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This article reviews HIV/AIDS knowledge and attitudes in various population groups in the Middle East and North Africa (MENA), and highlights their relevance to HIV epidemiology and the design and implementation of preventions and treatment efforts. PubMed and the MENA HIV/AIDS Epidemiology Synthesis Project database of grey/unpublished literature were searched. Levels of knowledge were categorised based on presence of basic knowledge, comprehensive knowledge, and misconceptions and misinformation. Attitudes towards people living with HIV/AIDS (PLHIV) were classified into positive or negative. Basic knowledge was overall high among key populations at higher risk of infection (KPAR), and bridging and general population groups, but still a few population pockets had low basic knowledge. Level of comprehensive knowledge was overall low, and misinformation and misconceptions were prevalent. Some KPAR, including people who inject drugs, men who have sex with men, and female sex workers, were unaware of some modes of HIV transmission. Perception of risk of infection was low even among KPAR. We found differentials in knowledge putting women, rural populations, refugees, and other marginalised minorities at a disadvantage. Attitudes towards PLHIV tended to be negative. These findings are of concern, particularly for KPAR currently experiencing emerging HIV epidemics.

Background This paper describes the methods and conceptual framework for Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study data collection. The National Institutes of Health, through the National Institute on Drug Abuse, is partnering with the Food and Drug Administration9s (FDA) Center for Tobacco Products to conduct the PATH Study under a contract with Westat. Methods The PATH Study is a nationally representative, longitudinal cohort study of 45 971 adults and youth in the USA, aged 12 years and older. Wave 1 was conducted from 12 September 2013 to 15 December 2014 using Audio Computer-Assisted Self-Interviewing to collect information on tobacco-use patterns, risk perceptions and attitudes towards current and newly emerging tobacco products, tobacco initiation, cessation, relapse behaviours and health outcomes. The PATH Study9s design allows for the longitudinal assessment of patterns of use of a spectrum of tobacco products, including initiation, cessation, relapse and transitions between products, as well as factors associated with use patterns. Additionally, the PATH Study collects biospecimens from consenting adults aged 18 years and older and measures biomarkers of exposure and potential harm related to tobacco use. Conclusions The cumulative, population-based data generated over time by the PATH Study will contribute to the evidence base to inform FDA9s regulatory mission under the Family Smoking Prevention and Tobacco Control Act and efforts to reduce the Nation9s burden of tobacco-related death and disease.

Objective To examine whether mental health problems predict incident use of 12 different tobacco products in a nationally representative sample of youth and young adults. Method This study analyzed Wave (W) 1 and W2 data from 10,533 12- to 24-year-old W1 never tobacco users in the Population Assessment of Tobacco and Health (PATH) Study. Self-reported lifetime internalizing and externalizing symptoms were assessed at W1. Past 12-month use of cigarettes, electronic nicotine delivery systems (ENDS), traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, other smokeless tobacco, bidis and kreteks (youth only), and dissolvable tobacco was assessed at W2. Results In multivariable regression analyses, high-severity W1 internalizing (adjusted odds ratio [AOR] = 1.5, 95% CI = 1.3−1.8) and externalizing (AOR = 1.3, 95% CI = 1.1−1.5) problems predicted W2 onset of any tobacco use compared to no/low/moderate severity. High-severity W1 internalizing problems predicted W2 use onset across most tobacco products. High-severity W1 externalizing problems predicted onset of any tobacco (AOR = 1.6, 95% CI = 1.3−1.8), cigarettes (AOR = 1.4, 95% CI = 1.0−2.0), ENDS (AOR = 1.8, 95% CI = 1.5−2.1), and cigarillos (AOR = 1.5, 95% CI = 1.0−2.1) among youth only. Conclusion Internalizing and externalizing problems predicted onset of any tobacco use. However, findings differed for internalizing and externalizing problems across tobacco products, and by age, gender, and race/ethnicity. In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use. Interventions addressing mental health problems may prevent youth from initiating tobacco use.

