The epidemiology of HIV infection in Morocco: systematic review and data synthesis.

Morocco has made significant strides in building its HIV research capacity. Based on a wealth of empirical data, the objective of this study was to conduct a comprehensive and systematic literature review and analytical synthesis of HIV epidemiological evidence in this country. Data were retrieved using three major sources of literature and data. HIV transmission dynamics were found to be focused in high-risk populations, with female sex workers (FSWs) and clients contributing the largest share of new HIV infections. There is a pattern of emerging epidemics among some high-risk populations, and some epidemics, particularly among FSWs, appear to be established and stable. The scale of the local HIV epidemics and populations affected show highly heterogeneous geographical distribution. To optimize the national HIV response, surveillance and prevention efforts need to be expanded among high-risk populations and in geographic settings where low intensity and possibly concentrated HIV epidemics are emerging or are already endemic

Estimating prevalence trends in adult gonorrhoea and syphilis in low- and middle-income countries with the Spectrum-STI model: results for Zimbabwe and Morocco from 1995 to 2016.

OBJECTIVE: To develop a tool for estimating national trends in adult prevalence of sexually transmitted infections by low- and middle-income countries, using standardised, routinely collected programme indicator data. METHODS: The Spectrum-STI model fits time trends in the prevalence of active syphilis through logistic regression on prevalence data from antenatal clinic-based surveys, routine antenatal screening and general population surveys where available, weighting data by their national coverage and representativeness. Gonorrhoea prevalence was fitted as a moving average on population surveys (from the country, neighbouring countries and historic regional estimates), with trends informed additionally by urethral discharge case reports, where these were considered to have reasonably stable completeness. Prevalence data were adjusted for diagnostic test performance, high-risk populations not sampled, urban/rural and male/female prevalence ratios, using WHO's assumptions from latest global and regional-level estimations. Uncertainty intervals were obtained by bootstrap resampling. RESULTS: Estimated syphilis prevalence (in men and women) declined from 1.9% (95% CI 1.1% to 3.4%) in 2000 to 1.5% (1.3% to 1.8%) in 2016 in Zimbabwe, and from 1.5% (0.76% to 1.9%) to 0.55% (0.30% to 0.93%) in Morocco. At these time points, gonorrhoea estimates for women aged 15-49 years were 2.5% (95% CI 1.1% to 4.6%) and 3.8% (1.8% to 6.7%) in Zimbabwe; and 0.6% (0.3% to 1.1%) and 0.36% (0.1% to 1.0%) in Morocco, with male gonorrhoea prevalences 14% lower than female prevalence. CONCLUSIONS: This epidemiological framework facilitates data review, validation and strategic analysis, prioritisation of data collection needs and surveillance strengthening by national experts. We estimated ongoing syphilis declines in both Zimbabwe and Morocco. For gonorrhoea, time trends were less certain, lacking recent population-based surveys

The distribution of new HIV infections by mode of exposure in Morocco.

OBJECTIVES: Building on a wealth of new empirical data, the objective of this study was to estimate the distribution of new HIV infections in Morocco by mode of exposure using the modes of transmission (MoT) mathematical model. METHODS: The MoT model was implemented within a collaboration with the Morocco Ministry of Health and the Joint United Nations Programme on HIV/AIDS. The model was parameterised through a comprehensive review and synthesis of HIV and risk behaviour data in Morocco, mainly through the Middle East and North Africa HIV/AIDS Synthesis Project. Uncertainty analyses were used to assess the reliability of and uncertainty around our calculated estimates. RESULTS: Female sex workers (FSWs), clients of FSWs, men who have sex with men (MSM) and injecting drug users (IDUs) contributed 14%, 24%, 14% and 7% of new HIV infections, respectively. Two-thirds (67%) of new HIV infections occurred among FSWs, clients of FSWs, MSM and IDUs, or among the stable sexual partners of these populations. Casual heterosexual sex contributed 7% of HIV infections. More than half (52%) of HIV incidence is among females, but 71% of these infections are due to an infected spouse. The vast majority of HIV infections among men (89%) are due to high-risk behaviour. A very small HIV incidence is predicted to arise from medical injections or blood transfusions (0.1%). CONCLUSIONS: The HIV epidemic in Morocco is driven by HIV incidence in high-risk population groups, with commercial heterosexual sex being the largest contributor to incidence. There is a need to focus HIV response more on these populations, mainly through proactive and sustainable HIV surveillance, and the expansion and increased geographical coverage of services such as condom promotion among FSWs, voluntary counselling and testing, harm reduction and treatment

