Arab men who have sex with men in Israel: knowledge, attitudes and sexual practices

Sexual and gender minority health in the Middle East and North Africa Region: A scoping review

Background

Researchers in studies from multiple countries suggest that sexual and gender minority people experience high rates of violence, stigma, and discrimination, as well as mistrust of health care providers and systems. Despite growing evidence related to sexual and gender minority health in North America and Europe, we know little about the health of this population in the Middle East and North Africa.

Objectives

We aimed to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.

Design

We conducted a scoping review informed by the framework recommended by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.

Data sources

We searched the following databases: PubMed (using Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid). The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority). Each was operationalized using multiple search terms and, where available, controlled vocabulary terms.

Review Methods

Research articles were identified and assessed for inclusion using an explicit strategy. Relevant information was extracted and synthesized to present a descriptive summary of existing evidence.

Results

Research designs of the 98 articles we reviewed included quantitative (n = 73), qualitative (n = 20), and mixed methods (n = 5). Most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23) and focused mainly on gender minority individuals (n = 46) and men who have sex with men (n = 32). Five themes emerged from the review: sexual health (52; 53%); mental health (20; 20%); gender identity (17; 17%); violence and discrimination (7; 7%); and experiences with the healthcare system (2; 2%). Although researchers focused on multiple health outcomes in some studies, we included them under the theme most closely aligned with the main objective of the study.

Conclusion

Although our study is limited to few countries in the Middle East and North Africa region, we found that sexual and gender minority individuals face multiple adverse sexual and mental health outcomes and experience high rates of stigma, discrimination, and violence. More research is needed from countries outside of Lebanon, Pakistan, and Iran, including community-based participatory approaches and multi-level intervention development. Nurses and other healthcare providers in the region need training in providing inclusive care for this population.

Knowledge of and willingness to take pre-exposure prophylaxis among men who have sex with men in Israel

Background

Oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) has been found to reduce viral acquisition among HIV-negative MSM. This cross-sectional study was conducted before pre-exposure prophylaxis (PrEP) licensure in Israel, and aimed to compare men who have sex with men (MSM) who had heard of PrEP with those who had not, as well as MSM willing to take PrEP with those who were hesitant or not willing to take PrEP.

Methods

HIV-negative MSM responded anonymously to questionnaires in 2017 regarding their knowledge of and willingness to take PrEP, prior use of PrEP and post-exposure prophylaxis (PEP), and their sexual behaviors.

Results

Among 1705 participants, 1431 (83.9%) had heard about PrEP. They were older and more often reported being Jewish, having an academic degree, self-identifying as gay/bisexual, being tested for HIV in the last year, participating in group sex, using alcohol or drugs before or during sex, and having prior use of PrEP/PEP compared with MSM who had not heard about PrEP. A total of 760 (44.8%) participants indicated that they would consider taking PrEP, 567 (33.5%) maybe would consider taking PrEP, and 367 (21.7%) would not take PrEP. Those who were willing to take PrEP had a lower level of education, were involved in high-risk sexual behaviors, used alcohol or drugs before or during sex, and had previously used PrEP/PEP compared with participants who maybe would consider taking or would not take PrEP. When participants were asked to indicate if they were willing to take PrEP at different potential efficacies and costs, the willingness to using PrEP increased with the potential efficacy of the drug and adversely related to its cost.

Conclusions

PrEP awareness was high, and 44.8% indicated willingness to take PrEP, especially those who reported high-risk sexual behaviors. This supports the current policy in Israel to allow PrEP to MSM who are at high-risk. In order to maintain a high level of PrEP-adherence, physicians should consider structural barriers, such as negative stigma of being promiscuous, lack of perceived HIV-risk, difficulties in accessing clinics or paying for PrEP, inability to follow-up or low tolerability of the medication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13584-021-00500-x.

The social construction of HIV: A narrative study of Israeli Arabs

"Social determinants of health"-that is, nonmedical care-related factors, forces, and structures that have a strong influence on health-play a vital role in HIV prevention and treatment. In this study, we focused on one such key factor: culture. Israeli Arabs, the largest minority group in Israel, share a unique culture. Although the incidence of HIV/AIDS is lower among Israeli Arabs than among Jews, Arabs account for only 1% of HIV tests in Israel and report poorer HIV-related knowledge, whereas the majority of newly diagnosed Arabs are usually diagnosed with full-blown AIDS. This study explored how HIV/AIDS is socially constructed in Israeli Arab society. A sample of 31 HIV-negative Israeli Arab participants wrote stories about a man living with HIV. Thematic analysis was used to analyze the data. The analysis identified two themes. The first, "HIV and 'forbidden' sexual practices," constructed HIV/AIDS as a sexually transmitted disease associated primarily with premarital sex (a norm transgression in Arab culture). The second theme, "living with HIV," involved two opposing subthemes: "life goes on" and "a ruined life." The former portrayed the life of men with HIV as moving on, at times into a successful future. The latter depicted the point of diagnosis as signifying a turn for the worst-a bleak and hopeless future. The findings suggest that HIV/AIDS is stigmatized among Israeli Arabs and the nature and extent of the stigma corresponds with cultural norms, stressing the importance of designing culturally informed interventions for HIV/AIDS prevention and treatment.

