Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco

The antiretroviral rollout and drug-resistant HIV in Africa: insights from empirical data and theoretical models

The U.S. Government has pledged to spend $15 billion in Africa and the Caribbean on AIDS. A central focus of this plan is to provide antiretroviral treatment (ART) to millions. Here, we evaluate whether the plan to rollout ART in Africa is likely to generate an epidemic of drug-resistant strains of HIV. We review what has occurred as a result of high usage of ART in developed countries in terms of changes in risky behavior, and the emergence and transmission of drug-resistant HIV. We also review how mathematical models have been used to predict the evolution of drug-resistant HIV epidemics. We then show how models can be used to predict the likely impact of the ART rollout on the evolution of drug-resistant HIV in Africa. At currently planned levels of treatment coverage, we predict that (over the next decade) in Africa: (i) the impact of ART on reducing HIV transmission (and prevalence) is likely to be undetectable (unless accompanied by substantial changes in behavior), (ii) the transmission rate of drug-resistant HIV will be below the WHO surveillance threshold of 5%, and (ii) the majority of cases of drug-resistant HIV that will occur will be due to acquired (and not transmitted) resistance. For the next decade, large-scale surveillance for detecting transmitted resistance in Africa is unnecessary. Instead, we recommend that patients should be closely monitored for acquired resistance, and sentinel surveillance (in a few urban centers) should be used to monitor transmitted resistance.

Sexually Transmitted Disease/HIV Transmission Risk Behaviors and Sexually Transmitted Disease Prevalence Among HIV-Positive Men Receiving Continuing Care

OBJECTIVE

HIV primary care clinics offer an environment in which to deliver prevention messages and to conduct sexually transmitted disease (STD) screening. Determination of the prevalence and factors associated with risk-taking behaviors among HIV clinic attendees is needed.

GOAL

The goal of this study was to describe risk behaviors and STD prevalence in males receiving HIV primary care.

STUDY

Participants underwent an interviewer-administered survey and STD testing during this cross-sectional study.

RESULTS

Over two thirds of study participants reported sexual activity within the prior 6 months of which 6% were infected with gonorrhea or chlamydia. Men performing insertive rectal sex were 5 times less likely to use condoms when the partner was HIV-positive (odds ratio [OR], 5.14; 95% confidence interval [CI], 1.90-13.91), whereas patients with higher CD4 counts were more likely to engage in unprotected receptive rectal sex (OR, 1.20; 95% CI, 1.02-1.42).

CONCLUSION

HIV primary care clinics provide access to patients in need of HIV prevention intervention and are appropriate sites for these activities.

Integrating HIV prevention and treatment: from slogans to impact

BACKGROUND

Through major efforts to reduce costs and expand access to antiretroviral therapy worldwide, widespread delivery of effective treatment to people living with HIV/AIDS is now conceivable even in severely resource-constrained settings. However, the potential epidemiologic impact of treatment in the context of a broader strategy for HIV/AIDS control has not yet been examined. In this paper, we quantify the opportunities and potential risks of large-scale treatment roll-out.

METHODS AND FINDINGS

We used an epidemiologic model of HIV/AIDS, calibrated to sub-Saharan Africa, to investigate a range of possible positive and negative health outcomes under alternative scenarios that reflect varying implementation of prevention and treatment. In baseline projections, reflecting "business as usual," the numbers of new infections and AIDS deaths are expected to continue rising. In two scenarios representing treatment-centered strategies, with different assumptions about the impact of treatment on transmissibility and behavior, the change in the total number of new infections through 2020 ranges from a 10% increase to a 6% reduction, while the number of AIDS deaths through 2020 declines by 9% to 13%. A prevention-centered strategy provides greater reductions in incidence (36%) and mortality reductions similar to those of the treatment-centered scenarios by 2020, but more modest mortality benefits over the next 5 to 10 years. If treatment enhances prevention in a combined response, the expected benefits are substantial-29 million averted infections (55%) and 10 million averted deaths (27%) through the year 2020. However, if a narrow focus on treatment scale-up leads to reduced effectiveness of prevention efforts, the benefits of a combined response are considerably smaller-9 million averted infections (17%) and 6 million averted deaths (16%). Combining treatment with effective prevention efforts could reduce the resource needs for treatment dramatically in the long term. In the various scenarios the numbers of people being treated in 2020 ranges from 9.2 million in a treatment-only scenario with mixed effects, to 4.2 million in a combined response scenario with positive treatment-prevention synergies.

CONCLUSIONS

These analyses demonstrate the importance of integrating expanded care activities with prevention activities if there are to be long-term reductions in the number of new HIV infections and significant declines in AIDS mortality. Treatment can enable more effective prevention, and prevention makes treatment affordable. Sustained progress in the global fight against HIV/AIDS will be attained only through a comprehensive response.

Secondary syphilitic lesions

An important theme that emerges from all early historical accounts is that in addition to the decreased virulence of Treponema pallidum, the incidence of secondary syphilis has decreased drastically over the past three centuries. Even in the early 20th century, most syphilologists were of the opinion that the disease had undergone changes in its manifestations and that they were dealing with an attenuated form of the spirochete. Such opinions were based primarily on the observations that violent cutaneous reactions and fatalities associated with the secondary stage had become extremely rare. The rate of primary and secondary syphilis in the United States increased in 2002 for the second consecutive year. After a decade-long decline that led to an all-time low in 2000, the recent trend is attributable, to a large extent, by a increase in reported syphilis cases among men, particularly homosexual and bisexual men having sex with men. The present review addresses the clinical and diagnostic criteria for the recognition of secondary syphilis, the clinical course and manifestations of the disease if allowed to proceed past the primary stage of disease in untreated individuals, and the treatment for this stage of the disease.

HIV status of sexual partners is more important than antiretroviral treatment related perceptions for risk taking by HIV positive MSM in Montreal, Canada

OBJECTIVE

To examine the role of antiretroviral treatment related perceptions relative to other clinical and psychosocial factors associated with sexual risk taking in HIV positive men who have sex with men (MSM).

METHODS

Participants were recruited from ambulatory HIV clinics in Montreal. Information on sociodemographic factors, health status, antiretroviral treatment related perceptions, and sexual behaviours was collected using a self administered questionnaire. At-risk sexual behaviour was defined as at least one occurrence of unprotected insertive or receptive anal intercourse in the past 6 months. Multivariate logistic regression was performed to evaluate the associations between at-risk sexual behaviour and covariates.

RESULTS

346 subjects participated in the study. Overall, 34% of subjects were considered at risk; 43% of sexually active subjects (n=274). At-risk sexual behaviour was associated with two antiretroviral treatment related perceptions: (1) taking antiretroviral treatment reduces the risk of transmitting HIV (adjusted odds ratio (OR), 2.10; 95% confidence interval (CI), 1.16 to 3.80); and (2) there is less safer sex practised by MSM because of HIV treatment advances (OR, 1.82; CI, 1.14 to 2.90). Other factors, however, were more strongly associated with risk. These were: (1) safer sex fatigue (OR, 3.23; CI, 1.81 to 5.78); (2) use of "poppers" during sexual intercourse (OR, 6.28; CI, 2.43 to 16.21); and (3) reporting a greater proportion of HIV positive anal sex partners, compared with reporting no HIV positive anal sex partners: (a) <50% HIV positive (OR, 16.79; CI, 4.70 to 59.98); (b) > or =50% HIV positive (OR, 67.67; CI, 15.43 to 296.90).

