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Your purchase has been completed. Your documents are now available to view. Purchase chapter. Cite this Share this. Showing a limited preview of this publication:. Cite this chapter. Williams, Phil, Blazakis, Jason M. Williams, P. Copied to clipboard. Copy to clipboard. Share this chapter. Supplementary Materials. Please login or register with De Gruyter to order this product. Register Log in. The Mediterranean Connection. Chapters in this book 13 Frontmatter. About the Book. Downloaded on

4 Tunisia: Oasis or Mirage of Stability?

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Official websites use. Share sensitive information only on official, secure websites. Wrote the first draft of the manuscript: GRM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, The quality, quantity, and geographic coverage of the data were assessed at country level. Risk of bias in predefined quality domains was described to assess the quality of available HIV prevalence measures. After multiple level screening, eligible reports were included in the review. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. With the HIV epidemic among PWID in overall a relatively early phase, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems. HIV is mainly transmitted through unprotected sex with an infected partner. However, people who inject drugs PWID have a particularly high risk of HIV infection because blood transfer through needle and syringe sharing can transmit the virus. These strategies include education and the provision of clean needles, syringes, and opioid substitution therapy. To maximize the effect of these harm-reduction strategies in specific regions, it is important to understand the status of the HIV epidemic among PWID. Several factors contribute to the likelihood of individuals injecting drugs in MENA. In this systematic review and data synthesis, the researchers use predefined criteria to identify all the published and unpublished data on HIV prevalence and incidence the number of new cases of a disease in a population in a given time among PWID in MENA and combine synthesize these data to assess the status of the HIV epidemic in this key population for HIV transmission in MENA. The data also revealed a high injecting and sexual risk environment among PWID in MENA for example, on average, about a quarter of PWID shared a needle or syringe in their most recent injection and only a third reported ever using condoms that, together with a high prevalence of HCV and sexually transmitted infections among PWID, indicates the potential for more and larger HIV epidemics. This window of opportunity to control the emerging epidemics should not be missed, warn the researchers. The MENA region has, however, witnessed a remarkable growth in HIV research over the last decade, with several countries developing surveillance systems to monitor the spread of HIV infection, including among most-at-risk populations \[10\]. A large fraction of studies conducted in the region has remained unpublished in the scientific literature, and only available in the form of difficult to access country reports. This has meant that data have not been analyzed or synthesized at either country or regional level, and no critical assessment of the quality of available evidence has been conducted. The present article follows on from a series of studies conducted as part of the Synthesis Project. The presented regional analysis takes on an additional importance with the need to capture the volume of bio-behavioral surveillance data that became available within the last few years in MENA, and is yet to be analyzed and synthesized within a country-specific or a regional context \[15\]. Increased availability and purity of heroin at lower prices in MENA appears to have led to a subsequent rise in injecting drug use \[17\]. Most PWID in the region are young adults and marginalized by family members and society; they are stigmatized and lack access to comprehensive and confidential HIV prevention and treatment services \[11\]. The secondary objective was to describe the risk behavior environment and the HIV epidemic potential among PWID by describing 1 their injecting and sexual risk behavior and knowledge, and 2 prevalence of proxy biological markers of these behaviors, namely hepatitis C virus HCV and sexually transmitted infections STIs , respectively. Details of the search criteria are provided in Text S2. Reference lists of all relevant papers and review articles were also searched. Titles and abstracts of all records identified were screened independently by two authors GRM and SR , and consensus on potential eligibility reached. Full texts of