Study looks at HIV infections in Middle East and North Africa

By Dr. Ananya Mandal, MDAug 3 2011

New research shows that sex between men (MSM - Men who have Sex with Men) is responsible for more than a quarter of new HIV infections in parts of the Middle East and North Africa.

High-risk sex between truck drivers in Morocco and Pakistan, prisoners in Lebanon and street children in Egypt are fueling the spread of HIV among those groups, researchers in Qatar found in a study of data from 23 nations published yesterday by the Public Library of Science in its journal PLoS Medicine.

This is the first survey that describes the state of HIV among gay and bisexual men in a region where same-sex intercourse is often criminal and the stigma associated with it can hinder efforts to prevent transmissions, the researchers said. 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. They hope the findings will spur governments to curb the epidemics, said Laith Abu-Raddad, an associate professor of public health at the Weill Cornell Medical College in Qatar who led the study. Abu-Raddad said, “Only a few countries have started in the right direction. The majority of countries still haven’t really acted.” He declined to say which nations are lagging behind, saying the matter is sensitive.

New HIV infections in the Middle East and North Africa more than doubled to 75,000 in 2009 from 36,000 in 2001, according to the Joint United Nations Programme on HIV/AIDS, or UNAIDS. Reliable data on epidemics in the region are scant, the Geneva- based agency said on its website.

Abu-Raddad and colleagues compiled data from 95 studies and articles. In most countries, fewer than 10 percent of gay and bisexual men have HIV, they found, less than western nations such as the U.S., where the rate is 21 percent. Infections were highest among a group of male prostitutes in Pakistan, where 28 percent have the virus.

Sex between men was responsible for more than half of Lebanon’s new HIV infections in 2008, compared with 13 percent of all infections in that nation since the first cases were detected. Gay sex accounted for 20 percent of new infections in Egypt, and at least a quarter in Oman and Syria, the study found. The men had between four and 14 sex partners in the past six months on average, and fewer than 25 percent said they regularly used condoms.

“Since we have this high-risk behavior and this potential for further spread, if HIV is introduced we might see growing epidemics,” said Ghina Mumtaz, a senior epidemiologist who was the lead author on the study. “This is why it’s important to act quickly.”

About 2 percent to 3 percent of men in the region engage in sex with other men, the researchers said, similar to the rate in other regions. While legal, social and religious taboos against homosexual sex in the Middle East and North Africa can make it difficult for governments to tackle HIV among gay and bisexual men, some are getting around the problem by supporting non-governmental organizations that provide testing, counseling, condoms and other support to men at risk of acquiring the virus, Abu-Raddad said. “It’s really time for action, for policy makers to think about it and also for them to know there are creative ways to dealing with the issue, even within the socially conservative context of this region,” he said.

The study was funded by the World Bank, UNAIDS and the World Health Organization. Weill Cornell Medical College in Qatar is a partnership between the Qatar Foundation and Cornell University in Ithaca, New York.

“We're all pretty much the same,” said 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.” 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.”

An estimated 33.3 million people worldwide had the human immunodeficiency virus (HIV) that causes AIDS in 2009, according to the latest United Nations data, and 22.5 million of those live in sub-Saharan Africa.