Epidemiology of HIV infection in the Middle East and North Africa
Abu-Raddad, Laith Ja,b,c; Hilmi, Nahlad; Mumtaz, Ghinaa; Benkirane, Manale; Akala, Francisca Ayodejid; Riedner, Gabrielef; Tawil, Oussamag; Wilson, Davidh
aWeill Cornell Medical College – Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar
bDepartment of Public Health, Weill Cornell Medical College, Cornell University, New York, New York, USA
cVaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
dHuman Development Sector, Middle East and North Africa Region, World Bank, District of Columbia, USA
eAssociation de Lutte Contre le Sida, Marrakesh, Morocco, Egypt
fRegional Office of the Eastern Mediterranean, World Health Organization, Egypt
gJoint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt
hGlobal HIV/AIDS Program, World Bank, Washington, District of Columbia, USA.
Correspondence to Laith J. Abu-Raddad, PhD, Weill Cornell Medical College – Qatar, Qatar Foundation – Education City, P.O. Box 24144, Doha, Qatar. Tel: +974 492 8321; fax: +974 492 8333; e-mail: firstname.lastname@example.org
Objective: The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region.
Methods: A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents.
Results: Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited.
Conclusion: Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.
Despite much progress on understanding HIV epidemiology globally, the Middle East and North Africa (MENA) stands as the only region where knowledge of the epidemic continues to be very limited and subject to much controversy . Despite emerging data revealing low HIV prevalence in the region, some surveys suggest more or less sizable pockets of very high risk . Still, more than 25 years since the discovery of the HIV virus, no scientific study has provided a comprehensive data-driven synthesis of HIV/AIDS spread in this region which continues to be viewed as the anomaly in the HIV/AIDS world map and ‘a real hole in terms of HIV/AIDS epidemiological data’ .
The apparent lack of HIV data has fuelled an intense polemical debate on the status of the epidemic in MENA . Some argue that MENA's cultural values, in terms of strong prohibitions against premarital and extramarital sex, homosexuality and alcohol and drug use, provide ‘sterilizing cultural immunity’ against HIV spread, and that HIV is unlikely to impact MENA societies [4–6]. Interestingly, the same cultural values are held responsible by an opposing viewpoint for slowing, if not freezing, the ability of MENA societies to deal with the epidemic [7,8]. This latter view argues that there is a public health crisis ‘behind the veil’ and that if this crisis is ignored, HIV/AIDS could debilitate or even destabilize some of MENA societies by its drastic effects on morbidity, mortality and economic productivity of the 15–49 years age group [7,8].
Similar to other regions, several vulnerability factors for HIV can be found in different parts of MENA. The process of modernization including mass education and urbanization, which may occur with abandonment of traditional patterns of behavior , continues in MENA at an accelerated pace. Most countries are experiencing diverse influences including changing family structures, exposure to different cultures, and enhanced communication and technology means [5–7]. In many areas of MENA, there appears to be a sociocultural transition leading to more tolerance and acceptance of practices such as premarital and extramarital sex and increased opportunities for sexual partnerships beyond traditional forms . The cultural traditions of balancing premarital chastity with early marriage are no longer the norm in most parts of MENA , and social and gender tensions have been exacerbated by the clashing forces of traditional and modern cultures .
MENA is also distinctively characterized by a massive youth bulge where one-fifth of the population are in the 15–24-year age group [13,14], normally the age of initiation of sexual activities . Complex emergencies such as conflicts and wars are prevalent in the region and can increase vulnerability to HIV by reducing access to HIV prevention services, breaking down of health infrastructure, disrupting social support networks, increasing exposure to sexual violence, and increasing population movement to an area of higher HIV prevalence . Extensive levels of migration, displacement, and mobility exist in MENA, which has the highest number of refugees and internally displaced persons in the world . MENA is flooded as well with inexpensive drugs due to high levels of production of heroin in Afghanistan and major drug trade routes that pass through the region .
The social determinants of health in terms of political conflict, limited resources, and gender inequity continue to challenge many countries in the region . Denial that HIV exists or is an important challenge still persists. High-risk groups are highly stigmatized and lack access to comprehensive and confidential services. Community organizations serving at-risk populations are emerging, but apart from some notable exceptions, are insufficient to meet current needs. Health promotion approaches remain overall didactic and prescriptive, are divorced from behavioral theory, and are nonparticipatory. Most importantly, there is lack of evidence-based policies that can guide effective interventions, and HIV response in MENA continues to be beset by numerous challenges.
With the apparent lack of empirical HIV data to support existing and emerging views on HIV epidemiology in this unique, evolving, and controversial context, the main objective of this investigation was to address the dearth of interpretable data on HIV in MENA by delineating an evidence-based and data-driven overview of HIV epidemiology in this region.
This systematic review summarizes major findings of the MENA HIV/AIDS Epidemiology Synthesis Project whose mandate was to collect and synthesize all available data on HIV, sexually transmitted infections (STIs), and sexual behavior in the MENA region. The project was conducted and funded through a partnership of the World Bank, the MENA Regional Support Team (RST) of the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the Eastern Mediterranean Regional Office (EMRO) of the World Health Organization (WHO) . The following data sources were identified as part of a comprehensive search of relevant studies and databases:
1. Scientific literature search of Medline (PubMed) using a strategy with both free text and MeSH headings, and with no language or year limitations. Although results of some of the searches have not been described in this article, the following set of criteria were used as part of the comprehensive search of the Medline database that was conducted for the Synthesis Project:
a. Studies of HIV infectious spread in its different modes of transmission under the strategy of (‘HIV Seropositivity’ OR ‘HIV’ OR ‘HIV Infections’) AND (‘Middle East’ OR ‘Islam’ OR ‘Arabs’ OR ‘Arab World’ OR ‘Africa, Northern’ OR ‘Mauritania’ OR ‘Sudan’ OR ‘Somalia’ OR ‘Djibouti’ OR ‘Pakistan’).
b. Studies of sexual behavior and levels of risk behavior under the strategy of (‘Sexual Behavior’ OR ‘Sexual Partners’ OR ‘Sexual Abstinence’ OR ‘Unsafe Sex’ OR ‘Sexology’ OR ‘Reproductive Behavior’ OR ‘Safe Sex’ OR ‘Condoms’ OR ‘Sex’) AND (‘Middle East’ OR ‘Islam’ OR ‘Arabs’ OR ‘Arab World’ OR ‘Africa, Northern’ OR ‘Mauritania’ OR ‘Sudan’ OR ‘Somalia’ OR ‘Djibouti’ OR ‘Pakistan’).
c. Studies of herpes simplex virus type two sero-prevalence under the strategy of (‘Herpesvirus 2, Human’ OR ‘Herpes Genitalis’) AND (‘Middle East’ OR ‘Islam’ OR ‘Arabs’ OR ‘Arab World’ OR ‘Africa, Northern’ OR ‘Mauritania’ OR ‘Sudan’ OR ‘Somalia’ OR ‘Djibouti’ OR ‘Pakistan’).
d. Studies of human papillomavirus and cervical cancer under the strategy of (‘HPV’ OR ‘Human papillomavirus’ OR ‘Human papilloma virus’ OR ‘Cervical cancer’) AND (‘Middle East’ OR ‘Islam’ OR ‘Arabs’ OR ‘Arab World’ OR ‘Africa, Northern’ OR ‘Mauritania’ OR ‘Sudan’ OR ‘Somalia’ OR ‘Djibouti’ OR ‘Pakistan’).
e. Studies of bacterial sexually transmitted infections under the strategy of (‘Chlamydia’ OR ‘Chlamydia Infections’ OR ‘Chlamydia trachomatis’ OR ‘Gonorrhea’ OR ‘Neisseria gonorrhoeae’ OR ‘Syphilis’ OR ‘Vaginosis, Bacterial’ OR ‘Pelvic Inflammatory Disease’) AND (‘Middle East’ OR ‘Arabs’ OR ‘Islam’ OR ‘Arab World’ OR ‘Africa, Northern’ OR ‘Mauritania’ OR ‘Sudan’ OR ‘Somalia’ OR ‘Djibouti’ OR ‘Pakistan’).
f. Studies of hepatitis C virus under the strategy of (‘Hepatitis C’ OR ‘Hepatitis C Antibodies’ OR ‘Hepatitis C Antigens’) AND (‘Middle East’ OR ‘Islam’ OR ‘Iran’ OR ‘Arabs’ OR ‘Arab World’ OR ‘Africa, Northern’ OR ‘Mauritania’ OR ‘Sudan’ OR ‘Somalia’ OR ‘Djibouti’ OR ‘Pakistan’).
2. Peer-reviewed publications published in local and regional research journals not indexed in Medline (PubMed), but identified most often through Google Scholar.
3. Country-level reports and databases, governmental and nongovernmental organizations studies and publications, as well as other institutional reports related to HIV and STIs in MENA.
4. International organizations' reports and databases related to HIV and other STIs. Among the organizations from which we obtained reports and data are UNAIDS, WHO, World Bank, United Nations Children's Fund (UNICEF), United Nations Office on Drugs and Crime (UNODC), International Agency for Research on Cancer (IARC), International Organization for Migration (IOM), International Centre for Prison Studies (ICPS), Office of the UN High Commissioner for Refugees (UNHCR), Population Reference Bureau (PRB) and Family Health International (FHI).
5. Demographic and Health Survey (DHS) reports of MENA countries.
6. Consultations with key experts, public health officials, researchers, and academics in the region and beyond.
The review covered all countries included in the MENA definitions of the World Bank, UNAIDS RST and WHO EMRO. These include Afghanistan, Algeria, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates, West Bank and Gaza (Occupied Palestinian Territories), and Yemen. Considering geographic proximity and similarity in the sociocultural context, data were occasionally included on Mauritania, the native Palestinian population in Israel, and Turkey.
In this paper, the MENA population was divided into three classes based on risk of infection. These are high-risk groups, bridging populations, and the general population. As a consequence of the nature of HIV epidemiology in MENA, we focus much of our discussion on the high-risk groups including injecting drug users (IDUs), men who have sex with men (MSM) as well as female sex workers (FSWs) and commercial heterosexual sex networks. Also, for this review, the Results section is primarily structured around summarizing studies on HIV prevalence, risk behavior, and HIV/AIDS knowledge. Findings of other studies, such as those that provide specific context, are presented in relevant parts of the Discussion section.
This review covered over 5000 sources of data. In addition to a large number of unpublished publications, country-level reports, NGOs' studies, international organizations' reports, DHS reports and others, a total of nearly 4000 peer-reviewed scientific sources of literature were identified through the Medline search as of 30 July 2009. More specifically, there were 1036 publications related to HIV infectious spread in its different modes of transmission, 1393 related to sexual behavior and levels of risk behavior, 27 related to herpes simplex virus type two sero-prevalence, 188 related to human papillomavirus and cervical cancer, 523 related to bacterial sexually transmitted infections, and 788 related to hepatitis C virus.
There is considerable evidence on HIV prevalence and risk behavior practices among IDUs, MSM, and FSWs in MENA. Earlier evidence suffered from methodological limitations, but the quality of evidence has increased substantially in recent years. The information reviewed on high-risk groups in MENA includes data originating from integrated biobehavioral surveillance surveys incorporating state-of-the-art surveillance methodologies of hard-to-reach populations such as respondent-driven sampling, from descriptive and qualitative studies such as formative assessments, from HIV testing data, in addition to countries' case notification reports.
Injecting drug users and HIV
Injecting drug use is a key HIV mode of transmission worldwide  and was found to be the dominant mode of transmission in several MENA countries such as Iran  and Libya . HIV has been documented among IDUs in the majority of the MENA countries' case notification surveillance reports . Table 1 describes the results of available HIV point-prevalence surveys among high-risk groups in MENA including IDUs [22–111].
Overall, HIV prevalence among IDUs was in the low to intermediate range compared to global figures , with significant variation across and within MENA countries. Although the prevalence of HIV among this risk group was low in several countries, there was robust evidence for concentrated epidemics among IDUs in at least Iran and Pakistan (Table 1) . Concentrated epidemics are defined as HIV prevalence consistently exceeding 5% in a high-risk group, while remaining below 1% in pregnant women . HIV incidence was found to be at very high levels of 16.8% per person-year among IDUs in a detention center in Iran . High prevalence rates were also documented among IDUs in Libya (up to 59.4%) , Oman (up to 27%) , and Bahrain (up to 21.1%) .
