HIV/AIDS
in the Middle East and North Africa: A Primer
Sandy
Sufian
Sandy
Sufian is an assistant professor of medical humanities and history
at the University of Illinois-Chicago and the founder of the Global
Network of Researchers on HIV/AIDS in the Middle East and North
Africa. She is presently completing her first book, Healing
the Land and the Nation: Malaria and the Zionist Project in Mandatory
Palestine, 1920-1947.
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AIDS
poster, Oman. (Jeremy Hartley/Panos Pictures)
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Have the
Middle East and North Africa largely escaped the global AIDS epidemic?
The available data seems to say so. UNAIDS reports that, at the
close of 2003, there were 480,000 adults and children living with
HIV/AIDS in the Arab world, Iran, Israel and Turkey. Compared
to sub-Saharan Africa, where there are approximately 25 million
cases of the disease, or South and Southeast Asia, where there
are approximately 6.5 million, this number is tiny—about
1 percent of the world’s caseload.
But this
low number offers no cause for celebration. UNAIDS estimates that
75,000 people from the Middle East and North Africa were newly
infected with HIV/AIDS in 2003 alone, while 24,000 adults and
children died from the disease in the same year. Moreover, the
quality of the available data is seriously lacking. No country
in the Middle East and North Africa conducts systematic surveys
of groups at high risk of infection. As a consequence, the UNAIDS
estimate of the total number of HIV/AIDS cases in the region lies
within a very broad range of possible cases, from 200,000 to 1.4
million people.[1]
Only 5 percent of Middle Easterners and North Africans who need
anti-retroviral treatment receive it.[2]
According
to a 2003 World Bank report, probably the most substantial research
document on HIV/AIDS in the Middle East and North Africa, the
assumption of low rates of infection has led governments to dismiss
the disease as an insignificant problem or exhibit complacency
in taking action. Many governments faced with pressing crises
of housing, employment and education see HIV/AIDS prevention and
treatment as low priorities. Other governments believe that social
and cultural conservatism will somehow avert an HIV/AIDS epidemic.
But, in the words of the report, “low prevalence does not equate
to low risks.”[3] Current scientific knowledge about HIV/AIDS transmission shows
that once infection rates exceed “a certain threshold, the virus
spreads very fast, sometimes increasing by as much as tenfold
in five years as has been the case in several southern African
countries.”[4] Calculating
that threshold is complicated. According to Joan MacNeil, senior
HIV/AIDS Specialist for the Global HIV/AIDS Program of The World
Bank Group, an epidemic threshold is reached “when enough critical
mass of risk behaviors and contributing biological factors exists
in a population to sustain an epidemic. This is described scientifically
by the concept of reproductive rate, which is the number of new
infections generated by each current infection. The threshold
is exceeded when the reproductive rate exceeds one. This means
that, if infected individuals, on average, infect more than one
additional person in their lifetimes, the epidemic will be sustained
and grow. However, the threshold can be influenced by the size
of risk populations, type and frequency of risk behavior, presence
of other sexually transmitted infections, especially ulcerative,
circumcision, networks linking key sub-populations and extending
beyond these groups.”[5]
At
base, the threshold is usually designated as, and equal to, a
5 percent infection rate in most countries.[6]
If governments delay action, scholars believe the trend witnessed
in other regions will likely recur in the Middle East and North
Africa.
At Risk
As in other
regions, known high-risk groups in the Middle East and North Africa
include men who have sex with men, female sex workers and their
clients, injecting drug users and prisoners. At least half of
the HIV cases reported in Tunisia are thought to be Libyans who
crossed the border to undergo drug rehabilitation or receive anti-retroviral
treatment, according to UNAIDS. HIV infection in Bahrain, Libya
and Oman is reportedly concentrated among injecting drug users.
Prisoners are often designated as an at-risk group because of
prevalent drug habits, tattoo practices and overall health conditions
in the prisons.
Tourists,
migrant workers and transport drivers are both transmitters of
the disease to locals as well as those who contract the disease
from risk groups like female sex workers. Displaced persons and
refugees are at risk for HIV/AIDS because of the lack of adequate
health care and unhygienic conditions, exposure to infected blood
and lack of access to condoms.
