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National AIDS Control Program in Lebanon

Background
The HIV epidemic was introduced to Lebanon in 1984, with the 1st diagnosed AIDS case. Since then, the number of cases have been slowly but steadily rising which led the Ministry of Public Health (MOPH) to establish the National AIDS Control Program (NAP) in 1989. The NAP’s main aim is to limit the HIV and AIDS epidemic, gather statistics on reported cases of HIV/AIDS coordinate with NGOs ministries, media, religious leaders, UN agencies and other key stakeholders and improve the situation of people living with HIV and limit its spread in Lebanon.
In 2015 (till November) 113 new cases of HIV/AIDS have been reported to the National AIDS Program (NAP) in Lebanon. A significant number of these cases (92.7%) have been linked to local spread whereas 7.3% are linked to travel to endemic areas.
Distribution of cases by age shows that the higher number of reported cases is in the age group 30-49 years old (38.1%).
Gender distribution shows that 85.8% of the newly reported cases are among males compared to 14.2% for females. However global gender distribution of AIDS cases in the world is around 50%. Low AIDS cases rates among women could help limit the spread of the disease in Lebanon.
The major mode of HIV transmission is by sexual relations (81.4%). Of the total infections by sexual transmission the highest rate is among men who have sex with men 34.5% and 50.4% non-specified which raises the question of under reporting due to fears of stigma and discrimination. The vertical transmission (mother to child) is nil.
Data on high risk groups (intravenous drug users, sex workers, prisoners), is incomplete.  Data on HIV/AIDS death is unavailable.
Blood safety is well controlled in the country. No new cases of HIV infections through blood transfused in Lebanon have been reported since 1993.
Antiretroviral treatment (ARV) is provided by the Ministry of Public Health free of charge.
By the end of November 2015, the cumulative total of HIV/AIDS cases reached 1893, whereas the UNAIDS estimates the number of people living with HIV (PLHIV) to be 1887. Source Spectrum 2015.
 
Activities
The Voluntary Counseling and Testing (VCT)
 
VCT is an ongoing activity whereby the National AIDS Program team trains health care workers and nurses from various NGO’s, health centers and clinics on VCT service delivery. This activity is done, with the support of UN agencies including WHO and UNICEF. The workshops help to develop new capacities for VCT services, increasing the availability and spread of VCT centers all around Lebanon. The service offers:
  • Information and brochures about HIV/AIDS and STIs;
  • Pre- test counseling, testing and posttest counseling in a private anonymous setting; and
  • Referral to the needed health care and social services.
KABP Survey
 
KABP (Knowledge, Attitude, Behavior and Practices) is being conducted with the National AIDS Program. This new KABP survey is being organized in collaboration with UNFPA and UNICEF and executed by La Sagesse University in 2012. The aim of this study is to give a clear description of the Lebanese population in relation to the knowledge about HIV/AIDS, the prevalence of the different risky sexual practices (multiple partners, commercial sex and condom use) and the prevalent attitudes toward people living with HIV/AIDS.

Center for the Distribution of HIV/AIDS Medications
 
As a step towards reducing stigma and discrimination associated with People living with HIV/AIDS, the NAP opened a center for the distribution of HIV/AIDS medications; a center that is independent of the Ministry’s dispensary. The NAP dispensary team always provides a continuous follow up with the drug companies to insure continuous sustainability and availability of treatment for people living with HIV/AIDS.

Drop in Center (DIC)

In coordination with UNODC and specialized NGO’s like SIDC, SKOUN and AJEM, the NAP opened a drop in center (DIC) to host people who use drugs especially injecting and other high risk groups. The DIC is a place where beneficiaries feel comfortable and are given awareness and education sessions. Also they can use the VCT facility that exist in the DIC and later on if needed, can be referred to more specialized services. This DIC is a pioneer in the region and Lebanon and plans are being put to later open in other geographical area in Lebanon.  

