In Tunisia, a worrying increase in cases of HIV contamination

One summer evening, Farouk*, looking to meet new people, discovers Ahmed’s profile on a dedicated application. Although the latter does not exactly correspond to his criteria, one detail attracts his attention: the mention “PrEP negative” in its description. This means that Ahmed is not infected with HIV and is taking prevention treatment against the AIDS virus, known as pre-exposure prophylaxis (PrEP).

PrEP is an HIV prevention strategy that involves the regular taking of an antiretroviral drug by individuals who are not infected but are at high risk of transmission. This method is known to reduce considerably the risk of contracting the virus in the event of contact with an infected person (by 93% according to a French study published in The Lancet Public Health in 2022). At 37, Farouk, an architect living in the northern suburbs of Tunis, adopts a cautious attitude during his casual sexual encounters with other men. However, he admits that condom use is not always systematic, with his partners often being reluctant.

Well familiar with PrEP, which he himself has been taking for years without a prescription thanks to contacts in Europe, Farouk had never seen this mention before in Tunisia. Intrigued, he talks with Ahmed, who reveals the existence of a PrEP pilot program at the University Hospital Center (CHU) in Monastir, a city located on the east coast. After making an appointment by email, Farouk makes the two-hour journey from Tunis to receive the treatment a few days later.

“Very active” epidemic

When he arrived, he noticed the presence of other men who had come for the same reason. “I wanted to start a conversation but they looked scared”he says, describing people who are anxious and try to hide their faces to escape the gaze of others.

Confirming these concerns, the doctor who welcomed Farouk revealed to him that the rare participants in this program fear being stigmatized or prosecuted by the authorities, due to the criminalization of sexual practices between people of the same sex, which incur up to three years in prison.

Despite this, the PrEP program specifically targets men who have sex with men, as part of the national HIV strategy. An initiative that remains little known. Between December 2022 and January 2024, only 58 people were able to benefit from the program, of which 43 are still ongoing. The obstacles linked to traveling to Monastir pushed Farouk to favor a solution outside official channels, which obtains its medicines abroad.

Originally from the governorate of Medenine, located in the south of the country, Malek, 30, did not benefit from the same opportunities. This activist queerwho discovered her HIV status a year earlier, did not have access to PrEP, even though the pilot program had just started. “I only learned about this program after I was diagnosed”he explains.

Despite a relatively low prevalence of infection, less than 0.1% in the general population, according to the UN and the Ministry of Health, the HIV epidemic is considered to be “very active” by the authorities with a constant increase in the number of infections over the past ten years. According to the latest data from the Joint United Nations Program on HIV/AIDS (UNAIDS), the number of people in Tunisia living with HIV is estimated at 7,100 in 2022, compared to 4,700 in 2010. Although antiretroviral treatment is free , only 26% of them benefit from it due to difficulties linked to screening and follow-up.

“Closing dialogue with the authorities”

As part of its screening strategy for the years 2022 and 2023, the Ministry of Health has noted a gradual increase in seroprevalence among populations most exposed to the virus. In particular, men who have sex with men, whose HIV rate reaches 8.2%, while for injecting drug users, it is 8.8%. “What is worrying is that we have gone from a stable epidemic to a concentrated epidemic status. Unlike other regions of the world where the epidemic is declining, ours is recording a constant increase”worries Ramy Khouili, director of Lawyers Without Borders (ASF) in Tunisia and active in the fight against AIDS for more than twenty years.

Supported by the Tunisian Association for the Fight against Sexually Transmitted Diseases and AIDS (ATL MST Sida), Malek was able to be treated at the Sfax care center, one of four in the country, located in hundreds of kilometers from his place of residence. Despite the difficulties of transport, accommodation and the stigmatizing remarks during his treatment, Malek followed his treatment and is one of the 24% of patients whose viral load is now undetectable, a percentage still far from the average. global target of 95%. “In addition to the low screening rate, many give up their right of access to health to avoid stigmatization”affirme Ramy Khouili.

Behind her office in the Tunis section of ATL MST Sida, Sonia Torkhani, responsible within the association, regrets that the 23 existing screening centers are not all active. “Many people prefer to come to association centers with a principle of community screening to avoid discrimination and stigmatization of medical personnel”, she testifies. With its mobile units and centers “low threshold” which offer drug users support and harm reduction services without requiring abstinence, the organization attempts to reach the most marginalized populations, including women, including in remote regions.

“It will remain very difficult to access these populations as long as they are criminalized”, believes for his part the director of ASF in Tunisia, who calls for the decriminalization of homosexuality, drug consumption and even sex work. Reforms which have been relegated to the background since the July 25, 2021 coup by President Kaïs Saïed, synonymous, according to Ramy Khouili, with “total closure of dialogue with public authorities”.