Egypt: Egypt's fearful gays shy from HIV testing

Pittsburgh Post-Gazette
In May 2001, police raided the Queen Boat, a floating nightclub moored on the Nile River, and arrested 52 gay men.
Ultimately, judges sentenced one defendant to five years in prison for debauchery and deriding religion, another to three years for deriding Islam, and gave 21 others three-year prison terms to be followed by three years of probation for "habitual debauchery."
Human rights groups around the world protested that the arrested men had been beaten and threatened with torture to confess their "crimes."

The Queen Boat incident began what many see as a crackdown on homosexuality, heightening gay people's distrust of the government and driving them even further into hiding.

So now that the government is offering anonymous HIV testing for the first time, many gays are understandably wary.

Some suspect that if they get tested for the infection, they could be identified publicly as gay, which could lead to imprisonment regardless of their HIV status.

"It's not anonymous [testing], don't believe that," warned one gay Egyptian who asked not to be named. "The first thing they do is call the cops."

The 22-year-old man said that when his partner visits the United States, friends ask him to bring back HIV tests that can be done at home, so that they can learn their status in private.

However, the only home-based test that is approved by the U.S. Food and Drug Administration requires that the blood sample be mailed to an American lab. Other home test kits have an indicator window and promise results in 15 minutes, much like a pregnancy test, but the FDA doesn't consider them reliable.

Rumors of HIV-positive gay men disappearing add to the fear. The Egyptian gay man spoke of trying to track down an infected acquaintance to offer help. He couldn't find the man and his family had no information on his whereabouts.

"Either they disappear or they stop having sex with people because they are too scared or they leave the country to get treated," he said. Besides, "it's becoming very, very difficult for any AIDS patient or HIV-positive patient to go and seek medication [in Egypt]. There have been too many horror stories lurking around."

Dr. Khalil Ghanem, of Johns Hopkins University, said HIV-positive people in Saudi Arabia and Lebanon, both gay and straight, have similar concerns about being stigmatized.

Those "who have money are actually leaving the country and getting treatment somewhere else," he said. "They go to France, they go to Switzerland, to the United States for care."

Ghanem pointed out that people who leave don't get counted in official case numbers. A small number of others, he said, may strongly suspect that they are infected, but avoid being tested.

"They are essentially dying without care," he said.

In Egypt, the same conservative social norms that make gays so fearful also make it hard to preach HIV prevention methods.

In this predominantly Muslim culture, both homosexuality and sex outside marriage are considered sinful, so any discussion of safe sex among unmarried partners or gays could amount to condoning forbidden behavior.

"Premarital and extramarital sex are not accepted socially and culturally," said Dr. Nasr El-Sayed, leader of the AIDS program for Egypt's Ministry of Health. "The girls should be virgins. It's not accepted for the girl to not be a virgin when she gets married."

As in other countries, people are not as young as they used to be when they wed. The marriage contract specifies that the prospective groom must provide the bride with a suitable apartment, but even down payments are far out of reach for the average worker.

So some men in the Middle East, unwilling to wait for years before they can have sanctioned sex with their wives, have sex with other men -- but they don't consider themselves homosexual or bisexual.

Bob Preston, an American gay man who does consulting work in Egypt, said these Egyptians "don't have access to have sex with women, so they have sex with men and it's OK because they're not married yet. They don't think of it as gay sex [if] they're the active partner," meaning they take the male role during intercourse.

A bisexual pattern

One of Preston's friends even attended the wedding of his Egyptian male partner of several years, and Preston broke off a relationship because he didn't want to play out the same scenario.

"He showed me the apartment he bought for his wedding," Preston recalled. "He was having it remodeled. And we went out with his straight friends."

Female prostitutes do exist as another outlet for unmarried men, but they are believed to have longer relationships with fewer partners.

The hidden world of gay sex and the obscurity of prostitution worry those who want to test for HIV.

"In Middle Eastern countries, the prostitution is kept so hidden that it's almost impossible to figure out what's going on," said Carol Jenkins, coauthor of a World Bank report on HIV and AIDS in the Middle East and North Africa.

Meanwhile, the general public doesn't seem to know much about AIDS or have much interest in learning about it.

"We used to have in our [news]paper that this disease is not present in our country because we are morally, culturally and religiously" superior, said Dr. Mervat El Gueneidy, a consultant with Egypt's AIDS hotline. "So people would not even try to learn about it because it's not our disease, it's the disease of those bad people."

