Part A: Country Epidemic Information

Country Epidemic Information

People living with HIV
PLHIV are estimated at 380 000 [280 000 – 510 000] according to UNAIDS reports in 2007 (Melhem, 2009) in the MENA region. In Lebanon, the current number of PLHIV is reported to be 3 000 [1 700 – 7 200] (UNAIDS, 2008). This figure is probably an under-report of the true figure of PLHIV and the confidence interval is very wide to provide a concrete profile. Either way, along with annual incidence, we might estimate a number along the higher 4 000.

Incident Cases
Incident cases are estimated at 40 000 [20 000 – 66 000] in the MENA region according to UNAIDS reports in 2007 (Melhem, 2009).The Lebanese National AIDS Program reported 92 incident case in 2007 (NAP, 2007).

Deaths associated with AIDS
Number of associated deaths is estimated at 27 000 [20 000 – 35 000] in the MENA region according to UNAIDS reports in 2007 (Melhem, 2009). In Lebanon, it is estimated to be <200>[<100 citation="t" id="2604149"> (UNAIDS, 2008).

Social profile of PLHIV
The 2008 Lebanon UNGASS report doesn’t present any figures or numbers on the social profile of PLHIV. However, it does state that PLHIV within the age group of 15-49 is estimated at 0.1% that is to say that 69.8% of PLHIV are within the age group of 15 – 49 years while 30.2% are 50 years of age and above. The 2008 UNGASS report as well the 2008 Epidemiological Fact Sheet on HIV and AIDS 2008 – Lebanon report do not report any HIV case to children less than 15 years of age (UNAIDS, 2008).

The NAP provides the following age groups break down; 14.9% of reported cases are lower than 31 years, 52.1% are between 31 and 50 years old, 27.9% above 50 years, while 5.1% are not specified. The cases are also distributed between 81.7% for male cases and 17.9% for females, 0.4% is not specified. NAP also reported that those cases that have not proceeded to symptomatic AIDS status constitute 42%, those who did constitute 40.9% while 17.1% of the cases had unspecified status (NAP, 2007).

ART coverage
PLHIV receiving ART was estimated at <500 citation="t" id="2604156">(UNAIDS, 2008). Yet, UNAIDS identified 940 [550 – 2 300] PLHIV in need for ART in that same year to establish a 26% [11% - 45%] treatment coverage for both sexes. The 2008 UNGASS reports different figures. It reports the total number of people in need for ART to be 432 while 246 of these individuals received treatment to establish a 56% coverage rate for both sexes.
In Lebanon, all individuals who are in need of ART have to go through the Ministry of Public Health (MOPH) by applying for the MOPH Drug Center. UNAIDS reported 9 children under the age of 15 receiving ART (UNAIDS, 2008), though no pediatric HIV case was reported in the UNGASS 2008 report of any other documentation.

Young women living with HIV
It is estimated to be 0.1% of females 15-24 years of age. That adds up to 190 cases of young females living with HIV in Lebanon in the year of 2007 (UNAIDS, 2008).

Dynamics of transmission
The main mode of transmission is unprotected sexual activity which accounts for 70% of the incident cases. Other modes of transmission include the transfer of contaminated blood content (6.4%), use of contaminated syringes for drug injection (5.7%), mother-to-infant (2.2%) as well as accidents resulting from the use of infected utensils (2.1%) (NAP, 2007).

Missing information
In Lebanon, there is a huge bulk of information missing. I would most probably state the lack of reliable figures in the UNGASS reporting, need for consistent size estimation in order to define the type of the epidemic, the experience of the Palestinian refugees living within the under-privileged and excluded conditions of the refugee camps as well as lack of continuous reporting and registry of the epidemic by the National AIDS Program to the public.

Social Inequalities

High Risk Groups
There is lack of a defined assessment of HIV prevalence in the country. Hence, it becomes to challenging to identify high risk groups. NAP accounts 11.65% of the HIV transmission to occur in people identified as homosexual or bisexual (the method of identification is not specified), 6.75% due to transfer of contaminated blood, 5.82% within the intravenous drug users population and 2.78% through vertical transmission (mother-to-child) (NAP, 2007).

In the light of these points, it would of interest to prevalence rates in possible population which might be considered vulnerable due to certain socio-economical factors. Of these populations are; Palestinian refugees, refugees of other nationalities (Iraqi, Sudanese…), Domestic workers and non-registered immigrants (Egyptians, Syrian…), women and girls, youth and youth coming from possible vulnerable populations (double standard), sex workers, prisoners and incarcerated individuals, as well as rural populations.

