21% of women in MENA are not married by age 30–39.150 In nearly half of the countries, women spend about one-third of their sexual activity lifespan (15–49 years of age) in an unmarried state.151 In Lebanon, about one out of five men and women aged 35–39 years was still single in 1996.152 In Algeria, Jordan, Kuwait, Lebanon, Libya, Morocco, Qatar, Syria, Tunisia, and the West Bank and Gaza, between 10% and 25% of women are never married.153 Even in a highly traditional and underdeveloped country such as the Republic of Yemen, marriage among women 15–19 years old declined from 27% to 17% between 1997 and 2003.154 Early and near universal marriage, where almost all adults spend most of their sexual activity lifetime being married, was once the highlight of this region. Yet, it will soon become the exception rather than the norm.155 In large part, the demographic transition in MENA is driven by stark changes in nuptiality.156
Youth and priority populations Youth contribute disproportionately to the priority populations in MENA, attesting to the vulnerability of this population group. Being an unemployed youth is a frequent characteristic of IDUs.157 Drug use in different forms appears to be considerable and probably increasing among youth in MENA.158 The profile of IDUs in a Tunisian study was that of young men raised in large families shattered by urban-rural migration.159 Among young prisoners in the Islamic Republic of Iran, 33.9% of inmates used opioid while in prison.160 IDUs in Oman reported hashish as their first drug at a mean age of 18, and then IDU of heroin at age 22.161 The largest burden of drug use in the West Bank and Gaza is in the 31–40 years age group, with a notable increase in drug use among 150
Ibid. Ibid. 152 Saxena, Kulczycki, and Jurdi, “Nuptiality Transition.” 153 Roudi-Fahimi and Ashford, “Sexual & Reproductive Health.” 154 Ibid. 155 Rashad, “Demographic Transition in Arab Countries.” 156 Ibid. 157 Zamani et al., “High Prevalence of HIV.” 158 Ibid. 159 Tiouiri et al., “Study of Psychosocial Factors.” 160 Bolhari and Mirzamani, “Assessment of Substance Abuse in Iran’s Prisons.” 161 Oman MOH, “HIV Risk among Heroin and Injecting Drug Users.” 151
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youth.162 Among high school students, marijuana was used by 2%–2.9% of males and 0.7%–1% of females, and heroin was used by 0.8%–1% of males and 0.4%–0.6% of females.163 The average age at first use of different forms of drugs ranged between 12.8 and 14.75 years for males and 12 and 16 years for females.164 Peer pressure was found to be a key determinant of starting drug use among these adolescents.165 The knowledge of harm was generally poor and multiple use of different drugs was reported by a considerable share of these users.166 The lack of engagement in meaningful activities is conducive to risky behavior in MENA. Of high school students in the West Bank and Gaza, 38.2% of males and 5.2% of females spend evenings hanging in streets, and among heroin users, these percentages were 66.7% for males and 42.9% for females.167 For MSM, more than half of the participants in a study in Sudan (60.1%) were between 15 and 24 years of age, and 85.5% of them had their first anal experience between the ages of 15 and 25.168 MSM tend to start having sex at a younger age compared to males who have sex with females.169 In Lebanon, 54% of MSM reported having their first anal sex at under the age of 18 years.170 In Egypt, young MSM were the group that changed their sexual partners most often among MSM.171 Also in Egypt, young MSM were found to be the most sexually active, with a frequency of sexual acts greater than one per day.172 In studies in Pakistan, male sex workers (MSWs) had an average age of 22.3,173 21.3,174 and 21.7175 years, and started
162
Shareef et al., “Drug Abuse Situation.” Afifi and El-Sousi, “Drug Abuse and Related Behaviors.” 164 Ibid. 165 Ibid. 166 Ibid. 167 Ibid. 168 Elrashied, “Generating Strategic Information.” 169 Monasch and Mahy, “Young People.” 170 Mishwar, “An Integrated Bio-Behavioral Surveillance Study.” 171 El-Rahman, “Risky Behaviours for HIV/AIDS Infection.” 172 El-Sayyed, Kabbash, and El-Gueniedy, “Risk Behaviours for HIV/AIDS Infection.” 173 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). 174 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II). 175 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round III). 163