Eradicating HIV 'within our grasp' in Middle East and North Africa, despite rising cases

HIV infections are rising in the Middle East and North Africa, despite a global decline, with researchers warning that stigma and discrimination are making the problem worse. There were an estimated 16,000 new cases of HIV in the Mena region last year, a 7 per cent increase since 2010, figures compiled by UNAIDS show. Infections dropped by an average of 31 per cent globally during that period. Campaigners at UNAIDS said that, with investment and political will, eradicating HIV as a public health threat in the region by 2030 is “within our grasp”. “We have an opportunity in the Arab region that other parts of the world are literally dying for,” Dr Shereen El Feki, director of the Mena regional support team at UNAIDS, told The National . “We could make HIV history.” However, stigma, discrimination, low levels of awareness and a lack of access to treatment are factors costing lives, she said. “You can live with HIV, but one of the things you can’t live with is the stigma and discrimination,” Dr El Feki said. “That is what is lethal, actually.” A pregnant woman living with HIV in Egypt was turned away from hospital just as she was about to deliver her baby, Dr El Feki said. The UN agency’s local partners had to find another medical centre that would admit her. A child in Lebanon with HIV-positive parents was expelled from several schools because none of the other children wanted to sit next to the pupil, said Elie Ballan, a UNAIDS consultant on communities, youth and communications. This was despite the fact that the child was HIV-negative. “You can imagine [how it is for] the children who are born with HIV,” said Mr Ballan, who is also living openly with HIV. “The amount of discrimination, the amount of stigma they face.” Many of the groups among which HIV cases are rising in the region are already marginalised. They include sex workers and people who inject drugs. Because of fear of discrimination, it can be difficult to reach these groups for testing and treatment. “Trying to get to a population that is technically labelled ‘illegal’ is really very tricky,” said Mr Ballan. “This is where the data is missing.” HIV is a virus that damages the immune system. If left untreated, it can lead to Aids and death. The virus is predominantly spread through unprotected sex or by sharing needles. It can also be passed on from an infected mother to her baby during pregnancy, labour and breastfeeding. More than 36 million people have died globally since the HIV and Aids epidemic first came to light in the 1980s. However, scientific advances have meant that the virus is no longer a death sentence. People with HIV can use antiretroviral treatment to allow them to lead long and healthy lives. But for this to happen, those who are HIV-positive need to know their status and gain access to medical treatment. UNAIDS set out an ambitious “90-90-90” plan in 2020 to help ends the AIDS epidemic. The plan involved every country ensuring that 90 per cent of all people living with HIV should know their status. Of those, 90 per cent should be receiving sustained antiretroviral therapy. Finally, 90 per cent of those people will have achieved viral suppression, meaning they are not at risk of passing the virus on to others. The Mena region is still some way off meeting these targets. The latest UNAIDS data shows that it has achieved 61 per cent, 43 per cent and 37 per cent on those targets respectively. With access to antiretroviral therapy, a pregnant woman living with HIV can be prevented from passing the virus on to her baby. But the Mena region has one of the lowest rates of prevention of mother-to-child transmission, said Dr El Feki. About a quarter of pregnant women living with HIV passed the virus on to their babies because they were unable to gain access to treatment in 2017, UK-based HIV and Aids charity Avert has said. “This is why we are very keen to bring attention to HIV,” said Dr El Feki, on the eve of World Aids Day, December 1. “People in our region think HIV is not an issue. We are one of two regions with a rising rate of HIV.” Eastern Europe and Central Asia is the other region, she said. Even though HIV cases are rising in Mena, the overall prevalence of the virus in the region is low, at less than 0.1 per cent of the adult population. This means the epidemic is still “manageable”, said Dr El Feki. Although domestic funding to tackle HIV in the Mena region increased by 14 per cent in the last decade, international funding has fallen by 30 per cent over the same period, Avert said. Many countries in the region are defined as middle or lower-middle income so they do not qualify for global funding available to poorer countries to fight HIV, said Dr El Feki. Tackling HIV is often at the “bottom of the list” of priorities for countries in the region affected by conflict, said Tania Kisserli of Frontline Aids, a British charity. “But relatively small investments could prevent the increased spread of HIV in that country and/or subregion,” she said. Another pressing issue is the lack of reliable data on HIV in many Mena countries. The data that is available is prone to “underestimation biases” because of its reliance on poor, infrequent and non-representative surveillance systems within health ministries, said Mohammad