Epidemiological features of HIV/AIDS in the Middle East and North Africa from 1990 to 2017

Abstract

The growing trend of HIV/AIDS is a major concern in the Middle East and North Africa (MENA) regions, as its incidence in the region has increased by 31% in the last decade. The study population in the countries of the MENA region included 21 countries with a population of approximately 400 million. The Global Burden of Disease database was used to calculate the number of HIV/AIDS cases. Modeling for each country is based on the availability and quality of data. The highest incidence rates of HIV/AIDS were in Sudan, United Arab Emirates (UAE), Tunisia, and Iran, respectively, and the highest mortality rates were in Sudan, UAE, Oman, and Morocco, respectively. The incidence, prevalence and mortality rates, as well as the disability adjusted life years (DALYs) rate declined in 2017 compared to 1990. The highest percentage of changes in DALY rates was reported for Turkey, the United Arab Emirates (UAE), and Sudan, respectively, and the lowest for Qatar, Kuwait, and Bahrain. In general, unsafe sex had the highest impact on the DALY index in all countries in the region except Iran and Bahrain. Policymakers should therefore be encouraged to develop harm reduction programs for people living with HIV, and invest globally in reducing HIV prevalence rates in commercial sex workers, people who inject drugs, and men who have sex with men in the region, as well as eliminating mother-to-child HIV transmission.

Keywords

Human immunodeficiency virus,acquired immunodeficiency syndrome,disability-adjusted life year burden of disease Middle East North Africa

Introduction

HIV/AIDS is an important public health issue worldwide.¹ According to the Joint United Nations Programme on HIV/AIDS² in 2019, around 1.7 million [1.2 million–2.2 million] individuals were newly infected with HIV/AIDS and/or from HIV/AIDS-related illnesses in the world in 2019, and around 690 000 [500 000–970 000] people died.² The burden of disease caused by global disability-adjusted life years (DALYs) associated with HIV/AIDS has declined by 16%, and from 2000 to 2017, about 1.5 million people have been saved from death due to timely initiation of HIV antiretroviral therapy (ART).³ In many countries, including Australia, Canada, and some Scandinavian countries, the incidence rate of new AIDS cases has dropped to near zero.⁴ However, the incidence rate of AIDS and its associated mortality in the Middle East and North Africa (MENA) region has more than doubled.⁵

Although the MENA region has the lowest prevalence of HIV in the world (0.1%),⁵,⁶ the growing trend of new infections is a major concern in the region as the newly diagnosed HIV infections in the region have increased by 31% since 2001, the largest increase among the regions in the world. While increasing awareness and experimentation may be one reason for this increase, many incidence rates are undoubtedly new.⁶ Almost two-thirds of these infections were reported from only three countries, namely Egypt, Iran, and Sudan.⁷

One-fifth of the population in the MENA region is in the age group of 15 to 25 years, which is typically the age of onset of sexual activity. On the other hand, issues such as war and conflicts in the region that cause problems such as reducing access to HIV prevention services, destroying health care infrastructure, disrupting social support networks, increasing exposure to sexual violence, and expanding immigration and displacement as well as the large production and trade of heroin in Afghanistan increase the vulnerability of the region to HIV.⁸ 83% of the world's heroin supply was reported to be produced in Afghanistan and more than 75% was smuggled through Iran and Pakistan.⁹ Therefore, cheap and easy access to heroin in the MENA region results in increased injecting drug use.¹⁰

The status of social stigma in the region causes problems, such HIV denial and being deprived of full access to comprehensive and confidential health services.⁸ Due to the scarcity of data and the fact that the HIV/AIDS epidemic status was relatively unknown in 2005, the MENA region was identified as a real gap in the HIV/AIDS epidemiological data in that year.¹¹ It believed that low prevalence of HIV in the region could be due to incomplete information and limited data.¹² Without effective preventive policy the disease can have serious social and economic consequences. Comparing the epidemiology of HIV/AIDS infection/disease in regional countries could encourage policymakers of these countries to plan establish and develop HIV/AIDS prevention programs.

