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IntroductionThe status of HIV and hepatitis C virus (HCV) infections among incarcerated populations in the Middle East and North Africa (MENA) and the links between prisons and the HIV epidemic are poorly understood. This review synthesized available HIV and HCV data in prisons in MENA and highlighted opportunities for action.MethodsThe review was based on data generated through the systematic searches of the MENA HIV/AIDS Epidemiology Synthesis Project (2003 to December 15, 2015) and the MENA HCV Epidemiology Synthesis Project (2011 to December 15, 2015). Sources of data included peer‐reviewed publications and country‐level reports and databases.Results and discussionWe estimated a population of 496,000 prisoners in MENA, with drug‐related offences being a major cause for incarceration. Twenty countries had data on HIV among incarcerated populations with a median prevalence of 0.6% in Afghanistan, 6.1% in Djibouti, 0.01% in Egypt, 2.5% in Iran, 0% in Iraq, 0.1% in Jordan, 0.05% in Kuwait, 0.7% in Lebanon, 18.0% in Libya, 0.7% in Morocco, 0.3% in Oman, 1.1% in Pakistan, 0% in Palestine, 1.2% in Saudi Arabia, 0% in Somalia, 5.3% in Sudan and South Sudan, 0.04% in Syria, 0.05% in Tunisia, and 3.5% in Yemen. Seven countries had data on HCV, with a median prevalence of 1.7% in Afghanistan, 23.6% in Egypt, 28.1% in Lebanon, 15.6% in Pakistan, and 37.8% in Iran. Syria and Libya had only one HCV prevalence measure each at 1.5% and 23.7%, respectively. There was strong evidence for injecting drug use and the use of non‐sterile injecting‐equipment in prisons. Incarceration and injecting drugs, use of non‐sterile injecting‐equipment, and tattooing in prisons were found to be independent risk factors for HIV or HCV infections. High levels of sexual risk behaviour, tattooing and use of non‐sterile razors among prisoners were documented.ConclusionsPrisons play an important role in HIV and HCV dynamics in MENA and have facilitated the emergence of large HIV epidemics in at least two countries, Iran and Pakistan. There is evidence for substantial but variable HIV and HCV prevalence, as well as risk behaviour including injecting drug use and unprotected sex among prisoners across countries. These findings highlight the need for comprehensive harm‐reduction strategies in prisons.

IntroductionThe recent availability of efficacious prevention interventions among stable couples offers new opportunities for reducing HIV incidence in sub‐Saharan Africa. Understanding the dynamics of HIV incidence among stable couples is critical to inform HIV prevention strategy across sub‐Saharan Africa.MethodsWe quantified the sources of HIV incidence arising among stable couples in sub‐Saharan Africa using a cohort‐type mathematical model parameterized by nationally representative data. Uncertainty and sensitivity analyses were incorporated.ResultsHIV incidence arising among stable concordant HIV‐negative couples contribute each year, on average, 29.4% of total HIV incidence; of those, 22.5% (range: 11.1%–39.8%) are infections acquired by one of the partners from sources external to the couple, less than 1% are infections acquired by both partners from external sources within a year and 6.8% (range: 3.6%–11.6%) are transmissions to the uninfected partner in the couple in less than a year after the other partner acquired the infection from an external source. The mean contribution of stable HIV sero‐discordant couples to total HIV incidence is 30.4%, with most of those, 29.7% (range: 9.1%–47.9%), being due to HIV transmissions from the infected to the uninfected partner within the couple. The remaining incidence, 40.2% (range: 23.7%–64.6%), occurs among persons not in stable couples.ConclusionsClose to two‐thirds of total HIV incidence in sub‐Saharan Africa occur among stable couples; however, only half of this incidence is attributed to HIV transmissions from the infected to the uninfected partner in the couple. The remaining incidence is acquired through extra‐partner sex. Substantial reductions in HIV incidence can be achieved only through a prevention approach that targets all modes of HIV exposure among stable couples and among individuals not in stable couples.

