







































 

_____________________________________________________________________________________________________ 
 
*Corresponding author: E-mail: Ahmedkhalaf214@gmail.com; 
 
Cite as: Khalaf, Ahmed A. M. 2025. “Human Immunodeficiency Virus Epidemic Among People Who Inject Drugs and Female 
Sex Workers in North Africa: A Systematic Review”. Asian Journal of Immunology 8 (1):50-59. 
https://doi.org/10.9734/aji/2025/v8i1159. 
 

 
 

Asian Journal of Immunology 
 
Volume 8, Issue 1, Page 50-59, 2025; Article no.AJI.125999 
 

 
 

 

 

Human Immunodeficiency Virus 
Epidemic among People who Inject 

Drugs and Female Sex Workers in 
North Africa: A Systematic Review 

 
Ahmed A. M. Khalaf a* 

 
a Ministry of Health, Tripoli, Libya. 

 
Author’s contribution 

 
The sole author designed, analysed, interpreted and prepared the manuscript. 

 
Article Information 

 
DOI: https://doi.org/10.9734/aji/2025/v8i1159  

 
Open Peer Review History: 

This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers, peer 
review comments, different versions of the manuscript, comments of the editors, etc are available here: 

https://pr.sdiarticle5.com/review-history/125999  
 
 
 

Received: 19/10/2024 
Published: 18/04/2025 

 
 

ABSTRACT 
 

Background: Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome 
(AIDS) remain major health problems worldwide, with high mortality and morbidity rates, particularly 
in developing countries. The United Nations Programme on HIV/AIDS (UNAIDS) reported that there 
were 38.4 million individuals globally who had HIV. Around 1.5 million new HIV infections were 
recorded in 2021, while approximately 650,000 individuals worldwide lost their lives due to AIDS-
related illnesses. The prevalence of HIV in people who inject drugs (PWID) and female sex workers 
(FSWs) has not been widely investigated. Information on the epidemiology of HIV infection among 
PWID and FSWs in North Africa is limited. The aim of the present study was to review the status of 
the HIV epidemic among PWID and FSWs in North African countries by explaining HIV prevalence. 
Methods: A comprehensive literature search was performed on studies related to the prevalence of 
HIV infection in PWID and FSWs published between 1990 and 2024 using search engines such as 
PubMed, Science-Direct, Google scholar. Reports that are entirely on North Africa were considered, 

Systematic Review Article 

https://doi.org/10.9734/aji/2025/v8i1159
https://pr.sdiarticle5.com/review-history/125999


 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
51 

 

including studies reporting HIV infection in high-risk groups, particularly PWID and FSWs, with the 
data organized into a customized database. 
Results: A total of 3605 records were retrieved in the initial search, 10 relevant records HIV among 
PWID and FSWs were recognized and included in the study. The overall prevalence of HIV in PWID 
ranged from 0.15% to 87.1% and 0% to 15.7% in FSWs. Injection drug abuse and women engaged 
in sex work were commonly associated with HIV infection. 
Conclusion: The findings of this study showed that the prevalence of HIV among PWID and FSWs 
in North Africa is high. PWID and FSWs has been identified as the dominant method of 
transmission in various North African countries like Libya, Egypt, Morocco and Tunisia. 
The execution of initiatives designed to improve sanitation infrastructure, elevate educational 
standards, and enhance socioeconomic situations is crucial for decreasing the prevalence of HIV 
infections among PWID and FSWs. 
 

 
Keywords: Human immunodeficiency virus; people who inject drugs; female sex workers; North 

Africa. 

 
1. INTRODUCTION 
 
Human immunodeficiency virus (HIV) is a 
member of the Lentivirus genus belonging to the 
Retroviridae family. In 1981, it was identified as 
the initial cause of the illness now referred to as 
acquired immunodeficiency syndromes (AIDS) 
(Gruters et al., 1987; Fauci, 1999). HIV is spread 
mainly from the body fluids of an infected person, 
including blood, breast milk, semen and vaginal 
fluids (World Health Organization [WHO], 
2024a). HIV infection is characterized by mild 
immune system alterations that occur before any 
symptoms or negative emotions appear. Before 
seroconversion, which occurs when an individual 
has just been exposed to HIV, this stage lasts for 
up to three months after infection. Although the 
course of an infection and the amount of time it 
takes for clinical signs to appear might vary 
widely from person to person, the disease 
typically advances rather slowly. The onset of 
progressive HIV illnesses and 
immunosuppressive symptoms takes several 
years after the first infection (Naif, 2013). HIV 
targets cells of the human immune system, such 
as CD4+ T cells, macrophages, and dendritic 
cells. CD4+ cells play an important role in 
maintaining the immune system. Following 
infection, HIV utilizes CD4+ cells as a host to 
replicate and infect additional cells. This results 
in the decrease of CD4+ cells in the body, 
causing a complete breakdown of the immune 
system. The progression from HIV to AIDS is 
monitored by the sharp decrease in CD4+ cells 
(Yousaf et al., 2011). Chronic HIV infection is 
causing a deficiency in cellular immunity. The 
unexpected emergence of opportunistic 
infections characterizes this final stage of HIV 
infection. The main contributors to HIV-related 
morbidity an death are these last ones. The use 

