worker.170 In Saudi Arabia, 90% of men who were infected with HIV heterosexually acquired it from FSWs.171 In Somalia, two studies reported that 40%172 and 54%173 of STD clinic attendees reported contacts with FSWs. In Sudan, 49.3% of STD patients reported acquiring their infection from FSWs.174 HIV prevalence in Southern Sudan was 14% among men who reported contacts with FSWs, but 0% among men who denied such contacts.175
Anal sex, oral sex, and STIs as cofactors Several studies have documented anal and oral sex practices in MENA. In Pakistan, FSWs in different cities reported having anal sex with a range of 0.6–4.1 clients last month.176 In Sudan, about 55% of FSWs reported engaging in anal sex and 40% did so regularly.177 Most often this was demanded or imposed by clients, but on occasion FSWs opted for anal sex to avoid pregnancy or to avoid having vaginal sex during menstruation.178 The HIV transmission probability per coital act in unprotected receptive anal intercourse (0.0082)179 is much higher than that of vaginal intercourse (0.0015).180 Oral sex appears to be common and was reported by 40% of FSWs in a study in Sudan.181 In Pakistan, FSWs in different cities reported oral sex with a range of 0.6–3.8 clients last month.182 Only 3% of FSWs in a study in Sudan reported refraining from sex while suffering from a reproductive tract infection, a practice of concern considering the biological association of HIV transmission and STI coinfections.183
Engagement of FSWs in injecting drug risk behavior FSWs report considerable levels of drug use both in injecting and noninjecting forms, and also report having sex with IDUs. These facts highlight the ease by which HIV can move between IDUs and FSWs. In particular, FSWs who inject drugs, or female IDUs who exchange sex for money or drugs, form subgroups at a heightened risk of HIV exposure, as has been seen in Asia.184 These FSWs are highly marginalized and in urgent need of prevention and care programs. Several studies have documented drug use among FSWs and sexual contacts with IDUs, but the data on female IDUs exchanging sex for money are limited. In Egypt, 9.3% of FSWs injected drugs and 78.8% used drugs.185 In the Islamic Republic of Iran, 2% of a group of mainly FSWs injected drugs and 15.3% reported noninjecting drug use.186 In another study, 2.5% of FSWs injected drugs and 60% used drugs.187 In Pakistan, 20% of FSWs reported that they had clients whom they knew to inject drugs and 1%–2% of FSWs reported injecting drugs.188 Also, in two studies in Pakistan, 3.3%189 and 2.3%190 of FSWs reported injecting drugs in the last six months and 13.5%191 and 9.9%192 had sex with IDUs. In yet more studies from Pakistan, 3% of FSWs reported injecting drugs in the last year,193 36% reported having sex with an IDU in the last year,194 20.3% reported IDUs as clients,195 22.4% reported lovers who inject drugs,196 and 26% reported having a husband who injects drugs.197 184
Commission on AIDS in Asia, Redefining AIDS in Asia. Egypt MOH and Population National AIDS Program, HIV/AIDS Biological and Behavioral Surveillance Survey. 186 Jahani et al., “Distribution and Risk Factors.” 187 Tehrani and Malek-Afzalip, “Knowledge, Attitudes and Practices.” 188 Bokhari et al., “HIV Risk in Karachi and Lahore, Pakistan.” 189 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). 190 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II). 191 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). 192 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round II). 193 Mayhew et al., “Protecting the Unprotected”; Hawkes et al., “HIV and Other Sexually Transmitted Infections.” 194 Hawkes et al., “HIV and Other Sexually Transmitted Infections.” 195 Mayhew et al., “Protecting the Unprotected.” 196 Ibid. 197 Hawkes et al., “HIV and Other Sexually Transmitted Infections.” 185
170
Rehan, “Profile of Men.” Alrajhi, Halim, and Al-Abdely, “Mode of Transmission of HIV-1.” 172 Burans et al., “HIV Infection Surveillance in Mogadishu, Somalia.” 173 Ismail et al., “Sexually Transmitted Diseases in Men.” 174 Omer et al., “Sexually Transmitted Diseases in Sudanese Males.” 175 McCarthy, Khalid, and El Tigani, “HIV-1 Infection in Juba, Southern Sudan.” 176 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). 177 Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” 178 Ibid. 179 Vittinghoff et al., “Per-Contact Risk.” 180 Wawer et al., “Rates of HIV-1 Transmission.” 181 Ati, “HIV/AIDS/STIs Social and Geographical Mapping.” 182 Pakistan National AIDS Control Program, HIV Second Generation Surveillance (Round I). 183 Korenromp et al., “Estimating the Magnitude.” 171
52
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa