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Background: HIV self-testing was introduced to enhance HIV testing uptake, especially among key populations. Despite the benefits, its use remains relatively low in the WHO Eastern Mediterranean Region., Aim: To assess the acceptability, usability and feasibility of HIV self-testing among key populations in Morocco., Methods: We assessed the usability and acceptability, as well as the feasibility of ordering online and picking up in pharmacies and of distribution by people living with HIV of an oral HIV self-testing kit among 3465 female sex workers, men having sex with men, and partners of newly diagnosed people living with HIV in Morocco. Data were collected using 4 questionnaires administered online anonymously and analysed using Stata version 14.0., Results: A total of 3465 individuals received the HIV self-testing kits, 54.4% male, 43.7% female and 1.9% transgender. High acceptability rates of 90.2%, 86.2% and 80.4% were reported among the female sex workers, men having sex with men, and partners of newly diagnosed people living with HIV, respectively. HIV positivity rates were 1.2% among the female sex workers and men having sex with men, and 4.3% among partners of people living with HIV. Between 44.0% and 73.4% of the participants had never been tested for HIV., Conclusion: Our findings highlight the value of extending HIV self-testing services to key populations in Morocco and possibly other countries in the Middle East and North Africa., (Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).)

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool, recommended for persons at substantial risk for HIV, such as female sex workers (FSW) and men who have sex with men (MSM). We present Morocco's and the Middle East/North Africa's first PrEP demonstration project. Our pilot aimed to assess the feasibility and acceptability of a community-based PrEP program for FSW and MSM in Morocco's highest HIV prevalence cities: Agadir, Marrakech, and Casablanca. From May to December 2017, 373 eligible participants engaged in a 5-9 month program with daily oral TDF/FTC and clinic visits. Of these, 320 initiated PrEP, with 119 retained until the study's end. We report an 86% PrEP uptake, 37% overall retention, and 78% retention after 3 months. No seroconversions occurred during follow-up. These results underscore PrEP's need and acceptability among MSM and FSW and demonstrate the effectiveness of a community-based PrEP program in Morocco. These findings informed Morocco's current PrEP program and hold potential for the wider region with similar challenges.

In 2017, Morocco became the first Arab country to incorporate pre-exposure prophylaxis (PrEP) in its HIV-prevention program. Yet no research has been published on PrEP from Morocco. Although female sex workers are one of the target populations of PrEP in Morocco, their enrollment in PrEP is lower than men who have sex with men. In this study, we conducted 38 semi-structured interviews with female sex workers, physicians who prescribe PrEP, policymakers, and community advocates to identify problems associated with access to and use of PrEP. We also investigated preferences for daily oral, vaginal ring, and long-acting injectable PrEP. A reflexive thematic analysis revealed seven themes: PrEP stigma; stigmatization and criminalization of sex work; one size doesn't fit all; knowledge and misconceptions about PrEP; economic burden; inconvenience of PrEP pills; and preferred PrEP modalities. This paper discusses the implications of the findings for increasing access and use of PrEP in Morocco., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In 2020, almost 20% of people living with HIV (PLHIV) in Morocco are still unaware of their HIV status. Under these circumstances, HIV self-test (HIVST) can be an efficient additional tool for improving the testing rates in Morocco and reaching the first objective of the UNAIDS 95-95-95 goal. ALCS, a Community-based organization, involved in HIV Testing since 1992, and the Ministry of Health of Morocco conducted, a study on the acceptability and usability of HIVST among Female sex workers (FSW) and MSM (men who have sex with men), using a salivary rapid test. To our knowledge, this is the first study in Morocco exploring these parameters., Methods: We conducted a pilot study on the usability of the OraQuick HIV-1/2 salivary self-test among MSM and FSW visiting the ALCS centers for standard HIV rapid testing in five Moroccan cities. Participants chose whether or not to be assisted by lay provider HIV testing. The counselors sampled them to perform a standard rapid test and then invited them to a private room to perform the HIV self-test simultaneously. In addition, a questionnaire was administered to collect socio-demographic data and to assess their opinion about the usability of the salivary HIVST., Results: Our study was carried out for 5 months and included 492 participants (257 MSM and 233 FSW). The average age of the participants was 29 years among MSM vs 34 years among FSW. The FSW have a lower educational level, 28,8% of them are Illiterate vs. 6,1% of the MSM. Only 18% of participants were aware of the existence of the HIVST, nevertheless, we recorded a very high rate of acceptability (90,6%) of the HIVST. Performing the HIVST was deemed very easy for 92,2% of MSM versus 80,6% of FSW. Although it was found very difficult for six participants, including five FSW, 4 of them could not read or write. Overall, the study registered a high HIV positivity rate (3,8%) and 100% of concordance between HIVST participants' interpretation and standard HIV testing performed by ALCS lay provider HIV testing., Conclusion: Our study shows very high acceptability of HIVST among FSWs and MSM in Morocco, HIV self-testing is still unknown by key populations in Morocco, and the low level of education of FSWs may be a barrier to the use of this test, but with the proposed assistance and adapted demonstration tools, the HIV self-testing will certainly improve access to testing in Morocco., (© 2022. The Author(s).)

