Substantial HIV Burden and Critical Gaps in the Care Cascade Among Men Who Have Sex With Men in Iran

Highlights

• HIV prevalence among Men who have Sex with Men (MSM) in Iran is estimated at 4.2%, a rate significantly higher than that of other key populations in the country.
• The HIV cascade of care reveals a sharp decline in outcomes, with only 35% of those living with HIV achieving viral suppression.
• Key risk factors for HIV seropositivity include older age, a history of incarceration, and involvement in lifetime sex work.
• Significant structural and sociocultural barriers continue to hinder testing and antiretroviral therapy (ART) adherence in this underserved population.

Background: The Challenge of Surveillance in Stigmatized Contexts

In the Middle East and North Africa (MENA) region, men who have sex with men (MSM) remain one of the most marginalized and ‘hard-to-reach’ groups. This marginalization is rooted in pervasive sociocultural stigma, legal frameworks, and religious norms that often criminalize or severely pathologize same-sex practices. Consequently, epidemiological surveillance in these populations is fraught with challenges, often leading to an underestimation of the true disease burden.

In Iran, while the government has made strides in harm reduction for people who inject drugs (PWID), the focus on MSM has historically been less robust. Understanding the HIV prevalence and the efficiency of the care cascade—the pathway from diagnosis to viral suppression—is essential for the Iranian national health strategy to meet the UNAIDS 95-95-95 targets. This study represents a critical effort to provide high-quality, nationwide data to inform public health policy.

Study Design and Methodology

This nationwide, cross-sectional biobehavioural survey was conducted between August 2021 and July 2022 across eight major Iranian cities. To overcome the challenges of reaching a hidden population, researchers employed Respondent-Driven Sampling (RDS). This chain-referral methodology uses the social networks of participants to recruit a representative sample, applying mathematical weights to account for non-random recruitment patterns.

The study enrolled 1,131 MSM aged 18 years or older who reported oral or anal sex with another man in the preceding 12 months. Participants underwent structured interviews covering sociodemographics, substance use, and sexual behaviours. Crucially, participants were tested for HIV using rapid diagnostic tests, with confirmatory testing provided for reactive results. The primary outcomes were HIV prevalence and the various stages of the HIV care cascade: awareness of status, linkage to care, ART initiation, and viral suppression.

Key Findings: HIV Prevalence and Associated Risk Factors

Among the 1,131 participants, the mean age was 29 years, and approximately 12% identified as transgender women. The study found a crude HIV prevalence of 5.6%, which, when adjusted for RDS weights, resulted in a population-level prevalence estimate of 4.2% (95% CI 2.5–5.8).

Multivariable Analysis of Risk

The researchers utilized multivariable logistic regression to identify independent predictors of HIV seropositivity. The findings highlighted several critical vulnerabilities:

• Age:

  Older MSM were significantly more likely to be HIV-positive (Adjusted Odds Ratio [aOR] 4.12, 95% CI 1.72–9.88), likely reflecting cumulative lifetime exposure.

• Incarceration:

  A history of incarceration was associated with a higher risk of HIV (aOR 2.31, 95% CI 1.11–4.83), pointing to the high-risk environments within prisons where access to prevention tools is limited.

• Sex Work:

  Engagement in lifetime sex work more than doubled the odds of being HIV-positive (aOR 2.22, 95% CI 1.24–3.98).

• Sexual Orientation:

  Men identifying as bisexual had lower odds of HIV infection compared to those identifying as homosexual (aOR 0.29, 95% CI 0.11–0.76).

• The Prevention Paradox:

  Interestingly, easy access to free condoms in the last 3 months was positively associated with HIV seropositivity (aOR 4.95, 95% CI 2.40–10.20). This likely indicates that those who perceive themselves to be at higher risk, or those already engaged with health services, are more likely to seek out and receive prevention materials.

The HIV Cascade of Care: Identifying the Leaks

The study provides a sobering look at the ‘leaks’ in the HIV care continuum among MSM in Iran. Of the 63 participants identified as living with HIV:

• 70% were aware of their status prior to the study.
• 67% had been linked to clinical care.
• 62% were currently receiving antiretroviral therapy (ART).
• Only 35% had achieved viral suppression.

The precipitous drop from ART initiation (62%) to viral suppression (35%) suggests significant barriers to treatment adherence. Viral suppression is not only vital for the individual’s health but is the cornerstone of ‘Undetectable = Untransmittable’ (U=U), the principle that effectively prevents further sexual transmission of the virus.

Expert Commentary: Structural Barriers and Clinical Implications

The findings from this nationwide survey suggest that MSM in Iran now face an HIV burden that exceeds that of other traditionally high-risk groups, such as people who inject drugs, whose prevalence has stabilized or declined due to successful harm reduction programs. The relatively low rate of viral suppression (35%) is particularly concerning from a public health perspective.

Several factors likely contribute to these gaps. First, the dual stigma of living with HIV and being a member of a marginalized sexual minority can lead to ‘internalized stigma,’ which discourages individuals from seeking care or remaining in treatment. Second, structural barriers, such as the fear of being outed or facing legal repercussions, may prevent MSM from utilizing centralized HIV clinics.

Clinicians and policymakers must consider decentralized, community-based care models. Integrating HIV services into broader health clinics or utilizing peer-led navigation programs could help bridge the gap between diagnosis and long-term viral suppression. Furthermore, the association between incarceration and HIV underscores the urgent need for expanded harm reduction and testing within the Iranian penal system.

Conclusion

This study provides essential evidence of the ongoing HIV epidemic among MSM in Iran. While the awareness of HIV status and linkage to care are relatively high compared to previous years, the low rate of viral suppression represents a major failure in the care continuum. To reach the UNAIDS targets, Iran must implement targeted interventions that address the unique sociocultural and structural challenges faced by MSM. Improving access to testing, simplifying ART delivery, and fostering a non-discriminatory healthcare environment are paramount to reducing the HIV burden in this underserved population.

Funding and Reference

This study was funded by UNAIDS.

Reference: Khezri M, Mehmandoost S, Tavakoli F, et al. 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. 2026 Feb;13(2):e116-e125. doi: 10.1016/S2352-3018(25)00230-9.