Aim

The purpose of this research was to report the epidemiological features and burden of HIV/AIDS infection in the MENA countries in order to develop effective policies for reduceing the incidence, mortality, and consequences of the disease in the region.

Methods

The MENA region consists of 21 countries including Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Palestine, Oman, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, Turkey, United Arab Emirates (UAE), and Yemen, with a population of about 400 million.¹³

The Global Burden of Disease (GBD) database was used to calculate the number of HIV/AIDS infected cases. In this system, modeling for each country is based on the availability and quality of data. It provides countries with data on population-based outbreak surveys or prenatal care clinics. The main data sources for HIV/AIDS were demographic and health surveys as well as data reported by the Ministry of Health to the Joint United Nations Programme on HIV/AIDS, which were collected and analyzed through Spectrum software.¹⁴

The prevalence and incidence of HIV/AIDS rates were estimated using an open-source version of the Estimation and Projection Package (EPP) that was originally developed by UNAIDS. The incidence rates were measured by pulling information from observed bias in the geographical region. A re-coded version of the Spectrum model was used to produce age-specific incidence, prevalence, and mortality for all countries.¹⁵

For all countries in the MENA Region the same method was used for every place and time to ensure valid and accurate comparisons between different locations and years. Age and sex standards were used to generate age-standardized rates; simple arithmetic means were used to standard population structure.

The age-standardized rate (ASR)¹⁶ and disability-adjusted life years (DALYs) index¹⁷ were used to compare different countries. DALYs were obtained with the sum of the years of life lost (YLLs) and the years lived with disability (YLDs).¹⁸ YLLs were estimated by multiplying the estimated number of deaths by age, by the standard life expectancy at that age. Details of estimation methods and data sources have already been published.¹⁵

All estimates were reported due to various sources of error including measurement error, bias, and modeling with 95% confidence intervals. In this study, all analyses were performed using Microsoft Office Excel 2016.

Results

In terms of ASR, the incidence rate of HIV/AIDS increased from 1990 to 2017 in the countries of the MENA region except for Kuwait, Lebanon, Bahrain, and Qatar, and the highest incidence rate in 2017 was in Sudan [17.35 (95% CI, 8.98–32.22)] and Oman [9.08(95% CI, 4.13–14.95)], respectively, and the lowest rates were in Syria [0.21(95% CI, 0.15–0.3)] and Qatar [0.28(95% CI, 0.22–0.34)], respectively.

However, the average global incidence rate of HIV/AIDS declined dramatically from 36.52 to 25.05 between 1990 and 2017 (all units are in 100,000). The incidence rate of HIV/AIDS in the countries of the MENA region was lower than the mean global incidence rates. In the countries of the MENA region except Sudan, DALYs and mortality rates were found to be higher than the global average. However, in all other countries of the region, the incidence, prevalence, mortality, and DALY rates were reported to be lower than the global average. Sudan (17.35[95% CI, 8.98–32.22]), Oman (9.08[95% CI, 4.13–14.95]), United Arab Emirates (UAE) (4.28[95% CI, 0.12–25.99]), Tunisia (3.90[95% CI, 0.46–15.39]), and Iran (3.58[95% CI, 2.45–4.98]) had the highest incidence rate of HIV/AIDS, respectively. The highest HIV/AIDS mortality rates were in Sudan (16.24[95% CI, 13.28–20.09]), United Arab Emirates (UAE) (7.41[95% CI, 0.12–49.04]), Oman (3.08[95% CI, 1.6–4.43]), and Morocco (1.70[95% CI, 0.04–10.23]), respectively. However, Qatar was reported as one of the countries in the region with the lowest incidence, prevalence, mortality, and DELAY rates in 2017 compared to 1990 (Table 1) (all units are in 100,000).

Table 1.

