'Robust' evidence of HIV epidemic among people who inject drugs in the Middle East and North Africa

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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 They used a broad range of sources, including published studies, unpublished “grey” literature, conference abstracts and regional databases of HIV prevalence prepared by WHO, UNAIDS and other organisations.



Short for people who inject drugs.

person years

In a study “100 person years of follow-up” could mean that information was collected on 100 people for one year, or on 50 people for two years each, or on ten people over ten years. In practice, each person’s duration of follow-up is likely to be different.

systematic review

A review of the findings of all studies which relate to a particular research question and which conform to pre-determined selection criteria. 

risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.


A sexually transmitted infection caused by the bacterium Treponema pallidum. Transmission can occur by direct contact with a syphilis sore during vaginal, anal, or oral sex. Sores may be found around the penis, vagina, or anus, or in the rectum, on the lips, or in the mouth, but syphilis is often asymptomatic. It can spread from an infected mother to her unborn baby.

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.

HIV prevalence 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.

“There are 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.”

Outbreak epidemics are present in Bahrain, Oman and Jordan, whereas Lebanon, Tunisia, the Palestinian Territories and Syria all currently have low-level epidemics.

These 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.

The investigators 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.

Prevalence of 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 with HIV.

Attitudes towards 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.”


Mumtaz GR et al. HIV among people who inject drugs in the Middle East and North Africa: systematic review and data synthesis. PLOS Medicine, 11(6): e1001663, 2014.