HIV/AIDS in the World, in the Eastern Mediterranean Region and in Iran
B. Sadrizadeh MD
Communicable Disease Control (DCD), World Health Organization, Regional Office for the Eastern Mediterranean, Alexander, Egypt
Global Situation
The epidemic of HIV infection is spreading rapidly throughout the world, particularly in developing countries. It has been estimated that worldwide 33.4 million persons were living with HIV at the end of 1998, more than 95% of them in developing countries.1 Of that number, 18.4 million were men, 13.8 million women, and 1.2 million children under 15 years. In 1998, 5.8 million persons were newly infected including 3.1 million men, 2.1 million women, and 590,000 children under 15 years of age. More than half of the newly infected persons were young. Considering the deaths that have occurred due to HIV infection, 47.3 million persons are estimated to have been already infected by the end of 1998.Most of the infected persons in developing countries do not know that they are infected.
About 2 million cases of AIDS have been reported worldwide since the beginning of the epidemic up until the end of 1998. Due to under-diagnosis, incomplete reporting, and delays in reporting, the actual number of cases is estimated to be more than 14 million.2 A cumulative total of 13.9 million persons had died of AIDS by the end of 1998, including 6 million men, 4.7 million women, and 3.2 million children under 15 years of age. Of these, 2.5 million died in 1998 and they included 1.1 million men, 0.9 million women, and 510,000 children.
Sub-Saharan Africa is the most severely effected region in the world, with about 4 million new infections, more than two-thirds of the global total, occurring there in 1998. About 2 million persons died of AIDS in 1998 in this region, comprising 80% of the AIDS-related deaths in the world as a whole; 67% of the persons living in the world with HIV at the end of 1998 were living in this region. All these figures are in sharp contrast to the fact that only 10% of the world population lives in this region.
The spread of the epidemic in Asia varies considerably between countries. In general, the prevalence rates are low, but because of large population sizes, the absolute number of infected persons is high. It is estimated that 6.7 million persons were living with HIV in Asia at the end of 1998. In Latin America the epidemic is also spreading, particularly among the male homosexual community and injecting drug users (IDUs). In Eastern Europe and Central Asia, the epidemic started spreading in the early 1990s. Most of the recent infections, and about 30% of HIV positive individuals at the end of 1998, acquired the infection in 1998. In North America and Western Europe, the number of AIDS cases has started to decline due to combination antiretroviral therapies and preventive measures initiated in the mid-1980s. Similarly, the number of deaths due to AIDS has also continued to decrease. However, the number of AIDS cases is increasing in developing countries because of their limited access to antiretroviral therapies and lack of effective preventive measures.
Situation in the Eastern Mediterranean Region
In the Eastern Mediterranean Region the AIDS epidemic started later than other regions of the world, due mainly to traditional religious and moral values and it appears that the epidemic is also spreading at a slower pace.3 The epidemic is still at a low level in the region, as the results of tests carried out on vulnerable groups in recent years has shown. The prevalence rates in these groups varied from country to country. The main affected groups were STD patients in Morocco, Sudan, and Yemen; prostitutes in Djibouti; injecting drug users in Bahrain and Iran; prisoners in Iran, Oman, Pakistan, and Yemen; and TB patients in Djibouti and Sudan.
More than 29,000 HIV infected individuals have been reported from the beginning of the epidemic until the end of 1998, but the actual number of infections is estimated to be more than 300,000 of whom 280,000 persons were living with HIV at the end of 1998. More than 7,400 cases of AIDS were reported by the end of 1998, but owing to under-recognition, under-reporting, and reporting delays, the actual number of cases is estimated to be over 22,000. The number of reported new cases has increased every year rising from 75 cases in 1987 to 1,207 cases in 1997. However, the number of cases reported in 1998 decreased to 1,045. This is mainly due to a decrease in the reported cases in two countries, namely Djibouti and Saudi Arabia. In Djibouti which reported the largest number of cases in 1996 and 1997 regionally, there was a sharp drop in 1998 due to severe resource constraints in gathering surveillance data. Until 1997 Saudi Arabia reported all diagnosed cases, both Saudi nationals and expatriates, but following a change in reporting policy in 1998, it now only reports cases among Saudi nationals.
Of the total reported cases, 71% were male and 29% female. But the proportion of female cases has increased steadily over the years. For example, the proportion increased from 17% in 1989 to 37% in 1996. Eighty nine percent of the reported cases belonged to the 15-49 year age group. Among the reported cases, 78% were due to heterosexual transmission, 7% due to homosexual transmission, 5% due to injecting drug use, 10% due to contaminated blood and blood products, and 3% due to perinatal transmission.
Situation in Iran
The first case of AIDS reported in Iran was in 1987. Since then, 215 cases have been reported until the end of 1998. Of them, 197 (92%) were male and 18 (8%) female. Fourteen cases were under 15 years, 183 cases 15-49 years, 12 cases above 49 years, and 6 unknown. Most of the earlier cases were due to contaminated blood and blood products but lately, cases due to heterosexual transmission started predominating with more recent cases being reported from among injecting drug users. In all, 63 cases were due to heterosexual transmission, 107 cases were due to contaminated blood and blood products, 44 cases due to injecting drug users, and 1 unknown. Out-breaks of HIV infection were reported from a few provinces among the injecting drug users in prisons and outside. HIV prevalence rate as found to be over 50% in some prisons, indicating a widespread dissemination of the infection. HIV infection was also detected among individuals who came for voluntary testing, patients with hemophilia, patients who received multiple blood transfusions, and blood donors.