Comparison of the burden of disease caused by HIV/AIDS in the world with the disease burden in the Middle East and North Africa (MENA) countries from 1990 to 2017 by ASR.

Country	Year	Incidence per 100000	Prevalence per 100000	Death per 100000	DALY per 100000
Afghanistan	1990	0.93 (0.05–3.87)	5.47 (0.35–19.49)	0.40 (0.02–1.47)	20.03 (1.58–72.42)
Afghanistan	2017	3.02 (0.14–12.61)	18.15 (1.86–74.44)	1.09 (0.02–5.54)	59.28 (2.04–272.98)
Algeria	1990	0.56 (0.11–2.75)	2.87 (0.60–13.77)	0.22 (0.03–1.17)	11.99 (2.55–63.44)
Algeria	2017	2.2 (0.02–8.51)	26.87 (3.89–79.98)	0.79 (0.03–4.47)	40.25 (3.79–213.94)
Bahrain	1990	3.02 (2.36–4.03)	16.53 (10.5–24.41)	1.00 (0.83–1.14)	44.22 (36.82–50.53)
Bahrain	2017	1.37 (1.17–1.63)	16.65 (13.93–20.42)	0.72 (0.62–0.81)	32.83 (27.56–37.07)
Egypt	1990	0.27 (0.20–0.39)	1.64 (1.21–2.17)	0.11 (0.07–0.14)	5.75 (4.08–6.66)
Egypt	2017	0.60 (0.41–0.8)	4.93 (4.13–5.78)	0.07 (0.05–0.1)	4.08 (3.01–5.61)
Iran	1990	0.29 (0.11–1.05)	2.36 (1.81–3.3)	0.09 (0.08–0.11)	4.89 (4.11–5.61)
Iran	2017	3.58 (2.45–4.98)	22.78 (18.36–28.78)	0.90 (0.8–1.01)	48.6 (43.72–54.17)
Iraq	1990	0.12 (0.07–0.23)	0.60 (0.36–1.00)	0.04 (0.03–0.06)	2.54 (1.78–3.74)
Iraq	2017	0.45 (0.23–0.86)	3.01 (1.55–5.67)	0.25 (0.18–0.38)	16.02 (10.62–25.34)
Jordan	1990	0.18 (0.12–0.26)	0.77 (0.47–1.19)	0.06 (0.05–0.06)	3.45 (2.77–4.15)
Jordan	2017	0.54 (0.35–0.74)	5.53 (4.55–6.82)	0.23 (0.16–0.3)	13.22 (10.36–16.59)
Kuwait	1990	0.52 (0.40–0.70)	3.63 (2.75–4.26)	0.30 (0.27–0.33)	18.93 (16.99–21.19)
Kuwait	2017	0.35 (0.28–0.44)	7.09 (5.96–8.02)	0.12 (0.11–0.14)	8.41 (7.47–9.59)
Lebanon	1990	3.14 (0.21–11.06)	21.53 (1.85–63.9)	1.67 (0.09–5.15)	86.21 (7.05–270.35)
Lebanon	2017	2.99 (0.15–13.53)	25.92 (3.23–92.79)	1.35 (0.04–6.52)	76.68 (3.88–354.86)
Libya	1990	0.65 (0.04–2.29)	3.52 (0.78–11.06)	0.23 (0.01–0.76)	12.32 (1.06–38.83)
Libya	2017	2.71 (0.15–11.97)	18.16 (2.37–72.29)	1.45 (0.12–5.98)	78.27 (8.62–320.23)
Morocco	1990	1.73 (0.11–5.91)	7.57 (1.55–21.43)	0.44 (0.02–1.36)	25.10 (2.06–79.68)
Morocco	2017	3.15 (0.16–13.91)	41.14 (5.52–139.08)	1.70 (0.04–10.23)	99.31 (4.88–540.94)
Palestine	1990	0.14 (0.10–0.20)	0.71 (0.46–1.09)	0.04 (0.03–0.04)	2.12 (1.73–2.45)
Palestine	2017	0.36 (0.24–0.54)	2.87 (1.62–5.00)	0.22 (0.19–0.26)	12.7 (10.55–15.12)
Oman	1990	1.11 (0.78–1.52)	5.02 (3.04–7.68)	0.28 (0.23–0.31)	13.07 (11.39–14.39)
