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HIV in the Middle East and North 2013 - 2015

Together for a Fast-Track Response

UNAIDS Regional Support Team for the Middle East & North Africa

Abdoul Razzak El-Sanhouri Street, 20

Nasr City ,

Tel: (+20) 222765257

Executive Summary some , stabilising in others, and increasing in a few. Similarly with AIDS deaths, the The HIV Epidemic in MENA regional total by 2014 has increased from 7500 in 2005 to 12,000, with 90 The UNAIDS Middle East and North per cent of these occurring in five Africa (MENA) includes 21 countries (Iran, , , countries1 that are home to 445 and ). Some million people. The region has one countries have seen doubling and of the youngest populations in even tripling of the number of the world, with around 300 million estimated AIDS deaths in the past people aged 15-39, of whom 42 ten years, while in others it has million are aged between 15 and 19 decreased. years old. Significant numbers of people in The region represents wide diversity the region are still left behind in in terms of social and economic terms of treatment and prevention. development and political stability. In too many countries, stigma, MENA is also the setting for several discrimination and human rights humanitarian crises, both recent violations constitute significant and protracted, the repercussions barriers to progress. of which have been felt throughout the region in terms of massive displacement of people, within and between countries, and the Political, policy and consequent strains on resources programmatic achievements and services. The challenges facing the region In 2014, more than The overall adult HIV prevalence in as it addresses HIV and AIDS are 60% of all adult the region is estimated to be 0.1 significant. Nonetheless, there new infections per cent, with an estimated number has been significant progress in were amongs key of 240 000 [150 000 – 320 000] adults advancing political leadership, populations, of and children living with HIV by the improving the policy environment that figures, 57% end of 2014. Six countries (Iran, and programming focus and scale- among PWID, 27% Sudan, Somalia, Morocco, up. among MSM and and Djibouti) are home to 90 16% among FSW. per cent of all people living with HIV The political leadership of the in the region. League of Arab States and UNAIDS, has resulted in the While the number of new infections development and endorsement of The leadrshop role of League of Arab increased by 16 per cent from the Arab AIDS Strategy in March States and the 19 000 in 2005 to 22 000 in 2014, the 2014 and the Council of Arab Council of Arab rate of increase of new infections Health Ministers following up the is slowing. Previous reports have implementation of the Strategy Health Ministers is highlighted the fact that within the in all Member States in February key in fast-tracking MENA region there are several HIV 2015. This leadership is also clearly HIV resposne in the region. epidemics occurring simultaneously. reflected in theAlgiers Call for As a result, the trajectory of new Action on Advancing gender infections varies throughout the equality and the HIV response that region, with numbers declining in followed the High Level Meeting of Women Leaders in MENA, held

1 The MENA region, by UNAIDS definition, includes Algeria, , Djibouti, Egypt, Iran, , , , , , Morocco, , Palestine, , , Somalia, Sudan, , , and .

1 HIV in the Middle East and North Africa 2013 - 2015

Djibouti is the jointly by the Leagues, UNAIDS, Most of the countries in the first UN Women and the Government of region have either updated or are ratifying the Arab Algeria in November 2014. updating their national strategic plans to be aligned with the Arab Convention on HIV The ratification of the Arab AIDS Strategy, 90-90-90 and Prevention and Convention on Preventing HIV Protection of the other Fast-Track targets. Financial and Protecting the Right of PLHIV, support from public and domestic Rights of People adopted by the Arab Parliament Living with HIV. sources comprise the majority of in 2012, took a decisive turn when the region’s resources, supported Djibouti became the first Arab by Global Fund grants and support country to ratify in October 2015. from other global and regional In an unprecedented step for civil donors. The six GCC countries totally their own HIV Civil Society society in MENA, the Regional responses. Algeria and Iran are networks at the Arab Network against AIDS already financing more than 90 regional level and (RANAA) signed a Memorandum country level are of Agreement in December 2015 per cent of their own responses. now an important with the League of Arab States In 2014, of a total regional spend partner in HIV on the role of civil society in the on HIV and AIDS of 140 million leadership and implementation of the Arab AIDS US , 100 million came from response. Strategy. This represents the first domestic resources. Over the past partnership within the region two years, 80 million US dollars have between civil society and such a been secured for three countries significant intergovernmental body. through the GF New Funding Mechanism and concept notes for A regional dialogue took place in other countries are in development. Cairo in October 2015 to mobilize political leadership and partnerships More than 70% for a resilient HIV response for Progress on access to HIV of people who affected countries in MENA in order prevention services inject drugs have to achieve the fast-track targets by In MENA, effective prevention used safe injection 2020 and to address the emerging depends upon reaching and equipment in Iran, priorities in rapidly changing engaging meaningfully with key Lebanon, Morocco regional and local environments. populations. and and Tunisia The protection of people affected Iran Morocco have expanding opioid substitution by humanitarian emergencies, therapy (OST) programmes at including refugees, asylum seekers communities and in prisons and internally displaced people, and is expanding its was identified as a key priority for Lebanon community OST programme. the region. Access to sterile injecting Also in January 2015, a group of equipment through needle and young leaders working on sexual syringe programmes (NSPs) has and reproductive health and rights, resulted in safe injection by more harm reduction, and HIV came than 70 per cent of people who together to establish a Regional inject drugs in Iran, Lebanon, Alliance for Youth Sexual and Morocco and Tunisia. Access to Reproductive Health Rights and OST and sterile injecting equipment HIV Advocacy which will enable has to be sustained and rapidly advocates throughout MENA scaled up in major urban centres to collaborate and ensure that in all countries throughout the the post-2015 agenda includes region, and particularly in Algeria, consideration of the needs and Egypt, Lebanon, Tunisia and the rights of young people. Gulf Cooperation Council countries. Libya, with very high prevalence

