populations in the Republic of Yemen, for example, were not adapted to the languages of those concerned, nor were the messages explicit in terms of transmission modes and prevention methods. Condoms were not included as part of prevention activities, and referrals to VCT were lacking. The situation is compounded by the limited capacities and resources of implementing partners to provide prevention materials, such as condoms and lubricants, and make them accessible as part of outreach activities.24 In a review of programs for IDUs in Egypt, provision of needles, syringes, condoms, and other HIV prevention commodities appeared to be inconsistent at the three sites reviewed.25 The outreach program for MSM in Tunisia is in desperate need of a robust and sustainable procurement system for water-based lubricants for distribution with the prevention kit. The use of condoms in HIV prevention protective strategies is reported to be generally low in the region (chapter 8). Condom use is also low and irregular among people who need them the most, including those reporting multiple and casual unprotected sexual contacts, although utilization rates among such groups are still considerably higher than in the general population (chapter 8). Despite the above evidence, condom promotion, access, and distribution are still conspicuously missing from many HIV prevention programs being implemented in the region. Even when programs have included condoms, access has remained difficult and limited to certain distribution points. Continuing to ignore the sensitive but essential issue of condom accessibility and neglecting the promotion of its protective role for everyone, particularly for people most at risk, are undoubtedly crippling effective HIV prevention efforts, as is the case in many countries of the region.
HIV TESTING AND COUNSELING Initially, most VCT centers across the region were located only in the capital cities as part of governmental health facilities, discouraging those fearing stigma from checking their HIV status. There was substantial delay in the 24 25
204
Semini, Njogou, and Mortagy, UNHCR/UNAIDS Joint Mission. UNAIDS/APMG, Recommendations for Interventions.
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
establishment of VCT services at a community level across the region. Morocco is one of the first countries to establish VCT centers with broad, national coverage. Today, Algeria has expanded its VCT network across the country and more than 75 centers have been established in Sudan. In Lebanon, the innovative model of establishing and managing VCTs through NGOs was adopted by the National AIDS Program and partners.26 However, the recent increase in VCT services has not translated into enhanced prevention efforts or an increased number of those who know their HIV status. A recent review revealed that VCT services are either not available or limited to major cities in most countries.27 Where they exist, these VCT services are underused. Different reasons may account for this, including the absence or low coverage of HIV prevention programs among priority groups and vulnerable and other populations, as well as weak message quality and lack of referrals to the VCT. Other factors could be the general concern that confidentiality may not be maintained and the negative attitudes of service providers in the VCT centers, which have been documented in some countries. The same review has demonstrated that HIV rapid tests have not been fully adopted in MENA. Where they are used, laboratory confirmation of reactive tests requires the use of ELISA (enzyme-linked immunosorbent assay), and, in many cases, Western blot assay. The resulting waiting time and cumbersome procedure for the clients to get their HIV test results increase the risk of losing the client before he or she is informed of the test result. Moreover, the review has shown that the majority of people in MENA learn their HIV status through mandatory testing. Out of tens of millions of HIV tests conducted in the region since 1995, only a little over 400,000 were administered through VCT. All countries of the region (except Djibouti and Morocco, which do mandatory testing only on military recruits to establish physical fitness) have mandated HIV testing for different purposes including preoperative, pre-employment, in-migration, and 26 27
Lebanon National AIDS Control Program, “A Case Study.” WHO/EMRO, “Regional Review of HIV Testing.”