HIV epidemics are
emerging among men who have sex with men (MSM) in a number of Middle Eastern
and North African countries, an international team of investigators report in
the online journal PLoSMedicine.
Prevalence of HIV was
as high as 28% among some populations of MSM in Pakistan, and in 2008 over 50%
of new HIV infections in Lebanon were in men who reported anal sex with another
High levels of risk
behaviour in many countries suggested that there was the potential for further
spread of HIV.
Alarmed by their
findings, the investigators suggest: “There is an urgent need to expand HIV
surveillance and access to testing, prevention, and treatment services in a
rapidly narrowing window of opportunity to prevent the worst of HIV
transmission among MSM in the Middle East and North Africa.”
Worldwide, MSM are one
of the groups most affected by HIV. The epidemic in most industrialised
countries is focused on MSM, and research conducted in sub-Saharan Africa has
found evidence of large but generally hidden MSM epidemics. Moreover, epidemics
in MSM are well established and growing in Latin America and South East Asia.
In contrast, little is
known about the MSM HIV epidemic in Middle Eastern and North African countries.
Sex between men is often highly stigmatised in this setting, and in five
countries in the region homosexuality is punishable by death.
Given this lack in
knowledge, a team of investigators lead by Dr Ghina Mumtaz undertook a
systematic literature review to gain a better understanding of the HIV
prevalence in MSM, their risk behaviour and knowledge of HIV, in 23 North
African and Middle Eastern countries.
The authors believe
their study “provides an integrated analysis and synthesis of the evidence to
address the gap in our knowledge of what could potentially materialise as the
key risk group for HIV sexual transmission in this region in the next decade”.
A total of 26 studies
were included in the investigators’ analysis. They defined MSM as men who had
insertive or receptive anal sex with other men. However, the researchers emphasised that there
was a huge diversity in MSM self-identity, role and behaviour in the region.
prevalence of MSM behaviour was consistently between 2 and 3%. However, in some
populations such as truck drivers (9 to 49%) or street children (15 to 77%), it was
Surveillance in 2006
suggested that 6% of MSM in Egypt were HIV-positive, but prevalence differed
between countries and was as high as 28% among some populations of MSM in
Pakistan. (Pakistan is treated as part of the Eastern Mediterranean region by the World Health Organization.)
There was also some
evidence that the epidemic was gaining pace among MSM. In Lebanon, 13% of all
HIV infections are in MSM, but in 2008, 52% of new HIV diagnoses were in this
The investigators also
found a trend for more recent studies to find a higher HIV prevalence. However,
they caution that this could be because of improved methodology or MSM
populations becoming more visible.
emerged of high levels of HIV risk behaviour among MSM.
In many of the
populations surveyed over 90% of MSM reported multiple or concurrent sexual
Paying for anal sex
with commercial sex partners was reported at rates of between 12 and 80%.
Overall condom use was
low and generally below 25%. Use of lubricants was as low as 18% in one study. Although over 80% of
MSM had heard of condoms, only 30 to 50% of men knew that their use offered
protection against HIV. Difficulty obtaining
condoms was widespread, and many men reported that they disliked using them.
Male sex work was
common and reported by between 20 and 76% of men and almost 100% of transgender hijras in Pakistan.
Up to 70% of MSM
reported ever having had sex with a woman, and between 3 and 35% said they were
currently married. A significant proportion of men also reported using female
sex workers and injecting drugs.
Levels of basic
knowledge about HIV were high. Between 82 and 100% of men reported ever hearing of
HIV in Egyptian studies.
MSM in Lebanon and
Tunisia had a good knowledge of HIV, its transmission, and the role of condoms
in its prevention. However, in other countries knowledge of HIV was limited.
comparatively good understanding of HIV, 33% of MSM in Lebanon thought they had
no chance of acquiring HIV. There was also a widespread belief that anal sex
involved a lower risk of HIV transmission than vaginal sex.
“MSM in MENA engage in
considerable levels of sexual risk behaviors. Multiple sex partnerships of
different kinds are practiced by the majority of MSM; commercial sex work
including selling and paying for sex is prevalent; condom and lubricant use is
limited; and overlap with opposite sex sex and injecting drug risk behaviors
is substantial,” comment the investigators.
A high prevalence of
sexually transmitted infections was detected in some MSM populations. Over a
quarter of MSM in Pakistan and Turkey had genital herpes, and syphilis and
gonorrhoea were detected in between 8 and 9% of Egyptian MSM.
“The window of
opportunity for prevention further HIV transmission among MSM is narrowing, and
prompt action and robust interventions are needed,” conclude the authors.