Key elements of HIV/AIDS control in the Arab world

HIV/AIDS remains one of the most pressing health challenges more than three decades after the first documented case in 1981. The Middle East and North Africa region (MENA) is one of lowest regions in terms of HIV/AIDS prevalence. At the end of 2011 there were 300,000 PLWHA in the region (adult prevalence was estimated at 0.2%). For the same year, 37,000 people were newly infected with the HIV virus, while 23,000 deaths were AIDS-related. Low prevalence, however, does not necessarily mean low risk, and the MENA region is affected in various ways. The burden of HIV/AIDS in the region is strongly believed to be underestimated. The number of new infections in the region is on the rise despite the overall global decrease. Concentrated epidemics are emerging among high-risk groups (HRG), mainly men who have sex with men (MSM) and injecting drug users (IDU). Attitudes about HIV/AIDS in the MENA region have largely been influenced by Islamic views. It is widely believed that certain sociocultural values, reflected in Islamic practices, provide protection against HIV/AIDS and that people are mainly infected because of misbehaviour. Therefore, the initial response to HIV/AIDS was denial. Despite acknowledging the influence of sociocultural features on HIV/AIDS control in the region, consideration of cultural aspects on control efforts has been very limited. This study was conducted in Jordan and is the first to study the cultural epidemiology of HIV/AIDS in the MENA region. The aims were, first, to gain a better understanding of the local perceptions of HIV/AIDS by assessing its priority in the local health agenda and in scientific research, and, second, to study sociocultural factors that are associated with HIV/AIDS control from the perspectives of PLWHA and HRGs. To address the first aim we clarified regional control policies and assessed the priority of HIV/AIDS through an exploratory observational study, involving discussions with policy makers, and a systematic review of literature and policy documents. The second aim was addressed by using the mixed-methods approach of cultural epidemiology among PLWHA and MSM. Findings showed that approaches to control in the region focus mainly on standard international approaches such as VCT services, promoting HIV testing, and condom use. Even though cultural norms have notable implications for HIV/AIDS control in the region, their impact is neither represented in the literature nor well-integrated into control strategies. This could explain, to a great extent, the failure of control interventions in the region. Studies on HIV/AIDS in the MENA region are very limited, particularly studies that focus on sociocultural aspects of the disease. There is a need for more comprehensive academic research and political commitment. Control programmes must consider sociocultural features of HIV/AIDS with regard to priority, prevention, and treatment. Thirty PLWHA from Jordan were interviewed to address the second aim. Thirty-three per cent were diagnosed with HIV through mandatory testing required to obtain residence permits in neighbouring countries. Forty-seven per cent sought help voluntarily and 67% were adherent to ART at the time of the study. The context in which patients are diagnosed and requirements for mandatory testing limited appropriate help-seeking and adherence to ART; voluntary testing and willingness to seek help were associated with better adherence. Side effects of prolonged medication, perceived stigma, access to treatment, anticipated ineffectiveness of treatment and religious beliefs were all found to affect adherence to ART. PLWHA reported adverse effects of stigma on social life, medical treatment, and their work life. A few respondents referred to experience of enacted stigma, mainly arising from health care workers. Most respondents reported concerns about felt or anticipated stigma. Sadness, anxiety, reduced social status, social isolation, reduced income, and job loss were illness-related experiences associated with higher levels of stigma. Perceived causes of HIV/AIDS associated with higher stigma included socially-mediated effects of specific behaviours such as sharing shaving blades and various sexual acts including masturbation. A second interview survey involved a sample of 97 MSM from the four main cities of Jordan. Approximately 25% of the respondents reported using a condom during their most recent sexual intercourse, and 38% had been tested at least once for HIV. Positive determinants of condom use were higher education level, acknowledging MSM as a HRG, seeking advice from a medical doctor, and the perceived cause of sex with prostitutes. Awareness of available treatment was a positive determinant of HIV testing. Blood transfusion as a perceived cause and asking advice from friends were negative determinants. Control of HIV/AIDS in Jordan and the wider MENA region is generally inadequate, unsustainable, and challenged by cultural values and religious teachings. HIV/AIDS prevention and control should be higher prioritised in national and regional public health agendas in terms of both resources and political commitment. Surveillance systems should be strengthened strategically to reduce the gap in HIV/AIDS-related data in the MENA region. The HIV testing policy, which currently depends heavily on mandatory or pre-marital testing, should be reformed to reach HRGs; and travel restrictions on PLWHA should be minimised to mitigate stigma. Most importantly, the recognition of local, sociocultural illness-related features should be essential in the design of interventions to enhance HIV/AIDS control. In addition, all stakeholders, and especially religious leaders, should be involved in the design and implementation of control strategies and their implementation.