As refugees in the Middle East and North Africa turn to sex work, the number of HIV cases and AIDS-related deaths has spiked. In the latest from our Best of 2015 series, Christopher Reeve analyzes the Tunisian model and suggests that an increase in funding and monitoring of HIV/AIDS projects will allow governments to address this growing public health problem.
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From the Spring Issue “The Unknown“
By Christopher Reeve
CAIRO—Mona Iraqi, an outspoken filmmaker turned television presenter, goes in for the kill. She had been staking out a Cairo bathhouse for some time. A hidden camera had recorded enough damning evidence to condemn the place. And now it’s time for action. Iraqi and a cameraman join Egyptian security forces as they raid the hammam. Dozens of bare-chested men, hands covering their faces, are herded out of the place while Iraqi and her crew record the sting operation’s climax for her show, “El-Mestakhabi” (“The Hidden”).
Hours later, Iraqi takes to Facebook to promote her upcoming special. “With pictures, we reveal the biggest den of group perversion in the heart of Cairo,” reads the text accompanying five images. Iraqi can be seen in two pictures wearing a blue shirt and dark scarf, poker-faced, standing just to the side and pointing her iPhone camera at the men. Scott Long, a Cairo-based human rights blogger, and his friend save the pictures and text before Iraqi removes them two hours later. Building anticipation for her special, “The Dens for Spreading AIDS in Egypt,” Iraqi blurs none of the men’s faces, lives ruined almost instantly.
Following the Egyptian military’s ouster of democratically-elected president Mohammad Morsi in the Summer of 2013, Egypt has embarked on a well-publicized witch hunt of men who have sex with men (who may or may not identify themselves as gay) and biological men who are gender nonconforming. A 2013 Valentine’s Day raid led to nine convictions for debauchery. The lawyer for one defendant explains the arrests were politically motivated. The military government had to prove to Egyptians it is at least as conservative as the now fallen Muslim Brotherhood. Just over a year after that raid, the arrests at the bathhouse show Egypt’s media nationalists are joining the security sector for a piece of the action—and, in Iraqi’s case, doing so in the name of fighting AIDS in Egypt.
Publicly arresting and shaming members of one of the three groups most at-risk for contracting HIV goes against all established public health guidelines for curbing HIV transmission. The HIV virus thrives on stigma and discrimination, conditions that disincentivize any widespread testing, treatment, or simply engaging with state health officials or non-profits to learn about the virus and how to protect oneself. And in places like Egypt, where homosexuality—sometimes proven first by an HIV-positive test result—is criminalized, staying in the shadows is arguably the least risky way to live.
Except that when it comes to HIV, the shadows can be quite dangerous.
REVERSAL OF FORTUNES
While the world rightfully applauds a global decrease in both new HIV infections and AIDS-related deaths, the Middle East and North Africa have seen quite the opposite. UNAIDS estimates that the region saw 25,000 new infections and 15,000 AIDS-related deaths in 2013, figures up 9 percent and 70 percent respectively, over 2005. The agency further estimates 230,000 persons are living with HIV in the Middle East and North Africa. The conclusion—governments will need to enact, change, and reinvigorate policies to circumvent a potentially serious situation, especially for most at-risk groups like men who have sex with men, sex workers, and intravenous drug users.
Other vulnerable groups, like refugees, youth, women and girls, transsexuals, and prisoners, also stand to benefit from an effective response to the threat of HIV. With the political turmoil wrought by the Arab Spring, fighting the threat of HIV, or simply staying alive and healthy for those living with the virus, has become all the more challenging. Bureaucratic hurdles to receiving medicine in Egypt, vulnerable Syrian refugees arriving in countries like Lebanon and Jordan, a violent and fractured Libya, and loss of domestic and international funding, not to mention the limited access for foreign medical and nursing expertise, ensure the current situation will only get worse.
EGYPT FINDS ITS ROOTS
Ahmed is a 52-year-old gay Egyptian man who has lived with HIV for over 30 years. He has dark hair, light eyes, and a kind face. In conservative Egypt, where sex education is not part of the school curriculum, Ahmed uses a popular gay website to try to teach—or at least warn—men who have sex with men about the dangers of HIV. Months after Egypt’s revolution unseated former leader Hosni Mubarak, Egypt’s Islamists swept Egypt’s parliamentary elections and talk about HIV and AIDS began to decrease.
