1. Antiretroviral treatment for people living with HIV. The estimated regional coverage remains low at 8%. Oman has the best estimated coverage in the Middle East and North Africa region, with 45% of adults and children living with HIV receiving treatment by the end of 2010, followed by Lebanon (37%) and Morocco (30%). Most countries are falling short of the goal of universal access to treatment. As well, the number of people needing treatment has increased from 57 000 in 2001 to 210 000 in 2010. However, it is worth noting that four countries in the region contribute 85% of the number of people eligible for antiretroviral therapy: Sudan (93 000), Somalia (25 000), Islamic Republic of Iran (26 000) and Pakistan (22 000). Achieving regional targets for access to antiretroviral therapy is dependent on those four countries’ scaling-up strategy and their commitment to expanding HIV testing and counselling as the most critical step to providing access to treatment.
2. HIV testing and counselling. Most countries have policies in place on HIV counselling and testing. Since 2006, the rate of HIV testing in these countries has steadily increased. However, the overall percentage of people tested remains much lower than the global percentage, and most of the testing is focused on migrant workers, not on the key populations who are at higher risk of HIV. Nearly 60% of the tests completed between 1995 and 2008 were for migrant workers, while only 4% of tests were for key populations at higher risk. It also appears that most of these tests were mandatory; mandatory testing is widely used by countries in the region, particularly for migrant and foreign workers. Only Djibouti and Morocco have explicit national policies prohibiting mandatory testing. For most countries, it is imperative to increase significantly the availability, accessibility and uptake of voluntary HIV testing among the key populations. Otherwise, these countries will struggle to strengthen their overall prevention programmes.
3. Prevention to mother-to-child transmission. Although the total number of women living with HIV who received antiretroviral therapy to prevent mother-to-child transmission in the region doubled in one year (from 550 in 2009 to 1100 in 2010), the estimated regional coverage remains very low, at 5%, and is well short of the UNAIDS goal of eliminating vertical transmission. Oman reports the highest percentage, with 78% of pregnant women living with HIV receiving antiretroviral therapy; Morocco has the next highest percentage at 26%. Also, the estimated number of mothers needing treatment to prevent mother-to-child transmission has increased, from 15 000 in 2001 to 20 000 in 2010.
4. Access to health services for most-at risk populations. In recent years, more countries in the region have moved to include references to key populations at higher risk (sex workers, injecting drug users and men who have sex with men) in their national strategic plans. However, the scope of services provided to these populations often does not cover the full spectrum of services related to HIV prevention and treatment as recommended by regional and international guidance. Consequently low coverage remains of great concern. Involvement of nongovernmental organizations is crucial to make the achievements towards working with most-at-risk populations and providing them with the prevention and treatment services they need.
5. Middle East and North Africa Harm Reduction Association (MENAHRA). MENAHRA has been working to prolong and improve the quality of life for people who inject drugs in the region. Launched in 2007 through a joint initiative by the World Health Organization and the International Harm Reduction Association, and with financial support from the Drosos Foundation, MENAHRA covers 19 countries in the MENA region.
There is evidence to suggest that the knowledge hubs’ training and advocacy workshops have contributed to changes that favour harm reduction in both policies and practices. As a result, six civil society organizations provide needle/syringe services to 2292 people who inject drugs (distributing 222 078 needles and syringes), and three civil society organizations (in Afghanistan, Egypt and the Islamic Republic of Iran) provide voluntary counselling and testing either on-site or via referral (1088 clients have used this service). Civil society organizations report that their harm reduction services have engendered a growth in harm reduction service provision beyond their individual projects.
6. Sexually transmitted infections. Recent data on sexually transmitted infections in the region are generally limited because of the lack of adequate surveillance systems. Available data show that rates of sexually transmitted infections among men who have sex with men vary widely, from 7% in Morocco (Agadir) to 36% among certain high-risk groups in Pakistan. The rates among sex workers were equally varied, from 9% (Agadir) in Morocco to more than 40% in Djibouti. The high rates of sexually transmitted infections in some countries are a serious concern, given that such infections amplify the risk of HIV transmission. Countries should be taking steps to introduce, expand and/or strengthen surveillance systems for sexually transmitted infections and to ensure the availability and accessibility of prevention and treatments services, particularly as an integral component of HIV prevention programmes for the key populations.
7. HIV-associated tuberculosis. Of the 11 countries that provided data on the percentage of estimated HIV-positive incident tuberculosis cases that received treatment for both infections in the 2011 Universal Access reporting, two countries performed extremely well: Oman (100%) and Algeria (99%). The remaining nine countries did less well, with five countries reporting less than 10% coverage and four countries reporting coverage between 22% and 55%. The challenge for most countries in improving the coverage of tuberculosis and HIV co-treatment is directly related to reaching the marginalized populations most in need of the services.
8. Blood safety. In recent years, there have been strong national commitments in countries to improve the safety of blood supplies. Nearly every country now has a national policy on the screening of blood for transfusions. More importantly, the ability of countries in the region to ensure that safe blood is available is steadily improving. 13 countries reported in 2010 that 100% of donated blood units are screened for HIV in a quality-assured manner. Although there is room for further improvement – especially in Yemen, Pakistan and Afghanistan – the trend in the region is clearly moving in the right direction.
9. Regional strategy. The WHO regional strategy for the health sector response to HIV (2011–2015), endorsed by all Ministers of Health from the region, includes a set of priorities agreed upon to scale-up HIV testing. Concrete steps and a timeline for implementation were discussed with the national AIDS programme managers at the 2011 meeting, where country-specific steps and milestones were identified depending on the level of advancement of the response in each country.