In most of the Middle East and North Africa, men who have sex with men (MSM) face severe stigma and harsh laws, creating a hidden population that HIV/AIDS researchers and outreach workers have difficulty reaching. Now the most comprehensive review yet done of HIV's spread in MSM who live in the region reveals that there are several hidden epidemics, too, with prevalence reaching as high as 28% in some groups.
Epidemiologists Ghina Mumtaz and Laith Abu-Raddad, both of Weill Cornell Medical College in Qatar, led the study, which over the past 8 years selected the highest quality HIV/AIDS reports they found in scientific publications, government documents, and nongovernmental organization (NGO) surveys. Although the discovery of widespread HIV in the region's MSM could reflect a long-standing epidemic that only has surfaced now because of increased research, Mumtaz and Abu-Raddad contend that this is not a case of detection bias. "The data suggest these epidemics are recent," says Mumtaz, who explains that several countries have documented a steady increase in prevalence over time.
As they detail in the August issue of PLoS Medicine , less than 25% of MSM in most locales reported consistent use of condoms, and exchanging sex for money was common, as was sex with females. Although MSM generally knew about HIV, many did not think they were at any risk of becoming infected. A key message of the study is that even though the Muslim-dominant region has a strong conservative bent, about 2% to 3% of males in the two dozen countries analyzed have anal sex with men, which is similar to global levels.
"We're all pretty much the same," says epidemiologist David Celentano of the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland. "Everyone says Muslims would never tolerate this, but if you go back in ancient history, there's a lot of same-sex sex. People profess to have these strong beliefs, but that doesn't govern their behaviors at all."
The study also challenges what the authors call "widely held perceptions" that HIV/AIDS epidemiological data about MSM in the region are "virtually absent." By reading documents in English, Arabic, and French, they concluded that there is "considerable and increasing epidemiological evidence on HIV and risk behavior among MSM in this region." Although the quality of the studies varied, they found "significant improvement" in data collection since 2003 in Morocco, Egypt, Lebanon, Iran, Tunisia, Sudan, and Pakistan. Several countries also have compulsory HIV testing for all workers who want to work abroad or for couples seeking a marriage license. "This is really a case of if you don't look for it, you don't find it," Celentano says. "I think these guys did a really good job of digging."
Even though the data may provide accurate HIV prevalence information, the authors stress that the studies they relied on often sampled the most visible MSM populations, which could introduce bias. In particular, the highest documented prevalence occurred in transgender sex workers and in homeless MSM. The data may also skew toward men who see themselves as gay, underestimating HIV in the population of males who, particularly if they are the "top" in anal sex with a man, do not identify themselves as homosexuals.
Abu-Raddad says the advent of the Internet and the growth of civil societies and activism in many Arab countries is making it easier to study HIV in MSM. "Ten years ago, people thought it would be impossible to work with MSM in this region—that the MSM wouldn't be willing to participate in studies because of fear," he says. "But NGOs have created bridges between governments and these populations. The NGOs rely on peer recruitment and don't have to find these groups. They're coming to them."