potentially relevant records were retrieved and assessed for eligibility. Studies satisfying any of the below criteria were eligible: 1 The proportion of PWID in the sample was specified, at least half were PWID, and data on any of the following outcomes were included: Prevalence or incidence of HIV; prevalence of injecting or sexual risk behaviors, or knowledge; prevalence or incidence of HCV; and prevalence or incidence of other STIs. HCV is transmitted primarily through percutaneous exposures and can be used as a proxy of the risk of parenteral exposure to HIV. Similarly, the prevalence of STIs is a useful marker of sexual risk behavior and potential for HIV sexual acquisition. Only studies with primary data were included. We used the term report to refer to the documents papers, conference abstracts, or public health reports presenting findings of a study \[20\]. Reports could contribute to more than one outcome. Findings duplicated in more than one report were included only once using the more detailed report. Data were extracted by one of the authors GRM using a pre-piloted data extraction form and entered into a computerized database. The few discrepancies were settled by consensus or by contacting authors. Data from articles in English, French, and Arabic were extracted from the full -texts. There were no records in other languages. We appraised the status of the evidence on our main outcome, HIV prevalence, at country level by examining the following criteria that take into consideration the quantity, quality, and geographical coverage of available data: 1 the number of HIV prevalence measures and the total sample size they cover, 2 the number of geographic settings with HIV prevalence measures, 3 the number of multi-city studies and the maximum number of cities per study, 4 the number of rounds of integrated bio-behavioral surveillance surveys IBBSS , and 5 the quality and precision of individual HIV prevalence measures. Based on the Cochrane approach for assessing ROB \[20\] , we classified each HIV prevalence measure as having a low, high, or unclear ROB for three quality domains: the sampling methodology, the type of HIV ascertainment, and the response rate. HIV prevalence measures extracted from international and regional databases were considered of unknown quality since original reports were not available for assessing their ROB. A minimum sample size of was considered to produce estimates with good precision. The quality of the evidence in each country was assessed by combining the above factors as described in Text S3. For example, quality was considered better if at least one round of IBBSS was conducted, since these surveys use standard methodology including state of the art sampling techniques of hard-to-reach populations such as respondent-driven sampling. Countries were categorized as having: 1 No evidence: virtually no data. However, the overall volume of data was not sufficient to be conclusive of the status and scale of the epidemic at the national level. The low-bound, middle, and high-bound national estimates of the number and prevalence of injecting drug use in MENA countries were extracted from reports. When more than one such estimate was available per country, we used the median of the estimates. The pooled numbers of PWID were rounded up to the next thousand. Middle estimates of the extracted prevalence of PWID were weighted by adult population size to derive the pooled prevalence of injecting drug use in MENA. Sub-national estimates of the number and prevalence of injecting drug use were extracted from reports and described separately. Concentrated epidemics can be either emerging HIV has started its initial growth and continues in a trend of increasing HIV prevalence ; or established the epidemic has reached its peak and HIV prevalence is stabilizing towards, or already is at, its endemic level. The study selection process is shown in Figure 2. A total of 6, citations were retrieved from PubMed, Embase, and the regional databases. In addition, HIV point-prevalence measures were extracted from the databases of biological markers Figure 2. The number and quality of HIV prevalence measures varied by country. Multi-city studies have been conducted in several countries including Pakistan, where up to 16 cities were included in one study \[37\]. Pakistan has the most repeated rounds of IBBSS with four rounds conducted between and \[37\] , \[50\] — \[52\]. A narrative justification for the classification of the scope and quality of evidence is in Text S3. Although a formal quality assessment was not made for the secondary outcomes in terms of injecting and sexual risk behavior and knowledge, the majority of these data were extracted from