Background While evidence suggests bidirectional associations between cigarette use and substance (alcohol or drug) use, how these associations are reflected across the range of currently available tobacco products is unknown. This study examined whether ever tobacco use predicted subsequent substance use, and ever substance use predicted subsequent tobacco use among 11,996 U.S. youth (12–17 years) from Waves 1 (2013–2014) and 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Methods Ever use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, smokeless tobacco excluding snus pouches, dissolvable tobacco, bidis, kreteks, alcohol, marijuana, prescription drugs, and other drugs (cocaine and other stimulants, heroin, inhalants, solvents, and hallucinogens) was assessed at Wave 1 followed by past 12-month use assessments at Wave 2. The analyses included covariates (demographics, mental health, sensation seeking, prior use) to mitigate confounding. Results Ever tobacco use predicted subsequent substance use. The magnitude of the associations was lowest for alcohol, higher for marijuana, and highest for other drugs. Ever substance use also predicted subsequent tobacco use. Specifically, ever alcohol, marijuana, and non-prescribed Ritalin/Adderall use predicted tobacco-product use. Ever e-cigarette and cigarette use exclusively and concurrently predicted subsequent any drug (including and excluding alcohol) use. E-cigarette and cigarette use associations in the opposite direction were also significant; the strongest associations were observed for exclusive cigarette use. Conclusion Tobacco and substance use prevention efforts may benefit from comprehensive screening and interventions across tobacco products, alcohol, and drugs, and targeting risk factors shared across substances.

Introduction Waterpipe use is common among U.S. young adults (aged 18–24 years), with estimates considerably higher than other age groups. Although studies have examined attitudes and beliefs associated with waterpipe use, no study has examined reasons for use in a nationally representative sample. Methods Using latent class analyses, this study examined subgroups based on self-reported reasons for use of past 30-day young adult (aged 18–24 years) waterpipe users (n=1,198) from Wave 1 (2013–2014) of the Population Assessment of Tobacco and Health Study. Data analyses were conducted in 2017. Covariates included sociodemographic characteristics, substance use, and internalizing and externalizing problems. Results A three-class model was identified: Class 1 (socializing and flavors, 57%), Class 2 (many reasons [flavors, socializing, less harmful than cigarettes, and affordability], 20%), and Class 3 (socializing, 23%). Class 3 was considered the referent group. Compared with non-Hispanic whites, non-Hispanic blacks were less likely to belong to Class 1, whereas Hispanics were more likely to belong to Class 2. Compared with less than high school education, greater than high school education was associated with membership in Class 1; however, high school graduation was associated with membership in Class 2. Past-year alcohol users compared with non-users were less likely to belong to Class 2. Past 30-day poly-tobacco users compared with non-users were more likely to belong to Class 2. Conclusions This study revealed distinct classes of waterpipe users based on self-reported reasons for use. Findings inform targeted policies for waterpipe tobacco control as part of public health efforts to mitigate harms associated with tobacco use.

Although non-cigarette tobacco product use is increasing among U.S. adults, their associations with substance use and mental health problems are unclear. This study examined co-occurrence of tobacco use, substance use, and mental health problems, and its moderation by gender, among 32,202U.S. adults from Wave 1 (2013-2014) of the nationally representative longitudinal Population Assessment of Tobacco and Health (PATH) Study.Participants self-reported current cigarette, e-cigarette, traditional cigar, cigarillo, filtered cigar, hookah, smokeless tobacco and other tobacco product use; past year alcohol, marijuana, and other drug use; and past year substance use, internalizing and externalizing problems.Compared to non-current tobacco users, current users were more likely to report alcohol or drug use (adjusted odds ratio (AOR)=2.6; 95% confidence interval (CI): 2.3, 2.9), with the strongest associations observed for cigarillo and hookah users. Across all tobacco product groups, users were more likely to report internalizing (AOR=1.9; 95% CI: 1.7, 2.1), externalizing (AOR=1.6; 95% CI: 1.5, 1.8), and substance use (AOR=3.4; 95% CI: 2.9, 4.1) problems than non-users. Gender moderated many of these associations and, of these, all non-cigarette tobacco product associations were stronger among females.This nationally representative study of U.S. adults is the first to comprehensively document tobacco use, substance use, and mental health comorbidities across the range of currently available tobacco products, while also demonstrating that female tobacco users are at increased risk for substance use and mental health problems. These findings may point to gender differences in vulnerability and suggest that interventions incorporate gender-specific approaches.

