Have the Middle East and North Africa largely escaped the global AIDS epidemic? The available data seems to say so. UNAIDS reports that, at the close of 2003, there were 480,000 adults and children living with HIV/AIDS in the Arab world, Iran, Israel and Turkey. Compared to sub-Saharan Africa, where there are approximately 25 million cases of the disease, or South and Southeast Asia, where there are approximately 6.5 million, this number is tiny — about 1 percent of the world’s caseload.
But this low number offers no cause for celebration. UNAIDS estimates that 75,000 people from the Middle East and North Africa were newly infected with HIV/AIDS in 2003 alone, while 24,000 adults and children died from the disease in the same year. Moreover, the quality of the available data is seriously lacking. No country in the Middle East and North Africa conducts systematic surveys of groups at high risk of infection. As a consequence, the UNAIDS estimate of the total number of HIV/AIDS cases in the region lies within a very broad range of possible cases, from 200,000 to 1.4 million people.  Only 5 percent of Middle Easterners and North Africans who need anti-retroviral treatment receive it. 
According to a 2003 World Bank report, probably the most substantial research document on HIV/AIDS in the Middle East and North Africa, the assumption of low rates of infection has led governments to dismiss the disease as an insignificant problem or exhibit complacency in taking action. Many governments faced with pressing crises of housing, employment and education see HIV/AIDS prevention and treatment as low priorities. Other governments believe that social and cultural conservatism will somehow avert an HIV/AIDS epidemic. But, in the words of the report, “low prevalence does not equate to low risks.”  Current scientific knowledge about HIV/AIDS transmission shows that once infection rates exceed “a certain threshold, the virus spreads very fast, sometimes increasing by as much as tenfold in five years as has been the case in several southern African countries.”  Calculating that threshold is complicated. According to Joan MacNeil, senior HIV/AIDS Specialist for the Global HIV/AIDS Program of The World Bank Group, an epidemic threshold is reached “when enough critical mass of risk behaviors and contributing biological factors exists in a population to sustain an epidemic. This is described scientifically by the concept of reproductive rate, which is the number of new infections generated by each current infection. The threshold is exceeded when the reproductive rate exceeds one. This means that, if infected individuals, on average, infect more than one additional person in their lifetimes, the epidemic will be sustained and grow. However, the threshold can be influenced by the size of risk populations, type and frequency of risk behavior, presence of other sexually transmitted infections, especially ulcerative, circumcision, networks linking key sub-populations and extending beyond these groups.” 
At base, the threshold is usually designated as, and equal to, a 5 percent infection rate in most countries.  If governments delay action, scholars believe the trend witnessed in other regions will likely recur in the Middle East and North Africa.
As in other regions, known high-risk groups in the Middle East and North Africa include men who have sex with men, female sex workers and their clients, injecting drug users and prisoners. At least half of the HIV cases reported in Tunisia are thought to be Libyans who crossed the border to undergo drug rehabilitation or receive anti-retroviral treatment, according to UNAIDS. HIV infection in Bahrain, Libya and Oman is reportedly concentrated among injecting drug users. Prisoners are often designated as an at-risk group because of prevalent drug habits, tattoo practices and overall health conditions in the prisons.
Tourists, migrant workers and transport drivers are both transmitters of the disease to locals as well as those who contract the disease from risk groups like female sex workers. Displaced persons and refugees are at risk for HIV/AIDS because of the lack of adequate health care and unhygienic conditions, exposure to infected blood and lack of access to condoms.
Women worldwide are particularly at risk for HIV/AIDS contraction because of their frequently weakened negotiating power in sexual relations with their husbands to practice safe sex (who may also be having sex with female sex workers or with men) as well as their relative lack of knowledge about the HIV/AIDS virus. Of the 480,000 infected people estimated by UNAIDS in the Middle East and North Africa, approximately 220,000 were women. Young people form an at-risk group because of their common risk-seeking behaviors like taking drugs, having multiple sex partners or sexually experimenting, and failing to use condoms. Scientific evidence has shown that individuals with sexually transmitted infections also have increased susceptibility to HIV/AIDS. 
Not only do most Middle Eastern and North African governments fail to survey these at-risk groups regularly, but they monitor risk behaviors only on an ad hoc basis. Governments, international agencies and independent researchers are thus left struggling to identify dangerous trends in health behavior. 
Strong taboos attached to HIV/AIDS in the Middle East and North Africa make it even harder to measure the scope of the problem and plan accordingly. Extreme stigma not only marginalizes those who are HIV-positive but also inhibits people from going for testing in the first place. Injecting drug users — at high risk because of shared needles — are stigmatized and many times go underground because their habit is illegal. People living with HIV/AIDS are commonly expelled from their homes or alienated from their families, have difficulty marrying or dating, are sometimes fired from their jobs and even have trouble getting medical care for fear of infection by health professionals. In a few countries in the region, people living with HIV/AIDS are placed in quarantine compounds far away from the general population. Before effective programs in Iran were in place, mortality from suicide for people living with HIV/AIDS exceeded mortality from the disease itself because of stigma. 
