sex Transm Infect 85 Antenatal Clinic in Khartoum, Sudan." J Obstet Suppl 2: ii17­22. Gynaecol 24: 513­15. Rodier, G. R., J. J. Morand, J. S. Olson, D. M. Watts, S. Ortayli, N., A. Bulut, and H. Nalbant. 2001. "The Said. 1993. "HIV Infection among Secondary School Effectiveness of Preabortion Contraception Students in Djibouti, Horn of Africa: Knowledge, Counseling." Int J Gynaecol Obstet 74: 281­85. Exposure, and Prevalence." East Afr Med J 70: 414­17. Ortayli, N., Y. Sahip, B. Amca, L. Say, N. Sahip, and Roudi-Fahimi, F., and L. Ashford. 2008. "Sexual & D. Aydin. 2001. "Curable Sexually Transmitted Reproductive Health in the Middle East and North Infections among the Clientele of a Family Planning Africa: A Guide for Reporters." Population Reference Clinic in Istanbul, Turkey." Sex Transm Dis 28: Bureau, Washington, DC. 58­61. Rowe, W. 2007. "Cultural Competence in HIV Prevention Ozcelik, B., I. S. Serin, S. Gokahmetoglu, M. Basbug, and and Care: Different Histories, Shared Future." Soc R. Erez. 2003. "Human Papillomavirus Frequency of Work Health Care 44: 45­54. Women at Low Risk of Developing Cervical Cancer: Ryan, C. A., A. Zidouh, L. E. Manhart, R. Selka, M. Xia, A Preliminary Study from a Turkish University M. Moloney-Kitts, J. Mahjour, M. Krone, B. N. Hospital." Eur J Gynaecol Oncol 24: 157­59. Courtois, G. Dallabetta, and K. K. Holmes. 1998. "Reproductive Tract Infections in Primary Healthcare, Pakistan National AIDS Control Program. 2005a. National Family Planning, and Dermatovenereology Clinics: Study of Reproductive Tract and Sexually Transmitted Evaluation of Syndromic Management in Morocco." Infections. Survey of High Risk Groups in Lahore and Sex Transm Infect 74 Suppl 1: S95­105. Karachi. Ministry of Health, Pakistan. 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: 113­18. 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: 1327­31. 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: 794­96. 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: 2101­4. 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: 321­22. 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: S1­15. Cervix." Lancet 2: 581­83. UNHCR (United Nations High Commissioner for Slomka, M. J. 1996. "Seroepidemiology and Control of Refugees). 2006­07. 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: R41­45. 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: S3­28. 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: 153­55. Sudan, and Southern Sudan AIDS Commission. van de Laar, M. J. W., F. Termorshuizen, M. J. Slomka, G. Stulhofer, A., and I. Bozicevic. 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 127­34. 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: 407­21. Blood Donors in Pakistan: A Ten-Year Experience." Walboomers, J. M., M. V. Jacobs, M. M. Manos, F. X. Int J Infect Dis 11: 407­12. 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: 12­19. Health Journal 14. Proxy Biological Markers of Sexual Risk Behavior 177 Watts, C. H., and R. M. May. 1992. "The Influence of WHO/EMRO (Eastern Mediterranean Region Office). Concurrent Partnerships on the Dynamics of HIV/ 1998. Report on the Intercountry Workshop on STD AIDS." Math Biosci 108: 89­104. Prevalence Study. Amman, Jordan. Watts, D. M., A. L. Corwin, M. A. Omar, and K. C. ------. 2006. Strengthening Health Sector Response to HIV/ Hyams. 1994. "Low Risk of Sexual Transmission of AIDS and Sexually Transmitted Infections in the Eastern Hepatitis C Virus in Somalia." Trans R Soc Trop Med Mediterranean Region 2006­2010. Cairo: WHO/EMRO. Hyg 88: 55­56. ------. 2007. "Prevention and Control of Sexually Weiss, H. 2004. "Epidemiology of Herpes Simplex Virus Transmitted Infections in the WHO Eastern Type 2 Infection in the Developing World." Herpes 11 Mediterranean Region." Intercountry meeting, Suppl 1: 24A­35A. PowerPoint presentation. Weiss, H. A., S. L. Thomas, S. K. Munabi, and R. J. Winer, R. L., S. K. Lee, J. P. Hughes, D. E. Adam, N. B. Hayes. 2006. "Male Circumcision and Risk of Syphilis, Kiviat, and L. A. Koutsky. 2003. "Genital Human Chancroid, and Genital Herpes: A Systematic Review Papillomavirus Infection: Incidence and Risk Factors and Meta-Analysis." Sex Transm Infect 82: 101­9; in a Cohort of Female University Students." Am J discussion 110. Epidemiol 157: 218­26. WHO (World Health Organization). 2001. "Global Yildirim, Y., M. M. Inal, and S. Tinar. 2005. "Reproductive Prevalence and Incidence of Selected Curable and Obstetric Characteristics of Adolescent Sexually Transmitted Infections, Overview and Pregnancies in Turkish Women." J Pediatr Adolesc Estimates." Geneva, Switzerland. Gynecol 18: 249­53. ------. 2003. Shaping the Future. World Health Report Zangeneh, M. 1999. "Epidemiology of the Gonococcal 2003. Geneva: World Health Organization. Infection in Women Kermanshah." West Iran. ------. 2004. Unsafe Abortion, Global and Regional Estimates Ziyaeyan, M., A. Japoni, M. H. Roostaee, S. Salehi, and of the Incidence of Unsafe Abortion and Associated Mortality H. Soleimanjahi. 2007. "A Serological Survey of in 2000, 4th Edition. Geneva: World Health Organization. Herpes Simplex Virus Type 1 and 2 Immunity in ------. 2007. "Human Papillomavirus and HPV Pregnant Women at Labor Stage in Tehran, Iran." Pak Vaccination: Technical Information for Policy-Makers J Biol Sci 10: 148­51. and Health Professionals." Department of Immunization, Vaccines, and Biologicals, Geneva, Switzerland. 178 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Chapter 11 Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA 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 Table 11.1 Status of the HIV Epidemic in MENA Countries Concentrated Concentrated Concentrated epidemic among epidemic among epidemic among Generalized Country IDUs MSM FSWs epidemic Afghanistan Possibly (in Kabul) Unknown Apparently not Unlikely Unknown (out of Kabul) Algeria Possibly Unknown Possibly (southern part Unlikely of Algeria) Apparently not (rest of country) Bahrain Possibly Unknown Unknown Unlikely Djibouti Unknown Unknown Established Established Egypt, Arab Rep. of Apparently not Possibly Apparently not Unlikely Iran, Islamic Rep of. Established Possibly Apparently not Unlikely Iraq Apparently not Unknown Unknown Unlikely Jordan Apparently not Unknown Unknown Unlikely Kuwait Unknown Unknown Apparently not Unlikely Lebanon Apparently not Apparently not Apparently not Unlikely Libya Possibly Unknown Unknown Unlikely Morocco Unknown Unknown Apparently not Unlikely Oman Possibly Unknown Unknown Unlikely Pakistan Established Possibly Apparently not Unlikely Qatar Unknown Unknown Unknown Unlikely Saudi Arabia Unknown Unknown Unknown Unlikely Somalia Unknown Unknown Likely Possibly in some parts Sudan Possibly Possibly Apparently not Unlikely (North Sudan) (North Sudan) (North Sudan) (North Sudan) Unknown Unknown Likely (Southern Likely (Southern Sudan) (Southern Sudan) Sudan) (Southern Sudan) Syrian Arab Republic Apparently not Unknown Apparently not Unlikely Tunisia Apparently not Unknown Apparently not Unlikely United Arab Emirates Unknown Unknown Unknown Unlikely West Bank and Gaza Unknown Unknown Unknown Unlikely Yemen, Rep. of Unknown Unknown Apparently not Unlikely 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 Figure 11.1 Analytical View of HIV Epidemiology in MENA General population Random infections due (including vulnerable to exogenous exposures populations) among nationals IDUs FSWs Bridging populations MSM Priority and bridging Limited HIV spread in populations: the part of the general population the population where most HIV transmissions are likely to occur 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. Settings of vulnerability FUTURE HIV EXPANSION IN MENA A large fraction of the MENA population belongs The levels of risky behavior and biomarkers of to one or another of several vulnerable groups risk among many priority populations are high including prisoners, youth, and mobile popula- and are conducive to substantial HIV epidemics. tions. The socioeconomic context that is leading The fact that HIV prevalence continues to be at to risky behavior includes poverty, unemploy- zero or low prevalence levels in many priority ment, social disruption, gender roles and expec- populations should not be mistaken for a lack of tations, sexual exploitation, and inadequate HIV epidemic potential. HIV may simply not yet social and health resources.131 Socioeconomic have had the opportunity to be introduced into disparities, large-scale population mobility, and some of these groups. Some of the priority political instability are contributing to increased groups in MENA tend to be quite isolated, limit- vulnerability. Complex emergencies are preva- ing the probability of virus introduction. lent in the region, such as in Afghanistan, Iraq, Even when the virus is introduced into a prior- Lebanon, Somalia, Sudan, and the West Bank ity population at higher risk of HIV, it may take and Gaza.132 Marginalization of priority groups many years before HIV starts to appreciably is contributing to the vulnerability of these expand. Figure 11.3 displays a simulated epidem- groups to HIV infection.133 ic among an MSM community of 1,000 persons. Though the virus was introduced into the popula- HIV knowledge, attitudes, and practices tion in the year 2000, it did not start appreciable growth until a decade later. The low HIV trans- Though basic knowledge of HIV/AIDS is high in mission probability per coital act,134 long duration MENA, low levels of comprehensive knowledge of latent infection, and slow disease progression135 of HIV/AIDS, and high levels of misconceptions, limit the expansion of HIV spread initially, but stigma, and discrimination, continue to plague once HIV prevalence becomes appreciable, HIV MENA populations. Use of protective measures incidence and therefore prevalence can increase such as condoms is limited and condoms are rapidly. not always widely or easily accessible. Most Indeed, this pattern of emerging epidemics in MENA populations perceive themselves not at priority populations appears to be occurring at risk of HIV infection even when they practice the moment in at least a few MENA countries. high-risk behaviors. There is a perception that The best recent example to this end is Pakistan, minimizing apparent risk behaviors is the best where exogenous exposures dominated the epi- protection against HIV, but at a cost of ignoring demiological profile for two decades, but then rapidly rising epidemics emerged among IDUs 128 Alrajhi, Halim, and Al-Abdely, "Mode of Transmission of HIV-1." and, to some extent, among MSM.136 129 Ramezani, Mohraz, and Gachkar, "Epidemiologic Situation"; Burrows, Wodak, and WHO, Harm Reduction in Iran. 130 134 Aidaoui, Bouzbid, and Laouar, "Seroprevalence of HIV Infection." Wawer et al., "Rates of HIV-1 Transmission per Coital Act." 131 135 World Bank, "Mapping and Situation Assessment." Mellors et al., "Prognosis in HIV-1 Infection." 132 136 Salama and Dondero, "HIV Surveillance in Complex Emergencies." Pakistan National AIDS Control Program, HIV Second Generation 133 Tiouiri et al., "Study of Psychosocial Factors." Surveillance (Rounds I, II, and III).. 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 HIV prevalence (%) 20 15 HIV virus is introduced into 10 the MSM population in the year 2000 HIV prevalence starts appreciable 5 growth in the MSM population around the year 2010 0 2000 2005 2010 2015 2020 2025 2030 time (years) Source: Abu-Raddad 2009. Note: Simulation produced using a stochastic compartmental model. 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: 1835­40. 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: iii10­17. 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: 2295­303. 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 1913­14. 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: 261­66. 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: 945­47. 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: 509­12. 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: 127­32. 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: 121­28. 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: 293­95. 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: 1559­63. "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: 486­92. AIDS 18: 1478­80. 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: 466­72. 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: 650­55. 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: 536­44. 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: 504­5. 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: 1391­96. 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: 138­43. 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: 133­35. 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: 1173­80. A Randomised Controlled Trial." Lancet 369: 643­56. 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 146­50. Defic Syndr 22: 294­301. 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: 144­48. Driving Force in the Dynamics of HIV in Accra, Bayoumi, A. 2005. Baseline Survey of Intravenous Drug Ghana." AIDS 18: 917­25. 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 (1997­2000)." African 189: 2154­66. Studies Review: 71­85. 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: 485­86. ii24­27. 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: 239­41. Models." Sex Transm Infect 78 Suppl 1: i78­90. 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: 203­9. 192­93. 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: 186­94. 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: 399­407. 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: 407­20. 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: 1121­32. 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: 1751­56. "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: 819­25. Rakai Project Team." AIDS 14: 2371­81. 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: 1­5. Immunodeficiency Syndrome in Saudi Arabia: The Elrashied, S. 2006. "Prevalence, Knowledge and Related American-Saudi Connection." JAMA 255: 383­84. 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 13­18, 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: 331­37. 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: 247­52. 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: 255­58. 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: 115­28. ------. 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: 856­63. Rev 4: 111­25. 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: 135­43. AIDS 1: 102­6. 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: 317­18. 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: 92­99. 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, 329­32. 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: 1109­13. Tuberculosis in Central Tunisia." Tunis Med 69: 349­52. 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 (1985­1986): 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: 24­31. 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: 1539­57. 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: 512­16. Preventive Interventions." Sex Transm Infect 83: 577­81. 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: 133­34. 10: 215­28. 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: 7­10. deficiency Syndrome in Lebanon from 1984 through 1998." Int J Infect Dis 4: 209­13. 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: 71­80. 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: 884­85. 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: 253­57. Karachi." J Pak Med Assoc 44: 8­11. 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: 175­90. Socio-Demographic Characteristics of Seroconverters Marcelin, A. G., M. Grandadam, P. Flandre, J. L. Koeck, in a Rural Population in Uganda: 1990­1994." Int J M. Philippon, E. Nicand, R. Teyssou, H. Agut, J. M. Epidemiol 25: 1077­82. 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 149­54. Prostitutes in Djibouti." J Med Virol 68: 164­67. 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: 843­48. "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: 129­32. 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: 5­8. Epidemiol 29: 911­15. 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: 726­31. 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: 18­20. Incidence." J Acquir Immune Defic Syndr 30: 248­56. 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: S23­32. 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: 765­66. 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: 1397­405. HIV/AIDS Integrated Report South Sudan, 2004­2005. 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: 1167­70. 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: 81­86. 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: 128­31. 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. ------. 2006­7. 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: 9­14. 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: S3­11. Sci 32: 716­21. 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: 2­4. Strains, Circulating Recombinant Form AE and a Mujeeb, S. A., M. R. Khanani, T. Khursheed, and A. Novel BC Recombinant." J Virol 74: 11286­95. Siddiqui. 1991. "Prevalence of HIV-Infection among Rakwar, J., L. Lavreys, M. L. Thompson, D. Jackson, J. Blood Donors." J Pak Med Assoc 41: 253­54. 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: 29­36. 13: 607­14. 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: 315­18. ------. 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: 45­46. 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: 682­86. Patients in Tunisia." East Mediterr Health J 5: 903­11. 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: 61­67. Risk Behavior in Injection Drug Users, Kabul, Afghanistan." Emerg Infect Dis 13: 1327­31. 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: 462­65. 414­17. 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. 395­96. ------. 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: 725­28. 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: S4­12. ------. 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: iii18­25. 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: 834­39. of HIV Infection and AIDS in Egypt over Four Years of Shah, S. A., A. Altaf, S. A. Mujeeb, and A. Memon. 2004. Surveillance (1986­1990)." J Trop Med Hyg 96: 113­17. "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: 812­14. Dis 191: 1403­9. 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: 761­66. 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 Snapshot on Response to HIV Epidemic in MENA: Linking Evidence with Policy and Programmatic Action to Avert the Epidemic 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 2004­5." (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 2004­07, and 11% in Tiaret28), populations in selected areas of urban cities. The and the NSP for 2008­12 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 injection­related 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 2­4); 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 number of PLHIV on ART 600 400 200 0 Jun. 05 Dec. 05 Jun. 06 Dec. 06 Jun. 07 Dec. 07 Jun. 08 Dec. 08 time Southern Sudan Somalia 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, 2006­08 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: 1166­72. 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 2009­2012." 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: 390­95. and out-of-Treatment: An 18-Month Prospective Follow-Up." J Acquir Immune Defic Syndr 6: 1049­56. 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: 966­67. 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 2007­2011." Ministry of City Syringe--Exchange Programmes." Lancet 348: Public Health/Department of Epidemiology and 987­91. 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. 2006­7. 