the IBBSS studies using standard survey methodology and large samples. Table 2 describes national estimates of the number and prevalence of PWID. These national estimates were extracted from included reports where they were derived using different methodologies including indirect methods such as capture-recapture and multiplier methods , population-based surveys, registered number of PWID, and rapid assessments. In two of the sources of data in Table 2 \[4\] , \[31\] , some of the country estimates are the collation of several such country-specific estimates using methods described in the original reports \[4\] , \[31\]. The specific year of the estimate was not mentioned in the original report, but the report covered data from — Iran, Pakistan, and Egypt have the largest number, with a median of about ,, ,, and 89, PWID, respectively. The weighted mean prevalence of injecting drug use in MENA is 0. It is lowest in Somalia 0. Studies of sub-national populations showed geographical heterogeneity Table S3. For example, in Iran, the prevalence of injecting drug use varied between 0. Overall, the mean proportion of females among PWID in included studies was 2. HIV prevalence measures from reports and databases are summarized in Tables 3 and S4 , respectively. Three HIV incidence studies were identified. A very high incidence rate A smaller contribution was reported in the remaining countries Table 4. Except for Bahrain, Egypt, and Iraq report and Pakistan report. The evidence was sufficient to characterize the HIV epidemic state in 13 countries, summarized in Table 5. Details on how the conclusions were reached are in Text S3. Countries are sorted by level of HIV prevalence, trend in HIV prevalence, geographical distribution, quality and scope of evidence, then alphabetical order. Iran is the only country with conclusive evidence for an established concentrated epidemic at the national level. HIV prevalence then increased considerably in the early s, reaching a peak by the mids Figure 3A. This graph displays all available HIV prevalence measures for these two countries as extracted from eligible reports Table 3 and various databases Table S4. These graphs display the trend of HIV prevalence in repeated rounds of bio-behavioral surveillance surveys using state of the art sampling techniques for hard-to-reach populations including respondent driven sampling and time-location sampling. For consistency between countries and between different rounds within a given country, unadjusted sample estimates are displayed. A pattern of emerging concentrated epidemics is observed in Pakistan A and Egypt B ; a pattern of established concentrated epidemic is observed in Iran B ; and a pattern of low-level HIV epidemic is observed in Tunisia D. In Afghanistan E , there is an emerging epidemic among PWID in apparently only part of the country; the effect of which was diluted in the second round with the inclusion of new cities with still very limited prevalence. In Tunisia, the potential link between the MSM and PWID epidemics is not clear because the studies were conducted after the epidemics had already risen. Consistently, The HIV epidemic in Libya is also concentrated, but the trend is unclear. Although the epidemic in Tripoli is most likely to be established, the level of evidence overall is insufficient to characterize whether the national epidemic is emerging, with few outbreaks in the past, or is established with endemic HIV transmission among PWID. However, most available data are from studies with unknown methodology or high ROB; therefore, the quality of evidence is insufficient to indicate whether there is a concentrated epidemic in these two countries, even if localized. The contribution of injecting drug use to the total notified cases also remains minimal in these countries, further confirming a low-level epidemic Table 4. The median age at first injection was 26 years IQR: 24—28 years , and the median duration of injecting drugs was 4. Reported levels of condom use varied but generally were on the low to intermediate range. The highest rates of same-sex sex have been reported in Pakistan. Reported condom use during anal sex was overall very low Table S6. These figures are consistent with the reported high levels of sharing of injection equipment, such as in Iran, Pakistan, and Libya Table S5. Overall, the mean prevalence of injecting drug use 0. Prevalence of injecting drug use in MENA varied between countries and was higher in the eastern part of the region. Injecting drug use appears to be heavily concentrated among men; but female PWID are one of the hardest-to-reach populations in MENA, thereby limiting our knowledge of this vulnerable group. From limited available