Middle East and North Africa

Zarah Ali (not her real name) remembers how things changed for the better. “In 2014, I received a loan of 40 000 Djiboutian francs (US$ 250) that I used to develop and improve my garment business. I was also trained in business entrepreneurship, including marketing and customer satisfaction. I import clothes from Dubai and Somaliland and earn a decent income that helps me support my 25-year-old son, my 16-year-old daughter in secondary school and my three-year-old adopted son. I am able to pay for my rent, electricity and water and have decent meals.”

Ms Ali’s loan came from an income-generation programme established by the World Food Programme in collaboration with the United Nations Development Programme, UNAIDS and the national network of people living with HIV in Djibouti (RNDP+). The programme supports the long-term empowerment of, and provides regular incomes to, women living with HIV in Djibouti City. It helps them to achieve financial security and have access to food and improves their access to health-care services. Income-generating activities such as those supported by the programme have a powerful potential to help people living with HIV adhere to antiretroviral therapy and optimize health outcomes. 

The loans, ranging from US$ 141 to US$ 438 per person, are for starting or building retail businesses. The beneficiaries, who are selected from among two networks of people living with HIV affiliated to RNDP+ (ARREY and Oui à la Vie – Yes to Life), also receive training on how to run their business. Government support in the form of favourable policies and legislation has been vital to the success of the programme. 

Dekah Mohammed (not her real name) now lives a fulfilling life after receiving help from the income-generation programme. Ms Mohammed, who lost her husband to AIDS, lives with six children. After she lost her job in the hospitality sector owing to her deteriorating health and to stigma and discrimination, she started her own clothing business and received a loan of 50 000 Djiboutian francs (US$ 313) to expand her business. The loan was repaid within 10 months. Her business has since expanded into furniture and electronics and she has recruited an employee. “I am no longer a desperate woman. I make enough to take care of my family and dependants,” she said. 

The programme has improved the quality of life of many Djiboutian women, allowing them to regain dignity and ensure their financial security. It empowers women and girls to protect themselves from HIV, make decisions about their health, live free from violence and be financially independent. 

Building on the belief that empowering women living with HIV and their households to be financially independent strengthens adherence to treatment and leads to more fulfilling and dignified lives, the programme contributes to the World Food Programme’s broader strategic contribution towards ending AIDS as a public health threat by 2030.

According to the World Health Organization, about one third of women worldwide have experienced violence. In some regions, women who have experienced physical or sexual intimate partner violence are 1.5 times more likely to acquire HIV than women who have not experienced such violence. Among marginalized populations, such as sex workers or transgender women, a high prevalence of violence is linked with higher rates of HIV infection.

In the Middle East and North Africa (MENA) region, UNAIDS estimates that around 220 000 people are living with HIV. New infections were up by 12% between 2010 and 2017 and AIDS-related deaths increased by 11% over the same period. The stigma and discrimination associated with HIV as well as high levels of gender-based violence are preventing several countries from making progress against the epidemic. Gender-based violence in the region is strongly associated with harmful gender norms and stereotypes.

In 2018, the LEARN MENA project was launched to provide women with a platform to share experiences and explore the linkages between gender-based violence and HIV in the region. Underpinning the project is the Action Linking Initiatives in Violence against Women and HIV Everywhere (ALIV(H)E) framework, a research project that collates evidence on what works to prevent violence and builds women’s awareness to understand and address linkages between violence against women and HIV.

Through community dialogues led by MENA-Rosa, a regional network of women living with or affected by HIV, women are strengthening their own understanding of the root causes of violence and the links with HIV. The dialogues have highlighted the fact that gender inequality is at the centre of violence against women and an increased risk of HIV infection. For example, through the dialogues it was revealed that some women had never been to school. Many had experienced early or forced marriage. Many women acquire HIV from sexual violence, including within their own marriage.

“Violence is everywhere. Over time, and as you get older, you get to see it as normal,” said an Algerian woman participating in one of the dialogues. 

The participants described multiple forms of violence across different settings, including in health-care settings, which impede their access to health care, including to HIV prevention and treatment services.

So far, the project has been implemented in seven countries―Algeria, Egypt, Jordan, Lebanon, Morocco, Sudan and Tunisia.

Findings from the project are helping women living with and affected by HIV to advocate for an improved response to the epidemic in the region and for measures to reduce the impact of violence against women. The dialogues have amplified the voices of marginalized women living with and affected by HIV, encouraging decision-makers and partners to build strengthened national community responses. UNAIDS is supporting countries to implement the recommendations and action plans developed from the project.

