The Arab Bed Spring? Sexual rights in troubled times across the Middle East and North Africa.

In recent decades, attitudes in many parts of the Arab region have hardened towards non-conforming sexualities and gender roles, a shift fuelled in part by a rise in Islamic conservatism and exploited by authoritarian regimes. While political cultures have proved slow to change in the wake of the 'Arab Spring', a growing freedom of expression, and increasing activity by civil society, is opening space for discreet challenges to sexual taboos in a number of countries, part of wider debates over human rights and personal liberties in the emerging political and social order.

The Global Commission on HIV and the Law: recommendations for legal reform to promote sexual and reproductive health and rights.

The Global Commission on HIV and the Law was established in 2010 to identify and analyse the complex framework of international, national, religious and customary law shaping national responses to HIV and the well-being of people living with HIV and key populations. Two years of deliberation, based on an exhaustive review of international public health and human rights scholarship, as well as almost 700 testimonials from individuals and organizations in more than 130 countries, informed the Commission's recommendations on reform to laws and practices that criminalize those living with and vulnerable to HIV, sustain or mitigate violence and discrimination lived by women, facilitate or impede access to HIV-related treatment, and/or pertain to children and young people in the context of HIV. This paper presents the Commission's findings and recommendations as they relate to sexual and reproductive health and rights, and examines how the Commission's work intersects with strategic litigation on forced sterilization of women living with HIV, legal reform on the status of transgender individuals, initiatives to improve police treatment of female sex workers, and equal property rights for women living with HIV in sub-Saharan Africa and Latin America.

HIV incidence and impact of interventions among female sex workers and their clients in the Middle East and north Africa: a modelling study.

BACKGROUND: The incidence of HIV infection among female sex workers and their clients in the Middle East and north Africa is not well known. We aimed to assess HIV incidence, the contribution of heterosexual sex work networks to these numbers, and the effect of interventions by use of mathematical modelling. METHODS: In this modelling study, we developed a novel, individual-based model to simulate HIV epidemic dynamics in heterosexual sex work networks. We applied this model to 12 countries in the Middle East and north Africa that had sufficient data to estimate incidence in 2020 and the impact of interventions by 2030 (Algeria, Bahrain, Djibouti, Iran, Libya, Morocco, Pakistan, Somalia, South Sudan, Sudan, Tunisia, and Yemen). Model-input parameters were provided through a systematic review of HIV prevalence, sexual and injecting behaviours, and risk group size estimates of female sex workers and clients. Model output was number of incident HIV infections under different modelling scenarios for each country. Summary statistics were generated on these model output scenarios. FINDINGS: Based on the output of our model, we estimated a total of 14 604 (95% uncertainty interval [UI] CI 7929-31 819) new HIV infections in the 12 countries in 2020 among female sex workers, clients, and spouses, which constituted 28·1% of 51 995 total new cases in all adults in these 12 countries combined. Model-estimated number of new infections in 2020 in the 12 countries combined was 3471 (95% UI 1295-10 308) in female sex workers, 6416 (3144-14 223) in clients, and 4717 (3490-7288) in client spouses. Contribution of incidence in heterosexual sex work networks to total incidence varied widely, ranging from 3·3% in Pakistan to 71·8% in South Sudan and 72·7% in Djibouti. Incidence in heterosexual sex work networks was distributed roughly equally among female sex workers, clients, and client spouses. Estimated incidence rates among female sex workers per 1000 person-years ranged from 0·4 (95% UI 0·0-7·1) in Yemen to 34·3 (17·2-59·6) in South Sudan. In countries where HIV acquisition through injecting drug use creates substantial exposure for female sex workers who inject drugs, estimated incidence rates per 1000 person-years ranged from 5·1 (95% UI 0·0-35·1) in Iran to 45·8 (0·0-428·6) in Pakistan. The model output predicted that any of the programmed interventions would substantially reduce incidence. Even when a subpopulation did not benefit directly from an intervention, it benefited indirectly through reduction in onward transmission, and indirect impact was often half as large as the direct impact. INTERPRETATION: Substantial HIV incidence occurs in heterosexual sex work networks across the Middle East and north Africa with client spouses being heavily affected, in addition to female sex workers and clients. Rapid scaling-up of comprehensive treatment and prevention services for female sex workers is urgently needed. FUNDING: Qatar National Research Fund (a member of Qatar Foundation), the Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medicine-Qatar, Qatar University-Marubeni, the UK Medical Research Council, and the UK Department for International Development.

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns.

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.