Oman	2017	9.08 (4.13–14.95)	74.53 (45.09–106.56)	3.08 (1.6–4.43)	133.63 (73.17–191.57)
Qatar	1990	1.36 (1.08–1.78)	8.09 (5.84–10.41)	0.57 (0.47–0.65)	33.2 (28.14–36.86)
Qatar	2017	0.28 (0.22–0.34)	5.67 (5.00–6.55)	0.23 (0.19–0.27)	12.9 (10.33–14.95)
Saudi Arabia	1990	1.46 (0.85–2.91)	7.48 (4.42–12.38)	0.53 (0.36–0.76)	29.24 (19.40–42.92)
Saudi Arabia	2017	1.71 (0.98–3.16)	15.7 (8.5–27.94)	1.35 (1.00–1.84)	69.86 (50.32–103.74)
Sudan	1990	16.46 (7.06–27.23)	37.61 (14.51–77.46)	1.12 (0.68–2.20)	60.67 (37.92–113.75)
Sudan	2017	17.35 (8.98–32.22)	252.03 (199.41–324.22)	16.24 (13.28–20.09)	820.68 (650.93–1037.45)
Syria	1990	0.11 (0.09–0.14)	0.7 (0.50–0.99)	0.05 (0.05–0.06)	3.29 (2.93–3.70)
Syria	2017	0.21 (0.15–0.3)	2.79 (1.99–4.38)	0.07 (0.05–0.11)	4.26 (3.18–6.23)
Tunisia	1990	0.47 (0.08–2.29)	2.26 (0.44–10.9)	0.13 (0.02–0.67)	7.14 (1.48–36.25)
Tunisia	2017	3.90 (0.46–15.39)	30.3 (5.43–99.57)	1.59 (0.05–6.56)	88.26 (5.14–369.31)
Turkey	1990	0.06 (0.00–0.20)	0.35 (0.05–0.6)	0.01 (0.00–0.02)	0.70 (0.03–1.13)
Turkey	2017	0.60 (0.40–0.88)	5.74 (4.10–8.39)	0.24 (0.19–0.29)	13.63 (10.8–16.57)
United Arab Emirates	1990	0.54 (0.04–1.99)	2.56 (0.26–9.38)	0.17 (0.01–0.61)	8.98 (0.83–28.35)
United Arab Emirates	2017	4.28 (0.12–25.99)	61.47 (1.87–390.37)	7.41 (0.12–49.04)	179.4 (7.48–1028.41)
Yemen	1990	1.62 (0.09–7.56)	10.27 (1.38–40.83)	0.72 (0.03–3.43)	36.07 (2.53–156.59)
Yemen	2017	3.75 (0.15–17.82)	26.99 (3.11–111.46)	1.40 (0.03–7.60)	77.61 (3.00–379.20)
Global	1990	36.52 (33.55–40.02)	163.24 (147.36–181.32)	6.61 (5.88–7.38)	380.22 (342.46–422.14)
Global	2017	25.05 (21.13–29.46)	462.36 (437.07–491.27)	12.14 (11.53–12.86)	704.82 (662.63–747.91)
North Africa and Middle East	1990	1.45 (0.78–2.41)	5.00 (2.83–9.08)	0.25 (0.16–0.38)	13.50 (9.21–20.60)
North Africa and Middle East	2017	2.84 (1.72–5.23)	28.82 (20.2–46.27)	1.55 (1.19–2.18)	83.80 (62.59–118.15)

Although HIV/AIDS-related DALYs in the countries in the MENA region were lower than the global average, most DALYs, similar to the global pattern, were associated with aged 36 to 284 days of age (i.e. transmission from mother to fetus). However, DALY was different in two countries of the United Arab Emirates (UAE) and Sudan, as it was found to be significantly higher than the global average in these countries in the age group above 25 years and 65 to 84 years, respectively (Figure 1).

