The emerging face of the HIV epidemic in the Middle East and North Africa.

PURPOSE OF REVIEW: A volume of quality HIV data has materialized recently in the Middle East and North Africa (MENA). This review provides a thematic narrative of the patterns of HIV infection transmission in this region in light of these data. RECENT FINDINGS: Tens of integrated bio-behavioral surveillance surveys among hard-to-reach key populations at higher risk have been conducted in MENA in the recent years. Many of the studies reported appreciable and growing HIV prevalence. A few studies found alarming prevalence of as much as 87.2% HIV prevalence among people who inject drugs in Tripoli, Libya. The discovery of these hitherto hidden epidemics was unsettling to some authorities after years in which the importance of a focus on HIV prevention among key populations was not recognized. SUMMARY: The new data from MENA indicate growing HIV epidemics among key populations across the region. There is heterogeneity, however, as to which key populations are affected and in what proportions in different countries. In a few countries, HIV appears to affect only one key population and often there is substantial geographical heterogeneity in HIV transmission. Data are indicative of a growing HIV disease burden in this part of the globe, in contrast with the declining epidemics in most other regions

Characterising the progress in HIV/AIDS research in the Middle East and North Africa.

OBJECTIVES: The Middle East and North Africa (MENA) region is perceived to have limited HIV data. The objective of this study was to quantitatively characterise the progress in HIV research in this region since the discovery of the epidemic. METHODS: Four indices were defined and implemented to measure the progress of HIV research using the PubMed, Embase, MENA HIV/AIDS Epidemiology Synthesis Project and US Census Bureau HIV/AIDS Surveillance databases. The four indices provide complementary measures to characterise different aspects of the progress of HIV research. RESULTS: A total of 2118, 2352, 683 and 4889 records were identified through the PubMed, the Embase, the Synthesis Project and the HIV Prevalence indices, respectively. The proportion of the total global HIV records that relate to MENA is 1.2%. Overall, the indices show steady progress in the number of new records every year, with an accelerated pace in the last few years. The rate of progress in MENA was also higher than the rate of progress in HIV records globally. There is no evidence so far of stabilisation or a peak in the number of new records year by year. About half of the records were produced after the year 2005. The number of records shows large heterogeneity across countries. CONCLUSIONS: MENA has witnessed a rapid growth in HIV research over the last decade. However, there are still large gaps in HIV scientific evidence in the region, and the progress is far from being uniform across countries. Ongoing and future research needs to be geared towards academic standard and production of scientific publications

Using hepatitis C prevalence to estimate HIV epidemic potential among people who inject drugs in the Middle East and North Africa.

OBJECTIVES: The objective of this study is to understand the association between HIV and hepatitis C virus (HCV) among people who inject drugs (PWIDs) in the Middle East and North Africa (MENA), and to estimate HIV epidemic potential among PWIDs using HCV prevalence. DESIGN/METHODS: Using data from a systematic review of HIV and HCV among PWID in MENA, we conducted two analyses, stratified by HIV epidemic state: a meta-analysis of the risk ratio of HCV to HIV prevalence (RRHCV/HIV) using DerSimonian-Laird random-effects models, and multivariable linear regression predicting log HIV prevalence. The HCV-HIV association from both analyses was used to estimate HIV prevalence at endemic equilibrium. We compared predicted with current HIV prevalence to classify HIV epidemic potential at country-level as low, medium or high, using predefined criteria. RESULTS: The review identified 88 HCV prevalence measures among PWID in MENA, of which 54 had a paired HIV prevalence measure. The pooled RRHCV/HIV were 16, 4 and 3 in low-level, emerging and established HIV epidemics, respectively. There was a significant linear relationship between HCV and HIV at endemic equilibrium (P = 0.002). The predicted endemic HIV prevalence ranged between 8% (Tunisia) and 22% (Pakistan). Of the nine countries with data, five have high and three medium HIV epidemic potential. Only one country, Pakistan, appears to have reached saturation. CONCLUSION: HCV prevalence could be a predictor of future endemic HIV prevalence. In MENA, we predict that there will be further HIV epidemic growth among PWID. The proposed methodology can identify PWID populations that should be prioritized for HIV prevention interventions

HIV incidence among people who inject drugs in the Middle East and North Africa: mathematical modelling analysis.

