Jocelyn DeJong

HIV/AIDS among female sex workers, injecting drug users and men who have sex with men in Lebanon: results of the first biobehavioral surveys.

Objectives:To measure HIV prevalence and associated risk factors among female sex workers, injecting drug users (IDUs) and men who have sex with men (MSM) in Lebanon and the prevalence of hepatitis B virus and hepatitis C virus among IDUs. Methods and design:A cross-sectional survey of 135 female sex workers, 81 IDUs and 101 MSM was recruited using respondent-driven sampling. A structured interview was conducted by members of nongovernmental organizations working with these populations and blood was collected for serological testing. Results:HIV prevalence was 3.7% among MSM but no HIV cases were detected among female sex workers or IDUs. Among IDUs, prevalence of hepatitis C virus antibody was 51% and prevalence of hepatitis B virus surface antigen was 5%. Three-quarters of MSM had nonregular male sexual partners during the last year but only 39% reported using a condom every time. There was evidence of overlapping HIV risk: 36% of MSM and 12% of IDUs reported that they had sold sex. Previous testing for HIV was lowest among MSM (at 22%) despite their having the highest level both of knowledge about HIV and of perception of being at risk of HIV infection (67%). Conclusion:Prevention efforts at greater scale are needed to reach these at-risk populations in Lebanon. These should target MSM in particular, including access to HIV testing, but will need to address and overcome stigma. For IDUs, surveillance and prevention efforts should integrate both hepatitis C virus and HIV.

Prevalence and determinants of suicide ideation among Lebanese adolescents: results of the GSHS Lebanon 2005.

The current study examined prevalence and risk factors for suicide ideation in 5038 Lebanese adolescents using Global School Health Survey data. Around 16% of Lebanese adolescents thought of suicide. Multivariate logistic regression models showed that risk factors for suicide ideation included poor mental health (felt lonely, felt worried, felt sad or hopeless), substance use (got drunk, used drugs), victimization (was bullied, was sexually harassed), and lack of parental understanding. Recommendations for future research and interventions are discussed.

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

Objective to provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes. Design a self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health. Setting childbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon. Participants in total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected. Measurements the survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008. Findings the study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries. Key conclusions and implications for practice there is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.

Quality of life in people living with HIV/AIDS in Lebanon.

Abstract The aim of the study was to determine the impact of HIV/AIDS on the quality of life (QoL) in Lebanese adult patients living with HIV/AIDS. The study design was a cross-sectional descriptive survey, using self-administered questionnaires. A convenience sample of 41 Lebanese adults (aged 18 years and above) living with HIV/AIDS was recruited from outpatient departments at two major medical centers in Lebanon. The instruments included the Multidimensional Quality of Life HIV (MQoL-HIV), the HIV Symptom Index and a stigma scale, and a demographic section. The majority of the sample were male and single. The mean age was 38 years (SD=9.93). The mean MQoL-HIV score was 176.85, with the highest scores for the cognitive functioning, social functioning, and medical care; the lowest domain scores were for financial status, sexual functioning, and mental health. A single item measuring overall QoL was rated by 47.5% as neither poor nor good. Mean stigma score was 2.05 (SD=0.62) and mean HIV Symptom Index score was 0.6. Prevalence of symptoms and perceived stigma were negative predictors of QoL, being married was a positive predictor of QoL. The results of this study, which is the first to look at the QoL in people living with HIV/AIDS in Lebanon and the Middle East and North Africa region, showed that these mostly asymptomatic well-functioning individuals reported a fair level of QoL. The strongest determinants of QoL revolved around psychosocial aspects of life, namely social relationships, mental health, and medical care.

Health and ecological sustainability in the Arab world: a matter of survival

Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects. In this report, we discuss the most pertinent population-environment-development dynamics in the Arab world, and the two-way interactions between these dynamics and health, on the basis of current data. We draw attention to trends that are relevant to health professionals and researchers, but emphasise that the dynamics generating these trends have implications that go well beyond health. We argue that the current discourse on health, population, and development in the Arab world has largely failed to convey a sense of urgency, when the survival of whole communities is at stake. The dismal ecological and development records of Arab countries over the past two decades call for new directions. We suggest that regional ecological integration around exchange of water, energy, food, and labour, though politically difficult to achieve, offers the best hope to improve the adaptive capacity of individual Arab nations. The transformative political changes taking place in the Arab world offer promise, indeed an imperative, for such renewal. We call on policy makers, researchers, practitioners, and international agencies to emphasise the urgency and take action.

