The World Health Organization (WHO) estimates that two-thirds of all STIs worldwide occur in young people--teenagers and those in their early twenties (WHO 1993, WHO 1995). The provision of STI services to these age groups should therefore be high on the agenda of STI programme planners and adolescent/young people's health programmers alike. However, attempts to promote the sexual health of young people have so far tended to focus on prevention, education and counselling, while the provision of services to those who have already faced the consequences of unprotected sexual activity, including pregnancy and STI, or sexual violence, has lagged behind. In 1999-2000 a review was commissioned by GTZ of the characteristics of adolescent sexuality, evidence of STI risk in adolescents, the profile of adolescents in need of STI care, types and evidence of success of different STI service delivery models for adolescents and the advantages and disadvantages of each of these, and to what extent a youth-specific approach to STI services or an STI-specific approach to adolescent health service delivery, is warranted. This review will be published jointly by GTZ and WHO with the title Sexually Transmitted Infections among Adolescents: The Need for Adequate Health Services. This is a shortened form of the Summary and Conclusions of this book.

Laith Abu-Raddad and colleagues assess the current state of knowledge of the HIV epidemic among people who inject drugs in the Middle East and North Africa. Please see later in the article for the Editors' Summary

Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

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A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries.

ObjectivesTo provide an overview of the current level of development and results from the national HIV surveillance systems of the 23 countries of the Middle East and North Africa (MENA), and to assess the quality of HIV surveillance systems in the period 2007–2011.MethodsA questionnaire was used to collect the information about the structure, activities and the results of HIV surveillance systems from the National AIDS Programmes. Assessment of the quality was based on four indicators: timeliness of data collection, appropriateness of populations under surveillance, consistency of the surveillance sites and groups measured over time, and coverage of the surveillance system.ResultsOnly in four countries did surveillance systems enable assessment of epidemic trends in the same populations and locations over time, such as in pregnant women (Morocco, Iran), injecting drug users (Iran, Pakistan), female sex workers (Djibouti, Morocco) and male sex workers (Pakistan). There is increasing evidence of HIV infection being firmly established in at least one of the populations most at risk of HIV in nine MENA countries, while lower risk populations show elevated HIV prevalence in South Sudan, Djibouti and some parts of Somalia.ConclusionsThe performance of HIV surveillance systems in several of the MENA countries has improved in recent years. The extent of HIV epidemics in the populations most at risk of HIV is still largely unknown in 10 countries. Multiple data sources that most of the countries still lack would enable indirectly estimation not only of the patterns of HIV epidemics but also the effectiveness of HIV responses.

Background HIV prevalence is low in the Middle East and North Africa (MENA) region, though the risk or potential for further spread in the future is not well understood. Behavioral surveys are limited in this region and when available have serious limitations in assessing the risk of HIV acquisition. We demonstrate the potential use of herpes simplex virus-2 (HSV-2) seroprevalence as a marker for HIV risk within MENA. Methods We designed a mathematical model to assess whether HSV-2 prevalence can be predictive of future HIV spread. We also conducted a systematic literature review of HSV-2 seroprevalence studies within MENA. Results We found that HSV-2 prevalence data are rather limited in this region. Prevalence is typically low among the general population but high in established core groups prone to sexually transmitted infections such as men who have sex with men and female sex workers. Our model predicts that if HSV-2 prevalence is low and stable, then the risk of future HIV epidemics is low. However, expanding or high HSV-2 prevalence (greater than about 20%), implies a risk for a considerable HIV epidemic. Based on available HSV-2 prevalence data, it is not likely that the general population in MENA is experiencing or will experience such a considerable HIV epidemic. Nevertheless, the risk for concentrated HIV epidemics among several high-risk core groups is high. Conclusions HSV-2 prevalence surveys provide a useful mechanism for identifying and corroborating populations at risk for HIV within MENA. HSV-2 serology offers an effective tool for probing hidden risk behaviors in a region where quality behavioral data are limited.

Background: It is perceived that little is known about the epidemiology of HIV infection among people who inject drugs (PWID) in the Middle East and North Africa (MENA). The primary objective of this study was to assess the status of the HIV epidemic among PWID in MENA by describing HIV prevalence and incidence. Secondary objectives were to describe the risk behavior environment and the HIV epidemic potential among PWID, and to estimate the prevalence of injecting drug use in MENA. Methods and Findings: This was a systematic review following the PRISMA guidelines and covering 23 MENA countries. PubMed, Embase, regional and international databases, as well as country-level reports were searched up to December 16, 2013. Primary studies reporting (1) the prevalence/incidence of HIV, other sexually transmitted infections, or hepatitis C virus (HCV) among PWIDs; or (2) the prevalence of injecting or sexual risk behaviors, or HIV knowledge among PWID; or (3) the number/proportion of PWID in MENA countries, were eligible for inclusion. The quality, quantity, and geographic coverage of the data were assessed at country level. Risk of bias in predefined quality domains was described to assess the quality of available HIV prevalence measures. After multiple level screening, 192 eligible reports were included in the review. There were 197 HIV prevalence measures on a total of 58,241 PWID extracted from reports, and an additional 226 HIV prevalence measures extracted from the databases. We estimated that there are 626,000 PWID in MENA (range: 335,000-1,635,000, prevalence of 0.24 per 100 adults). We found evidence of HIV epidemics among PWID in at least one-third of MENA countries, most of which are emerging concentrated epidemics and with HIV prevalence overall in the range of 10%-15%. Some of the epidemics have however already reached considerable levels including some of the highest HIV prevalence among PWID globally (87.1% in Tripoli, Libya). The relatively high prevalence of sharing needles/syringes (18%-28% in the last injection), the low levels of condom use (20%-54% ever condom use), the high levels of having sex with sex workers and of men having sex with men (15%-30% and 2%-10% in the last year, respectively), and of selling sex (5%-29% in the last year), indicate a high injecting and sexual risk environment. The prevalence of HCV (31%-64%) and of sexually transmitted infections suggest high levels of risk behavior indicative of the potential for more and larger HIV epidemics. Conclusions: Our study identified a large volume of HIV-related biological and behavioral data among PWID in the MENA region. The coverage and quality of the data varied between countries. There is robust evidence for HIV epidemics among PWID in multiple countries, most of which have emerged within the last decade and continue to grow. The lack of sufficient evidence in some MENA countries does not preclude the possibility of hidden epidemics among PWID in these settings. With the HIV epidemic among PWID in overall a relatively early phase, t...