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Background: Understanding gender disparities in adolescent health behaviors is crucial for developing targeted health promotion strategies. This study uses data from the Global School-based Student Health Survey (GSHS) across 17 MENA countries to analyze gender differences in adolescent health behaviors, aiming to provide a comprehensive overview for both boys and girls. Methods: This meta-analysis incorporates data from recent years of the GSHS, covering 17 MENA countries. The objective was to assess and compare health behaviors between adolescent girls and boys. A random-effects model was employed to calculate odds ratios for gender comparisons in these behaviors. Statistical analyses and modeling were performed using JAMOVI software. Results: In most MENA countries, boys consumed more vegetables compared to girls. Girls were less likely to frequent fast food establishments (OR = 0.82, 95% CI: 0.69-0.98) and generally exhibited better self-care behaviors. Boys reported a higher prevalence of physical altercations (OR = 2.18, 95% CI: 1.88-2.51) and were more involved in fights (OR = 3.00, 95% CI: 2.46-3.67). Girls were more likely to miss school without permission and were consistently described as kinder and more helpful across various income levels. However, in some countries such as Oman and Tunisia, boys missed school more frequently. There were no significant gender differences in parental oversight of homework or knowledge of students' activities, but girls were reported to have stronger parental relationships and better parental understanding of their problems and free time, with exceptions in Morocco and the Palestinian Territory-Gaza. Boys were more likely to engage in smoking (OR = 3.57, 95% CI: 2.69-4.76) and other substance use. Conversely, girls reported higher levels of physical inactivity and loneliness, but also demonstrated greater kindness and helpfulness in school settings and stronger parental relationships. Conclusion: Policymakers in the MENA region should develop and implement gender-specific interventions targeting key areas such as hygiene practices, physical activity, and substance use. By focusing on these targeted strategies, they can address the distinct health behaviors and needs of both boys and girls. Effective interventions in these areas are crucial for improving overall health outcomes and promoting healthier lifestyles, thereby enhancing adolescent health and well-being across the region.

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Background: Prophetic Medicine, integral to healthcare in Muslim-majority regions, particularly the Middle East and North Africa, is often underexplored in existing literature. Purpose: This concept analysis sought to explore the concept of Prophetic Medicine by delineating its attributes, antecedents, and consequences in order to augment healthcare providers' comprehension of Prophetic Medicine. It also seeks to enhance interdisciplinary dialogue, thereby enriching the integration of traditional healing modalities in modern medical practices. Methods: Walker and Avant's method was used to conduct the concept analysis by reviewing published literature on the concept. Results: The analysis identified the core attributes of Prophetic Medicine, such as Black Seeds, Dates, Miswak, Wet cupping, and Zamzam water, and explored cultural, spiritual, and practical underpinnings of these practices. Antecedents such as cultural background, spiritual beliefs, basic knowledge, lower cost, perceived safety, efficacy, simple techniques, and dissatisfaction with allopathic therapy were identified. The consequences of these practices include the multifaceted impact of Prophetic Medicine, highlighting the relationship between these traditional practices and health outcomes. Implications for Practice: This concept analysis underscores the significance of recognizing these aspects of Prophetic Medicine for healthcare providers to effectively integrate Prophetic Medicine into practice, aiming for favorable patient outcomes and fostering a more inclusive, culturally sensitive healthcare environment.

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Diabetes mellitus, a condition characterized by dysregulation of blood glucose levels, poses significant health challenges globally. This meta-analysis and systematic review aimed to evaluate the effectiveness of artificial intelligence (AI) in managing diabetes, underpinned by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review scrutinized articles published between January 2019 and February 2024, sourced from six electronic databases: Web of Science, Google Scholar, PubMed, Cochrane Library, EMBASE, and MEDLINE, using keywords such as "Artificial intelligence use in medicine, Diabetes management, Health technology, Machine learning, Diabetic patients, AI applications, and Health informatics." The analysis revealed a notable variance in the prevalence of diabetes symptoms between patients managed with AI models and those receiving standard treatments or other machine learning models, with a risk ratio (RR) of 0.98 (95% CI: 0.88-1.08, I2 = 0%). Sub-group analyses, focusing on symptom detection and management, consistently showed outcomes favoring AI interventions, with RRs of 0.97 (95% CI: 0.87-1.08, I2 = 0%) for symptom detection and 0.97 (95% CI: 0.56-1.57, I2 = 0%) for management, respectively. The findings underscore the potential of AI in enhancing diabetes care, particularly in early disease detection and personalized lifestyle recommendations, addressing the significant health risks associated with diabetes, including increased morbidity and mortality. This study highlights the promising role of AI in revolutionizing diabetes management, advocating for its expanded use in healthcare settings to improve patient outcomes and optimize treatment efficacy.

