being concentrated in priority groups, as delineated in this synthesis. Despite this limitation, the region has seen the foundation of a number of effective NGOs working on HIV efforts in recent years. By the mid1990s, there were at least 100 NGOs in MENA involved in HIV/AIDS prevention and education, although with limited capacity.20 There are a growing number of NGOs and associations in countries such as Algeria, Djibouti, the Arab Republic of Egypt, the Islamic Republic of Iran, Jordan, Lebanon, Morocco, and Sudan. These organizations provide much needed support for HIV prevention and treatment, including outreach centers for IDUs, FSWs, and MSM. Some of the NGOs have made impressive achievements, such as the comprehensive harm reduction approach by the Iranian NGO Persepolis that provides needle exchange, methadone maintenance, general medical care, VCT, and referral.21 In the Islamic Republic of Iran, NGOs have played a leading role in the transformation to effective policies as well as the promotion of close cooperation between health authorities, prison departments, judiciary authorities, academic institutions, religious leaders, and other stakeholders.22 Another achievement is Helem in Lebanon, the first and only aboveground organization working with MSM in MENA.23 Helem has made admirable contributions in addressing the health, legal, psychological, and social needs of MSM, by far the most culturally sensitive group of all priority groups.24 Helem is also involved in scientific surveillance research work and VCT efforts with MSM.25 In Djibouti, there have been a number of initiatives to address the high-risk behaviors among truck drivers and FSWs along the trade corridor, such as the High Risk Corridor Initiative.26
The attitude toward NGOs from outside the region can be negative among MENA populations.27 There is no escaping the fact that grassroots NGOs need to be developed within MENA. Considering the cultural sensitivity of working with priority groups, a successful formula for HIV efforts may be government organized NGOs (GONGOs), where governments fund and support NGOs to discreetly provide services to priority groups, such as sex worker self-help groups.28 NGOs may enable governments to deal with priority groups indirectly, thereby avoiding cultural sensitivities in explicit outreach efforts among stigmatized populations.29 Discreet interventions for HIV prevention have been proven effective in Bangladesh,30 Lebanon,31 Morocco,32 and Pakistan.33
RECOMMENDATION 5: AN OPPORTUNITY FOR PREVENTION There is still an opportunity for prevention that should not be missed to avert a larger epidemic34 and avoid the health and socioeconomic cost that the MENA region is largely unprepared to pay.35 It appears that there is increasingly a political feasibility for implementing and scaling up interventions, including those involving priority populations.36 Resources need to be allocated for interventions for the priority populations irrespective of whether these groups are “culturally safe” or not.37 Developing mechanisms for working with priority populations, even if discreetly, need to be explored. Efforts in MENA continue to be focused on awareness-raising activities among the general population, which is the group at the lowest risk of infection. 27
Blowfield, “Fundamentalists Call the Shots.” Jenkins, “Report on Sex Worker Consultation in Iran.” 29 Razzaghi et al., “HIV/AIDS Harm Reduction in Iran”; Vazirian et al., “Needle and Syringe Sharing.” 30 Jenkins et al., “Male Prostitutes.” 31 Jenkins and Robalino, “HIV in the Middle East and North Africa.” 32 Tawil et al., “HIV Prevention”; Boushaba et al., “Marginalization and Vulnerability.” 33 Jenkins et al., “Male Prostitutes.” 34 Khawaja et al., “HIV/AIDS and Its Risk Factors in Pakistan”; World Bank, “Preventing HIV/AIDS in the Middle East and North Africa”; Zaheer et al., “STIs and HIV in Pakistan.” 35 Jenkins and Robalino, “HIV in the Middle East and North Africa.” 36 Buse, “Political Feasibility of Scaling-Up.” 37 UNAIDS, “Notes on AIDS in the Middle East and North Africa”; Jordan National AIDS Program, “National HIV/AIDS Strategy for Jordan 2005–9.” 28
20
Wahdan, “The Middle East.” Razzaghi et al., “HIV/AIDS Harm Reduction in Iran”; Vazirian et al., “Needle and Syringe Sharing.” 22 Razzaghi et al., “HIV/AIDS Harm Reduction in Iran”; Ohiri et al., “HIV/ AIDS.” 23 Lebanon National AIDS Control Program, “A Case Study” (2008a). 24 International HIV/AIDS Alliance, “Supporting Men Who Have Sex with Men in Lebanon,” http://www.aidsalliance.org/sw51051.asp, accessed on January 12, 2007. 25 Mishwar, “An Integrated Bio-Behavioral Surveillance Study”; Lebanon National AIDS Control Program, “A Case Study” (2008a); Lebanon National AIDS Control Program, “A Case Study” (2008b). 26 O’Grady, “WFP Consultant Visit to Djibouti Report.” 21
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