Introduction
With HIV infection rates continuing to climb every year there is a growing need to intensify HIV prevention. This involves scaling up prevention measures in order to bridge the gap between the growing HIV prevalence and the need for treatment. HIV prevention requires political commitment, civil society engagement, funding and realistic targets. For success they must be rooted in the following key effective principles.
Human rights-based approach
Prevention from harm and disease and the right to health irrespective of race, religion, political belief and economic or social condition was promulgated in the WHO statement in 1946. This has been repeated and enhanced in numerous declarations since, including the Alma Ata declaration to a more recent UN Commission of Human Rights 2003, where there was a focus on non-discrimination especially for vulnerable populations.[1]
As well as a right to be treated, a human rights approach must extend to the right to chose to be tested. Further, prevention efforts cannot be effective unless the root determinants of vulnerability to HIV transmission are addressed, for example, freedom from all forms oppression: physical, social and economic.
Differentiated and locally adapted
HIV epidemics vary regionally. It is incumbent to understand the dynamics of the epidemic in the MENA region and tackle it accordingly.
Evidence-informed
Using evidence-based approaches according the nature of the epidemic in the region is vital. This means using the regional and local data comprising a social, anthropological and epidemiological matrix where previous implementations have been evaluated and adapted.
Comprehensive in scope
This involves all aspects of prevention including root causes like poverty reduction strategies, reversing women’s inequity in rights and education, education to youth in schools as well as prevention schemes such as VCT centres.
Sustainability
This requires long-term commitment and investment from all stakeholders with a vision to adapt HIV approaches according to lifestyles changes of new generations.
Coverage
Scaling up must meet the need for treatment and reverse the growing trend, but which is effective in both quantity and quality of prevention measures.
Community participation
Participation of civil society organisation and people living with HIV is fundamental in HIV prevention. It is not just about contribution but also ownership of programmes.[2]
Understanding HIV in a diverse region
The HIV epidemic in the region is as diverse in its patterns of intensity as the countries themselves. In the Islamic Republic of Iran and Afghanistan, there are concentrated epidemics with prevalence as high as 10% among injecting drug users (in 2002). In contrast, Djibouti, Sudan and Somalia have more generalised epidemics with a prevalence of 2.9%, 2.6% and 0.9% respectively among adults of the general population. Although the region is still considered to be of low prevalence (less than 1%), changing patterns in the socio-political matrix point towards a shift in HIV prevalence.
In order to assign correct prevention strategies, it is incumbent to identify the populations most at risk and vulnerable to HIV.[3]
Identifying key populations
Most at risk populations
Most at risk populations include men who have sex with men, injecting drug users and sex workers. In a study in Egypt, 6.2% of men who have sex with men were HIV positive.[4] In Iran 86% of all HIV positive people were injecting drug users. In Afghanistan using non-sterile injecting equipment among injecting drug users is the most common factor of spread and one of the leading factors increasingly in Oman and Bahrain[5] [6] Studies also showed this factor in Egypt 55%, 23% in Iran, 64.7% in Lebanon and 51% in Morocco. In Morocco 2.2% of sex workers were HIV positive in 2005 and 4.4% in Sudan in 2002. There is the added danger of most at risk populations sharing more than one risk factor, particularly with unprotected sexual transmission between injecting drug users.
Vulnerable Populations
Women
The underlying factors for women’s vulnerability are both biological and socioeconomic. Research has shown that women are twice as susceptible to viruses after unprotected sex possibly due to the large mucosal surface of the vagina and the exposure to more body fluids, i.e. semen.[7]
Women also are exposed to forms of inequality. Women sex workers may be threatened with violence or receive more money if they have unprotected sex. Men who display risk behaviours are often married and have unprotected sex with their wives. Women who suspect their husbands sexual misconduct are often unable to stop them or insist on protective sex.[8]
Women in the region are less educated than men (53% literacy rate[9]) where their knowledge of HIV and AIDS is limited to television and film. A study in Egypt revealed that women felt that AIDS was a disease for foreigners due to images from television. Women also tend to relegate their own health to the last priority in the family.[10]
Women who are particularly vulnerable are domestic workers in the Gulf and Lebanon where they are sometimes exposed to sexual abuse from employers. This vulnerability is exacerbated by their guest status at the hands of employers who keep their passports and lack of knowledge of where or how to seek help.
