Molecular epidemiology to aid virtual elimination of HIV transmission in Australia

The Global UNAIDS 95/95/95 targets aim to increase the percentage of persons who know their HIV status, receive antiretroviral therapy, and have achieved viral suppression. Achieving these targets requires efforts to improve the public health response to increase access to care for those living with HIV, identify those yet undiagnosed with HIV early, and increase access to prevention for those most at risk of HIV acquisition. HIV infections in Australia are among the lowest globally having recorded significant declines in new diagnoses in the last decade. However, the HIV epidemic has changed with an increasing proportion of newly diagnosed infections among those born outside Australia observed in the last five years. Thus, the current prevention efforts are not enough to achieve the UNAIDS targets and virtual elimination across all population groups. We believe both are possible by including molecular epidemiology in the public health response. Molecular epidemiology methods have been crucial in the field of HIV prevention, particularly in demonstrating the efficacy of treatment as prevention. Cluster detection using molecular epidemiology can provide opportunities for the real-time detection of new outbreaks before they grow, and cluster detection programs are now part of the public health response in the USA and Canada. Here, we review what molecular epidemiology has taught us about HIV evolution and spread. We summarize how we can use this knowledge to improve public health measures by presenting case studies from the USA and Canada. We discuss the successes and challenges of current public health programs in Australia, and how we could use cluster detection as an add-on to identify gaps in current prevention measures easier and respond quicker to growing clusters. Lastly, we raise important ethical and legal challenges that need to be addressed when HIV genotypic data is used in combination with personal data.

High HIV Incidence Among Men Who Have Sex With Men in 8 Chinese Cities: Results From a Trial

Background

In China, while the overall HIV prevalence has been decreasing within key populations, the epidemic among men who have sex with men (MSM) is still on the rise. This study aims to assess the HIV incidence rate and identify driving forces of HIV seroconversion among MSM in a closed cohort.

Methods

This study is a secondary analysis of a large trial of HIV testing promotion among Chinese MSM in 2016–2017. Sexual behaviors, HIV testing activities, and HIV serostatus were measured at baseline and follow-up every 3 months. HIV seroconversion in this study was defined as a self-reported HIV-positive test result. Participants who reported testing for HIV at least twice during different follow-up periods were included. Subgroup analysis and Cox regression were used to examine the correlates with HIV seroconversion.

Results

Overall, 347 participants were included in this study, with a mean age of 25.3 ± 6.1, and 71.2% were migrants. The sociodemographic characteristics of the included participants were similar to the rest of the participants in the trial (n = 1034); 7.2% (25/347) of participants seroconverted during the study period, resulting in an incidence rate of 15.56/100 person-years. In subgroup analysis, the HIV incidence rate was higher among migrants than nonmigrants (incidence rate ratio, 1.26; 95% confidence interval [CI], 0.47–3.87). In the time-dependent Cox regression model, bisexual MSM had a higher risk of contracting HIV than gay men (adjusted hazard ratio, 2.19; 95% CI, 1.02–4.72).

Conclusions

Our findings suggest a high HIV incidence rate among Chinese MSM. Further expansion of pre-exposure prophylaxis and other effective HIV prevention interventions are urgently needed.

HIV Prevention Research on Men Who Have Sex With Men: A Scoping Review of Systematic Reviews, 1988-2017

In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.

Trends and predictors of recent HIV testing over 22 years among a clinic sample of men who have sex with men in South Australia

Increasing the frequency of HIV testing is crucial for effective HIV prevention and care. The aim of the present study was to determine whether there has been a change in HIV testing among men who have sex with men (MSM) at the South Australia Specialist Sexual Health (SASSH) clinic over the past two decades.

METHODS

Computerised medical records of MSM who attended the SASSH at their first visit between 1994 and 2015 were used to determine whether HIV testing had changed among MSM. First HIV tests in each calendar year and return tests within 12 months were analysed. Factors associated with recent HIV testing were also examined.

