Francisca Ayodeji Akala

Epidemiology of HIV infection in the Middle East and North Africa.

Objective:The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region. Methods:A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents. Results:Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited. Conclusion:Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis

A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries.

Public-health challenges in the Middle East and North Africa

In the past couple of decades while there was modest growth and poverty reduction in the Middle East and North Africa (MEAN) region impressive gains have been achieved in health status through improvements in technology health-service delivery public-health programmes and socioeconomic development. In 2000 MEAN governments signed on to the Millennium Development Goals (MDGs) and most MEAN countries are on track to achieving most of the goals. But health outcomes are generally worse among the poorest than among the richest. The challenges facing the MEAN region can be grouped into health-transition and health-systems issues. (excerpt)

An Appraisal of Female Sex Work in Nigeria - Implications for Designing and Scaling Up HIV Prevention Programmes

Background The HIV epidemic in Nigeria is complex with diverse factors driving the epidemic. Accordingly, Nigerias National Agency for the Control of AIDS is coordinating a large-scale initiative to conduct HIV epidemic appraisals across all states. These appraisals will help to better characterize the drivers of the epidemic and ensure that the HIV prevention programmes match the local epidemic context, with resources allocated to interventions that have the greatest impact locally. Currently, the mapping and size estimation of Female Sex Workers (FSWs) - a major component of the appraisal has been completed in seven states. These states are using the data generated to plan, prioritize and scale-up sub-national HIV prevention programmes. Methodology It involved a two-level process of identifying and validating locations where FSWs solicit and/or meet clients (“hotspots”). In the first level, secondary key informants were interviewed to collect information about the geographic location and description of the hotspots. For the second level, FSWs were interviewed at each hotspot and information on population size estimates, typologies and operational dynamics of the FSWs were collected. Results Across the seven states, a total of 17,266 secondary key informants and 5,732 FSWs were interviewed. 10,233 hotspots were identified with an estimated 126,489 FSWs ranging from 5,920 in Anambra to 46,691 in Lagos. The most common hotspots were bars/nightclubs (30%), hotels/lodges (29.6%), streets (16.6%), and brothels (14.6%). Furthermore, the population density of FSWs (per thousand adult men) across the states ranged from 2 in Anambra to 17 in the Federal Capital Territory. Conclusion FSW populations in Nigeria are large and diverse, with substantial differences between and within states. Improved understanding of the location, population size, density, organizational typologies and clients of sex work has informed and is central to Nigerias planning process for scaling up focused HIV prevention programmes.

HSV-2 serology can be predictive of HIV epidemic potential and hidden sexual risk behavior in the Middle East and North Africa

BACKGROUND HIV prevalence is low in the Middle East and North Africa (MENA) region, though the risk or potential for further spread in the future is not well understood. Behavioral surveys are limited in this region and when available have serious limitations in assessing the risk of HIV acquisition. We demonstrate the potential use of herpes simplex virus-2 (HSV-2) seroprevalence as a marker for HIV risk within MENA. METHODS We designed a mathematical model to assess whether HSV-2 prevalence can be predictive of future HIV spread. We also conducted a systematic literature review of HSV-2 seroprevalence studies within MENA. RESULTS We found that HSV-2 prevalence data are rather limited in this region. Prevalence is typically low among the general population but high in established core groups prone to sexually transmitted infections such as men who have sex with men and female sex workers. Our model predicts that if HSV-2 prevalence is low and stable, then the risk of future HIV epidemics is low. However, expanding or high HSV-2 prevalence (greater than about 20%), implies a risk for a considerable HIV epidemic. Based on available HSV-2 prevalence data, it is not likely that the general population in MENA is experiencing or will experience such a considerable HIV epidemic. Nevertheless, the risk for concentrated HIV epidemics among several high-risk core groups is present. CONCLUSIONS HSV-2 prevalence surveys provide a useful mechanism for identifying and corroborating populations at risk for HIV within MENA. HSV-2 serology offers an effective tool for probing hidden sexual risk behaviors in a region where quality behavioral data are limited.