Women worldwide
are particularly at risk for HIV/AIDS contraction because of their
frequently weakened negotiating power in sexual relations with
their husbands to practice safe sex (who may also be having sex
with female sex workers or with men) as well as their relative
lack of knowledge about the HIV/AIDS virus. Of the 480,000 infected
people estimated by UNAIDS in the Middle East and North Africa,
approximately 220,000 were women. Young people form an at-risk
group because of their common risk-seeking behaviors like taking
drugs, having multiple sex partners or sexually experimenting,
and failing to use condoms. Scientific evidence has shown that
individuals with sexually transmitted infections also have increased
susceptibility to HIV/AIDS.[7]
Not only
do most Middle Eastern and North African governments fail to survey
these at-risk groups regularly, but they monitor risk behaviors
only on an ad hoc basis. Governments, international agencies and
independent researchers are thus left struggling to identify dangerous
trends in health behavior.[8]
Strong taboos
attached to HIV/AIDS in the Middle East and North Africa make
it even harder to measure the scope of the problem and plan accordingly.
Extreme stigma not only marginalizes those who are HIV-positive
but also inhibits people from going for testing in the first place.
Injecting drug users—at high risk because of shared needles—are
stigmatized and many times go underground because their habit
is illegal. People living with HIV/AIDS are commonly expelled
from their homes or alienated from their families, have difficulty
marrying or dating, are sometimes fired from their jobs and even
have trouble getting medical care for fear of infection by health
professionals. In a few countries in the region, people living
with HIV/AIDS are placed in quarantine compounds far away from
the general population. Before effective programs in Iran were
in place, mortality from suicide for people living with HIV/AIDS
exceeded mortality from the disease itself because of stigma.[9]
Breaking
the Silence
Such dire
statistics led Peter Piot, executive director of UNAIDS, to plead
with regional leaders in a 2002 speech to “break the silence on
AIDS.” Piot continued: “Most of the AIDS in the Middle East and
North Africa is still invisible. Progress is not possible unless
AIDS becomes visible, unless stigma is challenged and unless people
living with HIV are encouraged to play their part in a community-wide
AIDS response. All this requires resolute and courageous leadership
at various levels.”
Toward this
end, the UN Development Program sponsored a March 2003 gathering
in Cairo to raise awareness about HIV/AIDS in the Arab world.
Arab actors, singers and other media personalities attended. The
gathering was one example of how international agencies, like
UNAIDS and its affiliated agencies, have recently become more
engaged with governments to address the region’s potential rise
in HIV/AIDS infection. The World Health Organization, the one
UNAIDS affiliate that has worked in the region since the 1980s,
has developed a regional strategic plan for the Eastern Mediterranean
for 2002-2005.[10]
National AIDS programs and national steering committees were set
up to implement the plan. Actions by some national AIDS committees—as
yet incomplete—have included implementing universal health
precautions like using gloves and enforcing sterile environments,
addressing the care of opportunistic infections, like tuberculosis,
that come as a result of immuno-suppression, securing a safe blood
supply, and providing anti-retroviral therapy and counseling for
AIDS patients.[11]
All agencies
agree that every segment of society, including industry, clergy,
farmers and teachers, should work together to collect thorough
data. Without comprehensive quantitative and qualitative data,
especially acquisition of information about sexual behavior and
drug use, interventions are likely to fail.
Incomplete
Responses
Some countries
have fared better than others in carrying out these injunctions,
according to country reports that can be generated at the UNAIDS
website. Turkey has a national HIV case reporting system, an HIV/AIDS
action plan and a national AIDS committee, established in 1996,
with input from several ministries and non-governmental organizations.
The country’s estimated 3,700 adult AIDS patients are made up
mostly of males, the major modes of transmission being heterosexual
sex and injecting drug use. With about 3,300 adult AIDS cases
at the end of 2001, Israel has a national HIV/AIDS registry and
systematically tests blood donors, prisoners and immigrants from
countries with high rates of HIV/AIDS. The country has health
education programs on HIV/AIDS for at-risk groups, for the army
and for the general population. Israel has regional AIDS centers
around the country that provide treatment and follow-up to people
living with the disease.
Morocco,
which worked with the World Bank on an AIDS action plan in 2001,
has instituted extensive services for the prevention and treatment
of sexually transmitted infections. Algeria finalized a multi-sectoral
strategic plan for 2003-2006. In 1997, Tunisia developed a program
for youth that offers regional and provincial comprehensive services
in prevention, counseling, testing and condom distribution.[12] Since 1999, Jordan has provided
anti-retroviral therapy free of charge. The Syrian government
has instituted community-based HIV/AIDS education programs for
out-of-school youth and partnered with local organizations for
their implementation. Egypt has started an anonymous HIV/AIDS
hotline service that offers HIV/AIDS and sex education. It receives
1,000 calls a month on average. Lebanon has prepared a national
AIDS plan for 2004-2009 to help stakeholders in suitable interventions.
