Figure 1.3 Two Patterns of HIV Infectious Spread in a Population Flow of HIV infection in a general population HIV epidemic
General population
Bridging populations
Core groups
(a) Flow of HIV infection in a concentrated HIV epidemic
General population
Bridging populations
Core groups
(b) Source: Authors.
sensitivity of sexual and injecting attitudes and practices in conservative cultures, such as in MENA, adds a further limitation to behavioral research.34 Individuals may find it difficult to report their true risk practices. Furthermore, it is often not possible to ask explicit questions about sexual behavior, particularly to women. Asking a general question such as “did you have a sexual contact” may lead to an affirmative answer for the wrong reason, because what is defined for these women as a sexual contact may be merely kissing.35 Hence, in addition to reviewing HIV biological measures and risk behavior measures, this report also reviews the evidence for biological markers of risk behavior, including HCV infection prevalence for injecting drug users and STI prevalence, such as that of herpes simplex virus type 2 (HSV-2), for the sexually active populations. These proxy measures can gauge different aspects of the levels of risk behavior in the population and complement and validate reported levels of risk behavior. 34 35
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Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” Hajiabdolbaghi et al., “Insights from a Survey of Sexual Behavior.”
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
Countries covered in this report This report covers all countries that are included in the definition for the MENA Region at the World Bank, the UNAIDS MENA Regional Support Team (RST), and the Eastern Mediterranean Regional Office (EMRO) of WHO. Explicitly, this report includes data on Afghanistan, Algeria, Bahrain, Djibouti, the Arab Republic of Egypt, the Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, the Syrian Arab Republic, Tunisia, the United Arab Emirates, the West Bank and Gaza, and the Republic of Yemen. Considering similarity in the cultural context and geographic proximity, data were also occasionally included for Israel (mainly among Israeli Arabs), Mauritania, and Turkey, when appropriate, bearing in mind that there are still differences in the epidemiological context between these countries and MENA countries. Reflecting the availability of data at the country level, this report included more data from some countries than others. It is by no means an attempt to single out specific countries as opposed to others. The scale of HIV efforts is highly heterogeneous in the region and the level of willingness to share or report confidential data varies from one country to another.
Research methodology The research methodology consists of an evidence-based epidemiological synthesis and analysis to characterize HIV epidemiology and assess HIV epidemic potential. This is achieved by identifying, collecting, reviewing, and analyzing extensive literature to establish the epidemiological risk factors, determine the nature and phases of HIV epidemics, delineate the populations affected, analyze proxy measures, and understand the vulnerabilities and drivers of the epidemic in the MENA context. Identified and reviewed data sources In preparing this report, the following publications, reports, and data sources were identified and reviewed, and their evidence synthesized: