HIV in the Middle EastBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38994.400370.7C (Published 19 October 2006) Cite this as: BMJ 2006;333:851
All rapid responses
I thank Dr. Barss and his team for their comments in response to my
letter. With respect for the space I am allotted, I will respond
immediately to some of the concerns raised.
Firstly, my response was in the format of a letter to the
editor/readers response, it did not pretend to be a research article or a
systematic scientific analysis.
With respect to Miss El-Khatib, Dr. Barss is correct in stating that
she did not disclose any confidential information to others or myself.
Miss El-Khatib acted with the utmost professional integrity at all times
in her capacity in public health educator while in the UAE and while here
There are two major issues that come from this debate and that is of
the failure to disclose infection rates in the country and the practise of
deciding what is in the best interests of HIV positive Emiratis.
Dr. Mahmoud Fikri, the Assistant Under-Secretary for Preventive
Medicine UAE Ministry of Health, states that there have been no new
infections since 1985, in his address to the United Nations this past June
3, 2006 in New York (available at http://www.un.int/uae/fikri.htm). This
is a curious thing to state when the UAE has at the same time made reports
to the UNAIDS showing new infections up until 1998
Regardless of where the truth lies, what results is a generation of
youth and adults who perceive that there is no HIV threat because the
government has not declared it to be so. In numerous presentations that I
have done, some in Dr. Barss faculty and some in other educational
institutions with students of various levels, I have frequently
encountered both denial and shock at the very hint that there is HIV in
the country at all. When I asked students why this is so, the categorical
response has been, because "the government says there is none." While this
may not be the case with Dr. Barss students, who represent an elite crop
of students in the country, it is certainly a widespread perception in
lower academic levels.
Comments like those made by Dr. Mahmoud add to the perception that
HIV is not a concern in the country and increase the vulnerability of
those youth who think HIV is a problem with foreigners, Westerners and Non
-Muslims. By failing to publicly state that HIV is a concern in the UAE
and that the infection rate is increasing, the lack of disclosure
undermines the very preventive efforts that are occurring.
I do wish to acknowledge the good work that Dr. Barss is doing in his
efforts at increasing HIV awareness and state that I am aware of his
project. However, his project is one of very few (in fact, I believe it
was and still is the only one in the country). My concern is not about
preventive efforts per se but rather about the quality of the prevention
work being done to date.
In my own HIV presentations and discussions with students, I became
aware that not only was their knowledge about HIV (gained in government
secondary schools) lacking and in some cases non-existent, but their
knowledge about sexuality, reproductive health, and basic anatomy was
almost nil. Indeed, Visiting Professor Dr. Ganzak, who was also named on
Dr. Barss letter, presented much of the same findings with respect to HIV
knowledge in her own study (unpublished findings) of the UAE. While we can
say there is some preventive work being done, it is largely reserved in
and for the medical field. Where it is delivered in the general
population, it is still medically oriented and largely incomprehensible to
most people, including many of whom (like the mothers of many of my own
students) are illiterate or have little schooling.
I myself, attended a government sponsored AIDS awareness presentation
and quickly became perplexed with all the medical jargon, slides of viral
replication, and immune system functioning. There was nothing in the way
of prevention other than the standard message of “get married and be
faithful to your husband.” Condoms were never mentioned, safe and unsafe
sexual practises were never discussed, in fact, sex was never spoken of at
all. A session done with the Harvard doctor that Dr. Barss mentioned
showed us that a majority of the young women (many already married) we
spoke to did not even know what condoms were.
My concerns are that “prevention” work is being done to satisfy those
who are asking for it, but that the actual issues that increase the
susceptibility of acquiring HIV, especially in women, like domestic
violence, safe sex, partner drug use, infidelity, marital rape and the
like are not being addressed. To know how a virus replicates does not
inform a person to know what to do if her husband is cheating on her with
a sex worker. To know how a virus replicates does not inform a young woman
who wants to experiment with her illicit boyfriend how to keep herself
safe from contracting HIV or any other sexually transmitted disease.
The practise of offering a choice to HIV positive Emiratis about
continuing to work, go to school or retire is an interesting one. Many of
the HIV positive Emiratis I spoke with no longer worked because, in their
estimation, they had either been asked to leave their place of work or
were not offered a contract renewal. However, others chose not to return
on their own because they were met with such stigma that they felt they
could not return to work because of the shame they experienced.
