An overview of HIV/AIDS and key populations in the MENA region International AIDS Conference in Durban 2016 An overview of HIV/AIDS and key populations in the MENA region HIV in Conservative Social Settings: Promoting A Rights Based Approach to HIV Dr Yamina Chakkar Director, Regional Support Team, Middle East and North Africa Durban, July 18, 2016 International AIDS Conference in Durban 2016

Trend of the number of people living with HIV It is estimated that 230 000 [160 000 – 330 000] adults and children are living with HIV in the MENA region, making it the lowest prevalence UNAIDS region, with a prevalence of 0.1 per cent among adults [<0.1 – 0.1%]. From 220 000 adults, 89 000 are female. Estimation is available for Algeria, Djibouti, Egypt, Iran, Lebanon, Morocco, Oman, Somalia, Sudan, Tunisia and Yemen.

Trend of the number of new infections In MENA, the number of new infections is not declining. On the contrary, it increased by four per cent between 2010 and 2015, with more than 21 000 new infections in 2015.

Where are the new infections taking place? Sixty percent of all new infections are in Iran and Sudan, the five countries of Iran, Sudan, Somalia, Egypt and Morocco comprise almost 90% of all new infections

Where are the new infections taking place? More than a quarter of the new infections are occurring among people who inject drugs with less than one fifth among gay and other men who have sex with men and almost 10% among sex workers. It has to be noted that most of the intimate partners of key populations are female.

The Response and Achievements in 2013 - 2015 Political, policy and programmatic

MENA priorities and focus The inner circle depicts the MENA regional priorities as per UBRAF, the outer circle shows the consolidation of UNAIDS focus in MENA based on the workplan top-tasks

Engagement, Leadership, Commitment, Partnership The Arab AIDS Strategy, developed by the League of Arab States and endorsed by the Council of Arab Health Ministers High Level Meeting of Women Leader in MENA, Algiers Call for Action on Advancing gender equality and the HIV response Countries in the region came together and developed their roadmaps for reaching 90- 90-90 targets and came with Regional Declaration on fast-tracking HIV testing in MENA Regional Arab Network against AIDS (RANAA) signed a Memorandum of Agreement with the League of Arab States on the role of civil society vis-à-vis the AAS A regional dialogue to mobilize political leadership and partnerships for a resilient HIV response for affected countries in MENA in order to achieve the fast-track and to address the emerging priorities in rapidly changing regional and local environments Djibouti as the first country ratifies the Arab Convention on HIV prevention and protecting the rights of PLHIV Countries in the region have their national strategic plans aligned with the Arab AIDS Strategy, 90-90-90 and other Fast-Track targets The political leadership of the League of Arab States and UNAIDS, has resulted in the development and endorsement of the Arab AIDS Strategy in March 2014 and the Council of Arab Health Ministers following up the implementation of the Strategy in all Member States in February 2015. This leadership is also clearly reflected in the Algiers Call for Action on Advancing gender equality and the HIV response that followed the High Level Meeting of Women Leaders in MENA, held jointly by the Leagues, UNAIDS, UN Women and the Government of Algeria in November 2014. Countries also declared their commitment to fast track testing in the region and developed roadmaps for reaching 90-90-90 in the region. The Declaration of Algiers was presented during the High Level Meeting in New York by the minister of health of Algeria. In an unprecedented step for civil society in MENA, the Regional Arab Network against AIDS (RANAA) signed a Memorandum of Agreement in December 2015 with the League of Arab States on the role of civil society in the implementation of the Arab AIDS Strategy. This represents the first partnership within the region between civil society and such a significant intergovernmental body.   A regional dialogue took place in Cairo in October 2015 to mobilize political leadership and partnerships for a resilient HIV response for affected countries in MENA in order to achieve the fast-track targets by 2020 and to address the emerging priorities in rapidly changing regional and local environments. The protection of people affected by humanitarian emergencies, including refugees, asylum seekers and internally displaced people, was identified as a key priority for the region. The ratification of the Arab Convention on Preventing HIV and Protecting the Right of PLHIV, adopted by the Arab Parliament in 2012, took a decisive turn when Djibouti became the first Arab country to ratify in October 2015. Most of the countries in the region have either updated or are updating their national strategic plans to be aligned with the Arab AIDS Strategy, 90-90-90 and other Fast-Track targets.