Karamouzian, a research scientist at the World Health Organisation Collaborating Centre for HIV Surveillance in Kerman, Iran. For HIV and Aids campaigners such as Mr Ballan, “knowledge is everything”. He believes that when the public understand more about how the virus is transmitted and how people can live with it, the stigma will begin to disappear. Mr Ballan discovered he was HIV positive when he was 20 years old and living in Lebanon. Now he is 35. “The first few months after diagnosis were not easy at all,” he said. He told a few friends, in confidence. However, they spread the news that he had HIV. “The word was out without my consent,” he said. “It was very difficult to have people judge you before they meet you or talk behind your back or try to avoid you because of this.” But he also encountered supportive people. Mr Ballan recalls that he was working in a club when some customers told the manager they were not comfortable with him being there because of his HIV status. “He [the manager] said, ‘This is my party, this is my club, and Elie is my friend and my best employee, and I don’t care what he has because he does an amazing job. If you don’t like this, you don’t have to come to our club’,” recalls Mr Ballan. It was the first time that Mr Ballan had heard someone sticking up for him since he had the virus diagnosed 18 months earlier. “It just made me feel that I am not alone in this,” he said. In his role at UNAIDS, he works to support networks of people living with HIV people around the region. These peer support groups provide a lifeline to many living with the virus. “It helps people to accept who they are,” he said. “And to be at peace, and be able to manage their HIV, without having to worry what the entire world is thinking about them.” Denial, fear and despair are preventing people with HIV in Iran from gaining access to life-saving treatment, researchers warn. An estimated 54,000 people were living with HIV in the republic last year, among the highest tallies in the Middle East and North Africa, although academics say this is also down to Iran having better detection mechanisms than other Mena countries. “Fear of prosecution and stigmatisation deter many from seeking HIV testing and treatment, despite immunity offered by patient confidentiality,” according to a study published in the British Medical Journal last month looking at people living with the virus in Iran. There were about 3,200 deaths from Aids, the condition caused by HIV, in the country last year, even though Iran provides free access to antiretroviral treatment. The republic has managed to reverse the rate of new infections, which is rising in the rest of the Mena region, said the study’s author, Vira Ameli. But her research found stigma remains a barrier to treatment. It contained testimonies from several people with HIV in Iran, including a man who described being disowned by his family. “When I found out, I didn’t tell anyone,” he said. “But my brother found out, collected all my clothes, and threw me out of the house.” The study found many patients, men in particular, went into denial about their HIV-positive status for fear of being shunned. The “deadly stigma” was illustrated by one woman’s account. “Sometimes the pressures from stigma and the attitudes of the society are so strong that you just lose hope and want to end the whole process of treatment,” she said. “And it has happened to many of us.” Other people with HIV in Iran spoke of demeaning treatment at the hands of medical professionals. For example, one doctor asked his patient to put a glass of water she was drinking in the bin after he discovered she was HIV-positive. Economic sanctions and inflation have also taken their toll on people living with HIV, who struggle to cope with rising prices. “This year I just can’t take the prices any more,” said one female patient. “I’ve been thinking about giving up on this life.” HIV initially spread in Iran mainly through people injecting drugs, but it is now mostly transmitted sexually, said Ms Ameli, a doctoral candidate at the University of Oxford and public health researcher. Most of the global supply of heroin is produced in Afghanistan and more than three quarters of this is trafficked through Iran and Pakistan, the charity Avert said. This places intense pressure on the Mena region, where the availability of heroin makes those who inject drugs among the groups most at risk of HIV. Women were also vulnerable to HIV transmission as a result of relations within marriage. About 75 per cent of women living with HIV in Iran acquired the virus from their husbands, many of whom are thought to have contracted it through injecting drugs, Avert said. Iran has taken steps to tackle HIV. These include syringe exchange programmes to stop drug users sharing dirty needles. HIV self-testing kits are available in the country. In January, Tehran introduced regulations to ban discrimination against people living with HIV in healthcare settings. “Iran has a very advanced harm reduction programme,” Ms Ameli told The National . “Other countries could learn lessons through more collaboration.”

Eradicating HIV 'within our grasp' in Middle East and North Africa, despite rising cases

UN figures show that although there are many obstacles, and lives being lost, there is hope of regional progress by the end of the decade