Background and objective The Middle East and North Africa (MENA) is home to the world's largest producer of opioids, as well as to major drug trade routes. Over 80% of the global supply of heroin is produced in Afghanistan, and over 75% of this is trafficked through Iran and Pakistan. The increased availability and purity of inexpensive heroin in MENA appears to have led to a subsequent rise in injecting drug use. The objective of this sub-study was to estimate the proportion and number of people who inject drugs (PWID) in MENA, as part of a larger study of HIV epidemiology among PWID in this region. Methods This was a systematic review of literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sources of data included PubMed, Embase, regional databases, conference abstracts, as well as a large body of country-level reports. A generic "drug use" search of these databases was performed. Data on PWID population size estimates in the 23 MENA countries were extracted from relevant studies. Estimates were weighted by adult population size. When more than one such estimate was available per country, we used their mean. Adult population size was extracted from the United Nations World Population Database. Results After screening 4,985 citations, we extracted 121 and 105 measures on the number and proportion of PWID, respectively. We estimated that there are 0.6-1 million PWID in MENA. Pakistan, Iran, and Egypt have the largest number, with an average of about 210,000, 180,000 and 89,000 PWID, respectively. The weighted mean prevalence of injecting drug use was estimated at 0.23 per 100 adults (range 0.03-0.50%), and was highest in Iran (0.43%). Studies of sub-national populations showed geographical heterogeneity in the proportion of PWID. Data on the prevalence of female PWID were scarce. Overall, the mean proportion of females among PWID in included studies was 3.6% (range: 0-35%). Conclusion The mean prevalence of injecting drug use in MENA (23 in every 1000 adults) is comparable with global figures which range from 0.06% in South Asia to 1.50% in Eastern Europe. The prevalence of injecting drug use varied between MENA countries, being higher in the eastern part of the region; and appeared to be heavily concentrated among men. With recent evidence suggesting emerging HIV epidemics among PWID in several MENA countries, these findings take on additional importance. There is an urgent need to scale up harm reduction services for the nearly one million individuals who form this vulnerable population group in MENA.


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