Young Adults
By the end of 2006, more than half of HIV cases were between 25-39yrs in MENA. Changing lifestyles among youth indicates a tendency towards more unsafe risk behaviours. Youth unemployment is high in MENA and unemployment leads to poverty, low self esteem, drug abuse and crime.
Young people are tempted by media images of western values and forsake more traditional values of the Arab region. Marriage is often delayed (sometimes for economic reasons) and young people practise pre-marital sex: which is often unprotected. A study in Lebanon showed that two-thirds of 15-49 year olds were sexually active but only one quarter used condoms in the last sexual encounter. [11]
Children
Due to mother to child transmission, children are particularly vulnerable. Prevention depends on the mother knowing her HIV status and her capacity to implement prevention measures. Children’s vulnerability depends on women’s vulnerability. Children who live on the street are also vulnerable as well as children who have been orphaned by loss of a parents or parents to HIV. The number of street children in Egypt is estimated to be between 200 000 and one million in 2007. [12] The breakdown of the natural safety net of the family makes them more at risk to transmission.
Mobile populations
There are 14 million migrants to the MENA region and this does not include migration within countries. Such groups are at risk due to survival sex work, limited access to health care and lack of legal services and human rights. [13]
Conflict Zones
The MENA region bears the burden of six countries in a state of war and conflict: Iraq, Afghanistan, Sudan, Palestinian Territories, Lebanon and Somalia. Conflict situations predispose populations to vulnerability on all fronts. Although morbidity from HIV in five of the six countries is low in comparison to other diseases, they all present the characteristic picture of populations at risk.[14]
Health care has become politicised and under attack with attacks on health care facilities in Iraq, and medical convoys and ambulances in Palestine and Somalia. The wall in Palestine once complete will isolate 71 clinics from the population. There have been drastic effects on education in Afghanistan and Palestine [15]and poverty and unemployment in all countries. Women and young girls are particularly vulnerable by being exposed to rape in Darfur with the double burden of stigma of rape thus less likely of it being reported.
People in detention
The dearth of information renders it difficult to determine the magnitude of risk behaviours of people in detention and prison settings such as injecting drug users and men who have sex with men. However, there is some data which indicates that there is elevated HIV prevalence with stark disparities. In Sudan in 2002 there was 2% prevalence, Morocco in 2003, 0.8%, Libya in 2004, 18% and in Oman in 2005, 0.14%.[16]
Barriers to prevention
Socio-cultural barriers
In order to develop the best prevention strategies one must understand the obstacles. Socio-cultural sensitivities are significant barriers in the region. HIV is stigmatised due to its associations with sex. Taboos and traditional attitudes limit what can be discussed about sexuality.
Targeting sex workers, injecting drug users and men who have sex with men is difficult due to their illegal status and cultural unacceptability. Attitudes to HIV are often associated with illicit sexual practices, death and dying. Most information is gathered from television and film whereby ‘victims’ are sex workers and men have sex with foreign women: spreading the idea that it is a disease of foreigners.[17] Government policy in some countries in the Gulf and Egypt by only granting residency visas to foreigners if tested HIV negative only adds fuel to this mistruth.
This view can also be construed as denial of the imminent threat of the HIV epidemic whereby the conservative Islamic and Christian values protect against HIV transmission, when in fact more young people are having sex outside marriage.[18]
Legal and rights-based barriers
Repressive laws and the infringement of people’s rights often marginalise groups and hinder prevention strategies, for example, migrant workers in the Gulf have fewer rights to health care. The criminalization of men who have sex with men and sex workers creates an underground culture making it difficult to target them.
