Improving the Quality and Quantity of HIV Data in the Middle East and North Africa: Key Challenges and Ways Forward

Injection cessation and relapse to injection and the associated factors among people who inject drugs in Iran: The Rostam study

BACKGROUND

Drug injection is a major health-related problem worldwide. Injection cessation and relapse to injection could significantly alter the risk of HIV and hepatitis C virus (HCV) among people who inject drugs (PWID). This study aimed to estimate the rate of injection cessation and relapse to injection among PWID in Iran.

METHODS

This cohort study was conducted from 2018 to 2021 in the cities of Kerman and Tehran. Using a respondent-driven sampling (RDS) approach, 118 PWID with a history of injection in the last six months and negative HIV and HCV tests were recruited. Follow-up visits occurred every three months over a period of one year. Participants were interviewed and tested for HIV and HCV using rapid tests. Injection cessation was defined as the no injection of any type of drugs in the last three months. Relapse to injection was defined as re-initiating drug injection among those who had ceased injection. Two separate Cox regression models were applied, and an adjusted hazard ratio (aHR) with a 95% confidence interval (CI) were measured to assess the factors associated with each outcome.

RESULTS

The rate of injection cessation was 26.1 (95% CI: 21.3, 32.0) per 100 person-years, and the rate of relapse to injection was 32.7 (95% CI: 24.7, 43.2) per 100 person-years. At the baseline interview, 39.8% (n = 47) of participants reported injection cessation in the past three months before the interview. In the multivariable Cox regression analysis, the rate of relapse to injection was greater among women (aHR = 1.58; 95% CI: 1.01, 2.52), and those with higher monthly income (aHR = 1.63; 95% CI: 1.03, 2.59). However, there was no significant variable that predicted injection cessation.

CONCLUSION

Injection cessation was common among PWID in Iran, however, one-third relapsed to injection shortly after cessation. Harm reduction programs should include comprehensive strategies to reduce the probability of relapse among PWID who achieve injection cessation.

Trends and projection of incidence, mortality, and disability-adjusted life years of HIV in the Middle East and North Africa (1990-2030)

Evidence shows a growing trend of the HIV epidemic in the Middle East and North Africa (MENA). We aimed to project the incidence, mortality, and disability-adjusted life years (DALY) in the region from 1990 to 2019 and assess its trend by 2025, and 2030. We extracted the HIV incidence, mortality, and DALY data from the Global Burden of Disease (GBD) and UNAIDS databases. The joinpoint regression model was used to examine changes in HIV trends. The trend changes were estimated by average annual percent change (AAPC). In most countries, an increasing trend was observed in HIV incidence, mortality, and DALY. Specifically, the highest growth in the annual incidence rate was related to Egypt (AAPC = 14.4, GBD) and Iran (AAPC = 9.6, UNAIDS). Notably, Qatar (AAPC = - 5.6, GBD), Bahrain (AAPC = - 3.3, GBD), and Somalia (AAPC = - 4.2, UNAIDS) demonstrated a significant reduction in incidence. Regarding mortality rates, Djibouti (AAPC = 24.2, GBD) and Iran (AAPC = 16.2, UNAIDS) exhibited a significant increasing pattern. Furthermore, the estimated increase in incidence by 2030 was most marked in Djibouti (985%) and Iran (174%). Iran (422%) and Egypt (339%) showed a prominent rise in mortality rates. GBD data showed 16 countries had an increasing pattern in DALY in both genders. According to age and period effects, there was a significant upward trend in incidence, mortality rates, and DALY. Findings highlighted the urgent need for improved prevention and treatment services, including expanding access to HIV testing, promoting safe practices, increasing antiretroviral therapy coverage, and supporting targeted interventions for high-risk populations.

An Evolving HIV Epidemic in the Middle East and North Africa (MENA) Region: A Scoping Review

Human immunodeficiency virus (HIV) in the Middle East and North Africa (MENA) region is severely understudied despite the region's increase in new HIV infections since 2010. A key population that is particularly affected, due to the lack of adequate knowledge and proper interventional implementation, includes people who inject drugs (PWID). Furthermore, the paucity of HIV data (prevalence and trends) worsens an already critical situation in this region. A scoping review was conducted to address the scarcity of information and to synthesize the available data on HIV prevalence rates within the key population of PWID throughout the MENA region. Information was sourced from major public health databases and world health reports. Of the 1864 articles screened, 40 studies discussed the various factors contributing to the under-reporting of HIV data in the MENA region among PWID. High and overlapping risk behaviors were cited as the most prevalent reason why HIV trends were incomprehensible and hard to characterize among PWID, followed by lack of service utilization, lack of intervention-based programs, cultural norms, lack of advanced HIV surveillance systems, and protracted humanitarian emergencies. Overall, the lack of reported information limits any adequate response to the growing and unknown HIV trends throughout the region.