Sexual and reproductive health and rights in public health education.

Abstract This paper addresses the challenges faced in mainstreaming the teaching of sexual and reproductive health and rights into public health education. For this paper, we define sexual and reproductive health and rights education as including not only its biomedical aspects but also an understanding of its history, values and politics, grounded in gender politics and social justice, addressing sexuality, and placed within a broader context of health systems and global health. Using a case study approach with an opportunistically selected sample of schools of public health within our regional contexts, we examine the status of sexual and reproductive health and rights education and some of the drivers and obstacles to the development and delivery of sexual and reproductive health and rights curricula. Despite diverse national and institutional contexts, there are many commonalities. Teaching of sexual and reproductive health and rights is not fully integrated into core curricula. Existing initiatives rely on personal faculty interest or short-term courses, neither of which are truly sustainable or replicable. We call for a multidisciplinary and more comprehensive integration of sexual and reproductive health and rights in public health education. The education of tomorrows public health leaders is critical, and a strategy is needed to ensure that they understand and are prepared to engage with the range of sexual and reproductive health and rights issues within their historical and political contexts.

HIV/AIDS in the Middle East and North Africa: new study methods results and implications for prevention and care.

Of all areas of world, the Middle East and North Africa (MENA, see Figure 1 for countries included in this issues classification) may engender the most perceptions and misperceptions about the HIV/AIDS epidemic in the face of a paucity of accessible data. Figure 1 The Middle East and North Africa For example, the MENA region is perceived as the area of the world least affected by HIV/AIDS. According to most estimates, the overall prevalence of persons living with HIV/AIDS in the region is well below the world average [1]. On the other hand, there is also the perception that the infection rate is severely under-estimated among the marginalized populations most affected by HIV/AIDS, namely injection drug users (IDU), men who have sex with men (MSM), and female sex workers (FSW). The seldom-estimated size of these populations [2] and paucity of HIV prevalence and behavioral data from these groups may belie a greater existing burden of disease and the potential for rapidly evolving epidemics in some areas of the MENA. Another perception is that the threat of HIV to the region comes primarily from outside. Indeed, case reporting, patterns of migration, and molecular epidemiology [3,4,5] corroborate multiple, diverse origins of HIV from exogenous sources throughout three decades of the epidemic. A self-fulfilling result is that HIV testing is often targeted disproportionately to immigrant populations in many countries of the region [6]. Yet, there is also emerging evidence of sustained endogenous HIV transmission among most-at-risk populations (MARPs) including IDU, MSM, and FSW [4]. An effective response for the MENA must therefore also be home grown and based on locally-appropriate research among these populations [7–12]. It is also widely perceived that political and socio-cultural sensitivities restrict access to HIV-related data and stifle relevant research in the MENA. While these factors may contribute to the apparent lack of data, limited experience and capacity in designing, conducting, and disseminating the findings of local HIV research are also severe barriers. Fortunately, concerted efforts to address these barriers and move the field of HIV/AIDS research in the MENA from perception and misperception to a sound evidence base are being scaled-up. For example, the US National Institutes of Health (NIH) has recognized the need for new HIV/AIDS research in the region and, since 2006, have supported meetings in Cairo, Tunis, Beirut, Rabat and elsewhere in order to improve understanding of the epidemiology of HIV/AIDS in the region, to stimulate productive research collaborations between US- and MENA- based investigators, and generate innovative research grant submissions. One conclusion from these meetings was the need to increase the visibility of recent research from the MENA through publications in high impact, peer-reviewed scientific journals. Also, WHO and UNAIDS have focused their investment in recent years in training of national experts on state-or-the art methodologies for community-based surveys among IDU, MSM, and male and female sex workers in addition to technical and financial support to such epidemiological studies. This special issue of AIDS is an output of these concerted efforts to build research and scientific writing capacity and promote timely dissemination of recent HIV/AIDS research findings from the MENA. Several of the guest editors of this special issue first met at the Tunis conference and AUB subsequently organized a workshop