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 13­18, 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 7­9, 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 2004­2005 (Draft)." With United Nations General hommes." For ATL MST sida NGO­Tunis 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: 878­82. Study." Eur J Public Health 11: 153­59. 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 2004­2009." 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: S75­84. 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: 709­16. 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. Summary of Recommendations 215 being concentrated in priority groups, as delin- The attitude toward NGOs from outside the eated in this synthesis. region can be negative among MENA popula- Despite this limitation, the region has seen the tions.27 There is no escaping the fact that grass- foundation of a number of effective NGOs work- roots NGOs need to be developed within MENA. ing on HIV efforts in recent years. By the mid- Considering the cultural sensitivity of working 1990s, there were at least 100 NGOs in MENA with priority groups, a successful formula for involved in HIV/AIDS prevention and education, HIV efforts may be government organized NGOs although with limited capacity.20 There are a (GONGOs), where governments fund and growing number of NGOs and associations in support NGOs to discreetly provide services to countries such as Algeria, Djibouti, the Arab priority groups, such as sex worker self-help Republic of Egypt, the Islamic Republic of Iran, groups.28 NGOs may enable governments to Jordan, Lebanon, Morocco, and Sudan. These deal with priority groups indirectly, thereby organizations provide much needed support for avoiding cultural sensitivities in explicit out- HIV prevention and treatment, including out- reach efforts among stigmatized populations.29 reach centers for IDUs, FSWs, and MSM. Discreet interventions for HIV prevention have Some of the NGOs have made impressive been proven effective in Bangladesh,30 achievements, such as the comprehensive harm Lebanon,31 Morocco,32 and Pakistan.33 reduction approach by the Iranian NGO Persepolis that provides needle exchange, meth- adone maintenance, general medical care, VCT, RECOMMENDATION 5: AN OPPORTUNITY and referral.21 In the Islamic Republic of Iran, FOR PREVENTION NGOs have played a leading role in the transfor- There is still an opportunity for prevention that mation to effective policies as well as the should not be missed to avert a larger epidemic34 promotion of close cooperation between health and avoid the health and socioeconomic cost authorities, prison departments, judiciary that the MENA region is largely unprepared to authorities, academic institutions, religious lead- pay.35 It appears that there is increasingly a ers, and other stakeholders.22 political feasibility for implementing and scaling Another achievement is Helem in Lebanon, up interventions, including those involving prior- the first and only aboveground organization ity populations.36 Resources need to be allocated working with MSM in MENA.23 Helem has made for interventions for the priority populations admirable contributions in addressing the health, irrespective of whether these groups are "cultur- legal, psychological, and social needs of MSM, by ally safe" or not.37 Developing mechanisms for far the most culturally sensitive group of all prior- working with priority populations, even if dis- ity groups.24 Helem is also involved in scientific creetly, need to be explored. Efforts in MENA surveillance research work and VCT efforts with continue to be focused on awareness-raising MSM.25 In Djibouti, there have been a number of activities among the general population, which is initiatives to address the high-risk behaviors the group at the lowest risk of infection. among truck drivers and FSWs along the trade corridor, such as the High Risk Corridor Initiative.26 27 Blowfield, "Fundamentalists Call the Shots." 28 Jenkins, "Report on Sex Worker Consultation in Iran." 29 Razzaghi et al., "HIV/AIDS Harm Reduction in Iran"; Vazirian et al., 20 Wahdan, "The Middle East." "Needle and Syringe Sharing." 21 30 Razzaghi et al., "HIV/AIDS Harm Reduction in Iran"; Vazirian et al., Jenkins et al., "Male Prostitutes." 31 "Needle and Syringe Sharing." Jenkins and Robalino, "HIV in the Middle East and North Africa." 22 32 Razzaghi et al., "HIV/AIDS Harm Reduction in Iran"; Ohiri et al., "HIV/ Tawil et al., "HIV Prevention"; Boushaba et al., "Marginalization and AIDS." Vulnerability." 23 33 Lebanon National AIDS Control Program, "A Case Study" (2008a). Jenkins et al., "Male Prostitutes." 24 34 International HIV/AIDS Alliance, "Supporting Men Who Have Sex with Khawaja et al., "HIV/AIDS and Its Risk Factors in Pakistan"; World Men in Lebanon," http://www.aidsalliance.org/sw51051.asp, accessed Bank, "Preventing HIV/AIDS in the Middle East and North Africa"; on January 12, 2007. Zaheer et al., "STIs and HIV in Pakistan." 25 35 Mishwar, "An Integrated Bio-Behavioral Surveillance Study"; Lebanon Jenkins and Robalino, "HIV in the Middle East and North Africa." 36 National AIDS Control Program, "A Case Study" (2008a); Lebanon Buse, "Political Feasibility of Scaling-Up." 37 National AIDS Control Program, "A Case Study" (2008b). UNAIDS, "Notes on AIDS in the Middle East and North Africa"; Jordan 26 O'Grady, "WFP Consultant Visit to Djibouti Report." National AIDS Program, "National HIV/AIDS Strategy for Jordan 2005­9." 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." Summary of Recommendations 217 BIBLIOGRAPHY Transmitted Infections." J Infect Dis 191 Suppl 1: S42­54. Abu-Raddad, L. J., A. S. Magaret, C. Celum, A. Wald, El Feki, S. 2006. "Middle-Eastern AIDS Efforts Are I. M. Longini, S. G. Self, and L. Corey. 2008. "Genital Starting to Tackle Taboos." Lancet 367: 975­76. Herpes Has Played a More Important Role Than Any Ghys, P. D., C. Jenkins, and E. Pisani. 2001. "HIV Other Sexually Transmitted Infection in Driving HIV Surveillance among Female Sex Workers." AIDS 15 Prevalence in Africa." PLoS ONE 3: e2230. Suppl 3: S33­40. Aden, A. S., L. Dahlgren, and R. Guerra. 2004. Jenkins, C. 2006. "Report on Sex Worker Consultation "Experiences against HIV/AIDS/STDS of Somalis in in Iran." Sponsored by UNAIDS and UNFPA, Exile in Gothenburg, Sweden." Ann Ig 16: 141­55. Dec 2­18. Afshar, P. Unknown. "From the Assessment to the Jenkins, C., and D. A. Robalino. 2003. "HIV in the Implementation of Services Available for Drug Abuse Middle East and North Africa: The Cost of and HIV/AIDS Prevention and Care in Prison Setting: Inaction." Orientations in Development Series, World The Experience of Iran." PowerPoint presentation. Bank. Afshar, P., and F. Kasraee. 2005. "HIV Prevention Jenkins, C., A. Shale, R. Habibur, and M. M. Faisal. 2001. Experiences and Programs in Iranian Prisons" "Male Prostitutes in Dhaka: Risk Reduction through [MoPC0057]. Presented at the Seventh International Effective Intervention." Paper presented at the Congress on AIDS in Asia and the Pacific, Kobe. International Conference on AIDS in the Asia-Pacific, Ainsworth, M., and W. Teokul. 2000. "Breaking the Melbourne, October. Silence: Setting Realistic Priorities for AIDS Control in Jordan National AIDS Program. 2005. "National HIV/ Less-Developed Countries." Lancet 356: 55­60. AIDS Strategy for Jordan 2005­9." Draft. American University of Beirut. "Reaching `Hard to Reach' Population in HIV/AIDS Research in the Jurgens, R., A. Ball, and A. Verster. 2009. "Interventions Middle East: Methodological and Ethical Issues." to Reduce HIV Transmission Related to Injecting Drug Workshop held at the American University of Beirut, Use in Prison." Lancet Infect Dis 9: 57­66. Lebanon, October 23­25, 2008. Khan, O. A., and A. A. Hyder. 2001. "Responses to an Blowfield, M. 1994. "Fundamentalists Call the Shots." Emerging Threat: HIV/AIDS Policy in Pakistan." WorldAIDS: 3. Health Policy Plan 16: 214­18. Boushaba, A., O. Tawil, L. Imane, and H. Himmich. Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. 1999. "Marginalization and Vulnerability: Male Sex Vermund. 1997. "HIV/AIDS and Its Risk Factors in Work in Morocco." In Men Who Sell Sex: International Pakistan." AIDS 11: 843­48. Perspectives on Males Sex Work and AIDS, ed. Peter Lazarus, J. V., H. M. Himedan, L. R. Ostergaard, and Angleton, 263­74. London: UCL Press. J. Liljestrand. 2006. "HIV/AIDS Knowledge and Brenner, B. G., M. Roger, J. P. Routy, D. Moisi, M. Condom Use among Somali and Sudanese Immigrants Ntemgwa, C. Matte, J. G. Baril, R. Thomas, D. in Denmark." Scand J Public Health 34: 92­99. Rouleau, J. Bruneau, R. Leblanc, M. Legault, C. Lebanon National AIDS Control Program. 2008a. "A Tremblay, H. Charest, and M. A. Wainberg. 2007. Case Study of the First Legal, Above-Ground LGBT "High Rates of Forward Transmission Events after Organization in the MENA Region." Helem. Acute/Early HIV-1 Infection." J Infect Dis 195: 951­59. ------. 2008b. "A Case Study on Establishing and Buse, K., N. Lalji, S. H. Mayhew, M. Imran, and S. J. Building Capacities for VCT Centers for HIV/AIDS in Hawkes. 2009. "Political Feasibility of Scaling-Up Five Lebanon." Beirut, Lebanon. Evidence-Informed HIV Interventions in Pakistan: A Levi, I., B. Modan, T. Blumstein, O. Luxenburg, Policy Analysis." Sex Transm Infect 85 Suppl 2: ii37­42. T. Yehuda-Cohen, B. Shasha, A. Lotan, A. Bundstein, Butler, D. 2008. "Libya Progresses on HIV." Nature 452: 138. A. Barzilai, and E. Rubinstein. 2001. "Characteristics Chen, L., P. Jha, B. Stirling, S. K. Sgaier, T. Daid, R. Kaul, of Clients Attending Confidential versus Anonymous and N. Nagelkerke. 2007. "Sexual Risk Factors for Testing Clinics for Human Immunodeficiency Virus." HIV Infection in Early and Advanced HIV Epidemics Isr Med Assoc J 3: 184­87. in Sub-Saharan Africa: Systematic Overview of 68 Lewis, F., G. J. Hughes, A. Rambaut, A. Pozniak, and A. Epidemiological Studies." PLoS ONE 2: e1001. J. Leigh Brown. 2008. "Episodic Sexual Transmission Cohen, M. S., G. E. Henderson, P. Aiello, and H. Zheng. of HIV Revealed by Molecular Phylodynamics." PLoS 1996. "Successful Eradication of Sexually Transmitted Med 5: e50. Diseases in the People's Republic of China: MacKellar, D. A., L. A. Valleroy, G. M. Secura, S. Behel, Implications for the 21st Century." J Infect Dis 174 T. Bingham, D. D. Celentano, B. A. Koblin, M. Lalota, Suppl 2: S223­29. W. McFarland, D. Shehan, H. Thiede, L. V. Torian, Des Jarlais, D. C., M. Marmor, D. Paone, S. Titus, Q. Shi, and R. S. Janssen. 2005. "Unrecognized HIV Infection, T. Perlis, B. Jose, and S. R. Friedman. 1996. "HIV Risk Behaviors, and Perceptions of Risk among Incidence among Injecting Drug Users in New York Young Men Who Have Sex with Men: Opportunities City Syringe-Exchange Programmes." Lancet 348: for Advancing HIV Prevention in the Third Decade of 987­91. HIV/AIDS." J Acquir Immune Defic Syndr 38: 603­14. Doherty, I. A., N. S. Padian, C. Marlow, and S. O. Aral. Metzger, D. S., G. E. Woody, A. T. McLellan, C. P. 2005. "Determinants and Consequences of Sexual O'Brien, P. Druley, H. Navaline, D. DePhilippis, Networks as They Affect the Spread of Sexually P. Stolley, and E. Abrutyn. 1993. "Human 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 S239­47. Defic Syndr 6: 1049­56. 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 15­19. 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: 851­54. ------. 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 S75­84. 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: 85­90. 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: 21­23. 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: 1785­92. 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: 1384­87. Matters Most." AIDS 17: 895­903. 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: S3­11. 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: 423­26. M. Claeson, and R. Power. 2006. "HIV/AIDS Harm World Bank. 2005. "Preventing HIV/AIDS in the Middle Reduction in Iran." Lancet 368: 434­35. 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: 166­72. 2287­92. 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: ii1­2. 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. S33­38. 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: 709­16. H. Himmich, A. Boushaba, K. Pradeep, and M. Carael. Summary of Recommendations 219 Appendix A Table A.1 Estimated Number of People Living with HIV in MENA Countries Country Number of PLHIV Afghanistan Not available Algeria 21,000 (11,000­43,000) Bahrain Not available Djibouti 16,000 (12,000­19,000) Egypt, Arab Rep. of 9,200 (7,200­13,000) Iran, Islamic Rep. of 86,000 (68,000­110,000) Iraq Not available Jordan Not available Kuwait Not available Lebanon 3,000 (1,700­7,200) Libya Not available Morocco 21,000 (15,000­31,000) Oman Not available Pakistan 96,000 (69,000­150,000) Qatar Not available Saudi Arabia Not available Somalia 24,000 (13,000­45,000) Sudan 320,000 (220,000­440,000) Syrian Arab Republic Not available Tunisia 3,700 (2,700­5,400) United Arab Emirates Not available West Bank and Gaza Not available Yemen, Rep. of Not available Source: UNAIDS Country Database 2008, http://www.unaids.org/en/CountryResponses/Countries/default.asp. Note: PLHIV people living with HIV. Numbers within parentheses indicate the range within which the estimate could lie. 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 Effective mean rate of new sexual partner Duration of acquisition per year Transmission probability per partnership infectiousness in for sustainable STI years 1-Year partnership 10-Year partnership 20-Year partnership transmission a Gonorrhea 0.5 0.50 0.50 0.50 4 b Chlamydia 1.25 0.20 0.20 0.20 4 Syphilisc 0.5 0.30 0.30 0.30 7 Chancroidd 0.08 0.80 0.80 0.80 15 Herpes simplex virus Chronic reactivations 0.20 0.89 0.99 0.4 type 2e for lifetime Human papillomavirusf Chronic ~1.00 ~1.00 ~1.00 0.1 human immunodefi- 10 0.16 0.83 0.83 1.4 ciency virus­1g a Brunham and Plummer 1990; Yorke, Hethcote, and Nold 1978. b Brunham and Plummer 1990; Lycke et al. 1980. c Brunham and Plummer 1990; Schroeter et al. 1971. d Brunham and Plummer 1990; Plummer et al. 1983. e Abu-Raddad et al. 2008. f Winer et al. 2003. g Abu-Raddad et al. 2008. 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. Table C.1 HIV Prevalence of Different Population Groups in MENA Country HIV prevalence among different population groups Bahrain 0.0% (outpatient pediatric clinic; Al-Mahroos and Ebrahim 1995) Djibouti 0.0% (women; Marcelin et al. 2001) 5.0% (women; Marcelin et al. 2002) 5.0% (men; Marcelin et al. 2002) Egypt, Arab Republic of 0.0% (different population groups; Constantine et al. 1990) 0.0% (tourism workers; El-Sayed et al. 1996) 0.18% (fever patients; Watts et al. 1993) 1.9% (sexual contacts of HIV patients; Watts et al. 1993) 0.07% (international travelers; Watts et al. 1993) 0.97% (non-Egyptian residents; Watts et al. 1993) 0.0% (hospital patients; El-Ghazzawi, Hunsmann, and Schneider 1987) 0.0% (control group in a study; El-Ghazzawi et al. 1995) 0.0% (fire brigade personnel; Quinti et al. 1995; Renganathan et al. 1995) 0.0% (university students; El-Gilany and El-Fedawy 2006) Iran, Islamic Republic of 0.34% (healthy children; Karimi and Ghavanini 2001) 1.8% (gypsy population; Hosseini Asl, Avijgan, and Mohamadnejad 2004) 0.0% (runaways and other women seeking safe haven; Hajiabdolbaghi et al. 2007) Jordan 0.0% (public employees; Zamani et al. 2005; Razzaghi et al. 2006; Ministry of Health and Medical Education of Iran 2006; Afshar [date unknown(a)]; Afshar and Kasrace 2005; WHO/EMRO 2004) 0.0% (military personnel; Jordan National AIDS Program, personal communication) 0.0% (prisoners; Jordan National AIDS Program, personal communication) 0.64% (at-risk populations; Anonymous 2006) Mauritania 0.28% (general population; Baidy et al. 1993) Morocco 0.0% (newly recruited employees; Morocco MOH 2007) 0.0% (people seeking a health insurance card; Morocco MOH 2007) 0.0% (traditional barbers and their customers; Zahraoui-Mehadji et al. 2004) 0.10% (STD clinic attendees, pregnant women, and patients with pulmonary tuberculosis; Elharti et al. 2002) 0.0% (women at family planning clinics; WHO/EMRO Regional Database on HIV/AIDS) 0.32% (seasonal female laborers; Khattabi and Alami 2005) 0.72% (seasonal female laborers; Bennani and Alami 2006) 0.75% (seasonal female laborers; Morocco MOH 2007) 5.26% (male laborers; Khattabi and Alami 2005) 0.0% (male laborers; Bennani and Alami 2006) 0.0% (hotel staff; Khattabi and Alami 2005) 0.16% (hotel staff; Bennani and Alami 2006) 0.12% (hotel staff; Morocco MOH 2007) 224 Table C.1 (Continued) Country HIV prevalence among different population groups 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 Algeria 2.0% (Institut de Formation Paramédicale de Parnet 2004) 1.24% (Unknown, "Statut de la réponse nationale") 1.26% (Unknown, "Statut de la réponse nationale") 0.25% (Alami 2009) 1.19% (Alami 2009) 2.4% (Alami 2009) Djibouti 1.0% (Fox et al. 1989) 10.4% (Rodier et al. 1993) Egypt, Arab Republic of 0.0% (Saleh et al. 2000) 0.23% (Watts et al. 1993) 8.4% (Ali et al. 1998) Iran, Islamic Republic of 4.1% (Ghannad et al. 2009) 2.0% (Ghannad et al. 2009) 2.2% (Ghannad et al. 2009) Kuwait 0.0% (Al-Owaish et al. 2000) 0.0% (Al-Fouzan and Al-Mutairi 2004) 0.0% (Al-Mutairi et al. 2007) Morocco 0.15% (Khattabi and Alami 2005) 0.08% (Khattabi and Alami 2005) 0.25% (Khattabi and Alami 2005) 0.16% (Khattabi and Alami 2005) 0.1 (women; Ryan et al. 1998) 0.3% (women; Ryan et al. 1998) 2.9% (Ryan et al. 1998) 0.0% (men; WHO/EMRO Regional Database on HIV/AIDS) 0.2% (women; WHO/EMRO Regional Database on HIV/AIDS) 0.09% (Khattabi and Alami 2005) 0.23% (Khattabi and Alami 2005) 0.62% (Heikel et al. 1999) 5.0% (attendees with high risk and/or symptoms; Elmir et al. 2002) 0.10% (Khattabi and Alami 2005; Elharti et al. 2002) 0.25% (Elharti et al. 2002) 0.34% (Khattabi and Alami 2005) 0.26% (Khattabi and Alami 2005) 0.19% (Morocco MOH 2007) 226 Table D.1 (Continued) HIV prevalence among STD clinic attendees, VCT attendees, and people Country suspected of living with HIV Pakistan 0.0% (Iqbal and Rehan 1996) 0.0% (Mujeeb and Hafeez 1993) 0.3% (Shrestha 1996) 6.1% (Shrestha 1996) 0.22% (Rehan 2006) Somalia 0.0% (Corwin et al. 1991) 0.0% (Burans et al. 1990) 0.0% (Scott et al. 1991) 0.9% (UNAIDS 2006) 4.3% (WHO 2004) 5.5% (UNAIDS 2006) 6.3% (Somaliland Ministry of Health and Labour 2007) 12.3% (Somaliland Ministry of Health and Labour 2007) 7.4% (men; Somaliland Ministry of Health and Labour 2007) 5.4% (women; Somaliland Ministry of Health and Labour 2007) 1.7% (refugees; UNHCR 2006­07a) 0.9% (refugees; UNHCR 2006­07a) 2.0% (refugees; UNHCR 2006­07a) 1.0% (refugees; UNHCR 2006­07a) 2.0% (refugees; UNHCR 2006­07a) 0.3% (refugees; UNHCR 2006­07a) 0.0% (refugees; UNHCR 2006­07a) 2.3% (refugees; UNHCR 2006­07a) 1.9% (refugees; UNHCR 2006­07a) Sudan 5.8% (Southern Sudan; NSNAC and UNAIDS 2006) 5.8% (Yei town, Southern Sudan; SNAP, NSNAC, and UNAIDS 2006) 17.0% (VCT; Southern Sudan; SNAP, NSNAC, and UNAIDS 2006) 19.1% (VCT; Southern Sudan; NSNAC and UNAIDS 2006) 16.1% (VCT; Southern Sudan; NSNAC and UNAIDS 2006) 20.0% (VCT; Southern Sudan; UNHCR 2007) 2.0% (VCT; Southern Sudan; UNHCR 2007) 5.0% (VCT; Southern Sudan; UNHCR 2007) 6.2% (VCT; Southern Sudan; UNHCR 2007) 1.1% (North Sudan; Ahmed 2004g) 1.94% (North Sudan; SNAP 2008) 1.47% (North Sudan; SNAP 2008) 2.0% (North Sudan; Sudan MOH 2005) 1.86% (Red Sea; North Sudan; Sudan National AIDS Control Program 2005) 2.0% (Khartoum; North Sudan; Sudan National AIDS Control Program 2005; Sudan MOH 2005) 0%­4.4% (three Khartoum sites; North Sudan; SNAP and UNAIDS 2006) 2.0% (Khartoum; North Sudan; SNAP and UNAIDS 2006) 1.86% (Red Sea; North Sudan; SNAP and UNAIDS 2006) 0.0% (Khartoum; North Sudan; SNAP and UNAIDS 2006) 0.0% (Khartoum; North Sudan; SNAP and UNAIDS 2006) 4.4% (Khartoum; North Sudan; SNAP and UNAIDS 2006) 26.0% (suspected AIDS patients; North Sudan; Ahmed 2004a) 3.1% (refugees; UNHCR 2006­07b) Tunisia 1.8% (Sellami et al. 2003) Yemen, Republic of 1.8% (Al-Serouri 2005; WHO, UNICEF, and UNAIDS 2006s) Appendix D 227 Table D.2 HIV Prevalence of Tuberculosis (TB) Patients Country HIV prevalence among tuberculosis patients Afghanistan 0.2% (Todd et al. 2007) Algeria 0.2% (Unknown, "Rapport de l'enquête nationale de séro-surveillance") 