The latest figures on AIDS in a global scale reported by the World Health Organization are a cause for sobering reflection. They indicate that by the end of 1997, 30.6 million people worldwide were living with HIV/AIDS, and that 5.8 million people were infected with HIV in 1997, which represents approximately 16,000 new HIV infections per day. North Africa and the Middle East have 210,000 people living with HIV/AIDS, and in 1997 that region had 19,000 new cases of HIV infection.
Although the figures of HIV infection and AIDS in North Africa and the Middle East are lower than others in regions (just as a comparison, Sub-Saharan Africa had 20.8 million people living with HIV/AIDS, and there were 4 million cases of HIV infection in that region in 1997), these figures should not give rise to complacency. AIDS is a lethal disease that, if not controlled, can spread rapidly in the region and have momentous consequences in the economies of the countries affected.
AIDS is the group of diseases that occur as a result of human immunodeficiency virus (HIV) infection, and stands for AcquiredImmuno-Deficiency Syndrome (AIDS). AIDS involves not a single disease but several diseases that result from HIV infection, that lead eventually to the breakdown of the body’s immune system by the virus. HIV infection and AIDS differ in that an individual may be infected with HIV and continue to live for many years without apparent health complications.
The most advanced stage of infection is AIDS, and it occurs usually several years after HIV infection. With new "and most effective" treatments, the period between HIV infection and AIDS is becoming longer. A person will not manifest AIDS symptoms unless HIV infection has taken place.
Of the three ways in which AIDS can be transmitted "sexual contact; through HIV-infected blood, blood components, organs or tissues; and from an HIV-infected mother to her fetus or newborn" the prevalent mode of transmission in North Africa and the Middle East is through heterosexual contact.
The size and trends of the epidemic in the different countries in the region are difficult to establish. According to figures provided by the UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance, the countries in North Africa and the Middle East with the largest number of AIDS cases by the end of 1997 were Sudan (1649), Morocco (390), Tunisia (338) and Egypt (153).
Among the region’s characteristics are the late introduction of the virus, the status of women in society and the difficulty of carrying out effective sexual health programs. To these characteristics should be added the highly stigmatizing nature of sexually transmitted diseases (STD), which create a favorable terrain for infection by the HIV. The widespread practice of female circumcision in some countries such as Egypt is an additional possible cause of infection by the HIV. Perhaps the most recent and complete study of the status of the epidemic in a country in the region was carried out by a group of medical scientists in Egypt in 1996 working for the U.S. Agency for International Development (USAID). They were able to establish that although Egypt is at an initial stage of the epidemic, there are a number of factors that may allow the HIV infection to spread rapidly in the population.
One of these factors is the frequent presence of sexually transmitted diseases in the general population. These diseases have been associated with increased vulnerability to infection by the HIV. It is estimated that the presence of a sexually transmitted disease can increase the risk of HIV infection as much as tenfold. Although until the 1980s only five sexually transmitted diseases were regularly monitored, during the last several years the spectrum of these diseases has increased dramatically and now more than 50 organisms and syndromes are recognized.
Numerous studies have confirmed that although STD is a major public health problem worldwide, their prevalence is highest in the developing world. Rates of diseases like syphilis, for example, have been found to be up to 100 times higher in developing countries than in industrialized nations. Among the main reasons for these differences are poverty, lack of information and limited access to health care.
As Dr. Q. Monir Islam from the World Health Organization states, "Many women have symptomless STD, do not recognize symptoms of STD or are too embarrassed to seek treatment." In addition, stigmatization of people with STD, and cultural norms that discourage women from talking about sex, stop them from demanding care, even when it is available.
Among the most common diseases in this group are: syphilis, chlamydia, gonorrhea, genital warts, herpes, hepatitis B and several urinary and vaginal infections. In many cases, these diseases remain undetected "which increases their potential for spreading" and, even when they are recognized, many patients can not afford to buy the medicines to treat them.
Another condition that favors the spread of HIV infection is the presence in Egypt "as well as in other countries in the Middle East" of high-risk behavior groups (commercial sex workers, their clients, and homosexuals with multiple partners). Because the existence of these groups is largely unaccepted by society, they are difficult to reach with HIV/AIDS prevention programs.
In addition to those mentioned factors, Egypt also faces risks from health care settings which lack infection control, the existence of a sexually active youth, three million Egyptians who work outside the country and who are without their families, and several million tourists, many of whom come to Egypt from other countries with high prevalence of HIV infection.
Because transmission of HIV infection in Egypt is mainly heterosexual, and there is a lack of preventive messages directed to women, they are at a special risk of infection by their infected male partners. To these factors should be added that Egypt "as well as other countries in the Middle East" has a very conservative culture, which demands a very cautious approach to educating people on prevention of HIV infection and the transmission of other diseases through sexual contact.
There are many reasons why women are more susceptible than men to HIV infection. Aside from biological reasons, women’s lower social status and more limited access to economic resources force them to yield control of sexual relations to men. Afraid of a violent reaction from their partners or spouses they cannot demand them to use condoms, particularly in societies where the use of condoms is not culturally accepted.
Three interrelated strategies "reduction in the number of partners, control of sexually transmitted diseases and educational campaigns" targeted at populations at risk have resulted in other countries in an increase in the use of condoms. Adapted to the realities and cultural values of the region, they should also be used in the Middle East countries.
The needs and vulnerabilities of women should be taken into consideration when planning HIV-prevention programs. To be effective, these programs have to be culturally and gender-sensitive, and help women gain control not only of their sexual lives but of their economic and social lives as well. Women should have increased access to education, skills training and employment opportunities. At the same time, women have to be informed about their reproductive system to be better able to protect themselves from sexually transmitted infections.
Health services should be integrated so as to provide informed contraceptive choices, counseling services, facilities for the diagnosis and treatment of sexually transmitted diseases and reproductive tract infections and good follow-up care. Staff in those services should be trained to provide support and advice on prevention for people living with AIDS and their families. A strong political commitment is necessary if interventions are to be successful and sustained. That political commitment can manifest itself by putting AIDS and sexually transmitted diseases on the agendas of development programs and by allocating resources for the improvement of health services.
Epidemiologists have noted the late beginning of the epidemic in many countries in Asia, Africa and the Caribbean. In spite of that, the disease has spread rapidly in the population of those countries, and has developed as a major health and development problem. The impact of the disease has been punishing in many developing countries and has affected not only the economies of the families involved but the national economies as well. The gains that have been achieved in many developing countries in the last few decades will be canceled out by the spread of the HIV infection.
Egypt and the other countries in the Middle East are presently at a very early stage of the epidemic, which makes it an ideal time to implement HIV/AIDS effective prevention measures. The efficacy "and rapidity" with which these measures are taken will define the extent and the speed of the spread of this dangerous infection in the population. Until a cure or an effective vaccine is found, prevention will continue to be the most important weapon in the fight against AIDS.
Cesar Chelala, a Ph.D. and M.D. is an international medical consultant and a co-winner of an "Overseas Press Club of America" award for the best article on human rights.
This article appeared in Al Jadid Magazine ,Vol. 4, No. 23 (1998)
Copyright © 1998 by Al Jadid