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The Middle East has high youth population; however, it is challenged by uncertain economic situation. Higher education plays a crucial role in the development of nations by equipping generations with the knowledge and skill through cumulative curriculum development. Like other professions, pharmacy is a dynamic field of study where continuous improvements are required to keep the viability of the profession and endow future generations with up to date skills. This article describes a strategy for pharmacy curriculum development considering four layers. The strategy starts from the understanding of the current situation in a university, looking into national, international accreditations and job market. The strategy covers development from program to subject's level. The strategy is applied to pharmacy programs in the UAE. Upon analysis, several recommendations were obtained for curriculum improvements. At individual university level, there is a need to work on clinical oriented topics in the curriculum to fit with international accreditation and country's vision. Details on this can be taken form deeper analysis of job market and stakeholders in the UAE. On the national level, unifications of total credit hours for the degree across universities needs to be envisaged with limits on contact experiential hours. The strategy has the potential of extrapolating to other Middle Eastern countries.

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Lower tax revenues and greater government spending result in higher deficits and public debt. As a result, determining the degree of budgetary effects is vital, but important to assess the persistence of these effects. We aim to investigate the impact of climate change on the fiscal balance and public debt in the countries of the Middle East and North Africa. The empirical analysis relies on panel data in the period 1990-2019 and employs various models. The findings show that temperature changes adversely affect the government budget and increase debt, but we find no significant impact of changes in rainfall. The average temperature decreases fiscal balance by 0.3 percent and increases debt by 1.87 percent. Using projections of temperature and rainfall over the years 2020 to 2099, we find a significant decrease in the fiscal balance at 7.3 percent and an increase in the public debt at 16 percent in 2060-2079 and 18 percent in 2080-2099 under the assumption of a high greenhouse gas (GHG) emission scenario. On the contrary, under the low GHG emission scenario, the fiscal balance deteriorates by 1.7 percent in 2020-2039 and 2.2 percent in 2080-2099, while public debt rises by 5 percent in 2020-2039 and 6.3 percent in 2080-2099. Supplementary Information: The online version contains supplementary material available at 10.1007/s10584-022-03388-x.

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INTRODUCTION: Safety climate assessment is a key measure of organizational safety. A strong safety climate is integral to the high safety performance in aviation. Most survey instruments that purport to measure safety climate are derived from evidence obtained in developed countries in the west. It is rare for these studies to examine the influence of macro-environmental factors on safety climate, and rarer still in countries found in the Middle East and North Africa (MENA) region. METHOD: The researchers conducted 28 semi-structured interviews with experienced aviation maintenance engineers from a national carrier in the region. The interview questions were derived from an extensive review of existing studies of safety climate. Data from interview transcripts were coded, creating a data structure using participant quotes for 1st order codes and arriving at three aggregate dimensions: organizational commitment to safety, organizational safety practices and social relationships and their consequences. RESULTS: Commercial considerations influenced negatively organizational commitment to safety. Organizational safety practices were weak. There was a lack of safety training, a lack of resources to support safe working, poor safety communication, and a failure to report safety issues. Strong friendships were developed through working together in teams. This adversely influenced the reporting of errors and the punishment of violations. DISCUSSION AND CONCLUSION: The apparently weak organizational safety climate reported here was attributed to financial constraints following the imposition of economic sanctions and embargos, and to the influence of Arabic cultural values that privilege family connections and the importance of maintaining harmony in social relationships that precludes punishment. PRACTICAL APPLICATION: Financial constraints inevitably limit resources for safety and encourage prioritization of production. Arabic cultural values inhibit the development of a 'just' culture and a 'reporting' culture and challenge the universal adoption of approaches for promoting organizational safety developed in the West.