Guidelines of Opiates Substitution Therapy (OST)

As a part of the Harm reduction strategy, the final guidelines of Opiates Substitution Therapy (OST) have been agreed upon by the Ministry of Public Health and the OST team. The OST services started in 2011.the Cumulative number of people under OST Treatment is 1470 (MOPH web).

Participation in International and Regional Workshops

The National AIDS Program (NAP) is engaging in several international and regional workshops and activities as a step to build its team’s capacity and to share knowledge and experience. NAP was involved in the HARM Reduction conference in Lebanon in April 2011 by sharing and submitting a poster on its IBBS in April 2008 survey conducted among the MARPS (Most at risk population) in Lebanon. NAP represented Lebanon in the Global Human Rights on HIV/AIDS forum Geneva and also presented a poster on MARPS at the Harm Reduction Conference in Vienna July 2010 The NAP is also participating in workshops related to size estimations as a step to have a size estimation studies for the MARPS(IDU,MSM)

National Strategic Plan (NSP)

With the support of WHO , and in coordination with civil society, the National AIDS Program is currently developing a new National Strategic Plan (NSP) to fight HIV/AIDS for the coming five years. This includes all kinds of activities from prevention, treatment, to care and support with a special focus on Prevention of mother to child transmission and the most  at risk population, as well as refugees and their hosting communities
 
Awareness Sessions
  • NAP is constantly raising awareness lectures to the young generation through lectures in schools and universities. As a part of this activity, NAP participated in the E-learning program implemented by WHO. The aim of this project was to develop an e-learning CD where teachers and students can learn about HIV/AIDS, ways of transmission and treatment and to know all the information related to HIV/AIDS. The NAP team along with WHO conducted more than 100 awareness lectures in all the public schools in all the different regions in Lebanon to raise awareness on the importance of HIV/AIDS. The lectures targeted health/ life science teachers on HIV/AIDS and provide them with necessary tools to introduce that topic in their school curriculum. Three waves of VCT training workshop have been implemented where 550 health care workers were trained and 110 health care centers or more providing HIV services in Lebanon
Along with the e-learning activity, NAP participated in many open days at different universities as part of their health awareness day as a step towards raising awareness on HIV/AIDS issues.
 
HIV and AIDS
What is HIV and AIDS?

HIV (human immunodeficiency virus) is the virus that, if untreated, can cause AIDS (acquired immunodeficiency syndrome) now also called, advanced HIV.
In a healthy individual, the body has an immune system that fights infections effectively. HIV attacks the immune system and replicates itself in the body’s immune cells. If untreated, it gradually overpowers the immune system leaving the body vulnerable to infections.
Without treatment, people with HIV eventually progress to AIDS, though this may take ten years or more. However, people with HIV who take effective therapy are unlikely to develop AIDS. That’s why early detection is crucial.

How Does HIV Cause AIDS?

Inside the body are numerous cells with different jobs. A type of white blood cells, called CD4 Tcells, help the body stay healthy by fighting off disease. HIV replicates itself in CD4 cells, gradually killing them off, so that over time, the body can’t fight disease any more. When a person with HIV starts getting the range of illnesses associated with immune deficiency – called ‘opportunistic infections’, he or she is said to have AIDS.

How is HIV Transmitted?

HIV is transmitted through penetrative sex (vaginal or anal), blood-to-blood contact (e.g. via blood transfusion or use of sharp infected instruments like syringes, razors…), or breastfeeding from an infected mother.
 HIV is mainly present in four kinds of bodily fluids:
  • Blood
  • Semen (cum)
  • Vaginal fluid
  • Breast milk
Unprotected sex (sex without a condom) is the most common method of HIV transmission in Lebanon.  
HIV can be transmitted to the fetus during pregnancy and to the infant during birth or breastfeeding; however this might be prevented through effective anti-HIV treatments and consultation with a specialized physician.
Oral sex is classified as a low-risk (but not no-risk) activity for HIV transmission. You cannot get HIV by hugging, shaking hands, or by sharing food or toilet seats.

How Can I Avoid HIV Transmission?