The prevalence of injecting drug use in MENA, at 0.2% of the population, is overall in the intermediate range compared to other regions [25,32,113]. Nevertheless, some MENA countries such as Iran suffer from an extensive IDU problem. Iran has the highest rate of heroin and opium drug dependence (injecting and noninjecting) in the world (one in every 17 people) [114,115] and it is estimated in different studies that there are between about 100 000 and 300 000 IDUs in this country [32,115–119]. Overall, MENA is a major source, route, and destination for the global trade in illicit drugs and is flooded with inexpensive drugs due to record levels of heroin production in Afghanistan .
Substantial levels of risk behavior have been documented among IDUs in MENA. IDUs reported injecting drugs at a rate of about one to two injections per day  and multiple studies documented that about 50% of IDUs in MENA shared injecting equipment . Use of nonsterile injections appeared to be common in MENA and cleaning of syringes with bleach is very limited if at all existent . Other high-risk injecting drug practices have been documented in MENA such as deliberately drawing blood into the syringe during drug injection (‘jerking’) . There was also documented evidence for commercial sale of blood among IDUs , a practice that led to a large number of HIV infections in China through contaminated blood .
Levels of comprehensive HIV knowledge varied across the region, with both high and low levels being documented in different settings . However, despite comprehensive HIV/AIDS knowledge, when available, a large fraction of IDUs do not feel at risk of HIV infection. Only 33.9% , 31.1% , and 35.9%  of IDUs in Pakistan, and 27% of IDUs in Syria , reported self-perception of risk to HIV.
MSM and HIV
Sexual orientation, sexual identity, same sex attraction, and male–male sexual behavior are concepts that are often not clearly defined or distinguished in data collected under the broad topic of ‘MSM’. Moreover, transgendered persons of diverse cultural contexts are often combined with other MSM in many studies despite different identities, patterns of risk, and programmatic needs. Data from MENA are no exception to these limitations. In this review, we conform to the common terminology of ‘MSM’ that is often used in the literature  to refer to the population of men who engage in same-sex sexual activities, namely anal sex.
MSM are the most hidden and stigmatized of all HIV-risk groups in MENA. Although reliable estimates of the number of MSM are scarce, available data indicate that the proportion of the male population engaging in anal sex with males in MENA is comparable to global levels of roughly 2–3% (W. McFarland, 2008, personal communication) [122–124]. In this region of the world, sexual identities are complex and male same-sex behavior may take multiple forms, as is best seen in Pakistan where there is a complex tapestry of MSM and male sex workers (MSWs) including hijras or khusras (transgendered individuals who dress as women), khotkis (biological males who dress as men but have ‘female soul’ and feminized traits), banthas (biological men with a male sex identity) in addition to several other forms [88,125,126].
HIV transmission between MSM has been reported in most MENA countries [62,127,128]. Results of available point-prevalence surveys among MSM including MSWs, hijras, and hijra sex workers (HSWs) are shown in Table 1. Prevalence levels suggest considerable HIV transmission among MSM in MENA. Reported HIV rates among MSM ranged between as low as 0% in certain groups up to 9.8% in Sudan  and 27.6% at one site in Pakistan .
MSM studied in MENA have shown a wide range of high-risk behaviors such as multiple sexual partnerships of different kinds. Over 90% of many MSM populations in different settings reported having multiple partners per year [101,129,130] with large variations in the numbers, ranging from 2 to 42 partners per year [67,131,132]. Also, there was a relatively low rate of condom use, with lack of availability being one of the reported limitations in several settings [83,129,133]. On the contrary, male sex work was found to be prevalent among MSM in MENA who use it possibly to support their living in an environment of stigma and poor support network . Commercial sex work was reported by 42%  and 20%  in Egypt, 36% in Lebanon , and 67%  and 75.5%  in Sudan. It is worth noting that given that MSM are highly hidden in MENA and that representative samples of MSM remain scarce, the relative visibility of MSW may result in biases that overestimate the levels of sex work within the wider MSM population.
Levels of HIV knowledge among MSM in MENA appeared to vary, possibly reflecting the socioeconomic status of each MSM group . However, even in countries with relatively good levels of HIV awareness, many misconceptions were reported [45,136].
Female sex workers and HIV
Although reliable data on the number of FSWs in MENA are limited, available data indicate that commercial sex is fairly prevalent all over MENA with rates ranging between 0.1 and 1% of adult women [22,81,137–141]. These estimates are rather on the low side of the global range [138,142,143], but are consistent with the prevalence of sex work among women in Indonesia and Malaysia, two predominantly Muslim nations, at 0.4%  and 0.9% , respectively. Still, in MENA, the size of the commercial heterosexual sex networks (including FSWs and their clients) is substantially bigger than that of IDUs and MSM risk networks, implying a potentially larger HIV epidemic if HIV establishes itself firmly in commercial sex networks. Social and economic pressure, family disruption, and political conflicts are major drivers of commercial sex in this region .
The prevalence of HIV among FSWs in MENA continues to be at low levels in most countries, although at levels much higher than those in the general population. Although HIV did not appear to be well established among many commercial sex networks in MENA, HIV prevalence has reached high levels among FSWs in at least parts of Djibouti, Somalia, and Sudan (Table 1). For example, in Djibouti, rates of HIV up to 70% [38,39] and 25.6%  have been documented among street-based and bar-based FSWs, respectively. However, even in these three countries, observed rates remain generally at lower levels than those found in hyperendemic HIV epidemics in sub-Saharan Africa .
FSWs in MENA have been shown to engage in multiple sexual risk behaviors. Overall, the number of clients per FSW ranged between one and three clients per working day [82,147–150], which is broadly consistent, but rather on the low side, with global trends [146,151–154]. Nevertheless, higher levels of up to 4.6 clients per working day or 33.7 clients per month per FSW have been reported in Pakistan . There was significant variation in the rates of condom use by FSWs in MENA, although the general trend was on the low end especially in areas of high HIV prevalence among FSWs. For example, in Sudan, 13% of FSWs reported using condoms regularly  and, in another study, only 2% of FSWs clients used condoms during last sex . In many instances, condoms are seen as a contraceptive measure rather than an HIV prevention measure [149,156]. Several studies also documented anal and oral sex practices among FSWs in MENA . Considerable levels of STIs other than HIV have been documented among FSWs in MENA and there is evidence of propagation of these infections between FSWs and their clients . In many countries indeed, STD clinic attendees repeatedly reported acquiring their infection through paid sex [94,157–159].
Levels of comprehensive HIV knowledge among FSWs in MENA varied across the region, with both high and low levels being documented in different settings. However, regardless of the proportion of FSWs who have good knowledge of HIV/AIDS, many misconceptions about its mode of transmission were reported [45,95], and a significant percentage of FSWs reported not feeling at risk of infection [76,108,131].
Overlapping risks among high-risk groups
Considerable levels of risk behavior overlap are noted among the three high-risk groups in MENA. IDUs are mostly sexually active and engage in both heterosexual [2,22,76,160] and male-male sexual contacts [67,73,161]. Multiple sexual partnerships of different kinds, contacting FSWs and exchanging sex for money or drugs, are not uncommon among IDUs in MENA [2,27,63,67,129,162].
Similarly, MSM risk behaviors overlap considerably with heterosexual sex and injecting drug risk behaviors. Overall, 5–17% of MSM were married to females in different studies [45,81,88,136] and a higher proportion reported having sex with females or FSWs [45,48,76,130]. Also MSM in MENA reported somewhat high levels of drug use both in its injecting and noninjecting forms .
Although generally the levels of risk behavior among FSWs in MENA appeared to be on the low side, the subgroups of FSWs engaging in overlapping sexual and injecting risk behaviors may be particularly at high risk of HIV. Several studies have indeed documented injecting drug use among FSWs at a rate of 1–10% [13,45,76,81,150,163], whereas sexual contacts with IDUs as clients, partners or husbands were reported at higher rates of 10–36% [82,88,155,164].
Potential bridging populations and HIV
Bridging populations are defined as the populations that bridge HIV infections from the high-risk groups to the low-risk general population. These conventionally include clients of FSWs and sexual partners of IDUs and MSM, in addition to other groups such as truck and taxi drivers, military personnel, fishermen, sailors, and migrant labor. HIV point-prevalence surveys among potential bridging populations are still scarce in MENA. Main sources of data for this group are limited number of cross-sectional bio-behavioral surveys, HIV testing data, and countries' case notification reports.
Although a sizable segment of MENA populations belong to potentially bridging populations [165–169], a clear dynamical contribution of these groups to HIV transmission in MENA is not evident. This is particularly the case for sexual partners of high-risk populations and partners of clients of FSWs, as these are usually women who rarely engage in nonspousal partnerships , and probably seldom spread the infection further. Furthermore, the low HIV prevalence among FSWs in MENA limits the role of their clients in bridging HIV infection to the general population. Therefore, bridging populations have been labeled here as ‘potential’ bridging populations to highlight the specific nature of their context in MENA.
HIV point-prevalence surveys among potential bridging populations are summarized in Table 2 [171–179].
In most countries, HIV prevalence among selected potential bridging populations was often nil or 1.0% or less, with the exception of Sudan, where rates of 2.9 and 14.0% were reported among military personnel and clients of FSWs, respectively (Table 2). The low HIV prevalence found in available surveys, along with the context of HIV spread in high-risk groups, suggests that HIV transmission may still be limited through bridging populations in MENA, apart from Djibouti, Somalia, and Sudan.
Nevertheless, existing evidence suggests considerable levels of sexual risk behavior among potential bridging populations in MENA . Contact with FSWs appeared to be substantial, with rates sometimes reaching up to 35% such as among urban migrant males in Pakistan [167,169]. Polygamy and having multiple sexual partners also appeared to be common, with a considerable percentage reporting premarital or extramarital sex [163,175,177,180,181]. For example, in Djibouti, 14% of truck drivers and 22.7% of dockers were in polygamous unions ; in Sudan, 57.1% of military personnel had multiple partners ; and in Pakistan, 63.5% of urban migrants ever had sex with one or more nonmarital partners [168,169]. Several studies have also documented male-to-male contacts with men [5,167–169,175] as well as with MSWs or hijras such as in Pakistan [76,167]. Condom use was reported at very low levels of less than 10% in the majority of the countries [76,167,175,177,181].
General population and HIV
HIV prevalence in MENA has been measured in different general population groups, such as pregnant women and blood donors, as well as in few national and population-based surveys. Main sources of data for this group are cross-sectional serological surveys and HIV testing data. Some of the results of these point-prevalence surveys are presented in Table 3 [183–256].
Available data indicate that HIV prevalence in the general population is at very low levels of much less than 1% in all MENA countries apart from Djibouti, Somalia, and Sudan (Table 3). In Djibouti, HIV prevalence was reported to be around 3% nationally among ANC attendees and among blood donors [188,189,191]. Lower rates were observed of about 1% in Somalia, although in one setting, it was at 2.7% among pregnant women . Southern Sudan is of particular concern and could be already in a state of general population HIV epidemic, although conclusive evidence is still lacking. Rates of as low as 0% and as high as 11% have been reported at various locations among ANC attendees and blood donors in southern Sudan [244,245].
Sexual behavioral data among the general population in MENA remain rather limited, with, to our knowledge, no nationwide sexual behavior survey being ever conducted in the region. However, available data from several small-scale investigations indicate that sexual risk behaviors are present but relatively at low levels compared to other regions . Multiple partnerships, premarital and extramarital relationships, casual sex, and contact with FSWs are reported in most countries but with significant variations . Youth appear to engage to some extent in sexual risk behavior but not at levels seen in other regions . Although polygamy is common in MENA, it appears to be in decline with estimates usually ranging between 3 to less than 20% [14,137,229,257–260]. However, nonconventional forms of spousal relationships have been increasingly emerging in MENA such as zawaj al-muta'a (temporary marriage), zawaj urfi (clandestine marriage), and zawaj al misyar (travelers' marriage) . These nonconventional types of marriage possibly could be perceived as legitimization of premarital and extramarital sex and may be increasing the risk of STI transmission among those involved in such marriages [2,261].