Factors associated with lower knowledge of HIV and STI transmission, testing and treatment among MSM in Ireland: findings from the MSM Internet Survey Ireland (MISI) 2015

BACKGROUND

Poor knowledge regarding STI and HIV transmission, testing and treatment among men who have sex with men (MSM) may be contributing to their disproportionate burden of STIs. However, factors which predispose MSM to having this low knowledge are less understood.

AIM

The aim of this study was to identify factors associated with having lower knowledge of HIV and STI transmission, testing and treatment among MSM.

METHODS

The MSM Internet Survey Ireland 2015 was a self-completed online national survey available to MSM living in Ireland. Thirteen factual statements were used to assess participants' knowledge of HIV and STI transmission, testing and treatment. Respondents were defined as having 'lower knowledge' if they indicated prior knowledge of fewer than 11 true statements. Multivariable-adjusted logistic regression was used to identify factors associated with having lower knowledge.

RESULTS

3090 MSM completed the survey, of whom 2905 (94%) were included in this study. Thirty-six per cent (n=1055) had lower knowledge of HIV and STI transmission, testing and treatment. The factors associated with having lower knowledge included being 18-24 years of age (vs >40 years; adjusted OR (aOR) 1.98, 95% CI 1.50 to 2.61), born in Ireland (vs outside Ireland; aOR 1.62, 95% CI 1.25 to 2.10) and being out to none of their contacts (vs out to most/all; aOR 1.69, 95% CI 1.20 to 2.37). Knowledge was also lower among those who never tested for HIV (vs tested negative within last 12 months; aOR 2.32, 95% CI 1.88 to 2.86) and among MSM who never visited an MSM-specific health promotion website (vs visited website; aOR 1.81, 95% CI 1.45 to 2.25).

CONCLUSION

A range of demographic factors, sexual health variables and use of MSM-specific sexual health promotion materials are associated with low knowledge regarding HIV and STI transmission, testing and treatment among MSM in Ireland. Engagement with the main national MSM-specific sexual health promotion website was associated with higher knowledge levels.

Community Vs. hospital HIV testing sites in Jerusalem, Israel - who's tested and who's at risk?

Background

After decades of constant increase in HIV diagnoses among men who have sex with men (MSM), a gradual decrease has been reported in recent years. Timely detection of HIV leads to early treatment and behavioral changes which decrease further transmissions. This cross-sectional study aimed to assess demographic and behavioral characteristics of individuals who were tested for HIV in Jerusalem, Israel.

Methods

This study compared individuals who were tested at Hadassah AIDS Center (HAC) with those tested at the Jerusalem Open House (JOH) - an LGBTQ community center. Participants completed anonymous questionnaires regarding their demographic, HIV-testing history, and sexual behaviors. High-risk sexual behavior (HRSB) was defined as a diagnosis of sexually transmitted disease or condomless anal/vaginal sex during the last year.

Results

Among 863 participants, 104 (12.1%) were tested in HAC and 759 (87.9%) in JOH. Of those, 19 (18.3%) and 227 (29.9%) were HRSB, respectively. Two MSM were tested positive in JOH. JOH received more MSM, HRSB and individuals who were previously tested for HIV, while HAC received more migrants and health-care workers. HRSB-participants were more commonly younger, males, non-Jewish, with lower income, previously tested for HIV, reported more sexual partners, payed for sex or used drugs.

Conclusions

MSM and HRSB-individuals were more likely to be tested in JOH, while migrants and health-care workers in HAC, possibly due to the geographic location, reputation and specific atmosphere. In order to encourage HIV-tests among HRSB and non-Jews, additional interventions should be employed, including outreach activities, extending opening hours and reducing testing costs should be employed.