OBJECTIVES: Building on a wealth of new empirical data, the objective of this study was to estimate the distribution of new HIV infections in Morocco by mode of exposure using the modes of transmission (MoT) mathematical model. METHODS: The MoT model was implemented within a collaboration with the Morocco Ministry of Health and the Joint United Nations Programme on HIV/AIDS. The model was parameterised through a comprehensive review and synthesis of HIV and risk behaviour data in Morocco, mainly through the Middle East and North Africa HIV/AIDS Synthesis Project. Uncertainty analyses were used to assess the reliability of and uncertainty around our calculated estimates. RESULTS: Female sex workers (FSWs), clients of FSWs, men who have sex with men (MSM) and injecting drug users (IDUs) contributed 14%, 24%, 14% and 7% of new HIV infections, respectively. Two-thirds (67%) of new HIV infections occurred among FSWs, clients of FSWs, MSM and IDUs, or among the stable sexual partners of these populations. Casual heterosexual sex contributed 7% of HIV infections. More than half (52%) of HIV incidence is among females, but 71% of these infections are due to an infected spouse. The vast majority of HIV infections among men (89%) are due to high-risk behaviour. A very small HIV incidence is predicted to arise from medical injections or blood transfusions (0.1%). CONCLUSIONS: The HIV epidemic in Morocco is driven by HIV incidence in high-risk population groups, with commercial heterosexual sex being the largest contributor to incidence. There is a need to focus HIV response more on these populations, mainly through proactive and sustainable HIV surveillance, and the expansion and increased geographical coverage of services such as condom promotion among FSWs, voluntary counselling and testing, harm reduction and treatment.

The distribution of HIV-1 subtypes in a population tracks the spread and evolution of the epidemic. This study is a systematic review of all available evidence on HIV-1 molecular epidemiology and subtype distribution in the Middle East and North Africa. Sources of data included Medline and various institutional documents and databases. In several countries, a diverse distribution of HIV-1 subtypes was observed principally reflecting travel-related exogenous exposures. A trend for a dominant HIV-1 subtype was observed in a few other settings and was often linked to HIV transmission within specific high-risk groups such as subtype A and CRF35_AD among injecting drug users and subtype C among commercial sex networks. Multiple exogenous introductions of HIV-1 variants seemed common to all countries, as observed from the high diversity in subtypes, or the high genetic divergence among any specific subtype even if predominant. In several countries though, epidemic-type clustering of specific subtypes suggests established or nascent HIV epidemics among classic core risk groups for HIV infection. HIV prevention efforts in MENA must be prioritized for these high-risk groups.

SummaryMorocco has made significant strides in building its HIV research capacity. Based on a wealth of empirical data, the objective of this study was to conduct a comprehensive and systematic literature review and analytical synthesis of HIV epidemiological evidence in this country. Data were retrieved using three major sources of literature and data. HIV transmission dynamics were found to be focused in high-risk populations, with female sex workers (FSWs) and clients contributing the largest share of new HIV infections. There is a pattern of emerging epidemics among some high-risk populations, and some epidemics, particularly among FSWs, appear to be established and stable. The scale of the local HIV epidemics and populations affected show highly heterogeneous geographical distribution. To optimize the national HIV response, surveillance and prevention efforts need to be expanded among high-risk populations and in geographic settings where low intensity and possibly concentrated HIV epidemics are emerging or are already endemic.

