Are HIV epidemics among men who have sex with men emerging in the Middle East and North Africa?: a systematic review and data synthesis

Abstract

Background: Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.

Methods and findings: This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4-14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%-54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%-76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.

Conclusions: This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. 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. Please see later in the article for the Editors' Summary.

Figure 1. Flow of article selection for the specific MSM in MENA search of scientific databases.

This chart, adapted from PRISMA 2009 flow diagram, displays the flow of article selection for the specific MSM in MENA search of scientific databases, namely PubMed, Embase, and regional databases. Further relevant studies included in the review, mainly in the form of country-level reports, were identified through the comprehensive search of the MENA HIV/AIDS Epidemiology Synthesis Project.

Figure 2. Data synthesis.

Summary of the synthesis and triangulation of biological, behavioral, and contextual data about HIV among MSM in MENA corroborating emerging epidemics and HIV epidemic potential.

Figure 3. HIV prevalence among MSM in MENA, 1990–2010.

This graph displays available HIV point-prevalence measures (from Tables 3 and S2) and 95% confidence intervals among MSM in all MENA countries with available measures, irrespective of study methodology. Studies with sample size of less than 100 were excluded because of very wide confidence intervals. Countries with available data include Egypt, Iran, Iraq, Jordan, Lebanon, Morocco, Pakistan, Sudan, Syria, and Tunisia. Each blue dot represents one HIV prevalence measure among MSM from one of the listed MENA countries for the specific year, while the bars around it define the limits of the 95% confidence interval around the prevalence measure. The graph indicates limited transmission until after 2003, when considerable HIV prevalence started to be apparent in most studies and surveys.