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Could North Africa and the Middle East be a new hotspot for HIV in gay men?

HIV experts are concerned that the largely Islamic countries of the middle east and north Africa may be set to follow east and south-east Asia in seeing sharp rises in HIV infections in gay men and men who have sex with men. Studies presented at the 19th International AIDS Conference in Washington recently found relatively low HIV prevalence, but low rates of condom use in men who have sex with men (MSM).
One study from Marrakech and Agadir in Morocco found that a high proportion of men ‘never’ used condoms in anal sex with men, and in the case of Marrakech, not in vaginal sex with women  either. Meanwhile, a pioneering outreach project in the more conservative environment of Cairo, Egypt, found low rates of condom use and high rates of drug injection. A third, qualitative study from Beirut in Lebanon also found low rates of condom use and found that men who were uncomfortable with their sexuality had considerably lower rates of condom use and of testing for HIV but more sex partners. 
The Maghreb culture has prohibitions against homosexuality (as it does against adultery and sex work), and yet also has a history of relative tolerance of same-sex activity. It may have been protected against HIV in the past due to low background prevalence, universal male circumcision, and conservative sexual customs. However it also means that researching into men who have sex with men is fraught with difficulty. These studies therefore all featured highly selected groups of MSM, unlike the Thai study also reported at Washington.
The Morocco study recruited men by ‘respondent-driven sampling’ whereby volunteers recruited other MSM contacts; the Beirut study also did this but in addition adjusted recruitment in order to ensure a balance between over- and under-25s.
The Egyptian study was of men attending novel (for the area) HIV centres for high-risk populations and were recruited ‘deniably’. In other words, while they could be referred overtly by other MSM, they could also be referred by other groups of men who knew of the centre and who were defined in one way or another as being at high risk of HIV, such as drug injectors or taxi drivers, but disclosures of sexuality did not have to happen until participants were assured of confidentiality.

High HIV risk levels in MSM in Agadir and Marrakech, Morocco

The Moroccan study was prompted by a finding that, while HIV prevalence in the general Moroccan population is less than one per cent, 38% of all HIV cases were reported from Agadir and Marrakech. The three previous studies ever done in MSM has found HIV prevalence in MSM ranging from 2.4% to 4.4%.
The current study used respondent-driven sampling to recruit 669 MSM, 323 from Agadir and 346 from Marrakech. To be included, men had to report having had anal sex with another man at least once in the last six months and to be over 18.
HIV prevalence in this group overall was 4.2%, but in Agadir was 5.6%.
The average age of the men in the study was 21.5. Only a quarter defined as gay, while 70% defined as bisexual. Most were unemployed and two-thirds had been paid for sex in the last six months. For an Islamic country, there were high rates of alcohol use, with 78% drinking alcohol and three-quarters of those drinking at least once a week. The other recreational drug commonly used was hashish; use of other recreational drugs was in single percentage figures.
The vast majority of men (93.5%) had been the insertive partner in anal sex in the last six months but only 25% had been the receptive partner. As one audience member asked, “Where are all the bottoms?”, and it is not possible to tell from if this imbalance was due to this survey finding a specific group of largely male sex workers who generally took the active role, or whether stigma and shame about taking the receptive role led respondents to deny it.
Rates of condom use were quite low, and significantly lower in Marrakech than Agadir, where 63% of participants said they “never” used condoms for anal sex. When men took the active role, 58% of men in Agadir but only 25% of men in Marrakech had used a condom last time they had sex; when they took the passive role, 81% in Agadir and 59% in Marrakech used a condom. The average number of partners in the last six months was six when taking the insertive role and nearly eight in men taking the receptive role (nine in Agadir), suggesting that allowing oneself to be passive might also involve having more partners.
Eighty per cent of participants reported also having had sex with women and 36.5% reported more than five female sex partners in the last six months (44% in Agadir).
There was widespread ignorance about HIV testing: 72% of men in Marrakech said they did not know where to get an HIV test and while only 42% in Agadir said they did not know, only 48% of those who did had ever taken a test.
These average figures conceal extremes; for instance, a small group of respondents had much higher numbers of sex partners, in the order of several a week. As well as the HIV rates already quoted, rates of syphilis were quite high: 7% in Agadir and 11% in Marrakech (32% and 55% respectively in those testing HIV-positive).
All these findings led the researchers to call for an urgent scaleup of access to condoms and lubricants; systematic screening for STIs (whose symptoms were not recognised by participants); and a general expansion of outreach programmes to MSM.

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