O13.1 The Use of Rapid Epidemic Appraisals For Planning and Scaling Up Focused HIV Prevention Programmes For Female Sex Workers in Nigeria

Background The HIV epidemic in Nigeria is complex with substantial heterogeneity in its distribution across different regions and diverse factors that drive the epidemic. Therefore, it is critical that HIV prevention programmes and strategies match the local context and that resources are allocated to interventions with the greatest impact. Nigeria’s National Agency for the Control of AIDS (NACA) is coordinating a large-scale initiative to conduct rapid epidemic appraisals across most states, including the mapping and size estimates of female sex workers (FSWs). Seven states have completed the appraisal of FSWs, and are now planning programmes accordingly. Methodology Mapping was done using a two-level process of identifying and validating locations where FSWs solicit and/or meet clients. The first level involved conducting interviews with secondary key informants to collect information on the location and profile of hotspots, size estimates and typology of FSWs. The second level was done by interviewing primary key informants (FSWs themselves) at each hotspot to validate the information collected and generate more detailed information. Results A total of 10,233 hotspots were identified across the states and 126,489 FSWs {Hotel/Lodge (29.6%) Bar/Nightclub (30%), Home based (4.1%), Brothel (14.6%) and Street based (16.6%)} were mapped. There was substantial variability in the population density of FSWs (per thousand adult men) across the states ranging from 17 in Abuja to 2 in Anambra. Furthermore, there were clear differences in the density of FSWs per spot with the mean number of FSWs/spot ranging from 17 in Abuja to 8 in Ondo. Conclusion The FSW population in Nigeria is large and diverse, with substantial differences between and within states with respect to the population size, density and organisational typologies of sex work. This information is central to Nigeria’s planning process for scaling up focused HIV prevention programmes and services.

P1-S1.17 HIV-1 molecular epidemiology in the Middle East and North Africa

Background Human Immunodeficiency Virus Type I (HIV-1) is characterised by a high genetic variability. The distribution of HIV-1 subtypes in a population can help track transmission patterns and the evolution of the epidemic. The Middle East and North Africa (MENA) continues to be perceived as a region with limited HIV epidemiological data, but recent research indicates that nascent HIV epidemics appear to be emerging among high-risk groups including injecting drug users (IDUs), men who have sex with men (MSM), and female sex workers. The objective of this work was to review all evidence on HIV-1 subtype distribution in MENA where there remains several gaps in our understanding of the HIV epidemic. Methods A comprehensive systematic review of all HIV-1 molecular epidemiology data in MENA was undertaken. Sources of data included (1) PubMed using a strategy with both free text and MeSH headings, (2) country-level reports and database including governmental and non-governmental organisations publications, and (3) international organisations reports and databases. Results In several countries such as in Lebanon, Saudi Arabia, and Yemen, a very diverse distribution of HIV-1 subtypes was observed reflecting principally travel-related exogenous exposures. A trend of a dominant HIV-1 subtype was observed in few other settings and was often linked to HIV transmission within specific high-risk core groups such as subtype A and CRF35_AD among IDUs in Afghanistan, Iran, and Pakistan; and subtype C in heterosexual commercial sex networks in Djibouti and Somalia. Subtype B was predominant in Northern Algeria, Tunisia, and Morocco, but this appeared to reflect a mix of indigenous endemic transmission and exogenous exposures of West European and North American origin. Conclusions Multiple introductions of HIV-1 variants due to exogenous exposures of nationals seemed common to all MENA countries, as observed from the high diversity in subtypes or the high genetic divergence among any specific subtype even if predominant. This is in part a reflection of the high population mobility in MENA. In several countries though, epidemic-type clustering of specific subtypes suggests established or nascent HIV epidemics among classical core risk groups for HIV infection. With overall weak surveillance systems in MENA, molecular investigations could help identify the emergence of hidden epidemics among high-risk groups. HIV prevention efforts in MENA must be prioritised for these groups.