Then, the Muslim Brotherhood’s Mohammad Morsi was elected president in the country’s most free and fair presidential elections ever. The new Egypt seemed to be finding its religious roots. Outward expressions of religion seemed to be gaining in popularity. Taboos against any discussion of sex, sexuality, and sexually transmitted infections removed those topics from public discourse. Apart from learning about the virus when friends test positive or from watching “Asmaa,” a groundbreaking UNAIDS-funded film about a woman with HIV, Egyptians have little awareness about the virus, says Ahmed.
In the outdoor section of a nondescript café in Cairo’s Agouza neighborhood, Ahmed is joined by Hany, the 34-year-old leader of Friends of Life, an Alexandria-based NGO that supports Egyptians living with HIV. Hany and his wife both have the virus. It’s early afternoon, the café not yet filled with backgammon players and shisha smokers, so the men speak freely and openly—though not about ignorance and the need for sex ed. The men want to talk about the Egyptian Ministry of Health’s ineffectiveness at providing life-saving antiretrovirals and at monitoring the health of Egyptians living with HIV. The Ministry of Health, under Egypt’s National AIDS Program, ostensibly provides free medication to Egyptians living with HIV. Antiretrovirals stop the HIV virus from replicating. The medicine, when effectively administered, can allow the recipient to live almost as long as he would without HIV. It also counters further infections, as the person taking the antiretrovirals might see his viral load reach levels so low that his chances of infecting others are greatly decreased.
But in Egypt the medicine is frequently unavailable at distribution centers. When that happens, according to Ahmed and Hany, health officials alter dosages, give expired drugs, use substitute medicines, or send Egyptians living with HIV home empty-handed. Some have gone five months without medication. All such scenarios create ticking time bombs, as the virus develops resistance to the drugs. Hany says the virus in his blood is now resistant to all but two medicines, neither available in the Middle East and North Africa. Ahmed says that Ministry of Health equipment to test for CD4 (a white blood cell) count, viral load, and viral resistance to drugs is inoperative. People are dying because of the Ministry of Health’s incompetence, both men say. And with Egypt having received over $8 million from 2008 to 2012 to fight HIV from the Global Fund to Fight AIDS, Tuberculosis and Malaria, a public-private initiative based in Geneva, the men suspect corruption. Even Hany’s NGO is not receiving the funds, yet the money must be going somewhere.
Wessam El-Beih, former UNAIDS Egypt Country Coordinator, believes the funds aren’t going to sectors that would most effectively curb the HIV threat, such as targeting most at-risk population subsets, and that use of funds lacks transparency. But she cautions against charges of corruption. “I don’t think its right to accuse people of fraud without evidence to support that argument,” she continues. “Let’s acknowledge that healthcare in Egypt is compromised—no exception for HIV. It’s the general situation. We are the highest country in the world for prevalence of Hepatitis C since the ‘60s. And it has not been addressed.” Numerous attempts to reach Ihab Abdelrahman, former manager of the Ministry of Health’s National AIDS Program, go unanswered.
Last year, two Egyptian journalists, Mohammad El-Garhey of the daily Al-Masry Al-Youm and Alyaa Abo Shahba of the online portal Masrawy, produced unprecedented investigative reports on HIV and AIDS in Egypt. Specifically, they highlighted incompetence at the state level—incompetence that was costing Egyptian lives. Both journalists documented AIDS-related deaths. The deceased had registered their status with the Ministry of Health, and the effective treatment they hoped to receive simply did not materialize. El-Garhey confirmed the health-monitoring equipment Ahmed had complained about almost two years earlier was in fact inoperable. A project addressing Egypt’s prison population had been abandoned, due to the violence at prisons during the revolution. Abo Shahba found that the Ministry of Health analysis kept imported medicine at customs—sometimes for up to a month—a direct cause of Egypt’s not providing appropriate antiretroviral medication to its citizens with HIV. Lack of adequate foresight and planning on the part of the Ministry of Health was the overarching culprit. Yet both articles are colored with the voices of health officials who either downplay the allegations or claim nothing is awry with Egypt’s HIV medicine distribution program.