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PURPOSE OF REVIEW: This study investigated and pooled the long-term trends in prevalence, awareness, treatment, and control of hypertension (HTN) in the Middle East and North Africa (MENA) region. In this systematic review and meta-analysis, we searched MEDLINE/PubMed, Web of Science, Google Scholar, EMBASE, and Scopus between database inception and November 2020. All cross-sectional studies that investigated the prevalence of pre-HTN, HTN, awareness, treatment, and control in the MENA counties were included. The selection study, data extraction, and quality assessment were conducted by two investigators independently. Heterogeneity between studies was assessed using Cochran's Q test and I-squared, and due to sever heterogeneity between studies, the random effect model was used to pool the estimates. Sensitivity analysis was performed to estimate the long-term trends in prevalence, awareness, treatment, and control rates of HTN according to definition of HTN as systolic blood pressure of 140 mm Hg or more, or diastolic blood pressure of 90 mm Hg or more, or being on pharmacological treatment for HTN. RECENT FINDINGS: Overall, 178 studies met the inclusion criteria. Studies comprised 2,262,797 participants with a mean age of 45.72 ± 8.84 years. According to random effect model, the pooled prevalence of pre-HTN and HTN was 33% (95% CI 28, 39) and 26% (25, 27), respectively. Over the past three decades, prevalence of hypertension increased significantly in the region. The pooled awareness, treatment, and control rates were 50% (48, 53), 41% (38, 44), and 19% (17, 21), receptively. The pooled awareness, treatment, and control rates of HTN were lower significantly in men than women. According to definition of HTN as blood pressures above 140/90 mm Hg, over the past three decades, although the awareness and treatment rates did not change significantly, the control rates improved significantly in the region. The findings showed that HTN is a significant public health problem in the MENA region. Although there are low levels of pooled awareness, treatment, and control rates, the control rates improved over the past three decades in the region.

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Over the last decades, there has been a dramatic global increase in multidrug-resistant (MDR) pathogens particularly among Gram-negative bacteria (GNB). Pseudomonas aeruginosa is responsible for various health care-associated infections, while MDR P. aeruginosa causes significant morbidity and mortality. Middle East and North Africa (MENA) represent an unexplored geographical region for the study of drug resistance since many of these countries are at crossroads of high volume of travel, diverse expatriate populations, as well as high antibiotic consumption despite attempts to implement antimicrobial stewardship programs. This minireview analyzes epidemiology, microbiological, and genomic characteristics of MDR P. aeruginosa in the MENA region. Published data on MDR P. aeruginosa prevalence, antimicrobial resistance patterns, and genetic profiles from studies published during the past 10 years from 19 MENA countries have been included in this minireview. There is wide variation in the epidemiology of MDR P. aeruginosa in the MENA region in terms of prevalence, antimicrobial characteristics, as well as genetic profiles. Overall, there is high prevalence of MDR P. aeruginosa seen in the majority of the countries in the MENA region with similarities between neighboring countries, which might reflect comparable population and antibiotic-prescribing cultures. Isolates from critical care units are significantly resistant particularly from certain countries such as Saudi Arabia, Egypt, Libya, Syria, and Lebanon with high-level resistance to cephalosporins, carbapenems, and aminoglycosides. Colistin susceptibility patterns remains high apart from countries with high-level antibiotic resistance such as Saudi Arabia, Syria, and Egypt.

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OBJECTIVES: Traumatic brain injury (TBI) represents a major health concern worldwide with a large impact in the Middle East and North Africa (MENA) region as a consequence of protracted wars and conflicts that adversely affect the general population. Currently, systematic TBI studies in the MENA region are lacking, nonetheless they are immensely needed to enhance trauma management and increase survival rates among TBI patients. This systematic review aims to characterize TBI in the MENA region to guide future policy choices and research efforts and inform tailored guidelines capable of improving TBI management and patient treatment and outcome. Furthermore, it will serve as a road map to evaluate and assess knowledge of trauma impact on regional health systems that can be adopted by health-care providers to raise awareness and improve trauma care. METHODS: We conducted a comprehensive search strategy of several databases including MEDLINE/Ovid, PubMed, Embase, Scopus, CINAHL, Google Scholar, and the grey literature in accordance with the PROSPERO systematic review protocol CRD42017058952. Abstracts were screened, and selected eligible studies were reviewed independently by 2 reviewers. We collected demographics information along with TBI characteristics, mortality rates, and regional distribution. Data were extracted using REDCap and checked for accuracy. RESULTS: The search strategy yielded 23,385 citations; 147 studies met the eligibility criteria and were included in this review. Motor vehicle accident (MVA) was the leading cause of TBI (41%) in the MENA region, followed by the military- (15.6%) and fall- (8.8%) related TBI. Males predominantly suffer from TBI-related injuries (85%), with a high prevalence of MVA- and military-related TBI injuries. The TBI mortality rate was 12.9%. The leading causes of mortality were MVA (68%), military (20.5%), and assault (2.9%). The vast majority of reported TBI severity was mild (63.1%) compared to moderate (10.7%) and severe TBI (20.2%). Patients mainly underwent a Glasgow Coma Scale assessment (22.1%), followed by computed tomography scan (8.9%) and surgery (4.1%). CONCLUSIONS: Despite its clinical, social, and economic burden, the evidence of TBI research in the MENA region is scarce. Further research and high-quality epidemiological studies are urgently needed to gain a deep understanding of the TBI burden in the region, facilitate the allocation of adequate resources, implement effective preventive and intervention strategies and advise on the TBI patient management as reflective on the TBI patterns and modes.

