Characterizing the HIV Epidemic in the Middle East The MENA HIV/AIDS Epidemiology and Response Synthesis Project is financed as a joint activity by the World Bank (MENA Region); GAMET; UNAIDS MENA RST; and WHO/EMRO Laith J. Abu-Raddad Fred Hutchinson Cancer Research Center Seattle, Washington, U.S.A

The MENA region falls into “a real hole in terms of epidemiological data” Mark Kline, International Pediatric AIDS Initiative Baylor College of Medicine

Epidemiologic evidence in MENA Substantial increase in HIV epidemiological evidence in recent years Evidence suffers from methodological limitations with a minority of high quality data Evidence is amorphous, broadly distributed, not normally or easily available, and often unpublished

MENA HIV/AIDS Epidemiology and Response Synthesis Project Goal: To conduct an evidence-based and data-driven synthesis and review to produce a coherent and well-integrated picture of HIV transmission trends and dynamics in the region.

Middle East and North Africa HIV/AIDS Epidemiology Synthesis Project Sources of data Medline (PubMed) literature search of HIV and sexual behavior Literature search of local journals, other academic publications, and DHS reports International organizations reports (UNAIDS, WHO, World Bank, UNICEF, UNODC…etc) Country-level reports, government publications, institutional reports (National AIDS Programs, Ministries of Health…etc) Consultations with key experts, public health officials, researchers, and academics in the region and beyond

Injecting drug users: Synthesis Pattern: Low HIV prevalence in some settings High HIV prevalence (>20%) in other settings About half of IDUs in the region share injecting utensils (needle or syringe) High HCV prevalence in most settings

Men who have sex with men: Synthesis Pattern: Documented evidence of HIV spread among MSMs in the region Considerable evidence of high risk behavior among MSMs

Female sex workers: Synthesis Pattern: Apart from notable exceptions, HIV prevalence appears to be at relatively low levels but considerably higher than the general population Considerable evidence of high risk behavior among FSWs Substantial prevalence of STIs among FSWs

General population: Synthesis Apart from notable exceptions, consistently very low HIV prevalence in pregnant women, blood donors, and other general population groups Levels of sexual risk behavior tend to be generally on the low side Low levels of HSV-2, HPV and cervical cancers

Summary of 53 million HIV tests from country reports provided to the WHO HIV prevalence of 0.1%

An opportunity for prevention! Generally speaking HIV transmission appears to be focused in most at risk groups and their partners with limited inroads into the general population Though we already have concentrated epidemics in some most at risk groups, most epidemics appear to be still at low prevalence or early concentrated epidemic stages

Risk and vulnerability There are most at risk groups in every country of the region There are substantial levels of risk behavior among most at risk groups suggesting the potential for further spread of HIV There are various settings of vulnerabilities such as prisons, migration and mobility, youth, and gender We need to focus the programmatic response where the risks are

How can we know better? Surveillance of most at risk groups, bridge populations, and vulnerability settings. Size estimation of most at risk groups and bridge populations Trends of risk behavior and HIV prevalence

Acknowledgement Collaborators World Bank: F. Ayodeji Akala (MENA Region); David Wilson and Juliana Victor-Ahuchogu (GAMET) Iris Semini and Oussama Tawil (UNAIDS MENA RST) Gabriele Riedner (WHO/EMRO)