• HIV
• men who have sex with men
• lebanon
• fast-track
• sexually transmitted infections

A concerted global effort to end HIV transmissions is necessary. In the Middle East and North Africa (MENA), men who have sex with men (MSM) constitute a hard-to-reach population, due to the social stigma and criminalisation of homosexuality in most countries.1 When compared with other MENA countries, Lebanon is one of the safest for sexual minority groups. Its capital city, Beirut, is one of the most socially progressive cities in MENA, with a vibrant MSM community and gay bars, clubs and community centres.2 Yet, we know little about HIV prevalence, incidence and risk factors in MSM in Lebanon, a group disproportionately affected by the condition. This editorial sets an agenda for HIV research in this key population.

HIV care in Lebanon is offered through a collaboration between the National AIDS Control Program (NACP) (jointly funded by the Lebanese state and the World Health Organization) and various non-governmental organisations (NGOs). The NACP provides the NGOs with training, and provides access to HIV testing, and antiretroviral therapy for Lebanese citizens and refugees. Sexual healthcare is available through gay-friendly NGOs which are widely known in the Lebanese gay community as a space for accessing low-cost sexually transmitted infection testing and sexual healthcare. The cost of comprehensive care, clinical monitoring of HIV patients, and the treatment of other health issues (eg, mental health) are not covered by the NACP, which can undermine the quality of HIV care. The NACP also provides access to post-exposure prophylaxis (PEP) but not to pre-exposure prophylaxis (PrEP), which must be acquired privately. The exclusion of sexual healthcare from primary healthcare settings, the absence of sexual health coverage by private insurance companies, the instability of the Lebanese healthcare system, and HIV stigma, collectively, inhibit consistent access to HIV care.

According to the NACP, the HIV epidemic in Lebanon has remained at a plateau for the past 10 years, with relatively few recorded HIV-related deaths.3 Until December 2017, 2206 HIV/AIDS cases were recorded.3 The epidemic is concentrated in MSM and incidence has increased from at least 47.7% MSM of all HIV diagnoses in 2016 to at least 54.15% in 2017 (38.3% of the reported cases in 2016 had a 'not specified' sexual orientation vs 9.8% in 2017).3 According to a data synthesis, 3500 people were estimated to be living with HIV in Lebanon in 2011 (less than 0.01% of the general population and 3.7% of MSM).2 However, these data are now at least 7 years old. In a study of 213 MSM, a prevalence of 1.5% (3/197) was reported,2 while another study in 2017, using a similar sampling strategy, reported a prevalence of 12.3% in 292 MSM, 25% of whom were Syrian refugees.4 In short, we do not yet have reliable data on HIV epidemiology in MSM in Lebanon and other potential secondary makers of HIV infection, such as syphilis and gonorrhoea prevalence, are not reported to the NACP.

The lack of data can be attributed partly to low rates of HIV testing. According to a 2012 UNAIDS (Joint United Nations Programme on HIV/AIDS) report, testing rates in the MENA region are among the lowest in the world.5 Testing rates among Lebanese MSM ranged from 25% in 2010 to 38% in 2014.2 6 However, these data may not be representative of MSM in Lebanon for at least two reasons. First, studies have generally included more MSM in relationships, who are much more likely to have tested for HIV than men not in relationships, potentially causing selection bias.2 Second, participant samples have included a large number of MSM engaged in sex work (36% according to one study).6 Given the nature of their work, MSM sex workers report having a higher number of sexual partners (2–3 partners/day) than MSM who do not sell sex (10 partners/year).6 This group is less likely to use condoms and to access health services, due to socio-structural barriers such as poverty, stigma and legal issues. Furthermore, Wagner et al reported a testing rate of 62% in their study of 213 MSM from Beirut.2 Although the overall testing rates appear to have increased, there is a need to increase their prevalence and frequency in MSM.

Existing data indicate a high prevalence of sexual risk-taking in Lebanese MSM.2 4 6 In a study of 292 MSM, it was found that 65% reported condomless anal sex (CAS) and that 22% disclosed engaging in group sex.4 In another study of 213 MSM, 23% of participants reported CAS with a partner living with HIV or of unknown status.2 Current research suggests that condom use is determined by relationship context and type,2 and one study has shown that men in ‘committed relationships’ were almost three times more likely to engage in CAS when the HIV status of their sex partner was known.7 A study of MSM sex workers has shown a high prevalence of CAS with regular partners and a high prevalence of inconsistent condom use with clients.7 However, more data are needed to understand the psychosocial correlates of risk-taking behaviour.

Data on HIV care are also limited. In 2017, the cumulative number of people living with HIV in receipt of HIV care from the NACP reached 1320 (1320/2206; 59.83%).3 Treatment coverage and the rate of viral suppression in HIV-positive MSM are not known. There is some work on well-being among Lebanese HIV patients, with one study reporting a fair quality of life in patients.8 Symptomatic HIV and perceived stigma were negative predictors of quality of life. HIV status disclosure is also known to predict well-being. Although 80.5% of participants reported disclosing their HIV status to someone else, 72.5% reported being cautious about disclosure to avoid stigma and marginalisation.8 Understanding engagement with care, quality of life and HIV status disclosure in Lebanese MSM living with HIV is vital.

This editorial illustrates an urgent need for more reliable data on HIV prevalence, incidence and risk factors associated in Lebanese MSM, as well as the rate and nature of patient engagement with HIV care. The studies described enable us to identify the key characteristics of the HIV epidemic in Lebanon. Yet, the data also show that rates of HIV testing are unacceptably low. Behavioural interventions, higher rates of HIV testing and engagement with HIV care depend on our ability to understand medical, behavioural and cultural drivers. Future studies must recruit representative samples of MSM and focus on the psychosocial correlates of risk-taking. However, systematic research into HIV remains a challenge in Lebanon where social, cultural and religious norms around sexuality contribute to the stigmatisation and exclusion of MSM.