of cotrimoxazole and antiretroviruses can 
significantly lower the frequency of opportunistic 
infections and increase the life expectancy of HIV 
patients. The initiation of antiretroviral therapy for 
an individual with HIV is determined by their level 
of immune system weakness (Comlan et al., 
2017). The sensitive enzyme immunoassays 
available today can identify antibodies as soon 
as one to two weeks following infection. Other 
tests are necessary to support antibody 
investigation (p24 antigen, PCR), corroborate 
positive antibody screens (Western blot, PCR), 
and give clinicians treating HIV- positive patients 
additional information (qualitative and 
quantitative PCR, genotyping) (Fearon, 2005). 
Two types of HIV have been described which are 
HIV-1 and HIV-2. Globally, HIV-1 infection is the 
leading cause of the AIDS pandemic, while the 
emergence of HIV-2 is concentrated in West 
African countries (Campbell & Gandhi, 2011). At 
present, HIV infection continues to be one of the 
most serious global health issues facing humans. 
According to statistics from the United Nations 
(UN), the global number of individuals living with 
HIV in 2021 tallied at approximately 38.4 million. 
Furthermore, an estimated 1.5 million new cases 
of HIV infections emerged. Additionally, in 2021, 
around 650,000 deaths were attributed to AIDS- 
related illnesses. The UN program on HIV/AIDS 
estimated that at the end of 2021 there were 20.6 
million persons living with HIV infection in sub- 
Saharan Africa, which is the highest globally. 
Moreover, the lowest infection was in North 
Africa and the Middle East; roughly 180,000 
individuals were estimated to be living with HIV. 
Infection with HIV remains a major cause of 
illness and death in developing nations, including 
North African countries (UNAIDS, 2022). People 
who inject drugs (PWID) are at increased risk of 
HIV; worldwide, about 11 million people inject 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
52 

 

drugs, and around 1 in 8 (or 1.4 million) of these 
people are living with HIV. In addition, 10% of 
new HIV infections worldwide are due to the use 
of injection drugs (WHO, 2024b). Globally, sex 
workers are facing a greater impact from the HIV 
pandemic (WHO, 2012). Treatment 
abandonment among patients with HIV infection 
is a public health issue worldwide. At the end of 
December 2021, 75% of all people living with 
HIV were accessing treatment (UNAIDS, 2022). 
Adherence to antiretroviral therapy (ART) and 
loss of follow-up impact the prognosis of 
individuals living with HIV/AIDS in various 
regions globally (Lima et al., 2018). However, by 
the end of 2013, the ART coverage level in the 
North Africa and Middle East region remained 
the lowest in the world at 11%. HIV-positive 
individuals who inject drugs and sex workers who 
have discontinued treatment and follow-up 
contribute to increased morbidity, mortality risks, 
and HIV transmission, especially in North African 
countries (Gökengin et al., 2016). Although 
HIV/AIDS is a silent and fatal disease, little is 
known about its infection among PWID and FSW 
in North African countries. However, having 
updated literature on HIV prevalence is crucial 
for tracking the spread of infection and describing 
the burden on global public health. Hence, the 
aim of this study was to assess the status of the 
HIV prevalence among PWID and FSWs in North 
Africa to help understand the HIV epidemiology 
in this part of the African continent. 
 

2. METHODOLOGY 
 

Present systematic review summarizes main 
results of the HIV epidemiology among PWID 
and FSWs in North Africa. A comprehensive 
literature search was performed using Pub Med, 
Science-Direct and Google Scholar, databases 
for articles published in English from 1990 until 
2024. The data included in the present review 
were primarily conducted in the countries of 
North Africa. These data sources were 
recognized through a comprehensive search of 
pertinent studies and databases. The keywords 
used to question the databases included HIV in 
combination with prevalence, “PWID”, “FSWs”, 
as well as North Africa and country names. All 
articles were evaluated for pertinence before 
inclusion. The review involved all countries 
contained in the North Africa descriptions of the 
World Bank and WHO EMRO. These include 
Algeria, Libya, Egypt, Morocco, and Tunisia. In 
this article, the North Africa high-risk groups were 
including people who inject drugs (PWID) as well 
as female sex workers (FSWs). Eligibility and 

evaluation of the studies: Each study was 
examined and thoroughly assessed for its 
inclusion in the studies: All the studies were 
examined and thoroughly evaluated for inclusion 
in the study. All descriptive/cross-sectional, case- 
control, and epidemiological studies were 
included. Letters to the editor, editorials, case 
reports, hypotheses, studies on animals or cell 
lines, and unpublished reports were excluded. 
Studies were eligible for review if they reported 
HIV epidemiology in PWID and FSW. Therefore, 
studies reporting the prevalence of HIV in 
prisoners, man who have se with man, 
hemodialysis, HIV in patients with TB or cancer 
were excluded (Fig. 1). Data extraction: Relevant 
information from articles reporting the prevalence 
of HIV and its epidemiology in North African 
countries were extracted. Data on the number of 
participants in each eligible study, study country, 
prevalence of HIV infection population age 
group, and year of study were collected and 
classified in divide tables. 

