documented evidence for concentrated epidemics among priority groups in several MENA countries, such as the HIV epidemics among IDUs in the Islamic Republic of Iran and Pakistan, which are established concentrated epidemics.77 There is evidence that suggests that this could also be the case in Afghanistan (in Kabul),78 Bahrain,79 Libya,80 North Sudan,81 and Oman.82 There is no definitive evidence of the existence of concentrated epidemics among MSM, the most hidden of all risk groups, in any of the MENA countries. However, there is evidence that suggests that this could be the case in Egypt,83 North Sudan,84 and Pakistan.85 Though the evidence is not strong, there is an indication of an epidemic among MSM in Lebanon; however, it is not yet at the level to be categorized as a concentrated epidemic.86 There is no evidence of the existence of concentrated epidemics among FSWs in this group of MENA countries. HIV prevalence among FSWs has been found on occasions to be substantially higher than that of the general population, but not to the level of concentrated HIV epidemics (greater than 5%). Concentrated epidemics may exist, though, among subgroups of FSWs, such as in southern Algeria.87
HIV epidemic typology in the Subregion with Considerable Prevalence Djibouti,88 parts of Somalia,89 and Southern Sudan90 are in a state of generalized HIV epidemic, 77
Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Rounds I, II, and III); Ministry of Health and Medical Education of Iran, “Treatment and Medical Education.” 78 Todd et al., “HIV, Hepatitis C, and Hepatitis B Infections”; SandersBuell et al., “A Nascent HIV Type 1 Epidemic.” 79 Al-Haddad et al., “HIV Antibodies among Intravenous Drug Users.” 80 UNAIDS, and WHO, AIDS Epidemic Update 2003; Groterah, “Drug Abuse and HIV/AIDS.” 81 Bayoumi, Baseline Survey of Intravenous Drug Users. 82 Aceijas et al., “Global Overview”; Tawilah and Tawil, Visit to Sultane of Oman; Oman MOH, “HIV Risk among Heroin and Injecting Drug Users.” 83 Egypt Ministry of Health and Population, and National AIDS Program, HIV/AIDS Biological and Behavioral Surveillance Survey. 84 Elrashied, “Prevalence.” 85 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Rounds I, II, and III). 86 Mishwar, “An Integrated Bio-Behavioral Surveillance Study” (final report). 87 Fares et al., Rapport sur l’enquête nationale. 88 UNAIDS, “Notes on AIDS in the Middle East and North Africa.” 89 WHO, The 2004 First National Second Generation HIV/AIDS/STI Sentinel Surveillance Survey. 90 Ibid.
defined as an epidemic with an HIV prevalence consistently exceeding 1% among pregnant women.91 However, it appears that the epidemics in Djibouti and Somalia, and possibly Southern Sudan, are dynamically similar to those in West Africa where most HIV infections are concentrated in priority groups and bridging populations. The high HIV prevalence among FSWs in Djibouti92 and Southern Sudan93 suggests that commercial sex networks are playing the central role in these epidemics, just as in West Africa.94 There is no evidence of sustainable general population HIV epidemics in this group of MENA countries. The prevailing epidemics are best understood as concentrated epidemics focused around the commercial sex networks in settings where the size of the commercial sex network is large enough to support an epidemic with a prevalence exceeding 1% in the whole population. Southern Sudan is of particular concern. There are no sufficient data to characterize satisfactorily HIV epidemiology in this part of Sudan. Southern Sudan is the only part of MENA where limited male circumcision coverage is found. It could already be in a state of general population epidemic. With the recent peace treaty, the resettlement of refugees and internally displaced persons (IDPs), demobilization of soldiers, influx of peacekeepers, and mushrooming of commercial centers, there is a concern as to whether there is fertile ground for further HIV expansion in Southern Sudan.95 The two key epidemiologic characteristics that distinguish this subregion of MENA from the Core MENA Region are the concentrated epidemics among FSWs, implying higher levels of risk behavior in commercial sex networks, and the sizes of commercial sex networks, which appear to be significantly larger than those in the rest of MENA.
91
Pisani et al., “HIV Surveillance.” Etchepare, “Programme National de Lutte.” 93 McCarthy, Khalid, and El Tigani, “HIV-1 Infection in Juba, Southern Sudan.” 94 Cote et al., “Transactional Sex”; Alary and Lowndes, “The Central Role of Clients.” 95 NSNAC and UNAIDS, HIV/AIDS Integrated Report South Sudan. 92
Analytical Insights into HIV Transmission Dynamics and Epidemic Potential in MENA
183