INTRODUCTION: Emerging HIV epidemics have been documented among people who inject drugs (PWID) in the Middle East and North Africa (MENA). This study estimates the HIV incidence among PWID due to sharing needles/syringes in MENA. It also delineates injecting drug use role as a driver of the epidemic in the population, and estimates impact of interventions. METHODS: A mathematical model of HIV transmission among PWID was applied in seven MENA countries with sufficient and recent epidemiological data and HIV prevalence ≥1% among PWID. Estimations of incident and/or prevalent infections among PWID, ex-PWID and sexual partners of infected current and ex-PWID were conducted. RESULTS: The estimated HIV incidence rate for 2017 among PWID ranged between 0.7% per person-year (ppy) in Tunisia and 7.8% ppy in Pakistan, with Libya being an outlier (24.8% ppy). The estimated number of annual new infections was lowest in Tunisia (n = 79) and Morocco (n = 99), and highest in Iran and Pakistan (approximately n = 6700 each). In addition, 20 to 2208 and 5 to 837 new annual infections were estimated across the different countries among sexual partners of PWID and ex-PWID respectively. Since epidemic emergence, the number of total ever acquired incident infections across countries was 706 to 90,015 among PWID, 99 to 18,244 among sexual partners of PWID, and 16 to 4360 among sexual partners of ex-PWID. The estimated number of prevalent infections across countries was 341 to 23,279 among PWID, 119 to 16,540 among ex-PWID, 67 to 10,752 among sexual partners of PWID, and 12 to 2863 among sexual partners of ex-PWID. Increasing antiretroviral therapy (ART) coverage to the global target of 81% - factoring in ART adherence and current coverage - would avert about half of new infections among PWID and their sexual partners. Combining ART with harm reduction could avert over 90% and 70% of new infections among PWID and their sexual partners respectively. CONCLUSIONS: There is considerable HIV incidence among PWID in MENA. Of all new infections ultimately due to injecting drug use, about 75% are among PWID and the rest among sexual partners. Of all prevalent infections ultimately attributed to injecting drug use as epidemic driver, about half are among PWID, 30% among ex-PWID and 20% among sexual partners of PWID and ex-PWID. These findings call for scale-up of services for PWID, including harm reduction as well as testing and treatment services

Global population-level association between herpes simplex virus 2 prevalence and HIV prevalence.

BACKGROUND: Our objective was to assess the population-level association between herpes simplex virus 2 (HSV-2) and HIV prevalence. METHODS: Reports of HSV-2 and HIV prevalence were systematically reviewed and synthesized following PRISMA guidelines. Spearman rank correlation ((Equation is included in full-text article.)) was used to assess correlations. Risk ratios (RRHSV-2/HIV) and odds ratios (ORHSV-2/HIV) were used to assess HSV-2/HIV epidemiologic overlap. DerSimonian-Laird random-effects meta-analyses were conducted. RESULTS: In total, 939 matched HSV-2/HIV prevalence measures were identified from 77 countries. HSV-2 prevalence was consistently higher than HIV prevalence. Strong HSV-2/HIV prevalence association was found for all data ((Equation is included in full-text article.) = 0.6, P < 0.001), all data excluding people who inject drugs (PWID) and children ((Equation is included in full-text article.) = 0.7, P < 0.001), female sex workers ((Equation is included in full-text article.) = 0.5, P < 0.001), and MSM ((Equation is included in full-text article.) = 0.7, P < 0.001). No association was found for PWID ((Equation is included in full-text article.) = 0.2, P = 0.222) and children ((Equation is included in full-text article.) = 0.3, P = 0.082). A threshold effect was apparent where HIV prevalence was limited at HSV-2 prevalence less than 20%, but grew steadily with HSV-2 prevalence for HSV-2 prevalence greater than 20%. The overall pooled mean RRHSV-2/HIV was 5.0 (95% CI 4.7-5.3) and ORHSV-2/HIV was 9.0 (95% CI 8.4-9.7). The RRHSV-2/HIV and ORHSV-2/HIV showed similar patterns that conveyed inferences about HSV-2 and HIV epidemiology. CONCLUSION: HSV-2 and HIV prevalence are strongly associated. HSV-2 prevalence can be used as a proxy 'biomarker' of HIV epidemic potential, acting as a 'temperature scale' of the intensity of sexual risk behavior that drive HIV transmission. HSV-2 prevalence can be used to identify populations and/or sexual networks at high-risk of future HIV expansion, and help prioritization, optimization, and resource allocation of cost-effective prevention interventions

Prevalence of Chlamydia trachomatis infection in the general population of women in Qatar

Objectives The Arabian Gulf region has limited epidemiological data related to sexually transmitted infections. The objective of this study was to estimate the prevalence of Chlamydia trachomatis infection among general population women in Doha, Qatar. Methods Endocervical swabs were collected from healthy women attending primary healthcare centres in Doha, June–December 2008. The specimens were tested for C trachomatis by a commercially available PCR-based assay. Data on basic socio-demographic characteristics, medical history and sexual behaviour were obtained using self-administered questionnaires. The prevalence of C trachomatis and of background variables were stratified by nationality, Qatari nationals versus non-Qatari residents. Results A total of 377 women were enrolled in the study, out of whom 351 (37.9% Qataris, 62.1% non- Qataris) were tested for the presence of C trachomatis in their specimens. The mean age of participants was 41.2 years, and the vast majority (93%, 95% CI 90.3 to 95.7) were married. The mean age at sexual debut was significantly lower among Qatari women compared with non-Qatari women (19.2 vs 22.2 years, respectively p<0.001), but the mean number of reported lifetime sexual partners (1.1 partner) was nearly the same in both groups (p=0.110). The prevalence of C trachomatis infection was 5.3% among Qatari women and 5.5% among non-Qatari women, with no statistically significant difference between both groups ( p=0.923). Conclusions The prevalence of C trachomatis among women was higher than expected, with no significant difference between Qatari nationals and expatriate residents. The higher prevalence may reflect, in part, the limited access to and use of chlamydia screening and management.Research Committee of the College of Arts and Sciences, Qatar University (QUUG-CAS-DHS-10/11-6); Qatar National Research Fund (NPRP 4-924-3-251); The Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medical Colleg

Protocol for a systematic review and meta-analysis of hepatitis C virus (HCV) prevalence and incidence in the Horn of Africa sub-region of the Middle East and North Africa.