CONCLUSION

Despite much emphasis on HIV treatment related beliefs as an explanation for sexual risk taking in MSM, this concern may play a relatively minor part in the negotiation of risk by HIV positive MSM. Serosorting, safer sex fatigue, and the use of poppers appear to be more important considerations in understanding the sexual risk behaviours of HIV positive MSM.

A Longitudinal Study of the Association Between Treatment Optimism and Sexual Risk Behavior in Young Adult Gay and Bisexual Men

To determine whether optimism about highly active antiretroviral therapy is associated with sexual risk behavior among young adult HIV-negative gay and bisexual men, and to test 2 alternative explanations for this association: that treatment optimism leads to increased sexual risk or that treatment optimism is the result of previous sexual risk. Data on sexual risk behavior, treatment optimism, and perceived susceptibility to HIV infection were obtained from a sample of 538 HIV-negative or untested gay and bisexual men (ages 18-30) who were not in monogamous relationships. Follow-up data were collected 18 months later. In the cross-sectional data, treatment optimism was associated with the 2-month cumulative incidence of unprotected anal intercourse (UAI) with nonprimary partners; however, this effect was observed only among men who felt highly susceptible to HIV infection. Longitudinal analyses revealed that treatment optimism did not predict subsequent UAI, but UAI did predict later treatment optimism. Treatment optimism is associated with sexual risk behavior among young adult gay and bisexual men. However, these data suggest that optimism may result from, rather than precede, sexual risk.

Calculating the Contribution of Herpes Simplex Virus Type 2 Epidemics to Increasing HIV Incidence: Treatment Implications

Herpes simplex virus type 2 (HSV-2) is the most prevalent sexually transmitted pathogen worldwide. There is considerable biological and epidemiological evidence that HSV-2 infection increases the risk of acquiring HIV infection and may also increase the risk of transmitting HIV. Here, we use a mathematical model to predict the effect of a high-prevalence HSV-2 epidemic on HIV incidence. Our results show that HSV-2 epidemics can more than double the peak HIV incidence; that the biological heterogeneity in susceptibility and transmission induced by an HSV-2 epidemic causes HIV incidence to rise, fall, and then rise again; and that HSV-2 epidemics concentrate HIV epidemics, creating a "core group" of HIV transmitters. Our modeling results imply that findings from HSV-2 intervention trials aimed at reduction of HIV incidence will be variable and that positive findings will be obtained only from trials in communities in which HIV incidence is steeply rising.

A Case–Control Study of Syphilis Among Men Who Have Sex With Men in New York City

OBJECTIVE

The objective of this study was to determine factors associated with syphilis among men who report sex with other men in New York City. DESIGN, SETTING AND STUDY SUBJECTS: We conducted a case-control study among 88 men who reported sex with men in the previous year, 18 to 55 years old and diagnosed with primary or secondary syphilis during 2001; and 176 control subjects frequently matched by age and type of health provider.

RESULTS

HIV prevalence among syphilis cases was 48% compared with 15% among control subjects (P <0.001). Variables associated with syphilis in a multivariate model were HIV infection (odds ratio [OR], 7.3; 95% confidence interval [CI], 3.5-15.4), income >$30,000 per year (OR, 2.7; CI, 1.4-5.2), and barebacking (OR, 2.6; CI, 1.4-4.8). The median time since HIV diagnosis for HIV-positive was 6 years for cases and 7 years for control subjects (P = 0.70). Among HIV-infected participants, syphilis cases were more likely than control subjects to report being on antiretroviral therapy (69% vs. 44%, P = 0.05) and to report having undetectable viral load (58% vs. 24%, P = 0.02).

CONCLUSION

HIV infection was strongly associated with syphilis in this study. High-risk behavior reported by both cases and control subjects indicates the potential for increased HIV transmission.

Trends in HIV Prevalence Among Public Sexually Transmitted Disease Clinic Attendees in the Western Region of the United States (1989???1999)

OBJECTIVES

Using data from anonymous unlinked testing of routinely collected sera, trends in HIV are compared among sexually transmitted disease patients in 4 Western urban centers.

METHODS

Between 1989 and 1999, remnant sera obtained for routine syphilis testing from 256,819 patient visits to Denver, Los Angeles, San Francisco, and Seattle clinics were tested for HIV antibodies in an unlinked survey. HIV antibody test results were linked to anonymous demographic and risk information abstracted from the medical record.

RESULTS

Overall cumulative HIV seroprevalences among women and among men who had sex exclusively with women were < or = 2%, declined over time, and did not exceed 8% among those who injected drugs. In contrast, cumulative HIV seroprevalences among men who have sex with men ranged from 13% in Seattle to 30% in San Francisco and declined a mean of 2.1% (95% CI, 1.6, 2.6) to 2.8% (CI 2.6, 3.1) per year, after adjustment.

CONCLUSIONS

HIV infection declined over time across counties. Relative levels of HIV differed little by demographic and behavioral risk group despite differences in the severity of each county's epidemic. Because of the unique contribution of unlinked serosurveillance studies in monitoring these trends, their reinstitution in high-risk settings should be considered.

Is unsafe sexual behaviour increasing among HIV-infected individuals?

BACKGROUND

The number of new diagnoses of HIV infection is rising in the northwestern hemisphere and it is becoming increasingly important to understand the mechanisms behind this trend.

OBJECTIVE

To evaluate whether reported unsafe sexual behaviour among HIV- infected individuals is changing over time.

DESIGN

Participants in the Swiss HIV Cohort Study were asked about their sexual practices every 6 months for 3 years during regular follow-up of the cohort beginning on 1 April 2000.

METHODS

: Logistic regression models were fit using generalized estimating equations assuming a constant correlation between responses from the same individual.

RESULTS

At least one sexual behaviour questionnaire was obtained for 6545 HIV-infected individuals and the median number of questionnaires completed per individual was five. There was no evidence of an increase in reported unsafe sex over time in this population [odds ratio (OR), 1.0; 95% confidence interval (CI), 0.96-1.05]. Females (OR, 1.38; 95% CI, 1.19-1.60), 15-30 year olds (OR, 1.26; 95% CI, 1.09-1.47), those with HIV-positive partners (OR, 12.58; 95% CI, 10.84-14.07) and those with occasional partners (OR, 3.25; 95% CI, 2.87-3.67) were more likely to report unsafe sex. There was no evidence of a response bias over time, but individuals were less willing to leave questions about their sexual behaviour unanswered or ambiguous (OR, 0.93; 95% CI, 0.90-0.97).