Yemen has received funding from the World Bank to implement a
project focused on HIV/AIDS prevention and the reduction of risk
behaviors. Djibouti has also received World Bank funds both to
execute strategic plans for fighting HIV/AIDS, malaria and tuberculosis
and to examine HIV/AIDS transmission within the trucking industry.
The Gulf
states have also begun to address HIV/AIDS, according to the same
UNAIDS reports. Saudi Arabia has established an HIV/AIDS Health
Education Committee that includes governmental and non-governmental
agencies. It has not, however, integrated the HIV/AIDS issue into
general development plans. The Saudis have instituted health programs
for at-risk populations and reproductive and sex education programs
in schools. Saudi Arabia also supplies anti-retroviral therapy
for infected pregnant women. The government of Qatar provides
limited programs like screening of HIV patients’ families, tuberculosis
patients, school lectures and anti-retroviral therapy but does
not have a comprehensive, multi-sectoral program or a coordinating
agency. They do pre-screen foreign labor for the virus upon entry
to the country as well as new army recruits, but they do not screen
pregnant women. Stigma associated with HIV/AIDS and at-risk populations
remains a major problem. Oman, on the other hand, reports collaboration
among many sectors of society and boasts of a National AIDS Technical
Committee and a National AIDS Health Education Committee. The
government does not promote sex education for young people due
to “cultural and religious traditions,” although condoms are provided
free of charge at supermarkets, family planning clinics and private
pharmacies.
Iran has
perhaps made the most extensive strides in confronting its HIV/AIDS
problem. It has developed a national sentinel surveillance system
with 75 sites in juvenile detention centers, prisons and university
clinics. It has set up an extensive network of clinics for injecting
drug users that address HIV/AIDS and drug abuse education, care
and treatment. Their patient-centric approach provides social
support for patients and families as well as community outreach.
In addition, Iran has set up several regional committees with
university participation while its national AIDS committee includes
members from several ministries and civil society groups like
the Red Crescent and the Prison Organization. A National Harm
Reduction Committee has also been formed. Along with Morocco,
Algeria and Jordan, Iran received funding from the Global Fund
to Fight HIV/AIDS.
Iran’s innovative
campaign against HIV/AIDS makes HIV-positive drug users visible
by including them in outreach programs. Their participation is
intended to avert stigma by showing that people living with HIV/AIDS
are constructive members of society who can help others. Understanding
that the problems of high-risk groups like injecting drug users
are complex, Iran’s clinics address related social problems by
providing food and shelter, recreation, primary health care, employment
and family counseling.The “triangular” clinics’ integrated care
approach, based on the three prongs of sexually transmitted diseases,
drug use and HIV/AIDS screening and treatment, is meant to reduce
the effects of stigma by allowing patients to seek help for associated
problems, instead of attending the clinic solely and openly because
they may have HIV/AIDS.[13]
Dangers
of Inattention
Efforts to
contain the spread of HIV/AIDS in the Middle East and North Africa
remain inadequate, however, particularly given the stakes. The
stakes are economic as well as human. Further spread of the virus,
and especially deaths from the disease, could lead to a drastic
decline in productivity, a decrease in the labor force and a reduction
in capital investments. World Bank researchers conservatively
estimate that HIV/AIDS in the Middle East and North Africa could
cause a loss of one-third of the region’s current gross domestic
product by 2025.The average increase in health expenditures to
treat all AIDS patients by 2015 could reach between 1.2 and 5
percent of GDP. Simple, cost-effective interventions like encouraging
condom use and supplying safe needles to injecting drug users
could save regional governments millions of dollars. Delaying
these types of interventions could cost up to 1.5 percent of today’s
GDP for each year of inaction.[14]
The countries
of the Middle East and North Africa, with their young populations,
unresolved political conflicts, slow-growing economies, stressed
or crumbling health infrastructures, gender inequalities, population
mobility and shared borders with high-prevalence regions like
Central Asia and sub-Saharan Africa, are at risk for outbreaks
or epidemics of the HIV virus. Illiteracy, unemployment and the
drug trade exacerbate the danger. In the absence of effective
action against the virus, rapid transmission could very well transpire.
We may see a repeat in the Middle East and North Africa of the
situation in Indonesia, Africa or China where initial disregard
or delayed reaction has ended in large numbers of orphans, a shortage
of workers and huge health expenditures to care for HIV/AIDS patients.
Inattention to the HIV/AIDS problem in the Middle East and North
Africa could cause similar breakdowns in a region that is already
socially, politically and economically vulnerable.