Prevention and Control
The main objectives of prevention and control of HIV infection are to prevent the transmission of HIV infection and to provide care to persons with HIV infection. As there is no known cure for AIDS, emphasis has been laid on prevention in the national plan. Strategies for prevention include promotion of safer sexual behavior including the use of condoms, proper STD case management with emphasis on syndromic approach, ensuring safety of blood and blood products, demand and harm reduction in drug abuse, and universal precautions at health care settings. Blood safety and HIV infection among injecting drug users has been given very high priority in Iran.
Attention is also being paid to adequate care and counselling of persons with HIV infection. With particular attention being given to the patient's human rights and dignity, and avoidance of any form of discrimination. Use of an anti-retroviral therapy for prevention of mother to child transmission of HIV is being considered by a number of Member States. Epidemiological surveillance is being carried out to monitor the trend of the epidemic.
WHO/EMRO's priorities are focused on control of STD, strengthening of HIV infection surveillance, safe blood supply, care of persons with HIV infection, control (biosafety), planning, review, and evaluation. EMRO's activities include both intercountry activities as well as providing support structures. The former include intercountry workshops and production of international guidelines and educational material. Support for countries is provided in the form of consultants and staff visits, fellowships, national training activities, disseminating guidelines and educational material, supplies and equipment, as well as studies to determine the prevalence, and an overall evaluation of the whole process.
National Plans
National plans for AIDS prevention and control have been prepared in all countries of the region, adopting a multisectoral approach including the involvement of nongovernmental organizations (NGOs). There is a further need to involve all concerned sectors and more NGOs. Priority has been given to information, education, and communication; blood safety; and HIV infection surveillance. With the increasing number of HIV infections and AIDS cases being detected, attention needs also be given to counselling and care of persons with HIV infection. A few countries have also prepared national STD control plans.
Since the beginning of the AIDS epidemic, WHO has been providing technical and financial support to the Member States including Iran in the formulation, implementation, monitoring, and evaluation of their national plans for the prevention and control of HIV infection and STD.4 WHO has advocated high levels of national commitment to these plans and a multisectoral approach to the fight against the epidemic involving all relevant sectors and nongovernmental organizations.
Activities in Iran
A large number of activities have been carried out in Iran to prevent HIV transmission. They include publication of articles in newspapers, youth and women's magazines, distribution of brochures at seaports and airports, distribution of pamphlets to students, youths, workers, truck drivers, soldiers, and women, posters displays of different types, and organization and workshops for religious leaders, students, teachers, parents, policemen, and health workers.
All blood donations are being screened for HIV. Voluntary donation is being promoted and donation by relatives is being discouraged.
Posters have been displayed at blood banks to discourage people from high risk groups from donating blood. Workshops have been conducted for medical doctors promoting appropriate blood protocols. Pamphlets on drug abuse have been distributed. Drug users are being educated and counselled in drug treatment centers, rehabilitation centers and prisons.
A protocol for combination antiretroviral treatment has been prepared and distributed and training courses on the protocol provided for infectious disease specialists. Procurement of the equipment for viral load measurement is in progress. Infected persons are counselled and receive regular follow-up. STD control is integrated with AIDS control programmes. Steps have been initiated to formulate a new strategic plan. Serological surveillance has been conducted at 75 sites and behavioral surveillance at 35 sites.
There are several constraints in the implementation of national AIDS programme. Foremost among them is the difficulty in accessing drug users, their behavior is illegal, they are therefore afraid of discrimination and punitive action. Hence, it has not been possible to get an exact picture of the current situation nor to implement the interventions effectively. A number of organizations are concerned with the problem and it is difficult to obtain co-ordination, commitment and approval from all of them for interventions targeted at the IDUs. The human resources presently available are grossly inadequate for dealing with the current situation.
Recommendation
The immediate priority must be to make a round assessment of the situation of HIV infection in the country, especially among IDUs and to implement realistic and effective interventions. For this, commitment as well as cooperation will be required from all concerned sectors. Harm reduction should be given the highest priority. The increasing sexual transmission should also receive proper attention through various educational activities. Blood safety should be further improved by promoting voluntary non-remunerative donations. Adequate attention should also be given to the care of already-infected individuals. Adequate resources, both human and financial, should be made available for implementing the national programme.
References
1 UNAIDS and WHO. AIDS Epidemic Update. December 1998.
2 World Health Organization. Weekly Epidemiological Record. 73, 48 & 49, 1998.
3 Wahdan MH. Epidemiology of Acquired Immunodeficiency Syndrome (AIDS). World Health Organization, Regional Office for the Eastern Mediterranean, WHO-EM/STD/7/E/L/97, 1997.
4 World Health Organization, Regional Office for the Eastern Mediterranean. The Work of WHO in the Eastern Mediterranean Region, Annual Report of the Regional Director 1 January-31 December 1997. 1998.