Sexualized Substance Use among Female Sex Workers in Iran: Findings from a Nationwide Survey

Background: Female sex workers (FSWs) are at higher risk of HIV due to high-risk sexual and drug use related behaviors. This study characterized sexualized substance use among FSWs in Iran. Methods: In 2015, 1,337 FSWs were recruited from centers for vulnerable women and through outreach efforts in 13 major cities in Iran. Data were collected via face-to-face interviews from consenting FSWs on a range of socio-demographic and behavioral characteristics. The primary outcome of interest was sexualized substance use, defined as reporting alcohol or drug use before or during sex in the past month. Bivariable and multivariable modified Poisson regression models were used to assess the correlates of sexualized substance use. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) were reported. Results: The prevalence of sexualized substance use was 31.3% (95% CI: 28.7, 34.0). Inconsistent condom use during sex with clients in the past month (aPR = 1.31; 95% CI: 1.01, 1.71), regular (i.e., at least weekly in the past month) alcohol use (aPR = 2.87; 95% CI: 2.17, 3.80), regular opioid use (aPR = 2.09; 95% CI: 1.45, 3.02), regular stimulant use (aPR = 2.68; 95% CI: 2.12, 3.39), and self-reported HIV negative status (aPR= 1.88; 95% CI: 1.14, 3.10) were significantly and positively associated with sexualized substance use. Conclusions: Sexualized substance use was associated with riskier sexual behavior and self-reported HIV sero-negativity. Harm reduction messaging to FSWs needs to go beyond focusing on sexual health promotion and further highlight the risks associated with sexualized substance use.

"Older people tend to be invisible": a qualitative study exploring the needs and inclusion of older Syrian refugees in the context of compounding crises in host country, Lebanon

BACKGROUND

Older Syrian refugees in Lebanon are a marginalized population with under-recognized health needs. The inclusivity of this population within the humanitarian response is poorly understood. This study aims to identify the unique needs of older Syrian refugees in the context of recent concurrent crises in Lebanon, and explore the extent to which they are being met and prioritized by local and international aid agencies.

METHODS

We conducted in-depth interviews with a snowball sample of 26 stakeholders from 11 organizations operating in the health, nutrition, and water, sanitation, and hygiene sectors. Data analysis followed principles of thematic analysis.

RESULTS

Concurrent political, economic, and public health crises in host country promoted income insecurity among older refugees and increased dependency on younger relatives, leading to food insecurity, neglect, and poor health outcomes, including the sequelae of untreated non-communicable diseases. Mental illness was perceived to be exacerbated by Covid-19 related challenges, including social isolation, uncertainty about the future, and additionally due to feelings of guilt related to economic dependence and fundamental exclusion from labor force participation. Despite their vulnerability, older refugees are overlooked by the humanitarian response, which may be related to a lack of data. Pervasive medication shortages in the setting of the economic collapse, as well as inaccessible physical environments and competing interests were all identified as major barriers to care.

CONCLUSIONS

Older Syrian refugees in Lebanon experience dual vulnerability that is acutely exacerbated in the setting of concurrent crises. Sociopolitical, economic, and cultural barriers promote social exclusion and may confer an increased risk of income and food insecurity in this population, with significant implications for health. Humanitarian aid agencies operating in the context of fragmented, under-resourced health systems are currently unable to sufficiently address multi-faceted needs of this community. We recommend moving away from a donor-dependent model of aid by allocating resources toward strengthening inclusive national health systems that emphasize preventative care. We further call for age-disaggregation of routine data and normalization of data sharing among stakeholders in the academic and public health sectors in order to develop evidence-based initiatives that can meet the needs of this under-served community.

An on-site community-based model for hepatitis C screening, diagnosis, and treatment among people who inject drugs in Kerman, Iran: The Rostam study

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C virus (HCV) infection and its complications in many countries, including Iran. This pilot study aimed to evaluate the effect of a community-based HCV model of care on HCV testing and treatment initiation among PWID in Kerman, Iran.

METHODS

This study is part of the Rostam study and is a non-randomized trial evaluating the effect of on-site HCV- antibody rapid testing, venipuncture for HCV RNA testing, and treatment eligibility assessment on HCV testing and treatment initiation among PWID. Recruitment, interviews, and HCV screening, diagnosis, and treatment were all conducted at a community-based drop-in center (DIC) serving PWID clients.

RESULTS

A total of 171 PWID (median age of 39 years and 89.5% male) were recruited between July 2018 and May 2019. Of 62 individuals who were HCV antibody positive, 47 (75.8%) were HCV RNA positive. Of RNA-positive individuals, 36 (76.6%) returned for treatment eligibility assessment. Of all the 36 participants eligible for treatment, 34 (94.4%) initiated HCV antiviral therapy. A sustained virologic response at 12 weeks post-treatment was 76.5% (26/34) in the intention-to-treat (ITT group) analysis and 100% (23/23) in the per-protocol (PP group) analysis.

CONCLUSION

Our integrated on-site community-based HCV care model within a DIC setting suggested that HCV care including HCV testing and treatment uptake can be successfully delivered outside of hospitals or specialized clinics; a model which is more likely to reach PWID and can provide significant progress towards HCV elimination among this population.

