XV International AIDS Conference in Bangkok (July 2004)
Sponsors: Understanding the importance of academic exchange on this issue, USAID’s Asia and Near East Bureau, with the specific aid of Mr. Billy Pick, sponsored the meeting.
UNAIDS, WHO and the World Bank provided the expertise and experience of their senior professionals involved in action and research on HIV/AIDS in the MENA region.
The University of Illinois at Chicago Department of Medical Education provided the technical and administrative assistance for planning and executing the session.
The Jerusalem AIDS Project, particular Ms. Hani Oren, served as the local, regional, technical and financial coordinating partner.
Participants: Known researchers and policymakers presented their work and discussed research gaps, needed studies and future agendas. All expressed the crucial need for GNR-MENA as a way to facilitate scholarly interaction and support for solid, innovative research on HIV/AIDS in the region. This need is especially noteworthy because until GNR-MENA no such network that includes scholars across disciplines existed.
Speakers during the formal lecture portion of the Satellite Meeting included:
Drs. Arash and Kamiar Alaei of theNational Research Institute of Tuberculosis and Lung Disease (NRITLD). They talk was titled: “The Best Practice Model for Prevention and Care for HIV/AIDS and Potentials for Expansion into a Muslim Country Program.”
Dr. Carol Jenkins, independent scholar and affiliate of the World Bank. Dr. Jenkins spoke on “Vulnerability to HIV/AIDS in the Middle East and North Africa: A Socio-Epidemiology Overview”
Dr. Inon Schenker of Hebrew University of Jerusalem. His talk was entitled: “HIV/AIDS Prevention-Care Continuum in MENA: Realities and Obstacles”
Dr. Sandy Sufian. Founder, GNR-MENA. Dr. Sufian gave the welcoming address with her co-chair Dr. Arash Alaei.
Dr. Oussama Tawil of UNAIDS. Dr. Tawil spoke on “ Averting HIV/AIDS in the Middle East and North Africa Region: Challenges, Opportunities and the Way Forward.”
Dr. Hany Ziady of the WHO. “The Meaning of the 3 by 5 Initiative for Global Health and the Middle East”
The Roundtable Discussion followed the formal lectures noted above. The Roundtable session was called: Researching HIV/AIDS in MENA--
Challenges and opportunities
Drs. Inon Schenker and Etaf Maqboul co-chaired this part of the Satellite Meeting.
Roundtable participants included:
Dr. Suliman Eid, Aman Center, Gaza.
Dr. Hadia Karam of the World Bank
Dr. Etaf Maqboul of Bethlehem University
Dr. Hanni Oren of the Jerusalem AIDS project.
Dr. Inon Schenker. Hebrew University of Jerusalem.
Audience:
There were a total of approximately 80 audience members. The session went longer than the designated two hours due to interest and engaged discussion.
Audience members represented HIV/AIDS researchers from many different countries, including Tunisia, Sudan, Palestine, Nepal, USA, Laos, Egypt, Israel and Iran. Organizations such as UNICEF’s Regional Office for the Middle East and North Africa, the Fogarty Organization, and the sponsors’ organizations (UNAIDS, WHO, World Bank, USAID) were also represented.
The BBC Arabic was present at the meeting and videotaped the discussion.
Summaries of Presentations at Satellite Meeting at International HIV/AIDS Conference
In presentation order
Carol Jenkins, PhD. “Vulnerability to HIV/AIDS in the Middle East and North Africa: A Socio-Epidemiology Overview.”
In her talk on vulnerability to HIV/AIDS in the MENA region, Carol Jenkins gave an overview of the World Bank report she co-wrote called, “Cost of Inaction.” She discussed how the World Bank definition of the MENA region does not include the countries of Sudan, Somalia, Pakistan and Afghanistan. The World Health Organization puts the range of HIV/AIDS incidence at 37.8 million people worldwide. Countries with large amounts of people living with HIV/AIDS, such as Sudan, Libya, or Qatar have low quality surveillance data and some have no surveillance systems at all. This passive data collecting process includes neither sentinel nor behavioral or sero-surveillance.
Jenkins explained that due to this lack of quality data it is easy to miss the epidemic in its early stages and skip over hard to reach groups. As an example this possibility, Dr. Jenkins used the example of Indonesia and how HIV spread rapidly with IDU outbreaks and sex workers being high-risk groups. In the Middle East, we know that Tunisia has seen a rise in registered sex workers. Meanwhile the sex workers’ incidence ratio is shifting, with Jordan’s ratio decreasing and Yemen’s rising.
The question, Jenkins explained, is about knowing who’s infected. But the problem is that there are very few good studies covering the Middle East and North Africa. Egypt has conducted many surveys, Tunisia has done a study on male sexuality, Lebanon has performed rapid assessments and found that not many people are using condoms, and Iran has done studies on sex with sex workers. Some of these studies, however, are not published or are not conducted well.
