SUBMITTED 15 JAN 2023 1 REVISION REQ. 20 FEB 23; REVISION RECD. 6 MAR 23 2 ACCEPTED 21 MAR 23 3 ONLINE-FIRST: MARCH 2023 4 DOI: https://doi.org/10.18295/squmj.3.2023.015 5 6 Recent Increase in HIV cases in Oman 7 *Ali Elgalib, Samir Shah, Zeyana Al-Habsi, Maha Al-Fouri, Richard Lau, 8 Bader Al-Rawahi, Seif Al-Abri 9 Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman. 10 *Corresponding Author’s e-mail: elgalib@hotmail.com 11 12 The advent of antiretroviral therapy (ART) has transformed the human immunodeficiency (HIV) 13 infection prognosis from a life-threatening disease to a manageable chronic condition with a 14 near-normal life expectancy.1 Besides, people living with HIV/AIDS (PLWHA) on regular ART 15 with a suppressed HIV viral load (VL) do not infect their sexual partners .2 Despite these 16 remarkable developments in treatment and prevention, HIV/AIDS remains a major global public 17 health threat. The most recent Joint United Nations Programme on HIV and AIDS (UNAIDS) 18 global AIDS report shows that there were 38.4 million PLWHA in 2021; 1.5 million became 19 newly infected, far short of the 2025 target of 370,000 new infections.3 Furthermore, 650,000 20 AIDS-related deaths occurred in 2021, more than 2 folds of 2025 target of 250,000 deaths.3 21 22 Of concern, the 2022 UNAIDS report warned that the global HIV/AIDS response was in danger. 23 In Asia and the Pacific region, new HIV infections increased in 2021 where they had been 24 decreasing over the last decade. In addition, the Eastern Europe and Central Asia, the Middle 25 East and North Africa (MENA) and Latin America have all seen surges in annual HIV infections 26 over the past 10 years.3 Indeed, the new HIV infections in the MENA region have increased by 27 33% over the last 10 years. Of note, country-level data was only available for 11 out of 21 28 countries in the MENA region; the annual new HIV cases, in the period from 2011 to 2021, had 29 increased in Algeria (167%), Yemen (77%), Lebanon (41%), Qatar (40%), Oman (35%) and 30 Bahrain (8%). In contrast, the annual new HIV infections, over the same period, had decreased 31 in Djibouti (-63%), Morocco (-48%), Libya (-21%), Sudan (-2%) and Tunisia (-1%).4 32 33 Oman is situated in the Arabian Peninsula, with a total population of 4,931,506; 2,064,778 34 (41.9%) are non-Omanis.5 The first case of HIV/AIDS in Oman was diagnosed in 1984, and the 35 National AIDS Programme (NAP) was formed in 1987. Currently 14 public treatment centres 36 offer free HIV care, including antiretroviral therapy (ART) and testing for HIV genotyping, HIV 37 VL, and CD4 count. The country adopted treatment for all, irrespective of CD4 cell count, in 38 December 2015.6 39 40 A total of 3580 Omani citizens were diagnosed with HIV from 1984 to 2021, of whom 1996 41 (56%) were alive as of 31 December 2021.7 Figure 1 shows the HIV cases among Omani 42 nationals from 2010 to 2021, stratified by year of diagnosis and sex. Males accounted for 62% 43 (88/143) and 84% (169/202) of HIV cases among Omani citizens in 2010 and 2021, respectively; 44 however, the proportions of males among all HIV cases in the country, including the non-45 Omanis, were 57% (154/272) and 67% (221/335) in 2010 and 2021, respectively. In addition, the 46 distribution of age at diagnosis has changed over time; the percentage of those aged 25-34 years 47 rose from 31 % (44/143) in 2010 to 46% (92/202) in 2021, while the proportion of persons aged 48 35-44 years decreased from 26% (37/143) to 19% (39/202) in the same periods; however, the 49 percentage of those aged ≥ 45 years had remained the same, at 18% (Figure 1). Sexual 50 transmission has been the main driver of the epidemic; the proportions of new infections 51 attributed to sexual contact accounted for 94% (134/143) of infections in 2010, compared to 97% 52 (195/202) in 2021. The CD4 count at diagnosis is often used as marker of late HIV diagnosis. 