Breaking the Silence
Such dire statistics led Peter Piot, executive director of UNAIDS, to plead with regional leaders in a 2002 speech to “break the silence on AIDS.” Piot continued: “Most of the AIDS in the Middle East and North Africa is still invisible. Progress is not possible unless AIDS becomes visible, unless stigma is challenged and unless people living with HIV are encouraged to play their part in a community-wide AIDS response. All this requires resolute and courageous leadership at various levels.”
Toward this end, the UN Development Program sponsored a March 2003 gathering in Cairo to raise awareness about HIV/AIDS in the Arab world. Arab actors, singers and other media personalities attended. The gathering was one example of how international agencies, like UNAIDS and its affiliated agencies, have recently become more engaged with governments to address the region’s potential rise in HIV/AIDS infection. The World Health Organization, the one UNAIDS affiliate that has worked in the region since the 1980s, has developed a regional strategic plan for the Eastern Mediterranean for 2002-2005.  National AIDS programs and national steering committees were set up to implement the plan. Actions by some national AIDS committees — as yet incomplete — have included implementing universal health precautions like using gloves and enforcing sterile environments, addressing the care of opportunistic infections, like tuberculosis, that come as a result of immuno-suppression, securing a safe blood supply, and providing anti-retroviral therapy and counseling for AIDS patients. 
All agencies agree that every segment of society, including industry, clergy, farmers and teachers, should work together to collect thorough data. Without comprehensive quantitative and qualitative data, especially acquisition of information about sexual behavior and drug use, interventions are likely to fail.
Some countries have fared better than others in carrying out these injunctions, according to country reports that can be generated at the UNAIDS website. Turkey has a national HIV case reporting system, an HIV/AIDS action plan and a national AIDS committee, established in 1996, with input from several ministries and non-governmental organizations. The country’s estimated 3,700 adult AIDS patients are made up mostly of males, the major modes of transmission being heterosexual sex and injecting drug use. With about 3,300 adult AIDS cases at the end of 2001, Israel has a national HIV/AIDS registry and systematically tests blood donors, prisoners and immigrants from countries with high rates of HIV/AIDS. The country has health education programs on HIV/AIDS for at-risk groups, for the army and for the general population. Israel has regional AIDS centers around the country that provide treatment and follow-up to people living with the disease.
Morocco, which worked with the World Bank on an AIDS action plan in 2001, has instituted extensive services for the prevention and treatment of sexually transmitted infections. Algeria finalized a multi-sectoral strategic plan for 2003-2006. In 1997, Tunisia developed a program for youth that offers regional and provincial comprehensive services in prevention, counseling, testing and condom distribution.  Since 1999, Jordan has provided anti-retroviral therapy free of charge. The Syrian government has instituted community-based HIV/AIDS education programs for out-of-school youth and partnered with local organizations for their implementation. Egypt has started an anonymous HIV/AIDS hotline service that offers HIV/AIDS and sex education. It receives 1,000 calls a month on average. Lebanon has prepared a national AIDS plan for 2004-2009 to help stakeholders in suitable interventions. Yemen has received funding from the World Bank to implement a project focused on HIV/AIDS prevention and the reduction of risk behaviors. Djibouti has also received World Bank funds both to execute strategic plans for fighting HIV/AIDS, malaria and tuberculosis and to examine HIV/AIDS transmission within the trucking industry.
The Gulf states have also begun to address HIV/AIDS, according to the same UNAIDS reports. Saudi Arabia has established an HIV/AIDS Health Education Committee that includes governmental and non-governmental agencies. It has not, however, integrated the HIV/AIDS issue into general development plans. The Saudis have instituted health programs for at-risk populations and reproductive and sex education programs in schools. Saudi Arabia also supplies anti-retroviral therapy for infected pregnant women. The government of Qatar provides limited programs like screening of HIV patients’ families, tuberculosis patients, school lectures and anti-retroviral therapy but does not have a comprehensive, multi-sectoral program or a coordinating agency. They do pre-screen foreign labor for the virus upon entry to the country as well as new army recruits, but they do not screen pregnant women. Stigma associated with HIV/AIDS and at-risk populations remains a major problem. Oman, on the other hand, reports collaboration among many sectors of society and boasts of a National AIDS Technical Committee and a National AIDS Health Education Committee. The government does not promote sex education for young people due to “cultural and religious traditions,” although condoms are provided free of charge at supermarkets, family planning clinics and private pharmacies.