On December 2, 2014, ten months after El-Garhey’s and four months after Abo Shahba’s articles were published, the United Nations Information Centre (UNIC) and UNAIDS held a press conference in Cairo to commemorate World AIDS Day. Dr. Walid Kamal, the Ministry of Health’s National AIDS Program Manager, and Dr. Ahmed Khamis, UNAIDS Egypt Country Coordinator, presented Egypt’s new lofty goals to journalists: “Zero new HIV infections, Zero AIDS related deaths, and Zero Stigma and Discrimination by 2030,” according to UNIC’s website.
Both Kamal and Khamis agreed to discuss which, if any, changes had been implemented to ensure that Egyptians with HIV receive proper medication and treatment. But neither was available on the scheduled day and time and neither responded to follow-up messages to reschedule or replied to questions sent by email. Ahmed has little faith in UN agencies and the Ministry of Health: “As far as they’re concerned, they hope we all die.”
Syria has been engulfed in a bloody and destructive civil war since 2011 that has led to over 200,000 deaths. It is also home to the Islamic State. Many Syrians have fled the violence and gone to neighboring countries. In terms of HIV vulnerability, women and girls and displaced persons are particularly susceptible. About half of Syrian refugees are overlaps of those two categories. Some Syrians have entered a third category of vulnerability. To make ends meet in places like Lebanon and Jordan, some Syrian refugees are turning to sex work.
Marieke Ridder is a program manager for vulnerable communities at Aids Fonds, an Amsterdam-based public-private enterprise whose mission is “towards a world without AIDS.” On the group’s website, superimposed on a picture of a woman, are the words “People with HIV are just like you and me” in large font. Ridder, 44 and blonde with light eyes like the woman in the picture, is a wife and mother of two who lives in Rotterdam. When Ridder is enjoying downtime, her sense of humor and open nature ensure she is never alone. The kind of person with whom you let your guard down, she makes for good company. When Ridder is working, though, she is all business. And her business is empowering people living with HIV or vulnerable to HIV infection—generally various overlaps of youth, women and girls, sex workers, men who have sex with men, and transsexuals.
Ridder spent the first week of February this year in Lebanon, where she worked with local NGOs attempting to address the influx of Syrian refugees, some of whom already held refugee status in Syria as they originated in Palestine. UNHCR counts nearly 1.2 million Syrian refugees in Lebanon, a country with a population of about 4.5 million, meaning one in five persons currently in Lebanon is a Syrian refugee. With increased demands on resources like jobs and housing, some Syrians—boys, girls, men, and women—are turning to sex work to survive. The dire economic conditions facing Syrian refugees in Lebanon have also led to early marriage for girls, increased risk of gender-based and sexual violence, and survival sex sometimes in exchange for food.
Ridder says her local partners “all say that a lot of sex work takes place, but nobody wants to address it.” Although Lebanon is considered somewhat liberal, especially compared to its neighbors, sex work is still taboo and a source of shame.
A week and a half before she left for Lebanon, Ridder explained that her travels would take her to 13 countries, including some in sub-Saharan Africa. The focus would be on youths under 18 who are either engaged in sex work or so vulnerable that they are at risk of being lured into the sex industry.
Much of Ridder’s training and advocacy takes place in East Asia and sub-Saharan Africa. Addressing taboos is most challenging in the Middle East and North Africa. “You do walk on eggs, though, in all the countries,” she says. “There is the system that makes it difficult to work in. But no matter the country, there are people really ready to make the change.”
Lebanon has already deliberately placed voluntary HIV testing and counseling centers in areas with Syrian, as well as Iraqi, refugees. The country has a total of 60 such centers. According to Lebanon’s 2014 progress report submitted to UNAIDS, the country’s dramatic new influx of refugees has created a burden on spending to combat the spread of HIV.