0.3% (Unknown, "Rapport de l'enquête nationale de séro-surveillance") Djibouti 5.7% (Rodier et al. 1993) 44.4% (estimate; WHO 2005) 10.1% (estimate; Djibouti National TB Programme 2006) Iran, Islamic Republic of 1.8% (WHO/EMRO 2007) 3.0% (hospital attendees; Tabarsi et al. 2008) Iraq 0.0% (Abdul-Abbas, al-Delami, and Yousif 2000) 0.0% (estimate; Iraq National TB Programme 2006) Jordan 0.0% (Jordan National TB Programme 2006) Kuwait 0.3% (Kuwait National TB Programme 2006) Lebanon 0.5% (estimate; Lebanon National TB Programme 2006) Mauritania 1.5% (WHO 2002) Morocco 0.36% (WHO/EMRO 2007; Elharti et al. 2002) 0.12% (Khattabi and Alami 2005) 0.4% (Khattabi and Alami 2005) 0.94% (Khattabi and Alami 2005) 0.14% (Khattabi and Alami 2005) 0.5% (Khattabi and Alami 2005) 0.19% (Khattabi and Alami 2005) 0.34% (Khattabi and Alami 2005) 1.6% (Alami 2009) 0.39% (Bennani and Alami 2006) 0.76% (Morocco MOH 2007) Oman 2.0 (WHO/EMRO 2007) Pakistan 1.8% (Hussain et al. 2004) Qatar 0.0% (Qatar National TB Programme 2006) Saudi Arabia 1.1% (Alrajhi et al. 2002) Somalia 0.0% (Corwin et al. 1991) 0.0% (Scott et al. 1991) 1.6% (Kulane et al. 2000) 6.0% (UNAIDS 2006)]] 2.4% (UNAIDS 2006) 4.5% (WHO 2004) 5.6% (UNAIDS 2006) Sudan 1.6% (SNAP 2006) 7.2% (Sudan National AIDS Control Program 1999) 4.9% (settled population; El-Sony et al. 2002) 2.6% (IDPs; El-Sony et al. 2002) 4.0% (El-Sony et al. 2002) 2.0% (Ahmed 2004i) 1.85% (SNAP and UNAIDS 2006) 4.8% (Southern Sudan origin; El-Sony et al. 2002) 0.0% (Red Sea; North Sudan; Sudan National AIDS Control Program 2005) 3.0% (Algadarif; North Sudan; Sudan National AIDS Control Program 2005) 1.6% (White Nile; North Sudan; Sudan Government of National Unity 2007) 2.0% (White Nile; North Sudan; Sudan National AIDS Control Program 2005; SNAP and UNAIDS 2006) 1.3% (South Darfur; North Sudan; Sudan National AIDS Control Program 2005) 228 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table D.2 (Continued) Country HIV prevalence among tuberculosis patients 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) Table D.3 Point-Prevalence Surveys on Different Population Groups Men who Female STI Injecting have sex sex clinic Tuberculosis Pregnant Country drug users with men workers patients patients women Algeriaa 3.0% (2000) 0.0% (1998) 0.2% (2000) 1% (2000) 0.4% (2000) Bahrainb 21.1% (1991) 0.0% (1998) 2.9% (1994) 0.2% (1998) 0.9% (1998) 0.0% (1990) 0.0% (1995) 0.0% (1993) 1.4% (1993) 0.0% (1993) 0.8% (1996) 0.0% (1994) 1.6% (1994) 0.0% (1994) 0.7% (1997) 0.0% (1995) 0.0% (1995) 0.2% (1995) 0.7% (1998) 0.2% (1996) 1.1% (1996) 0.0% (1996) 0.2% (1997) 0.0% (1997) 0.0% (1997) 0.0% (1999) Djiboutic 19.5% (1990) 1.9% (1990) 5.9% (1991) 0.5% (1991) 26% (1991) 10.4% (1991) 6.2% (1992) 1.6% (1992) 36.6% (1992) 11.6% (1992) 7.4% (1993) 4% (1993) 37.7% (1993) 14.4% (1993) 15% (1996) 2.5% (2002) 26.3% (1993) 16.3% (1993) 44% (2000) 3.4% (1993) 25.5% (1994) 19.9% (1994) 8.7% (1994) 2.8% (1994) 36.8% (1995) 19.5% (1995) 12.8% (1995) 9.3% (1995) 32.6% (1996) 22.2% (1996) 14.9% (1996) 2.9% (1996) 32.7% (1997) 16.7% (1997) 1.9% (2000) 27.5% (1998) 17.2% (1998) 13% (1999) 24% (2000) 23% (2001) Egypt, Arab 2.8% (1992) 0.0% (1991) 0.0% (1991) 0.8% (1990) 0.0% (1991) 0.0% (1991) Republic of d 3.8% (1994) 0.7% (1992) 0.0% (1993) 0.0% (1991) 0.0% (1992) 0.0% (1992) 0.0% (1996) 0.0% (1993) 0.0% (1992) 0.0% (1992) 0.2% (1993) 0.0% (1993) 0.0% (1993) 0.0% (1994) 0.0% (1993) 0.2% (1993) 0.3% (1994) 0.0% (1994) 0.0% (1994) 0.0% (1995) 0.0% (1994) 0.0% (1994) 0.0% (1995) 0.0% (1992) 0.0% (1995) 0.0% (1996) 0.0% (1995) 0.0% (1995) 0.1% (1996) 0.0% (1993) 0.0% (1996) 0.0% (1997) 0.9% (1996) 0.0% (1996) 0.0% (1997) 0.0% (1994) 0.0% (1997) 1.3% (1998) 1.1% (1997) 0.0% (1997) 0.3% (1998) 0.0% (1995) 0.0% (1998) 1.4% (1999) 1.5% (1998) 0.0% (1998) 0.2% (1999) 0.0% (1996) (continued) Appendix D 229 Table D.3 (Continued) Men who Female STI Injecting have sex sex clinic Tuberculosis Pregnant Country drug users with men workers patients patients women 0.0% (1999) 0.8% (2000) 1.1% (1999) 0.0% (1999) 0.3% (2000) 0.0% (2004) 0.0% (2004) 1% (2001) 0.0% (2000) 0.0% (2000) 0.2% (2001) 0.0% (2004) 0 % (2001) 0.0% (2001) 0.0% (1991) 0.0% (2004) 0.0% (1992) 0.0% (1992) 0.0% (1993) 0.0% (1993) 0.0% (1994) 0.1% (1994) 0.0% (1995) 0.0% (1995) 0.0% (1996) 0.1% (1996) 0.0% (1997) 0.0% (1997) 0.0% (1998) 0.7% (1998) 0.0% (1999) 0.5% (1999) 0.0% (2002) 0.6% (2001) 0.0% (2004) 0.1% (2004) Iran, Islamic 5.7% (1996) 0.0% (1993) 0.0% (1992) 0.0% (1995) 0.0% (1993) Republic off 1.8% (1997) 0.0% (1994) 0.1% (1993) 0.0% (1997) 0.0% (1992) 0.5% (1998) 0.0% (1995) 0.0% (1994) 0.0% (1998) 0.0% (1994) 0.0% (1996) 0.0% (1992) 6.5% (2000) 0.0% (1997) 0.0% (1993) 4.2% (2001) 0.0% (1998) 0.0% (1994) 0.0% (1995) 0.0% (1996) 0.0% (1997) 0.0% (1998) Iraqe 0.0% (1993) 0.0% (1993) 0.0% (1993) 0.0% (1993) 0.0% (1997) 0.0% (1993) 0.0% (1994) 0.0% (1994) 0.0% (1994) 0.0% (1994) 0.0% (1993) 0.0% (1996) 0.0% (1995) 0.0% (1995) 0.0% (1995) 0.0% (1995) 0.0% (1994) 0.0% (1997) 0.0% (1996) 0.0% (1996) 0.1% (1996) 0.0% (1996) 0.0% (1995) 0.0% (1998) 0.0% (1997) 0.0% (1997) 0.0% (1997) 0.0% (1997) 0.0% (1996) 0.0% (1999) 0.0% (1998) 0.0% (1998) 0.0% (1998) 0.0% (1997) 0.0% (1999) 0.0% (1999) 0.0% (1998) 0.0% (1999) Jordang 1.3% (1991) 1% (1992) 0.0% (2001) 0.0% (1992) 0.0% (1993) 0.0% (1993) 0.0% (1994) 0.0% (1994) 0.0% (1995) 0.0% (1999) Kuwaith 1% (1993) 0.0% (1997) 0.0% (1995) 0.0% (1994) 0.0% (1993) 0.0% (1996) 0.0% (1995) 0.0% (1994) 0.0% (1997) 0.6% (1996) 0.0% (1995) 0.0% (1998) 0.0% (1997) 0.0% (1996) 0.0% (1993) 0.0% (1998) 0.0% (1997) 0.0% (1994) 0.0% (1999) 0.0% (1998) 0.0% (1995) 0.0% (1999) 0.0% (1996) 0.0% (1997) 0.0% (1998) 0.0% (1999) Lebanoni 0.3% (1992) 1.1% (1994) 0.1% (1994) 0.1% (1993) 0.0% (1995) 0.1% (1994) 0.0% (1995) Libyaj 0.5% (1998) 1.1% (1993) 0.0% (1990) 0.3% (1998) 0.0% (1998) 1.2% (1994) 230 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table D.3 (Continued) Men who Female STI Injecting have sex sex clinic Tuberculosis Pregnant Country drug users with men workers patients patients women Moroccok 0.0% (1993) 0.0% (1996) 0.0% (1994) 0.0% (1994) 0.0% (1997) 0.0% (1996) 0.0% (1996) 2% (1999) 0.0% (1997) 0.9% (1997) 0.0% (1996) 0.1% (1999) 0.4% (1999) 0.0% (1997) 0.0% (1996) 0.0% (1996) 0.6% (1999) 0.0% (1997) 0.0% (1997) 0.0% (1999) 0.0% (1999) Omanl 0.0% (1999) 4.2% (1996) 2.3% (1997) 1.9% (1998) 1.4% (1999) Pakistanm 1.1% (1996) 1.6% (1993) 0.0% (1995) 6.1% (1994) 0.0% (1994) 0.0% (1993) 0.0% (2000) 0.3% (1995) 1.2% (1993) 0.3% (1995) 2.8% (1995) 0.0% (1995) 0.0% (2001) 0.7% (1995) 0.5% (2001) 0.0% (1992) 0.0% (2001) 0.3% (1993) 0.0% (1996) 4.2% (1992) 0.0% (1993) 0.0% (1992) 0.0% (1994) 0.5% (1997) 0.8% (1993) 0.1% (1994) 0.0% (1993) 5.4% (1995) 1.7% (2001) 6.1% (1994) 0.8% (1995) 0.0% (1994) 0.7% (1995) 1% (1997) 0.1% (1995) 1.5% (1996) 0.2% (1998) 0.0% (1996) 0.1% (1997) 0.0% (1999) 0.2% (1997) 0.0% (1998) 2.1% (2001) 0.0% (1998) 0.0% (1999) 0.0% (1999) Qatarn 4.5% (1999) 0.0% (1993) 0.8% (1996) Somaliao 2.4% (1990) 0.0% (1990) 1.6% (1998) 0.0% (1998) 4% (2004) 2.4% (2004) 0.9% (2004) 4% (2005) 2% (2005) 1% (2005) 0.9% (1999) 6% (1999) 2% (1997) 4.3% (2002) 4.5% (2002) 0.6% (1997) 5.5% (2004) 5.6% (2004) 0.8% (2004) 0.0% (2005) Sudanp 4.4% (2002) 1.8% (2004) 17% (1995) 4.5% (1996) 6.8% (1991) 75% (1998) 0.5% (1998) 2% (1993) 2.8% (2004) 0.3% (2004) 3.6% (1994) 6.8% (1993) 0.0% (1994) 3.2% (1997) 14.2% (1994) 1.8% (1995) 1.1% (2002) 2.8% (1995) 1.7% (1996) 1.9% (2004) 2.1% (1996) 2.9% (1997) 9.9% (1997) 3.8% (1998) 7.2% (1999) 0.9% (2002) 1.4% (2004) 0.8% (2004) Syrian Arab 0.1% (1992) 0.0% (1992) 0.0% (1990) 0.1% (1995) 0.0% (1995) 0.0% (1993) Republicq 0.0% (1993) 0.6% (1994) 0.0% (1991) 0.3% (1996) 0.2% (1994) 3.6% (1995) 0.0% (1992) 0.2% (1997) 0.0% (1995) 0.9% (1996) 0.0% (1993) 0.1% (1998) 0.0% (1996) 0.0% (1997) 0.0% (1994) 0.0% (1990) 0.0% (1997) 0.6% (1998) 0.0% (1995) 0.2% (1993) 0.0% (1998) 0.0% (1999) 0.0% (1996) 1% (1994) (continued) Appendix D 231 Table D.3 (Continued) Men who Female STI Injecting have sex sex clinic Tuberculosis Pregnant Country drug users with men workers patients patients women 0.0% (1999) 0.0% (1997) 0.2% (1995) 0.1% (1998) 0.0% (1996) 0.0% (1999) 0.0% (1997) 0.1% (1998) 0.0% (1999) Tunisiar 1.1% (1993) 0.0% (1990) 0.0% (1995) 0.7% (1990) 0.0% (1991) 0.9% (1994) 0.3% (1993) 0.4% (1993) 0.2% (1996) 0.7% (1995) 0.1% (1994) 0.3% (1994) 0.2% (1997) 1% (1996) 0.0% (1995) 0.0% (1995) 0.2% (1998) 0.3% (1997) 0.4% (1996) 0.3% (1996) 0.2% (1999) 0.1% (1997) 0.0% (1998) 0.2% (2000) 0.0% (1998) 0.0% (1999) 0.0% (1999) Yemen, 4.5% (1998) 1.7% (1993) 2.1% (1996) Republic ofs 5.3% (1997) 0.5% (1998) 2.9% (1998) Note: This table is a summary of all point­prevalence 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. Table D.4 Hepatitis C Virus Prevalence in Different Population Groups Country Hepatitis C virus prevalence in different population groups Afghanistan 0.31% (ANC attendees; Todd et al. 2008) 0.3% (blood donors; Dupire et al. 1999) 1.9% (blood donors; Afghanistan Central Blood Bank 2006) 36.6% (IDUs; Todd et al. 2007) Algeria 0.18 % (blood donors; Ayed et al. 1995) 0.19% (pregnant women; Ayed et al. 1995) 0.63% (pregnant women; Aidaoui, Bouzbid, and Laouar 2008) Bahrain 0.3% (blood donors including Saudi subjects; Almawi et al. 2004) 9.24% (dialysis patients including Saudi patients; Almawi et al. 2004) 40.0% (children with hemolytic anemias; Al-Mahroos and Ebrahim 1995) Djibouti 0.3% (blood donors; Dray et al. 2005) Egypt, Arab Republic of 13.9% (healthy populations; meta-analyses; Lehman and Wilson 2009), 78.5% (hepatocellular carcinoma patients; meta-analyses; Lehman and Wilson 2009) 13.6% (blood donors; Darwish et al. 1993) 26.6% (blood donors; Bassily et al. 1995) 232 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table D.4 (Continued) Country Hepatitis C virus prevalence in different population groups 14.5% (blood donors; El Gohary et al. 1995) 2.7% (blood donors; El-Gilany and El-Fedawy 2006) 8.8% (blood donors; Tanaka et al. 2004) 24.8% (blood donors; Arthur et al. 1997) 20.8% (blood donors; Quinti et al. 1995) 10.0% (general population; Shemer-Avni et al. 1998) 27.5% (general population; El-Ghazzawi et al. 1995) 24.0% (rural population; Mohamed et al. 2005) 9.0% (rural population; Mohamed et al. 2005) 14.8% (rural population; Marzouk et al. 2007) 18.5% (rural population; Mohamed et al. 2006) 2.7% (rural population; Arafa et al. 2005) 19.0% (rural population; 10­19 years old; Darwish et al. 2001) 60.0% (rural population; 30 years old; Darwish et al. 2001) 8.7% (rural population; Nafeh et al. 2000) 14.4% (rural population; El Gohary et al. 1995) 15.5% (rural population; El Gohary et al. 1995) 24.3% (rural population; Abdel-Aziz et al. 2000) 10.3% (rural population; El-Sayed et al. 1997) 18.1% (rural population; Abdel-Wahab et al. 1994) 13.0% (healthy women; Kumar, Frossad, and Hughes 1997) 15.7% (pregnant women; rural area; Shebl et al. 2009) 19.0% (pregnant women; Kassem et al. 2000) 15.8% (pregnant women; Stoszek et al. 2006) 2.02% (children; El-Raziky et al. 2007) 12.0% (children; Quinti et al. 1995; El-Nanawy et al. 1995) 12.1% (children; Abdel-Wahab et al. 1994) 31.5% (applicants for visa abroad; Mohamed et al. 1996a) 39.0% (fire brigade personnel; Quinti et al. 1995) 22.1% (army recruits; Abdel-Wahab et al. 1994) 14.3% (tourism workers; El-Sayed et al. 1996) 31.4% (prisoners; Quinti et al. 1995) 7.7% (health care workers; El Gohary et al. 1995) 1.4% (dentists; Hindy, Abdelhaleem, and Aly 1995) 63.0% (IDUs; Saleh et al. 2000; El-Ghazzawi 1995) 5.3% (STD patients; Ali et al. 1998) 23.3% (kidney transplant recipients; Gheith et al. 2007) 84.0% (hepatocellular carcinoma patients; Mabrouk 1997) 27.3% (acute jaundice patients; Quinti et al. 1997) 73.5% (chronic liver disease patients; Waked et al. 1995) 46.2% (chronic liver disease patients; Abdel-Wahab et al. 1994) 70.4% (hemodialysis patients; El Gohary et al. 1995) 87.5% (hemodialysis patients; Gohar et al. 1995) 46.2% (hemodialysis patients; Abdel-Wahab et al. 1994) 81.25% (hemodialysis patients; Gohar et al. 1995) 16.4% (children with hepatosplenomegaly; Abdel-Wahab et al. 1994) 54.9% (hospitalized and multitransfused children; Abdel-Wahab et al. 1994) 44.0% (thalassemic children; Quinti et al. 1995; El-Nanawy et al. 1995) 75.6% (thalassemic children; El Gohary et al. 1995) 14.0% (family members of HCV positive patients; spouses; Madwar et al. 1999) 0.0% (family members of HCV positive patients; children; Madwar et al. 1999) 5­50% (various populations; Mohamed et al. 1996b) (continued) Appendix D 233 Table D.4 (Continued) Country Hepatitis C virus prevalence in different population groups 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) Country Hepatitis C virus prevalence in different population groups 63.8% (thalassemia patients; Ansar and Kooloobandi 2002) 18.3% (thalassemia patients; Kashef et al. 2008) 5.1% (thalassemia patients; Samimi-Rad and Shahbaz 2007) 15.7% (thalassemia patients; children; Karimi and Ghavanini 2001) 19.3% (thalassemia patients; Mirmomen et al. 2006) 15.65% (multitransfused hemophiliac patients; Karimi and Ghavanini 2001) Iraq 3.21% (pregnant women; Al-Kubaisy, Niazi, and Kubba 2002) 66.0% (HIV-infected hemophilia patients; Al-Kubaisy, Al-Naib, and Habib 2006a) 67.3% (children with thalassemia; Al-Kubaisy, Al-Naib, and Habib 2006b) Jordan 0.65 to 6.25% (hospitalized populations; Quadan 2002) 40.5% (multitransfused patients; Al-Sheyyab, Batieha, and El-Khateeb 2001) Kuwait 33.0% (thalassemia patients; Al-Fuzae, Aboolbacker, and Al-Saleh 1998) 0.8% (blood donors; Kuwaiti; Ameen et al. 2005) 5.4% (blood donors; non-Kuwaiti; Ameen et al. 2005) Lebanon 0.4% (blood donors; Tamim et al. 2001) 0.6% (blood donors; Irani-Hakime et al. 2001b) 0.40% (blood donors; Irani-Hakime et al. 2006) 0.7% (blood donors; Araj et al. 1995) 0.7% (general population; Baddoura, Haddad, and Germanos 2002) 2.6% (health care workers; Irani-Hakime et al. 2001a) 25.0% (HIV infected IDUs; Ramia et al. 2004) Libya 1.19% (national survey; Libya National Center for the Prevention of and Control of Infectious Diseases 2005) 7.9% (healthy subjects; Saleh et al. 1994) Morocco 1.1% (blood donors; Benjelloun et al. 1996) 1.0% (pregnant women; Benjelloun et al. 1996) 0.5% (ANC attendees and family planning clinic; WHO/EMRO Regional Database on HIV/AIDS) 5.0% (male barbers; Zahraoui-Mehadji et al. 2004) 35.1% (hemodialysis patients; Benjelloun et al. 1996) 76% (hemodialysis patients; Boulaajaj et al. 2005) 68.3% (hemodialysis patients; Sekkat et al. 2008) 42.4% (hemophiliacs; Benjelloun et al. 1996) Oman 1.5% (blood donors; Alnaqy et al. 2006) 0.9% (blood donors; Al-Dhahry et al. 1993) 26.5% (hemodialysis patients; Al-Dhahry et al. 1993) 13.4% (kidney transplant patients; Al-Dhahry et al. 1993) 0.0% (medical students; Al-Dhahry et al. 1993) 11%­53% (IDUs; Unknown 2006) Pakistan 1.70% (youth; Butt and Amin 2008) 16% (blood donors; Ahmad et al. 2007) 3.6% (blood donors; Abdul Mujeeb et al. 2006) 4.0% (blood donors; Khattak et al. 2002) 0.5% (blood donors; Abdul Mujeeb, Aamir, and Mehmood 2000) 3.01%­4.99% (blood donors; Sultan, Mehmood, and Mahmood 2007) 1.8% (blood donors; Akhtar et al. 2004) 1.18% (blood donors; Kakepoto et al. 1996) 7.5% (blood donors; Mujeeb and Pearce 2008) 4.1% (blood donors; Khattak et al. 2008) 0.5% (blood donors; college students; Mujeeb, Aamir, and Mehmood 2006; Abdul Mujeeb, Aamir, and Mehmood 2000) 2.8% (blood donors; weighted average in a review; Ali et al. 2009) 6.7% (general population; women; Parker, Khan, and Cubitt 1999) (continued) Appendix D 235 Table D.4 (Continued) Country Hepatitis C virus prevalence in different population groups 5.31% (general population; Khokhar, Gill, and Malik 2004) 15.9% (general population; Aslam and Aslam 2001) 4.6% (general population; Aslam et al. 2005) 33.7% (general population; rural area; Abbas et al. 2008) 5.4% (general population; weighted average in a review; Ali et al. 2009) 1.3% (children; Parker, Khan, and Cubitt 1999) 1.6 % (children; Jafri et al. 2006) 0.44% (children; Agboatwalla et al. 1994) 1.3% (children with HCV positive mothers; Parker, Khan, and Cubitt 1999), 2.1% (children; weighted average in a review; Ali et al. 2009) 21.0% (vaccinated population for smallpox; Aslam et al. 2005) 5.6% (health care workers; Aziz et al. 2002) 5.5% (health care workers; weighted average in a review; Ali et al. 2009) 3.12% (hospital attendees; Khan et al. 2007) 31.0% (operation room personnel; Mujeeb, Khatri, and Khanani 1998) 88.0% (IDUs; Kuo et al. 2006) 89.0% (IDUs; United Nations Office for Drug Control and Crime Prevention and UNAIDS 1999) 60.0% (IDUs; Achakzai, Kassi, and Kasi 2007) 87.0% (IDUs; Pakistan National AIDS Control Program 2005b) 91.0% (IDUs; Pakistan National AIDS Control Program 2005b) 22.0% (noninjecting drug users; Kuo et al. 2006) 20.5% (household contacts of HCV positive thalassemic children; Akhtar et al. 2002) 36.0% (type II diabetes patients; Ali et al. 2007) 13.2% (transfusion patients; Rizvi and Fatima 2003) 15.4% (transfusion patients; Rizvi and Fatima 2003) 44.0% (patients who received frequent injections; Khan et al. 2000) 33.0% (hepatocellular carcinoma cases; Abdul Mujeeb et al. 1997) 60.0% (thalassemia patients; Bhatti, Amin, and Saleem 1995) 34.8% (children with thalassemia; Akhtar and Moatter 2004) 68.0% (hemodialysis patients; Gul and Iqbal 2003) 23.7%­68.0% (hemodialysis patients; range in a review; Raja and Janjua 2008) Saudi Arabia 4.3% (blood donors; Mahaba, el-Tayeb Ael, and Elbaz 1999) 0.59% (blood donors; Bashawri et al. 2004) 0.4% (blood donors; El-Hazmi 2004) 1.7% (blood donors; Abdelaal et al. 1994) 1.1% (blood donors; Shobokshi et al. 2003) 3.6% (general population; males; Al Nasser 1992) 3.1% (general population; females; Al Nasser 1992) 1.7% (general population; males; Njoh and Zimmo 1997) 3.2% (general population; non-Saudi persons; Njoh and Zimmo 1997) 1.0% (children; Bakir et al. 1995) 1.8% (children; Al-Faleh et al. 1991) 0.1% (children; Shobokshi et al. 2003) 0.7% (pregnant women; Shobokshi et al. 2003) 2.2% (health care workers; Khan, Alkhalife, and Fathalla 2004) 5.09% (different population groups; Mahaba, el-Tayeb Ael, and Elbaz 1999) 74.6% (IDUs; Njoh and Zimmo 1997) 10.5% (non-IDU drug dependent patients; Njoh and Zimmo 1997) 5.87% (patients attending outpatient clinics; Saudis; Fakeeh and Zaki 1999) 22.54% (patients attending outpatient clinics; Egyptians; Fakeeh and Zaki 1999) 2.12% (patients attending outpatient clinics; Yemenis; Fakeeh and Zaki 1999) 3.38% (patients attending outpatient clinics; other Middle Eastern origins; Fakeeh and Zaki 1999) 4.98% (patients attending outpatient clinics; Asian countries origins; Fakeeh and Zaki 1999) 41.9% (hemodialysis patients; Ayoola et al. 1991) 9.24% (hemodialysis patients; including Bahraini patients; Qadi et al. 2004) 236 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table D.4 (Continued) Country Hepatitis C virus prevalence in different population groups 15%­80% (hemodialysis patients; different dialysis units; Karkar 2007) 6.9% (hemodialysis patients; Mahaba, el-Tayeb Ael, and Elbaz 1999) 45.5% (hemodialysis patients; Al Nasser 1992) 55.7% (hemodialysis patients; Shobokshi et al. 2003) 43.4% (hemodialysis patients; Saxena and Panhotra 2004) 17.9% (schistosomiasis patients; Khan, Alkhalife, and Fathalla 2004) 21.0% (non-Hodgkin's lymphoma patients; Harakati, Abualkhair, and Al-Knawy 2000) 63.6% (chronic liver disease patients; Ayoola et al. 1992) 11.0% (children under cancer chemotherapy; Bakir et al. 1995) 45.0% (multitransfused children; Al-Mugeiren et al. 1992) Somalia 0.6% (blood donors; Nur et al. 2000) 0.97% (healthy adults; Aceti et al. 1993) 6.5% (healthy adults; Bile et al. 1993) 0.0% (children; Bile et al. 1992) 1.5% (children; Bile et al. 1992) 0.0% (children; Aceti et al. 1993) 1.8% (FSWs, STD clinic attendees, male soldiers, and tuberculosis patients; Watts et al. 1994) 2.4% (blood donors, hospitalized children and adults; Nur et al. 2000) 2.2% (hospitalized persons; Aceti et al. 1993) 40.3% (chronic liver disease patients; Bile et al. 1993) Sudan 0.6% (pregnant women; Elsheikh et al. 2007) 0.36% (hospital attendees; Ati 2005) 2.2% (an area with a high prevalence