Iran has perhaps made the most extensive strides in confronting its HIV/AIDS problem. It has developed a national sentinel surveillance system with 75 sites in juvenile detention centers, prisons and university clinics. It has set up an extensive network of clinics for injecting drug users that address HIV/AIDS and drug abuse education, care and treatment. Their patient-centric approach provides social support for patients and families as well as community outreach. In addition, Iran has set up several regional committees with university participation while its national AIDS committee includes members from several ministries and civil society groups like the Red Crescent and the Prison Organization. A National Harm Reduction Committee has also been formed. Along with Morocco, Algeria and Jordan, Iran received funding from the Global Fund to Fight HIV/AIDS.
Iran’s innovative campaign against HIV/AIDS makes HIV-positive drug users visible by including them in outreach programs. Their participation is intended to avert stigma by showing that people living with HIV/AIDS are constructive members of society who can help others. Understanding that the problems of high-risk groups like injecting drug users are complex, Iran’s clinics address related social problems by providing food and shelter, recreation, primary health care, employment and family counseling.The “triangular” clinics’ integrated care approach, based on the three prongs of sexually transmitted diseases, drug use and HIV/AIDS screening and treatment, is meant to reduce the effects of stigma by allowing patients to seek help for associated problems, instead of attending the clinic solely and openly because they may have HIV/AIDS. 
Dangers of Inattention
Efforts to contain the spread of HIV/AIDS in the Middle East and North Africa remain inadequate, however, particularly given the stakes. The stakes are economic as well as human. Further spread of the virus, and especially deaths from the disease, could lead to a drastic decline in productivity, a decrease in the labor force and a reduction in capital investments. World Bank researchers conservatively estimate that HIV/AIDS in the Middle East and North Africa could cause a loss of one-third of the region’s current gross domestic product by 2025.The average increase in health expenditures to treat all AIDS patients by 2015 could reach between 1.2 and 5 percent of GDP. Simple, cost-effective interventions like encouraging condom use and supplying safe needles to injecting drug users could save regional governments millions of dollars. Delaying these types of interventions could cost up to 1.5 percent of today’s GDP for each year of inaction. 
The countries of the Middle East and North Africa, with their young populations, unresolved political conflicts, slow-growing economies, stressed or crumbling health infrastructures, gender inequalities, population mobility and shared borders with high-prevalence regions like Central Asia and sub-Saharan Africa, are at risk for outbreaks or epidemics of the HIV virus. Illiteracy, unemployment and the drug trade exacerbate the danger. In the absence of effective action against the virus, rapid transmission could very well transpire. We may see a repeat in the Middle East and North Africa of the situation in Indonesia, Africa or China where initial disregard or delayed reaction has ended in large numbers of orphans, a shortage of workers and huge health expenditures to care for HIV/AIDS patients. Inattention to the HIV/AIDS problem in the Middle East and North Africa could cause similar breakdowns in a region that is already socially, politically and economically vulnerable.
 See the UNAIDS fact sheet on the AIDS epidemic in the Middle East and North Africa, accessible online at http://www.unaids.org/Unaids/EN/Geographical+area/By+Region/North_Africa_Middle_East.asp.
 Though the number of people receiving anti-retroviral therapy has doubled worldwide, as of June 2004, just 440,000 people in low to middle-income countries were being treated. Robert Steinbrook, “After Bangkok—Expanding the Global Response to AIDS,” New England Journal of Medicine 351/8 (August 19, 2004).
 See UNAIDS and World Health Organization, Second Generation Surveillance for HIV 2003 (update) (Geneva). The threshold may be higher or lower than 5 percent, depending on factors like the size of risk populations, the type and frequency of risk behavior, the presence of other sexually transmitted diseases and the prevalence of circumcision. See chapter 4 in UNAIDS, Effective Prevention Strategies in Low HIV Prevalence Settings.
 See UNAIDS and World Health Organization Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections that can be generated at http://www.unaids.org.
 Carol Jenkins, “Vulnerability to HIV/AIDS in the Middle East and North Africa: A Socio-Epidemiology Overview,” Paper given at Twenty-Fifth International AIDS Conference, Satellite Meeting of Global Researchers of HIV/AIDS in the Middle East and North Africa Region, Bangkok, Thailand, July 13, 2004.
 Kamiar and Arash Alaei, “The Best Practice Model for Prevention and Care for HIV/AIDS and Potentials for Expansion into a Muslim Country Program,” Paper given at Twenty-Fifth International AIDS Conference, Satellite Meeting of Global Researchers of HIV/AIDS in the Middle East and North Africa Region, Bangkok, Thailand, July 13, 2004.
 World Health Organization, Improving Health Sector Response to HIV/AIDS and Sexually Transmitted Diseases in the Countries of the Eastern Mediterranean Region of WHO: Regional Strategic Plan, 2002-2005 (Cairo, 2002).
 World Health Organization, Best Practice in HIV/AIDS Prevention and Care for Injecting Drug Abusers: The Triangular Clinic in Kermanshah, Islamic Republic of Iran (Cairo, 2004), pp. 13, 15, 25, 27.