data, it appears that injecting drug use among females has a strong association with sex work and having a PWID sexual partner \[78\] , \[79\]. The HIV epidemic is in a concentrated state in about half the countries with available data. Iran is the only country with an established concentrated epidemic, while the most common pattern is that of emerging concentrated epidemics. Most observed epidemics in the region are recent, occurring only in the last decade; around the same time that HIV epidemics among MSM appear to have emerged \[14\]. Of note, our classification of epidemic states did not depend only on the size of the epidemic, but also on the trend of HIV prevalence and other biological data. For example in Pakistan, despite high HIV prevalence, the epidemic was classified as emerging since HIV prevalence continues in an increasing trend. However, there are settings with very high prevalence, most notably in Tripoli, Libya, which appears to have one of the highest HIV prevalence reported globally The available evidence in countries at low level is restricted to a few cities, and there could be hidden sub-epidemics in other sites. HIV may not have been introduced to the PWID community, may have been recently introduced, or may have been spreading slowly and inefficiently for some time. In Lebanon and Syria for example, it appears that PWID form closed small networks with injecting occurring in private homes and among friends, and not in large groups or at shooting galleries \[59\] , \[80\]. The low prevalence could also be a consequence of stochastic effects where the small number of individuals who introduced HIV to the PWID population happened by chance not to have links that could sustain transmission chains. Whilst it is conceivable that HIV prevalence may not grow in countries currently at low level, there are settings where HIV prevalence increased considerably in a short period of time. This pattern is not surprising given the reported risky practices and high HCV prevalence. In both Iran and Pakistan, injecting networks often seem to be well connected and we found reports of injecting and sharing occurring among persons who are not necessarily socially related, e. We found considerable overlap of risk behavior between PWID and other high-risk groups in MENA; this could play a role in emerging HIV epidemics, as it creates opportunities for an infection circulating in one population to be bridged to another one. Phylogenetic analyses found clustering of subtypes between the two populations, suggesting that the infection might have bridged from PWID to the transgender population \[86\]. While supported by behavioral data \[40\] , \[42\] , this needs to be confirmed by phylogenetic analyses. The majority of PWID are sexually active and about half are married. They often engage in risky sexual behavior as confirmed by the prevalence of STIs. This highlights the vulnerability of sexual partners of PWID, who are often female spouses. One limitation of our study is that the quantity and quality of data varied by countries. There were virtually no HIV data in four countries, and the data quality in six others was insufficient to assess the status of the epidemic. Six countries have recently conducted their first round of IBBSS; and in most of these, subsequent rounds are either planned or being implemented. While most of the data were from cross sectional surveys, there was a substantial improvement in the quality of data over time. Many studies were conducted with state of the art research methodologies in HIV research. These consist of IBBSS studies using innovative sampling methodologies for hard-to-reach populations such as respondent-driven sampling and time-location sampling. Most of these studies benefited from large sample sizes and some from broad geographical coverage at the national level. Of note that in several countries there were no recent national estimates of the number and proportion of PWID. The only national data available for these countries were extracted from earlier global reviews of injecting drug use \[4\] , \[31\]. Since we partly relied on secondary sources of data and since the data that we used came from studies using different methodologies, our pooled estimates of the number and prevalence of PWID in MENA should be considered as approximate figures. In assessing the status of the epidemic at the country-level, we did not limit our analysis to one line of evidence, but synthesized and corroborated findings from different data sources and types such as HIV prevalence and incidence, notified HIV cases, injecting and sexual risk behavior, and other related and contextual data. Thus we could make a comprehensive assessment of the