Prevalence and Correlates of Sexual Violence Experienced by Female Sex Workers in Iran: Results from a National HIV Bio-Behavioral Surveillance Survey

Sexual violence increases the risk of adverse health outcomes among female sex workers (FSWs). Using data from the 2015 national bio-behavioral survey, we explored the experience of sexual violence and its associated factors among Iranian FSWs. Lifetime and recent sexual violence were reported by 40.1% and 16.9%, respectively. History of substance use, ever engaging in anal sex, engaging in group sex within the last year, a high number of clients, recent unstable housing, and incarceration increased the likelihood of experiencing recent sexual violence. These findings underscore the need for community-empowerment and policy-level interventions to address violence among FSWs in Iran.

HIV Prevalence and Related Behaviors Among People Who Inject Drugs in Iran from 2010 to 2020

Injection drug use has been the leading route of HIV transmission in Iran. We assessed HIV prevalence, risk behaviors, and uptake of prevention services among people who inject drugs (PWID) in Iran between 2010 and 2020. We also examined the individual and environmental determinants of HIV among PWID. PWID were recruited in major cities across the country in three national bio--behavioral surveillance surveys in 2010, 2014, and 2020. Participants were tested for HIV and interviewed using a behavioral questionnaire. Between 2010 and 2020, the prevalence of HIV (15.1% to 3.5%), receptive needle sharing (25.2% to 3.9%) and unprotected sex (79.4% to 65.2%) decreased. Moreover, uptake of free needle/syringe increased (57.4% to 87.9%), while uptake of free condoms remained relatively stable across the surveys (34.3% to 32.6%). Multivariable analysis for the 2020 survey showed that a history of homelessness, incarceration, and a longer injection career significantly increased the odds of HIV seropositivity. During the past decade, HIV prevalence and drug- and sexual-related risk behaviors decreased among Iranian PWID. However, individual and structural determinants continue to drive HIV among this population. HIV prevention, diagnosis, and treatment among marginalized PWID with a history of homelessness or incarceration and those who inject drugs for a longer period, should be further prioritized in HIV care planning and resource allocation in Iran.

Lebanese People Living with HIV: Psychiatric Co-morbidities and Psycho-Social Environment

Data are lacking on the psychiatric and psycho-social profiles of Middle-Eastern people living with HIV (PLHIV). Our study aimed to establish the prevalence and correlates of mental illness in a sample of Lebanese PLHIV, and to delineate their socio-cultural reality. PLHIV, either attending a private ID clinic or a non-governmental organization, were interviewed. A total of 94 patients were included. Sixty-nine (73.4%) were found to have at least one psychiatric disorder. Only nine participants were currently receiving psychotropic medications. The most common diagnosis was major depression, occurring in half of the subjects. Homosexual or bisexual orientation predicted the presence of a current depression (p = 0.024), and ART status was negatively associated with current depression (p = 0.028). The rate of psychiatric disorders is clearly higher than that of the general population. PLHIV with a homosexual or bisexual orientation face a double stigma, perhaps making them more vulnerable to depression. Our findings need to be replicated in larger studies with more representative samples.

Bone Marrow Aspiration/Biopsy in the Evaluation of Fever of Unknown Origin in Patients with AIDS

BACKGROUND

HIV can interrupt the normal development of bone marrow cell lines. Bone marrow aspiration/biopsy (BMA/B) has been described as a diagnostic tool in AIDS patients with fever of unknown origin (FUO). In this review, we aimed to study patients with AIDS who had undergone a BMA/B to investigate FUO and describe the pathologies diagnosed in the biopsy.

METHODS

Thirty-four BMA/B samples were collected from AIDS patients admitted for work-up of FUO to the infectious disease ward of a tertiary referral HIV center in Tehran, Iran, between September 2014 and September 2015. Data including age, sex, duration of disease, CD4 cell counts, hepatitis B (HBV) and C (HCV) coinfection, the primary presentation of AIDS, and the treatment history were retrieved and analyzed. Patients underwent BMA/B. An expert pathologist reviewed the BMA/B specimens.

RESULTS

The mean age of the patients was 37.5 years (range, 26-56), and 27 (79%) were men. Twenty-seven (79%) patients contracted HIV from injection drug use, and 7 (21%) via sexual transmission. Only 3 (9%) of the BMA/B examinations were normal. Hypocellular bone marrow was diagnosed in 22 (65%) patients. Other pathologies included granulomas in 6 (18%), hematologic malignancies in 2 (6%), and leishmaniasis Aspergillosis, each in 1 (3%) patient. Six (17%) of the specimens were found to have tuberculosis infections.