of schistosomiasis; Mudawi et al. 2007) 34.0% (hemodialysis patients; El-Amin et al. 2007) 19.0% (hemodialysis patients; Kose et al. 2009) 3.0% (out-patient attendees; McCarthy et al. 1994) Syrian Arab Republic 0.95% (blood donors; Othman and Monem 2002) 1.96% (FSWs; Othman and Monem 2002) 60.5% (IDUs; Othman and Monem 2002) 3.0% (health care workers; Othman and Monem 2001) 0.0% (laboratory workers; Othman and Monem 2001) 54.4% (hemodialysis patients; Moukeh et al. 2009) 6.0% (hemodialysis staff; Othman and Monem 2001) 0.0% (dentistry workers; Othman and Monem 2001) 0.0% (surgery workers; Othman and Monem 2001) Tunisia 0.56% (blood donors; Hatira et al. 2000) 1.09% (blood donors; Slama et al. 1991) 1.7% (general population; Mejri et al. 2005) 0.2% (general population; Mejri et al. 2005) 0.71% (general population; Gorgi et al. 1998) 0.4% (general population; Triki et al. 1997) 39.7% (HIV patients; Kilani et al. 2007) 20.0% (hemodialysis patients; Hmaied et al. 2006) 32.6% (hemodialysis patients; Ben Othman et al. 2004) 45.10% (hemodialysis patients; Hmida et al. 1995) 42% (hemodialysis patients; Hachicha et al. 1995) 42.0% (hemodialysis patients; Jemni et al. 1994) 50.0% (hemophiliacs; Langar et al. 2005) 50.5% (hemophiliacs; Djebbi et al. 2008) Turkey 0.4% (blood donors; Ozsoy et al. 2003) 0.38% (blood donors; Gurol et al. 2006) 0.19% (blood donors; Sakarya et al. 2004) 0.45% (blood donors; Altindis et al. 2006) (continued) Appendix D 237 Table D.4 (Continued) Country Hepatitis C virus prevalence in different population groups 0.37% (blood donors; Mutlu, Meric, and Willke 2004) 0.39% (blood donors; Afsar et al. 2008) 0.28% (blood donors; Afsar et al. 2008) 0.37% (blood donors; Afsar et al. 2008) 1.0% (rural areas; general population; Akcam et al. 2009) 2.3% (general population; men; Bozkurt et al. 2008) 2.0% (general population; women; Bozkurt et al. 2008) 2.1% (general population; Yildirim et al. 2009) 0.6% (general population; Alim et al. 2009) 0.1% (engaged couples; Alim et al. 2009) 1.3% (study controls; Gulcan et al. 2008) 2.8% (barbers; Candan et al. 2002) 0.56% (soldiers; Altindis et al. 2006) 0.45% (soldiers; Altindis et al. 2006) 1.5% (health personnel; Koksal et al. 1991) 0.3% (health care workers; Ozsoy et al. 2003) 2.0% (spouses of chronic HCV patients; Tahan et al. 2005) 0.77% (FSWs; Gul et al. 2008) 2.8% (lymphoma patients; Sonmez et al. 2007) 0.9% (gynecology and obstetrics patients; Tekay and Ozbek 2006) 2.2% (outpatients; Demirturk et al. 2006) 7.0% (predialytic chronic kidney disease patients; Sit et al. 2007) 26.0% (hemodialysis patients; Selcuk et al. 2006) 12.7% (hemodialysis patients; Ocak et al. 2006) 43.6% (hemodialysis patients; Bozdayi et al. 2002) 20.2% (hemodialysis patients; Selcuk et al. 2006) 16.0% (hemodialysis patients; Selcuk et al. 2006) 51.2% (hemodialysis patients; Koksal et al. 1991) 0.0% (new hemodialysis patients; Koksal et al. 1991) 24.4% (children with hemophilia; Kocabas et al. 1997b) 4.0% (patients with multiple blood transfusions; Koksal et al. 1991) 20.8% (diabetic patients; Ocak et al. 2006) 3.2% (diabetic patients; Gulcan et al. 2008) 5.8% (children with cancer; Kocabas et al. 1997a) 2.0% at diagnosis and 14.0% at the end of cancer therapy (children with cancer; Kebudi et al. 2000) West Bank and Gaza 2.2% (general population; Shemer-Avni et al. 1998) Yemen, Republic of 1.1% (blood donors; Haidar 2002) 2.1% (healthy persons; El Guneid et al. 1993) 4.2% (healthy persons; Al-Moslih and Al-Huraibi 2001) 0.5% (health care workers; Haidar 2002) 3.5% (health care workers; Shidrawi et al. 2004) 37.1% (patients with liver disease; Al-Moslih and Al-Huraibi 2001) 21.5% (patients with liver disease; El Guneid et al. 1993) 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 Table E.1 Levels of HIV/AIDS Basic Knowledge in Different Population Groups Country High basic knowledge Low basic knowledge Afghanistan University students (Mansoor et al. 2008) General population women (Todd et al. 2007) FSWs (World Bank 2008) General population women (van Egmond et al. 2004) HCWs (Todd et al. 2009) Intrapartum patients (Todd et al. 2009) TB patients (Todd et al. 2007) High-risk groups (Action Aid Afghanistan 2006) IDUs (Zafar et al. 2003) FSWs (Action Aid Afghanistan 2006) Djibouti High school students (Rodier et al. 1993) Egypt, Arab Nurses and university graduates (Mohsen 1998) Street children (Egypt MOH and Population National Republic of General population women (Measure DHS 2004) AIDS Program 2006) General population women (NEJM 2008) Squatter populations (Shama, Fiala, and Abbas Ever-married women (Measure DHS 2006) 2002) General population (Kabbash et al. 2007) Drug users (Salama et al. 1998) 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) MSM (El-Sayyed, Kabbash, and El-Gueniedy 2008) Iran, Islamic Adolescents (Yazdi et al. 2006) Republic of Youth (Tehrani and Malek-Afzalip 2008) General population (Montazeri 2005) General population (Askarian, Mirzaei, and Assadian 2007) Truck drivers (Tehrani and Malek-Afzalip 2008) Teachers (Mazloomy and Baghianimoghadam 2008) Runaways and other women seeking safe haven (Hajiabdolbaghi et al. 2007) Prisoners (Nakhaee 2002) FSWs (Tehrani and Malek-Afzalip 2008) MSM (Eftekhar et al. 2008) Former prisoners (Ebrahim 2008) Iraq General population women (NEJM 2008) Jordan General population women (Measure DHS 1998) General population women (Measure DHS 2003) General population women (NEJM 2008) Kuwait Different populations (Al-Owaish et al. 1999) (continued) 239 Table E.1 (Continued) Country High basic knowledge Low basic knowledge Lebanon General population (Lebanon National AIDS Control Program 1996; Jurjus et al. 2004) Prisoners (Mishwar 2008) IDUs (Aaraj [unknown]; Hermez et al. [unknown]) IDUs (Mishwar 2008) FSWs (Mishwar 2008) FSWs (Hermez et al. [unknown]) FSWs (Rady 2005) MSM (Mishwar 2008) MSM (Hermez et al. [unknown]; Dewachi 2001) Morocco General population women (NEJM 2008) General population women (Zidouh [unknown]) Blood donors (Boutayeb, Aamoum, and Benchemsi 2006) Oman College students (Al-Jabri and Al-Abri 2003) Pakistan Female college students (Khan et al. 2005) Rural adolescents (Raheel et al. 2007) Medical students (Ali et al. 1996) Ever-married women (Measure DHS 2007) School students (Shaikh and Assad 2001) Paramedicals (Siddiqi, Majeed, and Saeed Khan Obstetrics and gynecology clinic attendees 1995) (Haider et al. 2009) Private health practitioners (Khan 1995) General population (Raza et al. 1998) Pakistanis traveling abroad (Pakistan AIDS Migrant workers (Faisel and Cleland 2006) Prevention Society 1992­93) IDUs (Pakistan National AIDS Control Program 2005a) Fishermen (Sheikh et al. 2003) IDUs (Pakistan National AIDS Control Program 2006­07) Male prisoners (Khawaja et al. 1997) IDUs (Pakistan National AIDS Control Program 2008) IDUs (Haque et al. 2004) Clients of FSWs (Bokhari et al. 2007) IDUs (Afghani refugees; Zafar et al. 2003) Clients of MSWs (Bokhari et al. 2007) IDUs (Khawaja et al. 1997) Different high-risk groups (Pakistan National AIDS Dancing girls, usually FSWs and their clients Control Program 2005c) (Haroon 1994) FSWs (Jamal, Khushk, and Naeem 2006) FSWs (Bokhari et al. 2007) FSWs (Pakistan National AIDS Control Program 2005a) FSWs (Pakistan National AIDS Control Program 2006­07) MSWs (Pakistan National AIDS Control Program 2005a) MSWs (Pakistan National AIDS Control Program 2006­07) 66.5% MSWs (Pakistan National AIDS Control Program 2008) HSWs (Pakistan National AIDS Control Program 2005a) HSWs (Pakistan National AIDS Control Program 2006­07) 66.5% HSWs (Pakistan National AIDS Control Program 2008) Hijras (Baqi et al. 1999) Hijras (Bokhari et al. 2007) Saudi Arabia Students (Abolfotouh 1995) General population women (IGAD 2006) Paramedical students (Al-Mazrou, Abouzeid, and HCWs (Mahfouz et al. 1995) Al-Jeffri 2005) Men in a management training institute (Badahdah 2005) HCWs (Al-Ghanim 2005) Somalia Youth (WHO/EMRO 2000) General population (WHO/EMRO 2000) Traveling merchants/drivers (WHO/EMRO 2000) 240 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table E.1 (Continued) Country High basic knowledge Low basic knowledge Sudan Street children (Ahmed 2004h) Youth (SNAP, UNICEF, and UNAIDS 2005) High school students (Elzubier, el Nour, and Ansari 1996) High school teachers and students (Elzubier, el Nour, and Ansari 1996) University students (Sudan National HIV/AIDS Control Program 2004) University students (Sudan National HIV/AIDS Control Program 2004; Ahmed 2004l) ANC women attendees (Mahmoud et al. 2007) ANC women attendees (Ahmed 2004b) Pregnant women (UNAIDS/WHO 2005) General population (Southern Sudan; NSNAC and UNAIDS 2006) General population (Southern Sudan; UNHCR 2007) Tea sellers (Gutbi and Eldin 2006) Tea sellers (Ati 2005) Tea sellers (Ahmed 2004j) Rural populations (SNAP, UNICEF, and UNAIDS 2005) Military personnel (Ahmed 2004d) Military personnel (Sudan National HIV/AIDS Control Program 2004) Prisoners (Assal 2006) Prisoners (Ahmed 2004e) Prisoners (Ati 2005) Truck drivers (Ahmed 2004k) Truck drivers (Farah and Hussein 2006) Internally displaced persons (Ahmed 2004c) Internally displaced persons (IGAD 2006) Sudanese refugees in Ethiopia (Holt et al. 2003) TB patients (Ahmed 2004i) STD clinic attendees (Ahmed 2004g) Suspected PLHIV (Ahmed 2004a) IDUs (Bayoumi 2005) FSWs (ACORD 2005) FSWs (Ati 2005) FSWs (ACORD 2006) FSWs (Yousif 2006) FSWs (Ahmed 2004f) MSM (Elrashied 2006) Syrian Arab FSWs (Syria National AIDS Programme 2004) Republic IDUs (Syria Mental Health Directorate 2008) Tunisia MSM (Hsairi and Ben Abdallah 2007) Turkey High school students (Savaser 2003) General population (Ayranci 2005) Drug users and nondrug users (Soskolne and Maayan 1998) FSWs (Gul et al. 2008) United Arab University students (Ganczak et al. 2007) Emirates (continued) Appendix E 241 Table E.1 (Continued) Country High basic knowledge Low basic knowledge Yemen, Republic of Youth (Al-Serouri 2005) Secondary school students (Gharamah and Baktayan 2006) Secondary 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: ANC antenatal clinic; FSW female sex worker; HCW health care worker; HSW hrija 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.2 MENA Populations with Low Levels of Comprehensive HIV/AIDS Knowledge Country Low comprehensive knowledge Afghanistan University students (Mansoor et al. 2008) Intrapartum patients (Todd et al. 2009) HCWs (Todd et al. 2007; Todd et al. 2009) Egypt, Arab Republic of Adolescents (El-Tawila et al. 1999) Students (Farghaly and Kamal 1991) Teachers (Farghaly and Kamal 1991) General population women (Measure DHS 2006) General population women (Measure DHS 2004) HCWs (Faris and Shouman 1994) Physicians (Sallam et al. 1995) Iran, Islamic Republic of Youth (Tehrani and Malek-Afzalip 2008) High school students (Tavoosi et al. 2004) Dentists (Askarian, Mirzaei, and Cookson 2007) Truck drivers (Tehrani and Malek-Afzalip 2008) Prisoners (Nakhaee 2002) FSWs (Tehrani and Malek-Afzalip 2008) MSM (Eftekhar et al. 2008) Jordan University students (Petro-Nustas, Kulwicki, and Zumout 2002; Petro-Nustas 2000) General population women (Measure DHS 1998) General population women (Measure DHS 2003) Kuwait Physicians (Fido and Al Kazemi 2002) Lebanon General population (Jurjus et al. 2004) Morocco General population women (Zidouh [unknown]) Pakistan Adolescents (Ali, Bhatti, and Ushijima 2004) Medical students (Shaikh et al. 2007) General population (Raza et al. 1998) HCWs (Najmi 1998) IDUs (Khawaja et al. 1997) FSWs (Jamal, Khushk, and Naeem 2006) FSWs (Pakistan National AIDS Control Program 2005a) FSWs (Pakistan National AIDS Control Program 2006­07) Hijras (Baqi et al. 1999) Saudi Arabia Paramedical students (Al-Mazrou, Abouzeid, and Al-Jeffri 2005) Primary health care users (Al-Ghanim 2005) Men in a management training institute (Badahdah 2005) Bus drivers (Abdelmoneim et al. 2002) 242 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table E.2 (Continued) Country Low comprehensive knowledge Somalia Young women (Somaliland Ministry of Health and Labour 2007) General population (WHO 2004) Somali immigrants to Denmark (Lazarus et al. 2006) Sudan Street children (Ahmed 2004h) Youth (SNAP, UNICEF, and UNAIDS 2005) University students (Sudan National HIV/AIDS Control Program 2004) University students (Ahmed 2004l) ANC women attendees (Ahmed 2004b) General population (Southern Sudan; NSNAC and UNAIDS 2006) Tea sellers (Ahmed 2004j) Tea sellers (Ati 2005) Internally displaced persons (Ahmed 2004c) Sudanese immigrants to Denmark (Lazarus et al. 2006) Sudanese immigrant to the U.S.A. (Tompkins et al. 2006) Sudanese refugees in Ethiopia (Holt et al. 2003) Military personnel (Ahmed 2004d) Military personnel (Sudan National HIV/AIDS Control Program 2004) Prisoners (Ahmed 2004e) Prisoners (Assal 2006) Truck drivers (Farah and Hussein 2006) Truck drivers (Ahmed 2004k) TB patients (Ahmed 2004i) STD clinic attendees (Ahmed 2004g) Suspected AIDS patients (Ahmed 2004a) FSWs and tea sellers (Basha 2006) FSWs (ACORD 2005) FSWs (Ati 2005) FSWs (ACORD 2006) FSWs (Yousif 2006) FSWs (Ahmed 2004f) MSM (Elrashied 2006) Syrian Arab Republic IDUs (Syria Mental Health Directorate 2008) Turkey Street children (Baybuga and Celik 2004) Youth (Baybuga and Celik 2004) United Arab Emirates University students (Ganczak et al. 2007) West Bank and Gaza Youth (PFPPA 2005) Yemen, Republic of Youth (Al-Serouri 2005) General population (Busulwa 2003) Marginalized minority (Al-Akhdam) (Busulwa 2003) Returnee families from abroad (Busulwa 2003) 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 Country High levels of misinformation Djibouti Truck drivers (O'Grady 2004) Egypt, Arab Republic of Squatter populations (Shama, Fiala, and Abbas 2002) Physicians (Sallam et al. 1995) 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 (Mohammadi et al. 2006) Adolescents (Yazdi et al. 2006) Youth (Tehrani and Malek-Afzalip 2008) Teachers (Mazloomy and Baghianimoghadam 2008) General population (Askarian, Mirzaei, and Assadian 2007) General population (Montazeri 2005) General population (Hedayati-Moghaddam 2008) Truck drivers (Tehrani and Malek-Afzalip 2008) FSWs (Tehrani and Malek-Afzalip 2008) MSM (Eftekhar et al. 2008) Jordan Youth (Jordan National AIDS Control Programme 2005) Kuwait Different populations (Al-Owaish et al. 1999) Lebanon Prisoners (Mishwar 2008) Morocco General population women (Zidouh [unknown]) Oman College students (Al-Jabri and Al-Abri 2003) Pakistan Adolescents (Ali, Bhatti, and Ushijima 2004) Female college students (Farid and Choudhry 2003) School students (Shaikh and Assad 2001) Obstetrics and gynecology clinic attendees (Haider et al. 2009) General population (Raza et al. 1998) Pakistanis traveling abroad (Pakistan AIDS Prevention Society 1992­93) FSWs (Jamal, Khushk, and Naeem 2006) Saudi Arabia Paramedical students (Al-Mazrou, Abouzeid, and Al-Jeffri 2005) Sudan Street children (Ahmed 2004h) Street children (Kudrati et al. 2002; Kudrati, Plummer, and Yousif 2008) Youth (SNAP, UNICEF, and UNAIDS 2005) High school students (Elzubier, el Nour, and Ansari 1996) University students (Ahmed 2004l) University students (Sudan National HIV/AIDS Control Program 2004) Teachers (Elzubier, el Nour, and Ansari 1996) ANC women attendees (Ahmed 2004b) General population (Southern Sudan) (NSNAC and UNAIDS 2006) Tea sellers (Gutbi and Eldin 2006), Tea sellers (Ahmed 2004j) Internally displaced persons (Ahmed 2004c) Military personnel (Sudan National HIV/AIDS Control Program 2004) Military personnel (Ahmed 2004d) Prisoners (Ahmed 2004e) Prisoners (Assal 2006) Truck drivers (Ahmed 2004k) Truck drivers (Farah and Hussein 2006) TB patients (Ahmed 2004i) STD clinic attendees (Ahmed 2004g) Suspected PLHIV (Ahmed 2004a) 244 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table E.3 (Continued) Country High levels of misinformation FSWs and tea sellers (Basha 2006) FSWs (ACORD 2006) FSWs (Yousif 2006) FSWs (ACORD 2005) FSWs (Ahmed 2004f) MSM (Elrashied 2006) Syrian Arab Republic FSWs (Syria National AIDS Programme 2004) IDUs (Syria Mental Health Directorate 2008) Tunisia MSM (Hsairi and Ben Abdallah 2007) Turkey Street children (Baybuga and Celik 2004) Youth (Baybuga and Celik 2004) General population (Ayranci 2005) Drug users and nondrug users (Soskolne and Maayan 1998) United Arab Emirates University students (Ganczak et al. 2007) West Bank and Gaza Youth (PFPPA 2005) Yemen, Republic of Youth (Al-Serouri 2005) Secondary school students (Gharamah and Baktayan 2006) General population (Al-Serouri et al. 2002) 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 Negative attitudes toward people Positive attitudes toward people living Country living with HIV/AIDS with HIV/AIDS Djibouti Dockers and truck drivers (O'Grady 2004) Egypt, Arab Republic of General population women (Measure DHS 2006) Tourism workers (El-Sayyed, Kabbash, and El-Gueniedy 2008) Industrial workers (El-Sayyed, Kabbash, and El-Gueniedy 2008) Drug users (Salama et al. 1998) Iran, Islamic Republic of Adolescents (Yazdi et al. 2006) General population (Montazeri 2005) High school students (Tavoosi et al. 2004) General population (IRIB 2006) Teachers (Mazloomy and Former prisoners (Ebrahim 2008) Baghianimoghadam 2008) PLHIV (Sherafat-Kazemzadeh et al. 2003) MSM (Eftekhar et al. 2008) Jordan College students (Petro-Nustas, Kulwicki, and Zumout 2002) General population women (Measure DHS 2003) General population women (Measure DHS 2003) Dentists (El-Maaytah et al. 2005) (continued) Appendix E 245 Table E.4 (Continued) Negative attitudes toward people Positive attitudes toward people living Country living with HIV/AIDS with HIV/AIDS Lebanon General population (Othman and Monem General population (Jurjus et al. 2004) 2002; Lebanon National AIDS Control General population (Lebanon National Program 1996) AIDS Control Program 2003) General population (Lebanon National AIDS Control Program 2003) Libya High school students (El-Gadi, Abudher, High school students (El-Gadi, Abudher, and Sammud 2008) and Sammud 2008) Morocco General population (Zidouh [unknown]) Saudi Arabia Paramedical students (Al-Mazrou, Abouzeid, and Al-Jeffri 2005) Somalia Youth (WHO/EMRO 2000) General population (WHO 2004) General population (WHO/EMRO 2000) Traveling merchants/drivers (WHO/EMRO 2000) Sudan Street children (Ahmed 2004h) University students (Sudan National HIV/ Youth (SNAP, UNICEF, and UNAIDS AIDS Control Program 2004) 2005) General population (Southern Sudan; University students (Sudan National HIV/ UNHCR 2007) AIDS Control Program 2004) University students (Ahmed 2004l) ANC women attendees (Ahmed 2004b) General population (Southern Sudan; UNHCR 2007) Tea sellers (Ahmed 2004j) Internally displaced persons (Ahmed 2004c) Military personnel (Ahmed 2004d) Military personnel (Sudan National HIV/ AIDS Control Program 2004) Prisoners (Assal 2006) Prisoners (Ahmed 2004e) Truck drivers (Farah and Hussein 2006) Truck drivers (Ahmed 2004k) TB patients (Ahmed 2004i) STD clinic attendees (Ahmed 2004g) Suspected AIDS patients (Ahmed 2004a) FSWs (Yousif 2006) FSWs (Ahmed 2004f) MSM (Elrashied 2006) Syrian Arab Republic FSWs (Syria National AIDS Programme 2004) Turkey General population (Ayranci 2005) United Arab Emirates University students (Ganczak et al. 2007) West Bank and Gaza General population (UNAIDS 2007c) General population women (UNAIDS 2007c) 246 Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa Table E.4 (Continued) Negative attitudes toward people Positive attitudes toward people living Country living with HIV/AIDS with HIV/AIDS Yemen, Republic of Youth (Al-Serouri 2005) Secondary school students (Gharamah and Secondary school students (Gharamah and Baktayan 2006) Baktayan 2006) General population (Al-Serouri et al. 2002) General population (Busulwa 2003) Marginalized minority (Al-Akhdam; Busulwa 2003) Returnee families from abroad (Busulwa 2003) 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 A­E 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: 210­16. 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: 135­37. in Somalia." Am J Trop Med Hyg 48: 581­84. 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 43­45. and HCV Prevalence." Hepatology 32: 111­15. 