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The Middle East and North Africa is home to the lowest percentage of people living with HIV in the world. According to UNAIDS, those in the region living with the virus numbered around 240,000 out of over 350 million in 2014 — just 0.1 per cent of people.
But the region is also ranked lowest in terms of treatment coverage to help suppress the virus. Only 14 per cent of those living with HIV have received treatment, compared with 41 per cent in Sub-Saharan Africa and 47 per cent in Latin America. 
There has also been a sharp increase in deaths from AIDS. In 2014, around 12,000 people died from AIDS — three times higher than the number of deaths at the beginning of the new millennium. This surge has in part been attributed to very low coverage of the antiretroviral drugs (ARVs) that are vital to keeping HIV in check.
Global vision, local realities
For World AIDS Day on 1 December, the Middle East region rallied around the theme of HIV Treatment for All, in line with the global vision of leaving no one behind when it comes to ARV access. [2,3]
But there are significant obstacles here. Armed conflicts, instability and the near total collapse of infrastructure in some countries mean that central governments are often unable to provide reliable health services of reasonable quality. The import of drugs has also stopped in some countries — and this includes drugs to treat HIV. Without access to drugs, the health of those living with HIV will decline, they will become more infectious and many more people will die.
“If we want to eliminate HIV in the region by 2030, we must change our current style of handling the epidemic.”
By Hany Ziady
HIV in the region is on the rise. In 2014, 22,000 people were newly diagnosed with HIV — a 26 per cent rise on the number of new cases at the turn of the century. Most of these were in two countries, Iran and Sudan, while five countries account for almost 90 per cent of the region’s cases: Algeria, Iran, Morocco, Somalia and Sudan. [1,3]
Conflict and political instability mean this grim picture is only likely to worsen, and there are real fears that the dire situation today is laying the groundwork for major problems in the fight against HIV in years to come.
Iran, which has the highest number of HIV positive people in the region, is the country most likely to see a large increase. The epidemic here is concentrated in certain social groups.
Injecting drug users account for 15 per cent of those infected — a situation not helped by syringe and needle replacement programmes to help contain HIV being few and far between.
Sex workers are another vulnerable group. Here the true picture remains sketchy: social and cultural stigma mean there is little information available on HIV prevalence among sex workers. Gay men are also vulnerable and, because same-sex relations are illegal in many countries (and punishable by death in Iran, Saudi Arabia, Somalia, Sudan and Yemen), many gay men are unable or scared to access health services.
Price of war
Over the last few years, the Middle East and North Africa has seen another group of people become particularly prone to HIV infection: displaced people and refugees. Their living and social conditions encourage the spread of HIV infection: people are away from home and often mixing with cultures they do not understand; drug abuse and risky sexual practices are more common, with sex often traded for food or other items needed to survive.
And, in the chaos of displacement, people have little information about or access to health services. HIV prevention efforts are limited: the supply of medicines is patchy at best, and examination and diagnosis services are almost non-existent.
Eliminating HIV by 2030
So where does the Middle East fit into the bigger picture of global HIV elimination campaigns? HIV/AIDS experts agree that the epidemic can be ended as a global health threat by 2030 by reducing new cases of infection, deaths, stigma and discrimination by 90 per cent based on 2010 rates.
Globally, deaths resulting from AIDS have decreased by 42 per cent from a peak in 2004. But the 2030 goals will not be achieved if efforts to combat the disease continue at current levels, and greater efforts are needed to reach the most vulnerable, as well as the general public. 
For the Middle East to eliminate HIV/AIDS, governments must start by expanding examination and counselling services to identify as many cases of infection as possible.
And governments need better scientific evidence to help them design health programmes. So far, most HIV/AIDS statistics in the Middle East and North Africa have been based on studies conducted on the most vulnerable groups mentioned above.
Iran and Morocco, in particular, have a lot of data on such groups. But other countries — including most of those in the Arab Gulf — have done virtually no studies on these groups at all, due to cultural, social or legal constraints.
Sometimes, estimates are even based on studies done in other neighbouring countries. All this means the true picture of HIV in the region is far from complete. If governments are to stop HIV spreading further among these groups, they will need to implement strategies based on sound and locally relevant evidence.
Partnerships against HIV
One way to reach these groups is to team up with civil society organisations, which tend to be well-placed to reach and engage with the most vulnerable people. They can also disseminate information to people, and even collect data on the size of these groups and the prevalence of the disease among them, so helping to plug data gaps and enabling public health services to draw up HIV programmes based on real evidence.
Efforts to eliminate stigma and discrimination are also crucial. To reduce discrimination within refugee groups, and to get treatment to them, governments and health services will need to coordinate with the international and local organisations that support them.
Governments also need proper administrative, economic and legal infrastructure to build momentum in the fight against HIV. And this will not be achieved without money, whether from local health department budgets, civil society organisations or donor aid.
None of this will be straightforward. But if we want to eliminate HIV in the region by 2030, we must change our current style of handling the epidemic. To get anywhere near this goal, governments and organisations must work together on all fronts.
This article was originally published on SciDev.Net’s Middle East and North Africa edition.
Hany Hassan Ziady is professor of public health at Alexandria University, Egypt. He worked for several years as medical officer in the HIV/AIDS & Sexually Transmitted Diseases Unit and Neglected Tropical Diseases Unit of the World Health Organization’s Regional Office for the Eastern Mediterranean, in Egypt.