One reason for these research gaps and flaws is that HIV/AIDS is a low priority for MENA governments. The disease and its treatment is an expensive one and so many governments, Jenkins argued, do not want to recognize it as a problem. Even the National AIDS Programs established in the 1980’s by MENA Ministries of Health are no longer active. It has been difficult in the 1990’s to focus on preventive efforts. There needs to be a strong effort to determine different modes of transmission and their relative weight in the HIV/AIDS crisis in MENA. Blood safety is also an important topic to research and address.
Currently efforts are being made to mobilize leadership at the highest level, explained Dr. Jenkins. Recognition of risk and vulnerability are important as well, although there has been limited action. Using national strategies to obtain a comprehensive vision is important as well. The last important effort is to make ARV available. Resources are being allocated to the health sector and different large agencies in MENA are increasing funding. Unfortunately, however, there has been an insufficient effort to involve the private sector and regional bodies.
Oussama Tawil: “Averting HIV/AIDDS in the Middle East and North Africa: Challenges, Opportunities and the Way Forward.”
Dr. Oussama Tawil discussed the challenges, opportunities, and future prospects of averting the HIV/AIDS epidemic in the Middle East and North Africa. He began by noting the dearth of information on this particular area of study, and mentioned that not enough research was being carried out in these regions. Tawil categorized his discussion on needs in the region into three parts: definition, situation, and response. All of these elements must take into account both historical information as well as current statistics.
Under his discussion of “definition,” he discussed the reality that the problem cannot be defined precisely and succinctly, in part due to the fact that this epidemic is infused with certain cultural and political realities, about which not much data has been accumulated thus far. Thus, the situation, as Tawil described it, is that there is an overall lack of data, and that social, political, and other tensions surround HIV/AIDS. The data is often misread and misinterpreted. Due to cultural and political circumstances, there is also a great deal of sensitivity concerning the talk of the spread of HIV/AIDS.
Despite lack of discussion and/or misinterpretation of existing data, levels of HIV infection in the Middle East and North Africa are on the rise, especially among young people and women. HIV/AIDS prevalence ranges from .01 percent to 2.9 percent. Tawil noted that there have not been many studies done on groups that were especially at risk. It is known, however, that the usual modes of transmission are sexual and drug-related. He discussed the factors of vulnerability, about which he noted that they were not dissimilar to those found to exist in other regions of the world: changing behavioral patterns amongst young people which include changes in sexual behavior and marriage patterns. There is also the effect of injecting drug use. The last topic that Tawil mentioned was the impact of conflict and displacement upon the HIV/AIDS crisis in the MENA region. Conflict and displacement cause a great deal of difficulties in terms of diagnosis, treatment and the carrying out of research and data collection.
In terms of responses to the HIV/AIDS situation in MENA, Tawil noted Global Fund support of 61 million dollars over a two-year period. He mentioned that data collection was one of primary areas of support. Eight countries in the region currently have national strategic planning committees. They have listed prevention as one of the priority areas, since young people are especially vulnerable due to certain preventable behaviors. Tawil discussed opportunities for progress, including ongoing social change in young people, women, and the role of civil society. He also mentioned the impact of health systems and their coverage by the regional media. This media is extremely strong and could potentially create a dialogue with community leaders. Finally, Dr. Tawil mentioned some of the challenges that needed to be addressed, including a lack of information on the epidemic, the phenomena of stigma and denial, reaching vulnerable groups, policy and legislation challenges, and coordination between parties.
Dr Inon Schenker, PhD, MPH: “HIV/AIDS Prevention-Care Continuum in MENA: Realities and Obstacles.”
Dr. Schenker presented a talk on “HIV/AIDS prevention-care continuum in MENA: realities and obstacles.” He explained that in most countries in MENA people are first exposed to HIV in a medical setting, mostly when they are already tested positive. That is due to lack of public awareness and publicity about the disease that is still a taboo. He proposed that while there is a documented sharp increase in HIV incidence and prevalence in MENA, this is not met with the same level of concern, resource mobilization and funding by international agencies, large NGOs and donors. That is partially because the attention to the region is given to other sectors and events: conflicts, economic crises, fundamentalism etc.
Dr. Schenker then gave a brief description of the HIV/AIDS situation in Israel, stating that the current policies are very supportive to the Prevention-Care Continuum, as there is universal VCT as well as prevention campaigns at schools, in the workplace and among professionals. There are also media efforts to highlight preventive messages as well as an updated complete and free of charge medical coverage for PLWHA. This includes tests, medications, ARV and psychological support. He mentioned the liberal approach to HIV in several areas including the law on testing minors for HIV/AIDS, which allows teenagers to be tested without the consent of their parents.