My concern is that this process that prohibits a return, or prevents
entry (the difference is in semantics and the end result is the same) is
not uniform, and may not take into account the wishes of the HIV positive
person. This process is subjective and because of widespread stigma seems
to generally result in a withdrawal (either imposed or chosen) from civil
society, rather than an advocacy process that would encourage or better
yet, enforce the rights of HIV positive Emiratis to stay in school, stay
in their work place and tap into the Marriage Fund like all other
Emiratis. Any process to decide on any of the three options mentioned is
still a contravention of rights since it is based on a positive HIV
status. Whether the patient is ill or not should result in a discussion
with his or her case worker to find accommodations in the workplace or
school environment that would permit regular life to continue as normally
as possible and not a committee to decide on his or her behalf.
With respect to school admissions, my own work place made it clear
that no HIV positive Emirati would be admitted. The ministry of Health and
Education continues to make an HIV negative status a prerequisite to
attendance in schools. In discussion with other Ministry of Health workers
in different emirates and also members of international NGOs, it was clear
that attendance in schools for HIV positive Emiratis routinely results in
a withdrawal or refusal of entry. Whether this is legislation or merely
common practise, there is little accountability and government advocacy
for change where HIV positive Emiratis can decide for themselves without
the threat of their status being disclosed or being pressured to withdraw
from civic life under the guise of ‘their protection.’
Finally, Dr. Barss is correct in stating that some of the evidence
presented is anecdotal. This is a simple result of the widespread fear
that exists about talking of HIV – as it relates specifically to the UAE –
and also of the widespread denial that it is an issue worth talking about.
I do not disagree with Dr. Barss in his estimation that there is a
willingness to address HIV in the country, certainly the economic
resources and expertise exists. My concern rather is the lack of
implementation in doing so as stated in my letter. There exists no public
advocacy for HIV positive Emiratis because officially there are no
positive Emiratis. Failing to disclose the fact that there are HIV
positive Emiratis (infected after 1985) makes it difficult to publicly
convince the population that it is an issue worth knowing about and
understanding. The very act of hiding numbers makes it harder to convince
youth that they are at risk through their practises, beliefs and
knowledge. Furthermore, not discussing practises, beliefs and knowledge
makes them vulnerable because they are not aware of the consequences
(which can be deadly) of their actions, nor how to make those consequences
I thank Dr. Barss for his letter and encourage him to continue
addressing HIV in his community. At the risk of making this an issue
between myself and him (which it is not), it would perhaps make the most
sense to ask the Ministry of Health and Education (those responsible
specifically for HIV) to comment for themselves rather than let others do
the talking for them by commenting on the following:
What is the exact process indicated above of selecting how an HIV
positive Emirati proceeds once they are diagnosed and what legislated
provisions exist to protect HIV positive citizens rights in employment,
education and access to social programs?
What is the rationale in removing or preventing HIV positive Emiratis
from educational institutions and what is being done to promote their
rights in education and protect their status in schools?
What legislative pieces are in place to protect the rights of
Emiratis who are HIV positive and who petition the decisions of private
school boards and government school systems who prevent their entry into
What future actions can we expect on the part of these two Ministries
to protect and promote the rights of HIV positive citizens?
I would be most appreciative for these responses as would those who
work in the HIV field in the UAE and certainly on behalf of the HIV
positive Emiratis who seek these answers but have been too afraid to ask
I will not be corresponding further in this forum, however, I welcome
letters or comments to my personal address in Canada if needed.
Competing interests: No competing interests
The information on HIV/AIDS in the United Arab Emirates (UAE) in the
letter in the 2006 special issue of BMJ on the Middle East is largely
invalid. We write to clarify the situation.
In 1985, HIV/AIDS was made a notifiable disease in the UAE and a
National AIDS Control and Prevention Program was established. National,
regional and local committees were set up. Initial efforts were directed
towards technical measures to prevent cases from transfusion of imported
blood. Subsequently, screening was implemented for persons seeking
employment, higher education, or marriage, as well as for special risk
groups such as antenatal, prisoners and drug addicts.
