The first step in tackling the spread of HIV/Aids is a frank recognition not only of the presence of the disease, but of the social, political and economic patterns that both fuel and bear its impact. Low prevalence can mistakenly (or deliberately) be equated with low risk and hinder awareness of the disease's potential for exponential growth if a timely, coordinated and multisectoral commitment to its treatment and prevention is not made.

This is the key message of a recent report, The Costs of Inaction, produced jointly by the World Bank, UNAids and the World Health Organisation on HIV/Aids in the Middle East and North Africa (MENA). It is estimated that 0.3 per cent, or around 550,000, of the region's adults are currently infected. Although the figures may seem low in comparison to Southern Africa or Asia, they are no less a cause for alarm or indeed action ? particularly since they are rising. The number of Aids deaths in MENA has increased six fold since the early 1990s to 37,000 in 2002 and the estimated number of people newly infected by HIV rose from 80,000 to 83,000 in 2001-2.

As in other regions, those perceived to be at greatest risk are sex workers and their clients, intravenous drug users, men who have sex with men and those who acquire STDs. But targeted surveillance and provision of information and services among these groups has been patchy to say the least. In order to establish effective prevention strategies, the report states, "the risk factors associated with these subpopulations must be researched and brought to light". The prevalent cultural conservatism of the region does not encourage bringing awareness of high risk behaviour to light, but nor does it provide the protection against the spread of the virus that officials have so far assumed it does. In the Arabian Gulf, drug use, extra-marital and homosexual sex may be punishable under its strict interpretation of Islamic law, but they are none the less widespread. Furthermore, social conditions and changes that increase vulnerability to widespread infection ? labour migration, conflict, displacement, tourism (including business trips abroad that often act as a cover for sex tourism), unemployment and poverty ? are characteristics spread, albeit to varying degrees, across the MENA region. In order to formulate an adequate response, therefore, it is essential that what may previously have been seen as a marginal problem is understood in terms of its broader national, regional and indeed international implications.

This is not to say that nothing has been done. In recent years, there have been signs of scattered activity which offer some hope that a crisis on the scale experienced in other regions might be averted. All the countries in MENA have national Aids committees and 14 of the 18 countries have UNAids Theme Groups. Efforts have been made in most to ensure safe blood supplies and precautions in the health services and many countries have also introduced medical management and counselling for HIV/Aids sufferers as well as providing antiretroviral therapy. However, recent reports from Iraq regarding the destruction of records during the war and looting of hundreds of vials of HIV and hepatitis blood samples and screening equipment are grounds for unease.

Beyond the medical arena lies the greater challenge of dismantling traditional taboos, raising awareness of risk, promoting safe sex and combating the stigma attached to the virus and those infected by it. Under Saddam Hussein, patients in Iraq were quarantined. In Saudi Arabia, claims are currently being investigated that a hospital dumped a barely-conscious, terminally ill Aids patient, who died soon afterwards, on the street. Although the authorities there appear to be reporting HIV/Aids figures more openly than in recent years, they claim that the majority of cases are among foreigners. At the end of last year, however, the Iranian Health Ministry issued a directive outlawing the refusal by health units to accept patients infected by HIV/Aids.

Of course, reducing discrimination needs to extend beyond health workers, but Iran has perhaps surprised many external observers over the last two years with an enlightened campaign to tackle the spread of the virus. So far, less than 5,000 cases of HIV infection (and 623 Aids deaths in 2003) have been identified, but estimates run to over 20,000. Around 65 per cent of positive cases are said to be attributable to intravenous drug use, which alongside related crimes and prostitution, is rising; in 2001 HIV prevalence among drug users in prison was reported to be 12 per cent, with one site reporting it to be as high as 63 per cent. The south eastern regions of the country, bordering on Afghanistan and Pakistan, have become increasingly vulnerable due to the movement of populations, drug trafficking and also a high rate of labour migration to the Gulf region. But, although systematic surveillance, particularly of high risk groups, is still highly inadequate, there have been dramatic advertising campaigns and local health education programmes that have displayed a will to overcome the cultural barriers preventing the open discussion of sex. In August this year, the government announced that free syringes will be distributed to drug users in Tehran and there has also been talk of introducing legalised brothels or "chastity Houses" in recognition of the fact that sex, rather than needle sharing, is now becoming the primary route of HIV transmission.

However this move is unlikely to gain support among the religious leaders and politicians, even though the widespread practice of sigheh (a temporary marriage based on an oral contract that can last for as little as a few minutes and where the woman usually gets paid) is religiously sanctioned.

The relatively young population of the region provides a further imperative for immediate action. More than half of Iran's population of 70 million is aged 25 or under and in Jordan this age group comprises 60 per cent of the total population. Whereas one in 900 of UK nationals between 15-49 are HIV positive, the statistic for Bahrain is one in 750. Both Bahrain and Jordan have also made significant advances in addressing the threat posed by HIV/Aids through awareness and counselling programmes. Indeed Bahrain is the first state in the Arabian Gulf to publicly come out of denial with its groundbreaking holistic Life Programme, spearheaded by the pioneering woman doctor, Somaye Al-Jowder.

With a population of only 5.2 million and HIV/Aids cases estimated at 324 (WHO estimate: 1,000), Jordan has also been active in setting up effective networks for prevention. Although HIV/Aids in MENA has so far been a low international priority, Jordan and Iran have both received funds from the Global Fund to Fight AIDS, TB and Malaria. Jordan has also received technical assistance and support from the US based nonprofit international public health organisation, Family Health International (FHI), which has been equally active in Egypt and Morocco. One of the major successes of the FHI "IMPACT" project in Jordan has been the peer education programme for university students which to date has trained at least 44 youth peer educators and reached more than 3,600 young people. The programme has sought to overcome cultural barriers through a gradual approach to discussions on the sensitive topics of sexuality, HIV/Aids stigma and discrimination towards people living with Aids. "There has been an unexpectedly enthusiastic involvement of young volunteers and there is a high demand among young Jordanians for reliable information about sexuality and gender", says Basma Khraisat, FHI/IMPACT Jordan Country Director.

This is just one of the many approaches to the epidemic included in the IMPACT project which also seeks to support and train local health educators and NGOs to enhance counselling skills, strengthen referral networks and collaboration with community based groups. It also aims to establish an adequate assessment of STI prevalence, promote public discussions among Islamic and Christian religious leaders and engage in behavioural change communication activities. However the road to success is not without its challenges. According to Khraisat, the level of stigma around HIV/Aids is "very, very high". In addition, there is a general lack of understanding of risk behaviours, few NGOs are willing to work with risk groups and funding is low. There is also a great need for evidence-based decision making and a shift from an expert-driven (medical) to a broadly participatory process. "Patience is key: a slow careful, participatory process can result in a solid foundation of active volunteerism and support for peer education, even around topics thought previously not to affect Jordan."

Still, Khraisat is optimistic: "Jordan is a low prevalence country, and we will do all that we can to keep it that way." The same could be said for the region as a whole, but only if the broad based action, joined up thinking, and of course financial investment that is needed, starts now while time is still on its side.