A review of research on the prevalence of HIV in the Middle East and North Africa has found that whilst cultural and religious practices may be behind a low prevalence of HIV in the region, they could potentially contribute to increasing the spread of HIV.
Research from the World Health Organisation, published in this week's BMJ, argues it is possible that some practices which are common among Muslim populations may contribute to decreasing the risk of HIV transmission. One is low alcohol consumption, which reduces 'risky' behaviours and another is potentially male circumcision which was shown in a recent clinical trial to have a protective effect but application of these results to other epidemiological, cultural and social settings still needs to be confirmed.
At the same time other population trends, beliefs and practices in the region may have an adverse effect. Most countries in the region have young populations with a rapidly increasing age at marriage, but young people may be ill-equipped to protect themselves against sexually transmitted infections. Traditional Muslim approaches have tended to be very conservative, and it is difficult to break the silence around issues of sexual behaviour - especially those which deviate from religious norms.
A detailed analysis of religious publications and doctrinal pronouncements revealed that strong moralising views were common - HIV was seen as divine retribution and religion was presented as a protection. This can mean that those with HIV/AIDS are stigmatised.
The construction of gender also plays a part - strong prohibitions against extramarital sex, which are applied more strictly to women, are associated with lower HIV prevalence. While there are fewer women than men with HIV in the region, this sex ratio appears to be shifting, suggesting the disease is spreading and highlighting women's special vulnerability as they are married to older men who are more likely to have been exposed to HIV infection. The cultural view that women are innocent reinforces the lack of information about sexual risk and makes it difficult for women to protect themselves.
The author notes that 'a theology of compassion and approaches advocating harm reduction seem to be emerging in several Muslim countries, and greater acceptance of HIV positive people is justified with reference to religion. Things are also improving on a practical level - in recent years better information systems to track HIV have been put in place in the region and around half of the countries have formulated national plans to tackle HIV.'
The author concludes that whilst knowledge is still inadequate and stigma and greater discrimination prevail in many settings, over the past couple of years 'there has been greater visibility and more public discussion of HIV/AIDS in the region. Throughout the region governments and non-governmental organisations have initiated promising projects to break the silence around HIV, spread information, promote prevention and provide care and treatment. The challenge now is how to capitalise on the strengths represented by cultural tradition while fostering effective responses to the epidemic.'