Avoiding HIV transmission is everybody’s responsibility.
You can protect yourself and your partner/s from HIV infection by using condoms* correctly when you have vaginal, anal, or oral sex, and by not sharing needles or injecting equipment.
*Most effective condoms must be latex, water-based, electronically tested, not have passed their expiry date, and not have been exposed to extreme temperatures.

STIs and HIV  
 
Diseases that are spread through sexual contact are usually referred to as STDs -sexually transmitted diseases. However, recently, it has been suggested to replace the term STD with a new term—sexually transmitted infection, or STI. Since the most common STDs have no signs or symptoms in the majority of persons infected. Or they have mild signs and symptoms that can be easily overlooked. So the sexually transmitted virus or bacteria can be described as creating “infection,” which may or may not result in “disease.”
Some of the most common STIs are: Chlamydia, Herpes, Gonorrhea, HIV, Hepatitis, Syphilis and HPV- human papilloma virus.
If a person becomes infected with an STI this increases his/her susceptibility to acquire HIV (if appropriate preventative methods haven’t taken place).
The most effective method of preventing an STD/HIV is by using a condom.

Should I Have an HIV TEST?

HIV is relatively rare in Lebanon but there are some circumstances that place you at increased risk of getting HIV. They are the following:
  • If you are a man who has sex with men, and you have ever had unprotected anal sex (anal sex without a condom), you should have an HIV test.
  • If your sexual partner has HIV, and you have ever had unprotected sex with him or her, you should have an HIV test.
  • If you have had unprotected sex (vaginal or anal) with a non-regular sexual partner you should have an HIV test.
  • If your current sexual partner has recently travelled to a high prevalence country and may have had unprotected sex there, you should consider an HIV test.
  • If you have had unprotected sex with a commercial sex worker, you should have an HIV test .
  • If you have ever shared injecting equipment you should have an HIV test.
 Where Can I Take an HIV Test?

You can take an HIV test in a medical laboratory, hospital, or Voluntary Counseling & Testing center (see attached list under VCT). HIV test are done free of charge at VCT centers.

 What Do I Do if my Test Comes Back Positive?
You may feel shocked and scared by your diagnosis. It’s a big thing to take in. But HIV is not a death sentence, with appropriate medication, care and support an HIV positive individual can live a relatively normal and healthy life.
Talking to a close friend, parent, counselor, VCT specialist can help to explore all your feelings about having HIV. Furthermore, you must visit an infectious disease specialist doctor who will inform you about your treatment options, talk to you about safety precautions, and help you find somebody to talk to about your feelings.
For more information See Treatment Care and Support

What is HIV Related Stigma and Discrimination?

UNAIDS defines HIV-related stigma and discrimination as :"...a 'process of devaluation' of people either living with or associated with HIV and AIDS...Discrimination follows stigma and is the unfair and unjust treatment of an individual based on his or her real or perceived HIV status."
We must all work hand- in- hand to decrease the stigma and discrimination that People Living with HIV/AIDS face to help pave the way towards their access to prevention, treatment, care, education, work, etc.
For more information on Human Rights and testimonies of People Living with HIV, kindly click on downloadable link "I live my Rights and Respect Other People’s Rights" (by UNAIDS & WHO) in Resources section.
 
Voluntary Counseling and Testing Centers (VCT)
What is a VCT?

It is a confidential, free, voluntary and anonymous service located within specific NGOs, whereby high risk individuals can speak with a qualified professional. The service offers information and brochures about HIV/AIDS and STIs, HIV testing (Pre and post-test counselling), and referrals to health care and social services (where required).

Goals
  
 
Voluntary Counselling and Testing centres have several goals: Prevention of HIV/AIDS transmission, decreasing HIV related stigma and discrimination and case finding.

