Middle East and North Africa

From left to right: Ms. Mahasen Abdelarman, wife of the governor of River Nile State; Dr Hamidreza Setayesh, UNAIDS Country Coordinator; H.E. Mdm Widad Babiker, Wife of the President of Sudan, and other wives of governors and civil society members of “Sudanese Coalition of Women and AIDS”, December 2012, Atbarah, River Nile.

Despite years of conflict and humanitarian emergencies, Sudan is stepping up its response to HIV. Across Sudan there are an estimated 69 000 people living with HIV and HIV prevalence is at 0.4%. Estimates also show that only 10% of the estimated number of people in need of antiretroviral treatment are receiving it.

Sudan has one of the largest populations of people living with HIV in Middle-East and North Africa, and the country is moving forwards in addressing some of the obstacles which have been preventing scale up of HIV prevention, treatment and care. Today, more than 150 centers are providing testing and counselling, and 32 treatment sites have been established around the country to make access to antiretroviral treatment more widely available.

At a meeting organized by the Sudanese Coalition on Women and AIDS* in Atbarah, River Nile State, government officials together with the Sudanese Coalition of Women and AIDS reaffirmed their commitment to providing a comprehensive response to HIV.

Her Excellency Widad Babiker, the wife of the President of Sudan, addressed participants and called for stronger partnerships to prevent new HIV infections. She said “In addition to federal and local governments, responsibility for HIV prevention remains with each of us. We shall commit to a generation free of stigma and discrimination and free from HIV. One of the ways to do that is to expand HIV testing for pregnant women.”

Participants discussed and learnt about the response to HIV in their country and throughout the Arab world. They debated human rights issues, particularly for women and girls in the context of HIV and learnt that the Middle-East and North Africa region has one of the fastest growing HIV epidemics in the world, meaning that prevention interventions in the region have not been sufficient to stop the spread of the epidemic.

Participants agreed that all sectors of the country will need to contribute to the development of an effective AIDS response that is evidence-based and anchored in the respect for human rights. During the meeting they put together a work plan for each constituency which includes supporting women living with HIV, leading stigma reduction campaigns, mobilizing charities and championing the “show your love, take the test” campaign which is designed to scale up efforts to stop new HIV infections in children.

The Sudanese government demonstrated firm commitment. At a press conference attended by three federal Ministers on the occasion of World AIDS Day, His Excellency Dr Ahmed Bilal, the Federal Minister of Culture and Communication and spokesperson of the Sudanese government said, “HIV is a reality in Sudan and cannot be effectively addressed if we continue to put our heads in the sand.”

His Excellency Dr Amira El-Fadil, Minister of Welfare and Social Security called for a building of sustainable partnerships with civil society, youth organizations and the media as well as the imams and religious leaders to reach all sectors of the population. Dr Bahar Idris, Federal Minister of Health added that reducing new HIV infections will need a significant multi-sectorial effort, “We cannot continue to live in denial and attribute AIDS to neighboring countries,” he said.

UNAIDS Country Coordinator, Dr Hamidreza Setayesh, commended the country’s political commitment to the AIDS response. He also stressed the need for a rapid and significant scale up in the coverage of HIV-related services as well as an increase in domestic resources for AIDS in Sudan. “It is unfortunate and unacceptable to see that 9 out of 10 people in need of antiretroviral treatment in Sudan are deprived of these life-saving measures,” said Dr Setayesh. “With the strong commitment demonstrated by the government and the leadership of Her Excellency Madam Widad, Sudan can show to the region and the Islamic world that universal access is achievable.”

*The Sudanese Coalition on Women and AIDS consists of wives of state governors, women living with HIV, Sudan AIDS Network member associations and local and federal authorities.

UNAIDS Deputy Executive Director, Management and Governance, Jan Beagle and Dr Ziad Memish, Deputy Minister for Public Health, Kingdom of Saudi Arabia.

The Arab region is breaking new ground in its actions on HIV and AIDS. “The increasing number of HIV infections and AIDS-related deaths indicate the importance of developing a clear roadmap for the Arab region with achievable goals” said Dr. Ziad Memish, Deputy Minister for Public Health of the Kingdom of Saudi Arabia.  He pledged the commitment of Saudi Arabia to continue its leadership in the development of the Arab AIDS Initiative, launched by the Arab Ministers of Health in October 2011, to scale up the HIV response at regional and national levels to achieve the targets set in the 2011 United Nations Political Declaration on HIV/AIDS.