RESULTS

There were 24036 HIV tests conducted among 8163 individual MSM over the study period. The proportion of newly registered MSM who reported ever being tested for HIV declined (P_trend=0.030), the proportion who reported recent HIV testing did not change (P_trend=0.955) and the proportion who have had current HIV testing increased (P_trend=0.008). The proportion of MSM who returned to the clinic for HIV testing within 12 months did not change (P_trend >0.05), with less than 40% of MSM returning for HIV testing. Factors independently associated with recent HIV testing included MSM aged ≥20 years, (odds ratio (OR) 1.79; 95% confidence interval (CI) 1.53-2.10), higher education (OR 1.28; 95% CI 1.12-1.45), non-Caucasian (African OR 1.68; 95% CI 1.30-2.17), having multiple sex partners (OR 1.47; 95% CI 1.29-1.69), having had sex interstate (OR 1.61; 95% CI 1.42-1.82) or overseas (OR 1.53; 95% CI 1.33-1.76) and injecting drug use (OR 1.56; 95% CI 1.29-1.88).

CONCLUSIONS

HIV testing rate among MSM attending SASSH was suboptimal. New approaches are needed to increase the uptake and early detection of HIV infection among the high-priority MSM population.

Making Meaning of the Impact of Pre-Exposure Prophylaxis (PrEP) on Public Health and Sexual Culture: Narratives of Three Generations of Gay and Bisexual Men

Pre-exposure prophylaxis (PrEP) with Truvada has emerged as an increasingly common approach to HIV prevention among gay, bisexual, and other men who have sex with men. This study examined generational differences and similarities in narrative accounts of PrEP among a diverse sample of 89 gay and bisexual men in the U.S. Over 50% of men in the older (52-59 years) and younger (18-25 years) generations endorsed positive views, compared with 32% of men in the middle (34-41 years) generation. Men in the middle cohort expressed the most negative (21%) and ambivalent (47%) views of PrEP. Thematic analysis of men's narratives revealed three central stories about the perceived impact of PrEP: (1) PrEP has a positive impact on public health by preventing HIV transmission (endorsed more frequently by men in the older and younger cohorts); (2) PrEP has a positive effect on gay and bisexual men's sexual culture by decreasing anxiety and making sex more enjoyable (endorsed more frequently by men in the middle and younger cohorts); and (3) PrEP has a negative impact on public health and sexual culture by increasing condomless, multi-partner sex (endorsed more frequently by men in the middle and younger cohorts). Results are discussed in terms of the significance of generation cohort in meanings of sexual health and culture and implications for public health approaches to PrEP promotion among gay and bisexual men.

Are there any differences between different testing sites? A cross-sectional study of a Norwegian low-threshold HIV testing service for men who have sex with men

OBJECTIVE

To describe a Norwegian low-threshold HIV testing service targeting men who have sex with men (MSM).

DESIGN AND SETTING

After the HIV testing consultation, all users of the HIV testing service were invited to answer the study questionnaire. The study setting included the sites where testing was performed, that is, the testing service's office in Oslo, cruising areas, bars/clubs and in hotels in other Norwegian cities.

PARTICIPANTS

MSM users of the testing service.

PRIMARY AND SECONDARY OUTCOME MEASURES

Data were collected on demographics, HIV testing and sexual behaviour as well as the participant's motivations for choosing to take an HIV test at this low-threshold HIV testing service. The data are stratified by testing site.

RESULTS

1577 HIV testing consultations were performed, the study sample consisted of 732 MSM users. 11 tested positive for HIV. 21.7% had a non-western background, 27.1% reported having a non-gay sexual orientation. 21.9% had 10 or more male sexual partners during the last year, 27.9% reported also having had a female sexual partner. 56.4% reported having practised unprotected anal intercourse during the last 6 months. 20.1% had never tested for HIV before. Most of these user characteristics varied by testing sites.

CONCLUSIONS

The Norwegian low-threshold testing service recruits target groups that are otherwise hard to reach with HIV testing. This may indicate that the testing service contributes to increase HIV testing rates among MSM in Norway.