HIV/AIDS-related beliefs among Israeli Arab-Palestinian women

Studies show that women are more vulnerable to human immunodeficiency virus (HIV) transmission than men because of biological and sociocultural risk factors. Israeli Arab-Palestinians are the largest ethnic minority group in Israel. Unofficial data suggest that merely one percent of the tests conducted in Israel to diagnose HIV/acquired immune deficiency syndrome (AIDS) are conducted by this population and that Israeli Arab-Palestinians are typically diagnosed late. Arab communities in Israel were found to be predominately patriarchal, characterised by conservative gender roles and structures, and the policing of overt sexual behaviours, particularly those of women. In order to advance our understanding of the HIV/AIDS phenomenon in different sociocultural contexts, as well as to design effective cultural-sensitive interventions, we must first understand how HIV/AIDS is constructed in different cultural sites. Against this backdrop, this exploratory study examines HIV/AIDS-related beliefs among non-infected, Israeli Arab-Palestinian women. We conducted semi-structured interviews with 12 women. Thematic content analysis was used in order to analyse the data. Five themes emerged from the analysis, in the first, personal responsibility and blame were assigned to people with HIV/AIDS for their illness. In the second theme, HIV/AIDS was constructed as a sexually transmitted disease, associated with 'deviant' sexuality and sexual conduct in the Arab culture. In the third theme, HIV/AIDS was believed to be transmitted by multiple, mostly mistaken, modes of contact. In the fourth theme, people with HIV/AIDS were believed to be subjected to severe negative social responses. In the fifth theme, individuals with HIV/AIDS were depicted as a symbol of physical and psychological malaise. In conclusion, the findings imply that Israeli Arab-Palestinian women hold negative beliefs concerning people with HIV/AIDS and are misinformed regarding HIV transmission. This suggests a need to design culturally appropriate interventions to address stigma-related beliefs and misconceptions concerning transmission, among Israeli Arab-Palestinian women.

HIV/AIDS stigma and beliefs about HIV transmission among Israeli Jews and Arabs: an exploratory study

Although HIV/AIDS incidence in Israel is lower than in most Western countries, HIV/AIDS burden in Israel is on the rise. The Arabs are the largest ethnic minority in Israel. Medical experts in Israel believe that HIV infection rates among Israeli Arabs are underestimated. Moreover, unofficial data suggest that Arabs are significantly less likely than Jews to be tested for HIV and that Arabs are typically diagnosed at a late stage of their disease. Since data concerning the levels of HIV/AIDS stigma and knowledge can inform policy, this exploratory study compares the extent of HIV/AIDS stigma and beliefs about HIV transmission of Jews to those of Arabs. A convenience sample of 183 Israelis was drawn (135 Jews, 48 Arabs). Data were collected via a computerized, open-ended, self-report questionnaire. The main findings revealed that compared to Jews, Arabs reported more misinformation about HIV transmission. Arabs differed from Jews in key manifestations of stigma (support for coercive policies, attribution of blame and responsibility, anger and fear), but not others (avoidance intentions and discomfort). Arabs scored higher on the Summary Index of Stigma, than did Jews. These preliminary findings indicate a need to design culturally-specific interventions to enhance HIV transmission-related knowledge and to debunk stigma among Israeli Arabs.

Sexual intermingling of Arab and Jewish MSM in Israel: results of a molecular epidemiology study

OBJECTIVES

MSM comprise ∼30% of new HIV infections in Israel, a country with mixed Jewish and Arab populations. We molecularly characterized HIV-1 in the Arab and Jewish MSM (AMSM, JMSM) populations to reveal possible interethnical connections.

DESIGN

Cross-sectional study.

METHODS

All Israeli-born, HIV-1-infected MSM diagnosed between 2005 and 2016 (n = 1143) were cross-matched with the National Civil Registry to identify religion (Jews/Muslims/Christians). Transmitted drug-resistance mutations (TDRM) and HIV-1 subtypes were determined on the first partial protease and reverse transcriptase sequences from treatment-naive patients and phylogenetic trees were constructed.

RESULTS

Among MSM, 6.4% (73/1143) were Arabs and 93.6% (1070/1143) were Jews. Interestingly, a higher proportion of Arabs was identified among non-MSM (19%, 46/247 versus 6.4%, 73/1143, P < 0.01). Subtype analysis of 62 HIV-1 AMSM and 440 randomly selected HIV-1 JMSM sequences revealed 80.6, 8.1, 4.8 and 6.5% of AMSM and 82.3, 9.5, 4.1 and 4.1% of JMSM had B, A, C and non-A/B/C, respectively. Overall, 13.1% (66/502) had TDRM; reverse transcriptase-K103N/S, M184 V, T215S and protease-L90M were the most common. TDRM prevalence was not significantly higher in JMSM compared to AMSM (P = 0.1) and no temporal changes were observed in their frequency. Phylogenetic analysis demonstrated AMSM and JMSM clusters including L90M, K103N/S or T215S TDRM.

CONCLUSION

Intermingling of AMSM and JMSM HIV-1 in clusters of HIV-1 sequences suggest interethnical sexual contacts among these MSM. Interventions aiming to prevent HIV-transmission in MSM should similarly address both populations groups. The high TDRM frequency requires continuation of resistance testing.