are coming from within the already existing sexual and injecting drug risk networks. MENA countries have made enormous progress in controlling parenteral HIV transmissions due to contaminated blood and poor safety measures. Nonetheless, the region as a whole is failing to control HIV spread along the contours of risk and vulnerability, despite promising recent efforts, such as in the Islamic Republic of Iran and Morocco. Priority populations, including IDUs, MSM, and FSWs, are documented to exist in every country of MENA. With the volume of evidence collected in this synthesis, there is no more room for denial that risk behaviors do exist and indeed are common in MENA.
Number of HIV infections It is estimated that Sudan has the largest number of HIV infections, about 320,000 to 350,000, which account for roughly 60% of all HIV infections in the broad definition of the MENA region used in this report (chapter 1).96 The majority of infections in this country appear to be concentrated in Southern Sudan, where the limitations in terms of public health are most severe.97 HIV prevalence in Southern Sudan is estimated to be up to eight times higher than that in the capital, Khartoum.98 For the rest of the MENA countries, the estimated number of HIV infections ranges between a few hundred in the small countries to tens of thousands in the larger countries.99 It is important to note that these estimates have wide confidence margins and are based on limited data. Given the evidence collected in this synthesis, there might be room to conduct a more precise quantitative assessment of the number of HIV infections. Reported numbers of HIV cases remain small and most HIV infections appear to be occurring in men and in urban areas.100 However, the number of case notifications has been increasing 96
UNAIDS, AIDS Epidemic Update 2007; SNAP, “Update on the HIV Situation in Sudan;” UNAIDS Country Database 2007, http:// www.unaids.org/en/CountryResponses/Countries/default.asp. 97 Del Viso, “UNDP Supports HIV/AIDS/STD Project”; Mandal, Purdin, and McGinn “A Study of Health Facilities.” 98 SNAP, HIV/AIDS/STIs Prevalence. 99 UNAIDS, AIDS Epidemic Update 2007; UNAIDS Country Database 2007, http://www.unaids.org/en/CountryResponses/Countries/ default.asp. 100 WHO/EMRO Regional Database on HIV/AIDS. 186
Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa
in recent years.101 The large fraction of AIDS cases among newly discovered HIV infections and the short interval from HIV notification to AIDS diagnosis102 suggest that HIV diagnosis and testing rates are low, and that a large fraction of HIV infections are being missed. The inertia in diagnosing HIV infections may be preventing a prompt response to ongoing or emerging HIV epidemics.
HIV prevalence HIV prevalence overall continues to be at low levels compared to other regions. The overarching pattern is that of very limited HIV spread in the general population but growing epidemics in priority populations, including IDUs and MSM and, to a lesser extent, FSWs. Although there is a considerable fraction of HIV infections that are being characterized as unknown,103 these infections possibly reflect the under-reporting of risky behavior due to the perceived adverse consequences that might come with admitting to culturally unacceptable behavior. The epidemic has reached the stages of a generalized epidemic, prevalence greater than 1% among pregnant women, in three countries, and the stages of a concentrated epidemic, prevalence greater than 5% in at least one priority group, in several other countries. The levels of reported sexual and injecting drug risk behaviors are substantial among the majority of the priority populations and are comparable to levels reported in other regions. The levels of proxy biomarkers including sexually transmitted infections (STIs) and HCV are also substantial in these groups. These facts confirm the potential for HIV infection to spread among at least some of the priority populations. HIV is spreading at different rates among priority populations. Consistent with global patterns,104 IDU epidemics are the fastest in terms of speed of growth. In Pakistan, HIV prevalence was 0.63% at the end of 2003 at a 101
WHO/EMRO Regional Database on HIV/AIDS; Madani et al., “Epidemiology of the Human Immunodeficiency Virus.” 102 WHO/EMRO Regional Database on HIV/AIDS; Chemtob and Srour, “Epidemiology of HIV Infection among Israeli Arabs.” 103 UNAIDS and WHO, AIDS Epidemic Update 2006. 104 Piyasirisilp et al., “A Recent Outbreak”; Nguyen et al., “Genetic Analysis.”