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In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.

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Coronavirus disease 2019 (COVID-19) has rapidly spread globally, forcing countries to apply lockdowns and strict social distancing measures. The aim of this study was to assess eating habits and lifestyle behaviours among residents of the Middle East and North Africa (MENA) region during the lockdown. A cross-sectional study among adult residents of the MENA region was conducted using an online questionnaire designed on Google Forms during April 2020. A total of 2970 participants from eighteen countries participated in the present study. During the pandemic, over 30 % reported weight gain, 6·2 % consumed five or more meals per d compared with 2·2 % before the pandemic (P < 0·001) and 48·8 % did not consume fruits on a daily basis. Moreover, 39·1 % did not engage in physical activity, and over 35 % spent more than 5 h/d on screens. A significant association between the frequency of training during the pandemic and the reported change in weight was found (P < 0·001). A significantly higher percentage of participants reported physical and emotional exhaustion, irritability and tension either all the time or a large part of the time during the pandemic (P < 0·001). Although a high percentage of participants reported sleeping more hours per night during the pandemic, 63 % had sleep disturbances. The study highlights that the lockdown due to the COVID-19 pandemic caused a variety of lifestyle changes, physical inactivity and psychological problems among adults in the MENA region.

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Diffuse large B-cell lymphoma (DLBCL) is a heterogenous disease with a variable prognosis. The International Prognostic Index (IPI), revised-IPI (R-IPI), and National Comprehensive Cancer Network-IPI (NCCN-IPI) have been developed and validated to predict prognosis in DLBCL. However, patients from the Middle East and North Africa (MENA) region were under-represented in such scores, and it is unclear whether ethnic background contributes to different disease biology or response to therapy. Following due Institutional Board Review approval, DLBCL patients diagnosed from January 2010 until December 2015 from the MENA region were retrospectively reviewed. A total of 122 were identified and further analyzed. There were 74 males (61%), and the median age at diagnosis for the cohort was 64 years (range: 18-98 years), with a median follow-up duration of 32.9 months (range: 0.2-123.7 months). Estimates of three-year progression-free survival found a significant difference among risk groups using all three prognostic models but were more discriminating among the groups using NCCN-IPI and R-IPI vs. IPI (p = 0.019 and 0.014 vs. 0.039, respectively). For overall survival estimates at three years, the NCCN-IPI was the best model compared to R-IPI and IPI (p = 0.0013 vs. 0.05 and 0.04, respectively). In conclusion, we validated that the IPI and its subsequent iterations were predictive of outcome in DLBCL patients from the MENA region; however, the NCCN-IPI appeared the most prognostic. These results warrant further confirmation.

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The worldwide obesity epidemic has impacted women more heavily than men. These gender-based differences are particularly pronounced in the Middle East and North Africa (MENA) region where gender obesity gaps on average exceed 10 percentage points. This paper examines one of the explanations, namely the role of female empowerment on gender gaps in obesity. We study the effect of several measures of female empowerment including female labor market participation on gender obesity gaps over a time span of 41 years (1975-2016) in a sample of 190 countries. We document that after controlling for a number relevant controls, gender obesity gaps are only associated to measures of female empowerment in the MENA region but that this is not true worldwide. We then use an instrumental variable approach in order to illustrate that the causality runs indeed from empowerment, proxy it by both labor market and political participation to gender obesity gaps and not vice versa. Our results reveal that a one percentage point increase in female labor market participation (female MPs in national parliament) predicts a 0.2 (0.09) percentage point decrease in gender gaps in obesity in the MENA region.