A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries., 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, Editors' Summary Background AIDS first emerged in the early 1980s among gay men living in the US. But, as the disease rapidly spread, it became clear that AIDS also affects heterosexual men and women. Now three decades on, more than 30 million people are infected with HIV, the virus that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and, globally, most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). In some countries, male-to-male sexual contact remains the most important transmission route. Moreover, although the global prevalence of HIV infection (the proportion the world's population infected with HIV) has stabilized, the prevalence of HIV infection among MSM seems to be increasing in multiple countries and new and resurgent HIV epidemics among MSM populations are being frequently reported. Why Was This Study Done? In the US and the UK, the MSM population is visible and has helped to raise awareness about the risks of HIV transmission through male-to-male sexual contact. In many other countries, MSM are much less visible, fearing discrimination, stigmatization (being considered socially unacceptable) or arrest. In the Middle East and North Africa (MENA, a geographical region that encompasses countries that share historical, socio-cultural, linguistic and religious characteristics), MSM are the most hidden HIV risk group. Consequently, very little is known about HIV transmission patterns among MSM in MENA. Indeed, it is widely thought that there is virtually no information available on the epidemiology (causes, distribution, and control) of HIV among MSM in this region. In this systematic review and data synthesis, the researchers use predefined search criteria to identify all the published and unpublished data on the epidemiology of HIV among MSM in MENA and combine (synthesize) these data to produce a coherent picture of the HIV epidemic in this potentially key group of people for HIV transmission in this region. What Did the Researchers Do and Find? The researchers identified 26 articles and 51 other country-level reports and sources of data that included data on the prevalence of male-to-male sexual contact, HIV transmission, levels of high-risk behavior, and the extent of knowledge about HIV among MSM in MENA. The prevalence of HIV infection among MSM was low in most countries but high in others. For example, the infection rate in Pakistan was 27.6% among one MSM group. Importantly, there was some evidence of increasing HIV prevalence and emerging epidemics among MSM in the region. Thus, by 2008, MSM transmission was responsible for more than a quarter of notified cases of HIV in several countries. Worryingly, MSM were involved in several types of HIV-related high risk behavior. For example, they had, on average, between 4 and 14 sexual partners in the past six months, their rates of consistent condom use were generally below 25% and, in some countries, MSM frequently reported injecting drug use, another common mode of HIV transmission. In addition, 20%–75.5% of MSM exchanged sex for money and contact between MSM and female sex workers and other female sexual partners was often common. Finally, although the level of basic knowledge about HIV/AIDS was high, the level of comprehensive knowledge was limited with a high proportion of MSM perceiving their risk of contracting HIV as low. What Do These Findings Mean? These findings indicate that there is considerable and increasing data about HIV transmission and risk behavior among MSM in MENA. However, the quality of this evidence varies greatly. Little has been collected over time in individual populations and, because only the visible part of the MSM populations in many MENA countries has been sampled, these findings may not be representative of all MSM in this region. Nevertheless, these findings suggest that HIV epidemics are emerging among MSM in several MENA countries. Importantly, the high levels of risk behaviors practiced by many MSM in MENA mean that MSM could become the pivotal risk group for HIV transmission in this region in the next decade. There is, therefore, an urgent need to expand HIV surveillance and access to HIV testing, prevention and treatment services among MSM in this region to limit the size of the HIV epidemic. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000444. Information about the status of the HIV epidemic in the Middle East and North Africa can be found in the World Bank/UNAIDS/WHO report Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for strategic action Information about the global HIV epidemic among men who have sex with men can be found in the World Bank report The Global HIV Epidemics among Men Who Have Sex with Men Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS HIV InSite has comprehensive information on all aspects of HIV/AIDS, including information on HIV transmission and transmission in gay men and other MSM and on safer sex Information is available from Avert, an international AIDS charity, on all aspects of HIV/AIDS, including information on HIV, AIDS and men who have sex with men and on HIV and AIDS prevention (in English and Spanish) The US Centers for Disease Control and Prevention also have information about HIV/AIDS among men who have sex with men (in English and Spanish)

OBJECTIVE: The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region. METHODS: A comprehensive systematic review of HIV sexually transmitted infections (STIs) and risk behavior studies in MENA irrespective of design was undertaken. Sources of data included Medline for peer-reviewed publications Google Scholar for other scientific literature published in nonindexed local and regional journals international organizations reports and databases country-level reports and database including governmental and nongovernmental organizations publications as well as various other institutional documents. RESULTS: Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users men who have sex with men (MSM) and to a lesser extent female sex workers with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited. CONCLUSION: Although they do not provide complete protection against HIV spread near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners in addition to exogenous exposures. HIV prevention efforts in this region which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that if missed may entail a health and socioeconomic burden that the region in large part is unprepared for.