 
3. RESULTS 
 
A total of 3605 records were identified from three 
databases. Duplicates studies were identified 
and removed, leaving 166 potential records, after 
review of titles and abstracts records were 
excluded based on selection criteria, and a total 
of 10 reports on the prevalence of HIV among 
PWID and FSWs covering 4 countries were 
included. The review process is presented in Fig. 
1. 

 
Seven studies recorded HIV positive among 
PWID, 5 recorded the HIV positive among FSWs 
Sample sizes ranged from 113 to 12,981 PWID, 
and 69 to1447 FSWs. PWID and FSWs data 
were obtainable for 4 of the 5 NA countries. No 
studies were available for Algeria. Egypt 
contributed the largest number of data points of 
HIV prevalence measures where, there were 4 
studies from Egypt, 2 from Tunisia, Morocco, and 
Libya, respectively. 

 
The prevalence of HIV across the key 
populations such as PWID and FSWs reported 
by the 10 studies was range between 0 and 
87.1%. When divided according to population 
categories, injecting drugs is a primary way HIV 
is transmitted globally (WHO, 2024b). Study 
population HIV prevalence ranged from 0.15% in 
a study from Egypt to 87.1% in a study from 
Libya (Table 1). The median HIV prevalence 
among PWID in all studies was 0.91%. Sexual 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
53 

 

hazard behavior associated with HIV infection 
among FSWs, The country-specific estimate 
FSWs ranged from 0% in Tunisia to 15.7% in 
Libya. Egypt and Morocco had a prevalence 
estimate < 9% (Table 2). The median HIV 
prevalence among FSWs in all studies was 
1.25%.  
 

 
 

Fig. 1. Flowchart of study selection 
 
Two studies were found in this review that 
recorded HIV/HCV and HIV/HBV co-infection, 
prevalence of HIV/HCV and HIV/HBV co- 
infections among PWID was 83.2% and 3.7%, 
respectively. Beside, the prevalence of HIV/HCV 
and HIV/HBV co-infections among FSWs was 
3.7% and 0%, respectively. 
 

4. DISCUSSION 
 
HIV infection among PWID and FSWs continues 
to be a major public health issue worldwide 
(Mirzoyan et al., 2013). Understanding the 
epidemiological characteristics of HIV infection 
are crucial and beneficial in defining the 
implications and problems of the infection. 
Injecting drugs is a primary way HIV is 
transmitted globally (WHO, 2024b). The findings 
revealed that the HIV prevalence among North 
African PWID population groups ranged from 0% 
to 87.1%, This results is higher than the previous 
estimates of global prevalence (Mathers et al., 
2008; Rashti et al., 2020). It is also higher than 
the findings of studies conducted in Europe 
(Wenz et al., 2016; Handanagic et al., 2016; 
Hatzakis et al., 2015), China (Zhang et al., 2007), 
Bangladesh (Azim et al., 2008) and Brazil 
(Oliveira-Filho et al., 2020). By contrast, it is 
relatively low compared with other studies 
reported from the USA (Peters et al., 2016), and 
Estonia (Platt et al., 2006). The differences that 
were noticed in HIV prevalence among studies, 
nations, and areas could arise from diverse 

factors like compliance with prevention methods 
and variations in community spread. In this 
study, HIV prevalence among PWID is high in 
the northern countries of Africa, particularly Libya 
(Mirzoyan et al., 2013). This occurrence can be 
ascribed to its geographical positioning,                  
which borders three sub-Saharan nations, along 
with socio-political challenges that have 
significantly facilitated the spread of HIV                    
and hindered the adherence to HIV control 
measures. These results highlight a need for 
continuing prevention of HIV transmission among 
PWID. 
 

The HIV epidemic, similar to other epidemics, 
arises within an intricate social setting. Social 
norms impacting transmission include sexual 
behaviors. Between 75 and 85 percent of the 
approximately 28 million HIV infections that have 
happened thus far are due to transmission 
through sexual contact (Royce et al., 1997). 
Concerning the investigation of HIV and related 
sexual risk like sex work, this systematic review 
shows that the HIV prevalence amongst North 
African FSWs population groups ranged from 0% 
to 15.7%. These outcomes are similar to 
numerous other systematic reviews conducted 
(Paz-Bailey et al., 2016; Leili et al., 2021). 
However, it is low compared to what is observed 
in India (Wayal et al., 2011), Kenya (Luchters et 
al., 2008). Additionally, it is higher than the 
results of studies conducted in China (Wang et 
al., 2009), Central America (Soto et al., 2007), 
and the Democratic Republic of the Congo 
(Vandepitte et al., 2007). 
 