CONCLUSION

Hypocellular bone marrow was the most common pathology on BMA/B examinations, followed by the presence of granulomas. Tuberculosis, Aspergillosis, and Leishmaniasis the opportunistic infections diagnosed on BMA/B specimens. Our results support BMA/B as an appropriate diagnostic tool for early diagnosis of opportunistic infections and malignancies in AIDS. BMA/B is indispensable in the armament of diagnostic tools of the physicians managing AIDS patients.

Epidemiological characterization and geographic distribution of human immunodeficiency virus/acquired immunodeficiency syndrome infection in North African countries

BACKGROUND

Human immunodeficiency virus (HIV) infection is a major global public health concern. North African countries carry a disproportionate burden of HIV representing one of the highest rates in Africa.

AIM

To characterize the epidemiological and spatial trends of HIV infection in this region.

METHODS

A systematic review was carried out on all the published data regarding HIV/acquired immunodeficiency syndrome in North African countries over ten years (2008-2017) following the PRISMA guidelines. We performed a comprehensive literature search using Medline PubMed, Embase, regional and international databases, and country-level reports with no language restriction. The quality, quantity, and geographic coverage of the data were assessed at both the national and regional levels. We used random-effects methods, spatial variables, and stratified results by demographic factors. Only original data on the prevalence of HIV infection were included and independently evaluated by professional epidemiologists.

RESULTS

A total of 721 records were identified but only 41 that met the criteria were included in the meta-analysis. There was considerable variability in the prevalence estimates of HIV within the countries of the region. The overall prevalence of HIV ranged from 0.9% [95% confidence interval (CI) 0.8-1.27] to 3.8% (95%CI 1.17-6.53). The highest prevalence was associated with vulnerable groups and particularly drug abusers and sexually promiscuous individuals. The dense HIV clustering noted varied from one country to another. At least 13 HIV subtypes and recombinant forms were prevalent in the region. Subtype B was the most common variant, followed by CRF02_AG.

CONCLUSION

This comprehensive review indicates that HIV infection in North African countries is an increasing threat. Effective national and regional strategies are needed to improve monitoring and control of HIV transmission, with particular emphasis on geographic variability and HIV clustering.

Determinants and effects or consequences of internal HIV-related stigma among people living with HIV in Morocco

BACKGROUND

HIV-related stigma and discrimination constitute a barrier to different intervention programs. Unlike external stigma, internal stigma is not well explored in in the Middle East and North African countries, while grasping this particular form of stigma is essential to limit its effects. The present study aims to measure internal stigma effects and to identify factors associated with this kind of stigma not yet documented among people living with HIV (PLHIV) in Morocco.

METHODS

The PLHIV Stigma Index questionnaire (adapted and translated into French and Moroccan Arabic dialect "darija") was used to collect information regarding the stigma and discrimination experienced by PLHIV across 8 cities in Morocco (September-October 2016). A randomly drawn cluster of 10 PLHIV, consisting of 5 men and 5 women, was drawn at each participating medical care center to achieve a nationally representative sample of PLHIV. Fifteen interviewers living with HIV and five supervisors were selected and trained to administer the questionnaire. An internal stigma score (range: 0-7), was calculated based on seven negative feelings/ beliefs. Negative binomial regression was used to identify characteristics associated with the internal stigma score.

RESULTS

Among 626 PLHIV, internal stigma was reported by 88.2%. The median [IQR] internal stigma score was 4 [2-5]. Regarding internal stigma, 51% avoided going to the local clinic when needed and 44% chose not to attend social gatherings. Belonging to at least one key population (aIRR [95%CI] = 1.15 [1.03; 1.28]), experiencing discriminatory reactions from family following HIV status disclosure (1.28 [1.11; 1.49]), avoiding HIV services for fear of stigmatization by staff (1.16 [1.05; 1.28]) and being denied health services because of HIV status (1.16 [1.03;1.32]), are among the factors significantly associated with an increase of the internal stigma score.

CONCLUSIONS

Internal stigma is high among Moroccan PLHIV and significantly impacting their life decisions and their healthcare access. Multi-level interventions are needed to address internal stigma experienced by PLHIV in Morocco.

Early sex work initiation and its association with condomless sex and sexually transmitted infections among female sex workers in Iran

Early sex work initiation among female sex workers (FSWs) increases their vulnerabilities to high-risk sexual practices and sexually transmitted infections (STIs). We examined the association of early sex work with condomless sex indicators, HIV, and other STIs, including human papillomavirus, chlamydia, trichomoniasis, syphilis, and gonorrhea, among FSWs in Iran. We recruited 1347 FSWs from 13 cities in 2015, with 1296 participants (94.2%) reporting information about their age of sex work initiation. Early sex work was defined as the initiation of selling sex before 18 years of age. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported using multivariable logistic regression. Overall, 10.1% of FSWs reported early sex work initiation. FSWs who initiated sex work earlier were more likely to report last-month inconsistent condom use (aOR = 3.31, 95% CI: 1.82, 6.02) and condomless sex with last client (aOR = 1.72, 95% CI: 1.15, 2.56). There was no statistically significant association between early sex work and HIV (aOR = 1.40, 95% CI: 0.43, 4.53) and any other STIs (aOR = 1.01, 95% CI: 0.69, 1.48), except for chlamydia (aOR = 2.09, 95% CI: 1.08, 4.04). These findings suggest that FSWs with early sexual debut would benefit from differentiated interventions including screening for STIs and enhanced counseling for condom use.