CONCLUSIONS

There was no evidence of a trend in unsafe sex behaviour over time. However, several subgroups were identified as being more likely to report unsafe sex and should be targeted for specific interventions.

The bisexual bridge revisited: sexual risk behavior among men who have sex with men and women, San Francisco, 1998-2003

From 1998 to 2003 in San Francisco, unprotected anal intercourse (UAI) with one or more partner of unknown HIV serostatus (potentially serodiscordant UAI) increased among bisexual men who have sex with men (MSM) in parallel and in magnitude compared with other MSM. Potentially serodiscordant UAI and unprotected vaginal intercourse increased from 1998 to 2001 then decreased from 2001 to 2003. Although elements of a 'bisexual bridge' are present, we note an encouraging decrease in risk from 2001 to 2003.

Resurgence in infectious syphilis in Ireland: an epidemiological study

INTRODUCTION

In 2000, a syphilis outbreak was identified in Ireland.

MATERIALS AND METHODS

A prospective enhanced database was established in 2000. Crude incidence rates for the general population, men who have sex with men (MSM), and HIV-positive MSM were calculated.

RESULTS

Three hundred fifty-six cases of infectious syphilis were diagnosed at 1 center. Eighty-five percent of cases were identified as MSM. Crude incidence rates in MSM, ranging in age between 20 and 44 years, peaked in 2001 at 719 cases per 100000 of the MSM population. A total of 17.4% of cases occurred in HIV-infected individuals. Crude incidence rates of syphilis in HIV-positive MSM in the center increased to 7280 per 100000. Similar percentages of MSM with and without HIV infection had unprotected anal intercourse (37% and 41%, respectively).

CONCLUSION

High-risk sexual behavior continues among HIV-infected and -noninfected MSM. Crude incidence rates among MSM in Ireland are alarming when compared with other outbreaks.

The changing face of the HIV epidemic in western Europe: what are the implications for public health policies?

In this review, we describe changes in dynamics of HIV transmission and shifts in affected populations in western Europe using HIV/AIDS surveillance data and published and unpublished reports. Despite substantial reductions in HIV-related morbidity and mortality since the introduction of highly active antiretroviral treatment, HIV continues to pose a major public health problem in western Europe. More than half a million people are living with an infection that remains incurable and requires costly lifelong treatment; many people remain unaware of their infection, and thousands of new infections continue to occur every year. Migrants from countries with a high prevalence of HIV/AIDS, notably sub-Saharan Africa, bear a disproportionate and increasing share of HIV throughout western Europe and, in most countries, account for the majority of heterosexually acquired HIV infections diagnosed in recent years. Prevention, treatment, and care must be adapted to reach migrant populations. Following a resurgence of risky sexual behaviour, HIV transmission may now be increasing among homosexual and bisexual men, and renewed safer sex campaigns are urgently needed.

Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study

BACKGROUND

Effective interventions are needed to prevent acquisition of HIV infection in men who have sex with men. To date, no behavioural interventions specifically for this risk group have been tested with HIV infection as the primary outcome.

METHODS

This multisite two-group randomised controlled phase IIb trial tested the efficacy of a behavioural intervention in preventing HIV infection among 4295 men who have sex with men. The experimental intervention consisted of ten one-on-one counselling sessions followed by maintenance sessions every 3 months. The standard condition was twice-yearly Project RESPECT individual counselling. Twice-yearly follow-up visits included testing for HIV antibody and assessment of behavioural outcomes.

FINDINGS

The rate of acquisition of HIV infection was 18.2% (95% CI -4.7 to 36.0) lower in the intervention group than the standard group. Adjustment for baseline covariates attenuated the intervention effect to 15.7% (-8.4 to 34.4). The effect was more favourable in the first 12-18 months of follow-up. The occurrence of unprotected receptive anal intercourse with HIV-positive and unknown-status partners was 20.5% (10.9 to 29.0) lower in the intervention than in the standard group.

INTERPRETATION

The results from the primary analyses allow us to rule out that the experimental intervention is associated with a 35% lower rate of HIV acquisition than in the standard group. The overall estimate of a difference of 18.2%, more favourable estimates of effect in the first 12-18 months, and similar effects on risk behaviours suggest that prevention of HIV infection among men who have sex with men by a behavioural intervention is feasible. Further work should be done to develop more effective interventions.

Decline in HIV infectivity following the introduction of highly active antiretroviral therapy

OBJECTIVE

Little is known about the degree to which widespread use of antiretroviral therapy in a community reduces uninfected individuals' risk of acquiring HIV. We estimated the degree to which the probability of HIV infection from an infected partner (the infectivity) declined following the introduction of highly active antiretroviral therapy (HAART) in San Francisco.

DESIGN

Homosexual men from the San Francisco Young Men's Health Study, who were initially uninfected with HIV, were asked about sexual practices, and tested for HIV antibodies at each of four follow-up visits during a 6-year period spanning the advent of widespread use of HAART (1994-1999).

METHODS

We estimated the infectivity of HIV (per-partnership probability of transmission from an infected partner) using a probabilistic risk model based on observed incident infections and self-reported sexual risk behavior, and tested the hypothesis that infectivity was the same before and after HAART was introduced.

RESULTS

A total of 534 homosexual men were evaluated. Decreasing trends in HIV seroincidence were observed despite increases in reported number of unprotected receptive anal intercourse partners. Conservatively assuming a constant prevalence of HIV infection between 1994 and 1999, HIV infectivity decreased from 0.120 prior to widespread use of HAART, to 0.048 after the widespread use of HAART- a decline of 60% (P=0.028).

CONCLUSIONS

Use of HAART by infected persons in a community appears to reduce their infectiousness and therefore may provide an important HIV prevention tool.

Ambivalent tales of HIV disclosure in San Francisco

In light of rising levels of unprotected anal intercourse (UAI) among men who have sex with men (MSM) in San Francisco, we sought to understand disclosure practices, the calculus of risk and attitudes about HIV seroconversion. In 2000, 150 MSM participated in interviews pivoting around a detailed narrative of a recent incident of UAI. In order to understand the relationship between individual and community norms, we analyzed the narratives as accounts situated within the respondents' experience of the HIV epidemic and the gay community in San Francisco. In justifying their risky sexual practices, MSM cited a community-wide shift toward non-disclosure and barebacking since the advent of highly active anti-retroviral therapy (HAART). Fearing rejection by HIV-positive partners who refuse to use condoms, HIV-negative men saw little advantage in disclosing to casual partners whom they perceived as overwhelmingly HIV-positive. By contrast, HIV-positive men appeared eager to disclose their positive status to release themselves from responsibility for transmission and facilitate "bareback" or unprotected sex. Disavowal of individual responsibility for safer sex in deference to community norms may contribute to the recent spiraling of risk behavior and HIV incidence. Implications for prevention policy are discussed.