HIV Research with Men who Have Sex with Men (MSM): Advantages and Challenges of Different Methods for Most Appropriately Targeting a Key Population

The difficulty in accessing hard-to-reach populations as men who have sex with men presents a dilemma for HIV surveillance as their omission from surveillance systems leaves significant gaps in our understanding of HIV/AIDS epidemics. Several methods for recruiting difficult-to-access populations and collecting data on trends of HIV prevalence and behavioural factors for surveillance and research purposes have emerged. This paper aims to critically review different sampling approaches, from chain-referral and venue-based to respondent-driven, time-location and internet sampling methods, focusing on its main advantages and challenges for conducting HIV research among key populations, such as men who have sex with men. The benefits of using these approaches to recruit participants must be weighed against privacy concerns inherent in any social situation or health condition. Nevertheless, the methods discussed in this paper represent some of the best efforts to effectively reach most-at-risk subgroups of men who have sex with men, contributing to obtain unbiased trends of HIV prevalence and HIV-related risk behaviours among this population group.

Factors associated with recent HIV testing among high-risk men who have sex with men: a cross-sectional study in Cambodia

Background

Despite remarkable success in the fight against HIV, HIV prevalence in many countries remains high among key populations including men who have sex with men (MSM), and HIV testing rates is relatively low among this hard-to-reach population. This cross-sectional study explores factors associated with recent HIV testing among MSM in Cambodia.

Methods

This study was conducted in 2014 and included 384 MSM randomly selected from two provinces of Battembang and Siem Reap, using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect data on socio-demographic characteristics, HIV testing history, sexual behaviors, HIV testing attitudes, and HIV knowledge. Multivariate logistic regression analysis was performed to identify factors independently associated with recent HIV testing.

Results

Mean age of the participants was 23.4 (SD = 5.2). Of total, 83.6 % had been tested for HIV at least once in their lifetime, and 65.1 % had been tested for HIV in the past six months. After controlling for other covariates, MSM who had been tested for HIV in the past six months were significantly more likely to regard themselves as female (AOR = 2.29, 95 % CI = 1.06-5.37), have received some form of HIV education in the past six months (AOR = 3.97, 95 % CI = 1.91-8.26), perceive that they were at higher HIV risk compared to the general population (AOR = 2.48, 95 % CI = 1.14-4.86), have been diagnosed with an STI in the past six months (AOR = 3.19, 95 % CI = 1.02-9.24), report using a condom at last sexual intercourse with a man or woman (AOR = 2.24, 95 % CI = 1.06-3.13), and report using a condom at last sexual intercourse with a boyfriend (AOR = 2.17, 95 % CI = 1.04-5.31).

Conclusions

This study highlights the common practices of risky sexual behaviors and relatively low rate of recent HIV testing among MSM in Cambodia. HIV education and social marketing should be expanded and tailored for MSM, specifically addressing the risk of unprotected anal intercourse and the importance of regular HIV testing for early enrolment in the care and treatment cascade.

Factors Associated with Low Levels of HIV Testing among Men Who Have Sex with Men (MSM) in Brazil

The aim of this study was to assess risk factors associated with low levels of HIV testing among MSM recruited through respondent driven sampling (RDS) in Brazil. Of 3,617 participants, 48.4% had never tested previously for HIV. A logistic model indicated that younger age, lower socioeconomic class, education, poor HIV/AIDS knowledge, no history of cruising, and having been tested during the study were characteristics independently associated with low levels of previous HIV testing. The HIV testing rate among MSM in Brazil is still low in spite of the availability of a large number services providing universal and free access to HIV/AIDS diagnosis and treatment. To respond to low utilization, the authors propose a higher priority for testing for key populations such as MSM, expanded education, expanding testing sites and a welcoming and nonjudgmental environment in health services.

"Any Condomless Anal Intercourse" is No Longer an Accurate Measure of HIV Sexual risk Behavior in Gay and Other Men Who have Sex with Men

BACKGROUND

Condomless anal intercourse (CLAI) has long been recognized as the primary mode of sexual transmission of HIV in gay and other men who have sex with men (MSM). A variety of measures of CLAI have been commonly used in behavioral surveillance for HIV risk and to forecast trends in HIV infection. However, gay and other MSM's sexual practices changed as the understanding of disease and treatment options advance. In the present paper, we argue that summary measures such as "any CLAI" do not accurately measure HIV sexual risk behavior.

