AIDS Regional Update: Middle East and North Africa

-- Related Links -- World Bank Report: Preventing HIV/AIDS in the Middle East and North Africa Feature Story: The Time to Act is Now

A Unique Opportunity

Countries in the Middle East & North Africa (MENA) region are today facing a unique opportunity to stem the tide of HIV/AIDS while prevalence rates are still low. According to UNAIDS, in 2005, 64,000 people were newly infected with HIV in the region and the total number of AIDS-related deaths has increased from 34,000 in 2003 to 37,000 in 2005. Additionally, the total number of deaths due to AIDS in the region has increased significantly since the early 1990s, and about 0.2 percent of the region's adults are currently infected.

However, the low prevalence does not mean low risk, and should not mean low priority. Political, socio-cultural and capacity-related barriers, inadequate surveillance systems, lingering stigma, fear and denial, in addition to the apparent current low prevalence, continue to push HIV prevention and care to a low priority level. This is despite the fact that factors such as high migration, increased intravenous drug use, poverty and high unemployment rates, a relatively large youth population and conflict situations create an enabling environment for the spread of the epidemic. Waiting to intervene could be socially devastating and economically expensive.

Early Intervention Is Vital

Although the current rate of HIV infection in MENA is low compared to other regions, early intervention to curb the spread of HIV/AIDS is vital. Experience has shown that once the prevalence of the infection exceeds a certain threshold, the virus spreads very fast, sometimes increasing by as much as tenfold in five years as has been the case in several southern African and Asian countries. The more widely HIV/AIDS spreads, the more difficult and costly prevention and treatment becomes. In Sub-Saharan Africa, it is estimated that a national HIV/AIDS prevention program would cost less than US$3 per capita while prevalence remained below 5%. Once rates reach 15% however, program costs could be US$12 per capita. The longer the introduction of programs is delayed, the greater the likelihood that the epidemic will grow exponentially. Countries therefore have two policy options:

1. Delay action while HIV prevalence remains low and incur far higher expenses to control it once it spreads; or
2. Take comprehensive action now to prevent the spread of HIV before it becomes a developmental menace.

Behavior Change Can Reduce HIV Transmission

Despite the lack of a vaccine for HIV/AIDS, behavior change has been proven to be a highly effective means of reducing HIV transmission. Young people are especially receptive to learning safe behavior messages and skills. Early and aggressive intervention against the epidemic has paid dividends in several places such as Uganda, Senegal, Thailand and Tamil Nadu in India. Prevention not only averts suffering and death, but pays vast dividends in future savings to the health system and the public sector at large. Cost-effective interventions such as public information programs, treatment of sexually transmitted infections and greater use of condoms, cost as little as US$8 per infection averted, compared to the hundreds of dollars that each case of AIDS costs to treat. For many individuals and couples, finding out about their infection status could be useful. One approach is to make voluntary testing services more convenient.

The Challenges

Overall, the challenge lies in how to galvanize the political and social leadership of MENA countries (given the low prevalence levels) into recognizing the seriousness of the threat and the importance of a pro-active approach. The experience of Eastern Europe and Central Asia (ECA) here is quite instructive. Ten years ago, scant attention was paid to the threat posed by HIV/AIDS in ECA, and now, the region is facing alarming rates of incidence. The lesson for MENA is that complacency now has enormous hidden costs which will be realized only in the future.

One major concern about HIV/AIDS in the region is the level of information about HIV prevalence rates and the reliability of the data. Inadequate surveillance system, which is a universal weakness in the region, can overlook outbreaks in marginalized, high risk groups. A Multisectoral and society-wide response involving several government ministries, different agencies, civil society organizations, the private sector and the community itself is needed to:

• Improve HIV/AIDS surveillance systems and obtain up-to-date accurate data on the extent of the problem in the region;
• Identify socioeconomic and cultural factors which may be contributing to the spread of the epidemic;
• Break the silence around the disease;
• Overcome the fear and stigma associated with the epidemic; and
• Monitor trends for appropriate action.

All of these actions require strong political will and commitment to create an enabling environment for them to take place.

