A total of 721 records were identified during the 10 years period ( 2008-2017) , after elimination of duplicate, 646 studies were remained. When the titles and abstracts were screened a 598 irrelevant records were excluded and only 48 were assessed for eligibility of which 7 were excluded and only 41 were finally included in meta-analysis. Figure 1, illustrated the flow of the diagram for study selection. There was steady increase in the number of publications and HIV records in NA with slight increase in the last two years. The highest number of publication and HIV data notification was reported in Morocco, Egypt, Sudan and to less extent in Algeria , Tunisia and very low in Libya and Mauritania. The characteristic of included studies are presented in Table 1. The forty-one studies were cross sectional and cohort in design and carried between 2008 and 2017.
The study quality assessment have shown that an overall, there were n= 7, low quality where no full text available, n= moderate quality and n= high quality studies. However, after conducting analysis according to quality assessment, there were no significant difference between of high /medium quality studies and low or medium studies .
Temporal Trends of HIV/AIDS in North Africa
During the study period (2008-2017), there was an increasing trend in the prevalence of HIV/AIDS within the Northern African region with great variation among the countries within the region Figure 2, shows the prevalence of HIV/AIDS in each North African country during the study period. In 2008, the highest prevalence was reported in Sudan (1.3%) followed by Algeria(1.2%) and Mauritania(1.3 %)[22-24] . Although it was less than 1% in Tunisia ( 0.9%), Morocco ( 0.3%) Egypt ( 0.2%) and Libya( 0.2%) [25-28]. In ten years period ( 2017), the overall prevalence was increased significantly ( P< 0.001) to reach more than four times that of 2008. The highest prevalence was reported in Sudan (4.3%), followed by Mauritania (2.3%), Algeria (2.2 %), Egypt (1.8%),Morocco (1.6%),Tunisia (1.2%) and Libya (0.9%). The overall prevalence of HIV among the North African countries varies greatly from one country to another and within the population of the same country in the studies analysed as illustrated in Forest plot-Figure 3. There was a clear relationship between the prevalence of HIV and attributable risk factors. General population and ordinary patients have low HIV prevalence comparable to other studied groups. For instances studies from blood donors, pregnant women carried in Egypt, Mauritania, Sudan, morocco, and those carried on General population in Libya, Tunisia and Algeria showed a low HIV prevalence which elevated on the risk groups within the same country. The overall odds ratio in the meta-analysis demonstrated a statistically significant variation among the population studied. The association appears a bit stronger in the studies related to high-risk groups. The test of heterogeneity showed a significant variation among the included studies indicating the nature and quality of these studies.
Demographic features of HIV/AIDS in North Africa
Figure 4 illustrated the gender and age specific distribution of HIV/AIDS among Northern African countries, Within the HIV/AIDS reported cases from 2008 till 2017, 76.9 % were male and 25.1% were female, with a male to female ratio of (M:F 3.1: 1). Although such prevalence among most of the North African countries, the number of the infected females was similar to male mainly in Morocco. The number of HIV/AIDS cases were predominantly reported among young individuals aged between 21 and 30 years old which reached 45% followed by meddle aged group (31- 40 years) at prevalence of 30 %. A remarkable increase in the number of HIV/AIDS cases was reported among a younger patients aged less than 20 years particularly in Sudan, Algeria and Morocco. In addition the prevalence of HIV/AIDS infected cases of those aged above 40 years was steady among all countries at 20 % a part from Libya which showed slight increase to reach 30 %. Few studies reported from Libya, Morocco and Sudan has reported on the education level and marital status of HIV/AIDS cases. Most of the infected cases were found predominantly among unmarried individual who were mainly, illiterate or with a low level of education[29-32].
Prevalence HIV among risk population
Figure 5 shows the prevalence of HIV/AIDS among high risk group populations within the Northern African countries. The highest prevalence was reported among PWID with an estimated median of 8% ranging from 3.80%, 95% CI( 2.46–4.67%) to be 15.7%, 95% CI (9.46–18.67%). This is particularly high in Morocco Egypt, Sudan and Libya. HIV/AIDS among Sexual Promiscuity was also reported to be on an average of 2.8% (1.7–11.3%). It found to be 4.9% in Morocco, Algeria, Tunisia and Egypt and higher than 10.5% in Tunisia and Sudan [33-36]. Among the Prisoners, it was reported to be high in Libya , Sudan and Egypt although it was less than that in Mauritania, and Algeria. HIV was also reported to be high in Hospital care setting in Northern African countries ranging from 0.8 to 9.7 %.[37-41]. The highest was reported in Mauritania, Algeria, Egypt, followed by Sudan Tunis and Morocco and Libya.
Distribution of HIV-1 subtypes
Based on our data, genotype distribution of HIV in the seven Northern African countries is shown in Figure 6. Analysis of HIV-1 subtypes distribution in is very poor particularly in Algeria, Mauritania , where only one study was reported for each of them[42,43]. The Tunisian sequences belongs to , Six HIV-1 subtypes (B, A1, G, D, C, and F2), five circulating recombinant forms (CRF02_AG, CRF25_cpx, CRF43_02G, CRF06_cpx and CRF19_cpx) and 11 unique recombinant forms were identified. Subtype B (46.4%) and CRF02_AG (39.4%) were the predominant genetic forms. A genetic analysis of HIV-1 strains in Libya demonstrated low subtype heterogeneity with the evolution of subtype B which composed of 74% followed by , CRF_20 AG(18%) , as well as HIV-1 subtype A(8%)[RR]. In Sudan it was found that 50% were subtype D and 30% were subtype C. Subtype A, subtype B, and three unique recombinants were also found, some partially unclassifiable[45-47]. While in Morocco, subtype B is the predominant one (76.7%), followed by a high diversity of non-B subtypes, especially CRF02_AG recombinant (15%), and to less extent Subtype A(1.0%) and F strains (0.5%). Egypt; The commonly isolated strains form Egypt was Subtype B composed of 95% followed CRF01_AE ( 1%0 and A (1%). In Algeria , we observed high HIV-1 diversity with a predominance of the B subtype followed by CRF02_AG and CRF06_cpx.5,6. Studies have indicated that, the diversity was maintained, but CRF06_cpx became widely predominant. The Phylogenetic analysis of different strains in Mauritania revealed CRF02_AG ( 64.6%) was the predominant stain followed by B variants with the predominance of 10%.
