PLoS Medicine: Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis

Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis
A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries.

Ghina Mumtaz1, Nahla Hilmi1,2, Willi McFarland3, Rachel L. Kaplan4, Francisca Ayodeji Akala2, Iris Semini5, Gabriele Riedner6, Oussama Tawil5, David Wilson7, Laith J. Abu-Raddad1,8,9*
1 Infectious Disease Epidemiology Group, Weill Cornell Medical College-Qatar, Cornell University, Qatar Foundation-Education City, Doha, Qatar, 2 Human Development Sector, Middle East and North Africa Region, World Bank, Washington (D. C.), United States of America, 3 HIV Research Section, San Francisco Department of Public Heath, San Francisco, California, United States of America, 4 Department of Social Welfare, School of Public Affairs, University of California, Los Angeles (UCLA), Los Angeles, California, United States of America, 5 Joint United Nations Programme on HIV/AIDS Regional Support Team, Middle East and North Africa, Cairo, Egypt, 6 Regional Office of the Eastern Mediterranean, World Health Organization, Cairo, Egypt, 7 Global HIV/AIDS Program, World Bank, Washington (D. C.), United States of America, 8 Department of Public Health, Weill Cornell Medical College, Cornell University, New York, New York, United States of America, 9 Vaccine and Infectious Disease Institute, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America

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

Citation: Mumtaz G, Hilmi N, McFarland W, Kaplan RL, Akala FA, et al. (2010) Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis. PLoS Med 8(8): e1000444. doi:10.1371/journal.pmed.1000444

Academic Editor: David D. Celentano, Johns Hopkins University, United States of America

Received: July 2, 2010; Accepted: June 13, 2011; Published: August 2, 2011

Copyright: © 2011 Mumtaz et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The MENA HIV/AIDS Epidemiology Synthesis Project was funded through a joint partnership of the World Bank, the MENA Regional Support Team (RST) of United Nations Programme on HIV/AIDS (UNAIDS), and the Eastern Mediterranean Regional Office (EMRO) of the World Health Organization (WHO). GM and LJA are grateful to the Qatar National Research Fund for supporting this work (NPRP 08-068-3-024 and NPRP 4-924-3-251), and the support provided by the Biostatistics, Epidemiology, and Biomathematics Research Core at the Weill Cornell Medical College in Qatar. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: FSW, female sex worker; HCV, hepatitis C virus; HSV-2, herpes simplex virus type 2; HSW, hijra sex worker; IDU, injecting drugs user; MENA, Middle East and North Africa; MSM, men who have sex with men; MSW, male sex worker; RDS, respondent driven sampling; STI, sexually transmitted infection

* E-mail: lja2002@qatar-med.cornell.edu

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PLoS Medicine: Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis





SIDA
El sexo entre hombres extiende el VIH en Oriente Medio y África del Norte
JANO.es · 03 Agosto 2011 09:26

.Un estudio regional alerta de que la incidencia del virus entre el colectivo de varones que mantiene relaciones homosexuales empieza a alcanzar dimensiones de epidemia emergente.

La incidencia del VIH entre estos grupos empieza a cobrar dimensiones de epidemia emergente.

En la mayoría de los países de Oriente Medio y el Magreb, las prácticas sexuales entre varones están castigadas con la cárcel o, en algunos regímenes, la muerte. Así y todo, son muchos los hombres que se libran al sexo homosexual, una conducta favorecida por la segregación, el hacinamiento o la dificultad de acceder a las mujeres, y que no implica necesariamente la ausencia de relaciones heterosexuales. Ahora, un estudio publicado en PLoS Medicine advierte de que la incidencia del VIH entre estos grupos empieza a cobrar dimensiones de epidemia emergente.

El trabajo, llevado a cabo por los expertos Abu Laith-Raddad y Mumtaz Ghina, del Infectious Disease Epidemiology Group en el Weill Cornell Medical College en Doha (Qatar), hace hincapié en la "necesidad de que los países de Oriente Medio y el Norte de África pongan los medios para facilitar el acceso a la prueba del VIH y, de ese modo, evitar que las cadenas de transmisión lleguen a otros grupos de población".

Los autores, que analizaron datos recogidos por los propios gobiernos y por organizaciones internacionales gubernamentales y no gubernamentales, observaron que, contrariamente a la percepción generalizada, existe una creciente evidencia epidemiológica en lo relativo al VIH. Así, en países como Egipto, Sudán y Túnez, la prevalencia entre los colectivos mencionados es del 5%, y en algunas regiones de Pakistán, alcanza el 28%.

Por otra parte, durante 2008, la transmisión del VIH por la vía del sexo anal entre hombres fue responsable de más de una cuarta parte de los casos notificados de VIH en varios países de la región. No todos los países, sin embargo, llevaron a cabo estudios para evaluar el nivel de infección por VIH entre los hombres de la población que mantienen relaciones homosexuales, lo que limita la comprensión de la magnitud del problema.

Hasta 14 parejas en seis meses

Asimismo, se observó que, en las zonas estudiadas, aproximadamente un 3,2% de los hombres practican el sexo anal con otros varones, una proporción comparable a la de otras regiones. Muchos de estos hombres habían tenido entre 4 y 14 parejas sexuales en los últimos seis meses y las tasas de uso consistente del condón fueron, en general, inferiores al 25%. Además, entre el 20% y el 75,5% de los hombres que mantuvieron relaciones sexuales con otros hombres intercambiaron sexo por dinero, y también habían tenido varias parejas sexuales femeninas.

Los autores destacaron que, dado el espectro de la expansión de la epidemia, los responsables políticos en Oriente Medio y África del Norte "deben enfrentarse a este desafío creciente desde la perspectiva de la salud pública". Unos pocos países de la región han desarrollado ya formas creativas de hacer frente a este problema a través de las organizaciones no gubernamentales. Estos programas, afirman los autores del estudio, "deben ampliarse e implantarse en el resto de países para lograr la cobertura deseada".


Plos Medicine (2011); doi:10.1371/journal.pmed.1000444
PLoS Medicine: Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis

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