The World Bank's Work

In order to raise awareness of the issue of HIV/AIDS in the region, the World Bank has implemented or supported the following activities over the last five years:

• Technical assistance support to the Government of Morocco, one of the countries which is openly addressing the AIDS situation in the region, in preparing their National AIDS Action Plan. This plan was finalized in September 2001 and the Government organized a national workshop to present it. With the action plan, Morocco became one of the first recipients of funds from the Global Fund to Fight AIDS, TB and Malaria (GFATM) in 2002.
• Collaboration with WHO-Eastern Mediterranean Regional Office (EMRO) and UNAIDS to produce a recent report titled "HIV/AIDS in the Middle East and North Africa: The Costs of Inaction" as a means of stimulating discussion and promoting dialogue among the region's policy and decision makers. A draft of this report was presented to top policy makers and senior officials from countries of the region at a regional Public Health Conference in Beirut, Lebanon in June, 2002. Comments from the countries were incorporated in the final published document which includes a macroeconomic analysis of the impact of HIV/AIDS in the region. This section of the report shows that the gross domestic product (GDP) losses resulting from the diffusion of HIV/AIDS could approximate 35 percent of the total GDP across the region, for the period 2000-2025.
• The Bank supported the Government of Lebanon, in preparing a comprehensive National AIDS Action Plan for 2004 to 2009 to guide leaders and stakeholders in the organization of appropriate interventions that would lead to a coherent and coordinated HIV/AIDS response at the national level. As a follow up to this, the Bank in 2005 has approved an Institutional Development Fund (IDF) grant of $350,000 to support the strengthening of the National HIV/AIDS Monitoring and Evaluation and Surveillance Systems, in line with the priorities of the National AIDS Action Plan.
• The Bank is financing a Health Reform Support Project in Yemen, with a $2 million component for health education that is adopting a 'communication for behavior change' strategy aimed at improving health behavior including the prevention of HIV/AIDS.
• The Bank approved in 2003 a $12 million grant to Djibouti, the country with the highest prevalence rate in the region (2.8%), to implement its National HIV/AIDS, Malaria and Tuberculosis Strategic Plans. The project design is being implemented through 11government ministries and several international and national NGOs.
• Another initiative, the International Road Corridor Rehabilitation project in Djibouti is a Bank funded initiative outside the health sector with an HIV/AIDS component that examines the potential of increased transmission of HIV/AIDS in the trucking industry and at construction sites, and explores mechanisms of cooperation to prevent such risks.
• In July 2005, the Bank, in collaboration with WHO and GFATM, organized a regional capacity building Workshop on "Managing Procurement and Logistics of HIV/AIDS Drugs and Related Supplies". Participants from Egypt, Iran, Jordan, Lebanon, Morocco and Yemen attended the five-day training in Beirut, Lebanon.
• In collaboration with the Government of Iran, UNAIDS, WHO-EMRO and the United Nations Organization for Drug Control, the Bank organized an inter-country Consultation on HIV/AIDS prevention among injecting drug users (IDUs). The four-day Consultation which was co-hosted by the Iranian Drug Control Headquarters of the Presidential Committee and the Ministry of Health, brought together high-level participants from five countries, namely Tajikistan, Afghanistan, Pakistan, Uzbekistan and Kyrgyzstan to Tehran so that they could learn from the successful Iranian experience implementing harm reduction and HIV/AIDS prevention among prisoners and IDUs. The event was highly successful, with the country representatives learning from local and international experts, participating in field visits to the prisons and some NGOs in Iran, and finally, developing concrete action plans for implementation in their respective countries.

The Bank launched, in December 2005, its HIV/AIDS Strategy for the region titled "Preventing HIV/AIDS in the Middle East and North Africa Region: A Window of Opportunity to Act" to support multisectoral activities to tackle the epidemic. The following four key strategic directions were identified as areas where the Bank could support MENA countries in the design, evaluation and implementation of HIV/AIDS programs:

1. Engage political leaders, policy makers, and key stakeholders to raise awareness and give greater priority to HIV/AIDS programs within the national development agenda, with particular focus on prevention and expanding access to information;
2. Support country efforts to upgrade their surveillance systems and strengthen research and evaluation of epidemiological, economic and behavioral aspects of HIV/AIDS;
3. Support the development of national HIV/AIDS strategies and programs with priority focus on prevention and expansion of access to information; and
4. Support capacity building and knowledge sharing for comprehensive management of HIV/AIDS programs.