HIV prevention cascades for injection and sexual risk behaviors among HIV-negative people who inject drug in Iran

BACKGROUND

The HIV prevention cascade complements the HIV treatment cascade and helps evaluate the access to and use of harm reduction programs among HIV-negative individuals at risk for HIV, including people who inject drugs (PWID). This study aimed to estimate the HIV prevention cascades among PWID in Iran.

METHODS

Using data from the 2014 national bio-behavioral surveillance survey, 2,391 PWID were recruited from 31 harm reduction facilities and through outreach efforts across 10 major cities. PWID aged ≥18 years who reported drug injection in the past year were interviewed, and information regarding their demographic characteristics, sexual and drug injection practices, and access to services were gathered. PWID were also tested for HIV infection. We examined the prevention cascade framework among HIV-negative PWID.

RESULTS

The majority of PWID were male (97.6%) and more than half aged ≥ 35 years old (55.5%). Overall, 2,092 (92.5% [95% CI: 90.8, 93.9]) were HIV-negative; 93% of whom knew illicit drug injection could increase the risk of HIV transmission, 54% had access to free-of-charge sterile needles and syringes, 51% used sterile needles and syringes in their last injection practice, and 33% used sterile needles and syringes in all injection practices in the past month. Also, 87.8% (95% CI: 85.1, 90.0) of HIV-negative PWID had sex with any partner in the past year; 88% of whom knew using condoms could reduce the risk of HIV transmission, 35% had access to free-of-charge condoms, 32% used condoms in their last sexual practice, and 18% used condoms in all of their sexual practices in the past month.

CONCLUSION

The majority of HIV-negative PWID in Iran were at risk for HIV acquisition through unsafe drug injection or sexual practices. Harm reduction programs should improve access to free sterile needles, syringes, and condoms for PWID.

HIV and Other Sexually Transmitted Infections Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis

Given the high burden of HIV and other sexually transmitted infections (STIs) among female sex workers (FSW) and their potential role in bridging HIV/STIs into the general population, estimating the prevalence of HIV/STIs among FSW is essential for future research and policy developments. This systematic review and meta-analysis synthesize the available HIV/STIs data among FSW in Iran. We searched MEDLINE, PsycINFO, CINAHL, Embase, Web of Science, Google Scholar, and Iranian databases from inception through to January 2018. Inclusion criteria were original quantitative studies that measured HIV/STIs prevalence among FSW. Pooled prevalence estimates were calculated using random-effects meta-analyses. Out of a total of 299 screened studies, 12 were included with total study participants of 4328 FSW. Heterogeneity was present but meta-regression analyses revealed no significant association between HIV prevalence and year of publication, city, and age. Pooled HIV prevalence was 2.23% (95% confidence interval [CI] 0.82, 3.64). We estimated the prevalence of other STIs as 0.77% (95% CI 0.01, 1.53) for hepatitis B, 6.18% (95% CI 1.32, 11.04) for hepatitis C, 0.33% (95% CI 0.00, 0.66) for syphilis, 1.47% (95% CI 0.22, 2.71) for gonorrhea, 9.80% (95% CI 4.70, 14.91) for chlamydia, and 6.18% (95% CI 4.92, 7.43) for trichomonas vaginalis. Based on the existing evidence, HIV and STIs prevalence among FSW are relatively low in Iran. Strategies for timely diagnosis and treatment of HIV and other STIs among FSW and their sexual and injecting partners are needed to reduce the burden of HIV/STIs among these vulnerable populations in Iran.

HIV-Related Knowledge and Stigma Among the General Population in the Southeast of Iran

Background: HIV-related stigma is a barrier to effective HIV responses among people living with HIV (PLHIV). Objectives: The current study aimed at measuring HIV-related stigma, and its associated factors among the general population in the Southeast of Iran. Methods: The current cross-sectional study was conducted on a convenience sample of 900 individuals in Kerman, Southeast of Iran, from July to September 2016. Data was collected using a self-administered questionnaire, including (I) demographic and background characteristics; (II) HIV-related stigma; and (III) HIV-related knowledge. Data were analyzed with SPSS version 20 using descriptive statistics, as well as bivariable and multivariable linear regressions. Results: Low, moderate, and high levels of stigmatizing attitudes toward PLHIV were reported by 39.1%, 57.8%, and 3.1% of the participants, respectively. Female sex(beta = 0.33, P value = 0.01) and those not having a history of HIV testing (beta = 0.45, P value < 0.001) had, on average, higher levels of stigmatizing attitudes, while those with a higher level of education (beta = -0.97, P value < 0.001) had, on average, lower levels of stigmatizing attitudes. Conclusions: Gender-sensitive educational interventions need to be developed to reduce the negative attitude towards PLHIV in Iran.

