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HIV among people who inject drugs in the Middle East and North Africa: systematic review and data synthesis.

Mumtaz GR, Weiss HA, Thomas SL, Riome S, Setayesh H, Riedner G, Semini I, Tawil O, Akala FA, Wilson D, Abu-Raddad LJ - PLoS Med. (2014)

Bottom Line: 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%.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, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.

View Article: PubMed Central - PubMed

Affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.

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, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.

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Trend of HIV prevalence among male people who inject drugs in (A) Iran and (B) Pakistan.This graph displays all available HIV prevalence measures for these two countries as extracted from eligible reports (Table 3) and various databases (Table S4). Each dot represents one HIV prevalence measure for the specific year, and the bars around it define the 95% confidence interval. A pattern of established HIV epidemic is observed in Iran (A), while a trend of emerging HIV epidemic is observed in Pakistan (B).
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pmed-1001663-g003: Trend of HIV prevalence among male people who inject drugs in (A) Iran and (B) Pakistan.This graph displays all available HIV prevalence measures for these two countries as extracted from eligible reports (Table 3) and various databases (Table S4). Each dot represents one HIV prevalence measure for the specific year, and the bars around it define the 95% confidence interval. A pattern of established HIV epidemic is observed in Iran (A), while a trend of emerging HIV epidemic is observed in Pakistan (B).

Mentions: Concentrated HIV epidemics among PWID were observed in Iran, Pakistan, Afghanistan, Egypt, Morocco, and Libya (Table 5). Iran is the only country with conclusive evidence for an established concentrated epidemic at the national level. The first HIV outbreaks among PWID in Iran were reported around 1996. HIV prevalence then increased considerably in the early 2000s, reaching a peak by the mid-2000s (Figure 3A). HIV prevalence in the 2006 and 2010 multi-city IBBSS was stable at 15% (n = 2,853 and n = 2,479, respectively) (Figure 4C) [43],[44]. The evidence suggests that the HIV epidemic among PWID in Iran is now established at concentrated levels of about 15%.


HIV among people who inject drugs in the Middle East and North Africa: systematic review and data synthesis.

Mumtaz GR, Weiss HA, Thomas SL, Riome S, Setayesh H, Riedner G, Semini I, Tawil O, Akala FA, Wilson D, Abu-Raddad LJ - PLoS Med. (2014)

Trend of HIV prevalence among male people who inject drugs in (A) Iran and (B) Pakistan.This graph displays all available HIV prevalence measures for these two countries as extracted from eligible reports (Table 3) and various databases (Table S4). Each dot represents one HIV prevalence measure for the specific year, and the bars around it define the 95% confidence interval. A pattern of established HIV epidemic is observed in Iran (A), while a trend of emerging HIV epidemic is observed in Pakistan (B).
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4061009&req=5

pmed-1001663-g003: Trend of HIV prevalence among male people who inject drugs in (A) Iran and (B) Pakistan.This graph displays all available HIV prevalence measures for these two countries as extracted from eligible reports (Table 3) and various databases (Table S4). Each dot represents one HIV prevalence measure for the specific year, and the bars around it define the 95% confidence interval. A pattern of established HIV epidemic is observed in Iran (A), while a trend of emerging HIV epidemic is observed in Pakistan (B).
Mentions: Concentrated HIV epidemics among PWID were observed in Iran, Pakistan, Afghanistan, Egypt, Morocco, and Libya (Table 5). Iran is the only country with conclusive evidence for an established concentrated epidemic at the national level. The first HIV outbreaks among PWID in Iran were reported around 1996. HIV prevalence then increased considerably in the early 2000s, reaching a peak by the mid-2000s (Figure 3A). HIV prevalence in the 2006 and 2010 multi-city IBBSS was stable at 15% (n = 2,853 and n = 2,479, respectively) (Figure 4C) [43],[44]. The evidence suggests that the HIV epidemic among PWID in Iran is now established at concentrated levels of about 15%.

Bottom Line: 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%.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, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.

View Article: PubMed Central - PubMed

Affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College - Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.

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, there is a window of opportunity for prevention that should not be missed through the provision of comprehensive programs, including scale-up of harm reduction services and expansion of surveillance systems.

Show MeSH
Related in: MedlinePlus