Characterizing the HIV/AIDS Epidemic in the Middle East and North Africa: Time for Strategic Action

Published: April 27, 2010

Men Who Have Sex with Men and HIV

This chapter focuses on the biological evidence for the extent of human immunodeficiency virus (HIV) spread among men who have sex with men (MSM), the behavioral evidence for sexual and injecting risk practices among this population group, and the context of homosexuality in the Middle East and North Africa (MENA).

HIV PREVALENCE AMONG MSM
HIV transmission between men who have sex with men has been reported in most MENA
countries.

The available prevalence levels indicate a considerable HIV spread among MSM in MENA. Although some prevalence levels are low, this should not be interpreted as limited potential for future spread. HIV prevalence among hijras in one study in Pakistan was 0% in 1998, but syphilis prevalence was at 37%.4 This suggests substantial levels of sexual risk behavior and potential for HIV infectious spread if HIV is introduced into sexual networks involving this population. This has been confirmed because recent data have shown some rapidly rising epidemics among MSWs and hijras in Pakistan.5 There is also a pattern of increasing HIV prevalence among MSM in other regions with a similar sociocultural background, such as in Indonesia in Southeast Asia.6

PREVALENCE OF HOMOSEXUALITY
Men who have sex with men form the most hidden and stigmatized risk group of all HIV risk medieval times, the regularity and apparent tolerance of male same-sex relations in the Arab and Islamic world were viewed in the West as a sign of moral decadence.11

There are no reliable estimates of the number of MSM in MENA. “Ever engaging” in anal sex is
probably a poor definition for MSM in the context of this region. Male same-sex sexual behavior in
MENA should not be understood in terms of the Western paradigm of rigid distinction between homosexuals and heterosexuals despite recent Westernization of lifestyles. Sexual identities are more complex and intertwined and there is a full spectrum between these two distinctions.13

Drawing on the experience in India, gender segregation, delayed marriage, difficulty in accessing females for sex, and overcrowded living conditions can contribute to casual anal same-sex contacts.14 It is possibly not uncommon for adolescent boys to have sex with each other,15 for older men to pursue sex with boys,16 and for married men to have extramarital homosexual relationships.17 Peer pressure at a young age and family instability were identified as reasons for engaging in same-sex anal sex and
male sex work in Sudan.18

Male same-sex sexual behavior in MENA extends well beyond the concept of an active MSM population and takes multiple forms. In Pakistan, there is a complex tapestry of MSM activity including hijras or khusras (transvestites who dress as women and often practice male sex work), khotkis (biological males who dress as men but have “female soul” and feminized traits and who practice male sex work), banthas (biological males with a male gender identity who often practice male sex work), zenanas (shemales), maalishias (masseurs and mainly boys), and chavas (MSM who switch sex roles) among other forms.19

Various studies have documented same-sex anal sex among MENA populations. In the Arab
Republic of Egypt, 77.4% of male street children reported ever having sex with males and 37.1% reported being forced to have sex with males.20 In Lebanon, 8.4% of prisoners reported anal sex with
a man in prison.21 In the Islamic Republic of Iran, 29% of single, sexually active males in Tehran reported homosexual contacts with no definition provided for the kind of contacts.22 In Pakistan, 11.3% of truck drivers reported ever having sex with an MSW, and 49.3% reported ever having sex with a man.23 In another study, 21.9% of truck drivers had sex with a male or hijra.24 Among truck drivers attending an STD (sexually transmitted disease) clinic, 53% reported anal sex with males.25 Among prisoners, 26% reported sexual relations with other males prior to incarceration,26 and among migrants, 1.7% reported ever having sex with a man.27 History of urethritis and genital ulcer disease among male prisoners was
associated with same-sex anal sex.28

In Sudan, 2% of males in mainly rural populations reported sex with males.29 Among truck
drivers, 0.2% reported having had sexual relations with both sexes, and 0.5% reported having
had sex only with males.30 Among prisoners, 2.2% reported having sex with males.31 Taking
advantage of boys and unemployed males for anal sex has also been reported in Sudan.32 In
the Republic of Yemen, it is estimated that there are 25,000 MSM, although there is no basis provided
for this estimate.33

There are also few estimates of the prevalence of commercial sex among men. In Pakistan, there were an estimated average of 2.3 MSWs and 2.4 HSWs per 1,000 adult men across different
cities.34 The range of prevalence varied from 1 to 4.8 per 1,000 adult men for MSWs and
0.4 to 3.7 per 1,000 adult men for HSWs.35

These data on male same-sex sexual behavior suggest that the prevalence of homosexuality in
MENA is comparable to global levels of a few percentage points of the male population engaging
in anal sex with males.36

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