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Report on key messages on AIDS 2011
1. Antiretroviral treatment for people living with HIV. The estimated regional coverage remains low at 8%. Oman has the best estimated coverage in the Middle East and North Africa region, with 45% of adults and children living with HIV receiving treatment by the end of 2010, followed by Lebanon (37%) and Morocco (30%). Most countries are falling short of the goal of universal access to treatment. As well, the number of people needing treatment has increased from 57 000 in 2001 to 210 000 in 2010. However, it is worth noting that four countries in the region contribute 85% of the number of people eligible for antiretroviral therapy: Sudan (93 000), Somalia (25 000), Islamic Republic of Iran (26 000) and Pakistan (22 000). Achieving regional targets for access to antiretroviral therapy is dependent on those four countries’ scaling-up strategy and their commitment to expanding HIV testing and counselling as the most critical step to providing access to treatment.
2. HIV testing and counselling. Most countries have policies in place on HIV counselling and testing. Since 2006, the rate of HIV testing in these countries has steadily increased. However, the overall percentage of people tested remains much lower than the global percentage, and most of the testing is focused on migrant workers, not on the key populations who are at higher risk of HIV. Nearly 60% of the tests completed between 1995 and 2008 were for migrant workers, while only 4% of tests were for key populations at higher risk. It also appears that most of these tests were mandatory; mandatory testing is widely used by countries in the region, particularly for migrant and foreign workers. Only Djibouti and Morocco have explicit national policies prohibiting mandatory testing. For most countries, it is imperative to increase significantly the availability, accessibility and uptake of voluntary HIV testing among the key populations. Otherwise, these countries will struggle to strengthen their overall prevention programmes.
3. Prevention to mother-to-child transmission. Although the total number of women living with HIV who received antiretroviral therapy to prevent mother-to-child transmission in the region doubled in one year (from 550 in 2009 to 1100 in 2010), the estimated regional coverage remains very low, at 5%, and is well short of the UNAIDS goal of eliminating vertical transmission. Oman reports the highest percentage, with 78% of pregnant women living with HIV receiving antiretroviral therapy; Morocco has the next highest percentage at 26%. Also, the estimated number of mothers needing treatment to prevent mother-to-child transmission has increased, from 15 000 in 2001 to 20 000 in 2010.
4. Access to health services for most-at risk populations. In recent years, more countries in the region have moved to include references to key populations at higher risk (sex workers, injecting drug users and men who have sex with men) in their national strategic plans. However, the scope of services provided to these populations often does not cover the full spectrum of services related to HIV prevention and treatment as recommended by regional and international guidance. Consequently low coverage remains of great concern. Involvement of nongovernmental organizations is crucial to make the achievements towards working with most-at-risk populations and providing them with the prevention and treatment services they need.
5. Middle East and North Africa Harm Reduction Association (MENAHRA). MENAHRA has been working to prolong and improve the quality of life for people who inject drugs in the region. Launched in 2007 through a joint initiative by the World Health Organization and the International Harm Reduction Association, and with financial support from the Drosos Foundation, MENAHRA covers 19 countries in the MENA region.
There is evidence to suggest that the knowledge hubs’ training and advocacy workshops have contributed to changes that favour harm reduction in both policies and practices. As a result, six civil society organizations provide needle/syringe services to 2292 people who inject drugs (distributing 222 078 needles and syringes), and three civil society organizations (in Afghanistan, Egypt and the Islamic Republic of Iran) provide voluntary counselling and testing either on-site or via referral (1088 clients have used this service). Civil society organizations report that their harm reduction services have engendered a growth in harm reduction service provision beyond their individual projects.
6. Sexually transmitted infections. Recent data on sexually transmitted infections in the region are generally limited because of the lack of adequate surveillance systems. Available data show that rates of sexually transmitted infections among men who have sex with men vary widely, from 7% in Morocco (Agadir) to 36% among certain high-risk groups in Pakistan. The rates among sex workers were equally varied, from 9% (Agadir) in Morocco to more than 40% in Djibouti. The high rates of sexually transmitted infections in some countries are a serious concern, given that such infections amplify the risk of HIV transmission. Countries should be taking steps to introduce, expand and/or strengthen surveillance systems for sexually transmitted infections and to ensure the availability and accessibility of prevention and treatments services, particularly as an integral component of HIV prevention programmes for the key populations.
7. HIV-associated tuberculosis. Of the 11 countries that provided data on the percentage of estimated HIV-positive incident tuberculosis cases that received treatment for both infections in the 2011 Universal Access reporting, two countries performed extremely well: Oman (100%) and Algeria (99%). The remaining nine countries did less well, with five countries reporting less than 10% coverage and four countries reporting coverage between 22% and 55%. The challenge for most countries in improving the coverage of tuberculosis and HIV co-treatment is directly related to reaching the marginalized populations most in need of the services.
8. Blood safety. In recent years, there have been strong national commitments in countries to improve the safety of blood supplies. Nearly every country now has a national policy on the screening of blood for transfusions. More importantly, the ability of countries in the region to ensure that safe blood is available is steadily improving. 13 countries reported in 2010 that 100% of donated blood units are screened for HIV in a quality-assured manner. Although there is room for further improvement – especially in Yemen, Pakistan and Afghanistan – the trend in the region is clearly moving in the right direction.