Health care system barriers
Many countries lack the capacity to approach HIV prevention. Ministries of health do not consider HIV prevention a priority and this in turn affects their financial capacity and commitment. Health care providers are poorly trained and ill equipped. In some countries health care workers in state-run settings are poorly paid and morale is low. Poorly educated and informed health care workers contribute to the breakdown and hinder prevention measures, whether they are technical or attitudinal. A survey in Yemen conveyed that more than two-thirds of health care workers refused to give care to HIV-positive patients. Eighty percent of all respondents reported accidental pricks from needles and only half would disinfect the site of the wound. [19]
Prevention strategies
Advocacy and Education
Addressing stigma and discrimination related to HIV status is a pre-requisite to prevention. Efforts should be directed at both policy and grassroots levels. This involves national governments adopting prevention education for young adults in mainstream education that dispels myths of the virus and informs them of its latent yet virulent status in the region.
At a more grassroots level approaching prevention through community cooperation with local NGOs and religious institutions will instil a sense of confidence between prevention workers and the public. Efforts should target mainstream education and focus on young people so that they adopt safe behaviours such warning against injecting drug use and unsafe sexual behaviour, for example the ABCs of HIV prevention approach: abstinence, being faithful and condom use.[20] Programmes should comprehensively deal with delay in onset of sexual activity, sufficient sex education and treating sexually transmitted infections at the earliest onset.[21]
Harm reduction Programmes
This involves targeting injecting drug users and educating them on the dangers of non-sterile injecting equipment. Programmes should also involve advocacy efforts to make political change, and educate on sexual behaviour, alcohol and stimulant abuse which expose people to high-risk behaviours like unprotected sex.[22] Iran is scaling up harm reduction and MENA has a harm reduction network.
Condom programming
This involves marketing male and female condoms, possibly through condom vending machines, and making them widely available. Education is necessary for correct condom use, especially female condoms which are fairly unknown and so far unpopular. In Tunisia, the department of the Family and Population in collaboration with UNFPA set up counselling centres for youths in student dormitories, college campuses and factories where they could be tested for sexually transmitted infections. Condoms were distributed with easy access and confidentiality. [23] Provision should also be made to sex workers.
Prevention for people living with HIV
Voluntary counselling testing should invest in educating people with HIV on protective sex, dealing with body fluids, pregnancy and safe needle use. This includes mother-to-child-transmission. Measures include preventing unwanted pregnancies, preventing transmission during pregnancy, caesarean sections instead of natural birthing and substituting breast milk for baby formula. Mothers need high quality natal and post-natal care and adequate advice on birth control measures.
Integrating treatment and prevention
Health sector personnel administering care and treatment for people with AIDS treatment should be trained in prevention education. The synergy of prevention and treatment in the same domain facilitates training of staff and portraying to people living with HIV/AIDS on prevention measures.
Integrating prevention with sexual and reproductive health
Taking advantage of the long term investment in sexual and reproductive health in the region, HIV prevention programmes can be integrated to already existing ones especially since they share similar disease patterns of exposure.[24]
Safety of blood supply
This requires the rigorous adherence to universal blood safety policies and requires rigid controls and supervision by governments to ensure they are followed. HIV contamination through blood transfusion or unsafe handling of needles and fluid by occupational exposure has decreased in the region from 12.1% in 1993 to 0.4% in 2003.[25] With the growth in private health care, the use of paid blood donors and health system failures, often due to the number of countries in a state of conflict and war, such decline in this form of transmission is fragile.