Background: Enacted or anticipated stigma among people living with HIV (PLHIV) can negatively impact healthcare engagement. We identified factors associated with having avoided HIV health services for fear of stigma among PLHIV in Morocco., Methods: The Stigma Index survey was conducted in Morocco in March-June 2016. Factors associated with avoiding HIV testing and treatment services for fear of stigma by (A) health personnel or family/neighbours and (B) health personnel and family/neighbours compared to people who did not avoid health services for fear of stigma from either of the two sources were assessed using multinomial logistic regression models., Results: Among 583 respondents, 280 (48.0%) were women and median number of years living with HIV was 5[IQR:2-7]. Half of the respondents reported avoiding health services for fear of stigma by health personnel and/or family/neighbours: (A) n = 228, 39.1% and (B) n = 68, 11.7%. After adjustment on perceived health status, not having had easy access to antiretroviral treatment ((A) aRR [95% CI] = 1.76[1.16; 2.68]; (B) 2.18[1.11; 4.27]), discrimination by PLHIV ((A) 1.87[1.12; 3.13]; (B) 3.35[1.63; 6.88]) and exclusion from social activities ((A) 1.70[1.10; 2.61]; (B) 2.63[1.39; 5.00]) were associated with having avoided health services for fear of stigma by health personnel or/and family/neighbours. Being female (2.85[1.48; 5.47]), not having been referred for an HIV test for suspected symptoms 3.47[1.67; 7.22], having discussed sexual/reproductive health with a health professional (4.56[2.38; 8.71]), and not having the feeling to influence decisions on local projects for PLHIV (3.47[1.37; 7.83], were associated with having avoided health services for fear of stigma by both sources., Conclusion: Results suggest a cumulative effect of fear of stigma and discrimination among PLHIV in Morocco. PLHIV who have experienced discrimination may seek to avoid similar situations at the expense of their health. These results should inform multi-level interventions and broader advocacy efforts to reduce stigma and discrimination., (© 2022. The Author(s).)

