Purpose of review: A volume of quality HIV data has materialized recently in the Middle East and North Africa (MENA). This review provides a thematic narrative of the patterns of HIV infection transmission in this region in light of these data. Recent findings: Tens of integrated bio-behavioral surveillance surveys among hard-to-reach key populations at higher risk have been conducted in MENA in the recent years. Many of the studies reported appreciable and growing HIV prevalence. A few studies found alarming prevalence of as much as 87.2% HIV prevalence among people who inject drugs in Tripoli, Libya. The discovery of these hitherto hidden epidemics was unsettling to some authorities after years in which the importance of a focus on HIV prevention among key populations was not recognized. Summary: The new data from MENA indicate growing HIV epidemics among key populations across the region. There is heterogeneity, however, as to which key populations are affected and in what proportions in different countries. In a few countries, HIV appears to affect only one key population and often there is substantial geographical heterogeneity in HIV transmission. Data are indicative of a growing HIV disease burden in this part of the globe, in contrast with the declining epidemics in most other regions.