Ehsan Mostafavi, DVM, PhD M#U#L# Know your HIV epidemic Ehsan Mostafavi, DVM, PhD Assistant Professor, Director of Department of Epidemiology, Pasteur Institute of Iran Internal Manager, Regional Knowledge Hub for HIV/AIDS Surveillance, mostafavi@pasteur.ac.ir Training course in sampling methods and analysis for surveys among populations at increased risk of HIV 20 – 24 November 2011, Tehran, Iran

Warm up questions What is your estimation about the prevalence of HIV infection in your country? How is the state of HIV Epidemic there? Who has the most effect on the epidemic level in your country?

The main objectives of this section are as follows To understand the definition of HIV epidemic levels. To know what information you need to define the epidemic level in your country. To understand that your country may shift from one level to another one over time. To identify the most-at-risk population in your country.

Classification of HIV epidemics M#U#L# Classification of HIV epidemics For the purposes of surveillance, UNAIDS and WHO suggest a classification that describes the epidemic by its current state; low level, concentrated, or generalized. These categories are suggestions. Countries should know best where new infections are coming from and what type of epidemic exists in their country. Because of the diversity among HIV epidemics, it is critical to “know your epidemic”. HIV prevalence among pregnant women attending clinics in urban areas is generally very similar to prevalence in the adult general population as a whole. “know your epidemic” means understanding how the epidemic differs within subpopulations and in geographical areas.

HIV Epidemic levels low-level Epidemic M#U#L# HIV Epidemic levels HIV Level HIV prevalence low-level Epidemic has not consistently exceeded 5% in any defined most-at-risk population and 1% in pregnant women in urban areas. Concentrated Epidemic consistently over 5% in at least one defined most-at-risk population, although it is below 1% in pregnant women in urban areas. Generalized Epidemic consistently over 1% in pregnant women in urban areas. These numerical cut-off points act as a convenient proxy for classification based on the dynamic of an epidemic.

Base surveillance activities on the type of epidemic Epidemic state, situation Surveillance focus low-level Epidemic HIV has not reached significant levels in populations most at risk for HIV infection as a result of high-risk behaviour. HIV is largely confined to people within populations most at risk for HIV infection as a result of high-risk behaviour. Focus surveillance activities in populations most at risk for HIV. Concentrated Epidemic HIV has spread rapidly in one or more populations most at risk for HIV infection as a result of high-risk behaviour. The epidemic is not yet well established in the general population. Continue surveillance among most-at-risk populations. Begin surveillance activities in the general population, especially in urban areas. Generalized Epidemic The epidemic has matured to a level where transmission occurs in the general population, independent of populations most at risk for HIV. Without effective prevention, HIV transmission continues at high rates in populations most at risk. With effective prevention, prevalence will drop in populations most at risk before they drop in general population. Focus routine surveillance on the general population. Conduct surveillance among populations most at risk for HIV.

Low Level Epidemic In a low-level epidemic, HIV infection has never expanded to a significant level in any most at- risk population, although it may have existed for many years. Infections are largely confined to individuals with higher risk behavior.

Concentrated Epidemic In a concentrated epidemic, HIV was spread rapidly in one or more most-at-risk population, but is not well-established in the general population.

Generalized Epidemic In a generalized epidemic, HIV is firmly established and transmission occurs in the general population (not dependent on most-at-risk population). Although sub-population at high risk may continue to contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic independent of sub-population at higher risk of infection. With effective prevention, in general, prevalence will drop in most-at-risk population before they drop in the general population.

Questions… What is the HIV Epidemic state in your country? Do you have enough information to define it?

Most-At-Risk populations of HIV M#U#L# Most-At-Risk populations of HIV The most-at-risk populations (MARPs) are groups of people who more frequently engage in behaviors that lead to HIV transmission.  They are at increased risk of passing HIV on to others, or of contracting HIV from others and infected at higher prevalence than the general population. In the countries with low-level and concentrated HIV epidemic, these populations account for most HIV infections and are also called “core groups” for HIV transmission. A population at increased risk will become infected at a faster rate than people who are not members of a population at increased risk.

Who are the MARPs? The risky behaviors that lead MARPs to HIV transmission include: Unprotected sex Sex with multiple partners Use of the same injecting equipment Throughout the world, men who have sex with men (MSM), female sex workers (FSWs) and their clients, and injecting drug users (IDUs) are considered most-at-risk populations. Mobile populations such as migrants, uniformed personnel, refugees and internally displaced persons, street children and prisoners are the other MARPs in some countries.

Why are MARPs important? M#U#L# Why are MARPs important? Many of the MARPs are marginalized, and in many countries their behavior is illegal. Because of stigma, discrimination and often illicit nature of their behaviors, they are difficult to reach so they also called hard to Reach Population. MARPs also can serve as bridges to other groups and the general population. As they play very important role in the HIV epidemic, it’s an essential priority for the health sector to recognize them, runs Bio-behavioral Surveillance Surveys among MARPs and delivers a range of interventions to reduce HIV transmission through them. An infected prisoner can have unprotected sex with his wife, infecting her. In this scenario, he has acted as a bridge, from which HIV infection has passed from the prisoner to his wife as one of the member of general population.

MARPs in the Middle East and North Africa

MARPs in the Middle East and North Africa M#U#L# MARPs in the Middle East and North Africa In MENA there is often stigma surrounding HIV especially because of cultural and religious beliefs. HIV epidemics are comparatively small and most infections are occurring in urban areas - except in Southern Sudan, where a more extensive epidemic is under way. HIV affects classical key populations at higher risk of HIV exposure including male who have sex with men, female sex workers and injecting drug users. Prisons are one of the high risk locations and some HIV epidemics have been reported in them. At least two broad epidemiological patterns are contributing to the spread of HIV. Contracting HIV while living abroad. Transmission within key populations. many people in the region are contracting HIV while living abroad, often exposing their sexual partners to infection upon their return to their home country.

MARPs in the Middle East and North Africa HIV has spread among injecting drug users in particular in Iran, Libya, Pakistan, and Afghanistan, and according to available data it features in the epidemics of Algeria, Morocco, Tunisia, Egypt and Syria. In this region, almost 50% of people living with HIV are women but in countries such as Iran, where injecting drug users are the main key populations at higher risk for HIV exposure, estimated females who live with HIV are less than 30% and HIV positive children are a few. As in many other regions, sex between men is officially forbidden and socially stigmatized. Nevertheless, the limited information available suggests that unprotected sex between men is a key factor in at least some of the epidemics in this region.

Definitions of High Risk Groups for HIV Surveillance in the Middle East and North Africa INJECTING DRUG USERS: Men/women who used non-therapeutic drugs by the injection route in the last month. MEN WHO HAVE SEX WITH MEN: Men who had anal sex, receptive or insertive, with men in the last six months. FEMALE SEX WORKERS: Women who had sex in exchange for money or goods in the last one month for ‘direct FSWs’ and in the last twelve months for ‘indirect’ FSWs.

Thank you