Zaatari Refugee Camp in Jordan, one of the largest refugee camps in the world—certainly the largest camp housing Syrian refugees—has just under 84,000 inhabitants, according to UNHCR. And the population of Zaatari is only 14 percent of about 600,000 Syrian refugees in Jordan. Nearly one in ten people in Jordan is a Syrian refugee. As is the case in Lebanon, various vulnerable categories overlap that increase the risk of HIV infection. Dire economic conditions have led to early marriage and sexual exploitation of Syrian women, aid workers told The Guardian early last year. One woman’s husband forces her “to work in bars and in illegal activities,” she writes in a note. There are tales of men from Jordan and the Gulf who seek young Syrian wives, whose families might accept a dowry much lower than they would have in Syria.
An official from Jordan’s Ministry of Health warns of an increase in HIV infections as a result of the influx of refugees. The HIV virus had been detected in eight Syrian refugees in the last two years, the official said, according to The Jordan Times. Jordan offers antiretrovirals to its citizens with HIV, but does not do so for non-Jordanians. While eight cases among a Syrian refugee population of over half a million is low, the number only represents those detected. According to Dareen Abu Lail, Y-PEER Network International Coordinator, actual numbers are unknown as Syrian refugees generally don’t get tested. She says that rape kits, with medication to prevent HIV infection and pregnancy, are offered to women in the camps who were victims of rape. As noted in Jordan’s UNAIDS-submitted progress report for January 2012-December 2013, “sexual violence is assumed to be underreported due to stigma and fear of retribution.” The report says that although there are no hard figures on survival sex and rape, there were 41 cases of post-abortion care in the months of February and March 2014 in Zaatari camp alone. The possibility that the unwanted pregnancies resulted from sexual violence or generally risky sexual behavior is clear.
With sex work, sometimes connected to trafficking and exploitation, the number of HIV infections can easily grow among Jordanians as well as non-citizens. Because Jordan is classified as an “upper middle-income country,” it does not currently receive Global Fund grant monies to address HIV. Jordan is, according to the Ministry of Health official, working with international organizations to treat non-citizens with the virus. Sexual and reproductive health education, lacking across the region, is one area international organizations address to teach vulnerable Syrians about HIV and safe sex to prevent HIV transmission.
The Y-PEER Network, spearheaded by UNFPA, is a network of youth leaders and advocates of youth health and rights. Y-PEERians offer comprehensive sexual and reproductive health education to young people, a vulnerable group, at Zaatari and other camps in Jordan. The group trains young Syrians who can then teach their own peers how to stay healthy. In 2013, 70 Y-PEER trainers reached some 120 young Syrian refugees in camps. They in turn conducted their own trainings that reached another 100 vulnerable youth. This is what the model looks like in action.
It isn’t logistically complicated to offer training at refugee camps. But most Syrian refugees in Jordan—some 80 percent—do not live in camps, making it more challenging to reach them with empowering health education.
LIBYA: GOOD NEWS, BAD NEWS
Amid the early violence of post-Qaddafi Libya was a general sense of optimism about the potential for a peaceful state under one government, while retaining the country’s territorial integrity. Today, three years since the killing of Muammar Qaddafi, Libya’s leader for over four decades, the country is in crisis. Libya’s elected government is based in Tobruk, having fled violence from Libya Dawn, some of whose militias are sympathetic to Ansar El-Sharia, the group responsible for the attack on the U.S. outpost in Benghazi that led to the death of Ambassador J. Christopher Stevens. Libya Dawn, with shaky alliances forming political and armed wings, is now in control of Tripoli. Libya has also become part of the battle against Islamic State. Egypt recently launched an aerial assault on the eastern city of Derna after a video was released showing Islamic State militants beheading 21 Egyptian Christians there.
Besides political violence, Libya is facing an economic challenge. With labor strikes, attacks on oil fields, and other security concerns, Libya now only profits from the sale of 200,000 to 300,000 daily barrels of offshore oil. Before the start of the 2011 civil war, the country was selling some 1.6 million barrels a day. With the price of oil only barely stabilizing after its sharp decline, the Libyan state is both turbulent and cash-strapped. Add to that the decline in air and sea trade due to closure of airfields and seaports, and the medical situation in Libya is on the verge of crisis.