AbstractIntroductionEmerging HIV epidemics have been documented among people who inject drugs (PWID) in the Middle East and North Africa (MENA). This study estimates the HIV incidence among PWID due to sharing needles/syringes in MENA. It also delineates injecting drug use role as a driver of the epidemic in the population, and estimates impact of interventions.MethodsA mathematical model of HIV transmission among PWID was applied in seven MENA countries with sufficient and recent epidemiological data and HIV prevalence ≥1% among PWID. Estimations of incident and/or prevalent infections among PWID, ex‐PWID and sexual partners of infected current and ex‐PWID were conducted.ResultsThe estimated HIV incidence rate for 2017 among PWID ranged between 0.7% per person‐year (ppy) in Tunisia and 7.8% ppy in Pakistan, with Libya being an outlier (24.8% ppy). The estimated number of annual new infections was lowest in Tunisia (n = 79) and Morocco (n = 99), and highest in Iran and Pakistan (approximately n = 6700 each). In addition, 20 to 2208 and 5 to 837 new annual infections were estimated across the different countries among sexual partners of PWID and ex‐PWID respectively. Since epidemic emergence, the number of total ever acquired incident infections across countries was 706 to 90,015 among PWID, 99 to 18,244 among sexual partners of PWID, and 16 to 4360 among sexual partners of ex‐PWID. The estimated number of prevalent infections across countries was 341 to 23,279 among PWID, 119 to 16,540 among ex‐PWID, 67 to 10,752 among sexual partners of PWID, and 12 to 2863 among sexual partners of ex‐PWID. Increasing antiretroviral therapy (ART) coverage to the global target of 81% – factoring in ART adherence and current coverage – would avert about half of new infections among PWID and their sexual partners. Combining ART with harm reduction could avert over 90% and 70% of new infections among PWID and their sexual partners respectively.ConclusionsThere is considerable HIV incidence among PWID in MENA. Of all new infections ultimately due to injecting drug use, about 75% are among PWID and the rest among sexual partners. Of all prevalent infections ultimately attributed to injecting drug use as epidemic driver, about half are among PWID, 30% among ex‐PWID and 20% among sexual partners of PWID and ex‐PWID. These findings call for scale‐up of services for PWID, including harm reduction as well as testing and treatment services.

AbstractLebanon, a middle-income country with ongoing political turmoil, unstable economic situation, and a fragmented and under-resourced health system, hosts about one million Syrian refugees since 2011. While the country is currently experiencing substantial COVID-19 epidemic spread, no outbreaks have been reported yet among Syrian refugees. However, testing of this population remains limited and exposure levels are high given dire living conditions and close interaction with the host community. Here, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability of Syrian refugees in Lebanon to potentially large COVID-19 epidemics.Syrian refugees live in close contact with the host community, and their living conditions are favorable for epidemic spread. We found that the high levels of crowding within Syrian refugee households and among those in informal tented settlements, the inadequate water supply and sanitation, limited use of masks, inadequate access to health care, and inadequate community awareness levels are vulnerability factors that directly impact important parameters of transmission dynamics, leading to larger epidemic scale. Poverty, stigma, and fear of legal consequences are contextual factors that further exacerbate this vulnerability. The relatively high prevalence of non-communicable diseases in this population could also affect the severity of the disease among those infected. Mathematical modeling simulations we conducted illustrated that even modest increases in transmission among Syrian refugees could result in a large increase in the incidence and cumulative total number of infections in the absence of interventions.In conclusion, while the young age structure of the Syrian refugee population might play a protective role against the scale and disease-burden severity of a potential COVID-19 epidemic, the epidemic potential due to several vulnerability factors warrants an immediate response in this population group. Local and international actors are required to mobilize and coordinate efforts to prevent the transmission of COVID-19, and to mitigate its impact amongst the vulnerable refugee populations globally.

