Hiv Among People Who Inject Drugs In The Middle East And North Africa: Systematic Review And Data Synthesis

Abstract

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...

Hepatitis C in HIV‐infected individuals: a systematic review and meta‐analysis of estimated prevalence in Africa

“…As a consequence, it was very difficult to evaluate the impact of MSM or IDU behaviour on the HCV seroprevalence from our results. Although HIV epidemics in PWID have been well-described in North Africa [17], data on PWID in sub-Saharan (SSA) are scarce [6,18]. Nevertheless, it is considered that IDU is on the rise in SSA, especially in large urban settings, and could contribute to the spread of HCV infection [19].…”

Status of HIV and hepatitis C virus infections among prisoners in the Middle East and North Africa: review and synthesis

“…By 2003, HIV prevalence reached concentration stage in most surveys (HIV prevalence !5%) [91]. Through overlapping risk behaviours [10,15,67,91,93Á95], HIV was introduced to the sexual networks of MSM [15,96] and heterosexual commercial sex [94,97Á99]. HIV transmission to spouses of PWID increased; the contribution of spouses to the number of notified HIV cases increased four-fold from 0.5% of all cases in 2001 to 2% in 2004 [91].…”

“…Today, the HIV epidemic among PWID in Pakistan is one of the world's largest. Through overlapping risk behaviours, the epidemic among PWID appears to have ignited an HIV epidemic among MSM and transgender people [10,15,28]. Predictably, spouses of PWID were affected, with the majority of infected women acquiring HIV from their infected spouses [111].…”

“…Injecting drug use is an important transmission route for HIV and HCV in the Middle East and North Africa (MENA) [10,11]. This region has several vulnerability factors for the practice; for example, the majority (80%) of the global supply of heroin is produced in Afghanistan [12], and over threequarters of this is trafficked through Iran and Pakistan [13].…”

“…Increased purity and availability of heroin in MENA at lower cost may have contributed to higher injecting drug use [14]. among PWID [10] and men who have sex with men (MSM) [15] in different MENA countries. The HIV epidemic in MENA is one of the two fastest growing HIV epidemics worldwide with most country-specific epidemics emerging only in the last decade [16].…”