Contrary to widely held perception of very limited data, there is a considerable amount of epidemiological data on HIV in MENA. Nevertheless, data are fragmented, lack integration, and are amorphous. The nature of evidence is best exemplified by shattered glass. Numerous studies and point-prevalence surveys are distributed among different disciplines and stakeholders at the local, national, and regional level with no coherent integration, synthesis, and analysis. As part of the systematic search, we have identified hundreds of studies, databases, focused assessments, and reviews that have never been published in scientific publications nor are easily or widely accessible. A large amount of data and studies continue to be disseminated within small circles at the national and regional levels in the form of confidential and nonconfidential reports and unpublished data.
However, the large sums of available data are not necessarily representative and are often not collected using standard accepted surveillance methodologies. A large fraction of data originates from facility-based surveillance on convenient samples of the population. It is often not clear whether internationally accepted ethical guidelines for research on humans were strictly followed in the conduct of studies. Generally speaking, HIV epidemiologic evidence in MENA is highly heterogeneous in terms of quality but, overall, of limited quality. Fortunately, the quality of data has been steadily improving in recent years, although the availability of data and HIV research capacity vary substantially from one country to another. Iran and Morroco, despite many limitations, continue to be a regional leaders in HIV research and HIV/AIDS response, with several countries such as Pakistan and Sudan catching up in building their capacity within the last few years.
Despite the limitations of available data, the diverse sources of data were consistent on the overall epidemiologic picture delineated in this article. There is no evidence for an HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan . It is worth noting that south Sudan has sociocultural attributes that are distinct from the rest of MENA countries and the epidemic in this subregion is probably best understood in terms of the context of HIV epidemiology in neighboring sub-Saharan countries such as Kenya and Uganda.
The general pattern in MENA countries points toward growing epidemics in high-risk populations including IDUs, MSM, and, to a lesser extent, FSWs . Table 4 summarizes the current status of the HIV epidemic in MENA countries based on the available and synthesized evidence. The limitations of the surveillance systems in MENA and the scarcity of reliable data are manifest as the status of the epidemic remains unknown in the majority of the risk groups for each country. This testifies to the heterogeneity of available evidence in the region.
Commercial heterosexual sex networks seem to be the major drivers of substantial HIV transmission only in Djibouti, Somalia, and Sudan due to the large size of the commercial sex networks in these settings and to the high levels of risk behavior practiced in these networks. Similar heterogeneities apply to the rest of high-risk groups. Whereas injecting drug use is large in scale in Iran and Pakistan and continues to be the major driver of the HIV epidemics in these countries, it appears to be smaller in scale and have a minor role in other MENA countries. The nature and levels of HIV spread among MSM remains, in relative terms, the least understood in MENA.
HIV epidemic patterns
As can be seen from the description of HIV epidemiology in high-risk groups, there is substantial heterogeneity in HIV spread across MENA, and different risk contexts are present throughout the region. However, the HIV epidemic in MENA can be coarsely classified into two groups based on the extent of HIV spread. The first is the group of somewhat considerable HIV prevalence, which includes the three countries Djibouti, Somalia, and Sudan (mainly southern Sudan). The second group, labeled here as Core MENA Region, is the group of more limited HIV prevalence, which includes the rest of MENA countries. As the latter group consists of most MENA countries, HIV epidemiology here represents the main dynamics found in MENA.
Two main patterns describe HIV epidemiology in the Core MENA Region countries (Fig. 1). The first pattern can be seen in countries' case notification reports of diagnosed cases and is that of exogenous HIV exposures among the nationals of these countries, and HIV acquisition by their sexual partners upon their return. This pattern exists in all MENA countries at varying levels. In fact, there appears to be limited epidemic or endemic transmission of HIV in all population groups, including high-risk populations, in few MENA countries . The number of newly diagnosed HIV infections continues to be rather stable at low frequency, with the majority linked to sexual and injecting exposures abroad [62,262]. For example, in Jordan, 450 out of 501 notified HIV/AIDS cases by 2006 were acquired abroad (Jordan National AIDS Program, 2008, personal communication), whereas in Lebanon, 45.36% of the cases in 2004 were linked to travel abroad . Mobility and migration are drivers of this pattern that has been persistent since the discovery of the epidemic and continues to be seen even among recent HIV acquisitions. This pattern of exogenous HIV exposures is not dissimilar from the pattern of exogenous exposures seen in most countries in the world, but it has importance in some MENA countries as the only observed pattern in absence of sustainable considerable high-risk group or general population HIV epidemics. Still, conclusive evidence as to whether exogenous HIV exposures are the only pattern of HIV transmission in these few MENA countries is still lacking , mainly due to poor surveillance of high-risk populations.
The second pattern of HIV epidemiology in Core MENA Region is that of concentrated HIV epidemics among some of the high-risk groups (HIV prevalence consistently exceeding 5%). There is already documented evidence for concentrated epidemics among IDUs  and suggestive evidence for concentrated epidemics among MSM in some countries such as Egypt , Sudan (north Sudan) , and Pakistan [81–83]. There is no evidence for concentrated HIV epidemics, at the country level, among FSWs in Core MENA Region countries.
Djibouti, Somalia and southern Sudan stand out from the Core MENA Region as having a state, or near state, of generalized HIV epidemics. Yet, most infections in these countries seem to be concentrated in high risk groups and bridging populations, more specifically in commercial heterosexual sex networks (Fig. 1) . There is no evidence of sustainable general population epidemic in these countries (apart from possibly southern Sudan); however the size of the commercial heterosexual networks in these settings is large enough to support an epidemic with a prevalence exceeding 1% in the population as a whole .
Several protective factors appear to have slowed and limited HIV transmission in MENA relative to other regions. A key factor is male circumcision, which has an established 60% efficacy against HIV heterosexual acquisition [263–265]. Male circumcision is nearly universal in MENA . Southern Sudan is the only part of MENA where this practice is not the norm . This could be partially contributing to the considerable spread of HIV in southern Sudan relative to the rest of MENA. The extensive coverage of male circumcision in MENA suggests limited potential for a sustainable HIV epidemic in the general population .
The influence of Islamic cultural traditions on the cultural and social traditions of MENA is another possible limiting factor to the spread of HIV in this region. Although from the available literature, one cannot definitely conclude that Islamic cultural traditions have reduced HIV transmission in the region, several observations, including some quantitative studies, support the protective role of Islamic cultural traditions. Being a Muslim has been repeatedly associated with lower risk behavior [269–274] and lower HIV prevalence [4,270,275–283], in both Muslim-majority countries as well as in Muslim minorities in predominantly non-Muslim nations [4,284]. Islamic cultural traditions have been cited as a protective factor even after adjustment for male circumcision . In fact, in addition to requiring male circumcision, Islam promotes a line of behavior that is in concordance with several themes of HIV/AIDS prevention including prohibitions against premarital and extramarital sex , prohibitions against alcohol consumption with alcohol's strong association with higher risk behavior [278,287,288], closed sexual networks of monogamous or polygamous marriages , among others. It is worth noting though that, despite being heavily influenced by Islamic traditions, parts of the region are experiencing a sociocultural transition at varying pace that is leading to more tolerance and acceptance of practices such as premarital sex and extramarital sex . Counting only on the ‘cultural immunity’ of religious and traditional mores  is, therefore, not enough to prevent an HIV epidemic in the region.
Vulnerability of sexual partners of high-risk group members
A key highlight of HIV epidemiology in MENA is that of the vulnerability of spouses and sexual partners of high-risk group members. Women are especially vulnerable, as most high-risk behaviors in MENA are practiced by men and the majority of infected women acquired the infection through their husbands or sexual partners. For example, 97% of HIV-infected women in Saudi Arabia acquired the infection from their husbands . Similarly, in Iran, 76% of HIV-infected women acquired the infection from their husbands who were predominantly IDUs [291,292]. Also, there appears to be a substantial gap in age in sexual partnerships between men and women in MENA, with women marrying older men. Intergenerational sex puts women at even higher risk of exposure to STI infections, including HIV .
Women who are sexual partners of high-risk group members appear to rarely engage in risk behavior and probably seldom bridge the infection to the rest of the population apart from occasionally to their own children through vertical transmission. Their limited role in HIV transmission dynamics could also be one of the factors behind the consistently very low HIV prevalence in the general population in MENA.
HIV epidemic potential in the Middle East and North Africa
The low HIV prevalence observed in some risk groups in MENA should not be interpreted necessarily as lack of HIV epidemic potential. The extreme within-country variation observed in the prevalence of HIV among different population samples is an indication of existing hidden subepidemics or potential epidemics in certain settings within any one country. Also, the heterogeneity in the availability of well designed studies across population groups and countries could be preventing the identification of hidden epidemics among some hard-to-reach high-risk populations.
The moderate to high prevalence of some proxy biological markers of risk behavior in MENA is another indicator of HIV potential in certain risk groups. For example, hepatitis C infection, which shares the parenteral mode of transmission with HIV, has been documented to be at moderate to high levels among IDUs in most MENA countries  compared to those reported in other regions . Recent rapidly growing HIV epidemics documented among IDUs in Pakistan [76,78,85,295], following many years of low HIV prevalence [41,75,77,296,297] affirms the epidemic potential for at least some of the MENA IDU populations. Similarly, HIV prevalence among hijras in one study in Pakistan was 0.0% in 1998, but syphilis prevalence was 37% [89,298]. This suggests substantial levels of sexual risk behavior and potential for HIV infectious spread in the event HIV is introduced into sexual networks involving this population. This seems to have been confirmed as recent data have shown some rapidly rising epidemics among MSWs and hijras in Pakistan [81–83]. There is also a pattern of increasing HIV prevalence among MSM in other regions with similar socio-cultural background to MENA countries such as in Indonesia in south-east Asia [299,300].
Apart from Djibouti, Somalia, and southern Sudan, the apparently lower levels of risk behavior among FSWs in MENA, in addition to the proven biological efficacy of male circumcision against HIV acquisition with its nearly universal coverage in this region, suggest a limited potential for massive or even concentrated HIV epidemics among FSWs in MENA . This, in turn, limits the role that bridging populations (mainly clients and partners of FSWs and sexual partners of IDUs and MSM) may play in HIV transmission in MENA. As pointed out earlier, a key characteristic of sexual partners of high-risk group members (mainly women) in this region is their vulnerability to HIV, rather than their role in HIV transmission dynamics. With all these factors interplaying, and if the existing social and epidemiological context in the region remains largely the same, it seems unlikely that the MENA region will experience a sustainable HIV epidemic in the general population in at least the foreseeable future, if ever. However, increasing economic pressures affecting, in particular, the large population of young people and ongoing political instability may lead to a rise in risk behavior practices and consequently HIV transmission. In a worst case scenario, the region may face up to a few percentage points prevalence in a few of its countries.
Although HIV prevalence levels in MENA are among the lowest globally, the nature of HIV epidemiology in MENA is no exception to HIV epidemiology in every other region apart from sub-Saharan Africa. HIV in MENA travels along the indigenous contours of risk and vulnerability just as in every other region. The HIV epidemic has not yet reached its epidemic potential in this region and there is an opportunity for prevention that should not be missed to control the epidemic . Missing this window of opportunity may entail a health and socioeconomic cost that the region, in large part, is unprepared for. Stigma associated with HIV/AIDS remains one of the major contributors for the region's unpreparedness to tackle the epidemic and a key barrier towards rational evidence-based policymaking.
The analytical insights drawn from this synthesis of thousands of studies and data sources indicate that there is no escape from the necessity of expanding scientific research on HIV in MENA to address the gaps in our knowledge of the status of the epidemic in different risk groups as manifested in Table 4. In particular, robust surveillance systems need to be developed to monitor HIV transmission, especially among high-risk groups. Effective surveillance of most at-risk populations is essential to detect emerging epidemics at an early stage. This would facilitate targeted prevention at an early phase of an epidemic. Monitoring recent infections and examining the nature of exposures could also be useful in detecting emerging endemic chains of transmission within MENA populations.