METHODS

Participants were 1,427 HIV-negative men from the Health in Men cohort study run from 2001 to 2007 in Sydney, Australia, with six-monthly interviews. At each interview, detailed quantitative data on the number of episodes of insertive and receptive CLAI in the last 6 months were collected, separated by partner type (regular vs. casual) and partners' HIV status (negative, positive, and HIV status unknown).

RESULTS

A total of 228,064 episodes of CLAI were reported during the study period with a mean of 44 episodes per year per participant (median: 14). The great majority of CLAI episodes were with a regular partner (92.6%), most of them with HIV-negative regular partners (84.8%). Participants were more likely to engage in insertive CLAI with casual than with regular partners (66.7 vs. 55.3% of all acts of CLAI with each partner type, p < 0.001). Men were more likely to report CLAI in the receptive position with HIV-negative and HIV status unknown partners than with HIV-positive partners (p < 0.001 for both regular and casual partners).

CONCLUSION

Gay and other MSM engaging in CLAI demonstrate clear patterns of HIV risk reduction behavior. As HIV prevention enters the era of antiretroviral-based biomedical approach, using all forms of CLAI indiscriminately as a measure of HIV behavioral risk is not helpful in understanding the current drivers of HIV transmission in the community.

Longitudinal analysis of key HIV-risk behavior patterns and predictors in men who have sex with men, Bangkok, Thailand

The HIV incidence among Thai men who have sex with men (MSM) enrolled in the Bangkok MSM Cohort Study (BMCS) has remained high since its inception in 2006. The purpose of this BMCS analysis was to determine: (1) changes in three HIV-risk behaviors (unprotected anal intercourse (UAI), recreational drug use, and multiple sexual partners i.e., more than four male/transgender partner) over time; and (2) factors associated with each one separately. Thai MSM aged 18 years or older and living in Bangkok were eligible to participate in the BMCS. At each follow-up visit, participants were asked to report their sexual and drug behaviors in the previous 4 months. We conducted a longitudinal analysis using generalized estimating equations logistic regression that included 1,569 MSM who were enrolled from 2006 to 2010 and contributed at least one follow-up visit. For each four-month visit increase, we found a 2, 1, and 1 % decrease in odds for reported UAI, recreational drug use, and multiple sexual partners, respectively. We found significant predictors associated with three HIV-risk behaviors such as binge drinking, participation in group sex, and use of erectile dysfunction drugs. The statistically significant decrease in odds of HIV-risk behaviors among the participants is encouraging; however, continued vigilance is required to address the factors associated with HIV-risk behaviors through currently available interventions reaching MSM.

Hepatitis C risk factors, attitudes and knowledge among HIV-positive, HIV-negative and HIV-untested gay and bisexual men in Australia

Background There are increasing reports of sexual transmission of hepatitis C virus (HCV) among HIV-positive men who have sex with men (MSM). Still unclear is the level of HCV knowledge and the risk factors specific to HCV transmission among this population. This study compared HCV knowledge and risk practices among HIV-positive, HIV-negative and HIV-untested gay and bisexual men in Australia.

METHODS

Participants (n=534) completed an online survey assessing sexual risk practices, HCV knowledge, perceived risk of acquiring HCV and perceptions of people with HCV and who inject drugs.

RESULTS

HIV-positive participants were older, reported greater engagement in sexual risk and injecting drug practices, felt they were at greater risk of acquiring HCV, were less likely to socially and sexually exclude people with HCV and had more positive attitudes towards people who inject drugs and people with HCV compared with HIV-negative and HIV-untested participants. HIV-untested participants were younger, reported fewer HCV-related serosorting practices and were more likely to socially and sexually exclude people with HCV than the other groups.

CONCLUSIONS

Findings suggest that HCV education and prevention for gay men may be most effective if tailored according to HIV status. For HIV-positive men, health promotion could focus on specific sexual practices and biological factors linked to HCV transmission, regular HCV testing and better strategies for disclosure of HCV serostatus. For HIV-negative and HIV-untested men, there should be a more general focus on awareness, changing attitudes towards HCV testing and increasing general knowledge around HCV, including evidence of sexual transmission.

