Sherine Shawky

HIV surveillance and epidemic profile in the Middle East and North Africa.

HIV infection is the most devastating infection that has emerged in the recent history. The risk of being infected can be associated with both individuals knowledge and behavior and community vulnerability influenced by cultural norms, laws, politics, and social practices. Despite that the countries in the Middle East and North Africa have succeeded in keeping low the HIV epidemic rates, the number of identified infected cases are increasing. Since the appearance of the first AIDS cases, all the national authorities devoted their efforts to abort the epidemic in its early stages. The rate of new HIV infections across the Middle East and North Africa region are not at an alarming level, but the need for a concerted effort from nation-states and nongovernmental organizations to stem the spread of the virus across the region is vital.Most countries of the region have put in place better information systems to track the HIV epidemic, yet the passive HIV/AIDS reporting remains the cornerstone in the HIV surveillance systems. Several countries still believe that their current strategies are optimal to the HIV status within their territories and that their national strategies are appropriate to their low epidemic status that is not expected to grow. Additionally, these countries fear that establishing an HIV national program to survey risk behaviors may be perceived as an approval of these behaviors that are culturally and religiously unacceptable. This background article aims to summarize the HIV surveillance strategies and epidemic profile in 17 Arab countries in the Middle East and North Africa. The article, also, displays the national surveillance system and the epidemic profile in Egypt and Lebanon as models for the region. This information aims to provide useful insights that may help the national authorities in finding out the best surveillance strategies that allow merging and collecting biological and risk data which is an integral part of their efforts to fight the HIV epidemic in the region.

HIV prevalence and risk behaviors of male injection drug users in Cairo, Egypt.

Objective:To measure HIV prevalence and related risk behaviors among male injection drug users (IDUs) in Cairo, Egypt in the context of the first survey wave of an integrated biological and behavioral surveillance system. Design and methods:Given the hidden nature of injection drug use, we used the peer-referral methodology of respondent-driven sampling in a cross-sectional study to recruit a sample of male IDUs in Cairo between May and August 2006. Behavioral data were collected through face-to-face interviews and serum was obtained for HIV antibody testing. Population estimates were produced using respondent-driven sampling Analysis Tool. Results:The study enrolled 413 male IDUs. The population estimated HIV prevalence was 0.6% (95% confidence interval 0.1–1.8). More than half (53.0%) reported injecting drugs with used needles or syringes and nearly one-third (32.4%) shared their used needle or syringe with one or more persons in the preceding month. Overall, 70.5% had sex in the preceding year, of whom 9.4% reported sex with male partners and 13.2% reported sex with commercial sex workers in the preceding 12 months. Ever use of a condom during sex was low with all partner types and only 5.8% ever had an HIV test. Conclusion:This first survey wave of integrated biological and behavioral surveillance system in Egypt to track the HIV epidemic among male IDUs found relatively low prevalence of infection compared to global estimates, though the figure is many times higher than the general population. In addition, risky injection practices and unprotected sex were high with sexual networks including men who have sex with men, female sex workers, wives, and other regular and casual partners. The respondent-driven sampling method was effective in recruiting male IDUs and the results are being used to inform surveillance and prevention programs.

Gender and HIV in the Middle East and North Africa: lessons for low prevalence scenarios.

Over the quarter century since its discovery, HIV has not been considered a health threat in the Middle East and North Africa (MENA). However, despite the low prevalence in most countries of the region, there is increasing evidence suggesting that the epidemic is in motion. Since the identification of the first MENA region AIDS cases in the 1980s, the number of detected people living with HIV has been steadily on rise. Although geographic proximity and shared cultural factors interconnect the region, estimated HIV-related epidemiological profiles vary dramatically, ranging from low level to generalized epidemics. Despite the overall regional prevalence remaining low, the total number of AIDS deaths in the region increased by at least 6-folds since the early 1990s. Globally, gender norms that subordinate women and trap men in damaging patterns of risk behaviors are increasingly recognized as fundamental forces that increase population health vulnerabilities, and the MENA region is no exception. Gender is a social construct that refers to a complex framework affecting both men and women in the society. All cultures interpret the biological differences between women and men into a set of culturally normative behaviors and attitudes. In the community-oriented MENA societies, the family, rather than the individual, is the core focus of concern. Femininity and masculinity are often translated into raising women to be ‘‘caregivers’’ and men to be ‘‘breadwinners.’’ For both women and men, early marriage is encouraged, sexual relations outside marriage are prohibited, and sex education is a sensitive topic. The prevailing gender norms offer men greater social power and access to resources as compared with women. Furthermore, normative societal ideals for the interaction between women and men in the region may increase both women’s and men’s transmission risk and ability to access care for those who are infected. In the conservative societies of the MENA, cultural norms uphold the institution of marriage as the only legitimate context for sexual relations. Ideals of premarital chastity and lifelong fidelity are encouraged for women, whereas men’s experiences and multiple partners are often tolerated as part of the masculine ideals. Women face steep barriers to accessing accurate information about HIVand risk reduction and having a proactive role in negotiating safer sex because they are not expected to be sexually experienced. The region’s prevailing norms of masculinity provide men with more privileges and freedoms, often putting them at risk by preventing them from seeking accurate information or admitting their lack of knowledge about sexuality and risk reduction. Although a range of transmission modes exist in the region, unprotected sexual transmission is overwhelmingly responsible for new infections in the MENA. The growing population of injecting drug users is another major route of infection that is accelerating