Wafaa Khafafa, head of the HIV drug department at the Libyan Ministry of Health’s Centers for Disease Control, says the country has been unable to import antiretrovirals for three months and expects to run out of its current stock in March 2015. “We are working with WHO on this,” she says. “If WHO helps us, we’ll be able to buy the drugs.” Khafafa anticipates that Libyans with HIV who depend on her office will go a month or two without treatment before the situation is rectified. Officials from WHO did not respond to requests for information.
The political situation means that Tripoli has lost contact with Benghazi. So Libyans from the east who have HIV must trek across their violent country to receive their life-saving medication. Some make the journey; others don’t. This is not the first time this scenario has played out. During the country’s 2011 revolution-turned-civil war, Libya went six months without HIV medication. As occurs in Egypt, Libyans found their viruses began to develop resistance to the drugs. There are several lines of resistance. When a person living with HIV crosses one line of resistance, the treatment regime must be altered to stop the virus from replicating. With each line of resistance that’s crossed, a patient is closer to developing AIDS and dying, as there are increasingly fewer options for treatment. Khafafa says that about 70 percent of Libyans with HIV can still use the first line of drugs. The other 30 percent are on the second line. One Libyan, a mother, is on the third line of antiretrovirals. Khafafa knows the woman. “If she doesn’t take her drugs, she will die.”
The security situation likely dissuades some Libyans with HIV from seeking medication. In Egypt, Egyptians found to have HIV medication have wound up in jail. Members of Egypt’s security apparatus have used HIV medicine as a pretext for arrest. It is assumed that men with HIV have sex with other men, punishable in Egypt through charges of debauchery under the country’s anti-prostitution legislation. If a Libyan carrying HIV medication is stopped by a member of a militia that sympathizes with Ansar El-Sharia or the Islamic State, it may prove difficult to get the man with the AK-47 to look at HIV treatment through a human rights lens rather than imagining that the virus came from acts he considers immoral.
Khafafa, 32, is the Libyan CDC’s Y-PEER focal point. Wearing glasses and a dark-striped hijab, she speaks proudly of the outreach work that Y-PEER does in Libya. Speaking of one particular Y-PEERian, Khafafa says, “Even with the current security situation, he doesn’t stop; he goes to schools, talks to people on the streets and in the media.” Much of this talk is about HIV, quite a feat in Libya, a remarkably conservative country. The week before our interview, Khafafa had spoken about HIV on Libyan television. To begin a new job, Libyans must show a health record to employers. An HIV-positive status generally disqualifies an applicant from being offered a job. Khafafa wanted to address this as well as stigma and discrimination in general. “I shook hands with people with HIV in front of the camera to show that it’s not transmitted like this.”
The ability to speak openly about HIV is new and a result of the 2011 revolution. “Under Qaddafi, we couldn’t talk about HIV freely. Now we can talk to the media. We can talk about the issue of medication,” Khafafa says. “We’re not afraid anymore. There is a change in the people, in government—they take care of people with HIV more because they understand more.” She raises her right hand with its index finger and thumb nearly touching and laughs. “It’s a little bit. It’s not a lot, but it’s okay.”
A REGION IN FLUX
Not only the poster child of the Arab Spring, Tunisia is considered a leading Arab state when it comes to addressing the threat of HIV. Part of Tunisia’s progress comes from an active civil society in which groups can publicly support the needs of Tunisians living with HIV and those most at risk of infection, including men who have sex with men, sex workers, and intravenous drug users. Activism by marginalized communities will need to take root in the Middle East and North Africa if real improvements are going to come in the near future. Ahmed, a gay human rights activist from Upper Egypt, now calls a refugee camp in an unnamed European city home. In Egypt, he advocated for the rights of refugees, including the right for those with HIV to remain in Egypt and not be deported to their war-torn countries. Besides advocacy, Ahmed, 30, was involved in educating young Egyptians about their health rights, including the right to information to protect themselves from HIV. Because of his work, he faced violence and the difficult decision to defect from his homeland. In the years following Egypt’s unseating of Mubarak, crackdowns on NGOs and the LGBT community impinged on the man’s sense of safety. As long as advocates like him are run out of countries, change will be slow in coming. After all, improved access to effective antiretrovirals in the United States followed very public protests by activists, many with HIV.