At a meeting  convened by the Kingdom of Saudi Arabia, under the auspices of the League of Arab States and supported by UNAIDS, governmental and non-governmental representatives recognized the need for urgent action as MENA is one of only two regions where the epidemic continues to grow. While overall numbers may be relatively low, estimates from the UNAIDS Global Report released in November 2012 indicate an increase in new HIV infections and AIDS-related deaths in MENA region. Since 2001 the number of people newly infected with HIV has increased by more than 35%, with a significant increase in AIDS-related deaths. The report also shows that despite a doubling of the number of people accessing HIV treatment in the region between 2009 and 2011, coverage of HIV treatment remains very low, at 15%.

Participants agreed that the guiding principles for the development of the Arab AIDS Strategy should include; evidence based and rights based; people centered; multi-sectoral; integrated; and gender and youth sensitive. The strategy should recognize and leverage the diversity of HIV situations and responses in the region.

“AIDS is not only a health issue, but a social and developmental issue that demands a coordinated evidence-based response” said Dr. Laila Negm, Director of the Health and Humanitarian Aid Department, League of Arab States. She emphasised the need for political mobilisation to address prevention, treatment, and stigma and discrimination and said that the region would count on the continued support of UNAIDS to move the Strategy forward.

“There is a window of opportunity for the region to demonstrate that it can be among the first to end AIDS, and leverage the AIDS response for broader health, human rights and development outcomes” said Ms. Jan Beagle, Deputy Executive Director of UNAIDS.

A new handbook to help design and implement HIV programmes focusing on men who have sex with men (MSM) in the Middle East and North Africa (MENA) was released on 27 September by UNAIDS in Cairo, Egypt. The handbook was presented at a workshop organized by the World Health Organization entitled "HIV Among Key Populations at Increased Risk of Sexual Transmission".

Entitled “HIV and Outreach Programmes with Men who Have Sex with Men in the Middle East and North Africa: From a Process of Raising Awareness to a Process of Commitment”, it aims to provide countries that are currently implementing MSM programmes with additional tools to improve them. It also provides other countries willing to initiate MSM programmes with sufficient elements to do so.

The new publication describes in four modules the whole cycle of a national HIV outreach programme aimed at engaging MSM. These four modules include: Situation analysis; outreach programme conceptualization, outreach approach, and monitoring. Each module contains scientific data and practical steps.

Prevailing taboos hamper the AIDS response

Sexuality and sexually transmitted infections (STIs) are sensitive issues that are rarely discussed in the MENA region and homosexuality and transexuality remain taboo subjects, according to the new report.

"Most countries in the region criminalise same sex relations making it virtually impossible for this key population to seek or receive the necessary HIV prevention, treatment and care services," said Ali Feizzadeh, Senior Strategic Information Advisor at UNAIDS.

An increasing number of bio-behavioural surveys in the region show that the AIDS epidemic is concentrated within key populations at higher risk—notably MSM. The same surveys reveal that MSM regularly change sexual partners, and may be drug users or sex workers while their knowledge of STIs remains limited.

The new UNAIDS publication stresses that, while the current regional AIDS response is characterized by low coverage of HIV prevention programmes for key populations at higher risk, there is a growing awareness of the need to work with populations such as MSM on HIV prevention in the region. Currently, these efforts are mainly undertaken by non-governmental associations.

"All the countries in the region approved the Human Rights Declaration, however, some sensitive areas of work cannot be undertaken by the present governmental bodies. The role of the Civil Society is to bridge the gap between national support and the actual need,” said Elie Aaraj, President of the Regional/Arab Network Against AIDS (RANAA) and Executive Director of MENAHRA. “This handbook will give a strong theoretical and technical background and support to outreach workers; be it health care providers or peer educators," he added.

The UNAIDS handbook provides useful information, tips and tools to effectively reach MSM communities, establish trust and build relationships through continuous dialogue. The handbook emphasizes the importance of engaging the MSM population in the effective design of HIV outreach programmes.

The handbook is the result of the analysis of existing programmes and fieldwork conducted by partner civil society organizations in nine countries across the region. It complements the recently published WHO Guidelines that focus on good practice recommendations in the area of prevention and treatment of HIV and other STIs among MSM and transgender people.