Importance of Sex Partner HIV Status in HIV Risk Assessment Among Men Who have Sex With Men

Clinical HIV risk assessments have not typically integrated questions about sex partners' HIV status with questions about condom use and type of sex. Since 2001, we have asked all men who have sex with men (MSM) evaluated in an urban sexually transmitted disease (STD) clinic how often in the preceding 12 months they used condoms for anal sex with partners who were HIV-positive, HIV-negative, and of unknown HIV status. Overall, MSM displayed a pattern of assortative mixing by HIV status, particularly for unprotected anal intercourse (UAI). Nevertheless, 433 (27%) of 1580 MSM who denied knowing they were HIV-positive and 93 (43%) of 217 HIV-positive MSM reported having UAI with a partner of opposite or unknown HIV status. Among men who denied previously knowing they were HIV-positive, 24 (9.6%) of 251 MSM who reported having UAI with an HIV-positive partner or partner of unknown HIV status compared with 11 (1.7%) of 620 MSM who denied such exposure tested HIV-positive (odds ratio=5.8, 95% confidence interval: 2.8-12.1). UAI with an HIV-positive partner or partner with unknown HIV status was 69% sensitive and 73% specific in identifying men with previously undiagnosed HIV infection; UAI regardless of partner HIV status was 80% sensitive but only 45% specific. The positive predictive value was highest for risk assessments that included partner HIV status. Integrating questions about anal sex partner HIV status and condom use identifies MSM at greatest risk for HIV acquisition and transmission. These risk criteria might be effectively used to triage MSM into more intensive prevention interventions.

HIV superinfection in the era of increased sexual risk-taking

Recent reports have documented increases in unprotected intercourse (UI) and sexually transmitted diseases (STDs) among men who have sex with men (MSM) and other at-risk populations. A further consequence of persons living with HIV engaging in unprotected intercourse or shared parenteral exposures with seroconcordant partners is HIV recombination and superinfection, possibly with a drug-resistant or more pathogenic virus. The epidemiologic, clinical, and therapeutic implications of recent case reports confirming superinfection in persons living with HIV, as well as research priorities aimed at providing a more thorough understanding of the consequences of unprotected sex among HIV-infected people, are explored here.

Can highly active antiretroviral therapy reduce the spread of HIV?: A study in a township of South Africa

BACKGROUND

Calls have been made for the large-scale delivery of highly active antiretroviral therapy (HAART) to people infected with HIV in developing countries. If this is to be done, estimates of the number of people who currently require HAART in high HIV prevalence areas of sub-Saharan Africa are needed, and the impact of the widespread use of HAART on the transmission and, hence, spread of HIV must be assessed.

OBJECTIVES

To estimate the proportion of people eligible for combination antiretroviral therapy and to evaluate the potential impact of providing HAART on the spread of HIV-1 under World Health Organization (WHO) guidelines in a South African township with a high prevalence of HIV-1.

DESIGN

A community-based cross-sectional study in a township near Johannesburg, South Africa, of a random sample of approximately 1000 men and women aged 15 to 49 years.

METHODS

Background characteristics and sexual behavior were recorded by questionnaire. Participants were tested for HIV-1, and their CD4 cell counts and plasma HIV-1 RNA loads were measured. The proportion of people whose CD4 cell count was less than 200 cells/mm and who would be eligible to receive HAART under WHO guidelines was estimated. The potential impact of antiretroviral drugs on the spread of HIV-1 in this setting was determined by estimating among the partnerships engaged in by HIV-1-positive individuals the proportion of spousal and nonspousal partnerships eligible to receive HAART and then by calculating the potential impact of HAART on the annual risk of HIV-1 transmission due to sexual contacts with HIV-1-infected persons. The results were compared with those obtained using United States Department of Health and Human Services (USDHHS) guidelines.

RESULTS

The overall prevalence of HIV-1 infection was 21.8% (19.2%-24.6%), and of these people, 9.5% (6.1%-14.9%) or 2.1% (1.3%-3.3%) of all those aged 15 to 49 years would be eligible for HAART (ranges are 95% confidence limits). In each of the next 3 years 6.3% (4.6%-8.4%) of those currently infected with HIV-1 need to start HAART. Among the partnerships in which individuals were HIV-1-positive, only a small proportion of spousal partnerships (7.6% [3.4%-15.6%]) and nonspousal partnerships (5.7%, [3.0%-10.2%]) involved a partner with a CD4 cell count below 200 cells/mm and would have benefited from the reduction of transmission due to the decrease in plasma HIV-1 RNA load under HAART. Estimates of the impact of HAART on the annual risk of HIV-1 transmission show that this risk would be reduced by 11.9% (7.1%-17.0%). When using USDHHS guidelines, the proportion of HIV-1-positive individuals eligible for HAART reached 56.3% (49.1%-63.2%) and the impact of HAART on the annual risk of HIV-1 transmission reached 71.8% (64.5%-77.5%).

CONCLUSIONS

The population impact of HAART on reducing sexual transmission of HIV-1 is likely to be small under WHO guidelines, and reducing the spread of HIV-1 will depend on further strengthening of conventional prevention efforts. A much higher impact of HAART is to be expected if USDHHS guidelines are used.

Transmission of HIV-1 drug resistance

BACKGROUND

The use of highly-active anti-retroviral therapy (HAART) for treating HIV infections is increasing. Recent studies have demonstrated that HAART is improving both the length and quality of life in HIV-infected patients. Resistant strains of HIV arise when drug adherence is poor. This can lead to the transmission of drug-resistant strains of HIV to susceptible individuals. This can lead to suboptimal first-line therapy, if the resistance profile of the transmitted virus is unknown.

OBJECTIVES

To review the mechanisms of how drug resistance arises; the methods used to characterise drug resistance; the problems arising with compliance leading to the development of drug-resistant HIV strains; the evidence for the incidence, prevalence and trends in the transmission of resistant HIV strains in different risk groups; and the evidence of suboptimal response to first-line therapy where transmission of a resistant HIV strain has occurred. On the basis of this, a case is presented for the routine resistance testing of all newly diagnosed HIV-infected individuals.

STUDY DESIGN

Literature review.

RESULTS AND CONCLUSIONS

There is evidence, though limited at present, that transmission of drug-resistant HIV strains can lead to suboptimal response to first-line therapy in newly diagnosed HIV-infected individuals. As the use of HAART can only increase in the future, and compliance will always be a problem in such HAART-treated patients, baseline resistance testing should become a routine part of their management.

Increase in sexual risk behavior associated with immunologic response to highly active antiretroviral therapy among HIV-infected injection drug users

This study identifies factors associated with high-risk sexual and drug injection behaviors among human immunodeficiency virus (HIV)-infected injection drug users (IDUs) after initiation of highly active antiretroviral therapy (HAART). Participants of a large cohort study of IDUs in Baltimore were seen at semiannual visits; blood samples to determine HIV serostatus and CD4+ cell count were obtained, as well as questionnaire data on risk behaviors and medication. Survival analysis conducted for 190 HIV-infected participants who initiated HAART during 1996-2000 revealed that an increase in CD4+ cell count (categorized as an increase of >0 cells/mm3 or of < or =0 cells/mm3) after HAART initiation was independently associated with engaging in any sexual intercourse (adjusted relative hazard [ARH], 1.83; 95% CI, 1.22-2.73) and with a 3-fold increase in the hazard of engaging in unprotected sexual intercourse (ARH, 3.29; 95% CI, 1.57-6.93) after HAART initiation. An increase in CD4+ cell count after HAART initiation was not associated with injection of drugs or needle sharing. Risk reduction counseling remains important, despite improvements in the treatment of HIV infection.

