Interview
AIDS in the Middle East

While HIV/AIDS prevalence in the Middle East remains low compared to most of the world, with less than 1% of the population reportedly infected in most countries of the region, experts say epidemics are possible.

Many countries in the Middle East have poor screening and prevention programmes and awareness of how HIV/AIDS is transmitted is low.

Based in Cairo, the Regional Support Team for the Middle East and North Africa (MENA) for UNAIDS covers 22 countries, including Iraq, Algeria, Morocco, Libya, Egypt, Saudi Arabia, Jordan, Yemen, Oman, Bahrain, Kuwait and Iran.

It estimates that between 230,000 and 1.4 million people are living with HIV/AIDS in the region today, and that about 67,000 people were infected in 2005.

In excerpts of an interview with IRIN, Oussama Tawil, UNAIDS director for the MENA region, stressed the need for better prevention and better information- gathering.

QUESTION: What is the overall situation in the region in terms of HIV/AIDS?
ANSWER: If you compare it to other regions in the world, it’s still a relatively low epidemic situation. However, over the last few years, the trend is on the increase. There’s a lot of diversity within the region itself between different countries... There is low prevalence as a general tendency, but there are a number of countries with a higher level of prevalence. We use the term “generalised epidemic,” meaning more than a 1% prevalence in the adult population. And there are some countries where there are epidemics believed to be taking place among certain vulnerable groups [for example, among drug users in Iran or in Libya].

Q: Have there been increases even in countries with very low prevalence rates?
A: There are a number of countries where, either in specific regions or specific vulnerable groups, the number of infections is quite high [for example among prison inmates in Libya, displaced persons in Sudan or intravenous drug users in Iran]. But this doesn’t generally affect the overall prevalence in the country. In many countries, there’s an incremental increase per year, a gradual increase. In some other countries, like Syria or Jordan, it stays at about the same level.

Q: What are the factors that have lead to the increase in HIV/AIDS among certain groups and areas?
A: For the most part in this region, [the primary means of transmission] is sexual transmission, but there is also concern in a number of countries [Iran, Libya and Egypt] about increasing transmission among drug users. [Transmission] through blood transfusions and lack of infection control is generally on the decrease, but this also remains a bit of a concern. [As far as risk factors], in general, young people are more concerned because of changing lifestyles, changing norms. Sudan and Somalia, where there is higher prevalence, are countries that underwent conflict or the consequences of conflict. Education, levels of development, the situation of women: all of these should be taken into consideration. There are other risks in terms of unprotected sexual contact in some settings, such as in the sex trade.

Q: It has been argued that, because societies in the Middle East are socially conservative, this has helped keep prevalence low. How true is this?
A: There is some evidence showing this is true. However, in terms of prevention, this isn’t sufficient. For example, a lot of the infections among women involve them just having sexual contact with their partner.

Q: Are there any countries in the region that have particularly effective HIV/AIDS prevention policies?
A: The main problem is that, until HIV/AIDS becomes significantly visible, there’s a tendency not to commit that much political energy to the issue. However, a number of countries are taking this more seriously. For example, in Algeria, there’s a certain high level of political commitment that has even led to the president making a very strong declaration about the issue. He’s not the only one in the region. The president of Sudan did this as well in 2003. In these declarations, [the leaders] call upon the different ministries to get involved in HIV/AIDS prevention work.

Q: What are the negative stereotypes that people with HIV/AIDS face?
A: One of the main issues with HIV/AIDS is its relationship with social and behavioural issues which are very sensitive, such as sexual behaviour and sexuality – very sensitive topics in all cultures, not least in Arab and Muslim cultures. Also, drug injection is usually associated with illegal behaviour and the people involved are viewed in a very socially marginalised way. This has obviously affected the ability to work on this issue. One of the ways to work on HIV/AIDS prevention is to focus on those at greatest risk, but reaching them poses a challenge. Also, regardless of the awareness campaigns, there is still a fear of being close to people living with HIV/AIDS, or integrating them into everyday family life, community life and work space. What you have in the region now are isolated families, small communities, living with this condition. It’s not at a point that it’s so visible. But obviously there are individuals trying to deal with [living with HIV/AIDS]. Whether their families are aware or not, the reactions of the neighbours, the reactions of the community, the issue of marriage for these people – are small tragedies taking place.

Q: What about people’s awareness and knowledge about HIV/AIDS, such as how it’s transmitted ?
A: The controversy is that the awareness campaigns have been going on since the late 80’s. But many will say that levels of real awareness are low. What should be looked at is the quality of the messages in those campaigns. It might stay at a relatively abstract and simple level. They’re not messages which are really reaching the population. We have to work on much more targeted, highquality messages.

Q: Are anti-retroviral drugs available through public health systems in the region?
A: The health authorities in many countries are making an effort to provide anti-retroviral drugs, but usually at a high cost. For example, there is a real problem in Sudan, where the estimated number of people living with HIV/AIDS is very high and the cost to the health system, where there are limited resources, is very high. But if you look at Gulf countries – where there are at the most a few hundred cases, strong health infrastructure and resources – they can cover treatment. In Egypt, this has taken a while in coming, but in 2005 [the Ministry of Health] started making anti-retroviral drugs available. The issue is of course the coverage, the continuity of treatment and the conditions of treatment.

Q: What are testing facilities [in the region] like?
A: The access to voluntary testing and counselling is low in the region. It’s a global problem. One out of 10 people who have HIV/AIDS is aware of it. In general, there isn’t much access [to testing facilities] in the region and there are issues related to confidentiality – and fear, whether justified or not, of what would happen if one tests positive. In Egypt, Morocco and Jordan, an effort is being made to increase access to voluntary testing and counselling. But it’s still far from what it should be. [In most countries], it’s one or two places, basically. Otherwise, people go through the private sector.

Q: Is it difficult to advocate the use of condoms?
A: Yes. Many countries are still debating, some not wanting this at all. Very few have opted for a more open attitude in terms of advocating condom use.

Q: How worried should we be about HIV/AIDS suddenly increasing in the region?
A: Right now, in many of these countries, we’re talking about low prevalence situations. It’s really far away from what some of the countries in South and Eastern Africa are experiencing. The tendency may continue in this region to be a low rise, but in a couple of contexts, you might have an outbreak. We shouldn’t be complacent and say that these societies, these countries are so different from any others that nothing’s going to happen. Prevention efforts are necessary – and quite intensive ones.