Women engaging in sex work networks appear 
to be the main drivers of considerable HIV 
transmission in Libya, Morocco, and Egypt, 
which may have been due to the extensive scale 
of commercial sex networks in these 
environments, coupled with the elevated levels of 
hazard manners exhibited within these networks. 
FSWs and their male clients are at high 
hazardous for HIV and have been significant in 
starting the epidemic in many African countries 
(Hunter, 1993). 
 
The HIV epidemic is very fluid and has expanded 
quickly; nearly every country worldwide is 
impacted. However, prevalence investigations 
have been conducted on a global level to gain 
understanding of HIV epidemiology. Monitoring 
prevalence changes is crucial for predicting 
pandemic evolution and developing a successful 
public health strategy (Bokazhanova & 
Rutherford, 2006). 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
54 

 

Table 1. Studies reporting HIV prevalence among people who inject drugs (PWID) across the North Africa 
 

Study/references Sampling 
location 

Year of study Study 
population 

Age group HIV prevalence among 
PWID 

Anan A et al. (2024) Egypt 2019-2022 146 11-50 31.5% 
Ghrabi A et al. (2018) Tunisia 2017-2018 113 32-47 10% 
Mirzoyan L et al. (2013) Libya 2010 328 15-≥50 87.1% 
Wahdan I et al. (2013) Egypt 2012 338 <25->45 12.4% 
Soliman C et al. (2010) Egypt 2006 413 18-65 1% 
Elmir E et al. (2002) Morocco 1991-1999 12981 30-≥40 11.1% 
Watts DM et al. (1993) Egypt 1986-1990 1961 Any age 0.15% 

 
Table 2. Studies reporting HIV prevalence among female sex workers (FSWs) across the North Africa 

 

Study/references Sampling 
location 

Year of study Study population Age group HIV prevalence among 
FSWs 

Johnston L et al. (2013) Morocco 2010-211 1447 18 ≥ 8.3% 
Valadez JJ, et al. (2013) Libya 2010 69 15-≥50 15.7% 
Wahdan I et al. (2013) Egypt 2012 338 <25-45+ 5.9% 
Znazen A et al. (2010) Tunisia 2007 188 14-≥34 0% 
Watts DM et al. (1993) Egypt 1986-1990 349 Any age 0% 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
55 

 

Situation in North Africa and the Middle East 
regarding HIV/AIDS: according to statistics from 
the United Nations (UN), around 180,000 people 
were estimated to be living with HIV, 
approximately 14000 people became newly 
infected with HIVV. Furthermore, roughly 5100 
fatalities were linked to diseases related to AIDS 
in 2021 (UNAIDS, 2022). Sub-Saharan Africa, 
this region is the most heavily affected by HIV 
worldwide, accounting for 52.6 million people 
living with HIV and 42000 of AIDS deaths in 2021 
(UNAIDS, 2022). This region borders North 
Africa, and many illegal immigrants come from it 
to north African countries. Therefore, individuals 
in communities with HIV may not know they are 
infected or carry the virus, leading to potential 
transmission to family members or other             
people. 
 
On the basis of the geographical countries of 
North Africa, the results indicated that Libya 
(Mirzoyan et al., 2013), Egypt (Anan et al., 2024), 
Morocco (Elmir et al., 2002) and Tunisia (Ghrabi 
et al., 2018), respectively had higher prevalence 
HIV among PWID. Moreover, prevalence 
estimates at the country level indicate a high 
burden of infection in Libya (Valadez et al., 
2013), Morocco (Johnston et al., 2013) and 
Egypt (Wahdan et al., 2013), respectively, 
among FSWs. The observed variation in the 
estimates of HIV prevalence among FSWs 
across various countries may be partially 
attributed to the diverse risk factors and spread 
pathways present in each nation. These results 
emphasize a continuous need for ongoing 
prevention of HIV spread among FSWs between 
North African countries. 
 
In Africa, despite the high HIV prevalence, the 
reported occurrence of HIV infection among 
PWID and FSWs in North Africa was 
considerably lower compared with South Africa 
(Jones et al., 2023; Asher et al., 2013). 
 
The North Africa region is still lacks sufficient HIV 
epidemiological information, leading to debates 
regarding the epidemic's prevalence in this part 
of the globe. It's crucial to have current HIV 
prevalence data for North African countries to 
understand the virus's spread. Hence, additional 
monitoring of HIV prevalence is necessary to 
evaluate and track the escalating HIV impact 
(Abu-Raddad et al., 2010). 
 
The environments where the HIV pandemic is 
happening are becoming more varied. The 
epidemics are primarily influenced by social, 

structural, and population-level risks and 
protections, which in turn affect the individual 
risks of HIV infection (Beyrer, 2007). 
 