“MENA-Rosa leaders have learned through this painful process that violence against us should be denounced and not brushed under the carpet,” said Rita Wahab, Regional Coordinator of MENA-Rosa. “Empowerment will help women in all their diversity to know and understand their rights. Our advocates will move forward to expose the links between violence against women and HIV. Gender equality starts at home, grows in society and blossoms in the legal environment.”

LEARN MENA is implemented by UNAIDS, Frontline AIDS and MENA-Rosa, with funding support from USAID. Additional technical support is provided by the Salamander Trust, the lead author of the ALIV(H)E framework.

When the family and neighbours of Salma Karim (not her real name) found out that she was living with HIV they chased her out of her home. With nowhere to go, she was forced to leave her two young children behind. This is not an uncommon story in Egypt. One in five people living with HIV report being forced to leave their homes by their landlords, family or neighbours.

High levels of stigma and discrimination are one of the key factors driving new HIV infections in the country, which doubled between 2010 and 2016. Women and adolescent girls are often the most vulnerable. Societal norms, gender inequality, economic dependence, legal discrimination and harmful practices affect them disproportionately, making them more vulnerable to HIV and facing greater levels of stigma and discrimination in the event of HIV infection.

In 2016, UNAIDS in partnership with the Egyptian Ministry of Health and Population joined efforts towards a gender-transformative response to the HIV epidemic. With funding from the Dutch government, a pilot project called Enhancing Sexual and Reproductive Health of Women Living with and Affected by HIV was launched. Three years later, the pilot has reached double its intended beneficiaries with stigma-free quality sexual and reproductive health services.

“I lost my first child as I didn’t know I had HIV,” explains Nour Tarek (not her real name). It was in one of the pilot project sites in Giza that she received the support to realize her reproductive rights free from discrimination. “I followed up with the doctor in the hospital and I became pregnant again.”

Thanks to the antiretroviral medicine she received while pregnant, her baby Mona (not her real name) was born HIV-negative. “I still have to test again until she is older to make sure she is fine,” explains Ms Tarek.  

Having proved its success, the pilot project is now being scaled up to a third of the country’s governorates. The aim is to deliver high-quality sexual and reproductive health and HIV services for 1300 women living with HIV and 3000 women at higher risk of acquiring HIV. Its focus on building the capacity of health-care providers and civil society organizations will be key to avoiding future stigma and discrimination, which is reported to lead one in four people living with HIV in Egypt not to disclose their HIV status when seeking care.

During his visit to Cairo on 9 April, the Executive Director of UNAIDS, Michel Sidibé, and the Ambassador of the Netherlands to Egypt, Laurens Westhoff, discussed the expansion of the project. Implemented through a new three-year Dutch grant, the scaled-up services will complement national efforts to achieve Egypt’s ambitious new National AIDS Strategy 2018–2022 and the Sustainable Development Goals.

“We cannot have sustainable development without sustaining peace. Neither can we build a secure future for everyone without addressing the root causes of our conflicts and vulnerabilities,” said Amina Mohammed, the United Nations Deputy Secretary-General.

Ms Mohammed was speaking in Marrakech, Morocco, at the twentieth session of the Regional Coordination Mechanism for Africa (RCM–Africa)―a joint United Nations and African Union body that supports African development.

“The United Nations is working with the Africa Union to try to get the 47% of people of the continent still under the poverty line out of poverty, bring energy to the doorsteps of 500 million people without electricity and garner the US$ 60 billion needed to empower African women,” said Vera Songwe, the Executive Secretary of the United Nations Economic Commission for Africa.

The African Union Commissioner for Human Resources, Science and Technology, Sarah Anyang Agbor, encouraged the participants to, “Live by Ubuntu. It is my, your, our responsibility to strengthen collaboration for the reforms.”

Michel Sidibé, the Executive Director of UNAIDS, co-chaired a panel meeting with Ms Anyang Agbor at the RCM–Africa session. During the panel meeting―entitled “Upscaling durable solutions, including addressing the forced displacement–development nexus”―the participants noted that more than a third of the world’s displaced people are in Africa. The participants agreed on the need to understand and address the root causes of displacement and build on what is known to work to break the cycle of vulnerability. Mr Sidibé emphasized that fostering resilient societies means first addressing the challenge of income inequality.

The RCM–Africa session was held on 23 and 24 March.