53 For Omani PLWHA diagnosed between 2010-2021, about two-thirds (69.9%) had a baseline 54 CD4 count of < 350 cells/mm3 and 41.3% had a baseline CD4 count of <200 cells/mm3. Out of 55 PLWHA who were alive as of 31 December 2021 (n=1996), 81% were on ART; the proportion 56 of patients with viral suppression (HIV VL <1000 copies/ml) out of those on ART was 90% 57 (1457/1617).7 58 59 The recent increase in the new diagnoses in Oman may be explained, in part, by an increase in 60 HIV testing rather than an increase in the HIV incidence as suggested by the persisting high 61 levels of late HIV diagnosis. However, the rise in new cases in persons aged 25-34 years might 62 suggest high risk-taking behaviour in this cohort.8 Indeed, the UNAIDS 2021 report shows that 63 the overall HIV incidence (0.07 per 1000 population) and prevalence (0.2 per 1000 population) 64 in Oman were stable in 2010-2021.3 Future epidemiological and behavioural studies to determine 65 the precise dynamic of HIV incidence, and the key populations in Oman are warranted. 66 67 The association between late HIV diagnosis and increased morbidity and mortality is well 68 established. Late HIV diagnosis is associated with a ten-fold increased risk of death within 12 69 months of diagnosis.9 Late-stage HIV diagnosis also increases the risk of onward transmission 70 and the cost of treatment and care.10, 11 The high proportion of late HIV diagnosis in Oman could 71 be due to several reasons. A primary factor is the high level of HIV-related stigma and 72 discrimination that prevent access to HIV testing services.12, 13 In addition, HIV prevention 73 services targeting key populations and their partners are very limited. Furthermore, social 74 disapproval of and punitive laws against high-risk behaviours such as sex work, injecting drug 75 use and homosexuality.13 To reduce the rates of late HIV diagnosis in Oman, the NAP has 76 recently published an HIV manual for primary health care (PHC) intending to increase the HIV 77 testing levels in PHC.14 Evidence shows that primary and secondary care providers frequently 78 miss opportunities for earlier HIV diagnosis, through a combination of lack of awareness of 79 clinical syndromes, identifying possible risk factors and a general reluctance to discuss HIV 80 testing.15 81 82 In September 2022, the World Health Organization (WHO) certified that Oman had eliminated 83 mother-to-child transmission of HIV and syphilis, becoming the first country in the WHO 84 Eastern Mediterranean Region and only the sixteenth country in the world to achieve this.16, 17 85 This accomplishment is a testimony of Oman’s potential to end the AIDS epidemic by 2030 86 realising the goal of the Global Health Sector Strategies on HIV, viral hepatitis and sexually 87 transmitted infections (GHSS) for the period 2022-2030.18 To achieve this ambitious goal, the 88 NAP in Oman must focus on two key GHSS targets, the reduction of the percentage of people 89 starting ART with a CD4 count of < 200 cells/mm3 to <10% and the use of combination HIV 90 prevention by 95% of people at risk of HIV by 2025. 91 92 The rates of ART coverage and viral suppression in Oman are encouragingly high19, 20, with a 93 consequent decline in the community HIV viral load; however, this has not resulted in reducing 94 the HIV incidence in the country due to the high levels of late-stage HIV diagnosis. High 95 proportions of PLWHA in Oman were diagnosed several years after acquiring the HIV infection 96 and would have infected many people prior to their HIV diagnosis and initiation of ART. To 97 reduce the rate of late HIV diagnosis and maximize the public health benefit of treatment as 98 prevention, it is paramount to expand the HIV testing services in the country through 99 decentralized and differentiated HIV testing services, with timely linkage to treatment and care. 100 Different HIV testing approaches, including clinical settings, community-based approaches or 101 self-testing might be used depending on epidemic dynamics and population needs; persons who 102 are at risk of HIV but who test HIV negative should also be linked to HIV prevention services. 