The field of HIV prevention is constantly 
changing, and there is now discussion about the 
potential for worldwide virtual eradication of HIV 
(Mutevedzi & Newell, 2014). Mitigation of HIV 
disease strategies will expected be required to 
decrease HIV prevalence in North Africa, where 
there might be restrictions on getting health care 
and accessing resources. The suitable approach 
can vary from one country to another and 
additionally have to be justifiably focused on 
prevention of HIV transmission. While countries 
must focus on addressing the underlying causes 
of HIV exposure risk, the main emphasis should 
be on addressing the immediate factors that 
increase individuals' risk of HIV exposure, as 
dealing with structural factors is time-consuming 
and outside the purview of the public health 
sector. Hence, there is an opportunity for 
prevention that should not be missed to control 
the epidemic in this region (Abu-Raddad et al., 
2010). This systematic review offers the latest 
extensive assessment of HIV prevalence by 
carefully evaluating existing literature. When 
interpreting results, it's vital to consider and 
navigate through various constraints in order to 
gain a comprehensive and robust understanding 
of the outcomes. The primary limitations come 
from the data that is currently available, with a 
scarcity of studies on prevalence. Despite these 
limitations, the present systematic review 
demonstrated that there is a significant burden of 
HIV infection in PWID and FSWs in most of the 
North African countries. However, additional 
investigation is required to fill the knowledge 
gaps. 

 
5. CONCLUSION 
 
The findings of this report provide a 
comprehensive overview of the prevalence of 
HIV among PWID and FSWs. Variation in 
prevalence of HIV observed in different regions 
in North Africa. PWID and FSWs has been 
identified as the dominant method of 
transmission in various North African countries 
like Libya, Egypt, Morocco and Tunisia. As the 
HIV pandemic is still evolving, more studies need 
to be conducted in this part of the African 
continent to comprehend the right burden of the 
illness. Studies in this region need to take into 
consideration societal and institutional factors. 
The extensive programs of monitoring of HIV 
prevalence are necessary to prevent these high- 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
56 

 

risk groups from further spreading the infection of 
HIV. Emphasize health education as a means to 
reduce prevalence of HIV infections among 
PWID and FSWs. This review demonstrates 
epidemiological HIV infection in PWID and 
FSWs. These data can be used to develop 
customized strategies for reducing the 
prevalence of HIV in the North African regions. 
 

DISCLAIMER (ARTIFICIAL INTELLIGENCE) 
 
Author(s) hereby declare that NO generative AI 
technologies such as Large Language Models 
(ChatGPT, COPILOT, etc.) and text-to-image 
generators have been used during the writing or 
editing of this manuscript. 

 
CONSENT AND ETHICAL APPROVAL 
 
It is not applicable. 

 
COMPETING INTERESTS 
 
Author has declared that no competing interests 
exist. 

 
REFERENCES 
 
Abu-Raddad, L. J., Hilmi, N., Mumtaz, G., 

Benkirane, M., Akala, F. A., Riedner, G., 
Tawil, O., & Wilson, D. (2010). 
Epidemiology of HIV infection in the Middle 
East and North Africa. AIDS, 24(Suppl 2), 
S5–S23. 

Anan, A. M., Alzahaby, A. A., Ghazy, A., & 
Abdelrazik, O. M. (2024). Clinico-
epidemiological study of HIV patients in El 
Beheira Governorate. International Journal 
of Medical Arts, 6, 4627–4634. 

Asher, A. K., Hahn, J. A., Couture, M. C., Maher, 
K., & Page, K. (2013). People who inject 
drugs, HIV risk, and HIV testing uptake in 
sub-Saharan Africa. Journal of the 
Association of Nurses in AIDS Care, 24(6), 
e35–e44. 

Azim, T., Chowdhury, E. I., Reza, M., Faruque, 
M. O., Ahmed, G., Khan, R., Rahman, M., 
Pervez, M. M., Jana, S., & Strathdee, S. A. 
(2008). Prevalence of infections, HIV risk 
behaviors and factors associated with HIV 
infection among male injecting drug users 
attending a needle/syringe exchange 
program in Dhaka, Bangladesh. Substance 
Use & Misuse, 43(14), 2124–2144. 

Beyrer, C. (2007). HIV epidemiology update and 
transmission factors: Risks and risk 

contexts—16th International AIDS 
Conference Epidemiology Plenary. Clinical 
Infectious Diseases, 44, 981–987. 

Bokazhanova, A., & Rutherford, G. W. (2006). 
The epidemiology of HIV and AIDS in the 
world. Collegium Antropologicum, 30(2), 3–
10. 

Campbell-Yesufu, O. T., & Gandhi, R. T. (2011). 
Update on Human Immunodeficiency Virus 
(HIV)-2 infection. Clinical Infectious 
Diseases, 52, 780–787. 

Comlan, D. A., Cossi, A. A., Angelo, A. C., 
Kadidjatou, S., Serge, A., Séraphin, A., 
Jivather, D., Francis, T. T., Zannou, D. M., 
Gabriel, A., & Fabien, H. (2017). Clinical 
and immunological characteristics in HIV-
infected patients at the treatment initiation 
at the University Hospital of Parakou 
(Benin). Open Journal of Immunology, 7, 
51–58. 

