NEW YORK // UN experts warn that the stigmatisation of drug users, sex workers and homosexuals across the Middle East and North Africa could be concealing the full scale of the region's Aids epidemic, which saw an estimated 35,000 people become infected last year.
Reports released by UNAids and the World Health Organisation on Tuesday warned of an "acute shortage of timely and reliable epidemiological and behavioural data" that has left experts guessing as to the true number of infections. The latest estimates indicate that the number of people living with HIV in the region rose from 200,000 in 2001 to 310,000 last year, but these figures could be inaccurate because those infected by the disease are criminalised and driven underground by social taboos.
"In many of these countries, the populations most at risk are highly stigmatised and are participating in illegal activities that could result in death penalties, so it is very difficult for non-governmental organisations to work with these groups - injecting drug users, men having sex with men, even sex workers," said Karen Stanecki, an epidemiology expert with UNAids. This year's 100-page Aids Epidemic Update said opinions were divided over whether conservative attitudes in Muslim-majority nations created a "cultural immunity" from the spread of Aids or whether the stigmatisation of high-risk behaviour masked the true scale of the epidemic.
Although experts conclude there are relatively low rates across the Middle East and North Africa and that an epidemic comparable in scale to those in sub-Saharan Africa is unlikely, they call for a policy overhaul and seek to "address the pervasive weakness of ongoing monitoring efforts in the region". "I think we need to try and encourage the countries in this region to gather more data so we can better set up prevention programmes to stop new infections from occurring," Ms Stanecki said. "We are slowly starting to see improvements in data collection, but in that region it is still sparse."
The available figures indicate that the region's HIV infections are concentrated among high-risk groups and rare among heterosexuals. The report says same-sex encounters between men in the Middle East and North Africa are "as common as in other regions", with the scarce data available indicating that infection rates among this group vary between one per cent in Lebanon to as high as 9.3 per cent in Sudan.
Needle-sharing among drug users also increases the risks of contracting Aids, with the few studies of this underground group revealing high rates of infection, ranging from 2.6 per cent in Egypt to 6.5 per cent in Morocco and 11.8 per cent in Oman. Although studies have not found high levels of infection among the region's prostitutes, HIV prevalence among sex workers in Djibouti is recorded to be as high as 26 per cent while estimates of the infection rate in Yemen range up to seven per cent.
The report highlights progress in Egypt in "undertaking biobehavioural studies of street children, women sex workers, men who have sex with men and injecting drug users", providing among the most comprehensive data on infection rates in the region. A 2006 study showed 6.4 per cent of high-risk men and 14.8 per cent of high-risk women were HIV-infected. Data remain extremely scarce in the oil-rich Gulf, where the only cited study for Saudi Arabia dates back to 2004 and revealed that 90 per cent of men who acquired Aids through heterosexual sex in the kingdom were infected during intercourse with a woman prostitute.
Studies on the impact of migration on HIV rates are likely to be particularly pertinent to the Gulf, with researchers warning that the many South Asian men working in the region are increasingly becoming infected with HIV during sex with prostitutes. Globally, the report revealed that Aids has killed 25 million people but new HIV infections have fallen by 17 per cent over the past eight years, with Michel Sidibé, the UNAids executive director, attributing the "good news" to improved prevention.
While most of the notable progress has been reported in Africa, where HIV incidence has fallen by a quarter in the east of the continent since 2001, experts warn that Middle East health chiefs cannot easily replicate the research methods undertaken there. "What we see in the Middle East and North Africa are concentrated epidemics and, in these situations, you actually have to find the key populations at highest risk, sex workers homosexual men and drug users," said Paul De Lay, a UNAids analyst.
"Household surveys which are used in Sub-Saharan Africa for generalised epidemics don't work with countries of concentrated epidemics. We can't rely on the standard household surveillance methodology, so we really do have to identify populations that are often underground." firstname.lastname@example.org