What Happens During a Service Session at a VCT Centre?
  • Pre-test Counselling
In the pre-test counselling, the counsellor with the help of the client will assess the behavioural/ social risk factors that the client might have been exposed to.  The counsellor will enquire about the time of exposure to the HIV virus, as the window period is extremely important for assessing the accuracy of HIV test results. In addition, the counsellor will explain the meaning of a positive or negative test for HIV/AIDS so that the client can make an informed decision. The counsellor will also provide adequate information and present a tailored harm reduction plan to the VCT service seeker.
  • HIV test
The counsellor performs an HIV test for the service seeker using a Rapid test (Rapid Anti-HIV 1&2 Test). This is a simple (only a drop of blood needed) and highly accurate test that detects the presence of HIV antibodies present in the blood.
  • Post-test Counselling
In the post test counselling the client will be informed of his/her test results. Accordingly the counsellor and client will decide on the harm reduction plan and where he/she needs to be referred to (if required).
 
List of NGOs/VCT Centers  
The VCT updated booklet
 
Treatment, Care, and Support
Treatment

There is no current cure for HIV, but effective HIV treatments (antiretroviral therapy) have been developed that block HIV replication, preventing immune damage and HIV-related illness. Treatment does not have to begin immediately after diagnosis, but once begun it needs to be maintained throughout a person’s life.
People living with HIV typically require Triple combination therapy of ARD (Anti-retroviral Drugs) which is usually prescribed by an infectious Disease Specialist Physician.
Antiretroviral Treatment is provided by the Ministry of Public Health free of charge (to Lebanese citizens and Palestinian refugees) and currently the MOPH is covering with ART all Syrian refugees registered with UNHCR as well as some refugees from other nationality  . Patients who are deemed eligible for treatment by their physician (i.e. if their CD4 Tcell count drops below 350cells/mm3 as per WHO guidelines) can obtain a medication card and pick up their anti-retroviral treatment from the National AIDS program at the Ministry of Public Health.

Care and Support

Getting infected with HIV is no longer a death sentence. People living with HIV AIDS can live a normal life if they take their medication regularly and follow their Care giver’s instructions. HIV/AIDS is now considered as a chronic disease.  There are more than 35 million people living with HIV around the globe by end of 2013 according to UNAIDS- so you are not alone.
Talking to a close friend, parent, counselor, VCT specialist can help to explore all your feelings about having HIV. Furthermore, you must visit an infectious disease specialist doctor who will inform you about your treatment options, talk to you about safety precautions, and help you find somebody to talk to about your feelings.
A number of NGOs are primarily founded by and for people living with HIV AIDS. And their aim is to enhance the lives of those who are affected directly and indirectly by the HIV/AIDS epidemic, provide social support, focus groups, peer to peer education, and a friendly atmosphere devoid of stigma and discrimination. It is important to encourage people living with HIV AIDS to express their feelings, frustrations and demands but it is also essential to let them know their rights and obligations towards themselves and their community. Some of these NGOs include Vivre Positif and Think Positive (See list of NGOs under VCTs
 
Hotlines

If you require urgent support, assistance, and or counseling you may day dial any of the centers below:
 
Centers Numbers
Anwar Al Mahabba Association 01-391396
Armenian Relief Cross (ARC) 01-253793
HELEM 01-748258
Jeunesse Contre la Drogue (JCD)  
SKOUN 01-202714
Soins Infirmiers et Développement Communautaire (SIDC) 01-482428
Vivre positif 01-480714    71/062321
L'Escale Drop-in Centre(DIC) 01-491705
Marsa 01-737647
Proud Lebanon 76/608204
Oui pour la vie 78/881331
 
Resources
  1. VCT Centers List 2015
  1. Mishwar Study: an Integrated Bio-Behavioral Surveillance (IBBS) study among Most at Risk Populations in Lebanon: Female Sex Workers, Injecting Drug Users, Men who have  Sex  with Men, and Prisoners.  
  2. Case Studies:
  • A case study on the Ajem center for drug user rehabilitation
  • A case study on behavior change among Female Sex Workers: Interventions   from 2001-2007
  • A case study of the first legal, above-ground LGBT organization in the MENA Region (Helem)
  • A case study on establishing and building capacities for VCT Centers for HIV/AIDS in Lebanon
  1. I Live my Rights and Respect Other People’s Rights (by UNAIDS & WHO)
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