HIV experts are concerned that the largely Islamic countries of the middle east and north Africa may be set to follow east and south-east Asia in seeing sharp rises in HIV infections in gay men and men who have sex with men. Studies presented at the 19th International AIDS Conference in Washington recently found relatively low HIV prevalence, but low rates of condom use in men who have sex with men (MSM).
One study from Marrakech and Agadir in Morocco found that a high proportion of men ‘never’ used condoms in anal sex with men, and in the case of Marrakech, not in vaginal sex with women either. Meanwhile, a pioneering outreach project in the more conservative environment of Cairo, Egypt, found low rates of condom use and high rates of drug injection. A third, qualitative study from Beirut in Lebanon also found low rates of condom use and found that men who were uncomfortable with their sexuality had considerably lower rates of condom use and of testing for HIV but more sex partners.
The Maghreb culture has prohibitions against homosexuality (as it does against adultery and sex work), and yet also has a history of relative tolerance of same-sex activity. It may have been protected against HIV in the past due to low background prevalence, universal male circumcision, and conservative sexual customs. However it also means that researching into men who have sex with men is fraught with difficulty. These studies therefore all featured highly selected groups of MSM, unlike the Thai study also reported at Washington.
The Morocco study recruited men by ‘respondent-driven sampling’ whereby volunteers recruited other MSM contacts; the Beirut study also did this but in addition adjusted recruitment in order to ensure a balance between over- and under-25s.
The Egyptian study was of men attending novel (for the area) HIV centres for high-risk populations and were recruited ‘deniably’. In other words, while they could be referred overtly by other MSM, they could also be referred by other groups of men who knew of the centre and who were defined in one way or another as being at high risk of HIV, such as drug injectors or taxi drivers, but disclosures of sexuality did not have to happen until participants were assured of confidentiality.
High HIV risk levels in MSM in Agadir and Marrakech, Morocco
The Moroccan study was prompted by a finding that, while HIV prevalence in the general Moroccan population is less than one per cent, 38% of all HIV cases were reported from Agadir and Marrakech. The three previous studies ever done in MSM has found HIV prevalence in MSM ranging from 2.4% to 4.4%.
The current study used respondent-driven sampling to recruit 669 MSM, 323 from Agadir and 346 from Marrakech. To be included, men had to report having had anal sex with another man at least once in the last six months and to be over 18.
HIV prevalence in this group overall was 4.2%, but in Agadir was 5.6%.
The average age of the men in the study was 21.5. Only a quarter defined as gay, while 70% defined as bisexual. Most were unemployed and two-thirds had been paid for sex in the last six months. For an Islamic country, there were high rates of alcohol use, with 78% drinking alcohol and three-quarters of those drinking at least once a week. The other recreational drug commonly used was hashish; use of other recreational drugs was in single percentage figures.
The vast majority of men (93.5%) had been the insertive partner in anal sex in the last six months but only 25% had been the receptive partner. As one audience member asked, “Where are all the bottoms?”, and it is not possible to tell from if this imbalance was due to this survey finding a specific group of largely male sex workers who generally took the active role, or whether stigma and shame about taking the receptive role led respondents to deny it.
Rates of condom use were quite low, and significantly lower in Marrakech than Agadir, where 63% of participants said they “never” used condoms for anal sex. When men took the active role, 58% of men in Agadir but only 25% of men in Marrakech had used a condom last time they had sex; when they took the passive role, 81% in Agadir and 59% in Marrakech used a condom. The average number of partners in the last six months was six when taking the insertive role and nearly eight in men taking the receptive role (nine in Agadir), suggesting that allowing oneself to be passive might also involve having more partners.
Eighty per cent of participants reported also having had sex with women and 36.5% reported more than five female sex partners in the last six months (44% in Agadir).
There was widespread ignorance about HIV testing: 72% of men in Marrakech said they did not know where to get an HIV test and while only 42% in Agadir said they did not know, only 48% of those who did had ever taken a test.
These average figures conceal extremes; for instance, a small group of respondents had much higher numbers of sex partners, in the order of several a week. As well as the HIV rates already quoted, rates of syphilis were quite high: 7% in Agadir and 11% in Marrakech (32% and 55% respectively in those testing HIV-positive).
All these findings led the researchers to call for an urgent scaleup of access to condoms and lubricants; systematic screening for STIs (whose symptoms were not recognised by participants); and a general expansion of outreach programmes to MSM.
Deniable outreach: how to set up a service for gay men in Cairo, Egypt
In Egypt, the prevailing culture is very intolerant of MSM, and helping them access appropriate services has been a real problem. Any overt acknowledgement of homosexuality would result in possible arrest and denial of services in many circumstances. And yet what few surveys have been done show Egypt has a growing presence of HIV in MSM: the latest prevalence figure for sentinel surveillance is 5.8%.Egypt also has the world's highest prevalence of hepatitis C.
