those who are sexually active.118 Islamic cultural traditions have been cited as a protective factor even after adjustment for male circumcision.119 While Islamic values provide protection against HIV/AIDS,120 several studies suggest that adherence to Islamic codes of conduct is not perfect and that Muslims do engage in sexual and injecting drug activities not sanctioned in Islam.121 What is promoted religiously is not necessarily what is put into practice.122 Though the social fabric of MENA societies is heavily influenced by Islamic traditions, the region is also experiencing a sociocultural transition that is leading to more tolerance and acceptance of behaviors such as premarital sex and extramarital sex.123 The evidence for recent increases in risky behavior points to this direction (see youth section in chapter 9). Counting only on the “cultural immunity” of religious and traditional mores124 is not enough to prevent the worst of the HIV epidemic.
Overlap of risky behaviors A hallmark of risky behavior in MENA is the intersection of priority groups, with abundant evidence of overlapping risk factors.125 The social, sexual, and injecting drug networks of priority groups overlap and intersect, allowing HIV to easily propagate between different priority populations (figure 11.2). HIV is spreading from one priority group to another. In the Islamic Republic of Iran and Pakistan, the epidemic among MSM appears to have been sparked by ample overlap with injecting drug practices.126 If HIV establishes itself in one priority population, it can easily find ways to spread through the overlapping risks to other priority populations.
118
Gilbert, “The Influence of Islam.” Hargrove, “Migration, Mines and Mores.” 120 Ridanovic, “AIDS and Islam.” 121 Gilbert, “The Influence of Islam”; Gibney et al., “Behavioural Risk Factors”; Kagimu et al., “Evaluation of the Effectiveness.” 122 Ridanovic, “AIDS and Islam.” 123 Busulwa, “HIV/AIDS Situation Analysis Study.” 124 Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan.” 125 UNAIDS, “Fact Sheet on Drug Use.” 126 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Rounds I, II, and III); Eftekhar et al., “Bio-Behavioural Survey on HIV.” 119
188
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Figure 11.2 A Schematic Diagram of the Overlap between Priority Populations in MENA
IDUs
FSWs
MSM
Source: Authors.
Risk network structures are not well understood Network structures among priority populations, and even the general population, appear to be complex and intricate and are not yet well understood. Some of the injecting drug and sexual networks appear to be sparse, consisting of many subcomponents that are loosely connected to each other. Each of these components is small and tightly knit, such as possibly among IDUs in Lebanon.127 Figure 10.3a illustrates this kind of network. Networks of this nature are not conducive to substantial HIV spread because the infection finds many obstacles in propagating from one subcomponent to another. It is not yet determined whether the sparse nature of some network structures has contributed to the limited HIV prevalence in MENA.
Vulnerability of spouses and other regular sexual partners Ample evidence documents men acquiring the infection through high-risk practices including IDU and sexual contacts with FSWs or other males, and then passing the infection to their wives. Matrimony, rather than sexual or injecting risk behavior, is the leading risk factor for HIV infection among women in MENA. Sexual partners of priority populations form a key group at risk of exposure to HIV, but they appear to rarely engage in risky behavior or pass the infection further. Ninety-seven percent of HIV-positive women in Saudi Arabia, who 127
Mishwar, “An Integrated Bio-Behavioral Surveillance Study” (midterm and final report).