The struggle for recognition by people living with HIV/AIDS in Sudan

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.

HIV incidence and impact of interventions among female sex workers and their clients in the Middle East and north Africa: a modelling study

BACKGROUND

The incidence of HIV infection among female sex workers and their clients in the Middle East and north Africa is not well known. We aimed to assess HIV incidence, the contribution of heterosexual sex work networks to these numbers, and the effect of interventions by use of mathematical modelling.

METHODS

In this modelling study, we developed a novel, individual-based model to simulate HIV epidemic dynamics in heterosexual sex work networks. We applied this model to 12 countries in the Middle East and north Africa that had sufficient data to estimate incidence in 2020 and the impact of interventions by 2030 (Algeria, Bahrain, Djibouti, Iran, Libya, Morocco, Pakistan, Somalia, South Sudan, Sudan, Tunisia, and Yemen). Model-input parameters were provided through a systematic review of HIV prevalence, sexual and injecting behaviours, and risk group size estimates of female sex workers and clients. Model output was number of incident HIV infections under different modelling scenarios for each country. Summary statistics were generated on these model output scenarios.

FINDINGS

Based on the output of our model, we estimated a total of 14 604 (95% uncertainty interval [UI] CI 7929-31 819) new HIV infections in the 12 countries in 2020 among female sex workers, clients, and spouses, which constituted 28·1% of 51 995 total new cases in all adults in these 12 countries combined. Model-estimated number of new infections in 2020 in the 12 countries combined was 3471 (95% UI 1295-10 308) in female sex workers, 6416 (3144-14 223) in clients, and 4717 (3490-7288) in client spouses. Contribution of incidence in heterosexual sex work networks to total incidence varied widely, ranging from 3·3% in Pakistan to 71·8% in South Sudan and 72·7% in Djibouti. Incidence in heterosexual sex work networks was distributed roughly equally among female sex workers, clients, and client spouses. Estimated incidence rates among female sex workers per 1000 person-years ranged from 0·4 (95% UI 0·0-7·1) in Yemen to 34·3 (17·2-59·6) in South Sudan. In countries where HIV acquisition through injecting drug use creates substantial exposure for female sex workers who inject drugs, estimated incidence rates per 1000 person-years ranged from 5·1 (95% UI 0·0-35·1) in Iran to 45·8 (0·0-428·6) in Pakistan. The model output predicted that any of the programmed interventions would substantially reduce incidence. Even when a subpopulation did not benefit directly from an intervention, it benefited indirectly through reduction in onward transmission, and indirect impact was often half as large as the direct impact.

INTERPRETATION

Substantial HIV incidence occurs in heterosexual sex work networks across the Middle East and north Africa with client spouses being heavily affected, in addition to female sex workers and clients. Rapid scaling-up of comprehensive treatment and prevention services for female sex workers is urgently needed.

FUNDING

Qatar National Research Fund (a member of Qatar Foundation), the Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medicine-Qatar, Qatar University-Marubeni, the UK Medical Research Council, and the UK Department for International Development.

'You just prefer to die early!': how socioecological context impedes treatment for people living with HIV in Iran

Introduction

Despite the low prevalence of HIV and broad provision of antiretroviral therapy, the Middle East and North Africa (MENA) remains the only region where new HIV infections and AIDS-related deaths are not declining. There is a dearth of evidence from MENA on antiretroviral therapy engagement. In this qualitative study, we sought to identify the ways in which successful treatment is hindered in Iran, which is home to 24% of HIV infections in MENA.

Methods

From August 2018 to January 2019, we used purposive sampling and conducted 12 individual interviews and 8 focus group discussions with 27 female and 31 male patients, in addition to 5 individual interviews with HIV care providers and 1 focus group discussion with 8 care providers. Social constructivism augmented with realist-informed thematic analysis was used to understand how the socioecological context triggers cognitive and affective mechanisms that disrupt antiretroviral therapy.

Results

The use of Thematic Network Analysis resulted in the identification of three key cognitive and affective mechanisms that appear to shape treatment experience and are triggered via HIV’s socioecological context and changing economic conditions in Iran: denial in response to societal negative perceptions of HIV; fear in response to societal lack of awareness regarding HIV and misinformation; and despair in response to HIV-related stigma and enacted discrimination, economic insecurity and social support.

Conclusions

To our knowledge, this is the first study within MENA to identify pathways through which successful treatment is hindered. It appears that lack of societal awareness regarding HIV is specific to low prevalence settings, such as MENA countries, where negative perceptions, stigma, discrimination and misinformation regarding HIV and its treatment produce denial, fear and despair, acting as mechanisms that disrupt antiretroviral therapy. The experience of despair, in response to changing economic conditions and social support, further impacts treatment experience.