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: 716­24. Afghanistan Central Blood Bank. 2006. Report of Testing of Abdel-Wahab, M. F., S. Zakaria, M. Kamel, M. K. Abdel- Blood Donors from March­December, 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: 563­67. Infections among Blood Donors in Izmir, Turkey." Abdelwahab, O. 2006. "Prevalence, Knowledge of AIDS Indian J Med Microbiol 26: 288­89. 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 13­18, abstract CDC0792. Congress on AIDS in Asia and the Pacific, July 1­5, 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: 269­70. 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. 45­46. 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 545­49. for Sentinel Surveillance." East Mediterr Health J 12: 735­41. 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 390­95. Baghdad (1996­98)." East Mediterr Health J 6: 1103­6. 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 271­81. 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: 164­67. 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: 215­18. 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: 509­12. 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: 311­12. 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 812­18. 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: 181­92. ------. 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: 58­61. 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: 261­66. Rural Pakistan: An Exploratory Study." Tohoku J Exp Med 204: 17­25. 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: 274­84. Prevalence and Risk Factors." Int J Infect Dis 13: 9­19. 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: 1072­73. Patients." J Ayub Med Coll Abbottabad 19: 46­49. 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: 309­14. Saudi Med J 30: 541­45. 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: 527­35. Prisoners in Hamedan--Iran." World J Gastroenterol 11: 4085­89. 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 211­15. 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: 273­77. 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: 264­69. Hemophiliacs." Transfusion Today 49: 4­5. ------. 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: 204­10. Donors: A Case-Control Study." J Gastroenterol Hepatol Al-Kubaisy, W. A., A. D. Niazi, and K. Kubba. 2002. 17: 1092­97. "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: 239­44. Bibliography for Appendixes A­E 249 Al-Mahroos, F. T., and A. Ebrahim. 1995. "Prevalence of Hepatitis B, Hepatitis C and HIV among Healthy Hepatitis B, Hepatitis C and Human Immune Population and Turkish Soldiers in Northern Cyprus." Deficiency Virus Markers among Patients with World J Gastroenterol 12: 6792­96. Hereditary Haemolytic Anaemias." Ann Trop Paediatr Ameen, R., N. Sanad, S. Al-Shemmari, I. Siddique, R. I. 15: 121­28. Chowdhury, S. Al-Hamdan, and A. Al-Bashir. 2005. Almawi, W. Y., A. A. Qadi, H. Tamim, G. Ameen, A. "Prevalence of Viral Markers among First-Time Arab Bu-Ali, S. Arrayid, and M. M. Abou Jaoude. 2004. Blood Donors in Kuwait." Transfusion 45: 1973­80. "Seroprevalence of Hepatitis C Virus and Hepatitis B Amiri, Z. M., A. J. Shakib, and M. Toorchi. 2005. Virus among Dialysis Patients in Bahrain and Saudi "Seroprevalence of Hepatitis C and Risk Factors in Arabia." Transplant Proc 36: 1824­26. Haemodialysis Patients in Guilan, Islamic Republic of Al-Mazrou, Y. Y., M. S. Abouzeid, and M. H. Al-Jeffri. Iran." East Mediterr Health J 11: 372­76. 2005. "Knowledge and Attitudes of Paramedical Anonymous. 2006. Scaling Up the HIV Response toward Students in Saudi Arabia toward HIV/AIDS." Saudi Universal Access to Prevention, Treatment, Care and Med J 26: 1183­89. Support in Jordan. Summary report of the national Al-Moslih, M. I., and M. A. Al-Huraibi. 2001. "Prevalence consultation. of Hepatitis C Virus among Patients with Liver Anonymous. 2007. "Improving HIV/AIDS Response Disease in the Republic of Yemen." East Mediterr among Most at Risk Population in Sudan." Orientation Health J 7: 771­78. Workshop, 16 April 2007. Al-Mugeiren, M., F. Z. Al-Faleh, S. Ramia, S. al-Rasheed, Ansar, M. M., and A. Kooloobandi. 2002. "Prevalence of M. A. Mahmoud, and M. Al-Nasser. 1992. Hepatitis C Virus Infection in Thalassemia and "Seropositivity to Hepatitis C Virus (HCV) in Saudi Haemodialysis Patients in North Iran-Rasht." J Viral Children with Chronic Renal Failure Maintained on Hepat 9: 390­92. Haemodialysis." Ann Trop Paediatr 12: 217­19. Arafa, N., M. El Hoseiny, C. Rekacewicz, I. Bakr, S. Al-Mutairi, N., A. Joshi, O. Nour-Eldin, A. K. Sharma, I. El-Kafrawy, M. El Daly, S. Aoun, D. Marzouk, M. K. El-Adawy, and M. Rijhwani. 2007. "Clinical Patterns Mohamed, and A. Fontanet. 2005. "Changing Pattern of Sexually Transmitted Diseases, Associated of Hepatitis C Virus Spread in Rural Areas of Egypt." Sociodemographic Characteristics, and Sexual J Hepatol 43: 418­24. Practices in the Farwaniya Region of Kuwait." Int J Dermatol 46: 594­99. Araj, G. F., E. E. Kfoury-Baz, K. A. Barada, R. E. Nassif, and S. Y. Alami. 1995. "Hepatitis C Virus: Prevalence Alnaqy, A., S. Al-Harthy, G. Kaminski, and S. Al-Dhahry. in Lebanese Blood Donors and Brief Overview of the 2006. "Detection of Serum Antibodies to Hepatitis C Disease." J Med Liban 43(1): 11­6. Virus in `False-Seronegative' Blood Donors in Oman." Med Princ Pract 15: 111­13. Arbesser, C., J. R. Mose, and W. Sixl. 1987. "Serological Examinations of HIV-I Virus in Sudan." J Hyg Al-Owaish, R. A., S. Anwar, P. Sharma, and S. F. Shah. Epidemiol Microbiol Immunol 31: 480­82. 2000. "HIV/AIDS Prevalence among Male Patients in Kuwait." Saudi Med J 21: 852­59. Arthur, R. R., N. F. Hassan, M. Y. Abdallah, M. S. el- Al-Owaish, R., M. A. Moussa, S. Anwar, H. Al-Shoumer, Sharkawy, M. D. Saad, B. G. Hackbart, and I. Z. and P. Sharma. 1999. "Knowledge, Attitudes, Beliefs, Imam. 1997. "Hepatitis C Antibody Prevalence in and Practices about HIV/AIDS in Kuwait." AIDS Educ Blood Donors in Different Governorates in Egypt." Prev 11: 163­73. Trans R Soc Trop Med Hyg 91: 271­74. Alrajhi, A. A., A. Nematallah, S. Abdulwahab, and Z. Askarian, M., K. Mirzaei, and B. Cookson. 2007. Bukhary. 2002. "Human Immunodeficiency Virus "Knowledge, Attitudes, and Practice of Iranian and Tuberculosis Co-Infection in Saudi Arabia." East Dentists with regard to HIV-Related Disease." Infect Mediterr Health J 8: 749­53. Control Hosp Epidemiol 28: 83­87. Al-Serouri, A. W. 2005. "Assessment of Knowledge, Askarian, M., K. Mirzaei, and O. Assadian. 2007. Attitudes and Beliefs about HIV/AIDS among Young "Iranians' Attitudes about Possible Human Immuno- People Residing in High Risk Communities in Aden deficiency Virus Transmission in Dental Settings." Governatore, Republic of Yemen." Society for the Infect Control Hosp Epidemiol 28: 234­37. Development of Women & Children (SOUL), Aslam, M., and J. Aslam. 2001. "Seroprevalence of the Education, Health, Welfare, and United Nations Antibody to Hepatitis C in Select Groups in the Punjab Children's Fund, Yemen Country Office, HIV/AIDS Region of Pakistan." J Clin Gastroenterol 33: 407­11. Project. Aslam, M., J. Aslam, B. D. Mitchell, and K. M. Munir. Al-Serouri, A. W., M. Takioldin, H. Oshish, A. Aldobaibi, 2005. "Association between Smallpox Vaccination and A. Abdelmajed. 2002. "Knowledge, Attitudes and and Hepatitis C Antibody Positive Serology in Beliefs about HIV/AIDS in Sana'a, Yemen." East Pakistani Volunteers." J Clin Gastroenterol 39: 243­46. Mediterr Health J 8: 706­15. Assal, M. 2006. "HIV Prevalence, Knowledge, Attitude, Al-Sheyyab, M., A. Batieha, and M. El-Khateeb. 2001. Practices, and Risk Factors among Prisoners in "The Prevalence of Hepatitis B, Hepatitis C and Khartoum State, Sudan." Human Immune Deficiency Virus Markers in Multi- Ati, H. A. 2005. "HIV/AIDS/STIs Social and Geographical Transfused Patients." J Trop Pediatr 47: 239­42. Mapping of Prisoners, Tea Sellers and Commercial Altindis, M., S. Yilmaz, T. Dikengil, H. Acemoglu, and S. Sex Workers in Port Sudan Town, Red Sea State." Hosoglu. 2006. "Seroprevalence and Genotyping of Draft 2, Ockenden International, Sudan. 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: 225­28. 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: 323­27. Saudi Patients with Chronic Liver Diseases." Benjelloun, S., B. Bahbouhi, S. Sekkat, A. Bennani, Hepatogastroenterology 39: 337­39. 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: 247­55. Hepatitis C Virus among Saudi Haemodialysis Bennani, A., and K. Alami. 2006. "Surveillance sentinelle Patients." J Med Virol 35: 155­59. 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: 269­71. Hospital Karachi." J Pak Med Assoc 52: 92­94. 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: 837­38. Virus Infection as a Cause of Chronic Liver Disease in Baddoura, R., C. Haddad, and M. Germanos. 2002. Somalia." Scand J Infect Dis 25: 559­64. "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: 150­56. 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: 133­35. Am J Trop Med Hyg 47: 357­64. 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: 255­65. Trop Pediatr 41: 206­9. 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: 300­4. Networks." Int J STD AIDS 18: 486­92. 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: 274­84. of HBV and HCV among Blood Donors in Eastern Saudi Arabia, 1998­2001." Clin Lab Haematol 26: Boutayeb, H., A. Aamoum, and N. Benchemsi. 2006. 225­28. "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: 538­47. 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: 13­18. 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: 291­300. 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: 503­5. 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: 591­97. 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: 1339­52. Bibliography for Appendixes A­E 251 Burans, J. P., M. McCarthy, S. M. el Tayeb, A. el Tigani, Eftekhar, M., M.-M. Gouya, A. Feizzadeh, N. Moshtagh, J. George, R. Abu-Elyazeed, and J. N. Woody. 1990. H. Setayesh, K. Azadmanesh, and A.-R. Vassigh. "Serosurvey of Prevalence of Human Immuno- 2008. "Bio-Behavioural Survey on HIV and Its Risk deficiency Virus amongst High Risk Groups in Port Factors among Homeless Men Who Have Sex with Sudan, Sudan." East Afr Med J 67: 650­55. Men in Teharan, 2006­07." Busulwa, R. 2003. "HIV/AIDS Situation Analysis Study." Egypt MOH (Ministry of Health), and Population Conducted in Hodeidah, Taiz and Hadhramut, National AIDS Program. 2006. HIV/AIDS Biological and Republic of Yemen. Behavioral Surveillance Survey. Summary report. Butt, T., and M. S. Amin. 2008. "Seroprevalence of El-Amin, H. H., E. M. Osman, M. O. Mekki, M. B. Hepatitis B and C Infections among Young Adult Abdelraheem, M. O. Ismail, M. E. Yousif, A. M. Abass, Males in Pakistan. East Mediterr Health J 14: 791­97. H. S. El-haj, and H. K. Ammar. 2007. "Hepatitis C Candan, F., H. Alagozlu, O. Poyraz, and H. Sumer. 2002. Virus Infection in Hemodialysis Patients in Sudan: "Prevalence of Hepatitis B and C Virus Infection in Two Centers' Report." Saudi J Kidney Dis Transpl 18: Barbers in the Sivas Region of Turkey." Occup Med 101­6. (Lond) 52: 31­34. El-Gadi, S., A. Abudher, and M. Sammud. 2008. "HIV- Related Knowledge and Stigma among High School Constantine, N. T., M. F. Sheba, D. M. Watts, Z. Farid, Students in Libya." Int J STD AIDS 19: 178­83. and M. Kamal. 1990. "HIV Infection in Egypt: A Two and a Half Year Surveillance." J Trop Med Hyg 93: El-Ghazzawi, E., L. Drew, L. Hamdy, E. El-Sherbini, Sel 146­50. D. Sadek, and E. Saleh. 1995. "Intravenous Drug Addicts: A High Risk Group for Infection with Human Corwin, A. L., J. G. Olson, M. A. Omar, A. Razaki, and Immunodeficiency Virus, Hepatitis Viruses, D. M. Watts. 1991. "HIV-1 in Somalia: Prevalence Cytomegalo Virus and Bacterial Infections in and Knowledge among Prostitutes." AIDS 5: 902­4. Alexandria Egypt." J Egypt Public Health Assoc 70: Darwish, M. A., R. Faris, N. Darwish, A. Shouman, 127­50. M. Gadallah, M. S. El-Sharkawy, R. Edelman, El-Ghazzawi, E., G. Hunsmann, and J. Schneider. 1987. K. Grumbach, M. R. Rao, and J. D. Clemens. 2001. "Low Prevalence of Antibodies to HIV-1 and HTLV-I "Hepatitis C and Cirrhotic Liver Disease in the Nile in Alexandria, Egypt." AIDS Forsch 2: 639. Delta of Egypt: A Community-Based Study." Am J Trop Med Hyg 64: 147­53. El-Gilany, A. H., and S. El-Fedawy. 2006. "Bloodborne Infections among Student Voluntary Blood Donors in Darwish, M. A., T. A. Raouf, P. Rushdy, N. T. Constantine, Mansoura University, Egypt." East Mediterr Health J M. R. Rao, and R. Edelman. 1993. "Risk Factors 12: 742­48. Associated with a High Seroprevalence of Hepatitis C Virus Infection in Egyptian Blood Donors." Am J Trop El Gohary, A., A. Hassan, Z. Nooman, D. Lavanchy, Med Hyg 49: 440­47. C. Mayerat, A. El Ayat, N. Fawaz, F. Gobran, M. Ahmed, F. Kawano, et al. 1995. "High Prevalence of Hepatitis Demirturk, N., T. Demirdal, D. Toprak, M. Altindis, and C Virus among Urban and Rural Population Groups in O. C. Aktepe. 2006. "Hepatitis B and C Virus in West- Egypt." Acta Trop 59: 155­61. Central Turkey: Seroprevalence in Healthy Individuals Admitted to a University Hospital for Routine Health El Guneid, A. M., A. A. Gunaid, A. M. O'Neill, N. I. Checks." Turk J Gastroenterol 17: 267­72. Zureikat, J. C. Coleman, and I. M. Murray-Lyon. 1993. "Prevalence of Hepatitis B, C, and D Virus Markers in Dewachi, O. 2001. "HIV/AIDS Prevention through Yemeni Patients with Chronic Liver Disease." J Med Outreach to Vulnerable Populations in Beirut, Virol 40: 330­33. Lebanon: Men Who Have Sex with Other Men and HIV AIDS; A Situation Analysis in Beirut, Lebanon." Elharti, E. E., Z. A. Zidouh, M. R. Mengad, B. O. Final report, April 29, 2001. Bennani, S. A. Siwani, K. H. Khattabi, A. M. Alami, and E. R. Elaouad. 2002. "Result of HIV Sentinel Djebbi, A., O. Bahri, H. Langar, A. Sadraoui, S. Mejri, Surveillance Studies in Morocco during 2001." Int and H. Triki. 2008. "Genetic Variability of Geno- Conf AIDS: 14. type 1 Hepatitis C Virus Isolates from Tunisian El-Hazmi, M. M. 2004. "Prevalence of HBV, HCV, Haemophiliacs." New Microbiol 31: 473­80. HIV-1, 2 and HTLV-I/II Infections among Blood Djibouti National TB Programme. 2006. "TB Facts and Donors in a Teaching Hospital in the Central Region Figures of Djibouti." Responsable du PNT, Ministere of Saudi Arabia." Saudi Med J 25: 26­33. de la Santé, Republique de Djibouti. El-Maaytah, M., A. Al Kayed, M. Al Qudah, H. Al Dray, X., R. Dray-Spira, J. A. Bronstein, and D. Mattera. Ahmad, K. Al-Dabbagh, W. Jerjes, M. Al Khawalde, 2005. "Prevalences of HIV, Hepatitis B and Hepatitis C O. Abu Hammad, N. Dar Odeh, K. El-Maaytah, Y. Al in Blood Donors in the Republic of Djibouti." Med Shmailan, S. Porter, and C. Scully. 2005. "Willingness Trop (Mars) 65: 39­42. of Dentists in Jordan to Treat HIV-Infected Patients." Dupire, B., A. K. Abawi, C. Ganteaume, T. Lam, P. Truze, Oral Dis 11: 318­22. and G. Martet. 1999. "Establishment of a Blood Elmir, E., S. Nadia, B. Ouafae, M. Rajae, S. Amina, and Transfusion Center at Kabul (Afghanistan)." Sante 9: A. Rajae el. 2002. "HIV Epidemiology in Morocco: A 18­22. Nine-Year Survey (1991­1999)." Int J STD AIDS 13: Ebrahim, H. 2008. "Iranian Epidemiological Training 839­42. Programs for AIDS Prevention in Mazandaran El-Nanawy, A. A., O. F. El Azzouni, A. T. Soliman, A. E. Province." Pak J Biol Sci 11: 2109­15. Amer, R. S. Demian, and H. M. El-Sayed. 1995. 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: 341­43. 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: 209­25. 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: 135­37. 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: 115­28. Infection in Egyptian Children." World J Gastroenterol 13: 1828­32. 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: 682­84. 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: 229­37. 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. 561­69. 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: 179­84. e571­78. 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: 905­15. 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: 277­83. 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, March­April. 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: 1058­66. East Mediterr Health J 6: 1114­16. 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: 309­15. among High Secondary School Teachers and Students Gholamreza, R., S. Shahryar, K. Abbasali, J. Hamidreza, in Kassala, Sudan." East Afr Med J 73: 295­97. 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: 424­26. J Med Sci 61: 263­68. 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. 465­84. 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: 889­92. Tunisia." Bull Soc Pathol Exot 91: 177. Bibliography for Appendixes A­E 253 Gul, A., and F. Iqbal. 2003. "Prevalence of Hepatitis C in 1999. "The Prevalence of Sexually Transmitted Patients on Maintenance Haemodialysis." J Coll Pathogens in Patients Presenting to a Casablanca STD Physicians Surg Pak 13: 15­18. Clinic." Eur J Epidemiol 15: 711­15. Gul, U., A. Kilic, B. Sakizligil, S. Aksaray, S. Bilgili, O. Hermez, J., E. Aaraj, O. Dewachi, and N. Chemaly. Demirel, and C. Erinckan. 2008. "Magnitude of Unknown. "HIV/AIDS Prevention among Vulnerable Sexually Transmitted Infections among Female Sex Groups in Beirut, Lebanon." PowerPoint presentation. Workers in Turkey." J Eur Acad Dermatol Venereol 22: Hindy, A. M., E. S. Abdelhaleem, and R. H. Aly. 1995. 1123­24. "Hepatitis B and C Viruses among Egyptian Dentists." Gulcan, A., E. Gulcan, A. Toker, I. Bulut, and Y. Akcan. Egypt Dent J 41: 1217­26. 2008. "Evaluation of Risk Factors and Seroprevalence Hmaied, F., M. Ben Mamou, K. Saune-Sandres, L. Rostaing, of Hepatitis B and C in Diabetic Patients in Kutahya, A. Slim, Z. Arrouji, S. Ben Redjeb, and J. Izopet. 2006. Turkey." J Investig Med 56: 858­63. "Hepatitis C Virus Infection among Dialysis Patients Gurol, E., C. Saban, O. Oral, A. Cigdem, and A. Armagan. in Tunisia: Incidence and Molecular Evidence for 2006. "Trends in Hepatitis B and Hepatitis C Virus Nosocomial Transmission." J Med Virol 78: 185­91. among Blood Donors over 16 Years in Turkey." Eur J Hmida, S., N. Mojaat, E. Chaouchi, T. Mahjoub, B. Khlass, Epidemiol 21: 299­305. S. Abid, and K. Boukef. 1995. "HCV Antibodies in Gutbi, O. S.-A., and A. M. G. Eldin. 2006. "Women Tea- Hemodialyzed Patients in Tunisia." Pathol Biol (Paris) Sellers in Khartoum and HIV/AIDS: Surviving Against 43: 581­83. the Odds." Khartoum, Sudan. Holt, B. Y., P. Effler, W. Brady, J. Friday, E. Belay, Hachicha, J., A. Hammami, H. Masmoudi, M. Ben Hmida, K. Parker, and M. Toole. 2003. "Planning STI/HIV H. Karray, M. Kharrat, F. Kammoun, and A. Jarraya. Prevention among Refugees and Mobile Populations: 1995. "Viral Hepatitis C in Chronic Hemodialyzed Situation Assessment of Sudanese Refugees." Disasters Patients in Southern Tunisia: Prevalence and Risk 27: 1­15. Factors." Ann Med Interne (Paris) 146: 295­98. Hosseini Asl, S. K., M. Avijgan, and M. Mohamadnejad. Haidar, N. A. 2002. "Prevalence of Hepatitis B and 2004. "High Prevalence of HBV, HCV, and HIV Hepatitis C in Blood Donors and High Risk Groups in Infections: In Gypsy Population Residing in Shar-e- Hajjah, Yemen Republic." Saudi Med J 23: 1090­94. kord." Arch Iranian Med 7: 22­24. Haider, G., N. Zohra, N. Nisar, and A. A. Munir. 2009. Hosseini-Moghaddam, S. M., H. Keyvani, H. Kasiri, S. M. "Knowledge about AIDS/HIV Infection among Kazemeyni, A. Basiri, N. Aghel, and S. M. Alavian. Women Attending Obstetrics and Gynaecology Clinic 2006. "Distribution of Hepatitis C Virus Genotypes at a University Hospital." J Pak Med Assoc 59: 95­98. among Hemodialysis Patients in Tehran--A Hajiabdolbaghi, M., N. Razani, N. Karami, P. Kheirandish, Multicenter Study." J Med Virol 78: 569­73. M. Mohraz, M. Rasoolinejad, K. Arefnia, Z. Kourorian, Hsairi, M., and S. Ben Abdallah. 2007. "Analyse de la G. Rutherford, and W. McFarland. 