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Tuberculosis (TB) is a disease that affects one-third of the world's population. Although currently available TB drugs have many side effects, such as nausea, headache and gastrointestinal discomfort, no new anti-TB drugs have been produced in the past 30 years. Therefore, the discovery of a new anti-TB agent with minimal or no side effects is urgently needed. Many previous works have reported the effects of medicinal plants against Mycobacterium tuberculosis (MTB). However, none have focused on medicinal plants from the Middle Eastern and North African (MENA) region. This review highlights the effects of medicinal plants from the MENA region on TB. Medicinal plants from the MENA region have been successfully used as traditional medicine and first aid against TB related problems. A total of 184 plants species representing 73 families were studied. Amongst these species, 93 species contained more active compounds with strong anti-MTB activity (crude extracts and/or bioactive compounds with activities of 0-100 µg/ml). The extract of Inula helenium, Khaya senegalensis, Premna odorata and Rosmarinus officinalis presented the strongest anti-MTB activity. In addition, Boswellia papyrifera (Del) Hochst olibanum, Eucalyptus camaldulensis Dehnh leaves (river red gum), Nigella sativa (black cumin) seeds and genus Cymbopogon exhibited anti-TB activity. The most potent bioactive compounds included alantolactone, octyl acetate, 1,8-cineole, thymoquinone, piperitone, α- verbenol, citral b and α-pinene. These compounds affect the permeability of microbial plasma membranes, thus kill the mycobacterium spp. As a conclusion, plant species collected from the MENA region are potential sources of novel drugs against TB.

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Acute pancreatitis (AP) is an uncommon potential complication of severe hypertriglyceridemia (HTG). We reported a case of a 45-year-old man admitted with HTG-induced AP (HTG-AP). The patient was a known diabetic (glycated hemoglobin levels: 9.5%), his triglycerides level was 3587.2 mg/dl, and the lipase level was 242 IU/L. A CT scan revealed AP. The patient was treated with a low-dose insulin infusion (0.05 unit/kg/hr) with dextrose for six days. His triglycerides came down to 673.1 mg/dl, and he was discharged. Further investigations are needed to understand the efficacy of low-dose insulin in the management of HTG-AP.

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This paper reviews the escalating burden of breast cancer (BC) in the Middle East (ME) and the prevalence of modifiable risk factors and underscores opportunities to promote the prevention of the disease. Similar to more developed countries, BC is the most frequent cancer among women in countries of the ME, accounting for one-third of total cancer cases and 24% of total cancer deaths. Average age at BC diagnosis appears to be a decade earlier in Middle Eastern countries compared to the Western countries, and its incidence is predicted to further increase. Although incidence rates of BC are still lower in Middle Eastern countries than Western ones, mortality rates are similar and at times even higher. It is estimated that 30% of BC cases are due to environmental and lifestyle factors, such as obesity and diet and hence can be preventable. The ME suffers from surging rates of obesity, with eight of its countries ranking among the highest worldwide in obesity prevalence among adults aged 18 and above. ME countries with the highest prevalence of obesity that are among the top 20 worldwide include United Arab Emirates (UAE), Lebanon, Egypt, Libya, Qatar, Saudi Arabia, Jordan, and Kuwait with rates ranging from 30% in UAE to 37% in Kuwait. In parallel, studies in the ME have consistently showed a shift in dietary intake whereby traditional diets, rich in fruits and vegetables, are progressively eroding and being replaced by westernized diets high in energy and fat. Accumulating evidence is reporting convincing association between consumption of such westernized diets and higher BC risk. Addressing these risk factors and studying their association with BC in terms of their nature and magnitude in Middle Eastern countries could provide the basis for intervention strategies to lower the risk and alleviate the burden of BC in these countries.

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The first step to achieve a world without fragility fractures is to devise a strategic plan to improve research and planning, and assisting member states to acquire the required financial, technical, and other resources. This article aims to outline the first strategic plan devised for the Middle East and North Africa region proposed by the International Osteoporosis Foundation's (IOF) Middle East and North Africa (MENA) Regional Advisory Council (RAC). PURPOSE: Osteoporosis is no exception in this rising tide of non-communicable diseases, not only sharing common risk factors but also contributing substantially to a heavy social and economic burden on society. During the past decade and after the establishment of the International Osteoporosis Foundation (IOF), a goal-directed movement has started to achieve a world without fragility fractures. In order to achieve this goal, regional councils were formed to maximize the effectiveness of national osteoporosis societies in raising awareness of effective prevention, diagnosis, and treatment strategies. METHODS AND RESULTS: The first step to achieve this goal is to devise a strategic plan to improve the research and planning, assisting all member states to acquire the financial, technical, and other resources needed in order to achieve a world-class program in the fight against osteoporosis. CONCLUSION: This article therefore aims to outline the first strategic plan devised by the IOF's MENA RAC for the Middle East and North Africa region.