Figure 1.

Age trends of HIV/AIDS-related DALY rates for both sexes in the MENA region in 2017.

The percentage of changes in HIV/AIDS from 1990 to 2017, the greatest percentage changes in the incidence rate was in Iran (11.32 [95% CI, 2.03–33.99]), Turkey (8.36[95% CI, 5.46_11.42]), Tunisia (7.22 [95% CI, 0.49–31.07]) and Oman (7.21[95% CI, 3.65–10.74]), respectively, and the lowest percentage of changes was in Qatar (−0.80[95% CI, −0.85_−0.74]), Bahrain (−0.54 [95% CI, −0.68_−0.40]), Kuwait (−0.33[95% CI, −0.52_−0.03]) and Lebanon (−0.05[95% CI, −0.92–5.04]), respectively.

The United Arab Emirates (UAE) (4585.78%), Turkey (3197.02%), and Tunisia (1375.65%) reported the highest percentage of change in mortality rates, respectively. The lowest percentage of change was reported in Qatar (−58.57%), Kuwait (−57.69%), and Bahrain (−22.32%), respectively. Turkey (3260.08%), the United Arab Emirates (UAE) (2081.73%) and Sudan (2011.42%) had the highest percentage of change in DELAY rates, respectively, and the lowest percentage of change was reported in Qatar (−60.32%), Kuwait (−54.33%) and Bahrain (−19.83%), respectively (Table 1).

In terms of ASR, the Sudanese (19.26), Iranian (3.71), and Tunisian (3.27) women had the highest incidence rate of HIV/AIDS in the region, respectively. Among men of the region, the Sudanese men (15.39), Omani men (11.62), and men in the UAE (5.96) had the highest incidence rate of HIV/AIDS by ARS, respectively. HIV/AIDS-related mortality rates by ASR were found to be higher than the global average in Sudan in both sexes, and in the UAE, it was close to the global average in men (Figure 2).

Figure 2.

HIV/AIDS-related incidence and mortality rates by ASR in the MENA countries in 2017.

An examination of the trend of HIV/AIDS incidence rate by ASR between 1990 and 2017 showed that due to a decrease in the mean global incidence rates and an increase in the incidence rate in the MENA region, the incidence rate of HIV/AIDS in the MENA region in the upcoming years will be similar to the global average and the difference become minimal. Overall, the highest percentage of HIV/AIDS incidence rate increase was observed in Oman and the United Arab Emirates (Figure 3).

Figure 3.

The incidence rate of HIV/AIDS by ASR in the MENA countries and in the world from 1990 to 2017.

The highest HIV/AIDS-related DALY rate was attributed to the risk factors of unsafe sex, drug use, and intimate partner violence. Oman, Iran, and Sudan had the highest DALYs due to unsafe sex, drug use, and intimate partner violence, respectively. In general, unsafe sex had the highest impact on the DALY index in all countries except Iran and Bahrain (Figure 4).

Figure 4.

Percentage of total DALY related to HIV infection by ASR in both sexes attributed to the risk factors of drug use, unsafe sex, and intimate partner violence in 2017.

