Narrow window to avert HIV epidemics among MSM in Middle East and North Africa

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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 man.

High levels of risk behaviour in many countries suggested that there was the potential for further spread of HIV.


risky behaviour

In HIV, refers to any behaviour or action that increases an individual’s probability of acquiring or transmitting HIV, such as having unprotected sex, having multiple partners or sharing drug injection equipment.


Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.


In everyday language, a general movement upwards or downwards (e.g. every year there are more HIV infections). When discussing statistics, a trend often describes an apparent difference between results that is not statistically significant. 


Insertive anal intercourse refers to the act of penetration during anal intercourse. The insertive partner is the ‘top’. 


Receptive anal intercourse refers to the act of being penetrated during anal intercourse. The receptive partner is the ‘bottom’.

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.

Overall, the 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 considerably higher.

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 population.

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.

Significance evidence 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 relationships.

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.

Despite their 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.


Mumtaz G et al. Are HIV epidemics among men who have sex with men emerging in the Middle East and North Africa?: a systematic review and data synthesis. PLoS Medicine 8:8, e1000444, 2011.