HIV Epidemics may be emerging in MSM of Middle East, North Africa

“HIV epidemics appear to be emerging” among men who have sex with men (MSM) in at least a few Middle East and North African countries “and could already be in a concentrated state among several MSM groups,” according to results of the first wide and detailed look at HIV among MSM in these parts of the world.

MSM typically remain a “hidden population” in the Middle East and North Africa because of stigma and discrimination. In many parts of the world, MSM account for high proportions of people with HIV. To determine whether HIV is spreading among MSM in the Middle East and North Africa, researchers conducted this systematic review of published reports, international organization reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and other institutional documents. This process turned up “considerable data” on MSM in the Middle East and North Africa.

Although HIV prevalence remains low among MSM in many target countries, there were exceptions. One MSM group in Pakistan had an HIV prevalence of 27.6%. HIV prevalence reached 14.8% in certain MSM groups in Iran and 9.3% in MSM groups in Sudan. Case notification reports showed that homosexual/bisexual sex contributed about 13% of HIV infections in Egypt, Lebanon, and Oman.

HIV prevalence increased in some areas, accounting for more than one quarter of notified HIV cases in several countries. In Lebanon sex between men “accounted for 52.3% of notified HIV cases in 2008, at a time when the cumulative proportion of infections due to MSM transmission was only 13.0%.”

The study documented high rates of HIV risk behaviors in some groups, including an average 4 to 14 partners in the last 6 months and consistent condom use generally below 25%. High rates of male sex work in study populations (20% to 76%) “and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.”

The investigators believe “there is an urgent need to expand HIV surveillance and access to HIV 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.”

The editors of PLoS Medicine caution that “because only the visible part of the MSM populations in many [of these] countries has been sampled, these findings may not be representative of all MSM in this region.” They stress that “high levels of risk behaviors practiced by many MSM in [the Middle East and North Africa] mean that MSM could become the pivotal risk group for HIV transmission in this region in the next decade.”