The rate of deaths from AIDS in the Middle East and North Africa is increasing sharply, in contrast to the encouraging downward trend in deaths from the disease globally.
In the Middle East and North Africa, deaths from AIDS between 2000 and 2015 rose by 274 percent, according to regional estimates from the World Health Organization, although the number of deaths worldwide from AIDS fell by 27 percent over the same period.
“A lot of people both in the Arab region and outside of it are unaware that HIV and AIDS are a problem,” says Navid Madani, a senior scientist in the department of health and social medicine at Harvard Medical School. “People are often shocked to learn that HIV is on the rise,” says Madani, who studies trends in infection with HIV, the virus that causes AIDS. “I think people in the Arab world are just beginning to accept that it’s happening.”
The actual number of deaths in many Arab countries is relatively small, but that could also change over time as the rate of infections increases, researchers say.
The pattern of HIV spread in the region is not even, and the medical data available are often thin. “Testing rates in the Middle East and southeast European countries like Turkey are much lower than other parts of the world,” says Ben Collins, director of International HIV Partnerships, a nongovernmental organization in London that seeks to promote HIV testing and treatment around the world.
In 2016, the worst-hit countries in the region that the World Health Organization defines as the Middle East and North Africa were Somalia, where the deaths of 1,700 adults and children were attributed to AIDS; Iran, where 4,000 people died of the disease; and Sudan, where 3,000 people died.
Deaths from AIDS in Arab countries may be more likely because of the reluctance of those at risk to get tested for HIV infection. In Sudan, just one in five people with HIV were aware that they were infected, according to a 2014 report by the Population Reference Bureau.
In Tunisia, Morocco and Egypt, fewer than 60 percent of HIV-positive people know their infection status. Algeria has a much higher rate of testing: Seventy-six percent of people who live with HIV are aware of their infections. But that proportion still falls short of the 90-percent international target set by the United Nations, although even many Western nations also fall short. (By comparison, a 2017 British government paper estimated that 88 percent of people in England with HIV were aware of their status.)
The goal of the Joint United Nations Programme on HIV and AIDS, also known as UNAIDS, is to have 90 percent of those diagnosed with infections in regular treatment. Of those in treatment, the aim is that 90 percent would have the amount of virus in their bloodstream suppressed to such a point that the virus would be effectively undetectable.
Collectively this strategy is referred to as the 90-90-90 plan, and no Arab country has yet managed to get close to the first 90. “People just don’t want to talk about it,” says Collins, of International HIV Partnerships.
Most of that increase happened in Iran, Sudan and Somalia, where 65 percent of the region’s new infections in 2016 were recorded, according to UNAIDS.
Researchers say a lack of willingness to discuss the topic and a general stigma surrounding the disease are part of the problem. They note that it might be possible to prevent further rapid spread, if swift action is taken.
“The rate of increase is terrible, but it’s important to point out that the numbers are still relatively low. Turkey is going through the same new infection increase, but it’s an increase on a low number,” says Collins.
In other words, the 18,000-a-year surge in new infections represents a larger percentage increase in the Arab world than it would be in sub-Saharan Africa, where there is already a large HIV-positive population.
“But it’s also an important reality that people don’t want to deal with how infections spread,” says Collins. Practices that can result in HIV transmission, such as prostitution and the use of injected illegal drugs, are taboo topics in many Arab societies.
The Associated Press reported that in Egypt AIDS patients are sometimes jailed.
In December, Egyptian newspapers reported that an HIV-positive woman threw herself from a fifth-floor Cairo balcony after neighbors forced her family to leave their apartment after learning that the woman had contracted the disease from her husband.
The United Nations has previously warned that the stigma that surrounds the disease hastens the spread of HIV. Part of the stigma comes from an ill-founded association with homosexuality, says Madani, of Harvard Medical School.
“HIV is incorrectly associated with homosexuals in some people’s mind,” she says. “In the MENA region, more heterosexuals have HIV than homosexuals, but it’s irrelevant to single out any single demographic because a virus doesn’t see race, gender or sexuality. As a scientist, I approach HIV like any other virus, such as the flu or hepatitis C.”
Experts say that men who have sex with men are also more likely to be proactive with their sexual health and get tested for HIV, which could mean that they are overrepresented in the statistics of those who are infected compared to other groups.
According to data from UNAIDS, just 18 percent of new HIV infections in the Middle East and North Africa are in men who have sex with men. The largest proportion was clients of sex workers, at 41 percent, followed by intravenous drug users, who may get HIV from sharing needles, at 28 percent.
Those who are infected often wait until it’s too late to seek medical attention because they are afraid of how they will be viewed by others. “Because of the stigma, people aren’t coming forward for diagnosis,” says Madani.
That means when people do eventually seek medical help, the disease may already be quite advanced. Treatment is more effective if it is delivered early after an infection.
The Marsa sexual health center, in Beirut, screens for HIV and other sexually transmitted diseases and provides care and counseling services for HIV-positive people. Sara Abou Zaki, a project manager at the clinic, says most of the beneficiaries of the HIV services are under the age of 30, well educated and from the Beirut area.
She worries that poorer and less educated people in Lebanon may have additional difficulty accessing services.
“We will usually waive the fee if you can’t afford it so finances shouldn’t be a problem,” she says. But she is concerned that the underprivileged and those living outside of Beirut may not be aware of the services, or have access to them. “We need more clinics in the rest of the country,” she adds.
She says anonymity is crucial in encouraging people to seek services. “No one shares their name at any point here. People are given a file number instead.”
The stigma coupled with high HIV infection rates in the region could create a widespread problem, warns Madani. “This is a virus that affects the young more than the old. If we don’t counter this now then we could have a huge epidemic in 10 years.”
The prognosis for infected patients has improved greatly since the virus first emerged in the 1980s. With proper treatment and without complications, HIV-infected patients can have a life expectancy similar to the general population. This makes the growing number of deaths from the disease in the region especially hard for physicians and researchers to accept.
“When there are viable treatments and prevention methods like we have with HIV, even one death or case is one too many,” says Madani.