Frequent detection of acute primary HIV infection in men in Malawi

BACKGROUND

Acute (antibody-negative) HIV infection is associated with high transmission potential but is rarely recognized.

DESIGN

Cross-sectional study.

METHODS

We examined the prevalence and predictors of acute HIV infection among 1361 consecutive male outpatients attending sexually transmitted disease (STD; n = 929) and dermatology (n = 432) clinics in Lilongwe, Malawi. Serum specimens negative for HIV antibodies were screened by HIV RNA PCR using a highly specific pooling/resolution testing algorithm.

RESULTS

Five-hundred and fifty-three men (40.6%) were HIV antibody positive and 24 (1.8%) had acute HIV infection; 23 of 24 acutely infected men were from the STD clinic, where they represented 4.5% of all HIV antibody-negative men and 5.0% of all HIV infections. HIV RNA levels for acutely infected men were significantly higher [median (interquartile range), 6.10 (5.19-6.54) log10 HIV RNA copies/ml] than for 58 HIV antibody-positive men [4.42 (3.91-4.95) log10 copies/ml; P < 0.0001]. The factor most strongly associated with acute HIV infection was STD clinic attendance: (odds ratio, 15.2; 95% confidence interval, 2.04-113.0). In multivariate analysis considering only STD patients, factors associated with acute HIV infection included inguinal adenopathy, genital ulceration and age 24-26 years, the age stratum associated with peak incidence of HIV infection among Malawian men.

CONCLUSIONS

Traditional HIV antibody tests alone are not sufficient to exclude HIV infection among men with acute STD in Malawi due to a surprising proportion of acute HIV infections in this population. Alternative screening methods are required for diagnosis of acute HIV infection; such screening could be important for research and for prevention of the sexual transmission of HIV in select populations.

Inconsistent condom use among HIV-infected patients with alcohol problems

BACKGROUND

Unsafe sexual behavior is common among persons with negative or unknown HIV status and it is augmented by alcohol use in some populations. We examined the association between alcohol consumption level (abstinent, moderate, at-risk) and inconsistent condom use in a cohort of HIV-infected individuals with a history of alcohol problems.

METHODS

Subjects (n=345) had up to seven structured interviews over 36 months. Identical questions on alcohol consumption and inconsistent condom use were asked at each interview. We used generalized estimating equations (GEE) multivariate logistic regression for repeated measurements analysis. We adjusted for potential confounding factors and explored possible interactions.

RESULTS

At baseline, 132 (38%) participants reported inconsistent condom use. We detected a significant (P=0.0002) interaction between alcohol consumption and injection drug use (IDU) variables. Among active injection drug users, at-risk drinking was associated with inconsistent condom use, adjusted odds ratio (OR; 95% confidence interval) 4.3 (1.5, 12.2). Among those who did not inject drugs, at-risk drinking and inconsistent condom use were not associated, 0.7 (0.4, 1.3). Inconsistent condom use was more common among women, those believing condoms to be 'a hassle', and persons living with a partner.

CONCLUSION

In HIV-infected drug-injecting individuals, excessive use of alcohol is associated with unsafe sexual practices.

Gay Asian men in San Francisco follow the international trend: increases in rates of unprotected anal intercourse and sexually transmitted diseases, 1999-2002

Worldwide, studies of men who have sex with men (MSM) report increases in HIV risk-related behavior. Less is known about trends within minority subpopulations of MSM, particularly those of Asian and Pacific Islander (A&PI) ethnicity. A&PI MSM are underrepresented among AIDS cases (2.7%) with respect to their estimated makeup in the gay community of San Francisco (4.5%). However, recent trends in unprotected anal intercourse (UAI) and sexually transmitted diseases suggest a reversal in the relative risk for HIV among A&PI MSM compared with White MSM. Starting from lower levels in 1999, UAI with multiple partners, UAI with multiple partners of unknown HIV serostatus, the incidence of male rectal gonorrhea, and the incidence of early syphilis among A&PI MSM surpassed levels among White MSM by 2002. A window of opportunity to prevent further spread of HIV among A&PI MSM may be closing.

Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: a longitudinal study

OBJECTIVE

To investigate longitudinally the association between highly active antiretroviral therapy (HAART)-related beliefs and the change from protected to unprotected anal intercourse with casual partners on an individual level.

METHODS

The study population included 217 HIV-negative homosexual men participating in the Amsterdam Cohort Study from September 1999 to May 2002, including five data waves with a 6-month interval. The selection criteria were: being under 31 years of age, having had anal sex with casual partners in the preceding 6 months, and participating in at least two data waves. Information was collected on the individual change from protected to unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI) and the level of agreement with different HAART-related beliefs.

RESULTS

The majority of men disagreed with the three treatment-belief factors that resulted from the principal component analysis: perceiving less HIV/AIDS threat since HAART, perceiving less need for safe sex since HAART, and perceiving high effectiveness of HAART in curing HIV/AIDS. Multivariate analyses revealed that the more men inclined to agree with the belief 'perceiving less HIV/AIDS threat', the more likely they were to change to URAI (adjusted OR 1.60; 95% CI 1.16-2.22).

CONCLUSION

Homosexual men are quite realistic about the effectiveness of HAART, the continued need for condom use, and the HIV/AIDS threat since HAART. However, a tendency towards agreement with 'perceiving less HIV/AIDS threat' was found to predict an individuals' change to URAI. This finding supports the hypothesis of a causal relationship between decreased HIV/AIDS threat since HAART and a change to URAI.

HIV incidence appears constant in men who have sex with men despite widespread use of effective antiretroviral therapy

OBJECTIVE

To estimate the trend in HIV incidence between 1995 and 2001 in men who have sex with men (MSM) attending sexually transmitted infection (STI) clinics in the UK.

DESIGN

The Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) was applied to serum specimens from MSM attending 15 STI clinics collaborating in an HIV unlinked anonymous prevalence serosurvey.

METHODS

STARHS was performed on anti-HIV-1 positive specimens and HIV incidence rates determined. Specimens from MSM with previously diagnosed HIV or an AIDS defining condition were excluded. National data on uptake of antiretroviral therapy (ART), AIDS mortality and diagnoses of gonorrhoea in MSM were used to aid interpretation of the HIV incidence findings.

RESULTS

Of 43,100 specimens collected from MSM 3565 were anti-HIV-1 positive. Of these, 1645 were eligible and available for STARHS testing, of which 317 were deemed to come from recently acquired infections. The overall estimated annual incidence ranged from 1.5% (1999) to 3.3% (1996). In 2001 it was 2.45%, with a 3.1% incidence in London and 1.0% elsewhere. No significant trends in HIV incidence were found.