2 of HIV among PWID, needs to offers another example of good identify and implement innovative coverage, with nearly two-thirds of approaches that can deliver services female sex workers knowing their in a context of ongoing conflict. status. In Algeria, Morocco, Tunisia In Lebanon, 75% and Iran, the respective figures of men who have Programmes for men who have sex are between 20 and 33 per cent. sex with men with men in the region have shown Rights-based, focused interventions know their HIV impact where services demonstrate have the potential to reverse the status respect for beneficiaries’ rights and trajectory of new infections in the dignity and when civil society and region. other partners are able to provide focus and saturation. Lebanon is an example of such success, with 75 Progress on elimination of In Algeria and per cent of MSM in reporting mother to child transmission Lebanon, more both knowledge of their HIV status than 80% of sex Elimination of mother to child and condom use. In Morocco and workers have transmission of HIV is a particular Tunisia, coverage by testing and reported condom challenge in HIV epidemics that condom use are increasing but use with their last are characterized by infection have not yet passed 50 per cent. client. Countries need to scale up good occurring mostly among members practices that currently have limited of key populations and their scope, overcome the obstacles that partners. However, this challenge prevent access and utilization of HIV has not prevented countries in the combination prevention services region from progressing towards Oman and United (including pre-exposure prophylaxis elimination. For example, Oman Arab Emirates (PrEP)) by MSM population across and the United Arab Emirates are the close the region. Algeria, Egypt, Iran, have become the first and second to eliminating Sudan and Yemen need to follow countries respectively to integrate mother to child the examples of good practices their eMTCT programme within transmission in the in the region and need to reach maternal and child health services region. Algeria, sufficient levels of coverage to and reach most of their elimination Djibouti, Iran, deliver impact in large cities and targets. Other GCC Countries, Morcco and Tunsia urban areas. notably Saudi Arabia and Kuwait, are moving on that are moving in a similar direction. direction. Prevention programmes with Djibouti, a low-income country, female sex workers and women is also progressing towards engaged in transactional sex elimination, through integration across the region also demonstrate of PMTC within antenatal care, success, with several countries while in middle-income countries - reporting high rates of condom use Algeria, Iran, Morocco and Tunisia among sex workers. For example, - the number of pregnant women Algeria and Lebanon report rates tested and knowing their status in excess of 80 per cent, while has increased from more than Djibouti, Iran, Jordan, Morocco 120 000, to more than 540 000 in and Tunisia report rates between the course of two years (2013 and 50 to 80 per cent. These results 2014). Algeria and Tunisia have were particularly hard to achieve both increased the number of considering that in most of the pregnant women tested more than countries sex workers are street- twelve-fold. These four countries, based and much more difficult to with established maternal and child reach with prevention programmes. health programmes, have been able Reported access of sex workers to support those who test positive to HIV testing in most countries to access effective care. is less than among MSM, with the exception of Djibouti. Lebanon

3 HIV in the Middle East and North Africa 2013 - 2015

Morocco has Progress on access to testing course of the past two years. For increased the and treatment services example, the number of people number of people tested in Morocco in 2014 was ten Despite having the lowest level of accessing HIV times more than in 2011. Similar ART coverage compared to other testing more than expansion of services has been seen , there is considerable 10 times over in other countries, such as Algeria, cause for optimism in MENA as the three years. Egypt, Iran and Sudan. Over the numbers of those tested, and those course of only two years ( 2013-14), living with HIV and receiving ART, the number of people on ART has are expanding rapidly. Countries increased by almost 15 000, a 60 The number of in the region are also simplifying per cent increase region-wide, and people living with HIV testing practices, expanding a 70 per cent increase in Algeria, HIV accessing ART availability of testing beyond Egypt and Yemen. In Libya, despite has increased by health facility settings. Innovative continuing crises, the number of more than 60% approaches include mobile testing people on ART has more than over the course of services at accessible locations doubled in this period. At this rate, two years. and provision of testing services MENA can reach to its treatment by lay providers. Together, these coverage target by 2020. have substantially increased the number of people seeking testing and receiving their results over the

Recommendations and game changers for Fast-Tracking 1. Transformative political leadership: strategic partnership with the League of Arab States can Fast-Track the response by implementing the Arab AIDS Strategy (2014–2020). 2. Legal and policy reform: engaging parliamentarians and promoting the ratification of the Arab Convention on HIV prevention and protection of people living with HIV can significantly alter the in terms of law reform, including abolition of punitive laws and application of broader, positive interpretation of existing laws and policies. 3. Sharpening focus on key populations: transforming HIV testing and treatment through community and private health service delivery, more rigorous referral and linkage to services, especially for members of key populations, and simplifying treatment regimens and service integration. 4. Empowering civil society: further enabling civil society partners, including religious leaders, community and grassroots organizations led by people living with HIV, women and young people, to be central to designing, implementing and monitoring the response. 5. Innovation in data, testing, service delivery and models: well-targeted testing and innovative approaches to delivering treatment, including strategic use of information technology.

6. Fast tracking the response and ambitious goals need increasing resources, sustaining and diversifying them following a strategy of increasing domestic financing andshared responsibility and regional solidarity.

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UNAIDS Regional Support Team for the Middle East & North Africa

Abdoul Razzak El-Sanhouri Street, 20

Nasr City Cairo, Egypt

Tel: (+20) 222765257