African leaders gather to review progress made in the implementation of the 2001 Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases and call for sustainable strategies to advance health towards 2015 and beyond.

L to R: President of Benin, Yayi Boni, United States Secretary of State Hillary Rodham Clinton and UNAIDS Executive Director Michel Sidibé
Credit: UNAIDS/B.Hamilton

NEW YORK/GENEVA, 26 September 2012— African leaders gathered in New York on the sidelines of the 67th Session of the United Nations General Assembly to discuss the African Union (AU) Roadmap. This initiative outlines long-term sustainable strategies to finance and provide access to HIV treatment and prevention services and other health services in Africa as called for in the Millennium Development Goals.

“Ten years after Abuja, millions of lives have been saved and Africa has prospered,” said President of Benin Boni YAYI, in his capacity as Chairperson of the African Union. “These foundations have to be made permanent for this generation and for all our future generations.” President Boni YAYI presented the African Union’s Roadmap for Shared Responsibility and Global Solidarity for AIDS, Tuberculosis and Malaria.

Shared responsibility and global solidarity

President Joyce Banda of Malawi embraced the concept of shared responsibility. “I am fully committed to mobilizing additional domestic resources while ensuring efficient use of external funds,” she said in a statement of support to meeting. President Banda also highlighted her country’s pioneering work to “ensure all HIV positive pregnant women, irrespective of their CD4 count, commence antiretroviral therapy and take HIV treatment for the rest of their lives.”

The transformation of access to health in Africa has come from inspired African leadership coupled with strong international support. Health investments, from funders and domestic resources have expanded manifold in Africa. Weak health systems have been replaced with a greater focus on human resources and ingenuity to provide health care in remote areas.

United States Secretary of State Hillary Rodham Clinton addressed the gathering and recognized the renewed commitment by the African Union to the AIDS response. “If every nation devastated by HIV follows the example of many of the leaders in this room and steps up to shared responsibility, we won’t just keep up our momentum—we will accelerate our progress and move even faster toward the day when we can announce the birth of an AIDS- free generation,” she said.

Towards the 2015 goals and the post 2015 agenda

With three years to go to meet the Millennium Development Goals, as well as the global AIDS targets agreed to in the 2011 United Nations Political Declaration on AIDS, participants echoed the need for strong political leadership and enhanced country ownership.

As a first step, African leaders agreed to accelerate the implementation of the Roadmap on Shared Responsibility and Global Solidarity for AIDS, Tuberculosis and Malaria adopted by the African Union in July 2012.

“Africa has not only shown that it cares but that it has increased its capacity to provide health care for its people. Millions of lives have been saved as investments into healthcare have increased—both domestic and international,” said Michel Sidibé, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) who moderated the high-panel debate. “For every African to realize their right to health, a new paradigm of sustainable health services has to be put in place. For this we must secure the investments needed, secure good laws, secure the science, secure shared responsibility and global solidarity as well as secure access to lifesaving health services.”

United Nations Special Envoy for Global Education Gordon Brown speaking at the event.

A key to this agreement is advancing a new model of mutual accountability that can help unite African governments and their development partners in a series of practical actions and which will bring Africa closer to ending the AIDS epidemic. Data released this year by UNAIDS shows that scientific advances and improved programme practices have helped to reduce the number of new HIV infections and AIDS-related deaths. Life-saving HIV treatment is now reaching more than 8 million people around the world—more than 6 million of which are in Africa, the region most affected by the epidemic.

“This is the time for Africa to intensify its efforts and create a new international compact against AIDS,” said President Macky Sall of Senegal.

During the dialogue it was agreed that the capacity of AIDS Watch Africa be strengthened. It was also suggested that AIDS Watch Africa, the African body mandated to ensure accountability for action, create a new model of accountability in consultation with Africa’s development partners.

Sustainable and innovative health financing

The leaders, which also included the Presidents of Comoros, Equatorial Guinea and Namibia, the Deputy Prime Minister of Kenya and development partners including France, Sweden, Brazil, the African Union Commission, European Commission and World Bank, also discussed ways to ensure that health financing is adequate and sustained. In recent years many countries in Africa have adopted innovative ways of generating resources for health, beyond traditional means. For example, Rwanda and Uganda now place levies on mobile phone usage with proceeds supporting HIV programmes. Zimbabwe’s AIDS levy now provides about US$ 30 million as the country’s economy expands. Social health insurance is also being explored by many countries.