CONCLUSIONS

Despite the widespread use of ART there was no significant decline in HIV incidence. Individuals whose HIV infection has been diagnosed should be less infectious. However, over 20% of infections in MSM remain undiagnosed, many with acute STI, and this pool of unmanaged HIV infection may be an important driver of the ongoing epidemic. Initiatives to diagnose and treat a greater proportion of HIV infections may be the key to reducing HIV incidence in MSM.

Decline in HIV infectivity following the introduction of highly active antiretroviral therapy

OBJECTIVE

Little is known about the degree to which widespread use of antiretroviral therapy in a community reduces uninfected individuals' risk of acquiring HIV. We estimated the degree to which the probability of HIV infection from an infected partner (the infectivity) declined following the introduction of highly active antiretroviral therapy (HAART) in San Francisco.

DESIGN

Homosexual men from the San Francisco Young Men's Health Study, who were initially uninfected with HIV, were asked about sexual practices, and tested for HIV antibodies at each of four follow-up visits during a 6-year period spanning the advent of widespread use of HAART (1994-1999).

METHODS

We estimated the infectivity of HIV (per-partnership probability of transmission from an infected partner) using a probabilistic risk model based on observed incident infections and self-reported sexual risk behavior, and tested the hypothesis that infectivity was the same before and after HAART was introduced.

RESULTS

A total of 534 homosexual men were evaluated. Decreasing trends in HIV seroincidence were observed despite increases in reported number of unprotected receptive anal intercourse partners. Conservatively assuming a constant prevalence of HIV infection between 1994 and 1999, HIV infectivity decreased from 0.120 prior to widespread use of HAART, to 0.048 after the widespread use of HAART- a decline of 60% (P=0.028).

CONCLUSIONS

Use of HAART by infected persons in a community appears to reduce their infectiousness and therefore may provide an important HIV prevention tool.

Managing Syphilis in the HIV-infected Patient

Syphilis has re-emerged in the United States and elsewhere, and clinicians caring for HIV-infected patients are challenged with syphilis diagnosis and management decisions. HIV alters the natural history of syphilis to an extent that is poorly understood, and initial presentation may be more varied in coinfected patients. Although commonly available diagnostic assays for syphilis should be interpreted as usual, such tests rely on antibody measurement and may be an imperfect indicator of active infection. Assessment of all available clinical and risk behavior data remains critically important in the diagnosis of syphilis in coinfected patients. Treatment of syphilis in such patients requires stage-appropriate therapy, with careful serologic monitoring to assess response. Clinicians must have heightened appreciation of the role of frequent risk assessment, serologic screening, symptom recognition, and follow-up of treated patients, as well as an understanding of public health functions such as sex partner treatment and communicable disease reporting.

Alcohol Use and High-Risk Sexual Behavior Among Men Who Have Sex With Men: The Effects of Consumption Level and Partner Type

Alcohol use may increase HIV sexual risk behavior, although findings have varied across study populations and methods. Using event-level data from 1,712 seronegative men who have sex with men, the authors tested the hypothesis that social context would moderate the effect of alcohol consumption on unprotected anal sex (UAS). For encounters involving a primary partner, rates of UAS did not vary as a function of alcohol use. However, consumption of 4 or more drinks tripled the likelihood of UAS for episodes involving a nonprimary partner. Thus, the effects of alcohol vary according to the context in which it is used. Interventions to reduce substance-related risk should be tailored to the demands of maintaining sexual safety with nonprimary partners.

The social course of drug injection and sexual activity among YMSM and other high-risk youth: an agenda for future research

The cumulative epidemiologic literature indicates that many injecting drug users (IDUs) initiate injection as a mode of drug administration during late adolescence or early adulthood. Recent studies have shown that IDUs are often exposed to viral infections relatively early in the course of injection, highlighting the importance of understanding this initiation process for both epidemiology and prevention. Epidemiologic evidence similarly suggests that at least some youth populations, most notably young men who have sex with men (YMSM), are at substantial risk for exposure to HIV and other sexually transmitted diseases (STDs) from early sexual activity. Despite the importance of this issue for both epidemiology and prevention, however, surprisingly little information is available on the social course of injection initiation, including the individual, social, or ecological factors that might mitigate or exacerbate transmission risks within the critical phase of early injection drug use. Similarly, we know little about the ways that YMSM and other high-risk youth understand risk, the kinds of exchanges and relationships in which they participate in the context of initiating sexual activity, or how drug use is operant in these exchanges and early sexual experiences. In this article, we explore key dimensions of the early initiation of injection and sexual risk, and discuss how a social network approach might be instrumental in understanding the social course of drug injection and sexual activities among youth and young adult populations.

Risk Factors for Rectal Gonococcal Infection Amidst Resurgence in HIV Transmission

BACKGROUND

Rectal gonorrhea in men has been increasing in San Francisco since 1995.

GOAL

The goal was to determine behavioral risk factors associated with rectal gonorrhea (RGC) among men who have sex with men (MSM) by HIV serostatus.

STUDY DESIGN

All men reporting receptive anal sex in the last 6 months are screened for RGC, regardless of reported condom use, at San Francisco's municipal sexually transmitted disease (STD) clinic. We surveyed a convenience sample of men screened for RGC at the clinic.

RESULTS

Among 564 MSM surveyed, 7.1% had RGC. HIV-positive MSM were significantly more likely (relative risk, 3.5, 95% confidence interval, 1.9-5.8) to have RGC. Behavioral risks for RGC infection varied significantly by HIV serostatus. HIV-positive MSM engaging in anonymous sex were at highest risk for RGC infection. Drug use during anal sex was the strongest risk factor for RGC infection among HIV-negative or unknown HIV status MSM.

CONCLUSION

Our data suggest that STD and HIV prevention efforts among MSM in San Francisco must consider the role that HIV serostatus plays in acquisition of new infections.

Correlates of sexual risk behaviors among HIV-positive men who have sex with men

This study examines correlates of unprotected sexual risk practices of an ethnically diverse sample of HIV-seropositive men who have sex with men (MSM) from the New York City and San Francisco metropolitan areas. Participants completed a self-report survey that assessed sexual risk behaviors and potential correlates. A total of 367 men reported sex with a casual male partner in the previous 3 months. Participants were divided into three groups based on level of HIV-transmission risk with HIV negative or unknown-status partners: no unprotected anal sex (58.9%), unprotected receptive anal sex only (14.2%), and unprotected insertive anal sex (22.6%). Multivariate logistic regression analyses indicated that men reporting unprotected anal insertive sex perceived less responsibility to protect their partners from HIV. Men reporting no unprotected anal sex also reported less use of nitrate inhalants, lower temptation for unsafe sex, and fewer HIV-negative and unknown-status partners. Men reporting unprotected receptive anal sex were less anxious than the other two groups but also reported greater depression than those not reporting unprotected anal sex and greater loneliness than those reporting unprotected anal insertive sex. Implications for interventions with HIV-positive MSM are presented.