Despite many limitations, there is increasingly a political feasibility for implanting and scaling up of interventions including those among high-risk groups . However, current efforts in MENA continue to be focused on awareness-raising activities among the general population, which is the group at the lowest risk of HIV infection. Resources need to be prioritized for interventions among those most at risk, irrespective of whether these groups are ‘culturally safe’ or not [13,303]. Developing creative mechanisms for working with high-risk groups, even if discreetly, need to be explored. A successful formula for HIV efforts could be government organized nongovernmental organizations (GONGOs), where governments fund and support NGOs to discreetly provide services to high-risk populations. NGOs may enable governments to deal with high-risk groups indirectly, thereby avoiding political or cultural sensitivities in explicit outreach efforts among hidden and stigmatized populations [304,305].
Although countries need to address the structural factors that drive risk of exposure to HIV, the priority should be on addressing the direct factors that put individuals at risk of HIV exposure, as tackling structural factors takes time and is beyond the control of the public health community . Access to testing, care, and treatment services need to be expanded substantially. Prevention efforts need to capitalize on the strengths represented by cultural traditions, and be culturally sensitive, while fostering effective responses to the epidemic [1,307,308]. One of the countries in the region, Iran, is already a world leader in harm reduction and has paved the way by showing how HIV prevention can be implemented within the cultural fabric of MENA and in consonance with its sociocultural values.
The MENA HIV/AIDS Epidemiology Synthesis Project was funded through a joint partnership of the World Bank, the MENA Regional Support Team (RST) of United Nations Programme on HIV/AIDS (UNAIDS), and the Eastern Mediterranean Regional Office (EMRO) of the World Health Organization (WHO). LJA and GM are also grateful for the Qatar National Research Fund for supporting this work (NPRP 08–068–3–024).
1. Obermeyer CM. HIV in the Middle East. BMJ 2006; 333:851–854.
2. Abu-Raddad L, Akala FA, Semini I, Riedner G, Wilson D, Tawil O, et al. Characterizing the HIV/AIDS epidemic in the Middle East and North Africa
: Time for Strategic Action. Middle East and North Africa HIV/AIDS Epidemiology Synthesis Project. World Bank/UNAIDS/WHO; 2010.
3. Bohannon J. Science in Libya. From pariah to science powerhouse? Science 2005; 308:182–184.
4. Gray PB. HIV and Islam: is HIV prevalence lower among Muslims? Soc Sci Med 2004; 58:1751–1756.
5. Khawaja ZA, Gibney L, Ahmed AJ, Vermund SH. HIV/AIDS and its risk factors in Pakistan. AIDS 1997; 11:843–848.
6. Lenton C. Will Egypt escape the AIDS epidemic? Lancet 1997; 349:1005.
7. Kelley L, Eberstadt N. Behind the veil of a public health crisis: HIV/AIDS in the Muslim world. NBR Special Report
8. Kelley LM, Eberstadt N. The Muslim face of AIDS. Foreign Policy 2005; 149:42–48.
9. Carael M, Cleland J, Adeokun L. Overview and selected findings of sexual behaviour surveys. AIDS 1991; 5(Suppl 1):S65–S74.
10. Busulwa R. HIV/AIDS Situation Analysis study, conducted in Hodeidah, Taiz and Hadhramut, Republic of Yemen
. The Detailed Report of the Findings. 2003.
11. Mohammad K, Farahani FK, Mohammadi MR, Alikhani S, Zare M, Tehrani FR, et al
. Sexual risk-taking behaviors among boys aged 15–18 years in Tehran. J Adolesc Health 2007; 41:407–414.
12. Abukhalil A. Gender boundaries and sexual categories in the Arab world. Fem Issues 1997; 15:91–104.
13. UNAIDS RST MENA. Notes on AIDS in the Middle East and North Africa
14. Roudi-Fahimi F, Ashford L. Sexual & Reproductive Health in the Middle East and North Africa. Population Reference Bureau. A Guide for Reporters
15. UNAIDS/UNHCR. Strategies to support the HIV related needs of refugees and host populations
. Geneva: UNAIDS/UNHRC; 2005.
16. UNODC. United Nations Office on Drugs and Crime (2007)
. World Drug Report. 2007.
17. Shaar AN, Larenas J. Social Determinants of Health. Palestine Country Paper
. Geneva: World Health Organization; 2005.
18. UNAIDS/WHO. AIDS epidemic update 2003
. Geneva: UNAIDS/WHO; 2003.
19. Iran Center for Disease Management MoHaME. AIDS/HIV Surveillance Report
20. UNAIDS/WHO. AIDS epidemic update 2001
21. UNAIDS/WHO. AIDS epidemic update 2002
22. SAR AIDS, The World Bank. Mapping and Situation Assessment of Key Populations at High Risk of HIV in Three Cities of Afghanistan
. Human Development Sector, South Asia Region, The World Bank; 2008.
23. Sanders-Buell E, Saad MD, Abed AM, Bose M, Todd CS, Strathdee SA, et al
. A nascent HIV type 1 epidemic among injecting drug users in Kabul, Afghanistan is dominated by complex AD recombinant strain, CRF35_AD. AIDS Res Hum Retroviruses 2007; 23:834–839.
24. Todd CS, Abed AM, Strathdee SA, Scott PT, Botros BA, Safi N, et al
. HIV, hepatitis C, and hepatitis B infections and associated risk behavior in injection drug users, Kabul, Afghanistan. Emerg Infect Dis 2007; 13:1327–1331.
25. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al
. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 2008; 372:1733–1745.
26. Mimouni B, Remaoun N. Ministry of Higher Education, Algeria. Etude du Lien Potentiel entre l'Usage Problématique de Drogues et le VIH/SIDA en Algérie 2004–2005
27. Rapport de l'enquête nationale de séro-surveillance sentinelle du VIH et de la syphilis en Algérie 2004–2005. unknown.
28. Fares G, et al. Rapport sur l'enquête nationale de sero-surveillance sentinelle du VIH et de la syphilis en Algérie en 2004
. Décembre. Ministère de la Santé de la population et de la reforme hospitalière. Alger; 2004.
29. Institut de Formation Paramédicale de Parnet. Rapport de la réunion d'évaluation a mis-parcours de l'enquête de sero-surveillance du VIH
. Juin; 2004.
30. Alami K. Tendances récentes de l'épidémie à VIH/SIDA en Afrique du nord
. Presentation. Research and AIDS Workshop in North Africa/Marrakech, Morocco; 2009.
31. Statut de la réponse nationale. Caractéristiques de l'épidémie des IST/VIH/SIDA
. Algeria. unknown.
32. Aceijas C, Stimson GV, Hickman M, Rhodes T. Global overview of injecting drug use and HIV infection among injecting drug users. AIDS 2004; 18:2295–2303.
33. Al-Haddad MK, Khashaba AS, Baig BZ, Khalfan S. HIV antibodies among intravenous drug users in Bahrain. J Commun Dis 1994; 26:127–132.
34. Fox E, Haberberger RL Jr, Abbatte EA, Said S, Polycarpe D, Constantine NT. Observations on sexually transmitted diseases in promiscuous males in Djibouti. J Egypt Public Health Assoc 1989; 64:561–569.
35. Philippon M, Saada M, Kamil MA, Houmed HM. Attendance at a health center by clandestine prostitutes in Djibouti. Sante 1997; 7:5–10.
36. Etchepare M. Programme National de Lutte contre le SIDA et les MST Draft report
. Djibouti: World Bank Mission for Health Project Strategy Development; 2001.
37. Rodier GR, Couzineau B, Gray GC, Omar CS, Fox E, Bouloumie J, et al
. Trends of human immunodeficiency virus type-1 infection in female prostitutes and males diagnosed with a sexually transmitted disease in Djibouti, east Africa. Am J Trop Med Hyg 1993; 48:682–686.
38. Marcelin AG, Grandadam M, Flandre P, Koeck JL, Philippon M, Nicand E, et al. Comparative study of heterosexual transmission of HIV-1, HSV-2 and KSHV in Djibouti. 8th Retrovir Oppor Infect
(abstract no. 585); 2001.
39. Marcelin AG, Grandadam M, Flandre P, Nicand E, Milliancourt C, Koeck JL, et al
. Kaposi's sarcoma herpesvirus and HIV-1 seroprevalences in prostitutes in Djibouti. J Med Virol 2002; 68:164–167.
40. El-Ghazzawi E, Hunsmann G, Schneider J. Low prevalence of antibodies to HIV-1 and HTLV-I in Alexandria, Egypt. AIDS Forsch 1987; 2:639.
41. Baqi S, Nabi N, Hasan SN, Khan AJ, Pasha O, Kayani N, et al
. HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh, Pakistan. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 18:73–79.
42. Saleh E, McFarland W, Rutherford G, Mandel J, El-Shazaly M, Coates T. Sentinel surveillance for HIV and markers for high risk behaviors among STD clinic attendees in Alexandria, Egypt. XIII International AIDS Conference
; Durban, South Africa; 2000; poster MoPeC2398.
43. El-Ghazzawi E, Drew L, Hamdy L, El-Sherbini E, Sadek Sel D, Saleh E. Intravenous drug addicts: a high risk group for infection with human immunodeficiency virus, hepatitis viruses, cytomegalo virus and bacterial infections in Alexandria Egypt. J Egypt Public Health Assoc 1995; 70:127–150.
44. Watts DM, Constantine NT, Sheba MF, Kamal M, Callahan JD, Kilpatrick ME. Prevalence of HIV infection and AIDS in Egypt over four years of surveillance (1986–1990). J Trop Med Hyg 1993; 96:113–117.
45. Egypt Ministry of Health and Population National AIDS Program. HIV/AIDS biological and behavioral surveillance survey
. Summary Report Egypt; 2006.
46. El-Rahman A. Risky behaviours for HIV/AIDS infection among a sample of homosexuals in Cairo city, Egypt. XV International AIDS Conference
; Bangkok; 11–16 July 2004; abstract WePeC6146.
47. Family Health International. Middle East and North Africa region final report, March 2005–June 2007
. USAID's implementing AIDS prevention and care (IMPACT) project; 2007.
48. El-Sayyed N, Kabbash IA, El-Gueniedy M. Risk behaviours for HIV/AIDS infection among men who have sex with men in Cairo, Egypt. East Mediterr Health J 2008; 14:905–915.
49. Khani M, Vakili MM. Prevalence and risk factors of HIV, hepatitis B virus, and hepatitis C virus infections in drug addicts among Zanjan prisoners. Arch Iranian Med 2003; 6:1–4.
50. Iran Ministry of Health Iran. AIDS/HIV Surveillance Report, Fourth Quarter
. Teheran: Ministry of Health; 2004.
51. Zamani S, Kihara M, Gouya MM, Vazirian M, Ono-Kihara M, Razzaghi EM, et al
. Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran. AIDS 2005; 19:709–716.
52. Zamani S, Kihara M, Gouya MM, Vazirian M, Nassirimanesh B, Ono-Kihara M, et al
. High prevalence of HIV infection associated with incarceration among community-based injecting drug users in Tehran, Iran. J Acquir Immune Defic Syndr 2006; 42:342–346.
53. Mojtahedzadeh V, Razani N, Malekinejad M, Vazirian M, Shoaee S, Saberi Zafarghandi MB, et al
. Injection drug use in Rural Iran: integrating HIV prevention into iran's rural primary healthcare system. AIDS Behav 2008; 12:S7–S12.
54. Rahbar AR, Rooholamini S, Khoshnood K. Prevalence of HIV infection and other blood-borne infections in incarcerated and nonincarcerated injection drug users (IDUs) in Mashhad, Iran. Int J Drug Policy 2004; 15:151–155.
55. Farhoudi B, Montevalian A, Motamedi M, Khameneh MM, Mohraz M, Rassolinejad M, et al. Human immunodeficiency virus and HIV - associated tuberculosis infection and their risk factors in injecting drug users in prison in Iran
56. Jahani MR, Kheirandish P, Hosseini M, Shirzad H, Seyedalinaghi SA, Karami N, et al
. HIV seroconversion among injection drug users in detention, Tehran, Iran. AIDS 2009; 23:538–540.