Countries will need to find more accurate ways of generating data on HIV. The official number of people living with HIV in Egypt is impossibly low—the Ministry of Health counting 3,641. UNAIDS estimates 7,400. Egypt, with a population of 82 million, has fewer documented cases of HIV than Libya, which reports 5,929 cases in a population of 6 million. Meanwhile Iran, with a population of 77 million (closer to Egypt’s), has 21,570 documented cases of HIV infection and estimates the true figure to be at over 78,000. When the real numbers come to light, governments are more likely to accurately perceive the threat of HIV.
Governments are paying attention, or are at least paying lip service. In March 2014, the health ministers from the 22 member states of the Arab League met in Cairo to endorse the Arab AIDS Strategy, which parallels a United Nations political declaration on the same topic. The document that came from that meeting, Working towards an AIDS-Free Generation in Arab Countries, is certainly laudable. But the commitment of some member states is questionable. The Kingdom of Saudi Arabia, recognized throughout the report for its leadership in the new initiative, is a state where, depending on circumstances, members of the three most at-risk groups for HIV infection can be incarcerated, even publicly beheaded. This not only discourages interaction with the state, but contributes to the stigma and discrimination where HIV thrives. The document itself acknowledges this point. On the plus side, regional gatherings of health ministers do provide opportunities for sharing good practices. Effective strategies in one country can be tailored to the cultural contexts of others.
Money is also an issue. As Wessam El-Beih, formerly of UNAIDS in Egypt, says, in conservative countries facing major budgetary constraints, using public funds to address HIV is a tough sell. The recent consensus of Arab health ministers addresses this point. The Arab AIDS Strategy calls for Arab states to support each other financially in the region-wide fight against HIV. This way, oil-rich countries not undergoing civil and political turmoil can support nations that have difficulty addressing the health needs of their citizens. Budgetary constraints, especially in places with stagnant economies like Egypt, can be ameliorated by a regional sharing of the monetary burden of fighting HIV.
Monitoring and evaluation of programs should include voices of persons living with HIV. “There is a huge gap between the official story and when we meet with people living with HIV and what they go through to get the medicine,” Ahmed, the Egyptian activist in exile says. Reports from UN agencies and the Egyptian government convey little sense that Egyptians who have registered with the Ministry of Health are dying. Articles like those in Al-Masry Al-Youmand Masrawy may prove essential to improving accountability and transparency. Further, if the way funds are used is made clear, charges of corruption will be more difficult to sustain.
LIGHT AT THE END OF THE TUNNEL
In a surprise move, a judge acquitted all 26 of the men arrested in Mona Iraqi’s hammam-gate television broadcast. How did Egyptians react to the news? “It was one of the biggest mysteries,” says one viewer. “I wish there was an explanation to this. In other cases there was no evidence offered whatsoever, and there were convictions. Everyone expected prison.” Fighting stigma and discrimination surrounding HIV and groups most at risk of infection is paramount to curbing HIV transmission and improving the lives of people living with the virus.
Demonizing and incarcerating people will not make them or HIV disappear. Doing so only disincentivizes interactions with state agencies and government-affiliated organizations, or even knowing one’s status. Unlike many of the region’s governments, HIV does not discriminate and easily passes into segments of populations not generally considered vulnerable. To curb the threat, criminal justice and legal systems will need to align effectively with countries’ public health needs. Egypt’s acquittal of the 26 men is a fair step in that direction.
Much of the Middle East and North Africa remain in a state of sometimes-violent uncertainty, with more pressing needs than HIV at the forefront of public discourse and consciousness. Nonetheless, making the changes necessary to effectively address the threat of HIV and meet the needs of persons living with the virus will put the region on track to reaching the lofty goals its health ministers signed off on in 2014.
Christopher Reeve is a writer and consultant. In 2013, he worked on several projects, including HIV awareness, at UNFPA’s Arab States Regional Office in Cairo.
[Photo courtesy of Aliq-Bairaq]