Ahead of Zero Discrimination Day, young people came together in Cairo, Egypt, to learn how to respond to HIV-related stigma and discrimination and to hear about how the HIV epidemic affects Egypt and the role that young people can play in the AIDS response.

“The burden of the epidemic is higher on young people. In Egypt, it is for young people to lead the HIV response,” said Walid Kamal, Egypt’s National AIDS Programme Manager.

During a discussion on stigma and discrimination, people living with HIV shared some of their testimonies and experiences, helping to give the participants a deeper understanding of how stigma and discrimination affects people living with HIV.

“It is our responsibility to help people living with HIV feel part of the community,” said one of the participating young people.

“It is not only about AIDS, it is about social justice, equality, the empowerment of women and promoting healthy gender norms,” said Ahmed Khamis, the UNAIDS Country Manager for Egypt.

The participants also learned how to plan, design and implement online awareness and advocacy campaigns on social media.

At the end of the meeting, organized by UNAIDS and the National AIDS Programme and held on 21 February, the young people agreed to lead social media campaigns to highlight the harm caused by stigma and discrimination. Starting on 1 March, Zero Discrimination Day, and running for three weeks, the campaigns will be supported by the UNAIDS country office in Egypt and are endorsed by Egypt’s Ministry of Health and Population.

In response to a call by women living with HIV in Egypt for an increase in the availability of quality sexual and reproductive health services delivered free from stigma and discrimination, UNAIDS mobilized partners and engaged with Egypt’s national AIDS programme.

The result was a pilot project that ran from 2016 to 2018 in which almost 300 women across the country were provided with family planning, antenatal care, support during delivery, postpartum care and guidance on the prevention of mother-to-child transmission of HIV.

On 30 May, national stakeholders, including representatives of the Ministries of Foreign Affairs and Health and Population, civil society, academia and people living with and affected by HIV, gathered to highlight the key achievements, experiences and lessons learned from the pilot.

“I benefited from the project counselling service throughout my pregnancy. I started taking medicine, and, with follow-up, I had a child free from HIV, which I never thought was possible or an option,” said an Egyptian woman living with HIV.

The pilot project achieved outstanding results, reaching nearly double the number of people originally planned to be reached and building institutional expertise in sexual and reproductive health. Counselling and psychosocial support was provided by health professionals and supported by women living with HIV.

“This project is a continuation of the collaboration and fruitful partnership between UNAIDS and the Egyptian Government. We congratulate the Government of Egypt for addressing the needs of a highly marginalized population,” said Ahmed Khamis, the UNAIDS Country Manager for Egypt.

Dr Ahmed Khamis, UNAIDS Country Manager, gives the opening speech on the closing and final dissemination of key results of the “Enhancing Sexual and Reproductive Health of Women Living with HIV” pilot project; with Dr Alaa Eid, Under Secretary for Preventive Medicine, Ministry of Health and Population, H.E. Laurens Westhoff, Ambassador of the Netherlands in Cairo and Ambassador Seif-alla Kandeel, Director of UN Specialized Agencies, Ministry of Foreign Affairs (from left to right). Photo taken by Mohamed Ezz

The pilot programme was funded through financial support from the Embassy of the Netherlands in Egypt and covered the Giza and Gharbia Governates of Egypt and was later extended to the Dakahlia Governate.

“The Netherlands is strongly committed to curbing the spread of HIV worldwide as an integral part of our contribution towards the achievement of the Sustainable Development Goals. We are proud of our partnership with UNAIDS and the Egyptian Ministry of Health. The Netherlands Government is committed to participate in the next step,” said Laurens Westhoff, Ambassador of the Netherlands to Egypt.

As the next step, the Netherlands is finalizing an agreement for a scaled-up three-year project, doubling the number of women living with HIV reached.

“There is no silver bullet to combat HIV. It’s only through partnership that the challenges of awareness, attention and access to medicine can be tackled,” said Seif-Allah Kandeel, Director, United Nations Specialized Agencies, Egyptian Ministry of Foreign Affairs.

Stigma and discrimination and other human rights violations occur in health-care settings worldwide, barring people from accessing health services or enjoying quality health care. Such stigma and discrimination further increases the vulnerability of people living with and affected by HIV.

To discuss this problem, nearly 300 Egyptian medical students, representing 18 universities across Egypt, met with representatives of academia, civil society, the government and the Egyptian Medical Syndicate. With support from UNAIDS, the Egyptian branch of the International Federation of Medical Students’ Associations held a one-day consultation on HIV-related stigma and discrimination in health-care settings on 21 April in Cairo, Egypt.

