World AIDS Day The Middle East’s invisible disease World Aids Day was marked on 1 December. Middle East Health looks at the state of the epidemic in the Middle East and North Africa with reference to the latest report from UNAIDS. In December UNAIDS published AIDS epidemic update 2004 which provides the most recent estimates of the epidemic’s scope and human toll and explores new trends in the epidemic’s evolution. In the report several countries in the Middle East are criticised for failing to collate and provide data regarding the spread of the epidemic and for the continued “invisibility” of the disease in the region. The report is unable to provide estimates of the prevalence of AIDS in the UAE, Saudi Arabia, Qatar and Kuwait because “sufficient data for the last six years was not available” from these countries. Estimates of the prevalence of AIDS for other countries in the region is provided below. Sudan, in particular, is praised for recently breaking a long silence over the epidemic in the country. It is presumed to have the most number of HIV/AIDS cases in the region – an estimated 500,000. The AIDS epidemic update 2004 says of the MENA region: “Effective interventions depend on systematic and reliable information about the epidemics’ patterns and trends. On both those fronts, too many countries are still too ‘slow off the mark’. Even basic steps such as condom promotion are largely absent in the region.” The report condemns health institutions in the region saying there is very little effort to defuse the social stigma attached to the disease and that there is still widespread discrimination experienced by vulnerable groups. It calls for much needed education and communication to deepen public knowledge of the epidemic. Worldwide Worldwide, the number of people living with HIV globally has also reached its highest level with an estimated 39.4 million people, up from an estimated 36.6 million in 2002, according to the AIDS epidemic update. The steepest increases in HIV infections occurred in East Asia, Eastern Europe and Central Asia over the past two years. And in line with the theme of World Aids Day 2004 – Women, girls, HIV and AIDS – the report highlights the fact that women are more physically susceptible to HIV infection than men. Male-to-female HIV transmission during sex is about twice as likely to occur as female-to-male transmission. The report warns that for many women in developing countries, the “ABC” prevention approach (Abstinence, Being faithful and reducing number ofsexual partners, and Condom use) is insufficient. The World Health Organisation (WHO) points out that if countries are to ensure and monitor equitable access to treatment – that is treatment for woman and girls as well as men – they will need to collect data not only on who is becoming infected but also on how many men, women and children are getting access to prevention and treatment. The WHO says to ensure equitable access for women and girls, countries need to address barriers preventing the access of women and girls to AIDS treatment and care, such as transport and distance, opening hours and waiting time in clinics. The integration of HIV/AIDS services with sexual and reproductive health services, such as family planning and antenatal care, can also help address women's different needs and reduce stigma. The AIDS epidemic update 2004 follows the United Nations Report on the Global AIDS Epidemic released in July last year. The UN report is the most comprehensive document published about the state of the global epidemic, which is without doubt the biggest challenge facing our generation. The report warns that the epidemic shows no sign of weakening its grip on human society. “AIDS is a new type of global emergency – an unprecedented threat to human development requiring sustained action and commitment over the long term,” Kofi Annan, secretary-general of the United Nations, writes in the preface. “The AIDS crisis continues to deepen… No region of the world has been spared.” MENA AIDS facts The AIDS epidemic update 2004 for the MENA region says: concerns that HIV would continue to strengthen its presence in the Middle East and North Africa are borne out by the latest estimates which show that 92,000 [34,000– 350,000] people became infected with HIV in 2004. That brings to 540,000 [230,000–1.5 million] the total number of people living with the virus in this region. AIDS killed an estimated 28,000 [12,000– 72,000] people in 2004. Among young people 15–24 years of age, 0.3% of women [0.1–0.8%] and 0.1% of men [0.1–0.3%] were living with HIV by the end of 2004. HIV is being transmitted along diverse paths in this region, including heterosexual sex, paid sex,sex between men and injecting drug use, and there exists significant scope for further expansion of the epidemic. In 2004, some 250,000 women were living with the virus. - In most Middle East and North African countries, the epidemics are still in their early stages – which boosts the chances that effective prevention efforts can limit the further spread of the virus. - Wracked by civil war and humanitarian crises, Sudan remains the region’s worst affected country, with its epidemic concentrated largely in the south. Latest estimates show that more than 2% of the adult population were living with HIV at the end of 2004 – some 500,000 people, which amounts to more than 80% of all people with HIV in this region. - Libya’s epidemic has been growing dramatically, with almost 90% of the officially reported 5,160 HIV infections among Libyans (at end-2002) having occurred in 2000–2002 alone. The vast majority – over 90% – of reported HIV cases are attributed to injecting drug use. - Risk behaviour among injecting drug users in the Egyptian capital, Cairo, is high and there is ample opportunity for HIV to spread from drug injectors to their sexual partners. More than half (55%) said they had injected with non-sterile injecting equipment in the previous month. Among the three quarters of the users who were sexually active, almost two thirds had never used a condom. - HIV infections in Algeria, Bahrain, Kuwait