October 20, 2003—More than 20 years after its first discovery, HIV/AIDS continues to batter Africa, leaving orphans, wrecked communities and disrupted societies in its wake. Faced with the unchecked epidemic that persists, UNAIDS and the World Health Organisation (WHO) declared an international state of emergency last month, comparable to that of war. Yet in the midst of the seemingly inexorable flow of bad news, a voice of hope is making itself heard. The World Bank’s newly appointed Lead Social Development Specialist, who is the focal point on HIV/AIDS for the Middle East and North Africa (MENA), Bachir Souhlal, believes that the countries of the Middle East are today facing an unique opportunity to stem the tide of the epidemic in their region. DevNews met with Souhlal, one of the lead architects of the Bank’s Africa Multi-Country HIV/AIDS Program (MAP), to discuss the challenges and opportunities facing his new region on the HIV/AIDS front.
You enter your new position following four years of work on HIV/AIDS in Africa. What lessons from this experience will you be bringing with you?
My experience working with Africa was an eye-opener, and after four years of working with these countries, my first thoughts upon coming to the MENA region, was that it is a region that is in a very special and privileged situation, with an HIV/AIDS prevalence rate as low as 0.3 percent.
The key lesson that I learnt from Africa, and that I will be bringing with me to MENA, is that it is better to act now, when prevalence rates are still low. Africa, for too many years, lacked the political involvement, as well as the resources. The problem was perceived as a medical issue. But HIV/AIDS is so much more than that. It is a social and developmental issue, where all stakeholders need to be involved.
Success stories, such as in Senegal, came about in areas where civil society and religious leaders were involved in maintaining the prevalence rates at relatively low levels. What is also important to note from these examples, is that the coalition of stakeholders that came together did not just focus on prevention, but also on taking care of the vulnerable groups, in terms of care and adequate treatment. This is essential.
What is the current situation in MENA with regard to HIV/AIDS?
In MENA, 99.7 percent of the population is not infected with HIV/AIDS. Its 0.3 percent is one of the lowest prevalence rates in the world. However, the vulnerability risk is very present. There are risks stemming from several sources: the high level of migration—internal, regional, as well as international—which increases vulnerability; the economic issues, such as poverty; and conflict. Conflict situations create the perfect environment for the development of the epidemic, and we have seen this is many countries, not only in Africa.
Therefore, I must emphasize that low prevalence does not mean low risk. Over the course of 2001 to 2002, the new cases of HIV rose to 83,000 from 80,000 in the MENA region. Examples from countries with high prevalence rates, like in Southern Africa, show that in the beginning, the prevalence growth is very slow, until it reaches the rate of 2 to 5 percent. After that, it increases exponentially.
What are the main challenges facing the region in successfully preventing the escalation of the disease?
Talking about death and sexuality is never easy—this goes for all cultures—and that is at the core of the issue. Recognizing that there is a problem, even if it is at the early stages, is a challenge, due to the stigma and the fear.
There are also social values that make it difficult to talk about HIV/AIDS in MENA, and challenge the leadership in being more open about this. Here, I am not simply referring to the political leadership, but to leadership at all levels, also religious and traditional. The voices of some of the people in the region who are very aware of the threats of HIV/AIDS, especially those of women, are not always heard.
Finally, a notable characteristic of the region, is that the majority of the population is under 24 years old. This represents both a challenge and an opportunity, and it is a segment of the population we should target and protect, because it represents not only our future, but our present too.
The World Bank just published a very interesting report—HIV/AIDS in the Middle East and North Africa: The Costs of Inaction—which shows that there is a lot of potential risk for this epidemic to increase, but also that there is a strong will to tackle the epidemic. We have to be very open, and use all the support, all the goodwill in the region, regardless of where it comes from, to make a difference.
In Africa the Bank has worked in partnerships with governments, civil society, and various religious groups. In the Middle East, many of our traditional partners have less of a voice in the public realm. How will the Bank tackle the challenge of operating in such a different environment?
Every region has its own specificity, but success stories from countries such as Thailand and Senegal show that the government can not solve the problem alone. It must be actively working with civil society and the private sector in tackling this issue. So having a multi-sectoral and a multi-stakeholder approach is essential. Now because we are still at low prevalence levels in MENA, it makes a lot of sense to focus on the medical response. But it is just as important to empower the communities, to talk about it, and focus on prevention. It’s not easy, but we can do it, all the while respecting the traditional values.
Do you think working with these different stakeholders could generate a positive spill-over effect, thereby empowering the groups and giving them a more prominent role in their societies?
I am convinced that it will. And I am more and more convinced that our partners in the governments are very open to this.
But the multi-stakeholder coalition goes well beyond national borders. We also have to work with other partners in the region, both donors and regional financial institutions, such as the Arab Fund, the African Development Bank, the OPEC Fund, UNAIDS, to name but a few.
That being said, I’d like to stress that there is already a lot of effort currently underway in the Middle East. For instance, there is a very interesting needle distribution to vulnerable groups program in Iran, because unlike Africa, HIV transmission is also significantly drug related in this region. And in Morocco and Lebanon, there are interesting programs focusing on groups at risk. As a matter of fact, Morocco is currently finalizing its national strategy on combating HIV/AIDS.
In my work in Africa, I have seen the level of despair that the epidemic can create, on the individual, on the family, on the community, on the country. But I have also seen that good targeted programs, with the involvement of the community, the government and of the private sector, can be extremely innovative and effective. In MENA, these elements are there, and for once, time is still on the region’s side, so it has everything it needs to succeed in keeping this disease at bay.
Useful links: For more information on the Bank’s work on HIV/AIDS, please visit: http://www1.worldbank.org/hiv_aids/
World Bank Lead Social Development Specialist for MENA Bachir Souhlal