“People living with HIV should have equal rights and opportunities. Denial of access to health-care services is unacceptable. Through this consultation, we aim to inform our national strategy with new interventions for addressing stigma and discrimination,” said Walid Kamal, the National AIDS Programme Manager for Egypt.

During the consultation, the participants took stock of the progress made in addressing stigma and discrimination and decided to hold an ongoing dialogue to identify actions to address stigma and discrimination in health-care settings.

“We are witnessing an unprecedented opportunity for addressing discrimination in health-care settings with political support and programmatic vision. While resources are scarce, we count on the support of medical students as leaders of tomorrow and the power of volunteerism to address this issue,” said Ahmed Khamis, the UNAIDS Country Manager for Egypt.

The participants agreed that accountability mechanisms need to be in place to monitor and evaluate interventions, ensuring that proper actions are taken by the relevant authorities to address rights violations in health-care settings.

“Medical ethics is a must among health-care providers. The Egyptian Medical Syndicate is organizing workshops and conferences to enforce ethics among health-care providers. I would like to remind you all of the rights of patients,” said Sherine Ghaleb, representative of the Egyptian Medical Syndicate.

The participants agreed to prioritize launching the Ministry of Health and Population’s stigma-free policy and integrating HIV-related stigma and discrimination in the module on ethics taught to all doctors who graduate in Egypt. They also agreed to give access to the accountability and investigation mechanism of the Egyptian Medical Syndicate to civil society organizations and people living with HIV in order to report violations and to roll out information on post-exposure prophylaxis in the curricula of medical schools.

The recommendations made during the consultation were endorsed by the National AIDS Programme and will be included in Egypt’s road map for addressing HIV stigma and discrimination in health-care settings. Progress of the road map will be monitored by a group that includes a strong representation from people living with HIV.

Morocco marks 30 years of its response to HIV in 2018, with much to celebrate. Concerted efforts in the country have resulted in a 42% reduction in new HIV infections since 2010, significantly greater than the decline across the Middle East and North Africa of just 4%. HIV treatment coverage has also increased in the country, from 16% in 2010 to 48% in 2016.

Morocco has also managed to keep HIV prevalence low among the general population (0.1%). However, there are areas of serious concern. Data show that HIV prevalence is high among populations at higher risk of HIV infection, such as female sex workers (1.3%), people who inject drugs (7.9%) and migrants (3%), showing the need to do more to reach key populations with HIV services. Morocco is scaling up efforts to reach key populations through combined prevention programmes, substitution treatment for people who use drugs and increasing HIV testing.

The Executive Director of UNAIDS, Michel Sidibé, visited Morocco to show his support to the 30-year response to HIV. During the visit he met with the President of the National Council of Human Rights (CNDH), the Secretary-General of the Ministry of Health, the Minister of Foreign Affairs and International Cooperation and the United Nations Resident Coordinator and Country Team.

He stressed the importance of the United Nations Country Team’s commitment to United Nations reform and to responding to HIV through the Joint Plan. He noted the importance of having a national strategy on human rights and HIV and congratulated the CNDH as a pioneer in the region. He praised the initiative of the CNDH for carrying out training in human rights and citizenship and highlighted the important role that Morocco can play in efforts to recruit 2 million community health workers in Africa and in encouraging the local production of medicines.

Mr Sidibé congratulated the Minister of Foreign Affairs and International Cooperation on the progress of the AIDS response under the leadership of King Mohammed VI, the government’s partnership with civil society and the increase in domestic funding for HIV.  

Mr Sidibé took part in the opening ceremony of the 12th meeting of the Association for the Fight against AIDS (ALCS) to celebrate the 30-year response. ALCS has been at the forefront of the response to HIV in Morocco, working on prevention for key populations, HIV counselling and testing, psychosocial support, advocacy, resource mobilization and introducing new innovations, including community screening and pre-exposure prophylaxis.

At the end of 2016, there were estimated to be 22 000 people living with HIV in Morocco, fewer than 1000 new HIV infections and fewer than 1000 AIDS-related deaths. UNAIDS is working closely with Morocco to expand innovative approaches to HIV prevention and testing for key populations, expand antiretroviral treatment services and their integration into the health system, implement a road map to eliminate mother-to-child transmission of HIV and implement a strategy for zero discrimination. UNAIDS also coordinates the United Nations Joint Support Plan and works to ensure the availability of strategic information and mobilize and implement grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria.