Women, culture and the HIV epidemic in MENA. J Int AIDS Soc. 2014;17:19074. [PMID: 24629846 PMCID: PMC3955763 DOI: 10.7448/ias.17.1.19074]

Breaking the silence - systematic review of the socio-cultural underpinnings of men's sexual and reproductive health in Middle East and North Africa (MENA): A handful of taboos?

Background

Sociocultural aspects can impact sexual and reproductive health (SRH). Despite this, no study appraised the socio-cultural underpinnings impacting men's SRH in MENA (Middle East and North Africa). The current systematic review undertook this task.

Methods

We searched PubMed and Scopus electronic databases for original articles on socio-cultural aspects of men's SRH published from MENA. Data were extracted from the selected articles and mapped out employing McLeroy's socioecological model. Analyses and data synthesis identified the factors impacting men's experiences of and access to SRH.

Results

A total of 53 articles were included. Five related socio-cultural underpinnings intertwined with taboos were observed that affect three main SRH topics, HIV, reproduction and sexuality across three broad population groups: HCP/health services, school/university students, and the general public/patients. These underpinnings included 1) Challenges to gender equality; 2) Religious prohibitions and misinterpretations; 3) Sexual rights and taboos; 4) Masculinity and manhood ideals; and 5) Large families and consanguinity. In terms of research, a paradox exists, as we found virtually no research on four socio-cultural underpinnings of men's SRH in MENA pertaining to: a) other STI, despite being common; b) other features of reproduction, despite that religio-cultural factors play a critical role; c) sexuality, despite the high prevalence of sexual disorders, and, d) gender-based violence, despite the widespread partner violence.

Conclusions

Socio-cultural underpinnings are deeply rooted across MENA population groups including HCPs, students, general public, and patients with negative impact on the perceptions and dealings pertaining to men's SRH issues including HIV, reproduction and sexuality. The findings call for concerted widespread efforts to enhance the socio-cultural acceptance of these population groups while highlighting any misinterpretations of religious rules pertaining to men's SRH. Moreover, breaking the silence on such issues necessitates more enthusiasm across MENA health systems, with future research examining the effects of such efforts on the socio-cultural aspects of men's SRH in MENA.

Trend Analysis of HIV/AIDS Burden in Iran: Results from the Global Burden of Disease 2017 Study

Background: Despite global efforts, human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) is still one of the major public health problems in the entire world. In this context, assessing the burden of this disease in different parts of the world is of great importance. In this study, we aimed to investigate the trends of HIV/AIDS incidence and mortality in Iran during 1990 and 2017. Methods: The HIV/AIDS burden data, including the age-standardized incidence rate (ASIR) and the mortality rate (ASMR), was extracted from the Global Burden of Diseases 2017 study for the total Iranian population and by gender from 1990 to 2017. The trend analysis was performed using joinpoint regression modeling approach. Results: The obtained results showed that in 2017, the HIV/AIDS ASIR and ASMR were, respectively, more than 12 and 10 times of these rates in 1990. Also, the estimated average annual percent change (AAPC) was 9.8% and 8.7%, respectively for the ASIR and the ASMR. In this period, women have experienced a sharper slope of ASIR and ASMR trends compared with Iranian men. Conclusion: The increasing trend of HIV/AIDS burden is a serious alarm for the Iranian health policymakers. To achieve the United Nations Programme on HIV and AIDS goals, there is an urgent need for an efficient national action plan that breaks the HIV/AIDS taboo in the society, promote access to HIV testing and prevention facilities, especially among the key populations, and provide care and treatments for all infected people.

HIV/AIDS-knowledge and attitudes in the Arabian Peninsula: A systematic review and meta-analysis

BACKGROUND

HIV/AIDS prevention has been widely adopted worldwide, but little is known about HIV/AIDS knowledge and attitudes in the Arabian Peninsula.

AIM

To summarize the level of knowledge and attitude about HIV/AIDS in seven Arabian Peninsula countries (Saudi Arabia, Oman, Kuwait, Qatar, Bahrain, Yemen, and the United Arab Emirates (UAE)).

METHODS

A systematic literature search was performed using combined keywords in four scientific databases of peer-reviewed publications from January 2010 to June 2019. Twenty-five articles were included in the systematic review, and twenty studies in the meta-analysis. The data was analyzed using a random-effect model due to the heterogeneity between the studies.

RESULTS

Seventeen studies reported on the level of knowledge and overall knowledge about HIV/AIDS in this region: 74.4% (95% confidence interval (CI): 66.8%-82.0%, p<0.001) and the attitude was 52.8% (95% CI: 36.9%-68.6%, p<0.001). A study from Oman reported higher knowledge levels (95.5%, 95% CI: 94.2%-96.8%) while less than a quarter of the Bahrain population had positive attitudes 22.5% (95% CI: 20.5%-24.5%). Medical doctors showed higher knowledge (94.1%, 95% CI: 92.9%-95.3%), but a positive attitude was only observed in 32.5% (95% CI: 28.8%-36.2%) of the dentists toward HIV/AIDS.

CONCLUSION

The overall knowledge about HIV/AIDS was found to be satisfactory (74.4%), but about half (52.8%) of those displayed negative attitudes toward HIV/AIDS. Regular training courses as well as reviewing and reinforcing HIV/AIDS prevention guidelines can be useful to update knowledge and improve attitudes in this region.