in Beirut with funding from the Ford Foundation. At that meeting, researchers shared epidemiological and behavioral research findings, discussed common methodological and ethical challenges, and concurred on a complementary set of articles to prioritize for publication. A second workshop in Beirut funded by the World Health Organization (WHO) Eastern Mediterranean Regional Office (EMRO) and the Ford Foundation (Regional Office for the Middle East and North Africa), comprised an intensive ten-day didactic and mentored retreat to generate ten manuscripts for simultaneous publication in this special issue funded by NIMH. The articles herein testify to the success of these workshops, the dedication of the authors, and the political support of their respective countries to make their data publicly available. The first article [4] is based on the MENA HIV/AIDS Synthesis Project [13] and is the most comprehensive effort to gather and synthesize all available data on HIV/AIDS in the MENA to date, identifying and interpreting several thousand sources from the published and grey literature. Contrary to perception, there is a considerable quantity of epidemiological data on HIV/AIDS in the MENA although fragmented across different disciplines, organizations, and geographic levels. Large numbers of focused assessments, reviews, and studies have never been published, are not easily accessible, and are disseminated only within small circles as confidential or unofficial reports. An encouraging conclusion of the review is that the quality of data from the region has steadily improved in recent years. The second article also synthesizes existing information from across the region, focusing on HIV testing and counseling practices and policies and complemented with original fieldwork in Oman, Egypt, Sudan, and Pakistan [6]. The work describes the predominance of mandatory testing in many countries, particularly targeting migrant and foreign workers, and highlights the need for true voluntary testing with accessibility to the populations most at risk. The majority of articles in this special issue present the first integrated biological and behavioral surveillance data for several countries, applying state of the art methods, such as respondent-driven sampling (RDS) to survey FSW, IDU, and MSM in Lebanon [7], IDU in Egypt [8], FSW in Sudan [10] and Somalia [11], and variations of venue-based or time-location sampling (TLS) to survey FSW in Afghanistan [12] and street children in Egypt [9]. These studies demonstrate the feasibility of reaching hidden populations even under the higher real or perceived stigma affecting MSM, FSW, and IDU in the MENA. The studies describe the unique challenges and locally-generated methodological solutions in implementing RDS and TLS in the region. One study from Pakistan presents the development and application of a pragmatic yet comprehensive method to estimate the size of hidden populations [2], an under-appreciated first step absolutely necessary in guiding the public health response to the HIV/AIDS epidemic worldwide. The final article includes updated data on antiretroviral drug resistance mutations in Iran, a testament to that countrys regional scientific leadership [5]. A final misperception that merits carefully consideration is that the MENA is homogeneous in ways protective against HIV. The near universality of Islam with accompanying male circumcision and probably limited connectivity of sexual networks due to conservative cultural norms may slow HIV transmission [4,13]. Indeed, with the possible exception of parts of Sudan, sustainable HIV epidemics in the general population have generally not occurred in the region. However, the MENA is not homogeneous culturally or epidemiologically. A listing of the countries included in our definition of MENA makes this clear: Afghanistan, Algeria, Bahrain, Djibouti, Egypt, Islamic Republic of Iran, Iraq, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen, and the occupied Palestinian territories (Figure 1). In the regions southern front (Sudan, Somalia, and Djibouti) generalized epidemics may have occurred in at least parts of these countries. The MENAs eastern flank includes the worlds number one producer (Afghanistan) and per capita consumer (Iran) of opioids with accompanying serious HIV epidemics among IDU. Throughout the region, male-male sexual behavior and sex work exist largely under the radar, but in some areas increasingly open despite strong stigma and severe legal and social proscription. In conclusion, the diversity of the populations at risk and the contexts in which they find themselves in the MENA require innovative, tailored responses guided by rigorous local research. We also conclude that there is no cause for complacency anywhere in the region. Our hope is that this special issue will give voice to a part of the world that has been relatively under-represented in the scientific literature in order to accelerate research and advocate for more vigorous and effective prevention and care programs. It is our perception that there is still a window of opportunity to prevent the further spread of HIV in each of the countries of the Middle East and North Africa.

