The Arab world is never far from the international headlines, but when it comes to HIV, it tends to take a back seat. That’s because the estimated rate of infection in the general population is low, 0.1% compared with around 5% south of the Sahara. There is a general impression—both within the Middle East and beyond—that HIV is at least one less problem in an otherwise troubled part of the world.
But this is wishful thinking, according to a new study from UNAIDS. HIV is thriving in the Middle East and North Africa. Infections have more than doubled since the beginning of the millennium, and AIDS-related deaths have almost tripled. This makes the Middle East and North Africa one of only two regions where HIV is still on the rise; in the rest of the world, infection rates and deaths from AIDS have either stabilized or are declining. Forget politics: HIV could be the deadliest Arab up-rising yet.
The epidemic is now firmly entrenched in “key” populations, among them men-who-have-sex-with-men, female sex workers and injecting drugs users, in many countries, alarmingly so: one recent study in Tripoli, Libya found that nearly 90% of the participants who inject drugs were also living with HIV. No man is an island when it comes to HIV, and that means that the virus is starting to spread beyond these most-at-risk groups. Women are increasingly hit hard; nearly three-quarters of those living with HIV have been infected by their husbands.
Although there have been plenty of grand political declarations about the need for action on HIV, only a couple of governments—among them Morocco’s—have managed to step up. On average across the region, less than one in five people living with HIV is getting the medicines they need, and the proportion of pregnant women receiving anti-retroviral therapy to prevent transmission to their children is less than half that. This is the lowest treatment rate in the world, all the more disturbing given that there are deep pockets across the region which could be reaching in, and out, to get treatment to all in need.
The factors that drive HIV elsewhere in the world are in full force across the Middle East: poverty, war, gender-based violence, and taboos around sex among them. But most devastating is the stigma and discrimination that people living with HIV or those at risk face on daily basis. It exists at all levels: in laws which criminalize same-sex relations, sex work and injecting drug use, which when reinforced by selective religious teachings, only serve to drive vulnerable people underground, turning them away from testing and treatment, and speeding the spread of HIV. Or in government policies which block the entry of migrant workers living with HIV or condone their expulsion if found to be infected: 12 of the 41 countries which still impose restrictions on the entry, stay or residence of people living with HIV are in the Arab region . Or in attitudes at home, in communities, on the job—even in hospitals and clinics—which make people living with HIV feel like outcasts. According to the HIV Stigma Index, which tries to quantify this exclusion, more than half of people living with HIV in Egypt have been denied treatment in healthcare facilities; in Yemen, a fifth have experienced physical harassment or assault; a third in both countries, as well as Sudan, have had to move or have been unable to find houseing because of their HIV-status.
In the political upheaval sweeping much of the Arab region, it is easy to focus on what is going wrong, and to overlook progress in the right direction. The same is true for HIV. There are small, remarkable steps forward in tackling the epidemic: the emergence of NGOs for people living with HIV, like MENARosa, a new group to support women, for example. Or efforts in Tunisia to provide legal services to people living with HIV. Or projects in Lebanon to increase distribution of condoms to groups at risk. Or studies in Oman to fully understand the nature of the emerging epidemic in vulnerable populations. HIV is not exactly a priority for most governnments, and communities, across the Arab region. This needs to change, because those same problems that top their to-do-list are also driving HIV. There is far less time than most people think to stop this crisis-in-the-making.
Shereen El Feki is the author of Sex and the Citadel: Intimate Life in a Changing Arab World (Chatto & Windus, 2013) and former Vice-Chair of the Global Commission on HIV and the Law.