BACKGROUND: In the Middle East and North Africa (MENA), hepatitis C virus (HCV) distribution appears to present a wide range of prevalence. The scale and nature of HCV disease burden is poorly known in the Horn of Africa sub-region of MENA including Djibouti, Somalia, and Sudan in addition to Yemen at the southwest corner of the Arabian Peninsula. The aim of this review is to provide a systematic review and synthesis of all epidemiological data on HCV prevalence and incidence among the different population groups in this sub-region of MENA. A second aim of the study is to estimate the national population-level HCV prevalence for each of these four countries. METHODS/DESIGN: The systematic review will be conducted based on the items outlined in the PRISMA statement. PubMed, Embase, and the World Health organization (WHO) regional databases will be searched for eligible studies without language or date restrictions. Observational and intervention studies reporting data on the prevalence or incidence of HCV in any population group in Djibouti, Somalia, Sudan, or Yemen will be included. Additional sources will be obtained through the database of the MENA HIV/AIDS Epidemiology Synthesis Project, including international organizations' reports and country-level reports, and abstracts of international conferences. Study and population characteristics will be extracted from eligible publications, with previously agreed pro formas; and entered into a computerized database. We will pool prevalence using DerSimonian and Laird random-effects models after a Freeman-Tukey transformation to stabilize variances. We will conduct meta-regression analysis to explore the effect of study-level characteristics as potential sources of heterogeneity. DISCUSSION: This proposed systematic review and meta-analysis aims to better describe HCV infection distribution across countries in the Horn of Africa sub-region of MENA; and between sub-population groups within each country. The study will provide empirical evidence necessary for researchers, policy-makers, and public health stakeholders to set research, policy, and programming priorities for HCV prevention, control, and treatment. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014010318

Age could be driving variable SARS-CoV-2 epidemic trajectories worldwide.

Current geographic spread of documented severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections shows heterogeneity. This study explores the role of age in potentially driving differentials in infection spread, epidemic potential, and rates of disease severity and mortality across countries. An age-stratified deterministic mathematical model that describes SARS-CoV-2 transmission dynamics was applied to 159 countries and territories with a population ≥1 million. Assuming worst-case scenario for the pandemic, the results indicate that there could be stark regional differences in epidemic trajectories driven by differences in the distribution of the population by age. In the African Region (median age: 18.9 years), the median R0 was 1.05 versus 2.05 in the European Region (median age: 41.7 years), and the median (per 100 persons) for the final cumulative infection incidence was 22.5 (versus 69.0), for severe and/or critical disease cases rate was 3.3 (versus 13.0), and for death rate was 0.5 (versus 3.9). Age could be a driver of variable SARS-CoV-2 epidemic trajectories worldwide. Countries with sizable adult and/or elderly populations and smaller children populations may experience large and rapid epidemics in absence of interventions. Meanwhile, countries with predominantly younger age cohorts may experience smaller and slower epidemics. These predictions, however, should not lead to complacency, as the pandemic could still have a heavy toll nearly everywhere

Analyzing inherent biases in SARS-CoV-2 PCR and serological epidemiologic metrics

Background: Prospective observational data show that infected persons with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remain polymerase chain reaction (PCR) positive for a prolonged duration, and that detectable antibodies develop slowly with time. We aimed to analyze how these effects can bias key epidemiological metrics used to track and monitor SARS-CoV-2 epidemics. Methods: An age-structured mathematical model was constructed to simulate progression of SARS-CoV-2 epidemics in populations. PCR testing to diagnose infection and cross-sectional surveys to measure seroprevalence were also simulated. Analyses were conducted on simulated outcomes assuming a natural epidemic time course and an epidemic in presence of interventions. Results: The prolonged PCR positivity biased the epidemiological measures. There was a lag of 10 days between the true epidemic peak and the actually-observed peak. Prior to epidemic peak, PCR positivity rate was twofold higher than that based only on current active infection, and half of those tested positive by PCR were in the prolonged PCR positivity stage after infection clearance. Post epidemic peak, PCR positivity rate poorly predicted true trend in active infection. Meanwhile, the prolonged PCR positivity did not appreciably bias estimation of the basic reproduction number R0. The time delay in development of detectable antibodies biased measured seroprevalence. The actually-observed seroprevalence substantially underestimated true prevalence of ever infection, with the underestimation being most pronounced around epidemic peak. Conclusions: Caution is warranted in interpreting PCR and serological testing data, and any drawn inferences need to factor the effects of the investigated biases for an accurate assessment of epidemic dynamics