Tailored mHealth intervention for improving treatment adherence for people living with HIV in Iran (HamRaah): protocol for a feasibility study and randomised pilot trial with a nested realist evaluation

INTRODUCTION

Middle East and North Africa (MENA) has a rising rate of new HIV infections and AIDS-related mortality. Consistent adherence to antiretroviral therapy (ART) leads to viral suppression, preventing HIV transmission and treatment failure. mHealth interventions can improve ART adherence by providing tailored support and directing patients to existing healthcare services. HamRaah (Persian for 'together-in-path') is the first mHealth-based intervention in a MENA country and is designed to improve adherence through two-way mobile messaging for people recently diagnosed with HIV in Tehran, Iran. The objectives of this pilot randomised controlled trial (RCT) are to examine the feasibility, acceptability and preliminary effectiveness of HamRaah, and to develop an explanatory theory for any observed effects through a nested realist evaluation.

METHODS

A feasibility study and two-arm RCT of HamRaah, with an embedded realist evaluation will be conducted. Participants will be randomised 1:1 to HamRaah or routine care for a 6-month intervention. The initial effectiveness of HamRaah will be assessed through the primary outcome of self-reported ART adherence and several secondary outcomes: retention in care, CD4 count and viral suppression. A theory-driven realist evaluation framework will be used to develop an explanatory theory regarding what works, for whom, how and in what context.

ETHICS AND DISSEMINATION

The study received ethical clearance from Tehran University of Medical Sciences Ethics Committee and Oxford Tropical Research Ethics Committee People living with HIV in Tehran and key country stakeholders in HIV policy and programming have been involved in the development of HamRaah and this pilot trial. Participants will provide informed consent prior to study enrolment. The results will be disseminated to all stakeholders and presented in peer-reviewed journal publications and conferences.

TRIAL REGISTRATION NUMBER

IRCT20100601004076N23; Pre-results.

Epidemiology of Treponema pallidum, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 among female sex workers in the Middle East and North Africa: systematic review and meta-analytics

BACKGROUND

The epidemiology of sexually transmitted infections (STIs) and the role of commercial heterosexual sex networks in driving STI transmission in the Middle East and North Africa (MENA) region remain largely unknown.

OBJECTIVE

To characterize the epidemiology of Treponema pallidum (syphilis), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 (HSV-2) among female sex workers (FSWs) in MENA using an in-depth quantitative assessment.

METHODS

A systematic review on ten international, regional, and country-level databases was conducted, and reported following PRISMA guidelines. Pooled prevalences of current and/or ever infection for each STI were estimated using random-effects meta-analyses. Sources of between-study heterogeneity were investigated through random-effects meta-regressions.

RESULTS

One T. pallidum incidence study and 144 STI prevalence studies were identified for 45 812 FSWs in 13 MENA countries. The pooled prevalence of current infection was 12.7% (95% confidence interval (CI) = 8.5%-17.7%) for T. pallidum, 14.4% (95% CI = 8.2%-22.0%) for C. trachomatis, 5.7% (95% CI = 3.5%-8.4%) for N. gonorrhoeae, and 7.1% (95% CI = 4.3%-10.5%) for T. vaginalis. The pooled prevalence of ever infection (seropositivity using antibody testing) was 12.8% (95% CI = 9.4%-16.6%) for T. pallidum, 80.3% (95% CI = 53.2%-97.6%) for C. trachomatis, and 23.7% (95% CI = 10.2%-40.4%) for HSV-2. The multivariable meta-regression for T. pallidum infection demonstrated strong subregional differences, with the Horn of Africa and North Africa showing, respectively 6-fold (adjusted odds ratio (AOR): 6.4; 95% CI = 2.5-16.7) and 5-fold (AOR = 5.0; 95% CI = 2.5-10.6) higher odds of infection than Eastern MENA. There was also strong evidence for declining T. pallidum odds of infection at 7% per year (AOR = 0.93; 95% CI = 0.88-0.98). Study-specific factors including diagnostic method, sample size, sampling methodology, and response rate, were not associated with syphilis infection. The multivariable model explained 48.5% of the variation in T. pallidum prevalence.

CONCLUSIONS

STI infection levels among FSWs in MENA are considerable, supporting a key role for commercial heterosexual sex networks in transmission dynamics, and highlighting the health needs of this neglected and vulnerable population. Syphilis prevalence in FSWs appears to have been declining for at least three decades. Gaps in evidence persist for multiple countries.

HIV epidemiology among female sex workers and their clients in the Middle East and North Africa: systematic review, meta-analyses, and meta-regressions

BACKGROUND

HIV epidemiology among female sex workers (FSWs) and their clients in the Middle East and North Africa (MENA) region is poorly understood. We addressed this gap through a comprehensive epidemiological assessment.