Social, economic, political and historical factors that affect the life choices and behaviors of people from vulnerable groups

1) Refugees;

i. Palestinian refugees;
Following the 1948 Arab-Israeli conflict, 750 000 Palestinian lost their homes and land and were forced to exile outside Palestine. Currently, Palestinian refugees are estimated around 400 000 individuals (almost 10% of the Lebanese populations) gathered in 12 official gathering/camps across Lebanon. Unlike those in Syria and Jordan, Palestinian refugees in Lebanon are not considered formal citizens of another state and thus can’t claim the same rights as other foreigners. In fact they are not allowed to work in almost 20 different professions and are denied some basic social and civil rights such as access to public social services, limited access to public health or educational services, estate possession…. UNRWA is the sole provider of education, health and relief and social services (UNRWA).
The current number and concentration of the Palestinian refugees along with lack of support from the Lebanese government and the denial of their rights, overwhelms the efforts and resources of the UNRWA and descends this population in a perilous circle of debt and poverty.

ii. Other Refugees;
Although Lebanon has not ratified the 1951 UN convention or the 1967 protocol relating to the status of refugees, the 1962 law concerning the entry and exit of foreigners “whose life or freedom is in danger for political reasons” may request political asylum in Lebanon. Yet, there has not been any mechanism, regulation or infrastructure put in place to process the claims for asylum. In that sense, people who enter illegally to Lebanon to seek asylum or those who do enter legally but overstay their visas as illegal immigrants who face fines, imprisonment or even deportation. (HRW, 2007)

Spiegel argues that it’s a misconception to presume that HIV rates are higher in refugees gatherings than in the host community. It is rather it is context specific. He states that issues of mobility and accessibility between the different populations, interaction, as well as exposure to violence govern the nature of HIV transmission in these populations (Spiegel, 2004). In Lebanon, due to the high interaction between the refugees and host community, mobility and lack of external acts of violence (yet the camps are always in a low security status), the dynamics that Spiegel has demonstrated to might lower HIV transmission are not in effect; and thus giving way to epidemic transmission similar to that in poor-resources settings

2) Foreign workers;

i. Domestic workers;
Jureidini presents his argument in women migrant domestic workers in Lebanon by the following statement: “Abuses of foreign domestic workers is not unique in Lebanon, but are astonishingly prevalent …”. He traces such abuses to the lack of a clear mechanism to translate international conventions to local language and systems as well as the lack of awareness among the law enforcement bodies (Jureidini, 2002).

ii. Foreign workers;
Foreign workers from Syria, Egypt, Sudan and other regional countries face major obstacles when it comes to securing self-sustaining and respectable job opportunities. Lower-priced and easier-to-manage (Young, 2000), such workers are usually faced with lower SES and other violations to their social and civil rights.

The continuous violations of the rights of foreign workers provide opportunities for such populations to be denied proper access to health services or affording such services when they are accessible.

iii. Rural population; in a highly centralized system, populations that exist in rural areas of the country experience lower accessibility to empowerment information, awareness and service provision.

Youth and risk of HIV
Studies have documented the low utilization rate of health services by young people in the Arab region (De Jong, Jawad, Mortagy, & Shepard, 2005). There are different factors that underley such a phenomena such as the stigma relating using certain health service which can be linked to sexual activity, a morally wrong behavior (such as going to the dermatologist or the gynecologist in some cases). Other factors is concerned with the high fees of such services, lack of free support health services, the youth being mostly uninsured (the culture of insurance is usually preserved for the more well-to-do individuals) and most importantly the lack of awareness needed to utilize such services.

Gender inequality
Recent movements in the civil society and by organizations such as KAFA (www.kafa.org.lb) have called to progress in the reporting to forms of violence against women as well as social segregation. Although a moderate country, Lebanon does provide space for suppression of women in private settings such as the case in domestic violence or in a more institutional manner by denying her right to pass her nationality to her children. The latter case have seen much progress and Lebanon has reach a stage where it is expected to annul that violation and produce a more legal guarantee to endure that the women have full rights as men in their nationality and that of their children.
Still, there remains a need to have a legal guarantee that can protect women from domestic violence and sensitize the law enforcement and the community about the need to “break the silence”. Until then, it remains a challenge to estimate the prevalence of gender-based violence.
Women who reside in a community that doesn’t provide their full protection from violations of human rights are less likely not be properly empowered to maintain their bodily rights and pursuit a safe sexual health.