Sexual behaviour and HIV prevention needs of men attending a suburban Sex on Premises Venue

Background Sexual behaviour and HIV prevention needs of men who have sex with men (MSM) attending suburban Sex on Premises Venues (SOPVs) are understudied. Methods: A cross-sectional survey examining sexual activity, health services utilisation, sexual health services needs and STI knowledge was conducted among MSM over 18 years old attending a SOPV in Western Sydney between June and July 2013. Results: A total of 213 MSM were sampled; approximately half of the respondents (51%) reported that they only had sex with other men, and 46% had sex with both men and women. Condom use varied considerably, with ~50% of responders not using condoms consistently during anal sex. Consistent condom usage was not associated with having regular, casual or a mix of regular and casual partners during anal sex (P = 0.09). The majority (59.5%) obtained sexual health screening services from general practitioners; only 15.0% sought services from a local sexual health clinic. Over half of respondents (57.7%) believed that SOPVs should offer on-site and free testing services. Those with the highest level of previous STI diagnoses were gay men (41%), those who only had casual partners (38%) and those who did not complete high school (65%). Conclusions: Sexual health services and non-government organisations should consider targeting bisexual men with rapid HIV testing and condom usage campaigns. Low cost or free on-site HIV and STI testing at SOPVs and stronger partnerships between general practitioners and sexual health services are needed.

Non-culpable ignorance and HIV criminalisation

In this essay, I argue that any legal framework that addresses sexual transmission of HIV should be sensitive to the way that culpability can be mitigated by moral and factual ignorance. Though it is wrong to transmit HIV, public officials should be wary of criminalising transmission because people with HIV may be excused if they suffer from blameless moral or factual ignorance. I begin with the widely shared premise that blameless ignorance about one's HIV status is an excuse for sexual transmission of infections. I then extend this premise to other kinds of non-moral ignorance about HIV. Next, I argue that blameless moral ignorance also excuses transmission of HIV. There is some evidence of significant blameless non-moral and moral ignorance about HIV transmission. In these cases, transmission is excused. In light of the presence of moral and non-moral ignorance about HIV, I conclude that public health officials should encourage moral deliberation about HIV transmission and also that criminal penalties for HIV transmission are unwarranted even in some cases of knowing or intentional transmission.

Mobilisation, politics, investment and constant adaptation: lessons from the Australian health-promotion response to HIV

ISSUE ADDRESSED

The Australian response to HIV oversaw one of the most rapid and sustained changes in community behaviour in Australia's health-promotion history. The combined action of communities of gay men, sex workers, people who inject drugs, people living with HIV and clinicians working in partnership with government, public health and research has been recognised for many years as highly successful in minimising the HIV epidemic.

METHODS

This article will show how the Australian HIV partnership response moved from a crisis response to a constant and continuously adapting response, with challenges in sustaining the partnership. Drawing on key themes, lessons for broader health promotion are identified.

RESULTS

The Australian HIV response has shown that a partnership that is engaged, politically active, adaptive and resourced to work across multiple social, structural, behavioural and health-service levels can reduce the transmission and impact of HIV.

CONCLUSIONS

The experience of the response to HIV, including its successes and failures, has lessons applicable across health promotion. This includes the need to harness community mobilisation and action; sustain participation, investment and leadership across the partnership; commit to social, political and structural approaches; and build and use evidence from multiple sources to continuously adapt and evolve. So what? The Australian HIV response was one of the first health issues to have the Ottawa Charter embedded from the beginning, and has many lessons to offer broader health promotion and common challenges. As a profession and a movement, health promotion needs to engage with the interactions and synergies across the promotion of health, learn from our evidence, and resist the siloing of our responses.