2007. "Insights situation de vulnérabilité vis-à-vis de l'infection à VIH from a Survey of Sexual Behavior among a Group of des hommes ayant des relations sexuelles avec des At-Risk Women in Tehran, Iran, 2006." AIDS Educ hommes." For ATL MST sida NGO­Tunis Section, Prev 19: 519­30. National AIDS Programme/DSSB, UNAIDS. Final Hajiani, E., J. Hashemi, R. Masjedizadeh, A. A. Shayesteh, report, abridged version. E. Idani, and T. Rajabi. 2006. "Seroepidemiology of Hussain, S. F., M. Irfan, M. Abbasi, S. S. Anwer, Hepatitis C and Its Risk Factors in Khuzestan Province, S. Davidson, R. Haqqee, J. A. Khan, and M. Islam. South-West of Iran: A Case-Control Study." World J 2004. "Clinical Characteristics of 110 Miliary Gastroenterol 12: 4884­87. Tuberculosis Patients from a Low HIV Prevalence Haque, N., T. Zafar, H. Brahmbhatt, G. Imam, S. ul Country." Int J Tuberc Lung Dis 8: 493­99. Hassan, and S. A. Strathdee. 2004. "High-Risk Sexual Husseini, A., and N. M. Abu-Rmeileh. 2007. "HIV/AIDS- Behaviours among Drug Users in Pakistan: Related Knowledge and Attitudes of Palestinian Implications for Prevention of STDs and HIV/AIDS." Women in the Occupied Palestinian Territory." Am J Int J STD AIDS 15: 601­7. Health Behav 31: 323­34. Harakati, M. S., O. A. Abualkhair, and B. A. Al-Knawy. Hyder, A. A., and O. A. Khan. 1998. "HIV/AIDS in 2000. "Hepatitis C Virus Infection in Saudi Arab Pakistan: The Context and Magnitude of an Emerging Patients with B-Cell Non-Hodgkin's Lymphoma." Threat." J Epidemiol Community Health 52: 579­85. Saudi Med J 21: 755­58. IGAD (Intergovernmental Authority on Development). Haroon, A. 1994. "Dancers of the Night." World AIDS 11. 2006. "IGAD/World Bank Cross Border Mobile Hatira, S. A., S. Yacoub-Jemni, B. Houissa, H. Kaabi, Population Mapping Exercise." Sudan, draft report. M. Zaeir, M. Kortas, and L. Ghachem. 2000. "Hepatitis Imani, R., A. Karimi, R. Rouzbahani, and A. Rouzbahani. C Virus Antibodies in 34,130 Blood Donors in 2008. "Seroprevalence of HBV, HCV and HIV Tunisian Sahel." Tunis Med 78: 101­5. Infection among Intravenous Drug Users in Shahr-e- Hedayati-Moghaddam, M. R. 2008. "Knowledge of and Kord, Islamic Republic of Iran." East Mediterr Health J Attitudes towards HIV/AIDS in Mashhad, Islamic 14: 1136­41. Republic of Iran." East Mediterr Health J 14: 1321­32. Institut de Formation Paramédicale de Parnet. 2004. Heikel, J., S. Sekkat, F. Bouqdir, H. Rich, B. Takourt, Rapport de la réunion d'évaluation a mis-parcours de F. Radouani, N. Hda, S. Ibrahimy, and A. Benslimane. l'enquête de sero-surveillance du VIH. Juin. 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: 255­58. 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: 20­23. 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." 1997­2000." Clin Lab Haematol 23: 317­23. 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 (15­49 Years) in Lower Egypt: Blood Donors in Lebanon, 1997­2003." Am J Infect Knowledge, Attitudes and Patterns of Use." East Control 34: 241­43. Mediterr Health J 13: 1405­16. 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: 18­20. 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: 249­53. 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: 703­6. 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: 564­66. 329­32. 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: 740­44. Commercial Sex Workers at Hyderabad City, Pakistan. Karkar, A. 2007. "Hepatitis C in Dialysis Units: The Saudi J Coll Physicians Surg Pak 16: 91­93. Experience." Hemodial Int 11: 354­67. 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: 33­36. Infection in Iranian Thalassemia Major Patients." Int J Javadzadeh, H., M. Attar, and M. Taher Yavari. 2006. Lab Hematol 30: 11­16. "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: 315­22. 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: 231­33. and Tuberculosis in Central Tunisia." Tunis Med 69: Kayani, N., A. Sheikh, A. Khan, C. Mithani, and M. 349­52. 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: 8­11. 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: 349­51. Hepatitis C, and Human Immunodeficiency Virus Bibliography for Appendixes A­E 255 Infections in Children with Cancer at Diagnosis and H. Jabbari, M. Mohraz, and W. McFarland. 2009. following Therapy in Turkey." Med Pediatr Oncol 34: "Prevalence and Correlates of HIV Infection among 102­5. Male Injection Drug Users in Detention, Tehran, Khamispoor, G., and R. Tahmasebi. 1999. "Prevalence of Iran." Unpublished. HIV, HBV, HCV and Syphilis in High Risk Groups of Khokhar, N., M. L. Gill, and G. J. Malik. 2004. "General Bushehr Province (Farsi)." Iranian South Medical Seroprevalence of Hepatitis C and Hepatitis B Virus Journal 1: 59­53. Infections in Population." J Coll Physicians Surg Pak 14: Khan, A. J., S. P. Luby, F. Fikree, A. Karim, S. Obaid, 534­36. S. Dellawala, S. Mirza, T. Malik, S. Fisher-Hoch, and Kilani, B., L. Ammari, C. Marrakchi, A. Letaief, M. J. B. McCormick. 2000. "Unsafe Injections and the Chakroun, M. Ben Jemaa, H. T. Ben Aissa, F. Transmission of Hepatitis B and C in a Periurban Kanoun, and T. Ben Chaabene. 2007. Community in Pakistan." Bull World Health Organ 78: "Seroepidemiology of HCV-HIV Coinfection in 956­63. Tunisia." Tunis Med 85: 121­23. Khan, M. S., M. Jamil, S. Jan, S. Zardad, S. Sultan, and Kocabas, E., N. Aksaray, E. Alhan, A. Tanyeli, F. Koksal, A. S. Sahibzada. 2007. "Prevalence of Hepatitis `B' and and F. Yarkin. 1997a. "Hepatitis B and C Virus `C' in Orthopaedics Patients at Ayub Teaching Hospital Infections in Turkish Children with Cancer." Eur J Abbottabad." J Ayub Med Coll Abbottabad 19: 82­84. Epidemiol 13: 869­73. Khan, S. J., Q. Anjum, N. U. Khan, and F. G. Nabi. 2005. Kocabas, E., N. Aksaray, E. Alhan, F. Yarkin, F. Koksal, "Awareness about Common Diseases in Selected and Y. Kilinc. 1997b. "Hepatitis B and C Virus Female College Students of Karachi." J Pak Med Assoc Infections in Turkish Children with Haemophilia." 55: 195­98. Acta Paediatr 86: 1135­37. Khan, S., M. A. Rai, A. Khan, A. Farooqui, S. U. Kazmi, Koksal, I., K. Biberoglu, S. Biberoglu, F. Koc, Y. Ayma, F. and S. H. Ali. 2008. "Prevalence of HCV and HIV Aker, and H. Koksal. 1991. "Hepatitis C Virus Infections in 2005-Earthquake-Affected Areas of Antibodies among Risk Groups in Turkey." Infection Pakistan." BMC Infect Dis 8: 147. 19: 228­29. Khan, T. M. 1995. "Country Watch: Pakistan." AIDS STD Kose, S., A. Gurkan, F. Akman, M. Kelesoglu, and U. Health Promot Exch 7­8. Uner. 2009. "Treatment of Hepatitis C in Hemodialysis Patients Using Pegylated Interferon Alpha-2a in Khan, Z. A., I. S. Alkhalife, and S. E. Fathalla. 2004. Turkey." J Gastroenterol 44: 353­58. "Prevalence of Hepatitis C Virus among Bilharziasis Patients." Saudi Med J 25: 204­6. Kudrati, M., M. L. Plummer, and N. D. Yousif. 2008. "Children of the Sug: A Study of the Daily Lives of Khanani, R. M., A. Hafeez, S. M. Rab, and S. Rasheed. Street Children in Khartoum, Sudan, with 1990. "AIDS and HIV Associated Disorders in Intervention Recommendations." Child Abuse Negl Karachi." J Pak Med Assoc 40: 82­85. 32: 439­48. Khani, M., and M. M. Vakili. 2003. "Prevalence and Risk Kudrati, M., M. Plummer, N. Dafaalla El Hag Yousif, A. Factors of HIV, Hepatitis B Virus, and Hepatitis C Mohamed Adam Adham, W. Mohamed Osman Virus Infections in Drug Addicts among Zanjan Khalifa, A. Khogali Eltayeb, J. Mohamed Jubara, Prisoners." Arch Iranian Med 6: 1­4. V. Omujwok Apieker, S. Ali Yousif, and S. Mohamed Khattabi, H., and K. Alami. 2005. "Surveillance senti- Elnour. 2002. "Sexual Health and Risk Behaviour of nelle du VIH, Résultats 2004 et tendance de la séro- Full-Time Street Children in Khartoum, Sudan." prévalence du VIH." Morocco Ministry of Health, International Conference on AIDS, Barcelona, Spain, UNAIDS. July 7­12; 14: Abstract no. LbOr04. Khattak, M. F., N. Salamat, F. A. Bhatti, and T. Z. Kulane, A., A. A. Hilowle, A. A. Hassan, and R. Qureshi. 2002. "Seroprevalence of Hepatitis B, C and Thorstensson. 2000. "Prevalence of HIV, HTLV I/II HIV in Blood Donors in Northern Pakistan." J Pak Med and HBV Infections during Long Lasting Civil Conflicts Assoc 52: 398­402. in Somalia." Int Conf AIDS: 13. Khattak, M. N., S. Akhtar, S. Mahmud, and T. M. Kumar, R. M., P. M. Frossad, and P. F. Hughes. 1997. Roshan. 2008. "Factors Influencing Hepatitis C Virus "Seroprevalence and Mother-to-Infant Transmission Sero-Prevalence among Blood Donors in North West of Hepatitis C in Asymptomatic Egyptian Women." Pakistan." J Public Health Policy 29: 207­25. Eur J Obstet Gynecol Reprod Biol 75: 177­82. Khawaja, Z. A., L. Gibney, A. J. Ahmed, and S. H. Kuo, I., S. ul-Hasan, N. Galai, D. L. Thomas, T. Zafar, M. A. Vermund. 1997. "HIV/AIDS and Its Risk Factors in Ahmed, and S. A. Strathdee. 2006. "High HCV Pakistan." AIDS 11: 843­48. Seroprevalence and HIV Drug Use Risk Behaviors among Khedmat, H., F. Fallahian, H. Abolghasemi, S. M. Injection Drug Users in Pakistan." Harm Reduct J 3: 26. Alavian, B. Hajibeigi, S. M. Miri, and A. M. Jafari. Kuwait National TB Programme. 2006. "TB Facts and 2007. "Seroepidemiologic Study of Hepatitis B Virus, Figures of Kuwait." Kuwait, Department of Public Hepatitis C Virus, Human Immunodeficiency Virus Health, Ministry of Health. and Syphilis Infections in Iranian Blood Donors." Pak Langar, H., H. Triki, E. Gouider, O. Bahri, A. Djebbi, J Biol Sci 10: 4461­66. A. Sadraoui, A. Hafsia, and R. Hafsia. 2005. "Blood- Kheirandish, P., S. SeyedAlinaghi, M. Hosseini, M. Transmitted Viral Infections among Haemophiliacs in Jahani, H. Shirzad, M. Foroughi, M. Seyed Ahmadian, Tunisia." Transfusion clinique et biologique 12: 301­5. 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: 92­99. Sarcoma Herpesvirus and HIV-1 Seroprevalences in Lebanon National AIDS Control Program. 1996. "General Prostitutes in Djibouti." J Med Virol 68: 164­67. 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: 1105­10. 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: 292­97. Review and Meta-Analysis." Int J Cancer 124: 690­97. 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: 534­36. 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: 18­20. That of Genital Neisseria Gonorrhoeae Infection." Sex Transm Dis 7: 6­10. 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." 177­82. ------. 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: 313­32. 2006­7." 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 69­80. 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: 185­93. 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: 23­25. "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: 469­73. 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: 319­23. 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: 404­418. 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: CR797­800. of Hepatitis C in Egypt." Hepatology 42: 683­87. Bibliography for Appendixes A­E 257 Mohamed, M. K., M. H. Hussein, A. A. Massoud, M. M. Nafeh, M. A., A. Medhat, M. Shehata, N. N. Mikhail, Rakhaa, S. Shoeir, A. A. Aoun, and M. Aboul Naser. Y. Swifee, M. Abdel-Hamid, S. Watts, A. D. Fix, G. T. 1996a. "Study of the Risk Factors for Viral Hepatitis C Strickland, W. Anwar, and I. Sallam. 2000. "Hepatitis Infection among Egyptians Applying for Work C in a Community in Upper Egypt: I. Cross-Sectional Abroad." J Egypt Public Health Assoc 71: 113­47. Survey." Am J Trop Med Hyg 63: 236­41. Mohamed, M. K., L. S. Magder, M. Abdel-Hamid, Najmi, R. S. 1998. "Awareness of Health Care Personnel M. El-Daly, N. N. Mikhail, F. Abdel-Aziz, A. Medhat, about Preventive Aspects of HIV Infection/AIDS and V. Thiers, and G. T. Strickland. 2006. "Transmission Their Practices and Attitudes concerning Such of Hepatitis C Virus between Parents and Children." Patients." J Pak Med Assoc 48: 367­70. Am J Trop Med Hyg 75: 16­20. Nakhaee, F. H. 2002. "Prisoners' Knowledge of HIV/ Mohamed, M. K., M. Rakhaa, S. Shoeir, and M. Saber. AIDS and Its Prevention in Kerman, Islamic Republic 1996b. "Viral Hepatitis C Infection among Egyptians of Iran." East Mediterr Health J 8: 725­31. the Magnitude of the Problem: Epidemiological and Nakhaie, S., and E. Talachian. 2003. "Prevalence and Laboratory Approach." J Egypt Public Health Assoc 71: Characteristic of Liver Involvement in Thalassemia 79­111. Patients with HCV in Ali-Asghar Children Hospital, Mohammad Alizadeh, A. H., S. M. Alavian, K. Jafari, and Tehran, Iran (Farsi)." Journal of Iranian University N. Yazdi. 2003. "Prevalence of Hbs Ag, Hc Ab & Hiv Medical Science 37: 799­806. Ab in the Addict Prisoners of Hammadan Prison (Iran, Nassirimanesh, B. 2002. "Proceedings of the Abstract for 1998)." Journal of Research in Medical Sciences 7: 311­13. the Fourth National Harm Reduction Conference." Mohammadi, M. R., K. Mohammad, F. K. Farahani, Seattle, USA. S. Alikhani, M. Zare, F. R. Tehrani, A. Ramezankhani, NEJM (New England Journal of Medicine). 2008. "Violence- and F. Alaeddini. 2006. "Reproductive Knowledge, Related Mortality in Iraq from 2002­2006." N Engl J Attitudes and Behavior among Adolescent Males in Med 359: 431­34. Tehran, Iran." Int Fam Plan Perspect 32: 35­44. Njoh, J., and S. Zimmo. 1997. "Prevalence of Antibodies Mohsen, A. M. 1998. "Assessment and Upgrading of to Hepatitis C Virus in Drug-Dependent Patients in Knowledge and Attitudes among Nurses and Jeddah, Saudi Arabia" East Afr Med J 74: 89­91. University Graduates towards AIDS." J Egypt Public Health Assoc 73: 433­48. Nobakht, Haghighi A., M. R. Zali, and A. Nowroozi. 2001. "Hepatitis C Antibody and Related Risk Factors Montazeri, A. 2005. "AIDS Knowledge and Attitudes in in Hemodialysis Patients in Iran. J Am Soc Nephrology Iran: Results from a Population-Based Survey in 12: 233A. Tehran." Patient Educ Couns 57: 199­203. NSNAC (New Sudan AIDS Council), and UNAIDS Morocco MOH (Ministry of Health). 2007. Surveillance (United Nations Joint Program on HIV/AIDS). 2006. sentinelle du VIH, résultats 2006 et tendances de la séro- HIV/AIDS Integrated Report South Sudan, 2004­2005. prévalence du VIH. With United Nations General Assembly Special Moukeh, G., R. Yacoub, F. Fahdi, S. Rastam, and S. Session on HIV/AIDS Declaration of Commitment. Albitar. 2009. "Epidemiology of Hemodialysis Patients in Aleppo City." Saudi J Kidney Dis Transpl 20: 140­46. Nur, Y. A., J. Groen, A. M. Elmi, A. Ott, and A. D. Osterhaus. 2000. "Prevalence of Serum Antibodies Mudawi, H. M., H. M. Smith, S. A. Rahoud, I. A. against Bloodborne and Sexually Transmitted Agents Fletcher, A. M. Babikir, O. K. Saeed, and S. S. Fedail. in Selected Groups in Somalia." Epidemiol Infect 124: 2007. "Epidemiology of HCV Infection in Gezira State 137­41. of Central Sudan." J Med Virol 79: 383­85. O'Grady, M. 2004. WFP Consultant Visit to Djibouti Mujeeb, S. A., K. Aamir, and K. Mehmood. 2006. Report, 30 July. "Seroprevalence of HBV, HCV and HIV Infections among College Going First Time Voluntary Blood Ocak, S., N. Duran, H. Kaya, and I. Emir. 2006. Donors." J Pak Med Assoc 56: S24­25. "Seroprevalence of Hepatitis C in Patients with Type 2 Diabetes Mellitus and Non-Diabetic on Mujeeb, S. A., and A. Hafeez. 1993. "Prevalence and Haemodialysis." Int J Clin Pract 60: 670­74. Pattern of HIV Infection in Karachi." J Pak Med Assoc 43: 2­4. Othman, B. M., and F. S. Monem. 2001. "Prevalence of Hepatitis C Virus Antibodies among Health Care Mujeeb, S. A., Y. Khatri, and R. Khanani. 1998. Workers in Damascus, Syria." Saudi Med J 22: "Frequency of Parenteral Exposure and 603­5. Seroprevalence of HBV, HCV, and HIV among Operation Room Personnel." J Hosp Infect 38: 133­37. ------. 2002. "Prevalence of Hepatitis C Virus Antibodies among Intravenous Drug Abusers and Prostitutes in Mujeeb, S. A., and M. S. Pearce. 2008. "Temporal Trends Damascus, Syria." Saudi Med J 23: 393­95. in Hepatitis B and C Infection in Family Blood Donors from Interior Sindh, Pakistan." BMC Infect Dis 8: 43. Ozsoy, M. F., O. Oncul, S. Cavuslu, A. Erdemoglu, G. Emekdas, and A. Pahsa. 2003. "Seroprevalences of Mutlu, B., M. Meric, and A. Willke. 2004. "Seroprevalence Hepatitis B and C among Health Care Workers in of Hepatitis B and C Virus, Human Immunodeficiency Turkey." J Viral Hepat 10: 150­56. Virus and Syphilis in the Blood Donors." Mikrobiyol Bul 38: 445­48. Pakistan AIDS Prevention Society. 1992­93. "Project Mutter, R. C., R. M. Grimes, and D. Labarthe. 1994. Report on Sexual Behavior/Practices of International "Evidence of Intraprison Spread of HIV Infection." Travellers to Areas with High Prevalence of HIV Arch Intern Med 154: 793­95. Infection." Karachi, Pakistan. 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: 239­44. ------. 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 2004­5. International Journal of Drug Policy 15: 151­55. ------. 2006­7. 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: 8­11. ------. 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 Association­European Dialysis and Transplant Parker, S. P., H. I. Khan, and W. D. Cubitt. 1999. Association; ERA-EDTA): 2055­56. "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: 2061­63. Immunol Infect 41: 4­8. Petro-Nustas, W. 2000. "University Students' Knowledge Raja, Y., and A. Farhan. 2005. "Knowledge and Attitude of AIDS." Int J Nurs Stud 37: 423­33. 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 118­25. 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: 463­66. 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: 179­82. Chancroid and Haemophilus Ducreyi in Nairobi, Raziq, F., N. Alam, and L. Ali. 1993. "Serosurveillance of Kenya." Lancet 2: 1293­95. 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: 229­33. East Mediterr Health J 10: 72­81. 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: S60­65. 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: 493­95. 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: 711­12. 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: 269­73. transfused Patients in Iran: A Review." Transfus Med Quinti, I., D. el-Salman, M. K. Monier, B. G. Hackbart, 17: 425­33. 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: 2017­23. Vox Sang 67: 100. Bibliography for Appendixes A­E 259 Rizvi, T. J., and H. Fatima. 2003. "Frequency of Hepatitis C "Prevalence of Anti-HCV Antibodies and in Obstetric Cases." J Coll Physicians Surg Pak 13: 688­90. Seroconversion Incidence in Five Haemodialysis Rodier, G. R., J. P. Sevre, G. Binson, G. C. Gray, S. Said, Units in Morocco." Nephrol Ther 4: 105­10. and P. Gravier. 1993. "Clinical Features Associated Selcuk, H., M. Kanbay, M. Korkmaz, G. Gur, A. Akcay, with HIV-1 Infection in Adult Patients Diagnosed H. Arslan, N. Ozdemir, U. Yilmaz, and S. Boyacioglu. with Tuberculosis in Djibouti, Horn of Africa." Trans 2006. "Distribution of HCV Genotypes in Patients R Soc Trop Med Hyg 87: 676­77. with End-Stage Renal Disease according to Type of Ryan, C. A., A. Zidouh, L. E. Manhart, R. Selka, M. Xia, Dialysis Treatment." Dig Dis Sci 51: 1420­25. M. Moloney-Kitts, J. Mahjour, M. Krone, B. N. Sellami, A., M. Kharfi, S. Youssef, M. Zghal, B. Fazaa, Courtois, G. Dallabetta, and K. K. Holmes. 1998. I. Mokhtar, and M. R. Kamoun. 2003. "Epidemiologic "Reproductive Tract Infections in Primary Healthcare, Profile of Sexually Transmitted Diseases (STD) Family Planning, and Dermatovenereology Clinics: through a Specialized Consultation of STD." Tunis Evaluation of Syndromic Management in Morocco." Med 81: 162­66. Sex Transm Infect 74 Suppl 1: S95­105. Semnani, S., G. Roshandel, N. Abdolahi, S. Besharat, Sakarya, S., S. Oncu, B. Ozturk, and S. Oncu. 2004. A. A. Keshtkar, H. Joshaghani, A. Moradi, K. Kalavi, "Effect of Preventive Applications on Prevalence of A. Jabbari, M. J. Kabir, S. A. Hosseini, S. M. Sedaqat, Hepatitis B Virus and Hepatitis C Virus Infections in A. Danesh, and D. Roshandel. 2007. "Hepatitis B/C West Turkey." Saudi Med J 25: 1070­72. Virus Co-Infection in Iran: A Seroepidemiological Study." Turk J Gastroenterol 18: 20­21. Salama, I. I., N. K. Kotb, S. A. Hemeda, and F. Zaki. 1998. "HIV/AIDS Knowledge and Attitudes among Shaikh, F, D., S. A. Khan, M. W. Ross, and R. M. Grimes. Alcohol and Drug Abusers in Egypt." J Egypt Public 2007. "Knowledge and Attitudes of Pakistani Medical Health Assoc 73: 479­500. Students towards HIV-Positive and/or AIDS Patients." Psychol Health Med 12: 7­17. Saleh, E., W. McFarland, G. Rutherford, J. Mandel, M. El-Shazaly, and T. Coates. 2000. "Sentinel Shaikh, M. A., and S. Assad. 