For a period of time, in common with many countries, there was
considerable fear and stigma associated with HIV/AIDS. More recently, as
elsewhere, people have realized the importance of accepting and publicly
discussing issues of transmission and prevention. Health education on
HIV/AIDS has been implemented in schools. Regional public health
departments, the Red Crescent, and other organizations also conduct health
promotion programs on HIV/AIDS. The police and UNICEF have collaborated
with mosques throughout the country to provide information about HIV/AIDS
During 2005-2006, three of us (PB, MG, FA) organized a team of female
medical students to survey UAE University students’ knowledge about
HIV/AIDS, and to assess attitudes towards persons living with HIV. On the
basis of the results of that survey, conducted with full cooperation from
the national university, we obtained university grant funding to develop,
implement, and evaluate an HIV/AIDS intervention for grade 12 students in
16 high schools in two of the four largest cities with four teams of
trained female and male medical students. We received full cooperation
from our Emiratii students, who stimulated us to organize the
intervention, and from the Ministry of Education, school principals, and
teachers. Our team succeeded in implementing training and workshops, which
resulted in highly significant improvements in both knowledge and
attitudes of students.
We are concerned with the validity of several statements in the
letter by Dr Louise Lambert. While it is fair to say that high-risk groups
are not publicized at present and that no large-scale epidemiologic study
has been conducted, this may soon change. Current data show low
prevalence. It is not fair to say that there is reluctance to debate AIDS.
There has been considerable recent health education on HIV/AIDS as noted
above, including a series of open conferences organized by public health
departments throughout the country. Indeed, Dr Lambert herself
participated in public programs, including as a speaker in a program for a
Scientific Day on HIV/AIDS in the general hospital for the city of Al Ain
on 18th February 2004, while she was working as a psychologist at a
woman’s college. We also invited her to speak on HIV/AIDS to medical
students and faculty at the UAE University, along with an HIV scientist
from Harvard University.
As for the issue of government employment and higher education,
employees and students are not “barred”; however, depending upon their job
category, a local committee of several professionals, including one of our
faculty, helps to assess whether UAE nationals should be offered a choice
of continuing to work, to study, or early retirement. Infected individuals
are provided with free medical care, as well as financial, psychological,
and social support for themselves and their families. These benefits do
not extend to non-nationals employed in the UAE and they must return to
their home country if they become HIV-positive.
With respect to young people’s concerns, we have already mentioned
positive activities. As for the issue of lethal punishment or forced
hormone treatments for homosexuals, we are unaware of any such incidents
in the UAE. While there are occasional media reports of police
investigations to assist teenagers who have been exploited illegally as
prostitutes, particularly young women from desperate families in
neighbouring occupied and other poor countries, we are not aware of very
young endemic “child sex workers”, as seen in some low-income countries.
With respect to intravenous drug users, such behaviour is currently
uncommon in the UAE and there are no data on prevalence of HIV among such
individuals. As for the proportion of cases transmitted heterosexually,
this has not yet been studied, as HIV-positive males are usually unwilling
to disclose the source of their infection; a survey using confidential
anonymous interviews would be necessary to properly assess this issue.
It is unprofessional to publish in a scientific evidence-based
medical journal serious allegations that harm the reputation of a country,
more so when these are anecdotal observations without an evidence base.
Furthermore, it is unbalanced to fail to mention the positive activities
and developments that have been undertaken in the UAE. The “scientific
“evidence cited consists mainly of unreferenced statements, an
unauthorized personal communication, and “inconclusive” unpublished
evidence. We have verified the five citations attached to the letter, and
with the exception of the newspaper article none contain any data about
the UAE to support the conjoined statements. As for the “personal
communication” from Ms El-Khatib, she was a public health professional in
UAE, is now living in Canada, and declared that she did not disclose
confidential information about patients, nor was her written permission
obtained to cite her as a source in the BMJ.
To extrapolate from other countries, especially low-income countries
such as Yemen, to the UAE is unscientific. It is therefore no more than
speculation to state that a high-income, low prevalence, country such as
the UAE may sustain a drop of GDP of 26% due to a lack of HIV prevention
and treatment. On the other hand, it is fair to say that there are
outstanding issues and challenges that need to be addressed in the UAE. It
is a rapidly developing affluent country that attracts many foreigners for
work, some legally and some illegally. The UAE is proactive in organizing
countrywide prevention of HIV/AIDS, with many positive developments and
great interest among young people in protecting themselves and their
Barss P*, Sheek-Hussein M**, Al-Maskari F*, Grivna M*, Ganczak
Dept of Community Medicine, United Arab Emirates University*; Dept of
Preventive Medicine, Al Ain Medical District**; Dept of Hygiene,
Epidemiology and Public Health Pomeranian Medical University, Szczecin,
Competing interests: No competing interests
This is an interesting article. We all know that HIV infection is
spreading faster than anybody can think.
