An HIV epidemic is emerging among injecting drug users in the MENA

It is known that HIV infection is a major issue among people who inject drugs (PWID) and with an abundance of cheap heroin pouring out of Afghanistan injecting drug use in the Middle East North Africa (MENA) region is on the increase. Middle East Health looks a recent study which aims to assess the current situation.

An article published in Global Research (February 15, 2014) notes that in the “course of the last four years, there has been a surge in Afghan opium production (heroin is made from opium). The Vienna-based UN Office on Drugs and Crime (UNODC) reveals that poppy cultivation in 2012 extended over an area of more than 154,000 hectares, an increase of 18% over 2011”.

Most of this Afghan heroin is trafficked through Iran and Pakistan, both MENA countries. The increased availability and purity of heroin at lower prices in MENA appears to have led to a subsequent rise in injecting drug use.

However, until recently, very little was known about the epidemiology of HIV infection among people who inject drugs (PWID) in the MENA region. This has now changed to some degree following the publication of an important and comprehensive study which looks to address this issue.

The study provides robust evidence for growing HIV epidemics, most of which have emerged within the past decade, among PWID in several MENA countries.

“HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis” by Ghina R Mumtaz, et al. was published in PLOS Medicine June 17, 2014. The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence.

They point out that they conducted the study to maximize the effect of harm-reduction strategies in specific regions. To do this they say it is “important to understand the status of the HIV epidemic among PWID”.

These harm-reduction strategies – designed by the Joint United Nations Programme on HIV/AIDS (UNAIDS) – include education and the provision of clean needles, syringes, and opioid substitution therapy.

The researchers estimate that there are 626,000 PWID in the MENA. They found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%-15%.

The authors note that “some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya)”.

The data also revealed a high injecting and sexual risk environment among PWID in MENA (for example, on average, about a quarter of PWID shared a needle or syringe in their most recent injection and only a third reported ever using condoms) that, together with a high prevalence of Hepatitis C and sexually transmitted infections among PWID, indicates the potential for more and larger HIV epidemics.

Analysis of notified HIV cases indicated that in 2011, injecting drug use contributed 20%, 23%, 38%, 49%, and 60% of all newly notified cases in this year in Egypt, Pakistan, Bahrain, Afghanistan, and Iran, respectively. A smaller contribution was reported in the remaining countries.

The researchers note that ‘concentrated HIV epidemics among PWID’ were observed in Iran, Pakistan, Afghanistan, Egypt, Morocco, and Libya. They point out that Iran is the only country with conclusive evidence for an established concentrated epidemic at the national level. The first HIV outbreaks among PWID in Iran were reported around 1996. HIV prevalence then increased considerably in the early 2000s, reaching a peak by the mid-2000s. HIV prevalence in the 2006 and 2010 multi-city IBBSS (Integrated Biological and Behavioural Surveillance Survey) was stable at 15%. The evidence suggests that the HIV epidemic among PWID in Iran is now established at concentrated levels of about 15%.

Emerging concentrated epidemics were seen in Pakistan, Afghanistan, Egypt, and Morocco. For example, in Pakistan, after almost two decades of very low HIV prevalence among PWID, a trend of increasing prevalence was observed after 2003. The authors say this trend is national and ongoing, reaching over 40% in recent studies and with no evidence yet of stabilization.

The researchers found that the HIV epidemic among PWID is low-level in Jordan, Lebanon, Tunisia, Occupied Palestinian Territory, and Syria.

They note that in Bahrain and Oman, data show that there are, or have been, at least some pockets of HIV infection among PWID, with reported prevalence up to 21.1% in Bahrain and 27% in Oman, but hasten to add that the quality of evidence is insufficient to indicate whether there is a concentrated epidemic in these two countries.

Interestingly, they point out that levels of basic HIV/AIDS knowledge among PWID in MENA was high overall with more than 90% having some knowledge of HIV/AIDS, but add that there was considerable variation in the proportion of PWID who correctly identified reuse of non-sterile needles as a mode of HIV transmission.

Overlap of risk behaviour

An important finding made by the study authors is that they found considerable overlap of risk behaviour between PWID and other high-risk groups in MENA.

“This could play a role in emerging HIV epidemics, as it creates opportunities for an infection circulating in one population to be bridged to another one.”

In Pakistan, the rapidly growing HIV epidemic among PWID was followed closely by an emerging epidemic among transgender sex workers. A similar pattern, but in the opposite direction, may have occurred in Egypt where an emerging epidemic among MSM (males who have sex with males) preceded the nascent epidemic among PWID.

The majority of PWID are sexually active and about half are married. They often engage in risky sexual behaviour as confirmed by the prevalence of Sexually Transmitted Infections (STIs). This puts sexual partners of PWID at risk of HIV. A substantial number of infections in MENA have been documented in women who acquired HIV from their PWID husbands; and in some countries, the majority of HIV infections among women were acquired from a PWID sexual partner.

Response to emerging epidemic

Not only does the region overall lag behind in responding to the emerging HIV epidemics among PWID; on occasions misguided policy has contributed to these epidemics. Most notably in Libya, the large HIV epidemic among PWID appears to have been exacerbated by restrictions imposed on the sale of needles and syringes at pharmacies in the late 1990s.

Overall, harm reduction programs still remain limited in MENA, and there is a need to integrate such programs within the socio-cultural framework of the region. Several countries though have made significant strides in initiating such programs in recent years. Needle/syringe exchange programs are currently implemented in nine countries, and opioid substitution therapy in five. Iran remains the leader in the provision of harm reduction services to PWID with the highest coverage of needle/syringe exchange programs in the region. It appears also to be the only country in MENA to provide such services in prisons and to provide female-operated harm reduction services targeted at female drug users.

The researchers note that other countries in the region have also made progress in revising their policies, adopting harm reduction programs, and integrating such programs in their national strategic plans such as Afghanistan, Egypt, Lebanon, Morocco, Pakistan, and Tunisia.

They point out that non-governmental organizations (NGOs) have been instrumental to the success in harm reduction in MENA. “In countries where NGOs are strong, HIV response has been also strong.”

Window of opportunity

The authors conclude that the window of opportunity to control the emerging epidemics should not be missed. HIV prevention among PWID must be made a priority for HIV/AIDS strategies in MENA; and obstacles must be addressed for the provision of comprehensive services and enabling environments for PWID.

“There is need to review current HIV programs among PWID in light of the emerging epidemics, and to develop service delivery models with embedded links between community-based prevention (needle/syringe exchange programs and condom provision), HIV testing, and treatment (opioid substitution and Antiretroviral Therapy).”


HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis. Ghina R Mumtaz, et al. PLOS Medicine. June 17, 2014. doi: 10.1371/journal.pmed.1001663

 Date of upload: 10th Jan 2015


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