There is “robust”
evidence of HIV epidemics among people who inject drugs (PWID) in multiple
countries in the Middle East and North Africa (MENA), according to a study
published in PLOS Medicine. The
authors analysed data from 23 countries and found that at least a third had HIV
epidemics among people who inject drugs with overall prevalence in the region of
10 to 15%. There was a high prevalence of high-risk injecting behaviours. Many of
the epidemics had emerged in recent years and there was evidence of “bridging”
with other high-risk populations.
“We found robust
evidence for HIV epidemics among PWID in multiple countries, most of which
emerged only recently and continued to grow,” comment the authors. “The high
risk and vulnerability context suggest potential for further HIV spread. HIV
surveillance among PWID must be expanded to detect and monitor these budding
and growing HIV epidemics, and to inform effective HIV policy and programming.”
Little has been
published about HIV prevalence and incidence in the Middle East and North
Africa. However, HIV surveillance has been enhanced across the region in the
past decade. An international team of investigators therefore conducted a
systematic review and data synthesis to determine the state of the HIV epidemic
among people who inject drugs in the region. They used a broad range of
sources, including published studies, unpublished “grey” literature, conference
abstracts and regional databases of HIV prevalence prepared by WHO, UNAIDS and
A total of 192
studies were selected for analysis. The authors estimated that there are
between 335,000 and 1,635,000 people who inject drugs in the region (median,
626,000). Almost all (98%) of these individuals are male. Iran, Pakistan and
Egypt have the highest number of people who inject drugs, with an estimated
median of 185,000, 117,00 and 89,000, respectively.
among people who inject drugs ranged between 1 and 21% (median, 8%). Research
conducted in Kabul (Afghanistan), three cities in Pakistan and Tehran (Iran)
examined HIV incidence among people who inject drugs and found this ranged
between 1.7-17.2 per 100 person years. Between 20 and 60% of notified HIV cases in
the region involve people who inject drugs.
There was firm evidence of an established epidemic
among people who inject drugs in Iran. The first outbreak was reported in 1996
and prevalence has now reached 15%. Emerging concentrated epidemics are present
in Pakistan, Afghanistan, Egypt and Morocco.
settings where HIV prevalence increased considerably in a short period of
time,” note the investigators. “For example in Karachi, Pakistan, after several
years of near zero prevalence, HIV prevalence in 2004 increased to 23% in less
than 6 months, and reached 42% in 2011.”
are present in Bahrain, Oman and Jordan, whereas Lebanon, Tunisia, the
Palestinian Territories and Syria all currently have low-level epidemics.
have the potential to expand. Prevalence of syringe/needle sharing ranges from
71% in Jordan to 97% in Oman. The median overall prevalence of sharing at the
last injection was 23%.
There is also a
high prevalence of sexual risk behaviour. Overall, 36% of people who inject
drugs reported ever using condoms. Only 12 to 25% reported consistent condom use
in the previous year.
also found evidence that people who inject drugs were mixing with other
populations at risk of HIV infection. A median of 18% of men reported sex with
another man, 45% reported ever having sex with a sex worker and between 5 and 29%
reported selling sex in the past year.
hepatitis C virus (HCV) infection was 44% and was very high in some settings,
reaching 94% in Karachi (Pakistan). Rates of syphilis infection ranged between
3 and 18%.
Only 45% (median)
of people who inject drugs rated themselves as having a high risk of infection
drug use and HIV are likely to worsen the situation. “National policies remain
inadequate and not sufficiently reflecting evidence-informed approaches,”
comment the authors. “Improving HIV programming among PWID in MENA is essential
not only to confront the growing HIV problem in this population group, but also
to prevent onward transmission of HIV, and the bridging of the infection to
other groups as has already occurred in part of the region.”