Sexual and reproductive health of women living with HIV in Muslim-majority countries: a systematic mixed studies review

Background

The number of women living with the human immunodeficiency virus (WLHIV) in Muslim-majority countries has increased significantly in the last decade. These women are often marginalized and face insecure sexual and reproductive health (SRH) needs and rights. However, little is known about the multi-faceted factors influencing these women’s fertility, contraceptive, and perinatal decisions and sexual life. This systematic mixed studies review aimed to synthesize the empirical evidence on social, cultural, and structural factors influencing the SRH of WLHIV in Muslim-majority countries.

Methods

This review provides a synthesis of quantitative, qualitative and mixed-method research findings searched from PubMed, EMBASE, Scopus, CINAHL and Cochrane databases. We screened 3452 SRH studies involving WLHIV. The studies, published in English between 2008 and 2017, were from 20 Muslim-majority countries with increased numbers of WLHIV. The quality of eligible studies was appraised using a mixed-methods appraisal tool (MMAT) version 2011. Findings were thematically analysed by a hybrid deductive-inductive approach. Two independent reviewers were involved in the study selection, data extraction, quality appraisal, and data synthesis.

Results

We included 13 SRH-related studies involving 1748 WLHIV in eight Muslim-majority countries. Most of these studies explored fertility desire and sexual health, while only a small proportion related to contraceptive use and the perinatal-care experience. We identified that WLHIV faced neglect of their SRH rights. These rights were predominantly affected by the socio-cultural, religious and health-services context of the women’s lives, which directed them to unsafe sex practices and stressful perinatal experiences.

Conclusions

This study points to the need for SRH laws, policies, and interventions which stop WLHIV experiencing SRH discrimination violence and achieving their SRH rights.

The changing modes of human immunodeficiency virus transmission and spatial variations among women in a minority prefecture in southwest China: An exploratory study

Liangshan Yi Autonomous Prefecture in Southwest China has a high human immunodeficiency virus (HIV) prevalence rate. This study examined the changing modes of HIV transmission among women with new HIV infections and explored the spatial heterogeneities in the factors associated with heterosexual transmission in this minority region.The data consisting of women with new HIV infections from 2011 to 2014 were collected from multiple sources. New infections were identified by BED capture enzyme immunoassay. The Bayesian hierarchical model was used to estimate the proportion of women with new HIV infections via heterosexual transmission across all townships in the Prefecture. A geographically weighted regression (GWR) model was utilized to investigate spatial variations in the sociodemographic characteristics associated with the changing modes of HIV transmission.An analytical sample of 927 women with new HIV infections was constructed and utilized to investigate the changing mode of HIV transmission. The rate of heterosexual transmission among women with new HIV infections in 2011 was below 20%. However, by 2014 this rate dramatically increased to nearly 80%. Among sociodemographic characteristics, GWR results revealed significant ethnic differences in heterosexual HIV transmission between Yi women and women in other ethnic groups, with Yi women demonstrating a lower risk of infection through heterosexual transmission. However, such ethnic differences were observed only in 30% of the townships in the Prefecture. Moreover, having a primary education decreased the odds of heterosexual transmission, which was observed in about 56% of the townships. Also, being involved in occupations other than agriculture or animal husbandry and being single or married decreased the odds of HIV infection through heterosexual contact among women, which did not significantly vary across the Prefecture.Heterosexual transmission was the predominant mode of HIV transmission among women in the Prefecture, and this transformation was clearly marked by a fast-growing trend and a spatial diffusion pattern. Spatial variations also existed in sociodemographic factors that were associated with the changing modes of HIV transmission.

HIV/AIDS: trends in the Middle East and North Africa region

OBJECTIVES

To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region.

METHODS

Articles on the MENA region were reviewed.

RESULTS

The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues.

CONCLUSIONS

The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed.

Early initiation of antiretroviral treatment: Challenges in the Middle East and North Africa

New World Health Organization guidelines recommend the initiation of antiretroviral treatment (ART) for asymptomatic patients with CD4+ T-cell counts of ≤ 500 cells/mm(3). Substantial reduction of human immunodeficiency virus (HIV) transmission is addressed as a major public health outcome of this new approach. Middle East and North Africa (MENA), known as the area of controversies in terms of availability of comprehensive data, has shown concentrated epidemics among most of it's at risk population groups. Serious challenges impede the applicability of new guidelines in the MENA Region. Insufficient resources restrict ART coverage to less than 14%, while only one fourth of the countries had reportable data on patients' CD4 counts at the time of diagnosis. Clinical guidelines need to be significantly modified to reach practical utility, and surveillance systems have not yet been developed in many countries of MENA. Based on available evidence in several countries people who inject drugs and men who have sex with men are increasingly vulnerable to HIV and viral hepatitis, while their sexual partners - either female sex workers or women in monogamous relationships with high-risk men - are potential bridging populations that are not appropriately addressed by regional programs. Research to monitor the response to ART among the mentioned groups are seriously lacking, while drug resistant HIV strains and limited information on adherence patterns to treatment regimens require urgent recognition by health policymakers. Commitment to defined goals in the fight against HIV, development of innovative methods to improve registration and reporting systems, monitoring and evaluation of current programs followed by cost-effective modifications are proposed as effective steps to be acknowledged by National AIDS Programs of the countries of MENA Region.