These directions are based on the Bank's comparative advantage, numerous consultations with regional partners and the business case for the Bank's engagement in this area.

Although a lot more needs to be done, a number of other HIV/AIDS initiatives have been commenced in several countries of the region, for instance a few countries have received approvals or grants from the Global Fund for HIV/AIDS programming. This indicates that the region is beginning to rise to the challenge of addressing the issue in a timely manner. Across the region, from Algeria to the Gulf, countries are mobilizing to address the HIV/AIDS issues:

• Declaration of Algiers 2005. The Algerian government, in collaboration with UNAIDS, organized a "Regional HIV/AIDS Workshop on Empowerment and Support of People Living with HIV/AIDS (PLWHA) in the Middle East and North Africa" in November 2005 with the objective of raising awareness on the needs and human rights of PLWHA and engaging them in the fight against stigma and discrimination. Participants came from 15 countries and represented civil society organizations, United Nations Agencies, the Global Fund to fight AIDS, Tuberculosis and Malaria, the World Bank as well as representatives from various Algerian ministries, including the Ministries of Health, Social Solidarity and Religious Affairs. This Workshop was the first event in the region where the specific perspectives of PLWHA were discussed and their needs addressed. At the close of the workshop, the Declaration of Algiers was adopted in which the words and visions of those living with HIV were reflected, to reinforce their engagement in the fight against the HIV/AIDS epidemic in the areas of advocacy, prevention, care and treatment, positive living and reducing stigma and discrimination surrounding the epidemic. The Declaration calls for a multi-stakeholder response where governments, NGOs, the civil society, faith based and community-based organizations as well as PLWHA become partners in the fight against HIV/AIDS. The Declaration built on the promises made by forty-two nations during the 1994 Paris AIDS Summit on the need for greater involvement of people living with or affected by AIDS. It specifically called on decision makers in the Middle East and North Africa to support the true participation of PLWHA in the development and implementation of HIV/ AIDS programs.
  
  
• SIDACTION Maroc 2005 Telethon. As part of a campaign to fight HIV/AIDS, and in commemoration of World AIDS Day 2005, the Moroccan Association "Association de Lutte contre le Sida" in cooperation with the Moroccan channel 2M, launched a telethon to raise funds to support PLWHA in Morocco and to convey a message of hope and compassion throughout the nation. Close to US$ 2.5 million was raised during the two-week campaign. The various sessions included PLWHA speaking about the stigma and discrimination they face, and Moroccan and foreign experts and celebrities as well as the Executive Director of UNAIDS participating in debates on various HIV/AIDS-related issues and discussions around the view of Islam on HIV/AIDS. The donations will provide medications for the people affected by HIV/AIDS, improve HIV screening and increase prevention and awareness to fight stigma associated with HIV/AIDS.
  
  
• Saudi Arabia- Seminar on Human Rights and HIV/AIDS in the Gulf Cooperation Council region. In November of 2005, the Health Ministers' Council for Gulf Cooperation Council States, in collaboration with WHO and UNDP, organized a seminar on Human Rights and HIV/AIDS in the Gulf region in Riyadh, Kingdom of Saudi Arabia. This conference, with the objective of determining how to adopt a human and social approach to fight HIV/AIDS, was the first of its kind in the Gulf region. The initial recommendations of the seminar include: (i) establishing an enabling legal environment and enhancement of societal acceptance through sustained sensitization of the population, and the elimination of stigma and discrimination; (ii) the improvement of the HIV surveillance system, especially among high risk and vulnerable groups; (iii) the need for a multi-sectoral approach to HIV/AIDS issues; (iv) the need for governments to set the example in respecting and applying the Universal Human Rights Declaration in treating HIV/AIDS patients, whether they are citizens or non-citizens; (v) the provision of health care to all patients equally, whatever the nature of their disease; (vi) the review of education and health programs to reinforce prevention; and (vii) the set-up of a comprehensive National Health Strategy that emphasizes HIV prevention and advocacy to reach out to vulnerable and high risk groups.

  Updated August 2006