This is who we are: building community for HIV prevention with young gay and bisexual men in Beirut, Lebanon.

Young gay men in Beirut are at significantly elevated risk of HIV infection compared with the general Lebanese population. Despite nascent HIV prevention efforts in the region, there is a need for effective community-level HIV prevention interventions tailored for young gay men. This qualitative study examined internal dynamics within Beirut's gay community as a basis for developing community-level interventions. Peer ethnographers were trained to collect field notes on conversations between young gay men in public spaces in Beirut, and conducted follow-up focus groups with young gay men. Analyses revealed three major themes: (1) the need for safe spaces in which to socialise, (2) the importance of being able to locate and connect with other young gay men, and (3) ambivalence regarding a gay community that was supportive in some ways but also fragmented and often judgemental. Study findings also confirm the existence of external threats to community such as stigma, cultural and familial norms regarding heterosexuality and criminalisation of refugee status. Understanding such community dynamics and the environmental context is central to designing effective community-based HIV prevention programmes.

Psycho-social Correlates of Condom Use and HIV Testing among MSM Refugees in Beirut, Lebanon.

MSM refugees have to deal with personal challenges and social/structural adversaries based on their refugee status on top of their sexual identity. To better customize interventions beside this population, we explored psycho-social and structural correlates of condom use and HIV testing in Lebanon by surveying and testing 150 participants. 67 % self-identified as gay. 84.6 % reported any unprotected anal intercourse (UAI) with men in the prior 3 months. Those who engaged in UAI, were lest comfortable with a doctor, didn't know where to get free HIV testing, experienced discrimination based on their refugee status and spent more time with their refugee peers, were less inclined to have seen a doctor in the past 12 month or knew where to get free HIV testing. Ever having been HIV tested was associated with being comfortable with medical doctors, knowing where to get HIV testing and spending time with other peer refugees. HIV prevention and testing promotion efforts targeting MSM refugees need to account for structural barriers, while fighting discrimination is crucial for a healthy sexual identity development.

HIV Prevalence and Demographic Determinants of Unprotected Anal Sex and HIV Testing among Male Refugees Who have Sex with Men in Beirut, Lebanon.

Men who have sex with men (MSM), the same as refugees are at higher risk for health issues including HIV infection. With the large influx of refugees to Lebanon, and to better understand HIV transmission in this setting, we explored the socio-demographic correlates of condom use and HIV testing among MSM refugees in Beirut, by surveying and testing 150 participants. 67 % self-identified as gay, 84.6 % of respondents reported unprotected anal intercourse (UAI) in the prior 3 months, and 56.7 % with men of positive or unknown HIV status (UAIPU). 2.7 % tested positive for HIV, and 36 % reported having engaged in sex work. Men in a relationship and men who self-identified as gay had higher odds of UAI, of ever been tested, but lower odds of UAIPU. HIV prevention and testing promotion efforts targeting MSM refugees need to account for how men self-identify in relation to their sexual behavior and relationship status. Such efforts also should place emphasis on MSM of lower socio-economic status.

HIV prevalence and demographic determinants of unprotected anal sex and HIV testing among men who have sex with men in Beirut, Lebanon.

The limited epidemiological data in Lebanon suggest that HIV incident cases are predominantly among men who have sex with men (MSM). We assessed the prevalence of HIV and demographic correlates of condom use and HIV testing among MSM in Beirut. Respondent-driven sampling was used to recruit 213 participants for completion of a behavioral survey and an optional free rapid HIV test. Multivariate regression analysis was used to examine demographic correlates of unprotected anal sex and any history of HIV testing. Nearly half (47 %) were under age 25 years and 67 % self-identified as gay. Nearly two-thirds (64 %) reported any unprotected anal intercourse (UAI) with men in the prior 3 months, including 23 % who had unprotected anal intercourse with men whose HIV status was positive or unknown (UAIPU) to the participant. Three men (1.5 % of 198 participants tested) were HIV-positive; 62 % had any history of HIV testing prior to the study and testing was less common among those engaging in UAIPU compared to others (33 % vs. 71 %). In regression analysis, men in a relationship had higher odds of having UAI but lower odds of UAIPU and any university education was associated with having UAI; those with any prior history of HIV testing were more likely to be in a relationship and have any university education. HIV prevention efforts for MSM need to account for the influence of relationship dynamics and promotion of testing needs to target high-risk MSM.

Sexual stigma, psychological well-being and social engagement among men who have sex with men in Beirut, Lebanon.

This qualitative study sought to explore sexual identity development among men who have sex with men in Beirut, Lebanon; the stigma experienced by these men; and how their psychological well-being and social engagement are shaped by how they cope with this stigma. Semi-structured interviews were conducted with 31 men who have sex with men and content analysis was used to identify emergent themes. While many men reported feeling very comfortable with their sexual orientation and had disclosed their sexual orientation to family, most men struggled at least somewhat with their sexuality, often because of perceived stigma from others and internal religious conflict about the immorality of homosexuality. Most participants described experiencing verbal harassment or ridicule or being treated as different or lesser than in social relationships with friends or family. Mechanisms for coping with stigma included social avoidance (trying to pass as heterosexual and limiting interaction with men who have sex with men to the internet) or withdrawal from relationships in an attempt to limit exposure to stigma. Findings suggest that effective coping with both internal and external sexual stigma is central to the psychological well-being and social engagement of men who have sex with men in Beirut, much as has been found in Western gay communities.

