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Studies Reveal HIV and HCV Epidemics Among Injection Drug Users in the Middle East and North Africa

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At least one-third of countries in the Middle East and North Africa that historically have had low rates of HIV infection now have emerging epidemics largely attributable to injection drug use, according to a systematic review published in the June 17 edition of the open access journal PLoS Medicine. Rates of hepatitis C virus (HCV) infection also appear to be high and rising.

The analysis, by Ghina Mumtaz from Weill Cornell Medical College in Qatar and colleagues, included nearly 200 published reports of HIV or HCV prevalence, incidence, and risk behavior in 23 countries, which are home to an estimated 626,000 people who inject drugs. Between 18% and 28% reported sharing needles or syringes.

The researchers found substantial variation across countries. While some, including Lebanon and Palestine, still have limited HIV transmission, 25% of people who inject drugs in Pakistan, and nearly 90% in Tripoli, Libya, are estimated to be HIV positive. The analysis also found that nearly half of injection drug users across the region have hepatitis C.

"With the HIV epidemic among [people who inject drugs] 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," they concluded.

Below is an edited excerpt from a Weill Cornell press release describing the findings in more detail.

Emerging HIV Epidemics Among People Who Inject Drugs in the Middle East and North Africa

Doha, Qatar -- June 17, 2014 --HIV epidemics are emerging among people who inject drugs in several countries in the Middle East and North Africa. Though HIV infection levels were historically very low in the Middle East and North Africa, substantial levels of HIV transmission and emerging HIV epidemics have been documented among people who inject drugs in at least one-third of the countries of this region, according to findings published today in PLOS Medicine.

The HIV epidemics among people who inject drugs (PWID) are recent overall, starting largely around 2003 and continuing to grow in most countries. However, they vary across the region. In countries such as Afghanistan, Bahrain, Egypt, Iran, Morocco, Oman, and Pakistan, on average between 10 and 15 percent of PWID are HIV-positive. The HIV epidemics in these countries appear to be growing; in Pakistan, for example, the fraction of PWID who are HIV-infected increased from 11 percent in 2005 to 25 percent in 2011. In Iran, the HIV epidemic among PWID has stabilized at about 15 percent. There are, however, other countries where limited HIV transmission was found among PWID, such as in Jordan, Lebanon, Palestine and Syria.

"Not only have we found a pattern of new HIV epidemics among PWID in the region, but we found also indications that there could be hidden HIV epidemics among this marginalized population in several countries with still-limited data," said Ghina Mumtaz, lead author of the study and senior epidemiologist at the Infectious Disease Epidemiology Group at Weill Cornell Medical College-Qatar. "For example in Libya, the first study among people who inject drugs was conducted only recently and unveiled alarmingly high levels of HIV infection, suggesting that the virus has been propagating, unnoticed, among this population for at least a decade. Eighty-seven percent of PWID in Tripoli, the capital of Libya, were infected with HIV, one of the highest levels reported among PWID globally."

The study estimated that there are about 626,000 people who inject drugs in the Middle East and North Africa. This translates into 24 people who inject drugs for every 1,000 adults in this part of the world. These individuals are typically involved in several types of behavior that expose them to HIV infection, such as sharing of needles or syringes, a behavior reported by 18 to 28 percent of injecting drug users during their last injection across these countries.

"The levels of HIV infection among people who inject drugs tell only half of the story. We also see high levels of risky practices that will likely expose this population to further HIV transmission in the coming years," said Dr. Laith Abu-Raddad, principal investigator of the study and associate professor of public health in the Infectious Disease Epidemiology Group at Weill Cornell Medical College-Qatar. "We found that nearly half of people who inject drugs are infected with hepatitis C virus, another infection of concern that is also transmitted though sharing of needles and syringes."

"Since the HIV epidemics among people who inject drugs in the Middle East and North Africa are still overall in an early phase, there is a window of opportunity to prevent these epidemics from further growth. This will also limit the potential for HIV transmission to be bridged to other population groups," Mumtaz said.

Although the region overall lags behind in responding to the emerging HIV epidemics among PWID, several countries have made significant progress in building and expanding harm-reduction programs and integrating them within the socio-cultural fabric of the region. These programs refer to policies and strategies aimed at reducing the harmful consequences of injecting drug use, including needle- and syringe-exchange programs and opioid-substitution therapies.

"It is of priority that countries in the region expand HIV surveillance systems among PWID to detect and monitor these budding and growing HIV epidemics. About half of the countries of the region still lack sufficient data to assess the levels of HIV infection among this population, and we continue to discover these epidemics several years after their onset. We need to be ahead of the epidemic to prevent a public health burden that this region is largely not prepared to handle," Dr.  Abu-Raddad said.

6/19/14

Reference

GR Mumtaz, HA Weiss, SL Thomas, et al. HIV among People Who Inject Drugs in the Middle East and North Africa: Systematic Review and Data Synthesis. PLoS Medicine. June 17, 2014.

Other Source

Weill Cornell Medical College. Emerging HIV Epidemics Among People Who Inject Drugs in the Middle East and North Africa. Press release. June 17, 2014.