Elmir, E., Nadia, S., Ouafae, B., Rajae, M., 
Amina, S., & Rajae el, A. (2002). HIV 
epidemiology in Morocco: A nine-year 
survey (1991–1999). International Journal 
of STD & AIDS, 13(12), 839–842. 

Fauci, A. S. (1999). The AIDS epidemic—
Considerations for the 21st century. New 
England Journal of Medicine, 341(14), 
1046–1050. 

Fearon, M. (2005). The laboratory diagnosis of 
HIV infections. Canadian Journal of 
Infectious Diseases and Medical 
Microbiology, 16(1), 26–30. 

Ghrabi, A., Zaied, S., Turki, J. K., Chamakh, A., 
Taieb, S. B., & Bouarrouj, S. (2018). HIV 
and hepatitis C virus infections and 
associated risk behaviours among injecting 
drug users attending a syringe service 
program: A cross-sectional study in Tunis, 
Tunisia. Journal of Virus Eradication, 4, 
24–25. 

Gruters, R. A., Neefjes, J. J., Tersmette, M., de 
Goede, R. E., Tulp, A., Huisman, H. G., 
Miedema, F., & Ploegh, H. L. (1987). 
Interference with HIV-induced syncytium 
formation and viral infectivity by inhibitors 
of trimming glucosidase. Nature, 
330(6143), 74–77. 

Gökengin, D., Doroudi, F., Tohme, J., Collins, B., 
& Madani, N. (2016). HIV/AIDS: Trends in 
the Middle East and North Africa region. 
International Journal of Infectious 
Diseases, 44, 66–73. 

Handanagic, S., Bozicevic, I., Civljak, M., 
Dominkovic, Z., Sevic, S., Barbaric, J., 
Nemeth Blazic, T., Dakovic Rode, O., & 
Begovac, J. (2016). HIV and hepatitis C 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
57 

 

prevalence, and related risk behaviours 
among people who inject drugs in three 
cities in Croatia: Findings from respondent-
driven sampling surveys. International 
Journal of Drug Policy, 32, 57–63. 

Hatzakis, A., Sypsa, V., Paraskevis, D., 
Nikolopoulos, G., Tsiara, C., Micha, K., 
Panopoulos, A., Malliori, M., Psichogiou, 
M., Pharris, A., Wiessing, L., van de Laar, 
M., Donoghoe, M., Heckathorn, D. D., 
Friedman, S. R., & Des Jarlais, D. C. 
(2015). Design and baseline findings of a 
large-scale rapid response to an HIV 
outbreak in people who inject drugs in 
Athens, Greece: The ARISTOTLE 
programme. Addiction, 110(9), 1453–1467. 

Hunter, D. J. (1993). AIDS in sub-Saharan Africa: 
The epidemiology of heterosexual 
transmission and the prospects for 
prevention. Epidemiology, 4(1), 63–72. 

Johnston, L. G., Bennani, A., Latifi, A., Oumzil, 
H., El-Omari, B., El-Rhoufrani, F., Ouarsas, 
L., Alami, K., & El-Rhilani, H. (2013). Using 
respondent-driven sampling to estimate 
HIV and syphilis prevalence among female 
sex workers in Agadir, Fes, Rabat and 
Tangier, Morocco. Sexually Transmitted 
Infections, 89(Suppl 1), A180–A180. 

Jones, H. S., Anderson, R. L., Cust, H., 
McClelland, R. S., Richardson, B. A., 
Thirumurthy, H., Malama, K., Hensen, B., 
Platt, L., Rice, B., Cowan, F. M., Imai-
Eaton, J. W., Hargreaves, J. R., & Stevens, 
O. (2023). HIV incidence among women 
engaging in sex work in sub-Saharan 
Africa: A systematic review and meta-
analysis. medRxiv. 
https://doi.org/10.1101/2023.03.23.232971
08 

Leili, A., NargesK, & Hamid, S. (2021). 
Prevalence of HIV infection among female 
sex workers in the Eastern Mediterranean 
Region countries: A systematic review. HIV 
& AIDS Review. International Journal of 
HIV-Related Problems, 20(4), 235–256. 

Lima, R. T., Melo, M. C., & Donalísio, M. R. 
(2018). Treatment abandonment among 
patients with HIV infection in a reference 
center in southeastern Brazil. Inter 
American Journal of Medicine and Health, 
1(1), e201801005. 

Luchters, S., Chersich, M. F., Rinyiru, A., Barasa, 
M. S., King'ola, N., Mandaliya, K., Bosire, 
W., Wambugu, S., Mwarogo, P., & 
Temmerman, M. (2008). Impact of five 
years of peer-mediated interventions on 
sexual behavior and sexually transmitted 

infections among female sex workers in 
Mombasa, Kenya. BMC Public Health, 8, 
143. 