HIV/AIDS-knowledge and attitudes in the Arabian Peninsula: A systematic review and meta-analysis

BACKGROUND

HIV/AIDS prevention has been widely adopted worldwide, but little is known about HIV/AIDS knowledge and attitudes in the Arabian Peninsula.

AIM

To summarize the level of knowledge and attitude about HIV/AIDS in seven Arabian Peninsula countries (Saudi Arabia, Oman, Kuwait, Qatar, Bahrain, Yemen, and the United Arab Emirates (UAE)).

METHODS

A systematic literature search was performed using combined keywords in four scientific databases of peer-reviewed publications from January 2010 to June 2019. Twenty-five articles were included in the systematic review, and twenty studies in the meta-analysis. The data was analyzed using a random-effect model due to the heterogeneity between the studies.

RESULTS

Seventeen studies reported on the level of knowledge and overall knowledge about HIV/AIDS in this region: 74.4% (95% confidence interval (CI): 66.8%-82.0%, p<0.001) and the attitude was 52.8% (95% CI: 36.9%-68.6%, p<0.001). A study from Oman reported higher knowledge levels (95.5%, 95% CI: 94.2%-96.8%) while less than a quarter of the Bahrain population had positive attitudes 22.5% (95% CI: 20.5%-24.5%). Medical doctors showed higher knowledge (94.1%, 95% CI: 92.9%-95.3%), but a positive attitude was only observed in 32.5% (95% CI: 28.8%-36.2%) of the dentists toward HIV/AIDS.

CONCLUSION

The overall knowledge about HIV/AIDS was found to be satisfactory (74.4%), but about half (52.8%) of those displayed negative attitudes toward HIV/AIDS. Regular training courses as well as reviewing and reinforcing HIV/AIDS prevention guidelines can be useful to update knowledge and improve attitudes in this region.

HIV-Related Stigma Among Healthcare Providers in Different Healthcare Settings: A Cross-Sectional Study in Kerman, Iran

Background: Stigmatizing attitudes among healthcare providers are an important barrier to accessing services among people living with HIV (PLHIV). This cross-sectional study aimed to assess the status and correlates of HIV-related stigma among healthcare providers in Kerman, Iran.

Methods: Using a validated and pilot-tested stigma scale questionnaire, we measured HIV-related stigma among 400 healthcare providers recruited from three teaching hospitals (n=363), private sectors (n=28), and the only voluntary counseling and testing (VCT) center (n=9) in Kerman city. Data were gathered using self-administered questionnaires at participants’ workplace during Fall 2016. To examine the correlates of stigmatizing attitudes, we constructed bivariable and multivariable linear regression models.

Results: The mean ± standard deviation (SD) of stigma score was 25.95 ± 7.20 out of the possible 50, with higher scores reflecting more stigmatizing attitudes. Paramedics, nurses’ aides, and housekeeping staff had the highest, and VCT personnel had the lowest average stigma scores, respectively. Multivariable regression analyses showed that prior experience of working with PLHIV (β=-2.48; P=.03), exposure to HIV-related educational courses (β=-2.03; P=.02), and <10 years of work experience (β=-2.70; P<.001) were associated with lower stigma scores.

Conclusion: Our findings highlight the need for health managers to provide training opportunities for healthcare providers, including programs that focus on improving HIV-related knowledge for healthcare providers. Enforcing policies that aim to reduce HIV-related stigma and discrimination among healthcare providers in Iran are urgently needed.

Special Measures for Quality and Challenged Providers: Study Protocol for Evaluating the Impact of Improvement Interventions in NHS Trusts

Background: Healthcare organisations in England rated as inadequate in terms of leadership and one other domain enter the Special Measures for Quality (SMQ) regime to receive increased support and oversight. There is also a ‘watch list’ of challenged National Health Service (NHS) providers at risk of going into SMQ that receive support. There is limited knowledge about whether the interventions used to deliver this support drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. The study will seek to determine how provider organisations respond to these interventions, and whether and how these interventions impact organisations’ capacity to achieve and sustain quality improvements over time.

Methods: This is a multi-site, mixed methods study. We will carry out interviews at national level to understand the programme theory underpinning the interventions. We will conduct 8 NHS case studies to explore the impact and implementation of the interventions that form part of the SMQ and challenged providers programme. We will use a conceptual framework based on models of organisational readiness for change and draw on board maturity research for implementing quality improvement. We will also review the use of quantitative metrics and data for tracking the progress of improvements in quality of care and sustainability upon leaving SMQ, as well as the costs and benefits of the interventions through a cost-consequence analysis (CCA).

Discussion: High-quality interventions that successfully support struggling healthcare organisations are essential and an issue that is an international concern. Our study will allow a greater understanding of the programme theory, impact, and staff views and experiences of the SMQ and challenged providers regime. Formative feedback will be reported to key stakeholders.