Interests in HIV prevention topics of HIV-seropositive men who have sex with men

As improved medical treatments have extended the lives of persons with HIV, prevention programs increasingly address these persons' ability to adopt and sustain HIV risk reduction behavior. Little is known about which HIV-seropositive persons would most likely use prevention programs or what program topics would best meet the needs of this population. A diverse sample of HIV-seropositive men who have sex with men (MSM, N = 206) rated their interest in a variety of program topics addressing physical and mental health issues. Topics specific to HIV prevention were of interest to most MSM, but the level of interest was generally lower than for other topics. Compared with White MSM, African American MSM had higher overall interest in programs addressing safer sex and programs addressing serostatus disclosure. Higher active coping was related to more interest in a broad range of program topics for HIV-seropositive men, programs addressing safer sex, and programs addressing serostatus disclosure. Risk behavior was not associated with program interests. Gaining a better understanding of interest in a variety of program topics among persons living with HIV is an important step in enhancing HIV transmission prevention programs.

Stochastic simulation of the impact of antiretroviral therapy and HIV vaccines on HIV transmission; Rakai, Uganda

OBJECTIVE

To model the effects of antiretroviral therapy (ART) and HIV vaccines on HIV transmission using empirical data from studies in Rakai, Uganda.

DESIGN

A stochastic simulation model estimated HIV incidence, probabilities of transmission per coital act and the reproductive number (R0) with ART and HIV vaccines. Model inputs included Rakai data on HIV transmission probabilities per coital act by HIV viral load, age and gender, and sexual behaviors. The impacts of therapy were derived from US programs, and vaccine assumptions included preventive efficacies ranging from 25 to 75%. Component projection models estimated the numbers of HIV-infected persons over 20 years.

RESULTS

The model incidence [1.57/100 person years (PY)] closely fitted empirical data (1.5/100 PY). Simulations of ART using DHHS treatment guidelines, predicted declines in HIV incidence, but R0 remained > 1.0, and the numbers of HIV-positive persons did not change substantially over 20 years. Preventive vaccines with > 50% efficacy and > 50% population coverage could reduce R0 to < 1.0, and substantially reduce the number of HIV-infected persons over 20 years. Concurrent ART and a preventive vaccine can have substantial impact at lower levels of population coverage and would markedly reduce the HIV infected population over 20 years. However, behavioral disinhibition with increased numbers of sexual partners in either ART or vaccine recipients, increased HIV incidence and diminished intervention impact.

CONCLUSION

ART alone cannot control the HIV epidemic in mature epidemics such as Rakai, and persons in need of therapy will increase over time. ART in combination with a low efficacy vaccine could control the epidemic, if behavioral disinhibition is prevented.

Attitudes toward HIV treatments influence unsafe sexual and injection practices among injecting drug users

OBJECTIVE

To determine if HIV treatment-related attitudes are associated with unprotected sex and needle sharing among HIV-seropositive and -seronegative injecting drug users (IDU) in Baltimore, Maryland.

DESIGN AND METHODS

IDU participating in a cohort study seen between December 2000 and July 2001 completed an interviewer-administered questionnaire on attitudes toward HIV treatment and risk behaviors (593 HIV-seronegative, 338 HIV-seropositive), including: perceived HIV transmissibility through unprotected sex and needle sharing, and safer sex and injection fatigue. Logistic regression was used to examine the role of attitudinal factors on needle sharing and unsafe sex.

RESULTS

Almost two-thirds of sexually active participants engaged in unprotected sex and approximately half of those injecting drugs shared needles. Among HIV-seropositive IDU, perception of reduced HIV transmissibility through unprotected sex was significantly associated with unprotected sex [adjusted odds ratio (AOR), 3.33; 95% confidence interval (CI), 1.05-10.55). Safer injection fatigue was independently associated with needle sharing among HIV-seropositive IDU (AOR, 6.55; 95% CI, 1.69-25.39). Among HIV-seronegative IDU, safer sex fatigue and safer injection fatigue were independently associated with unprotected sex (AOR, 3.12; 95% CI, 1.17-8.35) and needle sharing (AOR, 5.15; 95% CI, 2.33-11.37), respectively.

CONCLUSION

Among HIV-seropositive IDU, perceiving that HIV treatments reduce HIV transmission was significantly associated with unprotected sex. Risk reduction fatigue was strongly associated with unsafe sexual and injection behaviors among HIV-seronegative individuals. HIV prevention interventions must consider the unintended impact of HIV treatments on attitudes and risk behaviors among IDU.

Attitudes about combination HIV therapies: the next generation of gay men at risk

This study examined awareness of and attitudes about highly active antiretroviral therapies (HAARTs) among adolescent and young men who have sex with men (MSM). As part of the multisite Young Men's Survey, 813 MSM aged 15-22 years who attended public venues in two cities were questioned about HAART in 1997-1998. Overall, 45.1% had heard of HAART, 61.6% in Seattle, Washington, and 35.0% in New York City. MSM in New York City who were the youngest, men of color, men who were human immunodeficiency virus (HIV) antibody negative, and men who resided in New Jersey were significantly less likely to be aware of HAART. Attitudes about HAART were not associated with sexual risk behaviors. Prevention efforts among young MSM should focus on other determinants of risk, but also include information on the changing nature of HIV therapies.

Contraception use, family planning, and unprotected sex: few differences among HIV-infected and uninfected postpartum women in four US states

To describe pregnancy intentions and contraceptive use among a postpartum sample of women with and at risk for HIV infection, 258 HIV-seropositive and 228 HIV-seronegative women were recruited from prenatal clinics in 4 US states between June 1996-November 1998. Participants completed interviews at 24-40 weeks' gestation and at 6 months postpartum. At the 6-month interview, 78% of women reported vaginal sex, and 2% were pregnant. Among those not pregnant, 86% said that there was no likelihood of a pregnancy in the next 6 months. Condom use was reported by 68% of sexually active women; 65% of users reported consistent use. Those with HIV were more likely to report condom use, more likely to report condom use consistency, and less likely to report use of oral contraceptives than women without HIV (P < 0.05). In multivariate analysis, inconsistent condom use was associated with postpartum alcohol use (odds ratio [OR] 2.80; 95% CI = 1.34-5.84), with the respondent stating that a pregnancy would not be emotionally upsetting (OR 3.06; 95% CI = 1.41-6.59) and reporting an intention to terminate a pregnancy if one were to occur (OR 3.47; 95% CI = 1.58-7.60). HIV-seropositive women who had at least 1 child with HIV infection were less likely than seronegative women to report inconsistent condom use (OR 0.15; 95% CI = 0.03-0.76). Few differences were detected in reproductive behaviors as a function of HIV serostatus, although both cohorts engaged in unprotected sex. Counseling to decrease sexual risk behaviors should begin prior to or early in the postpartum period and include discussion of both reproductive and disease transmission issues.

If HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM?