Vaccines and Microbicides
Vaccines and microbicides are still in the process of testing for safety and effectiveness. Once these have been guaranteed, access must be available to all men and women. This involves finance, intellectual property rights, manufacturing, distribution and marketing to the target populations. [26]
Male circumcision
After three very important randomised trials that concluded in 2005-2006, male circumcision is considered to reduce HIV transmission by 60% from women to circumcised men. Male circumcision is now recognised as an effective risk reduction measure for prevention among heterosexual populations provided that it is promoted as a partial method of prevention and practised in combination with other measures such as reducing the number of sexual partners, condom use, delayed onset of sexual activity. [27] Due to religious and cultural reasons, male circumcision is widely practised in the MENA region. All countries in the region have a high prevalence of male circumcision (>80%) except Sudan which has an intermediate prevalence (20-80%). [28] There is a gap in research in the region assessing the male circumcision between different population groups.
National programmes to circumcise all males must assess the acceptability of male circumcision among populations that don’t practice it for ethnic, religious or traditional reasons. Ethical and legal concerns must be taken into consideration whereby voluntary and informed consent is sought and human rights are at the foundation of any approach.
Prevention in health care settings
Health care workers in all aspects of health care settings should conform to standard universal practices of precautions. Infection control programmes should be the driving force to install these comprehensive measures which include wearing protective clothing, aseptic technique, good hand washing technique, use of auto-disposable syringes, correct disposal of soiled goods, waste management, incineration of sharp instruments and environmental cleaning. [29] It goes without saying that health care workers must be trained on HIV transmission, prevention and the incumbency of adhering to these measures.
[1] COMMITTEE ON ECONOMIC, SOCIAL AND CULTURAL RIGHTS Twenty-second session Geneva, 25 April-12 May 2000 Agenda item 3 p10
[2] Intensifying prevention, UNAIDS position policy paper August 2005
[3] Observations on Data UNAIDS Middle East ad North Africa Support Team
[4] Observations on Data UNAIDS Middle East ad North Africa Support Team
[5] Draft Middle East and North Africa Briefing Note p3
[6] WHO EMRO , Regional Committee for the Eastern Mediterranean, 54th agenda, agenda item 4a Progress report on HIV/AIDS p3
[7] UNAIDS website
[8]Hind Khattab, Challenges involved in HIV/AIDS Research in the Political, Social and Cultural Context of the Arab, Global Forum for Health Research Forum 10, October 2006
[9] WHO EMRO , Regional Committee for the Eastern Mediterranean, 54th agenda, agenda item 4a Progress report on HIV/AIDS2p3
[10] Doc14
[11] Doc1ap8
[12] http://www.unicef.org/media/media_39599.html
[13] Observations on Data UNAIDS Middle East ad North Africa Support Team, p12
[14] S Watts, Social Determinants of Health in Countries of Conflict: The Eastern Mediterranean region, WHO/EMRO, June 2007, p 20
[15] P 29 S Watts, Social Determinants of Health in Countries of Conflict: The Eastern Mediterranean region, WHO/EMRO, June 2007,
[16] Observations on Data UNAIDS Middle East ad North Africa Support Team p10
[17] Hind Khattab, Challenges involved in HIV/AIDS Research in the Political, Social and Cultural Context of the Arab, Global Forum for Health Research Forum 10, October 2006
[18] Observations on Data UNAIDS Middle East ad North Africa Support Team p8
[19] World Bank, 2002, responses to HIV/AIDs p72
[20] Observations on Data UNAIDS Middle East ad North Africa Support Team p9
[21] Intensifying prevention book p33
P AHRNPAGE 14
[23] World Bank, 2002, responses to HIV/AIDs p76
[24] Intensifying HIV prevention p28
[25] Draft Middle East and North Africa Briefing Note p3
P39[26] Intensifying HIV prevention
[27] Safe, Voluntary, Informed Male Circumcision and Comprehensive HIV Prevention Programming, UNAIDS, June 2007 p2
[28] Male Circumcision, Religion and Infectious diseases: An ecological analysis of 118 developing countries, Drain PK et al http://www.dph.sf.ca.us/sfcityclinic/providers/MaleCircumcisionReligion.pdf
[29] Intensifying HIV prevention p 35