Mapping of new HIV infections in Morocco and impact of select interventions

Objectives: The aim of this study was to assess HIV modes of exposure in Morocco at the national level and also for Souss-Massa-Drâa, the region most affected by HIV. Another aim was to assess the impact of different scenarios of select intervention packages. Methods: The Modes of Transmission Model was adapted and used, and was parameterized using quality bio-behavioral surveillance data among key populations, routine data sources, and literature reviews. Results: Nationally in 2013, the largest number of new infections occurred among clients of female sex workers (FSWs) (25%; 95% confidence interval (CI) 14–37%), followed by men who have sex with men (MSM) (22%; 95% CI 12–35%), HIV serodiscordant couples (22%; 95% CI 12–34%), FSWs (11%; 95% CI 6–18%), and people who inject drugs (5%; 95% CI 2–9%). A similar pattern of results was observed in Souss-Massa-Drâa, but the HIV incidence rate was four-fold that at the national level. Different scenarios of feasible intervention packages reduced HIV incidence by 8–44%. Conclusions: Commercial heterosexual sex networks continue as the leading driver of the epidemic, with half of HIV incidence. A quarter of new infections occurred among MSM, a third of which in Souss-Massa-Drâa. Feasible expanded coverage of interventions could lead to large reductions in incidence. Keywords: Mathematical model, Modes of transmission, Interventions, Morocco, Middle East and North Afric

Estimating the Size of Hidden Populations Using Respondent-driven Sampling Data: Case Examples from Morocco.

BackgroundRespondent-driven sampling is used worldwide to estimate the population prevalence of characteristics, such as HIV/AIDS and associated risk factors in hard-to-reach populations. Estimating the total size of these populations is of great interest to national and international organizations; however, reliable measures of population size often do not exist.MethodsSuccessive sampling-population size estimation (SS-PSE) along with network size imputation allows population size estimates to be made without relying on separate studies or additional data (as in network scale-up, multiplier, and capture-recapture methods), which may be biased.ResultsTen population size estimates were calculated for people who inject drugs, female sex workers, men who have sex with other men, and migrants from sub-Saharan Africa in six different cities in Morocco. SS-PSE estimates fell within or very close to the likely values provided by experts and the estimates from previous studies using other methods.ConclusionsSS-PSE is an effective method for estimating the size of hard-to-reach populations that leverages important information within respondent-driven sampling studies. The addition of a network size imputation method helps to smooth network sizes allowing for more accurate results. However, caution should be used particularly when there is reason to believe that clustered subgroups may exist within the population of interest or when the sample size is small in relation to the population

Infectious Disease Epidemiology Group

Morocco Ministry of Health to identify the key modes of exposure to HIV infection among the Moroccan population. The project was funded by the Joint United Nations Programme on HIV/AIDS through a grant designated for undertaking MoT analyses in the Middle East and North Africa. The scientific study was conducted through a joint collaborative partnershi

The prevalence and incidence of active syphilis in women in Morocco, 1995-2016: Model-based estimation and implications for STI surveillance

<div><p>Background</p><p>Evolving health priorities and resource constraints mean that countries require data on trends in sexually transmitted infections (STI) burden, to inform program planning and resource allocation. We applied the Spectrum STI estimation tool to estimate the prevalence and incidence of active syphilis in adult women in Morocco over 1995 to 2016. The results from the analysis are being used to inform Morocco’s national HIV/STI strategy, target setting and program evaluation.</p><p>Methods</p><p>Syphilis prevalence levels and trends were fitted through logistic regression to data from surveys in antenatal clinics, women attending family planning clinics and other general adult populations, as available post-1995. Prevalence data were adjusted for diagnostic test performance, and for the contribution of higher-risk populations not sampled in surveys. Incidence was inferred from prevalence by adjusting for the average duration of infection with active syphilis.</p><p>Results</p><p>In 2016, active syphilis prevalence was estimated to be 0.56% in women 15 to 49 years of age (95% confidence interval, CI: 0.3%-1.0%), and around 21,675 (10,612–37,198) new syphilis infections have occurred. The analysis shows a steady decline in prevalence from 1995, when the prevalence was estimated to be 1.8% (1.0–3.5%). The decline was consistent with decreasing prevalences observed in TB patients, fishermen and prisoners followed over 2000–2012 through sentinel surveillance, and with a decline since 2003 in national HIV incidence estimated earlier through independent modelling.</p><p>Conclusions</p><p>Periodic population-based surveys allowed Morocco to estimate syphilis prevalence and incidence trends. This first-ever undertaking engaged and focused national stakeholders, and confirmed the still considerable syphilis burden. The latest survey was done in 2012 and so the trends are relatively uncertain after 2012. From 2017 Morocco plans to implement a system to record data from routine antenatal programmatic screening, which should help update and re-calibrate next trend estimations.</p></div