At the same time domestic investments for health have increased, but the majority of countries have not yet met the Abuja target of allocating 15% of government budget to health. Leaders at the meeting agreed that this goal should be maintained and all efforts be taken to achieve this target. However they also agreed that international investments, which have remained stable in recent years, must be sustained and increased. They also called for new and diversified sources of international investments—especially from countries with emerging economies.

Sustainable access to medicines

A majority of the pharmaceutical needs of Africa are met through imports. The need to boost local capacity to manufacture essential quality-assured medicines as well as developing regional markets for them, including through common regulatory frameworks was highlighted at the event.

“Africa must be a source of knowledge and science, not just needs and wants,” said President Moncef Marzouki of Tunisia. “We will make all efforts to ensure that Africa meets more of its pharmaceutical needs through increased local production.”

Getting to zero

“If every girl and every boy goes to school and is taught about HIV prevention we can reach the global goal of Zero new HIV infections, zero discrimination and zero AIDS-related deaths,” said Gordon Brown, the United Nations Special Envoy for Global Education. “To the UNAIDS vision of Zero if we add zero illiteracy, we can end AIDS faster.”

There are nearly 23.5 million people living with HIV in Africa. New HIV infections in the region have declined by 22% since 2001. By the end of 2011, an estimated 56% of people eligible for HIV treatment in sub-Saharan Africa were accessing it—with treatment coverage increasing by 22% across the region between 2010 and 2011.

Internally displaced woman with 8 day old baby
Credit: UNAIDS

“I want my child to be born HIV negative”, said Mr Mohamoud Mohamed Ahmed, accompanied by his smiling and visibly pregnant wife, Mrs Nasteho Farah Elmi, at a recent discussion with people living with HIV in Mogadishu. This bullet-ridden, crumbling city has a network of five hundred people living with HIV. Created by the South Central AIDS Commission of Somalia, its proactive Director, Mr Ahmed Mohamed Jimale, solves such concerns by directing women to clinics for the prevention of transmission of HIV from the mother to her unborn child. But, there is much frustration due to lack of funding for such services.

Little is known about HIV in Somalia – and even less so in Mogadishu, security concerns limiting the collection of data. The most recent verifiable data obtained was in 2004. Since then, estimates of 0.7% to 1% prevalence have been assumed. However, analysis of data from Voluntary Counselling and Testing Centres and in Tuberculosis clinics indicate HIV infection rates of up to 18% among people with TB and 5.2% among female sex workers. Throughout Somalia conditions exist for a growing epidemic: increased trade, migration and the sprouting of sex work at borders and ports.

The Minister of Women’s Development and Family Care, Mrs Maryam Aweis Jama, expresses deep concern about the lack of resources: “The Somali government has negligible resources for running the government, leave alone funding HIV programmes. We urgently need resources to fight stigma, discrimination and violence towards women living with HIV and their families”. Religious leaders – both male and female – are increasingly active in raising awareness of HIV issues. “We, as religious leaders, can have a major influence on society by creating awareness of HIV issues at Friday sermons”, says Mr Sharif Ibrahim Abdullahi. A woman religious leader, Mrs Hawo Siidow Abdi, reinforces this, saying that she speaks to women in mosques on a one to one basis to assist them to better understand the HIV epidemic. Ms Hind Khatib, Director, UNAIDS Middle-East and North Africa Regional Support Team said, “It is gratifying to know that these religious leaders, after participating in regional HIV training events, carry back messages to their communities.”

With the relative improvement of security in Mogadishu, the city is attracting a growing number of internally displaced persons in search of better livelihoods. They live under dire conditions, with little protection or access to basic services. World Food Programme feeding centres service the displaced and vulnerable populations. “The large numbers of people at these feeding sites could be a prime target for HIV education”, noted Mr. Kilian Kleinschmidt, the United Nations Deputy Humanitarian Coordinator, during a recent site visit.

Mogadishu is characterized by a highly militarized environment with police and militia evident everywhere. Mr Abdinor Osman Weheliya, of the NGO, Organisation for Somalis Protection and Development, said that often in the evenings women stand outside the military installations in search of an opportunity to exchange sex for survival money, making them highly vulnerable to HIV infection.