Discussion

Prevention of HIV infection is an important task for infectious diseases and public health professionals. Unfortunately, in most developing countries, due to the lack of reliable and available information, there is always a disagreement regarding understanding of factors affecting the disease epidemic dynamics and its changes over time, among different communities that are at high risk of infection. This information, however, is crucial for making strategic decisions about AIDS prevention. Knowledge and information in the Middle East and North Africa countries of the Middle East and North Africa are still limited and controversial despite the tremendous effort that has been made in the field of global cognition and epidemiology of HIV infection.⁸

The number of new HIV infections worldwide is declining each year, and consequently, the number of AIDS-related deaths has fallen sharply. However, there is concern about increased HIV incidence in the MENA countries and throughout the world.⁶ The results of the present study indicated that the incidence rate has increased in all countries in the region except Lebanon, Bahrain, and Qatar. Mandatory HIV testing (500,000 tests a year in Qatar) and free medical care, even for citizens and immigrants in these countries, can be a strong reason to reduce the incidence of HIV.¹⁹ The DALY and mortality rates in Sudan were higher than the global average and the incidence rate was higher in this country compared to other countries in the region.²⁰

Two decades of civil war, tensions and its associated consequences, displacement of almost 4 million people, arrival of refugees and foreign nationals in the new autonomous region, destruction of health care infrastructure and the lack of access to prevention, care and treatment services, high level of illiteracy, and the lack of knowledge about the ways of transmitting the disease can all be reasons for the high incidence of infection in this country. There is an urgent need in the country for a preventive strategy and medical coverage and the provision of necessary training through media and culturalization in this regard.

An examination of the trend of HIV/AIDS incidence rate by ASR from 1990 to 2017 showed that the incidence rate in the MENA region was lower than the global average, but in Sudan, it was close to the global average from 2010 to 2014 and showed a decreasing trend after 2014, which is consistent with the results of a study carried out in South Sudan. This phenomenon can be attributed to the impaired health care systems and the consequences of the conflicts following the independence of South Sudan from Sudan in 2011 via referendum. Also, surveys according to the reports provided by the Department of Health in this country, indicated 32 health care centers provided comprehensive HIV services in 2016, and the officials responsible for the Provider-Initiated Testing and Counseling (PITC) started their work in 2014.²¹

Oman had the highest DALYs in the region due to unsafe sex. In 2015, estimates demonstrated 66.8% of HIV transmission was through unsafe sex in this country.²² Based on the WHO guidelines, culturalization, awareness of HIV transmission, testing and treatment of men who have sex with men (MSM) and sex workers comprise the urgent needs that need to be addressed in the country.

Our findings showed that the highest impact of risk factors in HIV infection-related DALY index in Iran was attributed to drug use and in Sudan to intimate partner violence, which is consistent with the results of similar studies.⁸,²⁰,²³ Unsafe sex had the highest impact on the DALY index among regional countries other than Iran and Bahrain. The existence of cultural values and religious practices in these two countries²⁴ and the sensitivity and taboo of sex education in other countries in the region may be reasons for the existence of these statistics. Of course, we should not forget that in most of MENA countries due to stigma and many barriers, unsafe sex data and data on MSMs were not valid or available.²⁵

From 1990 to 2017, the countries of Iran, Turkey, Tunisia, and Oman had the highest percentage of change in the incidence rate, and Qatar, Bahrain, and Lebanon reported the lowest percentage of change in the incidence rate of HIV/AIDS. The dominant way of transmission in Turkey and Oman was unsafe sex, which is consistent with the results of similar studies.²²,²⁶ Social stigma and exclusion from society, insufficient support from health care professionals, and high medical costs in these countries have provided grounds for denial of infection, identification, and diagnosis at high stages of the disease.²⁷

Although mother-to-child transmission worldwide declined from 26% in 2009 to 10% in 2015,²⁸ the highest DALY rate in the world was reported to be associated with 28–364 days of age (i.e. transition from mother to child). Researchers have suggested that access to HIV testing during pregnancy and access to mother-to-child transmission prevention services in Sudan was very low; on the other hand, heterosexual transmission and unsafe sex in Sudan, along with an estimate in 2010 that indicated 59 percent of new HIV infections occurred in women of reproductive age (15–49 years)²⁹ provided a strong reason for the high rate of DALYs in the age groups below one year of age and above 25 years.