Barriers to and enablers of the HIV services continuum among gay and bisexual men worldwide: Findings from the Global Men's Health and Rights Study.

OBJECTIVES: To assess ecological, structural, community and individual level correlates of health services utilization along a continuum of HIV care, and sexual health and support services among gay and bisexual men worldwide. METHODS: Using a nonprobability internet sample of 6,135 gay and bisexual men, we assessed correlates of utilization of health services. Chi-Square Tests of Independence were performed to assess drop off along a continuum of HIV care. Multivariable logistic regression analyses using generalized estimating equation models were conducted adjusting for geographic region and clustering by country. In multivariable analyses, we determined the association between utilization outcomes, and ecologic, structural, community and individual correlates by fitting separate generalized estimating equation (GEE) logistic regression models for each of the outcomes, fitted with robust SEs, and accounting for clustering by country. Stratified by sexual identity, analyses adjusted for variables that could influence HIV-related health outcomes including racial/ethnic minority status, participant age, insurance, ability to make ends meet, as well as country-level income (income of country of residence defined by the World Bank). RESULTS: Among men living with HIV (n = 1001), being in HIV care (n = 867) was associated with being on ART (X2 = 191.17, p < .001), and viral load suppression (X2 = 14.03, p < .001); and using ART (n = 840) was associated viral load suppression (X2 = 21.66, p < .001). Overall, the pattern of utilization outcomes were similar for both gay and bisexual men. For example, utilization of PrEP, being in HIV care and utilization of most of the sexual health and support services were negatively associated with sexual stigma. Whereas, utilization of most HIV prevention, and sexual health and support services were positively associated with provider discrimination. Utilization of all HIV prevention and all sexual health services were positively associated with greater community engagement, and receiving services from LGBT-led organizations. Bisexual men had higher odds of reporting provider discrimination when utilizing condom services (gay: AOR = 1.14, [0.95-1.36]; bisexual: 1.58, [1.10-2.28]), PrEP (gay: AOR = 1.06, [0.77-1.45]; bisexual: AOR = 2.14, [1.18-3.89], mental health services (gay: AOR = 1.03, [0.86-1.23]; bisexual: AOR = 1.32, [1.07-1.64]), and community-based support (gay: AOR = 1.23, [1.05-1.45]; bisexual: AOR = 1.49, [1.14-1.93]) than gay men. Bisexual men also reported higher odds of accessing services from LGBT-led organizations when utilizing PrEP (gay: AOR = 5.26, [2.50-11.05]; bisexual: AOR = 7.12, [3.16-16.04]), and community-based support/self-help groups/individual counseling (gay: AOR = 2.63, [1.72-4.01]; bisexual: AOR = 3.35, [2.30-4.88]. CONCLUSIONS: It is essential that barriers to health services utilization be addressed at structural and community levels. Structural interventions should be designed to reduce sexual stigma, as well as train and sensitize healthcare providers; and strengthen community level interventions that bring gay and bisexual men together to lead comprehensive health services.

HIV/AIDS: trends in the Middle East and North Africa region.

OBJECTIVES: To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region. METHODS: Articles on the MENA region were reviewed. RESULTS: The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues. CONCLUSIONS: The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed.

Social, Relational and Network Determinants of Unprotected Anal Sex and HIV Testing Among Men Who Have Sex with Men in Beirut, Lebanon.

Social, relational and network determinants of condom use and HIV testing were examined among 213 men who have sex with men (MSM) in Beirut. 64% reported unprotected anal intercourse (UAI), including 23% who had UAI with unknown HIV status partners (UAIU); 62% had HIV-tested. In multivariate analysis, being in a relationship was associated with UAI and HIV testing; lower condom self-efficacy was associated with UAIU and HIV testing; gay discrimination was associated with UAIU; MSM disclosure was associated with UAI, UAIU and HIV testing; and network centralization was associated with HIV testing. Multi-level social factors influence sexual health in MSM.

A qualitative exploration of sexual risk and HIV testing behaviors among men who have sex with men in Beirut, Lebanon.

Men who have sex with men (MSM) may account for most new HIV infections in Lebanon, yet little is known about the factors that influence sexual risk behavior and HIV testing in this population. Qualitative interviews were conducted with 31 MSM living in Beirut, and content analysis was used to identify emergent themes. Mean age of the participants was 28.4 years, and all identified as either gay (77%) or bisexual (23%). Half reported not using condoms consistently and one quarter had not been HIV-tested. Many described not using condoms with a regular partner in the context of a meaningful relationship, mutual HIV testing, and a desire to not use condoms, suggesting that trust, commitment and intimacy play a role in condom use decisions. Condoms were more likely to be used with casual partners, partners believed to be HIV-positive, and with partners met online where men found it easier to candidly discuss HIV risk. Fear of infection motivated many to get HIV tested and use condoms, but such affect also led some to avoid HIV testing in fear of disease and social stigma if found to be infected. Respondents who were very comfortable with their sexual orientation and who had disclosed their sexuality to family and parents tended to be more likely to use condoms consistently and be tested for HIV. These findings indicate that similar factors influence the condom use and HIV testing of MSM in Beirut as those observed in studies elsewhere of MSM; hence, prevention efforts in Lebanon can likely benefit from lessons learned and interventions developed in other regions, particularly for younger, gay-identified men. Further research is needed to determine how prevention efforts may need to be tailored to address the needs of men who are less integrated into or do not identify with the gay community.