Most seriously, among communities visited and in the general population, there is a stark lack of awareness and understanding of the HIV epidemic. “If prevention of HIV is not undertaken with an immediacy and urgency, HIV could be another time bomb waiting to explode in Mogadishu” said Dr Renu Chahil-Graf, UNAIDS County Coordinator for Somalia.

Hind Khatib-Othman, Director of UNAIDS Regional Support Team for Middle East and North Africa introducing the report with Hamidreza Setayesh, UNAIDS Regional Program Advisor, Noha El-Mikawy, Representative, The Ford Foundation, MENA and Rita Wahab, Regional Coordinator of Menarosa.

In “Standing Up, Speaking Out”, a new UNAIDS report launched on 12 July in Cairo, Egypt, 140 women living with HIV from 10 countries in the Middle East and North Africa (MENA) express the realities that shape the hopes and grievances of their lives. The voices in the report belong to members of MENA-Rosa, the first regional group dedicated to women affected by HIV.

Through face-to-face meetings, and long-distance networking, MENA-Rosa offers women living with HIV an opportunity to talk about their many trials, and occasional triumphs, in dealing with HIV, from medical matters to family affairs. But for change to take root in their personal lives, the members of MENA-Rosa are looking to fix the big picture, raising awareness among key decision makers of their many needs, and mobilizing money to reach their goals.

“There is a lot to do for women living with HIV in MENA. They face particular circumstances and have particular needs,” said Hind Khatib-Othman, Director of UNAIDS Regional Support Team for Middle East and North Africa. “The solutions are available, but we have to confront the stigma and create awareness. All efforts protecting women’s rights should include the rights of those living with HIV.”

Of the estimated 470 000 people living with HIV in MENA, approximately 40% are women. In a region that remains one of the only two where HIV infections and AIDS-related deaths continue to rise, the new report sheds light on a complex set of social, cultural and economic factors that leave women most vulnerable to infection.

One testimonial after another reveal in the report that information about living with HIV is weak at best, if not altogether missing, deeply affecting the lives of women who often face stigma and discrimination as a result of their HIV status. “At first, when they knew that I was infected, my family told me not to sleep or sit by the side of my daughter. They took her away from me. Afterwards, they started to understand that it was ok,” reveals one woman living with HIV from Yemen.

The new report stresses that women engaging in risk-related behaviour, including sex work and injecting drug use, without adequate protection are wide open to HIV infection. Some women are infected through their husbands and others through harmful traditional practices such as early marriage. Economic dependency, which reduces women’s power to negotiate safe sex or to leave violent relationships, is also associated with heightened risk of HIV infection. Gender related violence runs deep in MENA as indicated by a number of national surveys.

Sexual and reproductive health is a pressing concern in the region, the report notes. Around 20 000 pregnant women across the region are estimated to be in need of services to prevent new HIV infection among children, while only an estimated 5% are receiving the care they need.

“Women have been at the heart of change in a region where people have taken to the streets demanding a life of dignity, equality, justice and human rights,” said Amr Waked, actor, activist and UNAIDS regional goodwill ambassador. “These are the same demands of women living with HIV and they deserve no less.”

Education, HIV prevention and access to quality HIV treatment are core to the solution according to the report. Efforts to engage governments, religious and community leaders to change policies, promote gender equality and confront stigma should not be spared.

Rita Wahab, Regional Coordinator of Menarosa speaking at the launch of the “Standing Up, Speaking Out” report with Hamidreza Setayesh, UNAIDS Regional Program Advisor.

The new report compiles the changes and recommendations put forward by women living with HIV in the MENA region. Some of these changes include improved access to quality education and employment for girls and women; guaranteed access to the best available care for HIV, including sustained anti-retroviral therapy; special training of doctors, nurses to reduce stigma and discrimination towards people living with HIV; and better access to sexual and reproductive health information and services, including HIV prevention and testing, for both married and single women.

“I hope, in future, people become more open so that the person living with HIV does not become isolated from society. We did not run towards this disease, nor choose to have it,” said a woman living with HIV from Algeria.

While the task is vast, the MENA region is still at an early stage of a major epidemic and has an opportunity of stopping HIV in its tracks. Groups like MENA-Rosa are raising their voices and advocating for a reform. The shifting political order in the Middle East and North Africa presents new challenges to, and new opportunities for, a better life for all citizens. For women living with HIV, the changes they want to see cannot come soon enough.