Mathers, B. M., Degenhardt, L., Phillips, B., 
Wiessing, L., Hickman, M., Strathdee, S. 
A., Wodak, A., Panda, S., Tyndall, M., 
Toufik, A., & Mattick, R. P.; 2007 Reference 
Group to the UN on HIV and Injecting Drug 
Use. (2008). Global epidemiology of 
injecting drug use and HIV among people 
who inject drugs: A systematic review. 
Lancet, 372(9651), 1733–1745. 

Mirzoyan, L., Berendes, S., Jeffery, C., Thomson, 
J., Ben Othman, H., Danon, L., Turki, A. A., 
Saffialden, R., & Valadez, J. J. (2013). New 
evidence on the HIV epidemic in Libya: 
Why countries must implement prevention 
programs among people who inject drugs. 
Journal of Acquired Immune Deficiency 
Syndromes, 62(5), 577–583. 

Mutevedzi, P. C., & Newell, M. L. (2014). The 
changing face of the HIV epidemic in sub-
Saharan Africa. Tropical Medicine & 
International Health, 19, 1015–1028. 

Naif, H. M. (2013). Pathogenesis of HIV infection. 
Infectious Disease Reports, 5(s1), e6. 

Oliveira-Filho, A. B., Silva, F. Q., Santos, F. J. A., 
Cardoso, Y. M. N., Di Miceli, J. F. F., 
Resque, R. L., Silva-Oliveira, G. C., 
Martins, L. C., Pinheiro, L. M. L., Machado, 
L. F. A., Pinto, A. R., Lemos, J. A. R., 
Fischer, B., & Kupek, E. (2020). 
Prevalence and risk factors for HIV-1 
infection in people who use illicit drugs in 
northern Brazil. Transactions of the Royal 
Society of Tropical Medicine and Hygiene, 
114(3), 213–221. 

Paz-Bailey, G., Noble, M., Salo, K., & Tregear, S. 
J. (2016). Prevalence of HIV among U.S. 
female sex workers: Systematic review 
and meta-analysis. AIDS and Behavior, 
20(10), 2318–2331. 

Peters, P. J., Pontones, P., Hoover, K. W., Patel, 
M. R., Galang, R. R., Shields, J., Blosser, 
S. J., Spiller, M. W., Combs, B., Switzer, W. 
M., Conrad, C., Gentry, J., Khudyakov, Y., 
Waterhouse, D., Owen, S. M., Chapman, 
E., Roseberry, J. C., McCants, V., Weidle, 
P. J., ... Duwve, J. M. (2016). HIV Infection 
Linked to Injection Use of Oxymorphone in 
Indiana, 2014–2015. The New England 
Journal of Medicine, 375(3), 229–239. 

Platt, L., Bobrova, N., Rhodes, T., Uusküla, A., 
Parry, J. V., Rüütel, K., Talu, A., Abel, K., 
Rajaleid, K., & Judd, A. (2006). High HIV 
prevalence among injecting drug users in 
Estonia: Implications for understanding the 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
58 

 

risk environment. AIDS, 20(16), 2120–
2123. 

Rashti, R., Sharafi, H., Alavian, S. M., Moradi, Y., 
Mohamadi Bolbanabad, A., & Moradi, G. 
(2020). Systematic review and meta-
analysis of global prevalence of HBsAg 
and HIV and HCV antibodies among 
people who inject drugs and female sex 
workers. Pathogens, 9(6), 432. 

Royce, R. A., Seña, A., Cates, W., Jr., & Cohen, 
M. S. (1997). Sexual transmission of HIV. 
The New England Journal of Medicine, 
336(15), 1072–1078. 

Soliman, C., Rahman, I. A., Shawky, S., Bahaa, 
T., Elkamhawi, S., El Sattar, A. A., Oraby, 
D., Khaled, D., Feyisetan, B., Salah, E., El 
Taher, Z., & El Sayed, N. (2010). HIV 
prevalence and risk behaviors of male 
injection drug users in Cairo, Egypt. AIDS, 
24(Suppl 2), S33–S38. 

Soto, R. J., Ghee, A. E., Nunez, C. A., Mayorga, 
R., Tapia, K. A., Astete, S. G., Hughes, J. 
P., Buffardi, A. L., Holte, S. E., & Holmes, 
K. K., Estudio multicentrico study team. 
(2007). Sentinel surveillance of sexually 
transmitted infections/HIV and risk 
behaviors in vulnerable populations in 5 
Central American countries. Journal of 
Acquired Immune Deficiency Syndromes, 
46(1), 101–111. 

UNAIDS. (2022). Global HIV & AIDS statistics. 
Fact sheet. Available: 
http://www.communications@unaids.org/e
n/resources/campaigns/globalreport2021/f
actsheet 

Valadez, J. J., Berendes, S., Jeffery, C., 
Thomson, J., Ben Othman, H., Danon, L., 
Turki, A. A., Saffialden, R., & Mirzoyan, L. 
(2013). Filling the knowledge gap: 
Measuring HIV prevalence and risk factors 
among men who have sex with men and 
female sex workers in Tripoli, Libya. PLOS 
ONE, 8(6), e66701. 