epidemic status and address potential limitations in any one line of evidence \[93\]. We did a rigorous appraisal of the scope and quality of the evidence within each country by assessing the amount and geographical coverage of available data, as well as the ROB and precision of individual point estimates. A qualifier for the scope and quality of the evidence at the country level was integrated with each HIV epidemic state assigned. Our search criteria were expansive, covering different literature sources. Before the present submitted work, the status of the epidemic across MENA country was poorly understood. On the basis of our integrated data synthesis and using rigorous methodology and data quality assessment, we were able to concretely qualify the epidemic status in 13 countries over half of MENA countries , and to document the overall trend of emerging epidemics. Not only does the region overall lag behind in responding to the emerging HIV epidemics among PWID; in occasions misguided policy has contributed to these epidemics. Most notably in Libya, the large HIV epidemic among PWID appears to have been exacerbated by restrictions imposed on the sale of needles and syringes at pharmacies in the late s \[11\] , \[94\]. Overall, harm reduction programs still remain limited in MENA, and there is a need to integrate such programs within the socio-cultural framework of the region \[95\]. Several countries though have made significant strides in initiating such programs in recent years \[11\] , \[96\]. It appears also to be the only country in MENA to provide such services in prisons \[96\] , \[97\] and to provide female-operated harm reduction services targeted at female drug users \[96\]. Among other interventions implemented in Iran are drop-in centers, integration of substance use treatment and HIV prevention into the rural primary health care system, and community education centers \[62\] , \[\] — \[\]. These efforts appear to have been successful in reducing sharing of injecting equipment \[\] — \[\] , though the coverage of harm reduction continues to be lower than adequate \[\]. Other countries in the region have also made progress in revising their policies, adopting harm reduction programs, and integrating such programs in their national strategic plans such as Afghanistan, Egypt, Lebanon, Morocco, Pakistan, and Tunisia \[11\] , \[\]. Access to antiretroviral therapy ART has also expanded in MENA in recent years, and treatment outcomes reported by country ART programs are comparable to globally reported outcomes \[\] , \[\]. Good adherence to ART has been also observed, such as in Morocco \[\] , though some non-adherence and treatment interruptions, among other obstacles, have been also reported in several countries \[\] — \[\]. The Iranian NGO Persepolis, for example, played an important role in the transformation to effective policies in Iran \[\]. MENAHRA has the objective of building the capacity of civil society organizations in harm reduction efforts through training, sharing of information, networking and providing direct support to NGOs to initiate or scale-up harm reduction services. The network is a collaborative initiative by regional and international organizations with funding from international donors, and has been influential in promoting harm reduction. Despite the recent progress in harm reduction, HIV prevention efforts among PWID in MENA remain impeded by generic and routine planning, competing priorities, limited human capital, and lack of monitoring and evaluation \[7\]. National policies remain inadequate and not sufficiently reflecting evidence-informed approaches \[7\]. The scope and coverage of prevention services remain patchy across and within countries \[11\] , \[96\] , \[\]. An indicator of the low effective coverage is that only a minority of PWID report ever being tested, and a smaller proportion report being tested within the last year \[11\]. Even where services are available, PWID may not be aware of them, and when aware of them, they may not utilize them. The in-depth analyses, the quality assessment of evidence, and the comprehensive synthesis of data facilitated, for the first time to our knowledge, a rigorous characterization of the state of the epidemic among PWID across different countries in this region. We found robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged only recently and continue to grow. The high risk and vulnerability context suggest potential for further HIV spread. This mainly includes conducting IBBSS studies among PWID in countries where such surveys have not been conducted yet, and implementing subsequent rounds, for the provision of longitudinal data, in countries that are already