Panellists at a conference session on 4 July focused on African innovation. (Left to right): UNAIDS Executive Director Michel Sidibé; Hon. Tim Thahane, Minister of Minerals, Energy and Water Affairs, Lesotho; Mr. Claude Sekabaraga, Senior Health Systems Strengthening and Results Based Financing Specialist, World Bank; Hon. Kebede Worku, State Minister of Health, Ethiopia; Ms Kampeta Sayinzoga, Permanent Secretary, Ministry of Finance, Rwanda.

Addressing 60 Ministers of Finance and Health at a conference in Tunis on 4 July, UNAIDS Executive Director Michel Sidibé praised African leaders for their increased engagement and partnership in HIV responses across the region.

“AIDS investments have fuelled progress across the health and development spectrum,” said Mr Sidibé, who participated in a conference session focused on African innovation.

Strategic HIV investments in Africa have yielded multiple returns. In 22 countries of sub-Saharan Africa, the rate of new HIV infections dropped by more than 25% between 2001 and 2009. More than 5 million Africans are now receiving antiretroviral treatment—up from just 50 000 a decade ago.

However, these gains are fragile. Every day, 3500 Africans die of AIDS. An estimated 5 million Africans who need HIV treatment are still not accessing it. About 300 000 children in Africa continue to be born with HIV every year.

In the current economic downturn, scarce resources must be used with greater efficiency, transparency and accountability, said the UNAIDS Executive Director, in a presentation entitled African solutions to achieve greater value for money. He highlighted cost-effective policies and programmes that have delivered sustainable results on the ground.

In South Africa, for example, unit costs of HIV drugs have been significantly reduced as more people access treatment—from US $500 to $200 per person. Other countries have reduced programme costs by eliminating parallel structures and stand-alone health services.

Investing in innovation

African leaders can accelerate progress by investing in innovation, said Mr Sidibé. Through partnerships with emerging and industrialized economies, they should facilitate the transfer of technologies for medicines and commodities. By focusing resources on HIV research and development, they could build Africa’s knowledge-based economy, he added.

Mr Sidibé encouraged ministers attending the conference to reduce Africa’s dependency on imported HIV medicines through the local production of antiretroviral drugs. He said that a single drug regulatory authority in Africa could ensure the faster roll out of quality-assured medicines.

A new paradigm

Africa is poised to transcend the outdated donor-recipient paradigm, said the UNAIDS Executive Director. Leaders are beginning to embrace a new global compact for shared responsibility and national ownership, he said.

Organized by Harmonization for Health in Africa and hosted by the African Development Bank, the two-day conference in Tunis brought together ministers, parliamentarians and high-level representatives from international organizations, civil society and the private sector.

UNAIDS Executive Director Michel Sidibé met on 3 July with the President of Tunisia, Moncef Marzouki (right) and other high-level government officials.

Meeting on 2-3 July with top officials of Tunisia’s new tripartite coalition government, UNAIDS Executive Director Michel Sidibé praised the country’s leadership for its strong commitment to reducing stigma and discrimination—a key barrier to progress in HIV responses across the region.

While Tunisia has a relatively low HIV prevalence, at about 0.06% of the national population, evidence has shown pockets of high HIV prevalence among key populations, including injecting drug users, sex workers and men having sex with men. These populations often face stigma and discrimination which can hamper access to health services and nurture the HIV epidemic.

In his discussions with the President of the Republic, Moncef Marzouki, Head of Government, Hammadi Jebali, and Vice-President of the National Constituent Assembly, Meherzia Laabidi—three leaders who recently came to power in the country’s first democratic elections—Mr Sidibé noted that youth were the engine of the revolution that brought political change to Tunisia.

“Investing in young people and responding to their aspirations for a more just and equitable society will be critical to the future advancement of this country,” said Mr Sidibé. “Youth can play an important role in accelerating Tunisia’s response to HIV and other health challenges,” he added.

Increasing local production of HIV medicines

Speaking with Mr Sidibé at the Presidential Palace on 3 July, President Marzouki expressed his strong commitment to strengthening the national HIV response. He said that Tunisia would strive to achieve the vision of “three zeroes”—zero new HIV infections, zero discrimination, zero AIDS-related deaths—and highlighted three priority areas for action: improving public health, ensuring human rights and addressing the socio-economic drivers of HIV.

