Bringing to light the HIV epidemiology of “hidden” MSM populations in the Middle East

What evidence is there of HIV epidemiology among MSM populations in the Muslim countries of the Middle East and North Africa (MENA)?  More than one might suppose, according to the authors of a recent systematic review, which draws on a comprehensive re-examination of all literature containing data points relating to HIV, as well as of specific data on MSM, in order to offer the fullest possible picture of a population that has, for reasons of stigma, remained largely hidden.  The recent scientific literature, they contend, contains some “well-designed” studies.

At roughly 2-3%, levels of MSM engaging in anal sex in MENA is consistent with reported global levels, though a fluidity of gender distinctions seems to be a characteristic of the region, with a large fraction of MSM not identifying as sharing any sexual orientation (i.e. “gay”, or “bisexual”).  Yet, up to 2003 or so, incidence of HIV was low.  Even today HIV prevalence among MSM in MENA is lower than in other global settings where MSM HIV transmission plays a key role in epidemiology.  Now, however, evidence points to a disquieting emergence of HIV epidemics in the region.  This evidence includes: 1. considerable MSM HIV prevalence documented in recent well-designed studies after limited or no earlier prevalence (e.g. rates of 14.8% and 9.3% in Iran and Sudan respectively); 2. increasing prevalence suggested by some recent and well designed studies (e.g. three rounds of surveillance surveys in Pakistan, indicating rates among hijra (transgender) sex workers of 0.8%, 1.8% and 6.4% in 2005, 2006, and 2008 respectively); 3. rising contribution of MSM transmission in case notification reports (e.g. 19.7% in Egypt, as in the most recent quarterly report, as opposed to 13.2% cumulatively prior to that report); 4. phylogenetic evidence in certain settings (e.g. Iran and Pakistan) linking MSM transmission to recent IDU epidemics.

In addition, much of this systematic review is taken up with characterizing aspects of MSM sexual practice and behaviour in MENA that could be seen as rendering MSM populations in this area particularly vulnerable as and when HIV epidemics emerge – such as the prevalence of male sex work in MENA; the engagement of MSM in heterosexual sex with non-commercial female partners; the overlapping of steady, casual and commercial relationships;  the overlap of MSM risk behaviours with IDU risk behaviour; low condom use and inadequate HIV knowledge.  Given the likelihood that HIV epidemics may still be at a relatively early stage, this paper offers a disquieting picture of immanent but probably still unrealized possibilities for further HIV expansion in MENA, as and when the disease reaches its epidemic potential.  The authors therefore urge prevention of MSM HIV as a “top priority” for HIV/AIDS strategies.  Given a moral, social and legal climate in MENA countries that seems unconducive to outreach for these vulnerable populations, the authors point to the past fruitfulness of programmes involving partnership of MENA governments with NGOs as a possible solution.

Ghina Mumtaz, Laith J. Abu-Raddad 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”, Public Library of Science (PLoS) – Medicine, 2nd August 2009Top of Form

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