Background: Worldwide, HIV incidence, and mortality has decreased since 2010; however, in the WHO Eastern Mediterranean region, trends continue to increase. We reviewed the regional progress to understand determinants of this situation and inform strategies to accelerate the response. Methods: We conducted a multicountry programme review of 22 countries in the WHO Eastern Mediterranean region from Jan 1, 2010 to Dec 31, 2020. We extracted data from WHO's global AIDS monitoring system, UNAIDS estimates, and country reports regarding incident cases, policy uptake, and antiretrovirals used. We analysed data to describe incidence, testing practices, treatment coverage, and mortality to identify bottlenecks leading to persisting incidence and mortality. Findings: Due to COVID-19 disruptions, the volume of HIV testing in 2020 halved to 3·0 million tests compared with 2019 with 8017 people living with HIV identified (0·27% positivity yield). In comparison with a 0·18% positivity yield from the 6·5 million tests in 2019. HIV tests were done in migrants (59·6%), groups at low risk (38·9%), and key populations (1·5%). Diagnoses with advanced disease increased from 27·3% in 2017 to 37·0% in 2019. In 2019, among 52 318 people on treatment, only 2888 (6%) received optimised regimens as per WHO recommendations. The number of people on treatment increased from 19 000 in 2010 with a coverage of 8% to 110 000 in 2020 with a coverage of 25%. Late diagnoses and suboptimal regimens could explain the increase in mortality from 9600 in 2010 to 17 000 in 2020. Interpretation: In the Eastern Mediterranean region, inefficient testing and suboptimal treatment lead to underdiagnosis, persisting transmission, late treatment, and rising mortality. The HIV epidemic is growing faster than the response. A change in thinking is needed to test groups at high risk, transition to optimised treatment, and deliver patient-centred services that maximise retention. Funding: World Health Organization.