Access to HIV prevention services Iran and Morocco have expanding opioid substitution therapy programmes at communities and in prisons and Lebanon is expanding its community programme More than 70 per cent of people who inject drugs in Iran, Lebanon, Morocco and Tunisia have safe injection In Lebanon 75 per cent of men who have sex with men reported both knowledge of their HIV status and condom use Algeria and Lebanon report condom use rates by female sex workers in excess of 80 per cent, while Djibouti, Iran, Jordan, Morocco and Tunisia report rates between 50 to 80 per cent In Djibouti and Lebanon nearly two-thirds of female sex workers reported knowing their status In Sudan, the percentage of sex workers reporting condom use has increased from 22% to 25% between 2013 and 2015, the same figure has increased from 20% to 27% among men who have sex with men; profoundly, HIV testing has increased from 9% to 29% among sex workers and from 5% to 17% among men who have sex with men. Iran and Morocco have expanding opioid substitution therapy (OST) programmes at communities and in prisons and Lebanon is expanding its community OST programme. Access to sterile injecting equipment through needle and syringe programmes (NSPs) has resulted in safe injection by more than 70 per cent of people who inject drugs in Iran, Lebanon, Morocco and Tunisia. Programmes for men who have sex with men in the region have shown impact where services demonstrate respect for beneficiaries’ rights and dignity and when civil society and other partners are able to provide focus and saturation. Lebanon is an example of such success, with 75 per cent of MSM in Beirut reporting both knowledge of their HIV status and condom use. Prevention programmes with female sex workers and women engaged in transactional sex across the region also demonstrate success, with several countries reporting high rates of condom use among sex workers. For example, Algeria and Lebanon report rates in excess of 80 per cent, while Djibouti, Iran, Jordan, Morocco and Tunisia report rates between 50 to 80 per cent. Reported access of sex workers to HIV testing in most countries is less than among MSM, with the exception of Djibouti. Lebanon offers another example of good coverage, with nearly two-thirds of female sex workers knowing their status. From 2013 to 2015, the condom use and access to HIV testing has increased considerably in Sudan for key populations.

Elimination of mother to child transmission Oman and the United Arab Emirates have become the first and second countries respectively to integrate their eMTCT programmes within maternal and child health services and reach most of their elimination targets Other GCC Countries, notably Saudi Arabia and Kuwait, are moving in a similar direction Djibouti, a low-income country, is also progressing towards elimination, through integration of PMTC within antenatal care In Algeria, Iran, Sudan and Tunisia, the number of pregnant women tested and knowing their status has increased from than 120 000, to more than 650 000 in the course of three years (2013 to 2015) Elimination of mother to child transmission of HIV is a particular challenge in HIV epidemics that are characterized by infection occurring mostly among members of key populations and their partners. However, this challenge has not prevented countries in the region from progressing towards elimination. For example, Oman and the United Arab Emirates have become the first and second countries respectively to integrate their eMTCT programme within maternal and child health services and reach most of their elimination targets. Other GCC Countries, notably Saudi Arabia and Kuwait, are moving in a similar direction. Djibouti, a low-income country, is also progressing towards elimination, through integration of PMTC within antenatal care In middle-income countries - Algeria, Iran, Morocco and Tunisia - the number of pregnant women tested and knowing their status has increased from more than 120 000, to more than 540 000 in the course of two years (2013 and 2014). Algeria and Tunisia have both increased the number of pregnant women tested more than twelve-fold. These four countries, with established maternal and child health programmes, have been able to support those who test positive to access effective care.

Progress on ART Coverage of antiretroviral therapy in the Middle East and North Africa was 17% [12-24%] in 2015, far below the global average, in major part due to low levels of HIV testing and diagnosis. However, just as rates of testing increased, in 2015 the number of people on treatment has also increased in recent years. Between 2013 and 2015 - this number increased by 47% in the region as a whole, and by more than 70% in Algeria and Egypt. If other countries replicate the pace of Algeria and Egypt, the region will be able to reach its target of 81% treatment coverage by 2020.

Recommendations and game changers for fast-tracking Transformative political leadership: implementing the Arab AIDS Strategy (2014– 2020). Legal and policy reform: ratification of the Arab Convention; law reform, including abolition of punitive laws and application of broader, positive interpretation of existing laws and policies. Sharpening focus on key populations: transforming HIV testing and treatment through community and private health service delivery and service integration. Empowering civil society: religious leaders, community and grassroots organizations led by people living with HIV, women and young people, to be central to designing, implementing and monitoring the response. Innovation in response and revolution in data: Data should predict the next infections and target the interventions to prevent them, not only to follow them. Fast tracking the response and the ambitious goals need increasing resources, sustaining and diversifying them following a strategy of increasing domestic financing and shared responsibility and regional solidarity. Transformative political leadership: strategic partnership with the League of Arab States can Fast-Track the response by implementing the Arab AIDS Strategy (2014–2020). Legal and policy reform: engaging parliamentarians and promoting the ratification of the Arab Convention on HIV prevention and protection of people living with HIV can significantly alter the landscape in terms of law reform, including abolition of punitive laws and application of broader, positive interpretation of existing laws and policies. Sharpening focus on key populations: transforming HIV testing and treatment through community and private health service delivery, more rigorous referral and linkage to services, especially for members of key populations, and simplifying treatment regimens and service integration. Empowering civil society: further enabling civil society partners, including religious leaders, community and grassroots organizations led by people living with HIV, women and young people, to be central to designing, implementing and monitoring the response. Innovation in data, testing, service delivery and models: well-targeted testing and innovative approaches to delivering treatment, including strategic use of information technology. Fast tracking the response and the ambitious goals need increasing resources, sustaining and diversifying them following a strategy of increasing domestic financing and shared responsibility and regional solidarity.

Closing Message New political commitments against HIV is a window of opportunity in the region for achieving strategic changes in order that: Stigma and discrimination doesn’t limit access to services Ending AIDS is part of the regional development agenda Access to delivery services is drastically increased