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A Spreading STIgma

Original illustration by Elizabeth Long '24, an Illustration major at RISD

In an anonymous statement to the United Nations Programme on HIV and AIDS (UNAIDS), an Egyptian woman described in painful detail her family’s reaction to her contracting HIV: They ostracized her, beat her, and withheld her inheritance. In an attempt to start anew, she moved with her children to a different part of Cairo, only to be shunned by her new neighbors, who had heard rumors of her illness. 

This woman is one of approximately 230,000 people living with HIV/AIDS in the Middle East and North Africa. The stigmatization surrounding the disease is not unique to the Arab world. However, in one of the only regions in which cases are on the rise, this stigma has particularly far-reaching implications for public health. In order to alleviate the social and physical impacts of the HIV/AIDS epidemic in the Arab world, we need to double down on efforts to support local communities, increase testing, and improve treatment accessibility. 

Three key populations—men who have sex with men (MSM), female sex workers, and intravenous drug users—are most at risk of contracting HIV/AIDS. However, “No man is an island when it comes to HIV,” in the words of Shereen El Feki, the UNAIDS Regional Director for the Middle East and North Africa. An HIV-positive female sex worker can easily transmit the virus to her male client. That client may be married, and thus able to pass the virus onto his wife. His wife could be pregnant, infecting their child. There are thousands of possible scenarios like this one. And they are all happening simultaneously, multiplying cases by the second. 

The effects of these perpetual cycles of transmission are reflected in the growing pervasiveness of the epidemic. Cases of HIV/AIDS are increasing in every Middle Eastern country. According to a UNAIDS report, the Arab world saw 20,000 new HIV infections in 2019, representing a 25 percent increase from 2010. That makes the Middle East one of only four regions where HIV cases are still on the rise. Meanwhile, between 2010 and 2021, there was a 32 percent global decrease in the number of new HIV infections. 

It would be easy to ascribe the rise in reported cases to increases in testing, but experts argue to the contrary. “The positive cases we are discovering via increased testing are not old cases,” said Dr. Nesrine Rizk, an HIV specialist at the American University of Beirut. “They are newly infected people, which shows that we are failing in stopping the spread of HIV in the region.”

The first measure in mitigating this public health crisis is prevention, but taboos surrounding contraception in Arab societies complicate their widespread adoption. Condoms, for instance, are highly stigmatized and many are misinformed about their purpose. “They are so rarely used. The reason for that is because birth control within marriage is the responsibility of a woman and so if you are using condoms you must be having sex outside of marriage, and that is forbidden,” said El Feki. 

When offered condoms by an NGO in Morocco, a group of female sex workers responded, “We don’t need condoms. No way are we going to become pregnant. We only have oral or anal sex because we want to get married.” This quote highlights the misconception that condoms only serve to prevent pregnancies. It also illuminates the social pressures placed on women to maintain their virginities, which incentivizes them to develop unsafe practices like avoiding contraception, testing, and treatment.

Not only are people dissuaded from taking preventative measures, but they are also disincentivized from pursuing testing and treatment once infected. Indeed, in 2020, only 61 percent of those infected with HIV/AIDS in the Middle East knew that they were sick, a mere 43 percent were pursuing treatment, and only 37 percent were virally suppressed. 

This is in part because the most at-risk groups face significant legal barriers to receiving care. Twenty-one countries in the region criminalize sex work; nine have laws against the posession of drugs; and 19 forbid same-sex sexual acts, with seven invoking the death penalty as punishment. Thus, many people may fear the legal repercussions of contracting an STI.

Moreover, those who do seek treatment may encounter discrimination in medical establishments. “When I went to the hospital to give birth, no one wanted to take care of me, no one wanted to touch me, I ended up in intensive care,” said Amina, an HIV-positive woman in Morocco. The very institutions tasked with protecting peoples’ health are making conscious efforts to deteriorate it. 

Beyond structural obstacles, infected people bear immense social penalties for their diagnosis. “To say that you have HIV is not something that you are going to speak openly about in the Arab region and particularly if you are a woman,” said El Feki. Seventy percent of women infected with HIV contracted it through their husbands, including the woman described in the first paragraph. But as we saw in her case, it is the woman who is blamed for transmitting the virus. She is the one accused of engaging in extramarital relations. She is the target of the social backlash. 

We must provide support to women—and other individuals—who are deterred from receiving care out of fear of such backlash. In our conversation, Joumana Hermez, Regional Advisor at the World Health Organization (WHO) for HIV, Hepatitis, and STIs in the Eastern Mediterranean, emphasized the importance of providing community support to those infected to “overcome the stigma barriers.” The WHO’s efforts include arranging for community groups to accompany infected patients to treatment. The organization has run programs in Sudan and Pakistan to help patients who have discontinued their treatments by having community members, usually people also living with HIV, follow up with them. This programming is effective because it not only connects patients with treatment resources, but also provides them with a community support network. 

The importance of local involvement is also demonstrated by Morocco. From 2010 to 2018, the country witnessed a 42 percent decrease in the number of HIV cases, compared to a mere 4 percent reduction in regional rates, making it a “model country” for HIV response. “The key secret to their success,” said Hermez, “is the engagement of community groups and NGOs.” 

One of these community groups is the Association for the Fight Against AIDS (ALCS), a Moroccan organization that challenges stigma around STIs while providing resources for infected patients. The ALCS hosts workshops to connect HIV patients with mental health support, runs HIV prevention and screening campaigns, and ensures patients are receiving medical treatment. It also provides a platform for people to share their stories and engages in rigorous testing and treatment initiatives. 

The success of the ALCS demonstrates a fact many have long known: The Arab world and international community have the resources to contain the spread of HIV/AIDS. However, the association of testing and treatment with sex positivity, homosexuality, and feminism presents significant barriers to doing so. Deconstructing these barriers and destigmatizing HIV/AIDS is a marathon, not a sprint, but we must start running now. Investing in local actors and increasing accessibility to testing and treatment are necessary steps toward providing assistance to infected people and preventing them from transmitting the virus.