In recent years, percentage of transmission with unsafe sex in the MENA region was increased, for example in Oman from 1984–2015 near 66.8% of HIV transmission through unsafe sex, the figure for Oman from 2015 to 2018 was higher than 88%.²²,³⁰

The highest DALY rate in the United Arab Emirates (UAE) was between the ages of 60 and 84 years, which was significantly above the global average. This may be due to the presence of temporary immigrants who migrate to the UAE from different countries to work. These people have been away from their families for a long time that the prevalence of high-risk behaviors such as unsafe sex and drug use among them are high. On the other hand, according to the results obtained from a study carried out in 2007, insufficient awareness among students as well as inadequate education and incorrect information³¹ could lead to the development and transmission of HIV infection in the community, and since HIV diagnostic tests in this country are not mandatory as in Qatar and Bahrain,¹⁹,³² many are unaware of their illness and become aware of the infection mainly in old age due to disability, aging, and referral to a physician. There is an urgent to focus on medical quality and coverage, support of HIV-infected patients, and special attention to high-risk groups in the UAE.

The result demonstrated that the lowest percentage of DALY changes was identified in Qatar, Kuwait, and Bahrain. In Qatar, 500,000 HIV tests are performed annually, the cost of treatment is paid by the government for all HIV-infected foreign nationals and immigrants, and voluntary HIV counseling and mandatory HIV testing have been incorporated into its strategic plans.³²,³³ Providing HIV education by non-governmental organizations in Bahrain and Kuwait³⁴ as well as mandatory prenatal testing, blood and organ donation, surgeries, and employment are among the other diagnostic methods considered in these countries.¹⁹ The most prevalent method of HIV transmission in Bahrain and Iran was injecting drug use, which is in line with the 2014 reports from Bahrain (55.8%). Iran's border with Afghanistan and the existence of heroin and narcotics trafficking routes in the country provided easy access to these drugs. On the other hand, most people who inject drugs are young people who have been rejected by the family and society and are deprived of access to HIV prevention and treatment services.⁹,³⁵ Countering the drug crisis not only requires close cooperation between the countries of Afghanistan, Pakistan, and Iran but also requires international resolve to help change the way of production and cultivation of drugs in Afghanistan as Afghan farmers can sustain their livelihoods.

Strengths and weaknesses of the study

The most important limitation of this study is the quality of data. The quality of HIV/AIDS in all part of the world was low but this underestimation in the countries of MENA region is so low. Spectrum is a standard tool to estimate population particularly HIV/AIDS in many settings, especially in developing countries where surveillance data is often based on prevalence studies but Spectrum has many limitations, the most important of which is the need for high quality data. Another limitation is about Sudan, given the country split into two countries in July 2011 but was considered a single country for this analysis. This study has many strengths, such as comparing the data of countries having a similar information registration system. Furthermore, by comparing different indicators between different countries, which are in the form of collective information in GBD, one can identify the risk factors as well as the strengths and weaknesses of different countries and thus employ the necessary measures required for future planning to control the relevant health problem.

Conclusion

Despite advances in HIV/AIDS control, there has been slow progress in the MENA region and fragile progress in many countries. As these countries are dependent on other countries, if they are affected by sanctions or political conflicts, the AIDS control program may also be subsequently affected. Policymakers should, therefore, be encouraged to develop harm reduction programs for people living with HIV, and invest globally in reducing HIV incidence in people who sell sex, people who inject drugs, and in men who have sex with men in the region.

Footnotes

Acknowledgments

We would like to acknowledge all the authors of the reviewed publications.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval

The ethics committee of the Kermanshah University of Medical Sciences (KUMS.REC.1394.315) approved this study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This article is the result of the findings of the research project 980328 that was approved and financed by the Behavioral Disease Research Center, Vice-Chancellor for research and Research and Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran.

ORCID iD

Mehdi Moradinazar

Data Accessibility Statement

Data made available for download on IHME Websites can be used, shared, modified or built upon by non-commercial users via the Creative Commons Attribution-NonCommercial 4.0 International License ().

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