METHODS

A systematic review of population size estimation and HIV prevalence studies was conducted and reported following PRISMA guidelines. Risk of bias (ROB) assessments were conducted for all included studies using various quality domains, as informed by Cochrane Collaboration guidelines. The pooled mean HIV prevalence was estimated using random-effects meta-analyses. Sources of heterogeneity and temporal trends were identified through meta-regressions.

RESULTS

We identified 270 size estimation studies in FSWs and 42 in clients, and 485 HIV prevalence studies in 287,719 FSWs and 69 in 29,531 clients/proxy populations. Most studies had low ROB in multiple quality domains. The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range = 0.2-2.4%) and of men reporting currently/recently buying sex was 5.7% (range = 0.3-13.8%). HIV prevalence ranged from 0 to 70% in FSWs (median = 0.1%) and 0-34.6% in clients (median = 0.4%). The regional pooled mean HIV prevalence was 1.4% (95% CI = 1.1-1.8%) in FSWs and 0.4% (95% CI = 0.1-0.7%) in clients. Country-specific pooled prevalence was < 1% in most countries, 1-5% in North Africa and Somalia, 17.3% in South Sudan, and 17.9% in Djibouti. Meta-regressions identified strong subregional variations in prevalence. Compared to Eastern MENA, the adjusted odds ratios (AORs) ranged from 0.2 (95% CI = 0.1-0.4) in the Fertile Crescent to 45.4 (95% CI = 24.7-83.7) in the Horn of Africa. There was strong evidence for increasing prevalence post-2003; the odds increased by 15% per year (AOR = 1.15, 95% CI = 1.09-1.21). There was also a large variability in sexual and injecting risk behaviors among FSWs within and across countries. Levels of HIV testing among FSWs were generally low. The median fraction of FSWs that tested for HIV in the past 12 months was 12.1% (range = 0.9-38.0%).

CONCLUSIONS

HIV epidemics among FSWs are emerging in MENA, and some have reached stable endemic levels, although still some countries have limited epidemic dynamics. The epidemic has been growing for over a decade, with strong regionalization and heterogeneity. HIV testing levels were far below the service coverage target of "UNAIDS 2016-2021 Strategy."

The realities of HIV prevention. A closer look at facilitators and challenges faced by HIV prevention programmes in Sudan and Yemen

Background: HIV/AIDS prevention has historically encountered many obstacles. Understanding the factors affecting HIV/AIDS prevention is central to designing and implementing suitable context-specific interventions. Research relating to HIV prevention in the Middle East and North African region is required to address the gradually increasing HIV epidemic. Objective: This study aimed to explore the perspectives of employees/health care professionals who are working or have worked within HIV prevention in Sudan and Yemen on the challenges and facilitating factors facing HIV prevention. Methods: A qualitative approach was employed using an open-ended questionnaire. Sixteen stakeholders from governmental and non-governmental agencies participated in the study. The questionnaire focused on the various challenges and facilitating factors facing HIV prevention as well as proposed possible solutions from the perspectives of the participants. The data were analysed using thematic analysis. Results: The study illustrated the similarities in context and HIV prevention systems between Sudan and Yemen. Thematic analysis resulted in three main themes: I) much is achieved despite difficulties; II) a programme left to be paralysed; this theme addressed the main obstacles facing HIV prevention in Sudan and Yemen generating a total of six sub-themes; III) comprehensive change is needed. The participants drew focus and attention to vital changes required to improve the delivery of HIV prevention services. Conclusion: Increased financial support for HIV prevention in Sudan and Yemen is urgently needed. De-stigmatisation and increased political support, advocacy and improved legislation for people living with HIV (PLHIV) are required for the sustainability and effectiveness of HIV prevention programmes in Sudan and Yemen. Civil society organisations must be aided and supported in their role in engaging key populations.

HIV/AIDS: trends in the Middle East and North Africa region

OBJECTIVES

To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region.

METHODS

Articles on the MENA region were reviewed.

RESULTS

The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues.

CONCLUSIONS

The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed.

HIV in Harare: the role and relevance of social stigma

HIV is a significant social, political and economic problem in Zimbabwe. However, few researchers have explored peoples' experiences of living with HIV in that country. Drawing on 60 qualitative interviews conducted with Zimbabweans living in Harare in 2010, this paper focuses on how people from four different urban communities cope with HIV-related social stigma. To provide theoretical context to this issue, we utilised the ideas of Erving Goffman for exploring the individual experience of stigma and the concept of structural violence to understand stigma as a social phenomenon. This paper considers the relevance and role of stigma in the context of a country undergoing significant social, political and economic crisis. We investigated the strategies adopted by the Zimbabwean state and the influence of traditional and religious interpretations to appreciate the historical roots of HIV-related stigma. We took into account the ways in which the articulation of HIV with gender has caused women to experience stigma differently than men, and more intensely, and how grassroots activism and biomedical technologies have transformed the experience of stigma.