2001. "Adolescent's Surveillance for HIV and Markers for High Risk Knowledge about AIDS--Perspective from Behaviors among STD Clinic Attendees in Alexandria, Islamabad." J Pak Med Assoc 51: 194­95. Egypt." XIII International AIDS Conference, Durban, Shama, M., L. E. Fiala, and M. A. Abbas. 2002. "HIV/ South Africa, Poster MoPeC2398. AIDS Perceptions and Risky Behaviors in Squatter Saleh, M. G., L. M. Pereira, C. J. Tibbs, M. Ziu, M. O. al- Areas in Cairo, Egypt." J Egypt Public Health Assoc 77: Fituri, R. Williams, and I. G. McFarlane. 1994. "High 173­200. Prevalence of Hepatitis C Virus in the Normal Libyan Sharifi-Mood, B., R. Alavi-Naini, M. Salehi, M. Hashemi, Population." Trans R Soc Trop Med Hyg 88: 292­94. and F. Rakhshani. 2006. "Spectrum of Clinical Disease Sallam, S. A., A. A. Mahfouz, W. Alakija, and R. A. al- in a Series of Hospitalized HIV-Infected Patients from Erian. 1995. "Continuing Medical Education Needs Southeast of Iran." Saudi Med J 27: 1362­66. regarding AIDS among Egyptian Physicians in Sharifi-Mood, B., P. Eshghi, E. Sanei-Moghaddam, and Alexandria, Egypt and in the Asir Region, Saudi M. Hashemi. 2007. "Hepatitis B and C Virus Infections Arabia." AIDS Care 7: 49­54. in Patients with Hemophilia in Zahedan, Southeast Samimi-Rad, K., and B. Shahbaz. 2007. "Hepatitis C Iran." Saudi Med J 28: 1516­19. Virus Genotypes among Patients with Thalassemia Shebl, F. M., S. S. El-Kamary, D. A. Saleh, M. Abdel- and Inherited Bleeding Disorders in Markazi Province, Hamid, N. Mikhail, A. Allam, H. El-Arabi, I. Elhenawy, Iran." Haemophilia 13: 156­63. S. El-Kafrawy, M. El-Daly, S. Selim, A. A. El-Wahab, Savaser, S. 2003. "Knowledge and Attitudes of High M. Mostafa, S. Sharaf, M. Hashem, S. Heyward, O. C. School Students about AIDS: A Turkish Perspective." Stine, L. S. Magder, S. Stoszek, and G. T. Strickland. Public Health Nurs 20: 71­79. 2009. "Prospective Cohort Study of Mother-to-Infant Infection and Clearance of Hepatitis C in Rural Saxena, A. K., and B. R. Panhotra. 2004. "The Egyptian Villages." J Med Virol 81: 1024­31. Vulnerability of Middle-Aged and Elderly Patients to Hepatitis C Virus Infection in a High-Prevalence Sheikh, N. S., A. S. Sheikh, Rafi-u-Shan, and A. A. Sheikh. Hospital-Based Hemodialysis Setting." J Am Geriatr Soc 2003. "Awareness of HIV and AIDS among Fishermen 52: 242­46. in Coastal Areas of Balochistan." J Coll Physicians Surg Pak 13: 192­94. Schroeter, A. L., R. H. Turner, J. B. Lucas, and W. J. Brown. 1971. "Therapy for Incubating Syphilis: Shemer-Avni, Y., Z. el Astal, O. Kemper, K. J. el Najjar, Effectiveness of Gonorrhea Treatment." JAMA 218: A. Yaari, N. Hanuka, M. Margalith, and E. Sikuler. 711­13. 1998. "Hepatitis C Virus Infection and Genotypes in Southern Israel and the Gaza Strip." J Med Virol 56: Scott, D. A., A. L. Corwin, N. T. Constantine, M. A. 230­33. Omar, A. Guled, M. Yusef, C. R. Roberts, and D. M. Watts. 1991. "Low Prevalence of Human Sherafat-Kazemzadeh, R., S. Shahraz, H. Mohaghegh- Immunodeficiency Virus-1 (HIV-1), HIV-2, and Shalmani, T. Ghaziani, L. Feghahati, Z. Mohammad- Human T Cell Lymphotropic Virus-1 Infection in Reza, and M. Mohraz. 2003. "Iranian Persons Living Somalia." American Journal of Tropical Medicine and with HIV/AIDS Unveil the Epidemic of Stigma: An Hygiene 45: 653. Overview of Patients' Attitudes towards the Disease and Community in First GIPA Gathering in Tehran." Sekkat, S., N. Kamal, B. Benali, H. Fellah, K. Amazian, Archives of Iranian Medicine 6. A. Bourquia, A. El Kholti, and A. Benslimane. 2008. 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: 307­17. "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: 562­65. 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: S81­86. in Rural Pregnant Egyptian Women." Trans R Soc Trop Shrestha, P. N. 1996. "HIV/AIDS Surveillance in the Med Hyg 100: 102­7. Eastern Mediterranean Region." Eastern Mediterranean Sudan Government of National Unity. 2007. United Health Journal 2: 82­89. 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: 200­2. 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: 133­37. 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 459­64. Blood Donors in Pakistan: A Ten-Year Experience." SNAP (Sudan National AIDS Programme). 2006. "HIV Int J Infect Dis 11: 407­12. 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: 283­91. 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 2004­2005 (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: 821­24. 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: 220­24. 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: 29­5. 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: 191­95. 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: 111­14. 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: 536­39. 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. Bibliography for Appendixes A­E 261 Taziki, O., and F. Espahbodi. 2008. "Prevalence of ------. 2006­7b. HIV Sentinel Surveillance among Conflict Hepatitis C Virus Infection in Hemodialysis Patients." Affected Populations. Kakuma Refugee Camp-- Saudi J Kidney Dis Transpl 19: 475­78. Refugees and Host Nationals, Great Lakes Initiative Tehrani, F. R., and H. Malek-Afzalip. 2008. "Knowledge, on HIV/AIDS. Attitudes and Practices concerning HIV/AIDS ------. 2007. "HIV Behavioural Surveillance Survey among Iranian At-Risk Sub-Populations." Eastern Juba Municipality, South Sudan." United Nations Mediterranean Health Journal 14. High Commissioner for Refugees. Tekay, F., and E. Ozbek. 2006. "Short Communication: Unknown. 2006. "HIV Risk among Heroin and Injecting Hepatitis B, Hepatitis C and Human Immuno- Drug Users in Muscat, Oman." Quantitative Survey. deficiency Virus Seropositivities in Women Admitted Preliminary Data. to Sanliurfa Gynecology and Obstetrics Hospital." Unknown. "Rapport de l'enquête nationale de séro- Mikrobiyol Bul 40: 369­73. surveillance sentinelle du VIH et de la syphilis en Todd, C. S., A. M. Abed, S. A. Strathdee, P. T. Scott, B. A. Algérie 2004­2005." Botros, N. Safi, and K. C. Earhart. 2007. "HIV, Unknown. "Statut de la réponse nationale: Hepatitis C, and Hepatitis B Infections and Associated Caractéristiques de l'épidémie des IST/VIH/SIDA." Risk Behavior in Injection Drug Users, Kabul, Algeria. Afghanistan." Emerg Infect Dis 13: 1327­31. UNODCP (United Nations Office for Drug Control and Todd, C. S., M. Ahmadzai, F. Atiqzai, S. Miller, J. M. Crime Prevention), and UNAIDS (UN Joint Programme Smith, S. A. Ghazanfar, and S. A. Strathdee. 2008. on HIV/AIDS). 1999. "Baseline Study of the Relationship "Seroprevalence and Correlates of HIV, Syphilis, and between Injecting Drug Use, HIV and Hepatitis C Hepatitis B and C Virus among Intrapartum Patients among Male Injecting Drug Users in Lahore." in Kabul, Afghanistan." BMC Infect Dis 8: 119. Vahdani, P., S. M. Hosseini-Moghaddam, L. Gachkar, Todd, C. S., M. Ahmadzai, F. Atiqzai, J. M. Smith, S. and K. Sharafi. 2006. "Prevalence of Hepatitis B, Miller, P. Azfar, H. Siddiqui, S. A. Ghazanfar, and S. Hepatitis C, Human Immunodeficiency Virus, and A. Strathdee. 2009. "Prevalence and Correlates of Syphilis among Street Children Residing in Southern HIV, Syphilis, and Hepatitis Knowledge among Tehran, Iran." Arch Iran Med 9: 153­55. Intrapartum Patients and Health Care Providers in Kabul, Afghanistan." AIDS Care 21: 109­17. van Egmond, K., A. J. Naeem, H. Verstraelen, M. Bosmans, P. Claeys, and M. Temmerman. 2004. Tompkins, M., L. Smith, K. Jones, and S. Swindells. "Reproductive Health in Afghanistan: Results of a 2006. "HIV Education Needs among Sudanese Knowledge, Attitudes and Practices Survey among Immigrants and Refugees in the Midwestern United Afghan Women in Kabul." Disasters 28: 269­82. States." AIDS Behav 10: 319­23. Waked, I. A., S. M. Saleh, M. S. Moustafa, A. A. Raouf, Torabi, S. A., K. Abed-Ashtiani, R. Dehkhoda, A. N. D. L. Thomas, and G. T. Strickland. 1995. "High Moghadam, M. K. Bahram, R. Dolatkhah, J. Babaei, Prevalence of Hepatitis C in Egyptian Patients with and N. Taheri. 2006. "Prevalence of Hepatitis B, C and Chronic Liver Disease." Gut 37: 105­7. HIV in Hemophiliac Patients of East Azerbaijan in 2004." Blood 2: 291­99. Watts, D. M., N. T. Constantine, M. F. Sheba, M. Kamal, J. D. Callahan, and M. E. Kilpatrick. 1993. "Prevalence Triki, H., N. Said, A. Ben Salah, A. Arrouji, F. Ben Ahmed, of HIV Infection and AIDS in Egypt over Four Years A. Bouguerra, S. Hmida, R. Dhahri, and K. Dellagi. of Surveillance (1986­1990)." J Trop Med Hyg 96: 1997. "Seroepidemiology of Hepatitis B, C and Delta 113­17. Viruses in Tunisia." Trans R Soc Trop Med Hyg 91: 11­14. Watts, D. M., A. L. Corwin, M. A. Omar, and K. C. UNAIDS (United Nations Joint Programme on HIV/ Hyams. 1994. "Low Risk of Sexual Transmission of AIDS). 2006. "Epidemiological Fact Sheets on HIV/ Hepatitis C Virus in Somalia." Trans R Soc Trop Med AIDS and Sexually Transmitted Diseases." Somalia. Hyg 88: 55­56. ------. 2007a. AIDS Epidemic Update. Geneva. http:// WHO (World Health Organization). 2002. "HIV/AIDS www.unaids.org. Epidemiological Surveillance Report for the WHO ------. 2007b. UNAIDS/WHO Global HIV/AIDS Online African Region 2002 Update." Database. ------. 2004. The 2004 First National Second Generation ------. 2007c. "Key Findings on HIV Status in the West HIV/AIDS/STI Sentinel Surveillance Survey, Somalia: A Bank and Gaza." Working document, Regional Technical Report. Support Team for the Middle East and North Africa. ------. 2005. "Summary Country Profile for HIV/AIDS ------. 2008. "Notes on AIDS in the Middle East and Treatment Scale-Up." Djibouti. North Africa." RST MENA. WHO/EMRO (Eastern Mediterranean Region Office). UNAIDS, and WHO (World Health Organization). 2005. 2000. "Presentation of WHO Somalia's Experience in AIDS Epidemic Update 2005. Geneva. Supporting the National Response." Somalia. Regional Ungan, M., and H. Yaman. 2003. "AIDS Knowledge and Consultation towards Improving HIV/AIDS & STD Educational Needs of Technical University Students Surveillance in the Countries of EMRO, Beirut, in Turkey." Patient Educ Couns 51: 163­67. Lebanon, Oct 30­Nov 2. UNHCR. 2006­7a. HIV Sentinel Surveillance among ------. 2004. "Best Practice in HIV/AIDS Prevention and Antenatal Clients and STI Patients. Dadaab Refugee Care for Injecting Drug Abusers: The Triangular Clinic Camps, Kenya. in Kermanshah, Islamic Republic of Iran." 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: 729­35. ------. 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: 1004­10. 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: 27­30. 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: 51­56. ------. 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/ 394­98. 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: 211­16. ------. 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: 115­19. ------. 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: 709­16. 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: 217­22. in a Cohort of Female University Students." Am Zidouh, A. Unknown. "VIH/SIDA et infections sexuelle- J Epidemiol 157: 218­26. ment transmissibles: connaissance et attitudes." Winter, J. 1996. "Where the Imams Play Their Part." AIDS Anal Afr 6: 1­2. Bibliography for Appendixes A­E 263 Index Boxes, figures, and tables are indicated by b, f, and t, respectively. A Africa. See HIV/AIDS in MENA region; abortions, unsafe, 169, 170f sub-Saharan Africa abuse AIDs in MENA. See HIV/AIDS in MENA region of FSWs, 43, 46 alcohol consumption by FSWs and their of migrant women, 134 clients, 49 of prisoners, 125 Algeria of refugee women, 141b civil society organizations and NGOs in, 216 of street children, 138­39 condoms, access to, 203 of women in general population, 70 as covered country, 6 Afghanistan FSWs in, 44t, 168, 202, 229t ART in, 207, 208 general population and HIV in, 66t, 68t, availability of drugs in, 16 69­70, 72, 73 condom use in, 102t, 103t HCV in different population groups, 232t as covered country, 6 HPV and cervical cancer in, 157t, 158f, 159t emergency situations in, 133 IDUs in, 11, 12t, 15t, 18t, 21, 22t, 124, 229t FSWs in, 47, 48, 50, 51, 53, 202 marriage in, 128 general population and HIV in, 66t, 68t, 70 molecular epidemiology in, 92, 93 HCV in different population groups, 232t MSM in, 201, 229t HPV and cervical cancer in, 157t overlapping risks in, 206 IDUs in, 11, 12t, 14t, 15t, 16, 17, 18t, 21, 22t, 123, PLHIV, associations of, 206 124, 135, 137, 200, 201 PLHIV, estimated numbers of, 221t knowledge of HIV/AIDS in, 109, 112, 113, polygamy in, 72 239t, 242t pregnant women, prevalence of HIV migrant population, 133, 135, 136 among, 229t molecular epidemiology in, 93 prevention efforts in, 201, 202 MSM in, 34 prisoners in, 121t, 124 origins and evolution of HIV in, 180 response programs, expanding coverage of, 205 overlapping risks in, 206 status of current epidemic in, 184t parenteral transmission other than IDU, 88 STIs/STDs, 163t, 167t, 168, 226t, 229t PLHIV, estimated numbers of, 221t TB and HIV in, 228t, 229t potential bridging populations in, 59, 60 transmission modes in, 86t prevention efforts, 209 VCT services in, 204, 226t prevention efforts in, 200, 201, 202, 207 women, premarital sex as leading cause prisoners in, 121t, 124 of suicide of, 73 refugees and IDPs, 136, 137, 138 anal sex status of current epidemic in, 184t FSWs, 48, 50, 52, 54 STIs/STDs, 163t, 165, 209 MSM, 32, 33, 34, 35, 37, 39 TB and HIV in, 228t as transmission mode, 85 vulnerable populations in, 189 youth and HIV, 128 youth and HIV in, 129, 132 anemia, hemolytic, 179 265 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, 82­84, 83f barbers, HCV prevalence among, 91 FSWs, 47 behavioral surveillance, increasing and expanding, general population, prevalence of HIV in, 65, 213­14 66­67t, 71, 72 bibliographies, 8­10 HSV-2 incidence, 152, 154 condom use, 113­18 migrants, 134 current status and future potential, 191­97 point-prevalence surveys, 229­32t epidemiological factors, 94­100 refugees and IDPs, 138 FSWs, 54­58 studies and surveys, 181 general population and HIV, 75­80 antiretroviral therapy (ART), 200, 203, 207­9, 208f, IDUs, 25­29 208t, 214 knowledge of HIV/AIDS, 113­18 antischistosomal therapy, 89 MSM, 39­41 Ar-Razi psychiatric hospital, Morocco, 201 potential bridging populations, 62­63 Arab Republic of Egypt. See Egypt, Arab Republic of proxy markers of risk behavior, 170­78 armed forces, as potential bridging population. See responses to HIV in MENA, 210­12 potential bridging populations strategic recommendations, 218­19 ART (antiretroviral therapy), 200, 203, 207­9, 208f, vulnerable populations, 141­49 208t, 214 blood and blood products Asia. See also East Asia and Pacific; Eastern Europe case notification surveillance reports, 82­84, 83f and Central Asia; South Asia general population, prevalence of HIV in, 65, FSWs, 52 68­69t 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, 179­81 concentrated in, 5 parenteral transmission other than IDU, youth and HIV in, 132 88­92, 90t Association Tunisienne de Lutte contre le SIDA safety and screening programs, 180, 207 (ATLS), 202 STIs/STDs, 165 attitudes toward PLHIV, 110­11, 113, 245­47t as transmission mode, 86­87t 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 207­9, 208t MSM in, 229t Caribbean. See Latin America and Caribbean origins and evolution of HIV in, 179 case notification surveillance reports, 82­84, 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, 129­31 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, 69­70, 72, 132, 156­62, 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, 182­83 China, truck driver network in, 61 vulnerable populations, 188­89 chlamydia, 162­69, 167­68t, 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, 5­6 female genital mutilation, 74 divorced women, sexual risk behaviors of, 70, 71 male, 4, 54, 62, 73­75, 160, 187, 190 Djibouti civil society organizations, 201, 205­7, 215­16 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, 3­6, 4­6f, 182­85, 185f 70, 74 condom use, 101­9 HCV in different population groups, 232t accessibility of condoms, 101­8, 203­4 HPV and cervical cancer in, 157t actual condom use, 101, 103­8t, 108 HSV-2 in, 153t bibliography, 113­18 IDUs in, 185, 229t conclusions regarding, 108­9 knowledge of HIV/AIDS in, 109­10, 131, 239t, 244t by FSWs, 50­51, 101, 108 molecular epidemiology in, 92, 93 general knowledge regarding, 101­9, 102­3t MSM in, 229t in general population, 70 origins and evolution of HIV in, 181 by IDUs, 21, 22­24t PLHIV, associations of, 206 by MSM, 36­37, 101, 108 PLHIV, estimated numbers of, 221t prevention programs, 202, 203­4 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, 130­31 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, 5­6 TB and HIV in, 228t, 229t as protective factors, 187­88 typology of disease in, 183 status of HIV in MENA and, 2­3 unsafe abortions in, 169 vulnerability due to cultural change, 2 VCT clinics and attendees, 81, 204, 226t cupping, 89 youth and HIV in, 129­30, 131 current status and future potential, 179­97 domestic violence. See abuse bibliography, 191­97 drug resistance monitoring, 209 dynamics of current disease in conceptual framework, 185f E expansion of HIV in MENA, 189­91, 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, 179­82 unsafe abortions in, 170f overlap among priority groups, 188f Eastern Europe and Central Asia. See also Asia prevalence of HIV, 186­87 HSV-2 in, 155t progress in controlling, 186 IDUs, prevalence of, 14 protective factors, 187­88 truck driver network, 61 response to epidemic, 199­212. 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, 70­71 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), 43­58 female circumcision/genital mutilation in, 74 abuse of, 43, 46 FSWs in, 44t, 47, 51, 52, 53, 202, 229­30t anal and oral sex, 48, 50, 52, 54 general population and HIV in, 68t, 71­72, bibliography, 54­58 73, 74 case notification surveillance reports, 82­84, 83f HCV in different population groups, 232­33t clients of, 47­48, 61, 62 HPV and cervical cancer in, 157t, 158, 159t, 160 conclusions regarding, 53­54 HSV-2 in, 152, 153t condom use, 50­51, 101, 108 IDUs in, 12t, 14t, 15­16, 15t, 17, 18t, 20, 21, 22t, dynamics of current epidemic and, 185f 52, 111, 124, 201, 204, 229­30t frequency of sexual contact/number of partners, intergenerational marriage in, 127 48­49, 61, 62 knowledge of HIV/AIDS in, 109, 110, 111, 112, future expansion of HIV among, 190­91 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, 229­30t HPV and cervical cancer, 69, 70, 159, 160f nontraditional marriages in, 71­72 HSV-2 incidence, 152, 155 origins and evolution of HIV in, 179 IDUs and, 20­21, 22­24t, 25, 49, 53­53, 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, 49­50 229­30t pimps, 45, 47 prevalence of HIV in, 180, 224t potential bridging populations and, 59­62 prevention efforts in, 201, 202, 204, 209, 210 practices of, 46­47 prisoners in, 121t, 124 prevalence of, 47 status of current epidemic in, 184t prevalence of HIV among, 43, 44­45t, 181, 187, STIs/STDs, 129, 163t, 166t, 167t, 169, 209, 210, 229­32t 226t, 229­30t prevention programs for, 202 street children in, 139 refugees and IDPs, 48, 141b TB and HIV in, 229­30t risk behaviors of, 48­53 transmission modes in, 86t sexual trafficking in, 46 youth and HIV in, 126, 127, 128, 129, social, economic, and political factors affecting, 130, 131 43­46 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, 51­52, 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, 85­87, 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, 52­53, 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 111­12 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, 84­85 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, 84­85 parenteral transmission other than IDU, transgender individuals, 31, 33, 35, 36, 37, 88­92, 179 38, 61, 202 prevalence in MENA, 14t, 232­38t vulnerability factors exacerbated by, 2, 61 in prison population, 120 vulnerability of sexual partners/spouses, 188­89 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, 127­28 herpes simplex virus type 2 (HSV-2), or genital general population, 65­80 herpes, 132, 152­56, 153t, 154f, 155t, bibliography, 75­80 214, 222t casual sex, 70 heterogeneity of risk, 3­4, 4f, 5f in conceptual framework, 3­4, 4f, 5f heterosexual sex, as transmission mode, 85, 86­87t conclusions regarding, 74­75 High Risk Corridor Initiative, 216 condom use, 70 hijamah (traditional medical practices), 89 extramarital sex, 69, 70­71 hijras, 31, 33, 35, 36, 37, 38, 60, 168, 202 female genital mutilation in, 74 HIV/AIDS in MENA region, 1­10 FSWs, contact with, 69, 70 bibliographies. See bibliographies male circumcision in, 73­75 as bloodborne pathogen. See entries at blood nontraditional marriages, 71­72 case notification surveillance reports, 82­84, polygamy, 69­70, 71, 72­73 83f, 186 premarital sex, 70, 71, 73 conceptual framework, 3­6, 4­6f, 182­85, 185f prevalence of HIV among, 65­69t, 187 condom use, 101­9. See also condom use risk behavior of, 69­73, 74 countries covered, 6. See also specific countries status of current epidemic, 184t current status and future potential, 179­97. STIs/STDs, 69­74 See also current status and future potential genital herpes (herpes simplex virus type 2 or epidemiological data for, 1, 7­8 HSV-2), 132, 152­56, 153t, 154f, 155t exogenous HIV exposures, 85­87, 180, 182 glass cupping, 89 FSWs, 43­58. 