Abstract
IntroductionEmerging HIV epidemics have been documented among people who inject drugs (PWID) in the Middle East and North Africa (MENA). This study estimates the HIV incidence among PWID due to sharing needles/syringes in MENA. It also delineates injecting drug use role as a driver of the epidemic in the population, and estimates impact of interventions.MethodsA mathematical model of HIV transmission among PWID was applied in seven MENA countries with sufficient and recent epidemiological data and HIV prevalence ≥1% among PWID. Estimations of incident and/or prevalent infections among PWID, ex‐PWID and sexual partners of infected current and ex‐PWID were conducted.ResultsThe estimated HIV incidence rate for 2017 among PWID ranged between 0.7% per person‐year (ppy) in Tunisia and 7.8% ppy in Pakistan, with Libya being an outlier (24.8% ppy). The estimated number of annual new infections was lowest in Tunisia (n = 79) and Morocco (n = 99), and highest in Iran and Pakistan (approximately n = 6700 each). In addition, 20 to 2208 and 5 to 837 new annual infections were estimated across the different countries among sexual partners of PWID and ex‐PWID respectively. Since epidemic emergence, the number of total ever acquired incident infections across countries was 706 to 90,015 among PWID, 99 to 18,244 among sexual partners of PWID, and 16 to 4360 among sexual partners of ex‐PWID. The estimated number of prevalent infections across countries was 341 to 23,279 among PWID, 119 to 16,540 among ex‐PWID, 67 to 10,752 among sexual partners of PWID, and 12 to 2863 among sexual partners of ex‐PWID. Increasing antiretroviral therapy (ART) coverage to the global target of 81% – factoring in ART adherence and current coverage – would avert about half of new infections among PWID and their sexual partners. Combining ART with harm reduction could avert over 90% and 70% of new infections among PWID and their sexual partners respectively.ConclusionsThere is considerable HIV incidence among PWID in MENA. Of all new infections ultimately due to injecting drug use, about 75% are among PWID and the rest among sexual partners. Of all prevalent infections ultimately attributed to injecting drug use as epidemic driver, about half are among PWID, 30% among ex‐PWID and 20% among sexual partners of PWID and ex‐PWID. These findings call for scale‐up of services for PWID, including harm reduction as well as testing and treatment services.
Highlights
Emerging HIV epidemics have been documented among people who inject drugs (PWID) in the Middle East and North Africa (MENA)
We examined the effect of select interventions targeted at PWID: (1) Reducing current sharing of needles/syringes by 25%, 50%, and 75% on HIV incidence among PWID, (2) Introducing opioid substitution therapy (OST) resulting in 10% reduction in the number of PWID and a 10%, 20%, or 30% reduction in the frequency of injecting, on HIV incidence among PWID, (3) Expanding antiretroviral therapy (ART) coverage among PWID based on most recent test-and-treat World Health Organization (WHO) guidelines [20,21] to reach coverage levels of 25%, 50%, and the global target of 81% [3], on HIV incidence among PWID and their sexual partners, and (4) Increasing current condom use by 25%, 50%, and 75% on HIV incidence among sexual partners
The estimated incidence rate among PWID was lowest in Tunisia and Afghanistan at 0.7% (95% uncertainty intervals (UI): 0.4% to 1.4%) and 1.2% (95% UI: 0.8% to 2.4%) per person-year respectively, and highest in Pakistan at 7.8% ppy (95% UI: 4.3% to 13.4%)
Summary
Emerging HIV epidemics have been documented among people who inject drugs (PWID) in the Middle East and North Africa (MENA). Of all prevalent infections attributed to injecting drug use as epidemic driver, about half are among PWID, 30% among ex-PWID and 20% among sexual partners of PWID and ex-PWID. These findings call for scale-up of services for PWID, including harm reduction as well as testing and treatment services. The Middle East and North Africa (MENA), which we define to include 24 countries from Morocco in the West to Afghanistan and Pakistan in the East, is one of few regions where the number of new HIV infections is increasing [3]. As a central population to the epidemic in several countries [4], PWID are a priority population if the Fast-Track targets are to be achieved in this region [2]
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