57. Nassirimanesh B. Proceedings of the abstract for the Fourth National Harm Reduction Conference
; Seattle, USA; 2002.
58. Talaie H, Shadnia SH, Okazi A, Pajouhmand A, Hasanian H, Arianpoor H. The prevalence of hepatitis B, hepatitis C and HIV infections in non-IV drug opioid poisoned patients in Tehran-Iran. Pak J Biol Sci 2007; 10:220–224.
59. Alizadeh AH, Alavian SM, Jafari K, Yazdi N. Prevalence of hepatitis C virus infection and its related risk factors in drug abuser prisoners in Hamedan–Iran. World J Gastroenterol 2005; 11:4085–4089.
60. Jahani MR, Alavian SM, Shirzad H, Kabir A, Hajarizadeh B. Distribution and risk factors of hepatitis B, hepatitis C, and HIV infection in a female population with “illegal social behaviour”. Sex Transm Infect 2005; 81:185.
61. Tassie J-M. Assigment report HIV/AIDS/STD Surveillance in I.R. of Iran
. Geneva: UNAIDS. UNAIDS.
62. WHO/EMRO. Regional database on HIV/AIDS
. WHO Regional Office for the Eastern Mediterranean.
63. Mishwar. An integrated bio-behavioral surveillance study among four vulnerable groups in lebanon: men who have sex with men; prisoners; commercial sex workers and intravenous drug users
. Final report; November 2008.
64. UNAIDS W. Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections, 2002 updat
. Geneva: UNAIDS, WHO; 2002.
65. Groterah A. Drug Abuse and HIV/AIDS in the Middle East and North Africa
. A Situation Assessment. Internal document. 2002.
66. Tawilah J, Tawil O. Visit to Sultane of Oman. Travel Report Summary. National AIDS Programme at the Ministry of Health in Muscat and Salalah and WHO Representative Office
. World Health Organization. Regional Office for the Eastern Mediterranean; 2001.
67. Ministry of Health. HIV Risk among Heroin and Injecting Drug Users in Muscat, Oman
. Quantitative Survey. Preliminary Data. 2006.
68. Morocco Ministry of Health. Surveillance sentinelle du VIH, résultats 2006 et tendances de la séroprévalence du VIH
69. Khattabi H, Alami K. Surveillance sentinelle du VIH, Résultats 2004 et tendance de la séroprévalence du VIH. Ministry of health. Morocco: UNAIDS; 2005.
70. Ministère de la Santé Maroc. Bulletin épidemiologique de surveillance du VIH/SIDA et des infections sexuellement transmissibles. Rabat, Ministère de la Santé Maroc. 2003/2004.
71. Ministère de la Santé Maroc. Bulletin épidemiologique de surveillance du VIH/SIDA et des infections sexuellement transmissibles. Rabat, Ministère de la Santé Maroc. 2005.
72. Iqbal J, Rehan N. Sero-prevalence of HIV: six years' experience at Shaikh Zayed Hospital, Lahore. J Pak Med Assoc 1996; 46:255–258.
73. Kuo I, ul-Hasan S, Galai N, Thomas DL, Zafar T, Ahmed MA, et al
. High HCV seroprevalence and HIV drug use risk behaviors among injection drug users in Pakistan. Harm Reduct J 2006; 3:26.
74. Platt L, Vickerman P, Collumbien M, Hasan S, Lalji N, Mayhew S, et al
. Prevalence of HIV, HCV and sexually transmitted infections among injecting drug users in Rawalpindi and Abbottabad, Pakistan: evidence for an emerging injection-related HIV epidemic. Sex Transm Infect 2009; 85(Suppl 2):ii17–ii22.
75. Parviz S, Fatmi Z, Altaf A, McCormick JB, Fischer-Hoch S, Rahbar M, et al
. Background demographics and risk behaviors of injecting drug users in Karachi, Pakistan. Int J Infect Dis 2006; 10:364–371.
76. Bokhari A, Nizamani NM, Jackson DJ, Rehan NE, Rahman M, Muzaffar R, et al
. HIV risk in Karachi and Lahore, Pakistan: an emerging epidemic in injecting and commercial sex networks. Int J STD AIDS 2007; 18:486–492.
77. Altaf A, Memon A, Rehman N, Shah S. Harm reduction among injection drug users in Karachi, Pakistan. International AIDS Conference 2004
. Bangkok; 2004; abstract WePeC5992.
78. Shah SA, Altaf A, Mujeeb SA, Memon A. An outbreak of HIV infection among injection drug users in a small town in Pakistan: potential for national implications. Int J STD AIDS 2004; 15:209.
79. Sindh AIDS Control Program. Surveillance data
. Pakistan: Government of Sindh; 2004.
80. Ur Rehman N, Emmanuel F, Akhtar S. HIV transmission among drug users in Larkana, Pakistan. Trop Doct 2007; 37:58–59.
81. Pakistan National AIDS Control Program. HIV Second Generation Surveillance In Pakistan. National Report Round 1. National AIDS Control Program, Ministry Of Health, Pakistan
. Canada-Pakistan HIV/AIDS Surveillance Project; 2005.
82. Pakistan National AIDS Control Program. HIV Second Generation Surveillance In Pakistan. National Report Round II. National AIDS Control Program, Ministry Of Health, Pakistan
. Canada–Pakistan HIV/AIDS Surveillance Project; 2006.
83. Pakistan National AIDS Control Program. HIV Second Generation Surveillance In Pakistan. National Report Round III. National AIDS Control Program, Ministry Of Health, Pakistan
. Canada–Pakistan HIV/AIDS Surveillance Project; 2008.
84. UNAIDS/WHO. AIDS epidemic update 2005
. Geneva: WHO; 2005.
85. Rai MA, Warraich HJ, Ali SH, Nerurkar VR. HIV/AIDS in Pakistan: the battle begins. Retrovirology 2007; 4:22.
86. Achakzai M, Kassi M, Kasi PM. Seroprevalences and co-infections of HIV, hepatitis C virus and hepatitis B virus in injecting drug users in Quetta, Pakistan. Trop Doct 2007; 37:43–45.
87. Pakistan National AIDS Control Programme. Pilot Study in Karachi & Rawalpindi. Ministry of Health, Government of Pakistan and Canada-Pakistan HIV/AIDS Surveillance Project
. Integrated Behavioral and Biological Surveillance; 2004.
88. Hawkes S, Collumbien M, Platt L, Lalji N, Rizvi N, Andreasen A, et al
. HIV and other sexually transmitted infections among men, transgenders and women selling sex in two cities in Pakistan: a cross-sectional prevalence survey. Sex Transm Infect 2009; 85(Suppl 2):ii8–ii16.
89. Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon A. Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. Int J STD AIDS 1999; 10:300–304.
90. Khan AA, Rehan N, Qayyum K, Khan A. Correlates and prevalence of HIV and sexually transmitted infections among Hijras (male transgenders) in Pakistan. Int J STD AIDS 2008; 19:817–820.
91. UNFPA. UNFPA survey among female sex workers in Karachi. Report found on Kaisernetwork Daily News (Jan 07, 2009) under title ‘UNFPA, Local NGO Partner for HIV Education Efforts Aimed at Pakistani Sex Workers’; 2009.
92. Njoh J, Zimmo S. Prevalence of antibodies to hepatitis C virus in drug-dependent patients in Jeddah, Saudi Arabia. East Afr Med J 1997; 74:89–91.
93. Jama H, Grillner L, Biberfeld G, Osman S, Isse A, Abdirahman M, et al
. Sexually transmitted viral infections in various population groups in Mogadishu, Somalia. Genitourin Med 1987; 63:329–332.
94. Burans JP, Fox E, Omar MA, Farah AH, Abbass S, Yusef S, et al
. HIV infection surveillance in Mogadishu, Somalia. East Afr Med J 1990; 67:466–472.
95. Corwin AL, Olson JG, Omar MA, Razaki A, Watts DM. HIV-1 in Somalia: prevalence and knowledge among prostitutes. Aids 1991; 5:902–904.
96. Ahmed HJ, Omar K, Adan SY, Guled AM, Grillner L, Bygdeman S. Syphilis and human immunodeficiency virus seroconversion during a 6-month follow-up of female prostitutes in Mogadishu, Somalia. Int J STD AIDS 1991; 2:119–123.
97. Watts DM, Corwin AL, Omar MA, Hyams KC. Low risk of sexual transmission of hepatitis C virus in Somalia. Trans R Soc Trop Med Hyg 1994; 88:55–56.
98. Testa AC, Kriitmaa K. HIV and Syphilis Bio-Behavioural Surveillance Survey (BSS+) Among Female Transactional Sex Workers in Hargeisa, Somaliland. International Organization for Migration
. Geneva: World Health Organization; 2009.
99. Elrashied S. Draft Report: Generating Strategic Information and Assessing HIV/AIDS Knowledge, Attitude and Behaviour and Practices as well as Prevalence of HIV 1 among MSM in Khartoum State, 2005
. Khartoum; 2006.
100. Basha HM. Vulnerable Population Research in Darfur
101. Anonymous. Improving HIV/AIDS Response among Most at Risk Population in Sudan
. Orientation Workshop; 16 April 2007.
102. Ahmed SM. Sex sellers. Situation analysis: behavioral survey. Results & discussions
. Report. Sudan National AIDS Control Program; 2004.
103. McCarthy MC, Khalid IO, El Tigani A. HIV-1 infection in Juba, southern Sudan. J Med Virol 1995; 46:18–20.
104. Syria Mental Health Directorate, Programme SNA. Assessment of HIV Risk and Sero-prevalence among Drug Users in Greater Damascus. Syrian Ministry of Health
. UNODC. UNAIDS; 2008.
105. Orak S, Dalkilic AE, Ozbal Y. Serological investigation of HIV infections, HBsAg and syphilis in prostitutes in Elazig. Mikrobiyol Bul 1991; 25:51–56.
106. Gul U, Kilic A, Sakizligil B, Aksaray S, Bilgili S, Demirel O, et al
. Magnitude of sexually transmitted infections among female sex workers in Turkey. J Eur Acad Dermatol Venereol 2008; 22:1123–1124.
107. Tiras MB, Karabacak O, Himmetoglu Ö, Yüksel S. Seroprevalence of hepatitis B and HIV infection in high-risk turkish population. Turkiye Klinikleri J Gynecol Obst 1998; 8:157–158.
108. Štulhofer A, Božicevic I. HIV bio-behavioural survey among FSWs in Aden, Yemen, 2008
109. Al-Serouri AW. Assessment of knowledge, attitudes and beliefs about HIV/AIDS among young people residing in high risk communities in Aden governatore, Republic of Yemen. Society for the Development of Women & Children (SOUL), Education, Health, Welfare
. United Nations Children's Fund. Yemen Country Office. HIV/AIDS Project; 2005.
110. WHO, UNICEF, UNAIDS. Yemen. Epidemiological Facts Sheets on HIV/AIDS and Sexually Transmitted Infections
111. Al-Qadhi H. A Silent Threat in Yemen: Confronting HIV/AIDS Choices
. United Nations Development Programme; 2001.
112. Pisani E, Lazzari S, Walker N, Schwartlander B. HIV surveillance: a global perspective. J Acquir Immune Defic Syndr 2003; 32(Suppl 1):S3–S11.
113. Aceijas C, Friedman SR, Cooper HL, Wiessing L, Stimson GV, Hickman M. Estimates of injecting drug users at the national and local level in developing and transitional countries, and gender and age distribution. Sex Transm Infect 2006; 82(Suppl 3):iii10–iii17.
114. UNODC. United Nations Office on Drugs and Crime (2005)
. World Drug Report; 2005.
115. Razzaghi EM, Movaghar AR, Green TC, Khoshnood K. Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran. Harm Reduct J 2006; 3:12.
116. Gheiratmand R, Navipour R, Mohebbi MR, Mallik AK. Uncertainty on the number of HIV/AIDS patients: our experience in Iran. Sex Transm Infect 2005; 81:279–280.