and Oman have also been attributed to injecting drug use. - In Iran, about 15% of all HIV infections since the start of the epidemic were reported in 2003 alone. While this increase partly reflects expanded surveillance, it almost certainly mirrors a recent escalation driven primarily by injecting drug use. - According to one study, around half of injecting-drug users in Iran were married and one third of the surveyed users reported extra-marital sex, pointing to the potential for further transmission. Such a secondary wave of infections would probably put sex workers (and their other clients) at risk too. Iran As elsewhere in the region, sex workers in Iran appear to be poorly equipped to avert HIV infections. A recent report in the Jordan Times says the trend of transmission in Iran has changed from intravenous drug users to high risk sexual behaviour. Dr Minoo Mohraz, a specialist in Iran's official AIDS Association, was quoted as saying: "People cannot afford to get married so young, and are getting married older. The gap is being filled by more prostitution.” According to official figures, just 7,510 people in Iran carry HIV. But experts point to a likely figure of at least 40,000, saying this is disguised by a lack of testing facilities and the unwillingness of sufferers to come forward. One expert was quoted as saying women in particular were reluctant to come forward for testing and support because of ignorance and the stigma attached to the disease. “AIDS is still largely a taboo… In our culture we have a problem with high risk behaviour and extramarital sexual activity,” the expert was quoted as saying. Saudi Arabia In Saudi Arabia the number of AIDS cases increased by about 100%, the Saudi Gazette quoted Dr Tariq Ahmed Madani, advisor to the minister of health, as saying recently. In 2003 230 Saudi patients were diagnosed with AIDS compared to previous years when the numbers ranged between 80- 120. Dr Madani said the number of expats with AIDS was four times that of nationals. From 1984 to 2001 4,761 expatriates were diagnosed with HIV/AIDS. Dr Madani did not state the total number of cases in the kingdom, but the newspaper quoted an official of the National Committee for Combating AIDS as saying the figure was 7,808 up to 2003 from 1984 when the count started. However, Dr Hala Abou-Taleb, UNAIDS Inter- Country Programme Development advisor for the MENA region said the AIDS count in the region was not very accurate and that “available figures may only be the tip of the iceberg”. Dr Madani said the WHO had recommended the free distribution of condoms in the kingdom, but that this was unacceptable in the kingdom as they did not want to promote premarital sex. On a positive note Dr Abou-Taleb said the recent two-day AIDS conference in Jeddah was a big step forward for combating the disease in the kingdom. And the newspaper reported that the health ministry planned to start AIDS awareness campaigns soon. Lebanon In Lebanon only a quarter of Lebanon's estimated 2,500 HIV sufferers are receiving treatment for the disease, said Dr Jacques Mokhbat, an AIDS expert in the country, in an interview with the Lebanese Daily Star. About two-thirds of those being treated for HIV related Young girl at the front door of her home, Cairo, Egypt. illness in Lebanon are men with an average age of 32, the youngest being seven and the oldest 70. Among the known cases, 68.4% contracted the disease through sexual contact. Mokhabt told the newspaper that Lebanese society still has a lot to understand about HIV/AIDS, its modes of transmission and its burden in relation to Lebanon and to the rest of the world. "Until protection during sexual intercourse becomes as accepted as brushing one's teeth, this country will face an AIDS epidemic,” he said. Oman Oman has 902 HIV/AIDS patients, out of whom 30% are women, according to Dr Ali Bin Mohammad Bin Mousa, Minister of Health. Dr Sharifa Bint Khalfan Bin Nasser Al Yahya'eea, Oman's Minister of Social Development said although the infection rate was low the spread of the disaease could be controlled through awareness campaigns, pointing out that a joint effort for preventing the spread of HIV/AIDS has been given serious consideration in the country, according to a report in Gulf News. UAE. In the UAE, although government figures are not made public it is believed the UAE has one of the lowest infection rates in the world. A 2003 WHO report stated that less than 1 in 500 people in the UAE were believed to be HIV positive. Dr Zainab Khazaal, HIV/AIDS co-ordinator at the UAE Ministry of Health, attributed the low infection rate to religious teachings and the conservatism of the culture in the Gulf. According to the UAE Ministry of Health a comprehensive strategy for the prevention and control of HIV/AIDS in the UAE has been developed since 1985. The strategy has been revised regularly to incorporate new control methods. Critical challenges According to the AIDS epidemic update 2004, for 2005, the critical challenges to progress concern competing political realities and the continued "invisibility" of the epidemic in the region. Accordingly, UNAIDS will support efforts in the region focusing on the expansion of actions at national level, using these "building blocks" as a base. Priorities include: - Improving data collection and analysis from the region, especially of vulnerable groups. - Building capacity of partners, government and civil society. - Engaging in regional initiatives as a way to accelerate national responses and address needs of specific populations (for the Horn of Africa, countries bordering the Sahara and countries in western Asia). Lack of information Above all, the continued lack of information on the determinants, scale and impact of the epidemic on the region, substantially undermines and hinders any possible effective response. It is imperative that adequate strategic surveillance systems are put in lace and that socio-behavioural data is collected and analysed, and UNAIDS will offer technical assistance to ensure that this is urgently addressed. -- For more information visit: www.UNAIDS.org  .