Gender and HIV in the Middle East and North Africa: Lessons for Low Prevalence Scenarios

Over the quarter century since its discovery, HIV has not been considered a health threat in the Middle East and North Africa (MENA). However, despite the low prevalence in most countries of the region, there is increasing evidence suggesting that the epidemic is in motion. Since the identification of the first MENA region AIDS cases in the 1980s, the number of detected people living with HIV has been steadily on rise. Although geographic proximity and shared cultural factors interconnect the region, estimated HIV-related epidemiological profiles vary dramatically, ranging from low level to generalized epidemics. Despite the overall regional prevalence remaining low, the total number of AIDS deaths in the region increased by at least 6-folds since the early 1990s. Globally, gender norms that subordinate women and trap men in damaging patterns of risk behaviors are increasingly recognized as fundamental forces that increase population health vulnerabilities, and the MENA region is no exception. Gender is a social construct that refers to a complex framework affecting both men and women in the society. All cultures interpret the biological differences between women and men into a set of culturally normative behaviors and attitudes. In the community-oriented MENA societies, the family, rather than the individual, is the core focus of concern. Femininity and masculinity are often translated into raising women to be “caregivers” and men to be “breadwinners.” For both women and men, early marriage is encouraged, sexual relations outside marriage are prohibited, and sex education is a sensitive topic. The prevailing gender norms offer men greater social power and access to resources as compared with women. Furthermore, normative societal ideals for the interaction between women and men in the region may increase both women's and men's transmission risk and ability to access care for those who are infected. In the conservative societies of the MENA, cultural norms uphold the institution of marriage as the only legitimate context for sexual relations. Ideals of premarital chastity and lifelong fidelity are encouraged for women, whereas men's experiences and multiple partners are often tolerated as part of the masculine ideals. Women face steep barriers to accessing accurate information about HIV and risk reduction and having a proactive role in negotiating safer sex because they are not expected to be sexually experienced. The region's prevailing norms of masculinity provide men with more privileges and freedoms, often putting them at risk by preventing them from seeking accurate information or admitting their lack of knowledge about sexuality and risk reduction. Although a range of transmission modes exist in the region, unprotected sexual transmission is overwhelmingly responsible for new infections in the MENA. The growing population of injecting drug users is another major route of infection that is accelerating growth of the epidemic in the MENA region. The vast majority of infections occur in men, yet, the increasing number of HIV infections due to unprotected heterosexual transmission has put women directly in the path of the virus. Little is known about the actual risk behaviors that increase vulnerability to HIV infection, and there is a widespread lingering denial on all levels. In MENA conservative societies, gender norms dictate a culture of silence around risk behaviors and reinforce pervasive stigma and misconceptions which are widely recognized as root causes for the region's slow response and resistance to adopting HIV prevention programs. As the fields of HIV prevention and public health have increasingly acknowledged the central role that structural factors have on health outcomes, understanding complex social-structural interactions that give rise to gender norms and disparities in power between women and men are critical in identifying how HIV transmission risks are produced and in advancing prevention. In the last few years, remarkable efforts were exerted in many countries of the MENA region in terms of gender empowerment and HIV prevention, and they serve as seeds for building more efficient programs. Despite the limited surveillance information across the MENA region and the diversity of policies and activities undertaken by each country, much can be achieved to advance HIV prevention by reducing the gap between “gold standard” top-down approaches, and implementation adapted to local contexts and realities. Scaling-up HIV prevention and care programs in the region is a necessity. However, it is time to think beyond prescriptive health care in the region and to move toward addressing the social factors that give rise to risk by empowering both women and men. In this series, we critically examine the influence of the regional gender norms in elevating HIV risks and impeding access to health care. The series begins with 2 introductory background articles. Sawires'1 article offers a broad introduc-tion to sociosocietal structural factors underlying the risk for HIV spread in low prevalence scenarios and the intersection between HIV prevention and care, highlighting the need for context-driven structural interventions. Shawky2 follows to describe the achievements in HIV surveillance demonstrating that although effective data collection projects focusing on limited populations have been made available throughout the region, these efforts are still in their infancy and are often impeded by gender-specific societal practices throughout the MENA region. Ehrhardt's3 article presents a framework for operationalizing empowerment in terms of gender and HIV, focusing on empowerment of women and men as key to reducing the gender imbalances that give rise to transmission risk. The focus then turns to a review of available HIV treatment and care in the region and identifying barriers to establishing optimal service delivery. Remien's4 article takes a close look at the intersection between gender and access to HIV testing and care, giving specific examples of MENA programs which have successfully adopted measures to address gender inequality, with an emphasis on identifying critical components to their success. Dworkin et al.5 attempts to examine the complex social interactions in the MENA region to facilitate a richer understanding of how to develop region-specific HIV surveillance and prevention programs based on making visible their influence on HIV risks and empowering both women and men as agents of social transformation and how to make them accessible to policy makers, the wider scientific community, and civil society. Peacock et al6 end the series with a piece on men's role in the epidemic and describe the components of transformative masculinities in achieving gender parity and the fight against HIV. Despite the many challenges to effective HIV prevention in the MENA region, there is much to be optimistic about. New efforts exist to systemize surveillance efforts across the region and consolidate the vast amount of available data from published literature and reports by national and international organizations. Heightened regional and international focus on strengthening civil society in MENA region and forging multisectoral collaborations exists. A focus on high-risk and vulnerable populations and although much remains to be accomplished in realms of stigma reduction and advancement of human rights, there is an increasing willingness to approach risk reduction and care in a nonpunitive way that prioritizes public health. Our hope is that the articles in this series and their accompanying recommendations will heighten attention and advance the dialog on the role of gender in HIV prevention for the MENA region and other low prevalence scenarios.

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