117. Razzaghi E, Rahimi A, Hosseini M, Madani S. Rapid Situation Assessment (RSA) of Drug Abuse in Iran
. Tehran: Prevention Department, State Welfare Organization, Ministry of Health, I.R. of Iran and United Nations International Drug Control Program; 1999.
118. Wodak A. Report to WHO/EMRO regarding control of HIV among and from injecting drug users in the IR Iran
. Unpublished 1997.
119. Ghys PD, Bazant W, Monteiro MG, Calvani S, Lazzari S. The epidemics of injecting drug use and HIV in Asia. AIDS 2001; 15(Suppl 5):S91–S99.
120. Lau JT, Thomas J, Lin CK. HIV-related behaviours among voluntary blood donors in Hong Kong. AIDS Care 2002; 14:481–492.
121. Young RM, Meyer IH. The trouble with ‘MSM’ and ‘WSW’: erasure of the sexual-minority person in public health discourse. Am J Public Health 2005; 95:1144–1149.
122. McFarland W, Caceres CF. HIV surveillance among men who have sex with men. AIDS 2001; 15(Suppl 3):S23–S32.
124. Mercer CH, Hart GJ, Johnson AM, Cassell JA. Behaviourally bisexual men as a bridge population for HIV and sexually transmitted infections? Evidence from a national probability survey. Int J STD AIDS 2009; 20:87–94.
125. Collumbien M, Qureshi AA, Mayhew SH, Rizvi N, Rabbani A, Rolfe B, et al
. Understanding the context of male and transgender sex work using peer ethnography. Sex Transm Infect 2009; 85(Suppl 2):ii3–ii7.
126. Rajabali A, Khan S, Warraich HJ, Khanani MR, Ali SH. HIV and homosexuality in Pakistan. Lancet Infect Dis 2008; 8:511–515.
127. Jenkins C, Robalino DA. HIV in the Middle East and North Africa: the cost of inaction. Orientations in Development Series, World Bank
128. Schmitt A, Sofer J. Sexuality and Eroticism Among Males in Moslem Countries
. In: New York: Harrington Park Press; 1992.
129. El-Sayed N, Abdallah M, Abdel Mobdy A, Abdel Sattar A, Aoun E, Beths F, et al. Evaluation of Selected Reproductive Health Infections in Various Egyptian Population Groups in Greater Cairo
. MOHP, IMPACT/FHI/USAID; 2002.
130. Hsairi M, Ben Abdallah S. Analyse de la situation de vulnérabilité vis-à-vis de l'infection à VIH des hommes ayant des relations sexuelles avec des hommes
. Rapport Final, version abrégée. 2007.
131. Hermez J, Aaraj E, Dewachi O, Chemaly N. HIV/AIDS prevention among vulnerable groups in Beirut, Lebanon
. Powerpoint presentation.
132. Khan OA, Hyder AA. HIV/AIDS among men who have sex with men in Pakistan. Sex Health Exch
133. Elrashied S. Prevalence, knowledge and related risky sexual behaviours of HIV/AIDS among receptive men who have sex with men (MSM) in Khartoum State, Sudan, 2005.
Abstract TUPE0509. XVI International AIDS Conference
; 13–18 August 2006; Toronto.
135. El-Sayed N, Darwish A, El-Geeneidy M, Mehrez M. Knowledge, attitude, and practice of homosexuals regarding HIV in Egypt
. Egypt: National AIDS Program, Ministry of Health and Population; 1994.
136. Elrashied SM. Generating Strategic Information and assessing HIV/AIDS Knowledge, Attitude and Behaviour and Practices as well as Prevalence of HIV1 among MSM in Khartoum State, 2005. A draft report subitted to Sudan National AIDS Control Programme
. Khartoum, Sudan: Together Against AIDS Organization (TAG); 2006.
137. Chaouki N, Bosch FX, Munoz N, Meijer CJ, El Gueddari B, El Ghazi A, et al
. The viral origin of cervical cancer in Rabat, Morocco. Int J Cancer 1998; 75:546–554.
138. Blanchard JF, Khan A, Bokhari A. Variations in the population size, distribution and client volume among female sex workers in seven cities of Pakistan. Sex Transm Infect 2008; 84(Suppl 2):ii24–ii27.
139. SNAP/UNICEF/UNAIDS. Baseline study on knowledge, attitudes, and practices on sexual behaviors and HIV/AIDS prevention amongst young people in selected states in Sudan
. HIV/AIDS KAPB Report. Projects and Research Department (AFROCENTER Group). 2005.
140. Ahmed SM. Antenatal. Situation Analysis-Behavioral Survey. Results & Discussions
. Report. Sudan National AIDS Control Program. 2004.
141. Ahmed SM. Tea Sellers. Situation Analysis-Behavioral Survey. Results & Discussions
. Report. Sudan National AIDS Control Program. 2004.
142. Vandepitte J, Lyerla R, Dallabetta G, Crabbe F, Alary M, Buve A. Estimates of the number of female sex workers in different regions of the world. Sex Transm Infect 2006; 82(Suppl 3):iii18–iii25.
143. Blanchard JF, Halli S, Ramesh BM, Bhattacharjee P, Washington RG, O'Neil J, et al
. Variability in the sexual structure in a rural Indian setting: implications for HIV prevention strategies. Sex Transm Infect 2007; 83(Suppl 1):i30–i36.
144. Indonesia Ministry of Health. National estimates of adult HIV infection, Indonesia
. Workshop report. 2002.
145. WHO. Regional Office for the Western Pacific
. Consensus report on STI, HIV, and AIDS epidemiology, Malaysia. 1999.
146. Morison L, Weiss HA, Buve A, Carael M, Abega SC, Kaona F, et al
. Commercial sex and the spread of HIV in four cities in sub-Saharan Africa. AIDS 2001; 15(Suppl 4):S61–S69.
147. Action Aid Afghanistan. HIV AIDS in Afghanistan. A study on knowledge, attitude, behavior, and practice in high risk and vulnerable groups in Afghanistan
148. Genc M, Gunes G, Karaoglu L, Egri M. AIDS awareness and knowledge among married women living in Malatya (Turkey): implications for province-based prevention programs. New Microbiol 2005; 28:161–164.
149. ACCORD. Socio Economic Research on HIV/AIDS Prevention among Informal Sex Workers. Agency for Co-operation and Research in Development
. Federal Ministry of Health, Sudan National AIDS Control Program, and the World Health Organization; 2005.
150. Syria National AIDS Programme. HIV/AIDS Female Sex Workers KABP Survey in Syria
151. Lau JT, Tsui HY, Siah PC, Zhang KL. A study on female sex workers in southern China (Shenzhen): HIV-related knowledge, condom use and STD history. AIDS Care 2002; 14:219–233.
152. Strathdee SA, Lozada R, Semple SJ, Orozovich P, Pu M, Staines-Orozco H, et al
. Characteristics of female sex workers with US clients in two Mexico-US border cities. Sex Transm Dis 2008; 35:263–268.
153. Elmore-Meegan M, Conroy RM, Agala CB. Sex workers in Kenya, numbers of clients and associated risks: an exploratory survey. Reprod Health Matters 2004; 12:50–57.
154. Wilson D, Chiroro P, Lavelle S, Mutero C. Sex worker, client sex behaviour and condom use in Harare, Zimbabwe. AIDS Care 1989; 1:269–280.
155. Ati HA. HIV/AIDS/STIs Social and Geographical Mapping of Prisoners, Tea Sellers and Commercial Sex Workers in Port Sudan Town, Red Sea State
. Draft 2. Sudan: Ockenden International; 2005.
156. Sudan National AIDS Control Program. Sex sellers situation analysis & behavioral survey: results and discussions
. Khartoum; 2004.
157. Rehan N. Profile of men suffering from sexually transmitted infections in Pakistan. J Pak Med Assoc 2006; 56:S60–S65.
158. Ismail SO, Ahmed HJ, Grillner L, Hederstedt B, Issa A, Bygdeman SM. Sexually transmitted diseases in men in Mogadishu, Somalia. Int J STD AIDS 1990; 1:102–106.
159. Omer EE, Ali MH, Taha OM, Ahmed MA, Abbaro SA. Sexually transmitted diseases in Sudanese males. Trop Doct 1982; 12:208–210.
160. Zamani S, Ichikawa S, Nassirimanesh B, Vazirian M, Ichikawa K, Gouya MM, et al
. Prevalence and correlates of hepatitis C virus infection among injecting drug users in Tehran. Int J Drug Policy 2007; 18:359–363.
161. World Bank. HIV/AIDS in Afghanistan
162. Todd CS, others a. Prevalence of HIV, Hepatitis C, Hepatitis B, and Associated Risk Behaviors among Injection Drug Users in Kabul, Afghanistan. Submitted for publication. 2007.
163. Tehrani FR, Malek-Afzalip H. Knowledge, attitudes and practices concerning HIV/AIDS among Iranian at-risk sub-populations. Eastern Mediterranean Health Journal
164. Mayhew S, Collumbien M, Qureshi A, Platt L, Rafiq N, Faisel A, et al
. Protecting the unprotected: mixed-method research on drug use, sex work and rights in Pakistan's fight against HIV/AIDS. Sex Transm Infect 2009; 85(Suppl 2):ii31–ii36.
165. El-Saharty S, Ali O. An effective well coordinated response to HIV in Djibouti. World Bank Global HIV/AIDS Program
. Geneva: World Bank; 2006.
166. Ryan S. Travel Report Summary. Kabul, Afghanistan. Joint United Nations Programme on HIV/AIDS
. Geneva: UN; 2006.
167. Agha S. Potential for HIV transmission among truck drivers in Pakistan. Aids 2000; 14:2404–2406.
168. Faisel A, Cleland J. Study of the sexual behaviours and prevalence of STIs among migrant men in Lahore, Pakistan. Arjumand and Associates
. Centre for Population Studies, London School of Hygiene and Tropical Medicine; 2006.
169. Faisel A, Cleland J. Migrant men: a priority for HIV control in Pakistan? Sex Transm Infect 2006; 82:307–310.
170. Aidaoui M, Bouzbid S, Laouar M. Seroprevalence of HIV infection in pregnant women in the Annaba region (Algeria). Rev Epidemiol Sante Publique 2008; 56:261–266.
171. Bennani A, Alami K. Surveillance sentinelle VIH, résultats 2005 et tendances de la séroprévalence du VIH. Ministry of health
. Morocco: UNAIDS; 2006.
172. Ahmed AJ, Hassan N, Pasha O, Fisher-Hoch S, McCormick JB, Luby SP. Prevalence of STDs among long-distance truck drivers in Pakistan. Proceedings of the Conference on HIV Surveillance
; Karachi, Pakistan; 1995.
173. Mujeeb SA, Hafeez A. Prevalence and pattern of HIV infection in Karachi. J Pak Med Assoc 1993; 43:2–4.
174. Burans JP, McCarthy M, el Tayeb SM, el Tigani A, George J, Abu-Elyazeed R, et al
. Serosurvey of prevalence of human immunodeficiency virus amongst high risk groups in Port Sudan, Sudan. East Afr Med J 1990; 67:650–655.
175. Farah MS, Hussein S. HIV Prevalence, Knowledge, Attitude, Practices and Risk Factors among Truck Drivers in Karthoum State
176. McCarthy MC, Hyams KC, el-Tigani el-Hag A, el-Dabi MA, el-Sadig el-Tayeb M, Khalid IO, et al
. HIV-1 and hepatitis B transmission in Sudan. AIDS 1989; 3:725–729.
177. Ahmed SM. Military. Situation Analysis-Behavioral Survey. Results & Discussions
. Report. Sudan National AIDS Control Program. 2004.
178. Sudan National AIDS Program, The New Sudan National AIDS Council, UNAIDS. Scaling-up HIV/AIDS Response in Sudan
. National Consultation on the Road towards Universal Access to Prevention, Treatment, Care and Support. 2006.
179. Botros BA, Aliyev Q, Saad M, Monteville M, Michael A, Nasibov Z, et al. HIV prevalence and risk behaviours among international truck drivers in Azerbaijan.