developing their surveillance base. Population size estimations and mapping and ethnographic studies are also needed for a better understanding of the profile and injecting and sexual networks of PWID in MENA. The window of opportunity to control the emerging epidemics should not be missed. Such comprehensive approach has already proven its utility in preventing HIV transmission among PWID \[\] — \[\] , but would require better resource allocation and sufficient services in priority areas for PWID. Prevention efforts need to prioritize those most likely to be reluctant to approach facility-based services, and those with multiple and overlapping risks. Outreach and peer education can provide a means to reach those most at risk with information and services. Such expansion must address the low diagnosis rate among people living with HIV \[\]. Reaching the at-risk populations even in discreet unpublicized ways would contribute positively to HIV prevention \[14\] , \[\]. Precision and risk of bias of individual HIV prevalence measures among people who inject drugs in the Middle East and North Africa as extracted from eligible reports. Summary of precision and risk of bias of HIV prevalence measures as extracted from eligible reports. Subnational estimates of the number and prevalence of people who inject drugs in the Middle East and North Africa. Measures of injecting risk behavior among people who inject drugs in the Middle East and North Africa. Measures of sexual risk behavior and sexually transmitted infections prevalence among people who inject drugs in the Middle East and North Africa. Narrative justification for quality of the evidence and status of the epidemic at the country level. The statements made herein are solely the responsibility of the authors and the funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. PLoS Med. Find articles by Ghina R Mumtaz. Find articles by Helen A Weiss. Find articles by Sara L Thomas. Find articles by Suzanne Riome. Find articles by Hamidreza Setayesh. Find articles by Gabriele Riedner. Find articles by Iris Semini. Find articles by Oussama Tawil. Find articles by Francisca Ayodeji Akala. Find articles by David Wilson. Find articles by Laith J Abu-Raddad. David D Celentano : Academic Editor. Open in a new tab. The table is sorted by country then by descending order of HCV prevalence. Only the most recent available report was used. Table S1 Precision and risk of bias of individual HIV prevalence measures among people who inject drugs in the Middle East and North Africa as extracted from eligible reports. Click here for additional data file. Table S2 Summary of precision and risk of bias of HIV prevalence measures as extracted from eligible reports. Table S3 Subnational estimates of the number and prevalence of people who inject drugs in the Middle East and North Africa. Table S6 Measures of sexual risk behavior and sexually transmitted infections prevalence among people who inject drugs in the Middle East and North Africa. Text S2 Search criteria. Text S3 Narrative justification for quality of the evidence and status of the epidemic at the country level. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Number HIV biological studies a. Number HIV incidence measures a. MOH, \[38\] Round I. Todd, \[69\]. Nasir, \[\]. Todd, \[\]. Al-Haddad, \[60\]. Elghamrawy, \[\]. Soliman, \[41\] Round I. Saleh, \[\]. Attia, \[\]. Hasan, \[\]. El-Ghazzawi, \[\]. Honarvar, \[\]. Mehrejredi, \[\]. Alipour, \[79\]. Ilami, \[\]. Hashemepour, \[\]. Dibaj, \[\]. Javadi, \[\]. Eskandarieh, \[\]. Zamani, \[\]. Ghasemian, \[\]. Zadeh, \[\]. SeyedAlinaghi, \[\]. Kazerooni, \[67\]. Aminzadeh, \[\]. Kheirandish, \[\]. MOH, \[43\] Round I. Malekinejad, \[\]. Alavi, \[\]. Ghanbarzadeh, \[\]. Tofigi, \[\]. Imani, \[\]. Mojtahedzadeh, \[62\]. Shamaei, \[\]. Pourahmad, \[\]. Farhoudi, \[\]. Khodadadizadeh, \[\]. Davoodian, \[\]. Behnaz, \[\]. Asadi, \[68\]. Alizadeh, \[\]. Mir Nasseri, \[\]. Sharif, \[\]. Rahbar, \[\]. Sharifi-Mood, \[\]. Mirahmadizadeh, \[\]. Nowroozi, \[\]. Alavian, \[\]. Azarkar, \[\]. Amini, \[\]. Alaei, \[\]. NAP, \[45\] Round I. Mahfoud, \[46\] Round I. Ramia, \[\]. Mirzoyan, \[47\] Round I. MOH, \[\] Round I. MOH, \[61\]. Elmir, \[\]. MOH, \[58\]. Nai Zindagi, \[66\]. Nai Zindagi, \[89\]. Platt, \[\]. Rahman, \[\]. Nai zindagi, \[\]. NAP, \[52\] Round I. Bokhari, \[83\]. Achakzai, \[\]. Bokhari, \[\] Pilot. Abbasi, \[\]. Altaf, \[74\]. Kuo, \[70\]. Shah, \[\]. Altaf, \[75\]. Hadi, \[64\]. Akhtar, \[\]. Nai Zindagi, \[72\]. Parviz, \[82\]. Baqi, \[81\]. Iqbal, \[\]. Khanani, \[\]. UrRehman, \[\]. Mental Health Directorate, \[59\]. MOH, \[54\] Round I. Population 15—64 Years \[33\].

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