103 While increasing the rates of HIV testing will, paradoxically, identify more cases in the short 104 term, the long term results will be improved morbidity and mortality in PLWHA and a decline in 105 onward transmission in the community. 106 107 Establishing combination HIV prevention, including male and female condoms, treatment as 108 prevention, pre-exposure prophylaxis, post-exposure prophylaxis and harm reduction services for 109 persons who inject drugs, is challenging; only 8% of people at risk of HIV in the world used 110 combination HIV prevention in 2020. The lack of data about the size of and HIV prevalence 111 among people at risk of HIV and the cultural context in Oman are compounding factors. 112 However, maintaining the status quo is not an option; establishing HIV prevention services that 113 respect Oman’s religion, culture and traditions is warranted. To raise awareness of HIV among 114 the general population, culturally-sensitive information about HIV prevention, diagnosis and 115 prevention can be disseminated through mass media, including social platforms. In addition, 116 outreach awareness campaigns in colleges, universities and workplaces can target young people, 117 including those aged 25-34 years. These initiatives can be led by a national committee, with 118 members from all relevant stakeholders, including PLWHA, people at risk of HIV, community 119 and faith leaders, civil society organisations, the ministry of health, the ministry of education and 120 law-enforcing agencies. 121 122 To conclude, the annual new HIV cases in Oman have exceeded 140 in the last four years. 123 However, despite this recent increase in HIV cases, the HIV epidemic in the Sultanate has 124 remained a low-prevalence one over the past decade. Sexual transmission has been the main 125 driver of the epidemic in the country, with males and those aged 25-34 years disproportionately 126 affected. Future epidemiological studies to determine the characteristics of people at risk for HIV 127 in Oman and inform targeted interventions are warranted. 128 129 Authors’ Contribution 130 AE and SA contributed to the idea conceptualization. SS, MA and AE contributed to data 131 curation and formal analysis. AE contributed to writing (original draft) the manuscript. SS, ZA, 132 MA, RL, BA and SA contributed to writing (review and editing) the manuscript. All authors 133 approved the final version of the manuscript. 134 135 References 136 1. Gueler A, Moser A, Calmy A, Günthard HF, Bernasconi E, Furrer H, et al. Swiss HIV cohort 137 study,. Swiss National Cohort. Life expectancy in HIV-positive persons in Switzerland: 138 matched comparison with general population. AIDS 2017;31 (3):427–36. 139 2. Prevention Access Campaign. Undetectable=untransmittable. 140 https://www.preventionaccess.org/undetectable (Accessed 16 August 2019). 141 3. Joint United Nations Programme on HIV/AIDS. In Danger: global AIDS update 2022. 142 Geneva: UNAIDS; 2022 https://www.unaids.org/en/resources/documents/2022/in-danger-143 global-aids-update. Accessed 22 December 2022. 144 4. AIDS info. Global data on HIV epidemiology and response https://aidsinfo.unaids.org. 145 Accessed 26 December 2022. 146 5. National Center for Statistics and Information. Population clock. 2022, December. Available 147 at: https://www.ncsi.gov.om/Pages/NCSI.aspx. (Accessed 27 December 2022). 148 6. HIV management in Oman. A guide for health care workers, 3rd edition. 2015. Available 149 from: www.moh.gov.om/en/web/directorate-general-of-disease-surveillance-150 control/resources. (Accessed 20 December 2022). 151 7. Annual health report. Department of Health Information and Statistics, MOH (2021) 152 (https://www.moh.gov.om/en/web/statistics/annual-reports; accessed 26 February 2023). 