In: 17th European Congress of Clinical Microbiology and Infectious Diseases
. ICC, Munich, Germany; 2007.
180. O'Grady M. WFP Consultant Visit to Djibouti Report. 30 July 2004.
181. Ahmed SM. Truck Drivers. Situation Analysis-Behavioral Survey. Results & Discussions
. Report. Sudan National AIDS Control Program. 2004.
182. Sudan National HIV/AIDS Control Program. HIV/AIDS/STIs Prevalence, Knowledge, Attitude, Practices and Risk Factors among University Students and Military Personnel
. Sudan: Federal Ministry of Health. Khartoum; 2004.
183. Todd CS, Ahmadzai M, Atiqzai F, Siddiqui H, Azfar P, Miller S, et al. Seroprevalence & correlates of HIV, syphilis, & hepatitis B & C infection among antenatal patients & testing practices & knowledge among obstetric care providers in Kabul, Powerpoint presentation
184. Todd CS, Ahmadzai M, Atiqzai F, Miller S, Smith JM, Ghazanfar SA, et al
. Seroprevalence and correlates of HIV, syphilis, and hepatitis B and C virus among intrapartum patients in Kabul, Afghanistan. BMC Infect Dis 2008; 8:119.
185. Dupire B, Abawi AK, Ganteaume C, Lam T, Truze P, Martet G. Establishment of a blood transfusion center at Kabul (Afghanistan). Sante 1999; 9:18–22.
186. Afghanistan Central Blood Bank. Report of Testing of Blood Donors from March – December, 2006
. Kabul, Afghanistan: Ministry of Public Health; 2006.
187. Maslin J, Rogier C, Berger F, Khamil MA, Mattera D, Grandadam M, et al
. Epidemiology and genetic characterization of HIV-1 isolates in the general population of Djibouti (Horn of Africa). J Acquir Immune Defic Syndr 2005; 39:129–132.
188. Ministère de La Santé de Djibouti/Association Internationale de Développement. Epidémie a VIH/SIDA/IST en République de Djibouti; Tome I: Analyse de la Situation et Analyse de la Réponse Nationale
. Décembre 2002. 2002.
189. Surveillance des infections à VIH et de la syphilis chez les femmes enceintes vues dans 8 centres de consultations prénatales dans le district de Djibouti. 2002. 2002.
190. Dray X, Dray-Spira R, Bronstein JA, Mattera D. Prevalences of HIV, hepatitis B and hepatitis C in blood donors in the Republic of Djibouti. Med Trop (Mars) 2005; 65:39–42.
191. Massenet D, Bouh A. Aspects of blood transfusion in Djibouti. Med Trop (Mars) 1997; 57:202–205.
192. Constantine NT, Sheba MF, Watts DM, Farid Z, Kamal M. HIV infection in Egypt: a two and a half year surveillance. J Trop Med Hyg 1990; 93:146–150.
193. Kandela P. Arab nations: attitudes to AIDS. Lancet 1993; 341:884–885.
194. Quinti I, Renganathan E, El Ghazzawi E, Divizia M, Sawaf G, Awad S, et al
. Seroprevalence of HIV and HCV infections in Alexandria, Egypt. Zentralbl Bakteriol 1995; 283:239–244.
195. Amini S, Mahmoodi MF, Andalibi S, Solati AA. Seroepidemiology of hepatitis B, delta and human immunodeficiency virus infections in Hamadan province, Iran: a population based study. J Trop Med Hyg 1993; 96:277–287.
196. Massarrat MS, Tahaghoghi-Mehrizi S. Iranian national health survey: a brief report. Arch Iranian Med 2002; 2:73–79.
197. Iran Ministry of Health. Treatment and medical education. Islamic Republic of Iran HIV/AIDS situation and response analysis
198. Sharifi-Mood B, Keikha F. Seroprevalence of human immunodeficiency virus (HIV) in pregnant women in Zahedan, Southeastern Iran. J Res Med Sci 2008; 13:186–188.
199. WHO/EMRO. HIV/AIDS Surveillance in Low Level and Concentrated HIV Epidemics
. A technical guide for countries in the WHO Eastern Mediterranean Region; 2007.
200. Pourshams A, Malekzadeh R, Monavvari A, Akbari MR, Mohamadkhani A, Yarahmadi S, et al
. Prevalence and etiology of persistently elevated alanine aminotransferase levels in healthy Iranian blood donors. J Gastroenterol Hepatol 2005; 20:229–233.
201. Rezvan H, Abolghassemi H, Kafiabad SA. Transfusion-transmitted infections among multitransfused patients in Iran: a review. Transfus Med 2007; 17:425–433.
202. Khedmat H, Fallahian F, Abolghasemi H, Alavian SM, Hajibeigi B, Miri SM, et al
. Seroepidemiologic study of hepatitis B virus, hepatitis C virus, human immunodeficiency virus and syphilis infections in Iranian blood donors. Pak J Biol Sci 2007; 10:4461–4466.
203. Al Katheeb MS, Tarawneh MS, Awidi AS. Antibodies to HIV in Jordanian blood donors and patients with congenital bleeding disorders. IV International Conference on AIDS
; Stockholm; 1988; abstract 5003.
204. Ameen R, Sanad N, Al-Shemmari S, Siddique I, Chowdhury RI, Al-Hamdan S, et al
. Prevalence of viral markers among first-time Arab blood donors in Kuwait. Transfusion 2005; 45:1973–1980.
205. Libya National Center for the Prevention of and Control of Infectious Diseases. Results of the National Seroprevalence Survey
206. El-Gadi S, Abudher A, Sammud M. HIV-related knowledge and stigma among high school students in Libya. Int J STD AIDS 2008; 19:178–183.
207. WHO. HIV/AIDS epidemiological surveillance report for the WHO African region 2002 update
208. Elharti E, Zidouh A, Mengad R, Bennani O, Elaouad R. Monitoring HIV through sentinel surveillance in Morocco. East Mediterr Health J 2002; 8:141–149.
209. Morocco Ministry of Health. Implementation of the declaration of commitment on HIV/AIDS. 2006 National Report
. Morocco: Morocco Ministry of Health; 2006.
210. Elmir E, Nadia S, Ouafae B, Rajae M, Amina S, Rajae el A, et al
. HIV epidemiology in Morocco: a nine-year survey (1991–1999). Int J STD AIDS 2002; 13:839–842.
211. Elharti E. HIV epidemiology in Morocco: a nine-year survey (1991–1999). Int J STD AIDS 2002; 13:839–842.
212. Mujeeb SA, Khanani MR, Khursheed T, Siddiqui A. Prevalence of HIV-infection among blood donors. J Pak Med Assoc 1991; 41:253–254.
213. Mujeeb SA, Aamir K, Mehmood K. Seroprevalence of HBV, HCV and HIV infections among college going first time voluntary blood donors. J Pak Med Assoc 2006; 56:S24–S25.
214. Abdul Mujeeb S, Aamir K, Mehmood K. Seroprevalence of HBV, HCV and HIV infections among college going first time voluntary blood donors. J Pak Med Assoc 2000; 50:269–270.
215. Sultan F, Mehmood T, Mahmood MT. Infectious pathogens in volunteer and replacement blood donors in Pakistan: a ten-year experience. Int J Infect Dis 2007; 11:407–412.
216. Kayani N, Sheikh A, Khan A, Mithani C, Khurshid M. A view of HIV-I infection in Karachi. J Pak Med Assoc 1994; 44:8–11.
217. Kakepoto GN, Bhally HS, Khaliq G, Kayani N, Burney IA, Siddiqui T, et al
. Epidemiology of blood-borne viruses: a study of healthy blood donors in Southern Pakistan. Southeast Asian J Trop Med Public Health 1996; 27:703–706.
218. Pakistan National Institute of Health. National AIDS Control Program Report
. Islamabad: Government of Pakistan; 1992.
219. Pakistan National Institute of Health. National AIDS Control Program Report
. Islamabad: Government of Pakistan; 1995.
220. Abdul Mujeeb S, Hashmi MR. A study of HIV-antibody in sera of blood donors and people at risk. J Pak Med Assoc 1988; 38:221–222.
221. State of Qatar. Report on the country progress indicators towards implementing the declaraion of commitment on HIV
222. El-Hazmi MM. Prevalence of HBV, HCV, HIV-1, 2 and HTLV-I/II infections among blood donors in a teaching hospital in the Central region of Saudi Arabia. Saudi Med J 2004; 25:26–33.
223. Alamawi S, Abutaleb A, Qasem L, Masoud S, Memish Z, Al Khairy K, et al
. HIV-1 p24 antigen testing in blood banks: results from Saudi Arabia. Br J Biomed Sci 2003; 60:102–104.
224. Al Rasheed AM, Fairclough D, Abu Al Sand, Osoba AO. Screening for HIV antibodies among blood donors at Riyadh Armed Forces Hospital. VI International Conference on AIDS
; Stockholm; 1988; abstract 5001.
225. WHO. The 2004 First National Second Generation HIV/AIDS/STI Sentinel Surveillance Survey, Somalia. A Technical Report
. Geneva: WHO; 2004.
226. Somaliland Ministry of Health and Labour. Somaliland 2007 HIV/syphilis seroprevalence survey. A technical report. Ministry of Health and Labour
. In collaboration with the World Health Organization, UNAIDS, UNICEF/GFATM, and SOLNAC. 2007.
227. WHO. The 2004 First National Second Generation HIV/AIDS/STI Sentinel Surveillance Survey, Central South, Somalia, A Technical Report
228. WHO. The 2004 First National Second Generation HIV/AIDS/STI Sentinel Surveillance Survey, Puntland, Somalia, A Technical Report
229. UNHCR. HIV Sentinel Surveillance among Antenatal Clients and STI patients
. Dadaab Refugee Camps, Kenya. United Nations High Commissioner for Refugees. 2006/07.
230. UNHCR. National AIDS and Sexually Transmitted Control Programme
. HIV sentinel surveillance in Dadaab refugee camps. Nairobi: UNHCR; 2003.
231. UNHCR. National AIDS and Sexually Transmitted Control Programme
. Sentinel surveillance report Dadaab refugee camps, Kenya January–May 2005. UNHCR: Nairobi; 2005.
232. WHO. WHO Somalia Statististic Report 2003
. Geneva: WHO; 2003.
233. Kulane A, Hilowle AA, Hassan AA, Thorstensson R. Prevalence of HIV, HTLV I/II and HBV infections during long lasting civil conflicts in Somalia. Int Conf AIDS
234. Sudan National AIDS Program. Update on the HIV Situation in Sudan
. Powerpoint presenation. 2008.
235. Sudan Ministry of Health. 2005 ANC sentinel sites results
. Khartoum. 2006.
236. Sudan National AIDS Control Programme. National Policy on HIV/AIDS
. 2005. 2005.
237. Kaiser R, Kedamo T, Lane J, Kessia G, Downing R, Handzel T, et al
. HIV, syphilis, herpes simplex virus 2, and behavioral surveillance among conflict-affected populations in Yei and Rumbek, southern Sudan. AIDS 2006; 20:942–944.
238. Gutbi OS-A, Eldin AMG. Women Tea-Sellers in Khartoum and HIV/AIDS: Surviving Against the Odds
. Khartoum, Sudan; 2006.
239. Sudan National AIDS/STIs Program. 2007 ANC HIV Sentinel Sero-survey, Technical Report, Federal Ministry of Health, Preventive Medicine Directorate, Draft. 2008.
240. Sudan National AIDS Control Program. Sentinel Sero-Survailance - 2005 Data
. Annual News Letter. 2005.
241. UNHCR. Kakuma Refugee Camp – Refugees and Host Nationals. Great Lakes Initiative on HIV/AIDS. HIV Sentinel Surveillance among Conflict Affected Populations
. United Nations High Commissioner for Refugees. 2006/07.
242. IRC. CDC. Kakuma refugee camp sentinel surveillance report
. Nairobi. 2002.
243. Sudan National AIDS Programme, UNAIDS. HIV/AIDS Integrated Report North Sudan, 2004-2005 (Draft). With United Nations General Assembly Special Session on HIV/AIDS Declaration of Commitment. 2006.
