BACKGROUND: Men who have sex with men (MSM) in the Middle East and north Africa are often referred to as hard-to-reach because same-sex practices are subject to pervasive stigma, which hinders epidemiological surveillance. We examined HIV prevalence, risk behaviours, and cascade of care among MSM in Iran.
METHODS: We did a cross-sectional biobehavioural survey using respondent-driven sampling (RDS) in eight major Iranian cities between August, 2021, and July, 2022. MSM aged 18 years or older who reported oral or anal sex with another man in the past 12 months were recruited, tested for HIV, and completed structured interviews on sociodemographics, substance use, and sexual behaviours. Multivariable logistic regression was used to identify factors associated with HIV seropositivity.
FINDINGS: Among 1131 MSM enrolled (mean age 29 years), 136 (12%) identified as transgender women. 63 (5·6%) had HIV (RDS-adjusted HIV prevalence 4·2%, 95% CI 2·5–5·8). In multivariable analysis, HIV seropositivity was positively associated with older age (adjusted odds ratio 4·12, 95% CI 1·72–9·88), lifetime sex work (2·22, 1·24–3·98), incarceration (2·31, 1·11–4·83), and easy access to free condoms in the last 3 months (4·95, 2·40–10·20). HIV seropositivity was also negatively associated with being bisexual compared to being homosexual (0·29, 0·11–0·76). Of 63 MSM with HIV, 44 (70%) were aware of their status, 42 (67%) were linked to care, 39 (62%) were on antiretroviral therapy (ART), and 22 (35%) achieved viral suppression.
INTERPRETATION: This study highlights the ongoing HIV burden among MSM in Iran, which is higher than burdens in all other key populations. While two-thirds of MSM living with HIV were aware of their status and engaged in care, gaps remain in HIV testing, ART initiation, and viral suppression. Targeted interventions addressing sociocultural, structural, and behavioural issues are crucial for improving HIV-related outcomes in this underserved population in Iran.
HIV prevalence, risk behaviours, and cascade of care among men who have sex with men in Iran: A nationwide, cross-sectional, biobehavioural survey
Lancet HIV [Epub 2025 Dec 16]. doi: 10.1016/S2352-3018(25)00230-9.