The President noted that Tunisia could help reduce Africa’s dependency on external aid by producing antiretroviral medicines. He pledged to advocate for greater local production of medicines at the next meeting of the New Partnership for Africa’s Development (NEPAD) in Addis Ababa. Currently, a majority of drugs dispensed in Tunisia—and across the African continent—are imported.

Reducing dependency on external aid

In a meeting with Mr Sidibé later that day in La Kasbah Palace, Tunisia’s Head of Government echoed the President’s remarks on local drug production. “I support the idea of Tunisia producing antiretroviral medicines to reduce its dependency on external aid,” said Mr Jebali. “The production of antiretrovirals presents not just an economic opportunity, but also a humanitarian opportunity,” he added.

There was mutual agreement between Mr Jebali and Mr Sidibé that Tunisia should assume greater ownership of HIV prevention programmes that support key affected populations; currently, such programmes are funded exclusively through international sources.

Acknowledging high-risk behaviours

It is time for Tunisia to face the facts on HIV, said the country’s Vice-President, Meherzia Laabidi, in a separate meeting with Mr Sidibé at the Palace of the Assembly. “We must move beyond official political denial. Just closing our eyes won’t stop the fire,” she added.

UNAIDS Executive Director Michel Sidibé (left) with the Tunisian Head of Government, Hammadi Jebali.

In her discussions with Mr Sidibé, the Vice-President recognized that ensuring a socially inclusive society is the responsibility of political leaders. She said that neglecting key populations at high risk of HIV infection puts everyone in danger. “We need to recognize the existence of high-risk behaviours in our societies, such as injecting drug use, sex between men and commercial sex,” she said.

Noting that access to basic health services is a human right, Ms Laabidi underscored the importance of including the “right to health” in the new Tunisian constitution, currently under development.

During his two-day mission in Tunisia, the UNAIDS Executive Director met with several other government officials, including the Minister of Health, Dr Abdellatif El Mekki, and the Minister of Human Rights and Transitional Justice, Samir Dilou. He also engaged with people living with HIV, representatives from key affected communities and the United Nations country team.

The HIV prevalence among people who inject drugs in the Libyan capital Tripoli is at an alarming 87% according to the results from bio-behavioral surveys conducted by the Liverpool School of Tropical Medicine with the support of the European Union. Reaching out to 328 injecting drug users, 227 men who have sex with men (MSM) and 69 female sex workers, the study was designed to indicate the progression of HIV prevalence among key populations at higher risk.

The results of the study were presented during the first National HIV Symposium in post-conflict Libya that took place 26 June in the Libyan capital Tripoli under the auspices of the Libyan Minister of Health in collaboration with the Joint United Nations Programme on HIV/AIDS (UNAIDS), the World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC).

In light of the new evidence, the Libyan Minister of Health, H.E. Dr Fatima Elhamrosh called for urgent action from all concerned sectors in Libya. “We will need to develop and implement comprehensive programs to respond to the growing AIDS epidemic among key populations in Libya,” said Minister Elhamrosh.

Before the revolution that took place in the spring of 2011, it was difficult for UNAIDS and international development partners to work systematically in Libya. AIDS was not openly discussed nor considered a priority. The new data confirms that the HIV situation in Libya is worse than what was officially reported in the past.

“We very much welcome the remarkable political commitment of the government of Libya towards responding to the AIDS epidemic,” said Hind Khatib, Director of UNAIDS Regional Support Team for Middle East and North Africa. “The commitment of Her Excellency, the Minister of Health to expand drug treatment services providing a range of evidence-based responses and the establishment of eight Voluntary Counselling and Testing centers focusing on key populations are clear examples of the growing governmental commitment,” added Ms Khatib.

UNAIDS recommendations in relation to HIV prevention responses among injecting drug users stress the need to develop a comprehensive set of measures consisting of the full range of treatment options—notably drug substitution treatment—and the implementation of harm reduction measures—through, among others, peer outreach to injecting drug users, and sterile needle and syringe programmes. Also, voluntary confidential HIV counseling and testing, prevention of sexual transmission of HIV among drug users (including condoms and prevention and treatment for sexually transmitted infections), access to primary healthcare and access to antiretroviral therapy. Such an approach must be based on promoting, protecting and respecting the human rights of drug users.

Following the change of government, UNAIDS has provided technical support to the Ministry of Health and UN Country Team in Libya to address the emerging HIV priorities. This has resulted in better identification of priorities, improved understanding of the HIV situation and response, the establishment of the Joint UN team on AIDS and improved commitment from the government, UN and civil society organizations.