HIV Modes of Transmission in Sudan in 2014

Background: In Sudan, where studies on HIV dynamics are few, model projections provide an additional source of information for policy-makers to identify data collection priorities and develop prevention programs. In this study, we aimed to estimate the distribution of new HIV infections by mode of exposure and to identify populations who are disproportionately contributing to the total number of new infections in Sudan.

Methods: We applied the modes of transmission (MoT) mathematical model in Sudan to estimate the distribution of new HIV infections among the 15-49 age group for 2014, based on the main routes of exposure to HIV. Data for the MoT model were collected through a systematic review of peer-reviewed articles, grey literature, interviews with key participants and focus groups. We used the MoT uncertainty module to represent uncertainty in model projections and created one general model for the whole nation and 5 sub-models for each region (Northern, Central, Eastern, Kurdufan, and Khartoum regions). We also examined how different service coverages could change HIV incidence rates and distributions in Sudan.

Results: The model estimated that about 6000 new HIV infections occurred in Sudan in 2014 (95% CI: 4651-7432). Men who had sex with men (MSM) (30.52%), female sex workers (FSW) (16.37%), and FSW’s clients accounted (19.43%) for most of the new HIV cases. FSW accounted for the highest incidence rate in the Central, Kurdufan, and Khartoum regions; and FSW’s clients had the highest incidence rate in the Eastern and Northern regions. The annual incidence rate of HIV in the total adult population was estimated at 330 per 1 000 000 populations. The incidence rate was at its highest in the Eastern region (980 annual infections per 1 000 000 populations).

Conclusion: Although the national HIV incidence rate estimate was relatively low compared to that observed in some sub-Saharan African countries with generalized epidemics, a more severe epidemic existed within certain regions and key populations. HIV burden was mostly concentrated among MSM, FSW, and FSW’s clients both nationally and regionally. Thus, the authorities should pay more attention to key populations and Eastern and Northern regions when developing prevention programs. The findings of this study can improve HIV prevention programs in Sudan.

Declining trends in HIV and other sexually transmitted infections among female sex workers in Iran could be attributable to reduced drug injection: a cross-sectional study

OBJECTIVE

The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran.

METHODS

We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher's exact test to compare the HIV prevalence between the two survey rounds.

RESULTS

HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus.

CONCLUSIONS

HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran.

Regional caries data availability in Saudi Arabia: Impact of socioeconomic factors and research potential

Background and aims

Monitoring oral diseases is needed to allocate resources, plan health services and train dental workforce. Caries is one of the oral diseases most commonly included in oral health surveillance systems. The present study assessed (1) caries data availability in the administrative regions of Saudi Arabia and (2) factors associated with this availability.

Methods

We collected caries data in the period 2008-2018 in Saudi Arabia (outcome variable). The explanatory variables included region-level factors: (a) socio-economic indicators (percentage of individuals with university education, percentage of category A governorates, percentage of owned houses, households with computers, internet and smart phones) and, (b) oral health research potential indicators (number of Dental Public Health (DPH) specialists, Ministry of Health (MoH) dentist to population ratio and number of dental schools). ArcGIS was used for data visualization and logistic regression was used for analysis.

Results

Twenty-two studies provided caries data for 46.2% of the regions which were inhabited by 84.7% of the population. Region-level data availability was associated with the number of dental schools (OR = 1.63) with 61.5% of the regions correctly classified. More regions were correctly classified when population to MoH dentist ratio (76.9%) and the number of DPH specialists (92.3%) were included.

Conclusions

Caries data were available for half of the administrative regions in Saudi Arabia and data availability was associated with higher number of dental schools. The presence of DPH specialist provided the critical mass to collect caries data.

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.

Estimation of HIV incidence and its trend in three key populations in Iran

In Iran, People Who Inject Drugs (PWID), Female Sex Workers (FSW), and prisoners are the main key populations at risk of HIV infection. This study aimed to evaluate the trend of HIV incidence among PWID, FSW and prisoners as an impact measure of HIV harm reduction and prevention efforts in Iran. Data were obtained from the two rounds of national bio-behavioral surveillance surveys among FSW (2010 (n = 872), 2015 (n = 1339)), PWID (2010 (n = 2417), 2014 (n = 2307)), and prisoners (2009 (n = 4536), 2013 (n = 5390)) through facility-based (FSW and PWID surveys) and cluster sampling (prisoner surveys). Time-at-risk was calculated assuming the age at first sex or drug injection as the beginning of the at-risk period and the age at the time of the interview or date when they received a positive HIV test result as the end of this period, adjusted for interval censoring. HIV incidence among PWID in 2014 was 5.39 (95% CI 4.71, 6.16) per 1,000 person-years (PY), significantly lower than in 2009 (17.07, 95% CI 15.34, 19.34). Similarly, HIV incidence was 1.12 (95% CI 0.77, 1.64) per 1,000 PY among FSW in 2015, a significant drop from 2010 (2.38, 95% CI 1.66, 3.40). Also, HIV incidence decreased among prisoners from 1.34 (95% CI: 1.08, 1.67) in 2009 to 0.49 (95% CI: 0.39, 0.61) per 1,000 PY in 2013. Our findings suggest that after an increase in the 2000s, the HIV incidence may have been decreased and stabilized among key populations in Iran.