9. Regional strategy. The WHO regional strategy for the health sector response to HIV (2011–2015), endorsed by all Ministers of Health from the region, includes a set of priorities agreed upon to scale-up HIV testing. Concrete steps and a timeline for implementation were discussed with the national AIDS programme managers at the 2011 meeting, where country-specific steps and milestones were identified depending on the level of advancement of the response in each country.
World AIDS Day 2011
In the Eastern Mediterranean Region, the HIV epidemic has been on the rise since 2001. Although the overall prevalence in the Region is still low, the rise in new infections has put the Region among the top two regions in the world with the fastest growing HIV epidemic. The rise in the estimated number of people living with HIV in the Region is presumably the result of an increased HIV prevalence among key populations at higher risk and an onwards transmission of the virus to a larger number of individuals who are generally at lower risk of infection. Recent modes of transmission studies in the Islamic Republic of Iran and Morocco and repeated rounds of surveys in countries such as Egypt and Tunisia have supported this assumption.
Annual estimated new infections among adults and children have substantially increased in the past decade. Approximately 560 000 people are living with HIV in the WHO Eastern Mediterranean Region, among them 42 000 children aged 0–14 years. It is estimated that 82 000 adults and 7 400 children have been newly infected.
AIDS-related deaths have also almost doubled in the past decade among both adults and children in the Region, reaching a total of 38 000 in 2010 including 4100 children. The estimated increase of AIDS-related deaths among reflects three problems: 1) an accelerating epidemic in the Region; 2) a rise in the total number of women living with HIV (40% in 2010); and 3) the generally inadequate coverage of services to prevent mother-to-child transmission of HIV.
In contrast, globally new infections and deaths are decreasing due to the increased availability of antiretroviral therapy, and care and support to people living with HIV, especially in sub-Saharan Africa.
For the third year, the World AIDS Campaign focuses on human rights. The right to health is a core value in delivering health services. The regional theme for the World AIDS Campaign 2011 is “stigma and discrimination in health care settings”.
In choosing this regional theme, we focus this year on reducing stigma and discrimination in health care settings. Stigma and discrimination against people living with HIV and those at increased risk of HIV transmission still exist to varying degrees across the Region. They remain massive barriers to people accessing prevention and care services. They are also major impediments when it comes to encouraging stigmatized population groups to seek and access health services and adhere to health interventions.
Many countries have witnessed women in labour not being allowed to deliver in hospitals because of their HIV positive status. Men, women and children living with HIV in dire need of surgery have been denied this right. Even with non-invasive procedures, some health care workers have refused to care for people living with HIV. Public and institutional measures have enacted mandatory HIV testing on individuals upon their admission to health care services, often resulting in denial of access to those who test positive, unnecessary isolation or, at the least, gossip.
In the Eastern Mediterranean Region, the 2011 World AIDS Campaign has prompted discussions among health care providers in the Region about injustices that remain and about improved conditions to work towards. The campaign asserts that upholding shared human rights is the best way to bring about HIV prevention, treatment and care for all. As enshrined in the WHO Constitution, access to the highest attainable level of health is a human rights imperative. The rights-based approach reinforces the principles that individuals should not be tested for HIV against their will or denied equal health services because of their HIV status.
While health care providers have the responsibility to comply with standard precautions and equal treatment of all patients, decision-makers in health also have the responsibility to make prevention supplies and post-exposure prophylaxis medicines available to health care workers. Regardless of an individual’s role in the health care system and the agencies that support it, everyone has the power to Take the Lead to Stop AIDS.
Threats of shortage of foods and medicines stocks in Libya
Dr Neema Al-Gasseer, Assistant Regional Director for the Eastern Mediterranean Regional Office, warned that medicine and food stocks available in libya hardly covers few weeks, a threat that urges all concerned parties to act fast to ensure smooth provision of humanitarian assistances to avoid any consequences of the lack of such crucial items. This was announced at the end of a field visit paid by Dr Neema Al-Gasseer along with a UN mission to Libyan Eastern governorates including Banghazi, Al Marj, Al Bayda, Sousa, Darnah, and Tobruk, in the context of WHO’s efforts to support health aspects in all Member States.
WHO, in collaboration with Libyan concerned authorities, directs the available support to ensure the provision of medicines and surgery-related requirements, in addition to ensuring the availability of medical staff, through humanitarian partners, in order to support the medical teams currently working in Libya, especially nurses. Recently 10 surgical kits crossed the Egyptian/Libyan borders to Libya. The kits, funded by Norway government covers 10000 persons for 10 days.
Based on direct observation of the flow of medical supplies, initiated by WHO since 17 February, the Eastern Mediterranean Regional Office renews its appeal to increase humanitarian aids to the Libyan people, immediate halt of armed operations against civilians, to stop the increasing blood shed that claimed so far more than 2000 deaths and much more injuries, according to the available estimates.
WHO, through the Assistant Regional Director, expresses deep concerns over lack of psychological care and support, lack of sufficient drugs and specialists in this field, and reiterates the importance of giving this issue the due interest and care.
WHO also is concerned about the deterioration of services provided to people with special needs in Libya, a matter that must be revisited immediately. WHO works closely with concerned parties to meet these needs as much as possible.