Ethical Considerations in HIV/AIDS Biobehavioral Surveys That Use Respondent-Driven Sampling: Illustrations From Lebanon

Respondent-driven sampling is especially useful for reaching hidden populations and is increasingly used internationally in public health research, particularly on HIV. Respondent-driven sampling involves peer recruitment and has a dual-incentive structure: both recruiters and their peer recruits are paid. Recent literature focusing on the ethical dimensions of this method in the US context has identified integral safeguards that protect against ethical violations. We analyzed a study of 3 groups in Lebanon who are at risk for HIV (injection drug users, men who have sex with men, female sex workers) and the ethical issues that arose. More explicit attention should be given to ethical issues involved in research implementing respondent-driven sampling of at-risk populations in developing countries, where ethical review mechanisms may be weak.

Patterns and determinants of antenatal care utilization: analysis of national survey data in seven countdown countries

Background Antenatal care (ANC) is critical for improving maternal and newborn health. WHO recommends that pregnant women complete at least four ANC visits. Countdown and other global monitoring efforts track the proportions of women who receive one or more visits by a skilled provider (ANC1+) and four or more visits by any provider (ANC4+). This study investigates patterns of drop–off in use between ANC1+ and ANC4+, and explores inequalities in women’s use of ANC services. It also identifies determinants of utilization and describes countries’ ANC–related policies, and programs. Methods We performed secondary analyses using Demographic Health Survey (DHS) data from seven Countdown countries: Bangladesh, Cambodia, Cameroon, Nepal, Peru, Senegal and Uganda. The descriptive analysis illustrates country variations in the frequency of visits by provider type, content, and by household wealth, women’s education and type of residence. We conducted a multivariable analysis using a conceptual framework to identify determinants of ANC utilization. We collected contextual information from countries through a standard questionnaire completed by country–based informants. Results Each country had a unique pattern of ANC utilization in terms of coverage, inequality and the extent to which predictors affected the frequency of visits. Nevertheless, common patterns arise. Women having four or more visits usually saw a skilled provider at least once, and received more evidence–based content interventions than women reporting fewer than four visits. A considerable proportion of women reporting four or more visits did not report receiving the essential interventions. Large disparities exist in ANC use by household wealth, women’s education and residence area; and are wider for a larger number of visits. The multivariable analyses of two models in each country showed that determinants had different effects on the dependent variable in each model. Overall, strong predictors of ANC initiation and having a higher frequency (4+) of visits were woman’s education and household wealth. Gestational age at first visit, birth rank and preceding birth interval were generally negatively associated with initiating visits and with having four or more visits. Information on country policies and programs were somewhat informative in understanding the utilization patterns across the countries, although timing of adoption and actual implementation make direct linkages impossible to verify. Conclusion Secondary analyses provided a more detailed picture of ANC utilization patterns in the seven countries. While coverage levels differ by country and sub–groups, all countries can benefit from specific in–country assessments to properly identify the underserved women and the reasons behind low coverage and missed interventions. Overall, emphasis needs to be put on assessing the quality of care offered and identifying women’s perception to the care as well as the barriers hindering utilization. Country policies and programs need to be reviewed, evaluated and/or implemented properly to ensure that women receive the recommended number of ANC visits with appropriate content, especially, poor and less educated women residing in rural areas.

Surviving testicular cancer: the Lebanese lived experience.

Background:Testicular cancer is thought to have a great impact on its survivors, yet there has been limited literature on the topic globally and no literature on the topic in Lebanon and the Arab region. Objective:The purpose of this study was to explore the lived experience of Lebanese testicular cancer survivors and gain an in-depth understanding of the psychosexual aspect of their experience. Methods:A hermeneutic phenomenological approach with semistructured digitally recorded interviews and observational field notes was utilized. A purposive sample of Lebanese testicular cancer survivors, aged between 18 and 50 years, in remission for at least 3 years, and willing to share personal information was recruited. Interviews were transcribed verbatim in Arabic. Data saturation was achieved at the seventh interview; a total of eight informants were recruited. The opening question was, “Tell me about your life since you got treated for testicular cancer,” and was followed by probing questions. Two to three weeks after the initial interview, informants were called to validate the investigators’ primary analysis. Results:Six core themes emerged: cancer perception in the Lebanese culture; “do not show, do not tell”; cancer experience is a turning point; fertility, manhood, and relationships; coping with cancer; and preserved aspects of life. Discussion:The findings provide an in-depth understanding of the experience of Lebanese testicular cancer survivors with a focus on the psychosexual aspect of this experience. The results suggest the need to educate patients about testicular cancer and its effect on their fertility.