244. The New Sudan AIDS Council (NSNAC). UNAIDS. HIV/AIDS Integrated Report South Sudan, 2004–2005
. United Nations General Assembly Special Session on HIV/AIDS Declaration of Commitment; 2006.
245. Southern Sudan AIDS Commission. Southern Sudan ANC Sentinel Surveillance Data. US Centers for Disease Control and Prevention (CDC), Sudan, in collaboration with Southern Sudan AIDS Commission
246. UNAIDS. Epidemiological country fact sheet
. Sudan 2000. 2000.
247. Gassmelseed DE, Nasr AM, Homeida SM, Elsheikh MA, Adam I. Prevalence of HIV infection among pregnant women of the central Sudan. J Med Virol 2006; 78:1269–1270.
248. Hashim MS, Salih MA, el Hag AA, Karrar ZA, Osman EM, el-Shiekh FS, et al
. AIDS and HIV infection in Sudanese children: a clinical and epidemiological study. AIDS Patient Care STDS 1997; 11:331–337.
249. Aiding refugees in the aftermath of civil war. Country focus: Sudan. AIDS Anal Afr
250. Afsar I, Gungor S, Sener AG, Yurtsever SG. The prevalence of HBV, HCV and HIV infections among blood donors in Izmir, Turkey. Indian J Med Microbiol 2008; 26:288–289.
251. Coskun O, Gul C, Erdem H, Bedir O, Eyigun CP. Prevalence of HIV and syphilis among Turkish blood donors. Ann Saudi Med 2008; 28:470.
252. Arabaci F, Sahin HA, Sahin I, Kartal S. Kan donörlerinde HBV, HCV, HIV ve VDRL seropozitifligi. Klimik Derg 2003; 16:18–20.
253. Yassin K, Awad R, Tebi AJ, Queder A, Laaser U. A zero prevalence of anti-HIV in blood donors in Gaza: how can it be sustained? AIDS 2001; 15:936–937.
254. Maayan S, Shinar E, Aefani M, Soughayer M, Alkhoudary R, Barshany S, et al
. HIV-1 prevalence among Israeli and Palestinian blood donors. AIDS 1994; 8:133–134.
255. Yemen National AIDS Control Programme. Ministry of Public Health Yemen
. AIDS/HIV surveillance report, fourth quarter 1998. 1998.
256. Yemen National AIDS Control Programme. Ministry of Public Health Yemen
. AIDS/HIV surveillance report, fourth quarter 2001. 2001.
257. Jurjus AR, Kahhaleh J, National AIDS Program, Organization-EMRO WH. Knowledge, Attitudes, Beliefs, and Practices of the Lebanese Concerning HIV/AIDS. Beirut, Lebanon; 2004.
258. Hammouda D, Munoz N, Herrero R, Arslan A, Bouhadef A, Oublil M, et al
. Cervical carcinoma in Algiers, Algeria: human papillomavirus and lifestyle risk factors. Int J Cancer 2005; 113:483–489.
259. Naffa S. Jordanian Women: Past and Present
260. Chaleby K. Women of polygamous marriages in an inpatient psychiatric service in Kuwait. J Nerv Ment Dis 1985; 173:56–58.
261. Zargooshi J. Characteristics of gonorrhoea in Kermanshah, Iran. Sex Transm Infect 2002; 78:460–461.
262. Abu-Raddad LJ. Multiple discussions with members of National AIDS Programs in MENA
263. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2:e298.
264. Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al
. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007; 369:643–656.
265. Gray RH, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F, et al
. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369:657–666.
266. Weiss HA, Halperin D, Bailey RC, Hayes RJ, Schmid G, Hankins CA. Male circumcision for HIV prevention: from evidence to action? AIDS 2008; 22:567–574.
267. UNHCR. HIV Behavioural Surveillance Survey Juba Municipality, South Sudan
. United Nations High Commissioner for Refugees; 2007.
268. Alsallaq RA, Cash B, Weiss HA, Longini IM, Omer SB, Wawer MJ, et al. Quantitative assessment of the role of male circumcision in HIV epidemiology at the population level. Epidemics
269. Bailey RC, Neema S, Othieno R. Sexual behaviors and other HIV risk factors in circumcised and uncircumcised men in Uganda. J Acquir Immune Defic Syndr 1999; 22:294–301.
270. Rakwar J, Lavreys L, Thompson ML, Jackson D, Bwayo J, Hassanali S, et al
. Cofactors for the acquisition of HIV-1 among heterosexual men: prospective cohort study of trucking company workers in Kenya. AIDS 1999; 13:607–614.
271. Isiugo-Abanihe UC. Extramarital relations and perceptions of HIV/AIDS in Nigeria. Health Transit Rev 1994; 4:111–125.
272. Biaya TK. Les plaisirs de la ville: Masculinité, sexualité et féminité à Dakar (1997-2000). Afr Stud Rev
273. Gilbert SS. The influence of Islam on AIDS prevention among Senegalese university students. AIDS Educ Prev 2008; 20:399–407.
274. Shirazi KK, Morowatisharifabad MA. Religiosity and determinants of safe sex in Iranian nonmedical male students. J Relig Health 2009; 48:29–36.
275. Kengeya-Kayondo JF, Kamali A, Nunn AJ, Ruberantwari A, Wagner HU, Mulder DW. Incidence of HIV-1 infection in adults and socio-demographic characteristics of seroconverters in a rural population in Uganda: 1990–1994. Int J Epidemiol 1996; 25:1077–1082.
276. Malamba SS, Wagner HU, Maude G, Okongo M, Nunn AJ, Kengeya-Kayondo JF, et al
. Risk factors for HIV-1 infection in adults in a rural Ugandan community: a case–control study. AIDS 1994; 8:253–257.
277. Gray RH, Kiwanuka N, Quinn TC, Sewankambo NK, Serwadda D, Mangen FW, et al
. Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team. AIDS 2000; 14:2371–2381.
278. Mbulaiteye SM, Ruberantwari A, Nakiyingi JS, Carpenter LM, Kamali A, Whitworth JA. Alcohol and HIV: a study among sexually active adults in rural southwest Uganda. Int J Epidemiol 2000; 29:911–915.
279. Bwayo J, Plummer F, Omari M, Mutere A, Moses S, Ndinya-Achola J, et al
. Human immunodeficiency virus infection in long-distance truck drivers in east Africa. Arch Intern Med 1994; 154:1391–1396.
280. Nunn AJ, Kengeya-Kayondo JF, Malamba SS, Seeley JA, Mulder DW. Risk factors for HIV-1 infection in adults in a rural Ugandan community: a population study. AIDS 1994; 8:81–86.
281. Abebe Y, Schaap A, Mamo G, Negussie A, Darimo B, Wolday D, et al
. HIV prevalence in 72 000 urban and rural male army recruits, Ethiopia. AIDS 2003; 17:1835–1840.
282. Drain PK, Smith JS, Hughes JP, Halperin DT, Holmes KK. Correlates of national HIV seroprevalence: an ecologic analysis of 122 developing countries. J Acquir Immune Defic Syndr 2004; 35:407–420.
283. Meda N, Ndoye I, M'Boup S, Wade A, Ndiaye S, Niang C, et al
. Low and stable HIV infection rates in Senegal: natural course of the epidemic or evidence for success of prevention? AIDS 1999; 13:1397–1405.
284. Kagee A, Toefy Y, Simbayi L, Kalichman S. HIV prevalence in three predominantly Muslim residential areas in the Cape Town metropole. S Afr Med J 2005; 95:512–516.
285. Hargrove J. Migration, Mines and Mores: The HIV epidemic in Southern Africa
. Inaugural Address. Stellenbosch University; 2007.
286. Pickthall M. The Meaning of the Glorious Qur'an. Hyderabad, India
. Chapters and Verses; 17:32, 26:165-166, 5:90. 1930.
287. Kaljee LM, Genberg BL, Minh TT, Tho LH, Thoa LT, Stanton B. Alcohol use and HIV risk behaviors among rural adolescents in Khanh Hoa Province Viet Nam. Health Educ Res 2005; 20:71–80.
288. Fisher JC, Bang H, Kapiga SH. The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies. Sex Transm Dis 2007; 34:856–863.
289. Huff B. Male circumcision: cutting the risk?
American Foundation for AIDS Research; 2000.
290. Alrajhi AA, Halim MA, Al-Abdely HM. Mode of transmission of HIV-1 in Saudi Arabia. AIDS 2004; 18:1478–1480.
291. Ramezani A, Mohraz M, Gachkar L. Epidemiologic situation of human immunodeficiency virus (HIV/AIDS patients) in a private clinic in Tehran, Iran. Arch Iran Med 2006; 9:315–318.
292. Burrows D, Wodak A, WHO. Harm Reduction in Iran
. Issues in national scale-up. Report for World Health Organization. 2005.
293. Hallett TB, Gregson S, Lewis JJ, Lopman BA, Garnett GP. Behaviour change in generalised HIV epidemics: impact of reducing cross-generational sex and delaying age at sexual debut. Sex Transm Infect 2007; 83(Suppl 1):i50–i54.
294. Sy T, Jamal MM. Epidemiology of hepatitis C virus (HCV) infection. Int J Med Sci 2006; 3:41–46.
295. United Nations Programme on AIDS. AIDS Epidemic Update 2005
. Geneva: WHO; 2005.
296. United Nations Office for Drug Control and Crime Prevention. United Nations Office on AIDS. Baseline study of the relationship between injecting drug use, HIV and hepatitis C among male injecting drug users in Lahore
. Islamabad: UNDCP and UNAIDS; 1999.
297. Agha A, Parviz S, Younus M, Fatmi Z. Socio-economic and demographic factors associated with injecting drug use among drug users in Karachi, Pakistan. J Pak Med Assoc 2003; 53:511–516.
298. Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon A. Seroprevalence of HIV, HBV and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. J Pak Med Assoc 2006; 56:S17–S21.
299. Pisani E, Girault P, Gultom M, Sukartini N, Kumalawati J, Jazan S, et al
. HIV, syphilis infection, and sexual practices among transgenders, male sex workers, and other men who have sex with men in Jakarta, Indonesia. Sex Transm Infect 2004; 80:536–540.
300. Commission on AIDS in Asia. Redfining AIDS in Asia. Crafting an Effective Response. Report of the Commission on AIDS in Asia. Presented to Mr. Ban Ki-moon, UN Secretary General
. Oxford University Press; 2008.
301. World Bank. Preventing HIV/AIDS in the Middle East and north Africa: a window of opportunity to act
. Orientations in Development Series, World Bank; 2005.
302. Buse K, Lalji N, Mayhew SH, Imran M, Hawkes SJ. Political feasibility of scaling-up five evidence-informed HIV interventions in Pakistan: a policy analysis. Sex Transm Infect 2009; 85(Suppl 2):ii37–ii42.
303. Jordan National AIDS Program. National HIV/AIDS Strategy for Jordan 2005–2009
. Draft. 2005.
304. Razzaghi E, Nassirimanesh B, Afshar P, Ohiri K, Claeson M, Power R. HIV/AIDS harm reduction in Iran. Lancet 2006; 368:434–435.
305. Vazirian M, Nassirimanesh B, Zamani S, Ono-Kihara M, Kihara M, Ravari SM, et al
. Needle and syringe sharing practices of injecting drug users participating in an outreach HIV prevention program in Tehran, Iran: a cross-sectional study. Harm Reduct J 2005; 2:19.
306. Pisani E, Garnett GP, Grassly NC, Brown T, Stover J, Hankins C, et al
. Back to basics in HIV prevention: focus on exposure. BMJ 2003; 326:1384–1387.
307. Aden AS, Dahlgren L, Guerra R. Experiences against HIV/AIDS/STDS of Somalis in exile in Gothenburg, Sweden. Ann Ig 2004; 16:141–155.
308. Lazarus JV, Himedan HM, Ostergaard LR, Liljestrand J. HIV/AIDS knowledge and condom use among Somali and Sudanese immigrants in Denmark. Scand J Public Health 2006; 34:92–99.
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AIDS; epidemiology; HIV; Middle East and North Africa; review
© 2010 Lippincott Williams & Wilkins, Inc.
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