There are regions of the world where intravenous drug use (IDU) is known to have a key role in evolving HIV epidemics.  Information about IDU populations, on the basis of which to motivate and inform public health interventions, can be scant and of poor quality (STI/Aceijas & Hickman).  This deficiency is particularly important to address, given the possibility in some contexts of these populations serving as a bridge into other populations (STI/Reza & Blanchard; STI/Decker & Beyrer), and the practicality and cost-effectiveness of interventions that could make a difference (e.g. needle/syringe exchange programmes) (STI/Demyanenko & Vagaitseva; STI/Boci & Hallkaj).

The Middle East and North Africa (MENA) is among the regions of the world in which IDU might be expected to be a key epidemiological factor – given the availability and cheapness of drugs (US$ 4 per gram of heroine, as against US$ 100 in Europe).  But, as recently as 2005, the region was characterized as “as real hole in terms of HIV/AIDS epidemiological data” – let alone in terms of IDU HIV data.  STI/Reza & Blanchard in an alarming study of epidemiological bridging in Pakistan do not include other MENA countries among the epidemiological parallels to which they refer – perhaps because of the lack of data.

A recent systematic review by Mumtaz & Abu-Raddad (M&R) may go some way to addressing this need, but points to the importance of further research.  M&R review and synthesize data from sources (e.g. international and regional databases, and country-level reports) relevant to actual and potential HIV risk for IDU populations across 23 nations in MENA.  They estimate average IDU over the region at 0.24 per 100 adults, and HIV prevalence in these populations averaging 10-15% (both figures comparable with what we find in other regions).  Among the 10 (23) nations for which good evidence is available, 6 show concentrated epidemics suddenly emerging over the last ten years (Iran, Pakistan, Afghanistan, Egypt, Morocco, Libya), at national (Iran, Pakistan) or local (Afghanistan, Egypt, Morocco, Libya) level; 4-5 others show low level epidemics.

This study delivers a strong message.  Data from countries for which there is evidence of low level IDU HIV epidemics suggests “moderate HIV potential” (i.e. high levels of unsafe practices reflected in prevalence of Hepatitis C and other STIs).  The same, for all anyone knows, may also be true for those 13 countries for which the evidence is not available.  Pakistan saw rocketing levels of HIV (from near 0% to 23% in six months) following introduction of the infection into IDU populations.  Low prevalence countries, including those about which we know little, may have only a brief “window of opportunity” before they experience a comparable explosion of HIV among their own IDU populations.  This, according to M&A makes it imperative to conduct studies in those 13 countries, and to implement further rounds of surveillance in those for which there is already evidence, with a view to making timely and effective interventions.  M&A cite, as evidence of the patchy coverage of IDU by existing prevention services over the region, the very small proportion of the IDU population reporting ever being tested for HIV as indicated by studies conducted in Morocco and Pakistan.