An October article in a student newspaper of the American University in Cairo noted mixed feelings about having HIV education available on campus. Some said they knew enough already; others thought there was no such thing as too much information.

And some, like the student union president who called HIV a "shameful disease," worried that an awareness campaign would encourage people to have sex.

In 1996, with the assistance of the Ford Foundation, the health ministry's El-Sayed started the AIDS hotline as a way for people to get information anonymously. In the early days, callers had questions about basic reproductive biology and sexuality, not just HIV.

The hotline's El Gueneidy hoped the service would also discreetly broaden sex education for women, but men make up the overwhelming majority of callers. Women are more likely to be illiterate, so they may not be aware of the service, she said. There may be no phone in the home, and they may be uncomfortable asking sensitive questions on a public phone.

There are still myths that need to be dispelled, such as the idea that AIDS can be avoided by not having sex with a foreigner -- which does not keep young Egyptian men from trying to strike up conversations with female tourists, whom they think are more promiscuous than their countrywomen.

Another common belief is that HIV patients are quarantined, a rumor that is hard to refute because not even foreign and local health experts are convinced that it's an urban legend.

"Once you're found to be HIV positive, the police show up at your house and accompany you to the fever hospital," Jenkins said. "If international donors came and talked to people they would be told that doesn't happen. But we know it happens."

Others say AIDS patients were quarantined in the past, but it doesn't happen anymore.

"This is 10 years before," said Dr. Cherif Soliman, of Family Health International, the agency that helped develop the new anonymous HIV testing program. "Now, they can go out and in, they have no problem."

El-Sayed, of the health ministry, just laughed at the quarantine notion. "Never happened," he said emphatically. "This happened in a movie and the people believe the movie was fact. They mentioned in this movie that any person who had HIV, they put in quarantine. But we never had a quarantine."

There is far less stigma attached to AIDS now, El-Sayed continued. Fifteen years ago, his experience was that family members typically demanded that their HIV-positive relative be kept in a hospital. "They didn't want to take [them]," he said. "Now almost 97 percent of the families are accepting."

Could it explode?

So far, low infection numbers and conservative sexual behavior seem to have prevented the rapid spread of the virus in Egypt. How long that will last, though, no one knows. To get an epidemic rolling, an HIV-positive person "has to infect more than one person," said Karen Stanecki, a senior advisor on demographics for the United Nations AIDS agency. "People tend to think that once it gets started, it's just going to explode," she said. "But that's not necessarily the case. If it's just a very small group of people then it's not necessarily going to break out into any kind of major epidemic."

But behaviors can change, especially with globalization increasing the movement of people and ideas across borders, and very little research is being conducted to keep tabs on the cultural landscape. For example, even though sex outside marriage is considered illicit, a study conducted by Family Health International and the U.S. Agency for International Development found that 16.5 percent of about 1,200 unmarried Egyptian university students have had sex.

And there has been an increase in unofficial "orfi" marriages, which fulfill people's desires for a romantic, sexual relationship in a climate where weddings are extremely expensive. Orfi unions are not legally binding, so there are no protections for the partners, or their children, if the relationship sours.

"You have to be ever vigilant as to what's happening in terms of changes in behaviors," Stanecki said. Public health experts say societies cope best with HIV and AIDS when leaders talk about it openly. But such discussions can still be divisive in the Muslim world.

In 2003, American professor and Muslim theologian Amina Wadud presented a paper at an HIV conference for Muslim scholars in Kuala Lumpur, Malaysia. Among other things, she said that Muslim women are more vulnerable to getting HIV because they're expected to have sex with their husbands, who are under no obligation to say whether they are infected with the disease. Those remarks infuriated some audience members, 10 of whom walked out. The moment became a hallmark of the tension between religious traditionalists and reformers.

Even if a rigorous surveillance effort were to confirm a low prevalence of HIV, "it doesn't let you off the hook," said Hopkins' Ghanem. "In fact, it should prompt you to be more aggressive from the prevention standpoint."

As the experience of other nations has shown, he and other experts say, it's never too soon to act.

By Anita Srikameswaran, Pittsburgh Post-Gazette, published on Monday, March 14, 2005

Taken from the March 2005 +M Bulletin by Positive Muslims