Condom Use and its Associated Factors Among Iranian Youth: Results From a Population-Based Study

Background: Given the young structure of Iran’s population and the fact that extramarital sexual relationships are both prohibited by legislation and shunned by society and religion, examining condom use practices among Iranian youth is highly important. The aim of this study was to explore condom use and its correlates among Iranian young adults.

Methods: In a sample of 3,045 individuals aged 19-29 who were recruited from a nation-wide study, we analyzed data from 633 participants who reported a history of extramarital sex. Subjects were asked about their condom use practices during their last penetrative sex. Data were collected through a self-administered questionnaire where the respondents completed the survey on their own and passed it to trained gender-matched interviewers. Multivariable regression models were constructed to report adjusted odds ratios (AOR) along with 95% CI.

Results: Of the 633 participants, 222 (35.1%) reported condom use at last sex. Men reported significantly higher condom use than women (38.5% vs. 25.7%). Having a stable job (AOR = 1.86, 95% CI: 1.01, 3.43), higher knowledge of condom use (AOR = 1.57, 95% CI: 1.03, 2.37) and sexual transmission of HIV (AOR = 1.83, 95% CI: 1.18, 2.85) were positively associated with condom use at last sex. Conversely, experience of sex under the influence of substances (AOR = 0.66, 95% CI: 0.45, 0.94) was significantly associated with reduced odds of condom use at last sex.

Conclusion: This study shows that only one out of every three young adults reported using condoms at last sex. While educational programs are helpful, multi-sectoral approaches (eg, individual-, community-, and structural-level interventions) are required to change sexual behaviours towards safe sex practices and reinforce negotiating condom use among youth.

Ensuring HIV Data Availability, Transparency and Integrity in the MENA Region Comment on "Improving the Quality and Quantity of HIV Data in the Middle East and North Africa: Key Challenges and Ways Forward"

In this commentary, we elaborate on the main points that Karamouzian and colleagues have made about HIVdata scarcity in Middle Eastern and North African (MENA) countries. Without accessible and reliable data, no epidemic can be managed effectively or efficiently. Clearly, increased investments are needed to bolster capabilities to capture and interpret HIV surveillance data. We believe that this enhanced capacity can be achieved, in part, by leveraging and repurposing existing data platforms, technologies and patient cohorts. An immediate modest investment that capitalizes on available infrastructure can generate data on the HIV burden and spread that can be persuasive for MENA policy-makers to intensify efforts to track and contain the growing HIV epidemic in this region. A focus on key populations will yield the most valuable data, including among men who have sex with men (MSM), transgender women and men, persons who inject drugs (PWIDs), female partners of high risk men and female sex workers.

Consistent Condom Use with Paying and Nonpaying Partners among Female Sex Workers in Iran: Findings of a National Biobehavioral Survey

OBJECTIVES

Little is known about the dynamics of condom use among female sex workers (FSWs) in Iran. We investigated the correlates of consistent condom use (CCU) among FSWs, using data from a national biobehavioral surveillance survey in 2010.

METHODS

A total of 872 FSWs were recruited using a facility-based sampling strategy from 21 sites in 13 cities in Iran. Data were collected through face-to-face interviews using a standardized questionnaire.

RESULTS

Overall, 33.6% and 17.3% of FSWs reported CCU with paying and nonpaying sex partners, respectively. Consistent condom use with paying partners was significantly associated with temporary marriage, accessing family planning services and history of working in brothels. Conversely, temporary marriage or married status, condom rupture/slippage, and HIV seropositivity remained independently significantly associated with CCU with nonpaying sex partners.

CONCLUSION

Our findings indicated the urgent need for scaling up condom promotion interventions catered toward FSWs and their sex partners to practice safe sex consistently.

The Elephants in the Room: Sex, HIV, and LGBT Populations in MENA. Intersectionality in Lebanon Comment on "Improving the Quality and Quantity of HIV Data in the Middle East and North Africa: Key Challenges and Ways Forward"

In response to this insightful editorial, we wish to provide commentary that seeks to highlight recent successes and illuminate the often unspoken hurdles at the intersections of culture, politics, and taboo. We focus on sexual transmission and draw examples from Lebanon, where the pursuit of data in quality and quantity is teaching us lessons about the way forward and where we are experiencing many of the challenges referenced in the editorial such as discrepancies between national statistics and rates derived via research as well as the impact of protracted political conflict and displacement. Two important points were raised in the editorial about HIV in Middle East and North Africa (MENA) that we would like to expand further: (1) The epidemic is largely driven by drug-related and sexual behavior among key populations; and (2) Several key populations continue to be criminalized and excluded from surveillance programs.