HIV and other sexually transmitted infection research in the Middle East and North Africa: promising progress?

The mere association of the words sexually transmitted infections (STIs), including HIV/AIDS, and sexuality, to Middle East and North Africa (MENA) in any discussion, social or academic, seems to elicit heated debates and controversy. The MENA region is, in the minds of many, an area where socio-cultural sensitivities surrounding sex and disease still abound. Are there HIV epidemics shrouded behind a wall of denial? Is there a ‘conspiracy of silence’ resulting in a failure to confront a public health scourge? Lack of data seems to have fuelled this debate, but the reality of the situation is more nuanced. There are probably shreds of truth in the polemics about HIV infection and other STIs in this region, but partial truths often distort reality. This special supplement of Sexually Transmitted Infections provides a critical piece of the solution to this problem: evidence from the field. This evidence suggests a reality that this region should be able to confront and deal with. The purpose of this special supplement is to showcase the progress of STI research in MENA, and to demonstrate stronger evidence about the HIV epidemic to inform policy and programming. We chose studies that broadened our knowledge in this field, and testified to the feasibility of conducting quality research in this region. To highlight progress, we invited contributors to submit studies dealing with diverse research questions and methodologies. We encouraged novelty and weighed the studies’ potential to impact policy and programming. Our goal was to have a broad representation from the MENA region, but we only achieved partial success. Though eventually the supplement included data from multiple countries in one form or another, the countries with more advanced research capacity contributed more. A few of the invited articles from other countries did not materialise for a variety of reasons. One of the greatest challenges facing research in the MENA region is the paucity of trained investigators. Although this supplement provides evidence that a core group of investigators are actively conducting vital research in the region, the challenge of further expanding the field remains. MENA, in this supplement, extends from Morocco in the West to Afghanistan and Pakistan in the East (figure 1). It is a diverse region that comprises more than 10% of the World’s 15–49 age group population. Recently, the region has attracted global attention with its youth movements, known as the Arab Spring, that swept through the region and roiled decades-old regimes. Regrettably the region has largely failed to benefit from its demographic dividend. There are, however, bright spots. This supplement highlights the outcome of research conducted mostly by young and motivated local investigators, working in challenging conditions. This supplement is the result of concerted efforts by many individuals and organisations over 2 years. These efforts were spearheaded and funded by the Eastern Mediterranean Regional Office of the WHO (WHO/EMRO), the Regional Support Team for MENA of the Joint United Nations Programme on HIV/AIDS (UNAIDS MENA), and the Weill Cornell Medical College—Qatar. This endeavour was envisioned to address a structural weakness of HIV efforts in the MENA region. Many of the studies were conducted or supported through national programmes that had limited interest in using the data beyond informing HIV policy, and possibly some programming at the national level. 2 To alleviate this challenge, the MENA Regional Expert Group on HIV Surveillance and Strategic Information recommended, in its meeting in May of 2011 in Cairo, Egypt, the establishment of an editorial support team from the members of this group, to assist authors from the region in drafting the results of their investigations (please note the Acknowledgment below). The supplement is the outcome of this effort. The first article in this supplement describes the progress in HIV research in the MENA region since the discovery of the epidemic. Saba et al show that published reports on HIV in the MENA region have been steadily increasing over the years with much of the progress occurring in the last few years. Reports on HIV in the MENA region now account for about 1% of the global reports on HIV, a fact that may surprise some. Though there are still large gaps, the progress has been solid in both quantity and quality of product. This optimistic finding, however, is tempered by several important pitfalls which include significant heterogeneity in the progress among countries, a large volume of scientific work conducted but not published in the scientific literature, and the critical need to ensure quality standards in research methodology regardless of whether it is conducted by academia or not. The article is followed by an editorial by Nasirian et al which points to some of the barriers facing researchers when publishing their results. Bozicevic et al then provide an encompassing overview of the development, quality and progress of HIV surveillance in the 23 MENA countries through a large effort led by WHO/EMRO to assess the capacity of HIV surveillance systems in this region. The study highlights recent progress, but again emphasises its heterogeneity across countries. Though four countries have fully functioning systems, close to half of MENA countries lag far behind, to the extent that we have limited knowledge of the epidemic in these countries. These data suggest that much work still needs to be done before we have functioning and durable HIV surveillance systems that monitor epidemic trends and generate data that can inform HIV policy and programming. These papers are followed by several HIV surveillance studies of different populations in different countries. In the first of these, Elhadi et al present the Infectious Disease Epidemiology Group, Weill Cornell Medical College—Qatar, Cornell University, Doha, Qatar; Department of Public Health, Weill Cornell Medical College, Cornell University, New York, New York, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Regional Support Team for Middle East and North Africa, Joint United Nations Programme on HIV/AIDS (UNAIDS), Cairo, Egypt; Sudan Country Office, Joint United Nations Programme on HIV/AIDS (UNAIDS), Khartoum, Sudan; HIV Department, World Health Organization, Geneva, Switzerland; Regional Office of the Eastern Mediterranean, World Health Organization, Cairo, Egypt