On AIDS, Avoid Acting Too Late

Dec. 1 is World AIDS day, and this provides an appropriate backdrop to underline how frightening it is to compare the HIV-AIDS pandemic in sub-Saharan Africa to the situation in the Middle East and Northern Africa (MENA).

Although HIV-AIDS infection rates in the MENA region remain much lower than those in sub-Saharan Africa, and the disease has not become an epidemic; it is growing silently, and the number of those infected in North Africa, for example, has trebled between 2001 and 2003. While countries such as Egypt face other epidemics, such as Hepatitis C, HIV-AIDS is poised as the next disaster. While official adult infection rates for the MENA region are at 0.3 percent, compared to sub-Sahara's 7 percent, this figure may be drastically underestimated considering reluctance to test for the virus and widespread ignorance.

In MENA, new infections are increasing, with 92,000 reported new infections in 2004. Sudan has the largest number of infected people (2 percent of the adult population lives with HIV), while dramatic increases have also been recorded in Libya and Iran. Drug abuse in Egypt, Libya and Iran has been identified by the Joint United Nations Program on HIV-AIDS, or Unaids, as one of the largest contributors to the spread of the virus, and many of the drug users, it has been reported, are either married and-or do not practice safe sex. Sex workers, spouses or partners of people who use drugs are at a very high risk of being infected, putting the general population at greater risk.

In sub-Saharan Africa the most serious problems have been the stigmatization of people living with HIV-AIDS and cultural and religious norms working against safe sex and sex education. Even stronger societal norms exist in the MENA region, and the silence surrounding sexual behavior may allow the disease to spread and multiply as it did in Southern and Eastern Africa. It is common both in Northern Africa and the Middle East to blame HIV-AIDS on a breakdown of traditional and religious morality, making safe-sex education controversial. However, sex education will be imperative if the region is to avoid a full-fledged epidemic. Governments in sub-Saharan Africa have adopted an advocacy scheme called "ABC" - abstinence, be faithful and-or use a condom.

The stigmatization of HIV-positive persons has been and remains a serious issue in MENA and sub-Saharan regions where religious leaders of all faiths claim the disease is punishment for sins. However, as infection rates topped 30 percent in countries such as Botswana and large portions of populations were infected because of religiously sanctioned sexual activity (a high proportion of women got HIV from their husbands) the argument lost much merit in sub-Saharan Africa.

Religious leaders in North Africa and the Middle East have made similar pronouncements, and this is perhaps the most worrying similarity between MENA and sub-Saharan Africa. In Botswana, where the government can afford to provide AIDS drugs for free, not all people living with HIV are coming to government clinics to be tested because they fear stigmatization. In Egypt a large number of university students are ignorant of what a condom is, let alone how to use it. Statistics show that only 14.3 percent of boys and 5.1 percent of girls between the ages of 16 and 19 know of condoms. In the Mideast, where strong cultural and religious norms discourage premarital sex, this ignorance has not yet caused an explosion in the infection rate.

However, some cultural control over sexuality seems to be slipping. Sex work has been increasing, and a look at infection rates in Iran shows a sharp increase, as do statistics from Libya: 90 percent of reported infections in Libya occurred in the period 2000-2002 (based on 2002 statistics). In Iran, 15 percent of all HIV-AIDS cases were reported in 2003 alone. In Egypt, relatively high levels of sexually transmitted diseases in sex workers and women visiting family planning and antenatal clinics prove that cultural and religious norms are not successfully curbing the spread of diseases. The infection rates in Sudan and Djibouti are already considered to be in the epidemic range.

Public education on HIV-AIDS has clearly been a problem in MENA, in the same way it has been in southern and eastern Africa. In Egypt, the Health Ministry has set up a hotline to talk confidentially to any person about HIV-AIDS and safe sex. However, reports indicate that when public education is attempted in universities, the lecturers have to be very careful not to offend religious leaders.

In Iran the government has made the important decision of giving high school students AIDS education. This is impressive, considering how difficult it has been to persuade southern African governments to provide sex education to high school students. In contrast, the impression one gets in Cairo is that HIV-AIDS is not taken seriously. In southern Africa all newspapers, television channels and radios are full of advertisements about HIV-AIDS. Perhaps this is too late, but if the Middle East does not start now, it will be too late too.

HIV and AIDS spread on fear. Sexual conduct has always been an intensely private matter and most societies discourage sex before marriage. There is, therefore, a strong societal disincentive to admit to having had extra-marital sex. Thus, fear of societal isolation means that people resist testing for HIV. The stronger the societal pressures, the stronger the fear. This fear can only be counteracted by a strong education campaign to persuade citizens to test for HIV. If the population does not test and infection rates are based on known AIDS cases, or through antenatal clinics, the extent of infection may be underestimated. Southern Africa was shocked into action in the mid-1990's because infection rates were in the epidemic range. If North Africa and the Middle East is to avoid this, a much more vigorous campaign is needed.

One of the most dangerous misconceptions about HIV in MENA and sub-Saharan Africa has been that AIDS only affects "the other." It is the disease of foreigners, homosexuals, prostitutes, drug users or truck drivers. People, especially youths, never admit that they are at risk.

This attitude is changing, but again too late. Dismissing risk is not only dangerous because it ignores the rights of despised groups such as prostitutes and drug users, but also because HIV-AIDS spreads into the general population very easily. Men who visit sex workers spread HIV to their wives, as do drug users. HIV-AIDS cannot be compartmentalized, and we learned too late in southern Africa that to imagine so is to walk over a cliff with one's eyes closed.

The disaster that is HIV-AIDS can be averted in MENA if the governments and peoples of the region are willing to learn from the mistakes of sub-Saharan Africa. On one level the lesson has been learned: governments are making efforts at education, though these are limited. But on another level the impression is still that AIDS is a disease of the other, of those from sub-Saharan Africa. It is this ignorance that may allow the disease to grow to epidemic proportions in MENA.