At the end of the symposium, participants endorsed a statement of commitment to scale up the national AIDS response in Libya with focus on HIV prevention programs among key populations, rights of people living with HIV and expanded role of civil society in the national response.

UNODC also re-launched the second phase of their HIV project in Libya that focuses on HIV prevention among people who injecting drug and in prison settings. The project, funded by the Libyan government, was suspended in 2011 due to the security problems and is now being resumed.

"UNODC warmly welcomes the expressions of political will and commitment by the Libyan government to respond to the HIV and drug use crisis as a matter of national priority,” stated Masood Karimipour, Regional Representative of United Nations Office on Drugs and Crime. “UNODC is proud to be in partnership with Libya to help provide a comprehensive response to prevent drug use and the spread of HIV as well as to treat people in need in coordination with all national stakeholders, UNAIDS and the international community,” Added Mr Karimipour.

UNAIDS Executive Director Michel Sidibé (right) met with a group of young Moroccans on 4 April at the national headquarters of OPALS in Rabat.

Speaking with a group of young Moroccans on 4 April, UNAIDS Executive Director Michel Sidibé urged youth across the country—and region—to break the silence on AIDS and lead a revolution in HIV prevention.

“Young people were at the forefront of revolutions that brought political change to this region. I urge youth to launch a similar movement to stop new HIV infections,” said Mr Sidibé, addressing a group of young people at the national headquarters of OPALS (Organisation Pan Africaine de Lutte contre le sida), a non-profit organization based in Rabat.

Over the past decade, the number of new HIV infections among adults and children in the Middle East and North Africa increased from 43 000 to 59 000, according to UNAIDS estimates. In 2010, there were an estimated 470 000 people in the region living with HIV, up from 320 000 in 2001.

During the meeting, Mr Sidibé expressed concern over widespread stigma and discrimination in the region against people living with HIV and populations at high risk of infection, including sex workers, people who inject drugs and men who have sex with men. He noted that stigma drives vulnerable populations underground and away from HIV and health services.

Across the region, the special needs of youth—particularly sex workers, people who inject drugs, men who have sex with men and people living with HIV—remain inadequately addressed, noted the UNAIDS Executive Director.  He underscored the importance of empowering all young people with the knowledge and resources they need to lead a healthy sexual lifestyle.

Through 17 drop-in clinics, OPALS provides health services, access to condoms and HIV testing for young people, women, migrants, sex workers and other vulnerable populations in Morocco. Representatives from OPALS also travel in remote areas, providing door-to-door HIV testing and other prevention services.

In the meeting with Mr Sidibé, several young people highlighted the lack of sexual education in Morocco—both at school and within families. They expressed enthusiasm for UNAIDS’ youth-led policy project CrowdOutAIDS, which leverages new technologies to enable young people to fully participate in the development of the organization’s strategy on HIV and youth. Since the launch of the project in October 2011, some 5000 young people around the world have taken part.

Reaching most-at-risk populations

During his three-day mission to Morocco, Mr Sidibé paid a visit to the Association de Lutte contre le sida (ALCS) in Rabat, the first AIDS association established in the Maghreb region and the Middle East. Mr Sidibé praised Hakima Himmich, President of ALCS, and her staff for the organization’s excellent contribution to the HIV response—particularly its efforts to prevent HIV among populations at high risk of infection.

ALCS was established in 1998 when there were just 30 registered cases of AIDS in Morocco. In 1992, ALCS opened its first voluntary HIV testing and counselling centre, and since 1995, the organization has offered HIV prevention programmes for key populations at high risk of infection.

By 2011, more than 122 000 people at high risk of infection—including vulnerable and bridge populations (for example, clients of sex workers)—were benefiting from HIV prevention programmes in Morocco, largely through ALCS.  That same year, an estimated 58 000 people in Morocco were tested for HIV, many of them through ALCS.

According to studies conducted in 2011 by Morocco’s National AIDS Programme, ALCS and UNAIDS, 45% of sex workers and men who have sex with men in the country are currently reached through HIV prevention programmes and the rate of condom use among these key populations is about 50%.

During his visit to ALCS, Mr Sidibé sat in on a group discussion with women focused on HIV prevention. He also met a peer support group for people living with HIV and spoke with health personnel at an HIV testing centre.