Dr Schenker further discussed the obstacles in MENA in providing ARV treatment. He suggested that while the number of patients is small in most countries, a united effort of Ministries of Health to negotiate together prices with pharmaceutical companies (under UNAIDS/WHO coordination) may yield higher coverage of ARVs for PLWHA. He called for a more comprehensive and targeted approach by the media -- particularly stations broadcasting in Arabic to the Arab world-- as this may lead to exposure of youth seeing those stations to information and education on HIV/AIDS. Touching also on the aspects of religion and language Dr. Schenker provided an optimistic view on the possibility of uniting forces against HIV/AIDS, a virus that knows no borders - in the Middle East by all peoples of the region. He elaborated on the initiative of the Jerusalem AIDS Project that developed a sustained network of AIDS educators coming from diverse communities in the region to work together in the fight against HIV/AIDS. These included Israeli, Palestinian, Egyptian, Jordanian, Turkish and Moroccan health and education professionals.
Dr. Kamiar Alaei: “The Best Practice Model for Prevention and Care for HIV/AIDS and Potentials for Expansion into a Muslim Country Program.”
Dr. Alaei discussed a model for prevention and care for HIV/AIDS patients and the model’s potential for expansion into a Muslim country program. Alaei noted that HIV/AIDS patients in Iran are viewed as social deviants. As such, stigmatization of PLWHA leads to general fear, ignorance, and denial, and-- in the extreme—a high suicide rate, especially in the first year of diagnosis. Women are especially stigmatized due to certain cultural realities, and as a result they often avoid being tested. Individuals that are involved in the most high-risk behavior are often the most difficult to reach.
In Iran, 6.5 million people are affected, roughly half of which are under the age of nineteen. Drug users are especially at risk, and opium use is worthy of mention; these individuals make up a population of 1 to 2.2 million in Iran. Dr. Alaei also mentioned the “huge ignorance” that lasted from 1982 to 1995, at which point a national hospital was established in Kermanshah that was actually opposed by its citizens. This example points once again to some of the stigmas associated with HIV/AIDS.
In 1998, Project Kermanshah began in Western Iran, and Dr. Alaei discussed many of the observations that were made. For example, drug use was reported at 5 percent, and HIV was very much ignored. The major means of mortality for HIV/AIDS patients was actually suicide, due in large part to the absence of psychosocial support. The Alaeis’ strategy included implementation of programs and services at the local level, especially in response to high-risk behavior. The establishment of a public clinic in a high drug use area provided family networks and a greater sensitivity to cultural norms. Their strategy also includes intake assessments, needle exchange for drug users, and a peer education program and other outreach programs for affected individuals and their families.
Four committees established consisted of superior, national, technical subcommittees, and provincial committees. Due to the establishment of these four committees, similar clinics were created in prisons, where the majority of people affected are male and the main route of transmission is drug use.
Other countries are involved as well in adopting the Alaei model. Iran has a global network with Afghanistan, while Tajikistan created a website. In the year 2005 there will be an international conference in Indonesia and Malaysia, thus extending the Alaei model/Iran model to other Muslim countries.
Due to self-help groups, mass information, syringe collection, music groups and more, Iran is now reporting a total of 1700 HIV cases. In fact, there has been a 50% reduction in active TB in HIV cases and the attitude of people is changing, resulting in fewer suicides and more cooperation. PLWHA are involved in match making and have targeted drug users through various means. They also do a long-term follow-up and maintain self-help groups. There are 20 such camps in the country and there are now around 250 ex-drug users. Fourteen thousand people are now receiving care and support, which has motivated the government to get more involved and cooperate in the process. The government have taken a further step and made a National Program for the years 2001-2006. They have also created a National Committee of AIDS and Harm Reduction.
Dr. Hany Ziady: “The Meaning of the 3 by 5 Initiative for Global Health and the Middle East.”
Dr. Ziady discussed the meaning of the WHO’s “3x5 Initiative” for global health and for the Middle East. The initiative is named to point to the charge that three million people be in treatment under the WHO program by the end of 2005. Dr. Ziady presented universal access to ARV as a human right. He explained that many people are being deprived of treatment. In the Middle East and North Africa, only 5000 individuals are receiving ARV out of a total of roughly 100,000 affected people living with HIV/AIDS. The 3x5 initiative covers six countries, including the Sudan.
Ziady pointed out that some of the challenges faced by the extension of ARV therapy include a weak infrastructure, limited human resources, inadequate funding, and geographic constraints. All of thee factors affect coverage of medical services. Dr. Ziady mentioned the need for donors, especially in those areas that have been most heavily affected, and discussed the role of the World Bank.
He mentioned that some of the sociopolitical complexities that exist in the MENA region, include stigma and discrimination. There are also critical uncertainties that have logistical influence, including the questions of when to start treatment, how to monitor patients, and increasing coverage. Dr. Ziady went on to mention in detail some of the logistical challenges, including decentralization of services and quality of care, as well as lab technology in which manual methods were compared to the shipping of samples to central labs.