Background: HIV-related stigma and discrimination constitute a barrier to different intervention programs. Unlike external stigma, internal stigma is not well explored in in the Middle East and North African countries, while grasping this particular form of stigma is essential to limit its effects. The present study aims to measure internal stigma effects and to identify factors associated with this kind of stigma not yet documented among people living with HIV (PLHIV) in Morocco., Methods: The PLHIV Stigma Index questionnaire (adapted and translated into French and Moroccan Arabic dialect "darija") was used to collect information regarding the stigma and discrimination experienced by PLHIV across 8 cities in Morocco (September-October 2016). A randomly drawn cluster of 10 PLHIV, consisting of 5 men and 5 women, was drawn at each participating medical care center to achieve a nationally representative sample of PLHIV. Fifteen interviewers living with HIV and five supervisors were selected and trained to administer the questionnaire. An internal stigma score (range: 0-7), was calculated based on seven negative feelings/ beliefs. Negative binomial regression was used to identify characteristics associated with the internal stigma score., Results: Among 626 PLHIV, internal stigma was reported by 88.2%. The median [IQR] internal stigma score was 4 [2-5]. Regarding internal stigma, 51% avoided going to the local clinic when needed and 44% chose not to attend social gatherings. Belonging to at least one key population (aIRR [95%CI] = 1.15 [1.03; 1.28]), experiencing discriminatory reactions from family following HIV status disclosure (1.28 [1.11; 1.49]), avoiding HIV services for fear of stigmatization by staff (1.16 [1.05; 1.28]) and being denied health services because of HIV status (1.16 [1.03;1.32]), are among the factors significantly associated with an increase of the internal stigma score., Conclusions: Internal stigma is high among Moroccan PLHIV and significantly impacting their life decisions and their healthcare access. Multi-level interventions are needed to address internal stigma experienced by PLHIV in Morocco.

Background: Truck drivers constitute an important bridging group in the HIV epidemic in Morocco. This study examined the effect of a community-based educational intervention in Morocco on HIV testing and counseling, in representative samples of truck drivers before (2007) and after (2012) the intervention., Methods: Face-to-face structured interviews, adapted from UNAIDS documents, collected data on socio-demographic characteristics, HIV testing and counseling, and HIV risk behaviors in both the 2007 and 2012 surveys. Information about exposure to the intervention was also collected in the latter. Individuals exposed to the intervention were compared with those unexposed (i.e. unexposed in 2012, and all the 2007 pre-intervention sample)., Results: The 2012 group included 459 men with a median [IQR] age of 38 [31-44] years, 53% of whom reported exposure to the educational intervention. The percentage of participants tested for HIV and receiving HIV counseling in the last 12 months, was significantly higher in the 2012 group (29.6% vs 4.3% in 2007). Data from the 2012 survey confirmed a significant positive trend between being HIV tested and receiving counseling and the number of times a participant was exposed to the intervention (once: (OR = 5.17(2.38-11.25)), twice or more (OR = 19.16(10.33 - 35.53)). These results were confirmed after adjustment for employment, knowledge that the HIV test results would remain confidential, inconsistent condom use with occasional partners or sex workers, and when including individuals from 2007 considered unexposed., Conclusions: Community-based educational interventions targeting truck drivers can be effective in increasing coverage of HIV testing and counseling, particularly if they are repeated and cover a considerable portion of this at-risk population. These results are encouraging for other countries which urgently need to implement prevention interventions for most-at-risk populations. Furthermore, they clearly show the power of community-based organization interventions in settings where resources for HIV prevention remain limited.

Objective: To collect baseline measurements of HIV and syphilis prevalence and sexual risk behaviours among men who have sex with men (MSM) in Agadir and Marrakech, Morocco, and provide strategic information to improve outreach programmes., Methods and Design: Respondent-driven sampling was used to recruit men who reported having anal sex with another man in the last 6 months, aged 18 years and older and living in either Agadir or Marrakech for the past 6 months, regardless of nationality. Data were analysed with the multiplicity estimator using respondent-driven sampling analysis tool V.6.0., Results: 323 MSM in Agadir and 346 in Marrakech were recruited into the survey. Most MSM in both cities reported being < 25 years, being unemployed, bisexual and in a couple with both a man and a woman. Most reported selling sex and having sex with women. HIV prevalence was 5.6% in Agadir and 2.8% in Marrakesh; syphilis was 7.0% in Agadir and 10.8% in Marrakesh. Among MSM who tested positive for HIV, 31.6% in Agadir and 56.4% in Marrakesh were co-infected with syphilis., Conclusions: HIV and syphilis findings coupled with high risk activities indicate the need for expanding programmes targeting MSM throughout Morocco. Selling sex and sex with women may be a strategy to cope with extreme stigma towards MSM. Criminalisation and discrimination of MSM in Morocco underscores the urgent need for long-term and sustainable risk reduction through legal reforms and promotion and protection of human rights.