Systematic reviews of HIV prevention research provide clear evidence that behavioral interventions can influence the sexual behavior of men who have sex with men (MSM). However, if HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM in major European, Australian, Canadian, and U.S. cities? The evidence generated by systematic reviews alone may not provide a clear answer to this question. This is because (a) it is uncertain whether experimental interventions shown to be effective in one setting, place, or moment in time can be repeated successfully in another; (b) we have limited understanding of the processes that underlie the interventions; (c) interventions shown to work in an experimental study may not necessarily be effective in everyday life. To answer the question, we need to be alert to the changing risk environment in which men have sex with other men. We also need to develop a new program of research addressing the transferability, sustainability, and effectiveness of sexual health promotion among MSM. Randomized controlled trials will remain one of the optimal means of evaluating behavioral interventions in such a program. By further strengthening the evidence base, we may identify opportunities for innovative as well as effective HIV prevention initiatives.

Population-based patterns of human immunodeficiency virus-related Hodgkin lymphoma in the Greater San Francisco Bay Area, 1988-1998

BACKGROUND

Epidemiologic characteristics of human immunodeficiency virus (HIV)-related Hodgkin lymphoma (HL) have not been examined in the Greater San Francisco Bay Area, a center of the HIV/acquired immunodeficiency syndrome (AIDS) epidemic, for a decade, despite changes in AIDS-associated diseases after the availability of highly active antiretroviral therapies (HAART).

METHODS

With population-based cancer registry data for 1988-1998, the authors examined risk factors, Epstein-Barr virus (EBV) association, incidence rates, and survival probabilities for 1752 patients with HL who were classified as HIV-positive or HIV-negative by a cancer registry-based method.

RESULTS

One hundred twenty-eight patients with HL (7%) were classified with HIV/AIDS; 95% were male. Among males, multivariate analysis (n=514 patients) found that HIV-related HL was associated strongly at diagnosis with ages 30-49 years, San Francisco residence, late-stage disease, lymphocyte depletion and unspecified histologic subtypes, and tumor cell EBV but not with other clinical features or mixed cellularity histology. Survival among patients with HIV-related HL, although it was poor, did not differ by race/ethnicity but was worse for patients with the nonnodular sclerosis histologic subtypes. Patients who were HIV-positive with HAART era (1996-1998) diagnoses were slightly older, were less likely to live in San Francisco, and were much more likely to be Hispanic compared with HIV-positive patients who were diagnosed before the HAART era; they had somewhat less aggressive disease and better survival. Incidence rates were higher for patients with HL overall compared with patients who had HIV-unrelated HL by 11% for white patients, 22% for black patients, and by 14% for Hispanic patients; excesses were greater in young adults.

CONCLUSIONS

Among males in the San Francisco Bay Area, HIV-related HL had distinctive demographic features, more aggressive clinical characteristics, stronger EBV association, and poorer survival and contributed to elevated regional HL incidence rates, particularly in young adults. Patients with HIV-related HL who were diagnosed after HAART was introduced appeared to have less aggressive disease and better survival.

Increases in gonorrhea and sexual risk behaviors among men who have sex with men: a 12-year trend analysis at the Denver Metro Health Clinic

BACKGROUND

Recent increases in rates of sexually transmitted diseases (STDs) and decreases in safe sex behaviors among men who have sex with men (MSM) in several American and European cities have been noted by researchers. It has been suggested that these trends are the result of perceptions that HIV/AIDS is less serious because of the availability of highly active antiretroviral therapy (HAART).

GOAL

The goal of the study was to examine trends in STD rates and risk behaviors among MSM and men who have sex with women (MSW) visiting a public STD clinic in Denver and to determine whether there is an ecological association with the availability of HAART.

STUDY DESIGN

This is a two-part retrospective analysis of male visits to the Denver Metro Health Clinic (DMHC). The first part describes gonorrhea and early (primary and secondary) syphilis trends among MSM between 1982 and 2001. For the second part, data were grouped into two 6-year time periods to represent pre-HAART and post-HAART time frames, 1990 to 1995 and 1996 to 2001.

RESULTS

Gonorrhea and early syphilis cases among MSM declined precipitously between 1982 and 1988 and then stabilized at low rates. The proportion of male visits to the clinic made by MSM decreased from 14.1% in 1990 to 7.2% in 1995 and then increased to 13.0% in 2001. Gonorrhea positivity rates among MSM increased after 1995 and were significantly higher in the period 1996 to 2001 (12.9%) than in the period 1990 to 1995 (8.1%; P<0.0001). Conversely, gonorrhea rates among MSW dropped from 11.2% in the first period to 6.9% in the second (P<0.0001). Among MSM known to be HIV-infected, gonorrhea rates increased from 11.6% in the first time period to 24.0% in the second period (P<0.0001). Reports of anal sex among MSM increased from 64.4% to 70.9% (P<0.0001). Reporting more than one sex partner increased for MSM from 65.2% to 70.3% (P<0.0001), but it significantly decreased from 52.6% to 46.2% for MSW (P<0.0001). No or inconsistent condom use increased from 60.9% to 63.0% for MSM (P=NS) and decreased from 85.1% to 82.4% among MSW (P<0.0001).

CONCLUSIONS

These trends appear to reflect a change toward higher risk-taking behaviors among MSM but not MSW since the time HAART became available and raise concerns about the potential for increased HIV transmission in this group.

Access to antiretroviral treatment and sexual behaviours of HIV-infected patients aware of their serostatus in Côte d'Ivoire

OBJECTIVE

To compare sexual behaviours of HIV-infected patients in Côte d'Ivoire whether or not they had access to antiretroviral treatment (ARV).

DESIGN AND METHODS

Cross-sectional survey using face-to-face interviews among all patients, informed of their HIV serostatus, attending the eight health centers in charge of HIV care in Abidjan and Bouaké. Univariate comparisons of declared sexual behaviours during the prior 6 months between the 164 ARV-treated and the 547 non-ARV-treated respondents. Multiple logistic regressions to identify factors related to sexual abstinence in the total sample and to unprotected sexual intercourse in the subsample of sexually active respondents during the same period were performed.

RESULTS

More than half of the 711 respondents (53.0%) declared an absence of sexual activity during the previous 6 months, with this proportion being significantly higher among women (60.6%), and among both men (85.7%) and women (92.4%) who were not living in a stable relationship. Among the 334 sexually active patients, 49.7% declared a low frequency of sexual intercourse ('once a month or less'), and 43.7% declared at least one episode of unprotected sexual intercourse. In multivariate analysis, recent diagnosis of HIV infection (< 9 months), having only one sexual partner and not knowing her/his serostatus, high alcohol consumption, absence of episodes of acute morbidity, not participating in household's expenditures and not being ARV-treated were significantly related to a higher likelihood of HIV-related risky sexual behaviours.

CONCLUSION

Sexual abstinence is the preventive strategy of choice for a majority of HIV-infected patients aware of their serostatus and consulting for care in Côte d'Ivoire. In these patients, access to ARV is not associated with an increase in HIV-related risky sexual behaviours.