Vandepitte, J. M., Malele, F., Kivuvu, D. M., Edidi, 
S., Muwonga, J., Lepira, F., Abdellati, S., 
Kabamba, J., Van Overloop, C., & Buvé, A. 
(2007). HIV and other sexually transmitted 
infections among female sex workers in 
Kinshasa, Democratic Republic of Congo, 
in 2002. Sexually Transmitted Diseases, 
34(4), 203–208. 

Wahdan, I., Wahdan, A., El Gueneidy, M., & Abd 
El Rahman, I. (2013). Prevalence and 
determinants of condom utilization among 
people living with HIV/AIDS in Egypt. 
Eastern Mediterranean Health Journal, 
19(12), 967–974. 

Wang, H., Chen, R. Y., Ding, G., Ma, Y., Ma, J., 
Jiao, J. H., Wu, Z., Sharp, G. B., & Wang, 
N. (2009). Prevalence and predictors of 
HIV infection among female sex workers in 
Kaiyuan City, Yunnan Province, China. 
International Journal of Infectious 
Diseases, 13(2), 162–169. 

Watts, D. M., Constantine, N. T., Sheba, M. F., 
Kamal, M., Callahan, J. D., & Kilpatrick, M. 
E. (1993). Prevalence of HIV infection and 
AIDS in Egypt over four years of 
surveillance (1986–1990). Journal of 
Tropical Medicine and Hygiene, 96(2), 
113–117. 

Wayal, S., Cowan, F., Warner, P., Copas, A., 
Mabey, D., & Shahmanesh, M. (2011). 
Contraceptive practices, sexual and 
reproductive health needs of HIV-positive 
and negative female sex workers in Goa, 
India. Sexually Transmitted Infections, 
87(1), 58–64. 

Wenz, B., Nielsen, S., Gassowski, M., Santos-
Hövener, C., Cai, W., Ross, R. S., Bock, C. 
T., Ratsch, B. A., Kücherer, C., Bannert, N., 
Bremer, V., Hamouda, O., Marcus, U., 
Zimmermann, R., & Druck Study Group. 
(2016). High variability of HIV and HCV 
seroprevalence and risk behaviours among 
people who inject drugs: Results from a 
cross-sectional study using respondent-
driven sampling in eight German cities 
(2011–14). BMC Public Health, 16(1), 927. 

World Health Organization (WHO). (2012). 
Guidelines: Prevention and treatment of 
HIV and other sexually transmitted 
infections for sex workers in low- and 
middle-income countries. Geneva: World 
Health Organization. 

World Health Organization (WHO). (2024). 
Global HIV, Hepatitis and STIs 
Programmes: People who inject drugs. 
Available: 
https://www.who.int/teams/global-hiv-
hepatitis-and-stis-
programmes/populations/people-who-
inject-drugs 

World Health Organization (WHO). (2024). HIV 
and AIDS. Available: 
https://www.who.int/news-room/fact-
sheets/detail/hiv-aids 

Yousaf, M. Z., Zia, S., Babar, M. E., & Ashfaq, U. 
A. (2011). The epidemic of HIV/AIDS in 
developing countries; the current scenario 
in Pakistan. Virology Journal, 8, 401. 

Zhang, Y., Shan, H., Trizzino, J., Ruan, Y., 
Beauchamp, G., Mâsse, B., Ma, J., Gu, Y., 
He, Y., Rui, B., Wang, J., Poundstone, K., 



 
 
 
 

Khalaf; Asian J. Immunol., vol. 8, no. 1, pp. 50-59, 2025; Article no.AJI.125999 
 
 

 
59 

 

Jiang, Y., Brooks Jackson, J., & Shao, Y. 
(2007). Demographic characteristics and 
risk behaviors associated with HIV positive 
injecting drug users in Xinjiang, China. 
Journal of Infection, 54(3), 285–290. 

Znazen, A., Frikha-Gargouri, O.,                        
Berrajah, L., Bellalouna, S., Hakim, H., 

Gueddana, N., & Hammami, A.                    
(2010). Sexually transmitted                   
infections among female sex                      
workers in Tunisia: High prevalence of 
Chlamydia trachomatis. Sexually 
Transmitted Infections, 86(7),                         
500–505. 

 
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual 
author(s) and contributor(s) and not of the publisher and/or the editor(s). This publisher and/or the editor(s) disclaim responsibility for 
any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. 

_________________________________________________________________________________ 
© Copyright (2025): Author(s). The licensee is the journal publisher. This is an Open Access article distributed under the terms 
of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, 
distribution, and reproduction in any medium, provided the original work is properly cited. 

 
 

 

Peer-review history: 
The peer review history for this paper can be accessed here: 

https://pr.sdiarticle5.com/review-history/125999  

https://pr.sdiarticle5.com/review-history/125999