Could the employment-based targeting approach serve Egypt in moving towards a social health insurance model?

The current health insurance system in Egypt targets the productive population through an employment-based scheme bounded by a cost ceiling and focusing on curative care. Egypt Social Contract Survey data from 2005 were used to evaluate the impact of the employment-based scheme on health system accessibility and financing. Only 22.8% of the population in the productive age range (19-59 years) benefited from any health insurance scheme. The employment-based scheme covered 39.3% of the working population and was skewed towards urban areas, older people, females and the wealthier. It did not increase service utilization, but reduced out-of-pocket expenditure. Egypt should blend all health insurance schemes and adopt an innovative approach to reach universal coverage.

Measuring Geographic and Wealth Inequalities in Health Distribution as Tools for Identifying Priority Health Inequalities and the Underprivileged Populations

Background Currently, there is no consensus on standard measure that can be routinely part of the health information systems to alert countries to inequalities in health and identify the priority health inequality conditions. Objectives To identify the health inequality measures relevant for assessing geographic and wealth inequalities; use the measures as a demonstration to what can happen in practice to recognize the geographic and wealth-related priority health inequalities within a country; and identify the geographic and wealth underprivileged populations. Method Egypt data were used as demonstration. Pearson coefficient of correlation was calculated to compare the various geographic and wealth health inequality measures. T test was used to identify significant correlations. The relevant inequality measures were used to rank geographic and wealth health inequalities and identify the underprivileged populations. Results The wealth inequalities in health measured by the concentration index provide a familiar and perform adequately in identifying economic inequalities in health. However, the geographic health inequalities identified by the index of dissimilarity appear to provide a more comprehensive profile of health inequalities within a country. Conclusion There is a need for a feasible inequality measure in the health information systems. A country’s geographic health distribution measured by the index of dissimilarity appears to provide a feasible first-step alarm to inform and guide the uptake of equity-sensitive policies.

Assessment of hepatitis B immunization programme among school students in Qatar

Background In 2010, Qatar adopted the target of reducing hepatitis B prevalence to < 1% in children by 2015. The World Health Organization Region for the Eastern Mediterranean is identified with intermediate hepatitis B virus (HBV) endemicity, ranging from 2% to 7%. It is estimated that 4.3 million individuals are living with HBV infection in the Region. Aims This study was conducted to assess hepatitis B seroprevalence in children, hepatitis B vaccination coverage, potential exposure to risk factors, and knowledge among parents/guardians about hepatitis B infection. Methods We carried out this cross-sectional study in Qatar during the academic year 2015/16. Multistage cluster sampling was used to select a nationally representative sample of 2735 grade 1 school students aged ≥ 5 years. Blood was collected by finger prick and tested using the point-of-care test/rapid test. A self-administered, precoded questionnaire was used to assess parent/guardian knowledge about HBV and collect information on the childs HBV vaccination coverage. Results All blood samples were HBsAg negative. Qataris had a vaccination card and were totally vaccinated but 17.7% of non-Qataris did not hold a vaccination card and most parents/guardians were not aware of the vaccination status of their children. Children were exposed to various hepatitis B risk practices. Knowledge about hepatitis B among parents/ guardians was low. Conclusions Qatar has averted the hepatitis B threat and maintained high vaccination coverage for children.

Primary health care in the Eastern Mediterranean Region: from Alma-Ata to Doha

The celebration in Doha of the 30th anniversary of the Alma-Ata Declaration at the International Conference on Primary Health Care renewed the commitment of the Eastern Mediterranean Region to primary health care as the tool for better health. The principles agreed at Alma-Ata in 1978 apply as much now as they did before. The event provided an opportunity for the Eastern Mediterranean countries to define future directions to steer the health systems to integrate primary health care and harness the intersectoral approach.