Background The Middle East and North Africa (MENA) continues to be perceived as a region with limited HIV epidemiological data. The objective of this work was to review and synthesise for the first time all available data related to HIV in Lebanon, in order to assess the status of the epidemic in this country and provide the basis for future interventions, prevention, and research needs. Methods A comprehensive systematic review of HIV and risk behaviour studies in Lebanon was undertaken. Sources of data included (1) PubMed using a strategy with both free text and MeSH headings, (2) country-level reports and databases including governmental and non-governmental organisations publications, and (3) international organisations reports and databases. Results Available data indicate that HIV prevalence among the high risk groups ranged between 0 and 3.6% among men who have sex with men (MSM), 0 and 3.9% among injecting drug users (IDUs), and 0%–0.3% among female sex workers (FSWs). HIV prevalence in the general population was very limited (∼0%). Analysis of HIV notified cases indicated a substantial recent increase in the contribution of male same-sex sex, whereby 52% of notified cases in 2008 were due to MSM transmission compared to 13% in the cumulative period until 2008. Substantial levels of risk behaviour were reported by the three high-risk groups. MSM reported an average of 9.5 sexual partners in the last year and up to 36% engaged in male sex work. Seventeen to 65% of IDUs shared needles/syringes, 33%–47% had sex with FSWs, 17%–33% engaged in sex work, and 24.7% reported male same-sex sex. FSWs reported an average of 11.7 sexual partners per week. Despite relatively high levels of risk behaviour, condom use in Lebanon was high and among the highest in the MENA region, so were the levels of knowledge of HIV/AIDS and of its modes of transmission. Molecular epidemiology evidence indicated a diverse HIV subtype distribution suggesting multiple exogenous introductions of the virus. Conclusions The evidence gathered in this review indicates that HIV endemic transmission appears to be still limited in Lebanon with most diagnosed cases representing exogenous exposures. There are however few indications suggesting an emerging epidemic among MSM. HIV surveillance of high-risk groups needs to be actively expanded in Lebanon to track such potential emerging epidemics and prevent further HIV transmission among population groups at high risk of HIV infection.

Background Human Immunodeficiency Virus Type I (HIV-1) is characterised by a high genetic variability. The distribution of HIV-1 subtypes in a population can help track transmission patterns and the evolution of the epidemic. The Middle East and North Africa (MENA) continues to be perceived as a region with limited HIV epidemiological data, but recent research indicates that nascent HIV epidemics appear to be emerging among high-risk groups including injecting drug users (IDUs), men who have sex with men (MSM), and female sex workers. The objective of this work was to review all evidence on HIV-1 subtype distribution in MENA where there remains several gaps in our understanding of the HIV epidemic. Methods A comprehensive systematic review of all HIV-1 molecular epidemiology data in MENA was undertaken. Sources of data included (1) PubMed using a strategy with both free text and MeSH headings, (2) country-level reports and database including governmental and non-governmental organisations publications, and (3) international organisations reports and databases. Results In several countries such as in Lebanon, Saudi Arabia, and Yemen, a very diverse distribution of HIV-1 subtypes was observed reflecting principally travel-related exogenous exposures. A trend of a dominant HIV-1 subtype was observed in few other settings and was often linked to HIV transmission within specific high-risk core groups such as subtype A and CRF35_AD among IDUs in Afghanistan, Iran, and Pakistan; and subtype C in heterosexual commercial sex networks in Djibouti and Somalia. Subtype B was predominant in Northern Algeria, Tunisia, and Morocco, but this appeared to reflect a mix of indigenous endemic transmission and exogenous exposures of West European and North American origin. Conclusions Multiple introductions of HIV-1 variants due to exogenous exposures of nationals seemed common to all MENA countries, as observed from the high diversity in subtypes or the high genetic divergence among any specific subtype even if predominant. This is in part a reflection of the high population mobility in MENA. In several countries though, epidemic-type clustering of specific subtypes suggests established or nascent HIV epidemics among classical core risk groups for HIV infection. With overall weak surveillance systems in MENA, molecular investigations could help identify the emergence of hidden epidemics among high-risk groups. HIV prevention efforts in MENA must be prioritised for these groups.