Lebanon, a middle-income country with ongoing political turmoil, unstable economic situation, and a fragmented and under-resourced health system, hosts about one million Syrian refugees since 2011. While the country is currently experiencing substantial COVID-19 epidemic spread, no outbreaks have been reported yet among Syrian refugees. However, testing of this population remains limited and exposure levels are high given dire living conditions and close interaction with the host community. Here, we use quantitative insights of transmission dynamics to outline risk and contextual factors that may modulate vulnerability of Syrian refugees in Lebanon to potentially large COVID-19 epidemics. Syrian refugees live in close contact with the host community, and their living conditions are favorable for epidemic spread. We found that the high levels of crowding within Syrian refugee households and among those in informal tented settlements, the inadequate water supply and sanitation, limited use of masks, inadequate access to health care, and inadequate community awareness levels are vulnerability factors that directly impact important parameters of transmission dynamics, leading to larger epidemic scale. Poverty, stigma, and fear of legal consequences are contextual factors that further exacerbate this vulnerability. The relatively high prevalence of non-communicable diseases in this population could also affect the severity of the disease among those infected. Mathematical modeling simulations we conducted illustrated that even modest increases in transmission among Syrian refugees could result in a large increase in the incidence and cumulative total number of infections in the absence of interventions. In conclusion, while the young age structure of the Syrian refugee population might play a protective role against the scale and disease-burden severity of a potential COVID-19 epidemic, the epidemic potential due to several vulnerability factors warrants an immediate response in this population group. Local and ...

BACKGROUND: Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA. METHODS AND FINDINGS: This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4-14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%-54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread. CONCLUSIONS: This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa. Please see later in the article for the Editors' Summary.

Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, fi nancial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specifi c and cause-specifi c mortality among children under 5 years, and stillbirths by geography over time. ; Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, fi nancial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specifi c and cause-specifi c mortality among children under 5 years, and stillbirths by geography over time.

Background The UN's Sustainable Development Goals (SDGs) are grounded in the global ambition of "leaving no one behind". Understanding today's gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990-2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030. Methods We used standardised GBD 2016 methods to measure 37 health-related indicators from 1990 to 2016, an increase of four indicators since GBD 2015. We substantially revised the universal health coverage (UHC) measure, which focuses on coverage of essential health services, to also represent personal health-care access and quality for several non-communicable diseases. We transformed each indicator on a scale of 0-100, with 0 as the 2.5th percentile estimated between 1990 and 2030, and 100 as the 97.5th percentile during that time. An index representing all 37 health-related SDG indicators was constructed by taking the geometric mean of scaled indicators by target. On the basis of past trends, we produced projections of indicator values, using a weighted average of the indicator and country-specific annualised rates of change from 1990 to 2016 with weights for each annual rate of change based on out-of-sample validity. 24 of the currently measured health-related SDG indicators have defined SDG targets, against which we assessed attainment. Findings Globally, the median health-related SDG index was 56.7 (IQR 31.9-66.8) in 2016 and country-level performance markedly varied, with Singapore (86.8, 95% uncertainty interval 84.6-88.9), Iceland (86.0, 84.1-87.6), and Sweden (85.6, 81.8-87.8) having the highest levels in 2016 and Afghanistan (10.9, 9.6-11.9), the Central African Republic (11.0, 8.8-13.8), and Somalia (11.3, 9.5-13.1) recording the lowest. Between 2000 and 2016, notable improvements in the UHC index were achieved by several countries, including Cambodia, Rwanda, Equatorial Guinea, Laos, Turkey, and China; however, a number of countries, such as Lesotho and the Central African Republic, but also high-income countries, such as the USA, showed minimal gains. Based on projections of past trends, the median number of SDG targets attained in 2030 was five (IQR 2-8) of the 24 defined targets currently measured. Globally, projected target attainment considerably varied by SDG indicator, ranging from more than 60% of countries projected to reach targets for under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria, to less than 5% of countries projected to achieve targets linked to 11 indicator targets, including those for childhood overweight, tuberculosis, and road injury mortality. For several of the health-related SDGs, meeting defined targets hinges upon substantially faster progress than what most countries have achieved in the past. Interpretation GBD 2016 provides an updated and expanded evidence base on where the world currently stands in terms of the health-related SDGs. Our improved measure of UHC offers a basis to monitor the expansion of health services necessary to meet the SDGs. Based on past rates of progress, many places are facing challenges in meeting defined health-related SDG targets, particularly among countries that are the worst off. In view of the early stages of SDG implementation, however, opportunity remains to take actions to accelerate progress, as shown by the catalytic effects of adopting the Millennium Development Goals after 2000. With the SDGs' broader, bolder development agenda, multisectoral commitments and investments are vital to make the health-related SDGs within reach of all populations. Copyright The Authors. Published by Elsevier Ltd. This is an Open Access article published under the CC BY 4.0 license. ; Peer reviewed