Criminalization of drug use
The 1947 law (amended in 1998) stopped viewing a drug user as a “criminal” but rather a “sick” person in need of help and is to be referred to treatment. Yet in light of scarcity of resources, certain cases end up in incarceration.

On the other hand, the law criminalizes the selling, trading and third party facilitation of such drugs (classified into categories) with imprisonement from 3 months to 3 years and a fine of 2 – 5 million Lebanese pound (1 300 – 3 300 USD). It makes no distinction between the amount seized and the kind of trade being done (consumer, small-time dealer or drug-lords) (SKOUN).

Criminalization of commercial sex work
Commercial sex work is technically legal under certain conditions. Permits, brothel establishments are possible under certain circumstances. Yet the government had stopped issued permits for years now and all forms of prostitutions is punished by imprisonment from one month to one year. It is notable to mention that though the sex workers are punished, their customers are not.

Yet, women from Eastern Europe (Russia, Ukraine, Belarus, Moldova…) are contracted under “artist visa” to work as dancers, waitresses and models at “super nightclubs”. The contracts are signed at the General Security Office where the officials “inform her not to engage in commercial sex work” and request her to take periodical HIV/AIDS test (which is quite preposterous since that only shows that they are aware of her true working conditions). There are “…approximately 5,000 artist visas are issued every year and there are 2,500 artists in the country at any given time”, which raises concerns on issues of human trafficking (KAFA, 2008).

Criminalization of HIV transmission
There are identified law that criminalize HIV transmission in Lebanon.

Criminalization of Homosexuality
Homosexuality is criminalized in the country under the penal code law “534”. The law does not specifically targets homosexuals but rather any form of “un-natural” sexual intercourse. Under the efforts of the civil society organizations for personal liberties over the last decade, currently the law enforcements do not actively use the law to persecute or criminalize identified homosexuals (HELEM).

Stigma and discrimination against sexual minorities
Being a non-secular country, Lebanon experiences stigma fueled by the unyielding religious views of Christianity and Islam that views homosexuality as a sin. Almost most of the moral views in the Lebanese societies are based on the adoption of the teachings of either Christian scripture or the Islamic sharia’a.

References

CAS. (2006). National Survey of Household Living Conditions 2004-2005. Beirut: Central Administration of Statistics.

De Jong, J., Jawad, R., Mortagy, I., & Shepard, B. (2005). The sexual and reproductive health of young people in the Arab countries and Iran. Reproductive Health Matters , 13 (25), 49-59.

HELEM. (n.d.). HELEM. Retrieved March 14, 2010, from HELEM: www.helem.net

HRW. (2007). Rot Here or Die There: Bleak choices for Iragi refugees. Human Rights Watch.

Jureidini, R. (2002). International Migration Papers: Women Migrant Domestic Workers in Lebanon. Interntional Labour Office, International Migration Program. Geneva: Interntional Labour Office.

KAFA. (2008). Shadow Report on Article 6th to 40th CEDAW Session. Beirut: KAFA.

Melhem, N. (2009, February 11). PhD, Associate Professor, AUB. Concepts of Immunology for Public Health Professionals/HIV - EPHD300 . Beirut, Beirut, Lebanon: AUB.

MOPH. (2008). 2008 UNGASS Progress Report. Beirut: MOPH.

NAP. (2007). National AIDS Program. Retrieved 03 14, 2010, from Ministry of Public Health: www.cms1.omsar.gov.lb

SKOUN. (n.d.). Drugs in Lebanon. Retrieved March 14, 2010, from SKOUN: http://www.skoun.org/drugs3.html

Spiegel, P. B. (2004). HIV/AIDS among Conflict-affect and Displaced Populations: Dispelling Myths and Taking Action. Disasters , 28 (3), 322-339.

UNAIDS. (2008). Country Profile. Retrieved March 13, 2010, from UNAIDS: http://www.unaids.org/en/CountryResponses/Countries/lebanon.asp

UNAIDS. (2008). Epidemiolocical Fact Sheet on HIV and AIDS: Core data on epidemiology and response, Lebanon 2008 Updates. UNAIDS, WHO, UNICEF. Switzerland: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance.

UNRWA. (n.d.). UNRWA-Lebaon. Retrieved March 14, 2010, from UNRWA: http://www.unrwa.org/etemplate.php?id=65

Young, M. (2000). Migrant Workers in Lebanon. Beirut: Lebanese NGO Forum.