Funding from the NGO FHI360 allowed the setting-up of three Comprehensive Care Centres in Cairo which provide injection equipment and condoms, run peer education, support groups and counselling for addiction and HIV diagnosis, provide voluntary HIV testing and run an HIV and STI clinic. They cannot, however, directly prescribe antiretroviral drugs (ARVs) as in Egypt this is a monopoly of the Health Ministry. Referral to the centre was, as described above, by other MSM but also ‘deniably’ via other at-risk populations who also attended the centre, which was widely publicised informally among taxi drivers.
Between 2008 and 2012, of the 5841 men who sought care, 1510 (28%) admitted having sex with other men. Nearly half were under 25 and nearly a quarter were married and they were in general quite highly educated: 51% had a university degree. Nearly half (44%) had exchanged sex for money over the last year, as worker or client.
A high proportion – 15% - had injected drugs in the last month and the same proportion had exchanged sex for drugs during the last year. One-third had a single steady or occasional male partner; of the two-thirds who had casual partners, only a third used condoms with them.
So far HIV prevalence in this group is relatively low at 3.3%. The biggest problem faced by the CCC clients is that they need to go to the health ministry if they need ARVs, but presenter Sherif Elkamhawi said that people going to the government clinics for prescription were not quizzed about the risk group they belonged to. Otherwise, he said, “the CCC model offers an attractive and practical solution for reaching MSM with proper care and support services; the positive impact of peer support is ideal.”
He recommended extending the CCC model to Egypt’s 26 other governorates.
Self-worth, disclosure and safer sex in Beirut, Lebanon
Finally, Frances Aunon of the Rand Corporation presented a qualitative study of MSM in Lebanon, exploring factors influencing sexual risk behaviour and HIV testing.
On the surface, Beirut, Lebanon’s capital, has a more liberal attitude towards homosexuality, with a commercial gay scene promoted by travel journalists. However homosexuality remains illegal and highly stigmatised. Although the law is not often enforced, 36 men were recently arrested and subjected to invasive testing after exposure of a gay porn cinema on a cable TV show.
The study conducted semi-structured interviews with 31 subjects living in greater Beirut. Half were under 25. Fifty-seven per cent were Christian, 29% Muslim and 14% said they were atheist. Three-quarter identified as gay and the other quarter as bisexual, while a third had actually had sex in the last year with women as well as men. One participant had HIV, while seven (23%) had not taken an HIV test. For eighty per cent, the most frequent way of meeting partners was via gay websites.
Half the participants reported inconsistent condom use, though five of these only had unprotected sex with their primary partner. Some others, however, dropped condom use as soon as a relationship moved beyond the one-night-stand area: “There are some partners I sleep with more than once, so I don’t use a condom because I trust them,” said one.
One third of participants were comfortable with their sexual orientation, but the other two-thirds felt guilt (“The prophet Mohammed prohibited sex between men and every time I pray, I feel guilty”), stigma (“Everything you want to do you have to do in secret. That is what hurts”), and society’s expectations (“To be successful in this society I have to get married and have kids and my homosexuality prevents me, therefore I hate it.”)
Only half even thought their parents suspected they were gay. Those who came out encountered reactions from support (“My family says that they’ll love me no matter what...my sister is my biggest supporter”) to hostility (“Being gay has hurt me a lot and created a lot of conflicts in my family. That’s why I moved out.”)
The study found that men who were uncomfortable with, and did not disclose, their sexual orientation tended to show higher sexual risk behaviours. They had higher rate of unsafe sex (69%, versus 33% of those who did disclose), had more sexual partners (37 versus 17 a year, on average), had lower rates of ever testing for HIV (54% versus 89%) and were less likely to discuss HIV with sex partners (39% versus 89%).
“We need to look more at the role of sexual identity development in promoting sexual health,” said Frances Aunon.
Mellouk O (presenter Abadie A) et al. Men who have sex with men and the HIV epidemic in Morocco: results from a respondent-driven sampling study. Nineteenth International AIDS Conference, Washington DC. Abstract THAC0302. 2012. See here for abstract.
Elkamhawi S et al. The MSM population in a conservative environment: Egypt. Nineteenth International AIDS Conference, Washington DC. Abstract THPDC0104. 2012. See here for abstract.
Wagner GJ (Presenter Aunon FM) et al. Relationship between comfort with and disclosure about sexual orientation on HIV-related risk behaviours and HIV testing among men who have sex with men in Beirut, Lebanon. Nineteenth International AIDS Conference, Washington DC. Abstract THAD0504. 2012. See here for abstract.