The prevalence of this infection is still low in the Middle East region.
There are various factors (mostly cultural beliefs) behind this. However,
the spread of disease is alarming especially in young women. Another
important thing is the ignorance about the entity. These young women are
at risk of transmitting the infection to the next generation and so on.
The fear of stigma and under reporting, denial and ignorance are the main
factors in the spread of the disease. In the light of the current situation,
when sexually transmitted infections are very common, HIV infection should
be discussed seriously. In my opinion, health education is the most
effective tool to tackle the situation.
The high risk population should be informed about the spread of the
disease and methods of prevention. The young generation especially women
should be encouraged to talk about safe sexual practices. This might help
in breaking the silence around the disease.
As we are aware that resources for diagnosis and treatment of HIV are poor
in most of the developed countries, prevention is the best tool to fight
Competing interests: No competing interests
The national policy for HIV/AIDS of the United Arab Emirates (UAE)
lacks implementation strategies
(www.moh.gov.ae/moh_site/prev_med/anbk/s19.htm). There is reluctance to
identify high risk groups and debate AIDS as the political costs are more
destabilising than public health benefits.(1) Instead, authorities rely
on mandatory HIV testing. HIV positive nationals are barred from
government employment, educational institutions, and drawing on the
marriage fund. This contravenes the regulations of the International
Labour Organization, of which the UAE is a member, and violates human
Legal and political restraints determine the status of non-governmental
organisations and prevent them from working with risk groups. One such
organisation told me that they are not allowed to criticise government
policies. No civic participation makes accountability difficult.
Young people’s sexual concerns are ignored since they are considered
sexually inactive. Men, unwilling to wait for sanctioned sex, have sex
with other men in Kuwait, Oman, Qatar, and Yemen.(1) Homosexual sex is
punishable by death or subject to forced hormone treatments, making harm
reduction absent. Child protection organisation ECPAT identifies the UAE
as the most cited destination for trafficking, where sex workers come to
work in brothels (www.ecpat.org.uk/).
HIV infection in intravenous drug users is high; Bahrain identified 73% of
its prison inmates as HIV positive,(1) and in one Iranian city 66% were
identified.(2) Similar trends in the UAE are likely. Treatment is
available within prisons and psychiatric wards since drugs are
Nearly 80% of infections in the Middle East and North Africa are
heterosexually transmitted.(3) In Saudi Arabia, women are infected by
their husbands’ engagement in extramarital sex.(4) The same trend for
Emirati women is suggested.
Evidence is inconclusive, but premarital sex seems to be increasing.
The teaching of sexual health in schools is limited and censors edit
textbooks. In 2004 the HIV/AIDS coordinator from the Ministry of Health
stated: “we cover HIV/AIDS as part of the science curriculum.”(5)
The UAE’s gross domestic product during 2000-25 could be reduced by 25.6%
as a result of not investing in prevention, paying for treatment, and
mobilising resistant efforts, all undermining social and economic
development.(1) The international community can help avert an epidemic by
putting pressure on this resource rich country to tackle HIV immediately.
Competing interests: None declared.
1. Robalino DA, Jenkins C, El Maroufi K, eds. Risks and macroeconomic
impacts of HIV/AIDS in the Middle East and North Africa: Why waiting to
intervene can be so costly. Washington, DC: World Bank Group, 2002.
2. Nakhaee FH. Prisoners’ knowledge of HIV/AIDS and its prevention in
Kerman, Islamic Republic of Iran. East Mediterr Health J 2002;8(6).
3. UNAIDS. 2004 report on the global HIV/AIDS epidemic. 4th global report.
Geneva, Switzerland: UNAIDS, 2004.
4. Madani TA, Al-Mazrou Y, Al-Jeffri M, Al Huzaim N. Epidemiology of the
human immunodeficiency virus in Saudi Arabia; 18-year surveillance results
and preventions from an Islamic perspective. BMC Infect Dis 2004;4(25).
5. Bardsley D. Anti-AIDS drive a great success. Gulf News 2004;1:3.
Competing interests: No competing interests