153 https://www.unaids.org/en/resources/documents/2022/in-danger-global-aids-update https://www.unaids.org/en/resources/documents/2022/in-danger-global-aids-update https://aidsinfo.unaids.org/ http://www.moh.gov.om/en/web/directorate-general-of-disease-surveillance-control/resources http://www.moh.gov.om/en/web/directorate-general-of-disease-surveillance-control/resources https://www.moh.gov.om/en/web/statistics/annual-reports 8. Kann L, McManus T, Harris WA, Shaanklin SL, Flint KH, Queen B, et al. Youth risk 154 behavior surveillance—United States, 2017. MMWR Surveill Summ. 2018;67(8):1-114. 155 9. Lucas SB, Curtis H, and Johnson MA. National review of deaths among HIV-infected adults. 156 Clin Med 2008; 8: 250–252. 157 10. Marks G, Crepaz N, and Janssen RS. Estimating sexual transmission of HIV from persons 158 aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20: 1447–159 1450. 160 11. Krentz H, Auld M, and Gill M. The high cost of medical care for patients who present late 161 (CD4 < 200 cells/lL) with HIV infection. HIV Med 2004; 5: 93–98. 162 12. Feyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and 163 discrimination in healthcare settings: a systematic review of quantitative evidence. PLoS 164 One. 2019;14(1):e0211298. 165 13. Gökengin D, Doroudi F, Tohme J, Collins B and Madani N. HIV/AIDS: trends in the 166 Middle East and North Africa region. Int J Infect Dis. 2016 Mar;44:66-73. 167 14. HIV in primary health care manual, Directorate General for Disease surveillance and control, 168 Ministry of Health, Oman, First edition, 2019. www.moh.gov.om/en/web/directorate-169 general-of-disease-surveillance-control/resources. 170 15. Burns FM, Johnson AM, Nazroo J, Ainsworth J, Anderson J, Fakoya A, et al; SONHIA 171 Collaboration Group. Missed opportunities for earlier HIV diagnosis within primary and 172 secondary healthcare settings in the UK. AIDS 2008; 22: 115–122. 173 16. Elgalib A, Al-Hinai F, Al-Abri J, Shah S, Al-Habsi Z, Al-Fouri M et al. Elimination of 174 mother-to-child transmission of HIV in Oman: a success story from the Middle East. East 175 Mediterr Health J. 2021 Apr 27;27(4):381-389. 176 17. World Health Organisation. Press release: Oman first country in the Eastern Mediterranean 177 Region to eliminate mother-to-child transmission of HIV and syphilis. Geneva: WHO; 2022 178 https://www.who.int/news/item/19-10-2022-oman-first-country-in-the-eastern-179 mediterranean-region-to-eliminate-mother-to-child-transmission-of-hiv-and-syphilis. 180 Accessed 22 December 2022. 181 18. World Health Organisation. Global health sector strategies on, respectively, HIV, viral 182 hepatitis and sexually transmitted infections for the period 2022-2030. Geneva: WHO; 2022 183 https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/full-final-184 http://www.moh.gov.om/en/web/directorate-general-of-disease-surveillance-control/resources http://www.moh.gov.om/en/web/directorate-general-of-disease-surveillance-control/resources https://www.who.int/news/item/19-10-2022-oman-first-country-in-the-eastern-mediterranean-region-to-eliminate-mother-to-child-transmission-of-hiv-and-syphilis https://www.who.int/news/item/19-10-2022-oman-first-country-in-the-eastern-mediterranean-region-to-eliminate-mother-to-child-transmission-of-hiv-and-syphilis https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/full-final-who-ghss-hiv-vh-sti_1-june2022.pdf?sfvrsn=7c074b36_13 who-ghss-hiv-vh-sti_1-june2022.pdf?sfvrsn=7c074b36_13. Accessed 22 December 2022. 185 19. Elgalib A, Shah S, Al-Habsi Z, Al-Fouria M, Al-Sawafi H, Al-Noumani J, et al. HIV viral 186 suppression in Oman: Encouraging progress toward achieving the United Nations ‘third 90’. 187 Int J Infect Dis. 2018 Jun; 71: 94-99. 188 20. Elgalib A, Shah S, Al-habsi Z, Al-fouri M, Lau R, Al-kindi H, et al. The cascade of HIV care 189 in Oman, 2015-2018: a population-based study from the Middle East. Int J Infect Dis. 2019 190 Sep 27. doi: 10.1016/j.ijid.2019.09.017. 191 192 193 Figure 1: New HIV cases among Omani Nationals stratified by Sex, 2010-2021 194 https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/full-final-who-ghss-hiv-vh-sti_1-june2022.pdf?sfvrsn=7c074b36_13