Geospatial distribution of HIV/AIDS in North Africa
HIV/AIDS infections spread gradually from the capital coastal cities to the other regions of Northern Africa countries. Figure 7, display the spatial distribution of HIV-seropositive individuals living in North African between 2008 and 2017[48-51]. There is a clear change in the regional patterns of HIV with a significant spatial heterogeneity within each country. The substantial variability ranged from a low of 0.01 percent to 5% with no clear regional patterning of the space-time interaction.
A higher level was reported in Sudan, Morocco and Algeria and to less extent Mauritania and Tunis. Although the patterning persists in Libya and Egypt. In Sudan, the HIV patterns reached its highest in Southern regions, It is estimated that HIV prevalence in the 10 states that now make up South Sudan was 3.0%, ranging from zero in Northern Bahr el Ghazal to 7.2% in Western Equatoria State(WES). Followed by Kassala State- Eastern Sudan, (0.2-3%), Khartoum (0 to 5.7%.), Gadarif State (0.1-0.4 %), Kosti (0.1-0.7%).
In Morocco the highest was reported in Agadir Souss-Massa-Drâa,-SOUTH , Fes, Rabat in the central region followed by Nador and Tanger, in north and Marrakech in the south west.
In Egypt the prevalence was high in East Cairo Sector followed by Alexandria and South Sinai. Though in Libya was high both in Eastern and western coasts followed by Central south of Sebha area. In Tunisia the prevalence was the highest in the capital, Bizerte and Hammamet, followed by other coastal cities of Sousse and Sfax , though its less in meddle and the southern regions of the country. In Algeria, Northeastern Algeria reported the highest HIV prevalence particularly in the neighboring area of Tunis. Followed by Oran and Sidi Bel Abbes. Such prevalence was less in the central and southern regions of Algeria. In Mauritania, HIV prevalence reached its highest (1-2%)in Nouakchott area followed by the central region though no data available on most of Eastern regions and Western Sahara.
The North African countries has experienced high-risk clustering areas of HIV/AIDS cases during the 10 year study period. Figure 8 shows the Distribution of HIV spatial clustering in the region; Areas in dark red indicate statistically significant hotspots of higher than expected rates. The results of spatio-temporal cluster analysis suggested a special characteristic in temporal and spatial distribution for HIV/AIDS incidents. A total of ELEVEN statistically significant high-risk areas, at different periods were reported in several regions and provinces of the seven counties.
In Morocco has experienced two clusters, the highest spatio-temporal cluster area was located in Agadir Souss-Massa-Drâa,-at the south in 2011 and Fes, Rabat in the central region followed by Nador and Tanger, . The second one, in the north at 2012 and Marrakech in the south west at 2014.The main clusters were reported among PWID followed by MSM and FSWs. For PWID networks contributed to (6%; 95% CI 3–10%) , most transmission appears to be in the north of Morocco. The epidemic in commercial heterosexual sex networks and MSM appears to be most intense in the south of Morocco, and especially in Souss-Massa-Drâa. The largest contribution to HIV incidence was among clients of FSWs (25%; 95% confidence interval (CI) 14–37%), followed by MSM (22%; 95% CI 12–35%), stable heterosexual couples (corresponding to HIV serodiscordant couples; 22%; 95% CI 12–34%), and FSWs (11%; 95% CI 6–18%).
In Sudan, The biggest cluster was reported in Southern Sudan at Western Equatoria State(WES)-2012. Among 420 antenatal clinic attendees, HIV seropositivity was 10.7% (95% , CI = 8.0%–14.2%), and among 388 voluntary counseling and testing attendees, HIV sero-positivity was 13.1% (CI = 10.0%–17.0%), indicating high HIV prevalence in WES.
In Libya three clusters were reported between 2008-2017, the first cluster occurred during 2008–2012, consisted of 203 cases and It was located in Tripoli in the western region. The second one was reported in Musrata (largest in the central region) and consisted of 406 HIV cases detected between 2013 and 2017. While the third cluster was detected in Sebha( the largest city in the South) between 2013 and 2017 and consisted of 317 HIV cases.
In 2011, Egypt has experienced a concentrated epidemic among MSM and IVDUs in East Cairo Sector, Alexandria and South Sinai. The HIV prevalence ranged from (5.4% to 6.9% and 6.9% among MSM though it was (6.7-7.7%) in IVDUs.
Minor clusters were reported in Algeria , Tunisia and Mauritania A study (2013) carried in two hospitals in Northeastern Algeria reported a high clustering of HIV among pregnant women with a prevalence rate reached up to prevalence of 5.3/1000. In Tunisia however, a small cluster was reported among at the North of the country particularly within in the capital Tunis which was mainly associated with FMSW and MSM in 2 011. As well as In Mauritania a minor cluster was reported among blood donors in December 2015 at Hodh El Gharbi region which is located 800km from Nouakchott (capital) South-East of the country.