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BACKGROUND: Diabetes mellitus (DM) in women of childbearing age may affect the fetus, thereby accelerating the intergenerational risk of DM. The Middle East and North Africa (MENA) region is experiencing a growing epidemic of DM. We aim to conduct two systematic reviews to summarize the burden of DM in women of childbearing age in the MENA region. In the systematic review 1, we aim to (1) systematically aggregate the evidence on type 2 DM (T2DM) and prediabetes and (2) to synthesize overall estimate on the prevalence of T2DM and overall estimate on the prevalence of prediabetes, in women of childbearing age (15-49 years). In the systematic review 2, we aim to (1) systematically aggregate the evidence on gestational DM (GDM) and (2) to synthesize overall estimate on the prevalence of GDM in pregnant women. METHODS: For systematic reviews 1 and 2, we will conduct a comprehensive search of the literature published in six electronic databases (MEDLINE-PubMed, EMBASE, Web of Science, SCOPUS, Cochrane Library, and Academic Search Complete). Variant and broad search terms will be designed to identify epidemiologic studies on the prevalence of T2DM and prediabetes in women of childbearing age, and GDM in pregnant women, published between 2000 and 2017. The MENA region will be defined according to the World Bank Country and Lending Groups. Retrieved citations will be screened, and data from the eligible research reports against specific eligibility criteria will be extracted. The findings of each systematic review will be reported separately following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA). DISCUSSION: Published literature on the prevalence of different types of DM among different population groups has been recently increased in the MENA region. This is the first review to fill an evidence gap on the overall burden, in the form of prevalence, of T2DM, prediabetes, and GDM in women of childbearing age in the MENA region. The findings of the two reviews will help in understanding the regional burden of these three types of DM in specific population groups to identify priority areas for interventions. SYSTEMATIC REVIEW REGISTRATION: The PROSPERO registration number for the systematic review 1 is " CRD42017069231 " dated 12/06/2017 and for the systematic review 2 is " CRD42018100629 " dated 18/06/2018.

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Middle East and North Africa (MENA) region is lagging far behind the global average to reach 90-90-90 targets. This study uses the UNAIDS 90-90-90 program to evaluate the HIV current situation in MENA countries, and understand the challenges that exist in the way of approaching the program goals. All articles and publications were searched based on the 90-90-90 program indexes among national and international data resources such as official national reports and online scientific databases such as PubMed, Medline, and Scopus up to December 2017. The data were categorized into four main stages: (1) estimated number of HIV-positive people (people living with HIV [PLWH]); (2) PLWH who know their status; (3) PLWH receiving antiretroviral therapy (ART); and (4) virally suppressed PLWH. A total of 41 papers were included in the study. 19 out of 24 MENA countries have met the inclusion criteria. The proportion of diagnosed people ranges from 6% in Pakistan to 76% in Algeria. The percentage of diagnosed people receiving ART ranges between 7% in Pakistan and 86% in Algeria. Viral suppression levels vary from 4% to 72% in Pakistan and Kuwait, respectively. Lack of appropriate surveillance systems, low access to HIV-care facilities along with complicated socioeconomic and geopolitical situation of the region have made it challenging for MENA countries to reach 90-90-90 goals by 2020. To achieve these goals, the foremost strategy is global effort to establish peace in this region and rebuild the infrastructure in the countries involved in war and to setup comprehensive surveillance systems in the majority of the MENA countries.

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The human papilloma virus (HPV) vaccine is the recommended prevention strategy for viruses-related cancers, but its acceptability remains controversial, primarily because of the relationship between sexual activity and HPV infection. Countries in the Middle East and North Africa are conservative vis-à-vis sexual behaviors, where Islam shapes people's practices including sexual health, and imposes that sex be carried out within lawful context. Many sexually transmitted infections can be prevented if the rules of Islam are unfailingly applied by Muslims in that region. However, this is not guaranteed and a noticeable shift in the sexual behavior of the youth has been detected, including a drastic increase in unofficial sexual practices, which in the long-term increase HPV incidence and its related diseases. This study examines the available epidemiological data as well as the teachings in Islam's sacred texts and scholars' perspectives to describe the tensions that exist in Muslim cultures around sexuality. Understanding their influence and the function of these tensions can help illuminate the factors that contribute to barriers to accepting the vaccine.

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