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, 65­80. See also general gonorrhea, 162­69, 166t, 169f, 222t. See also sexually population transmitted infections (STIs) and diseases IDUs, 15­29. See also injecting drug users (STDs) other than HIV knowledge about HIV/AIDS, 109­13 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, 6­7, 222­23 Index 269 HIV/AIDS in MENA region (continued) IDPs (internally displaced persons). See refugees molecular epidemiology/subtypes, 92­94 and IDPs MSM, 31­41. 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, 179­82 India point-prevalence surveys, 7­8, 82, 224­38t IDUs in, 15 potential bridging populations, 59­63. 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, 151­78. See also proxy markers of migrant population, 134, 136 risk behavior MSM in, 31 research methodology, 6­8 injecting drug users (IDUs), 15­29 response to, 199­212. See also responses to HIV in availability of drugs in MENA, 2, 16 MENA bibliography, 25­29 STDs/STIs. See sexually transmitted disease blood, commercial sale of, 21 (STD) clinic attendees; sexually transmitted case notification surveillance reports, 82­84, 83f infections (STIs) and diseases (STDs) other conclusions regarding, 24­25 than HIV dynamics of current epidemic and, 185f strategic recommendations regarding, 213­19. female, 16, 52­53, 54 See also strategic recommendations frequency of injection, 17­19 sustainable transmission period and transmission FSWs and, 20­21, 22­24t, 25, 49, 53­53, 54, probability, 222t 188f, 206 TB patients. See tuberculosis (TB) patients, future expansion of HIV among, 190 HIV/AIDS among HCV transmission modes, 85, 86­87t 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, 2­3 "jerking," 21 vulnerable populations, 119­49. See also knowledge of HIV/AIDS among, 21­24, 109 vulnerable populations law enforcement approach to HIV control, HIV International Alliance, 202 avoiding, 215 homophobia in MENA, 31­32 migrants as, 135 homosexuality. See men who have sex with men MSM and, 21, 22­24t, 25, 38, 188f, 206 HPV (human papillomavirus) and cervical cancer, networks of, 19­20 69­70, 72, 132, 156­62, 157t, 158f, 159t, nonsterile equipment, use of, 17, 18t 160f, 161f, 222t number and frequency of sexual partners, 20­21, 61 HPV (human papillomavirus) vaccination, 161­62 OST, 200­201 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, 13­16, 15t, 186­87 herpes, 132, 152­56, 153t, 154f, 155t, prevalence of HIV infection among, 11, 12­13t, 214, 222t 229­32t human papillomavirus (HPV) and cervical cancer, prevention programs for, 200­201 69­70, 72, 132, 156­62, 157t, 158f, 159t, prisoners as, 91, 119­20, 123, 128 160f, 161f, 222t refugees and IDPs, 137 human papillomavirus (HPV) vaccination, 161­62 risk behaviors of, 16­21, 18t, 22­24t 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, 86­87t 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, 83­84 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, 48­49, 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, 234­35t vulnerable populations in, 189 HPV and cervical cancer in, 157t, 159t, 161 Islam and HIV/AIDS, 110, 111, 113, 187­88, 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, 92­93 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, 152­54 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, 109­13 avoiding, 215 basic knowledge levels, 109, 239­42t Lebanon bibliography, 113­18 attitudes toward PLHIV in, 246t comprehensive knowledge levels, 109, 242­43t civil society organizations and NGOs in, 216 conclusions regarding, 112­13 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 239­45t exogenous HIV exposures, 85, 180 differentials in, 111­12 FSWs in, 44t, 49, 50, 51, 53, 129, 230t among FSWs, 53 general population and HIV in, 71, 72 among IDUs, 21­24 HCV in different population groups, 235t misinformation levels, 109, 244­45 HPV and cervical cancer in, 157t, 158, 159t, 160 mother-to-child transmission, 112­13 HSV-2 in, 153t among MSM, 38­39 IDUs in, 12t, 14t, 15t, 18t, 19, 20, 22t, 24, 123, perception of risk, 109­10, 131 124, 140b, 200­201, 230t PLHIV, attitudes toward, 110­11, 113, 245­47t knowledge of HIV/AIDS in, 109, 240t, 242t, 244t prevention efforts, 199­204 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, 200­201, 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, 165­68, 166t, 167t, 169, 230t 272 Index TB and HIV in, 228t, 230t men who have sex with men (MSM), 31­41 transmission modes in, 86t anal sex, 32, 33, 34, 35, 37, 39 VCT services in, 204 bibliography, 39­41 vulnerable populations in, 189 case notification surveillance reports, 82­84, 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, 22­24t, 25, 38, 188f, 206 marriage in, 128 knowledge of HIV/AIDS among, 38­39, 109 mobile populations in, 133 migrants and, 33, 135 molecular epidemiology in, 93 MSWs, 34­36, 60, 128­29, 202 MSM in, 230t oral sex, 34, 35, 36 parenteral transmission other than IDU, 89 potential bridging populations and, 59­61 PLHIV, estimated numbers of, 221t prevalence of HIV among, 31, 32t, 187, 229­32t pregnant women, prevalence of HIV among, 230t prevalence of homosexuality in MENA and, 31­32 prevalence of HIV in, 181 prevention programs for, 201­2 prisoners in, 121t prisoners, 33, 125 status of current epidemic in, 184t risk behaviors of, 33­38 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, 86­87t HPV and cervical cancer in, 157t truck drivers, 33, 60­61 male circumcision, 4, 54, 62, 73­75, 160, 187, 190 youth and HIV, 128­29 male sex workers (MSWs), 34­36, 60, 128­29, 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, 206­7 Middle East and North Africa Harm Reduction marriage. See also extramarital sex; premarital sex Association (MENAHRA), 201 early/intergenerational, 61, 73, 127, 128 migrants, 133­36 nontraditional, 71­72 case notification surveillance reports, 82­84, 83f polygamy, 69­70, 71, 72­73 exogenous HIV exposures, 85­87 youth and HIV, 127­28 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, 135­36 general population and HIV in, 66t, 68t research priorities regarding, 214­15 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, 133­35 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, 133­38. See also migrants; NGOs (nongovernmental organizations), 200­202, refugees and IDPs 204­7, 210, 215­16 molecular epidemiology of HIV, 92­94, 217 Niger, molecular epidemiology of HIV/AIDS in, 92 monitoring and evaluation (M&E) systems, 206­7 nikah al misyar, 72 Morocco nongovernmental organizations (NGOs), 200­202, ART in, 208t, 209 204­7, 210, 215­16 attitudes toward PLHIV in, 246t nonsterile equipment, IDU use of, 17, 18t civil society organizations and NGOs in, 216 nontraditional marriages, 71­72 condom use in, 102t, 104­5t, 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, 163­64t, 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, 86­87t availability of drugs in, 16 knowledge about, 112­13 civil society organizations and NGOs in, 216 nosocomial outbreaks, 89 condom use in, 102t, 105­6t, 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), 34­36, 60, 128­29, 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, 235­36t 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, 12­13t, 13, 14t, 15t, 16, 17­21, transmission) services, 138, 209 18t, 23t, 24, 38, 52, 87, 123, 185, 186­87, point-prevalence surveys, 7­8, 82, 224­38t 201, 232t polygamy, 69­70, 71, 72­73 knowledge of HIV/AIDS in, 109, 111, 240t, 242t, Population Reference Bureau (PRB), 7 244t, 247t postconflict situations, 133 migrant population, 134­35, 136 potential bridging populations, 59­63 molecular epidemiology in, 93 bibliography, 62­63 MSM in, 31, 32t, 33, 34­35, 36, 37, 38, 128­29, in conceptual framework, 3­4, 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, 59­60, 60t 90t, 91 research on, 59­63 PLHIV, estimated numbers of, 221t risk behavior of, 60­61 PMTCT services, 209 sexual partners, 61­62 potential bridging populations in, 59, 60­61, 60t case notification surveillance reports, 82­84, 83f pregnant women, prevalence of HIV among, 231t of FSWs, 47­49 prevalence of HIV in, 181, 186­87, 225t of IDUs, 20­21 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, 213­14 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, 128­29 refugees and IDPs, 137 Palestinian refugees, 127, 136. See also Israel; West youth involvement in, 127, 129­31 Bank and Gaza prevention of HIV. See responses to HIV in MENA Pap smears, 132, 160­61 prevention of mother-to-child transmission parenteral transmission other than IDU, 88­92, 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, 110­11, 113, 245­47t drug users; men who have sex with men care and treatment, 206f, 207­9, 208t behavioral surveillance, increasing and expanding, estimated numbers by country, 221t 213­14 knowledge of HIV status, 208 case notification surveillance reports, 82 migrants, 136 in conceptual framework, 5 response efforts, involvement in, 205­7 current status and future potential, 182­83, 185f, sexual partners of. See under potential bridging 186, 188f populations focused prevention programs for, 200­203 stigma and discrimination against, 210 harm reduction as aim for, 217 strategic recommendation to rely on, 215­16 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, 119­26 refugees and IDPs, 136­38 case notification surveillance reports, 82­84, 83f conclusions regarding, 138 conclusions regarding, 125­26 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, 119­20, 123­25, 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, 121­22t risk behavior, 137­38 rates of imprisonment in MENA, 120, 121­22t studies and surveys, 181 risk behaviors, 120­25 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, 187­88, 217 tattooing, 125 remittances from migrant populations, 133 as vulnerable population, 119­20 renal dialysis, 89 youth and HIV, 128 Republic of Yemen. See Yemen, Republic of prostitution. See sex workers research for evidence-based policy, 214­15 protective factors, 187­88 responses to HIV in MENA, 199­212 provider-initiated testing and counseling (PITC), 205 access to prevention programs, 203­4 proxy markers of risk behavior, 151­78 bibliography, 210­12 bacterial STIs (syphilis, gonorrhea, and blood safety and screening efforts, 180, 207 chlamydia), 162­69, 163­68t, 169f care and treatment, 206f, 207­9, 208t bibliography, 170­78 civil society organizations, involvement of, 201, conclusions regarding, 169­70 205­7, 215­16 HPV and cervical cancer, 69­70, 72, 132, 156­62, conclusions regarding, 210 157t, 158f, 159t, 160f, 161f expanding coverage for, 205 HSV-2, 132, 152­56, 153t, 154f, 155t FSWs and MSWs, prevention programs for, 202 unsafe abortions, 169, 170f IDUs, prevention programs for, 200­201 validity of reported risk behavior, verifying, 151­52 M&E systems, 206­7 MSM, prevention programs for, 201­2 Q NGOs, involvement of, 200­202, 204­7, 210, Qatar 215­16 as covered country, 6 outreach efforts, 207 general population and HIV in, 68t PLHIV, involvement of, 205­7, 215­16 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, 199­200 migrant population, 135 STIs/STDs, 209­10 origins and evolution of HIV in, 179 strategic focus on prevention, 216­17 parenteral transmission other than IDU, 90t testing and counseling, 204­5, 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, 206­7 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, 48­53 of general population, 69­73, 74 R heterogeneity and sustainability of, 3­5, 4­6f R0, concept of, 4­5, 5f of IDUs, 16­21, 18t, 22­24t 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, 84­85 276 Index of migrants, 135 security approach to HIV control, avoiding, 215 of MSM, 33­38 sex workers perception of risk from HIV, 109­10, 131 female. See female sex workers of potential bridging populations, 60­61 hijras, 31, 33, 35, 36, 37, 38, 60, 168 priority populations, overlapping risks among, MSWs, 34­36, 60, 128­29, 202 188f, 206 prevention programs for, 202 of prisoners, 120­25 street children as, 33, 46, 138­39 proxy markers of, 151­78. See also proxy markers sexual abuse. See abuse of risk behavior sexual identity in MENA, fluidity of, 32­33 of refugees and IDPs, 137­38 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, 128­32 potential bridging populations rural/urban vulnerability of, 188­89 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, 82­84, 83f migrant FSWs in United Arab Emirates, 135 chancroid, 168 surveillance efforts in, 214 FSWs, 51­52, 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, 81­82, 181, 226­27t, Saudi Arabia 229­32t 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, 236­37t bacterial STIs, 162­69, 163­68t, 169f HPV and cervical cancer in, 157t, 158, 159t, 160 chancroid, 168, 222t HSV-2 in, 154 chlamydia, 162­69, 167­68t, 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, 51­52, 53, 81 marriage, age at, 127 in general population, 69­74 migrant population, 133, 135 gonorrhea, 162­69, 166t, 169f, 222t molecular epidemiology in, 93 heterogeneity of risk, 4 origins and evolution of HIV in, 179, 180 HPV and cervical cancer, 69­70, 72, 132, 156­62, parenteral transmission other than IDU, 89, 90t 157t, 158f, 159t, 160f, 161f, 222t PLHIV, estimated numbers of, 221t HSV-2, 132, 152­56, 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, 188­89 knowledge of, 112 status of current epidemic in, 184t literature review, criteria for, 222­23 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, 72­73 scientific research for evidence-based policy, 214­15 potential bridging populations and, 60, 62 seafarers, as potential bridging population. See prevention efforts, 209­10 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, 162­69, 163­65t, 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, 213­19 sigheh (temporary marriage), 71 behavioral surveillance, increasing and expanding, Singapore, HPV and cervical cancer in, 157t 213­14 skin scarification, 2, 89 bibliography, 218­19 Skoun, 201 civil society organizations and PLHIV, involvement Soins Infirmiers et Developpement Communautaire of, 215­16 (SIDC), 201 law enforcement approach, avoiding, 215 Somalia prevention, focus on, 216­17 ART in, 208, 208f, 208t, 209 scientific research for evidence-based policy, attitudes toward PLHIV in, 246t 214­15 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, 138­39 general population and HIV in, 65, 66­67t, 68t, as vulnerable population, 138­39 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, 164­65t, 166t, 168t, 210, 227t, 231t subtypes of HIV, 92­94 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, 102­3t, 106­7t 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, 73­74, 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, 231­32t 241t, 243t, 244­45t, 247t TB and HIV in, 231­32t male circumcision in, 73­74 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, 201­2 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, 201­2, 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, 86­87t TB and HIV in, 228­29t, 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 207­9, 208t prevalence, 183 trichomonas, 168 VCT clinic attendees and services, 81, 204, 227t truck drivers youth and HIV in, 127, 128, 129, 130­31, 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 213­14 mobile populations, vulnerability of, 133, 134 syphilis, 162­69, 163­65t, 169f, 222t. See also MSM, 33, 60­61 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, 82­84, 83f FSWs in, 49, 50, 51, 129, 141b, 231­32t 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, 228­32t IDUs in, 13t, 14t, 15t, 16, 18t, 19, 21, 24t, 53, 123, Tunisia 124, 231­32t condom use in, 103t, 107­8t knowledge of HIV/AIDS in, 110, 241t, 243t, 245t as covered country, 6 marriage in, 128 DHS reports, 7 MSM in, 231­32t 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, 237­38t 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, 182­83 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), 71­72 ART, use of, 207 covered countries, 6 V data limitations, 8 vaccination against HPV, 161­62 epidemiological fact sheets, 82 voluntary counseling and testing (VCT) attendees, on epidemiology of AIDS in MENA, 1 204­5 literature review, 7 case notification surveillance reports, 82­84, 83f prevention programs for FSWs, 202 FSWs and, 48, 81, 202 280 Index prevalence of HIV among, 81­82, 226­27t covered countries, 6 prevention efforts, 202, 203 data limitations, 8 surveillance practices, 214 on epidemiology of AIDS in MENA, 1 vulnerable populations, 119­49 literature review, 7 bibliography, 141­49 STI/STD response, 209 conclusions regarding, 139­41 defined, 119 Y emergency situations, 133 Yemen, Republic of mobile populations, 133­38. See also migrants; ART in, 208t, 209 refugees and IDPs attitudes toward PLHIV in, 247t prisoners, 119­26. See also prisoners condom use in, 103t, 108t research on, 214­15 as covered country, 6 sexual partners, 188­89 DHS reports, 7 situations contributing to, 189 exogenous HIV exposures, 85 street children, 138­39. See also street children female circumcision/genital mutilation in, 74 surveillance of, 213­14 FSWs in, 45t, 47, 50, 51, 53, 232t youth, 126­32. 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, 126­32 youth and HIV in, 126, 127, 128, 129 conclusions regarding, 132 Western blot assays (WBA), 156, 204 condom use, 130­31 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, 131­32 Regional Office (EMRO) marriage phenomena, 127­28 ART, 207, 209 migrants, 128, 131 case notification surveillance reports, 82 MSM, 128­29 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, 128­29 zawaj al-muta'a (temporary marriage), 71 sexually risky behavior, 129­32 zenanas, 33 STIs/STDs, 129, 132, 165 282 Index Eco-Audit Environmental Benefits Statement The World Bank is committed to pre- Saved: serving endangered forests and natural · 16 trees resources. The Office of the Publisher · 5 million Btu of has chosen to print Characterizing the total energy HIV/AIDS Epidemic in the Middle East · 1,568 lb. of net and North Africa on recycled paper greenhouse gases with 50 percent postconsumer fiber in · 7,553 gal. of accordance with the recommended waste water standards for paper usage set by the · 459 lb. of solid Green Press Initiative, a nonprofit pro- waste gram supporting publishers in using fiber that is not sourced from endan- gered forests. For more information, visit www.greenpressinitiative.org. Despite global progress in understanding the epidemiology of the human immunodeficiency virus (HIV), knowledge about the epidemic in the Middle East and North Africa (MENA) remains very limited and subject to much controversy. In the more than 25 years since the discovery of HIV, no scientific study has provided a comprehensive, data-driven synthesis of the spread of HIV/AIDS (acquired immunodeficiency syndrome) in the region. Consequently, the effectiveness of policies, programs, and resources intended to address the spread of HIV/AIDS has been compromised. 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