No drama: key elements to the success of an HIV/STI-prevention mass-media campaign

We qualitatively examined gay men's reactions to the national "Drama Downunder" HIV/STI social marketing campaign targeting gay men in Australia to identify key campaign elements that underpinned the demonstrated effectiveness of the campaign. We present findings from six qualitative focus groups held with 49 participants as part of the evaluation of the sexual-health-promotion campaign over 2008-2009. Participants identified attention-grabbing images, a humorous approach, positive and simple tailored messaging, and the use of mainstream media as campaign features crucial in normalizing sexual health testing, driving campaign engagement, and ensuring high message exposure. Our results suggest that designers of future campaigns should strive to balance positive and negative campaign images and messages, and find new ways to engage men with sexual health topics, particularly younger gay men. We discuss the implications of our findings about campaign effectiveness for future health-promotion campaigns and message design.

Worsening epidemic of HIV and syphilis among men who have sex with men in Jiangsu Province, China

BACKGROUND

Epidemics of human immunodeficiency virus (HIV) and syphilis among men who have sex with men (MSM) are major public health concerns in most parts of China. A dearth of information regarding the current trend of HIV in this hard-to-reach population in several regions including Jiangsu, coupled with the reemergence of syphilis, calls for an effort to understand the dynamics of the dual epidemic in this province.

METHODS

To estimate the occurrence and burden of these 2 sexually transmitted diseases and the distribution of their potential sociobehavioral correlates among MSM in Jiangsu, 2 cohort studies were conducted in Yangzhou and Changzhou cities.

RESULTS

Among 839 participants, 48% were married, 51.7% had sex with women in the last 6 months, and 25.5% did not use condoms during their last anal intercourse. The observed incidence of HIV was 13.59 and 12.62 and that of syphilis was 7.33 and 13.25 per 100 person-years among the participants of Yangzhou and Changzhou, respectively. The baseline prevalence of HIV and syphilis was 16.0% and 29.9% in Yangzhou and 13.6% and 14.9% in Changzhou, respectively.

CONCLUSIONS

Considerably high incidence and prevalence of HIV and syphilis among participants and their potential bridging role in transmitting these infections to the general population in Yangzhou and Changzhou cities calls for urgent effective intervention strategies.

Homosexual experience and recent homosexual encounters: the Second Australian Study of Health and Relationships

Background The aim of this study is to describe homosexual experience and characteristics of recent homosexual encounters among Australian adults and identify changes between 2001–02 and 2012–13. Methods: Computer-assisted telephone interviews were completed by a representative sample of 20 094 men and women aged 16–69 years and the participation rate among eligible people was 66.2%. Respondents indicated the number of same-sex partners they had had in their lifetime and in the last 12 months. Those who reported any homosexual experience were asked the age at which this first occurred and about characteristics of the first and most recent homosexual encounter. Results: Reporting ever having same-sex experience was more common in women (13.5%) than in men (6.5%, P < 0.001). Among these people, men reported more lifetime and recent same-sex partners than women (P < 0.001). Same-sex experience was associated with some but not all indices of higher socioeconomic status. In men, it was associated with living in a major city (P = 0.02) and in women, it was associated with younger (<30 years) age and with very low income (P < 0.001). Men were younger than women at their first homosexual encounter (P = 0.005). Women were more likely than men to have their first same-sex encounter with a regular partner. For women but not men, there was a significant increase in the proportion reporting same-sex experience since 2001–02. Conclusion: Same-sex experience is not uncommon and is increasing in prevalence in young Australian women. The high number of same-sex partners among homosexual and bisexual men places them at greater risk of sexually transmissible infection.

A novel time-limited pop-up HIV testing service for gay men in Sydney, Australia, attracts high-risk men

Background HIV diagnoses have been increasing steadily in Australia and are concentrated among gay, bisexual and other men who have sex with men (GBM). HIV testing is a key control strategy, and in 2013, a novel time-limited pop-up community HIV testing service (Pop-up) was introduced to raise awareness and increase testing options for GBM. The Pop-up service offered rapid HIV tests only. We compared uptake and outcomes of the Pop-up service to an established clinical model [a fast-track screening service in a sexual health clinic offering rapid and/or conventional HIV tests and sexually transmissible infection (STI) tests].

METHODS

Service delivery data was collated and analysed from the HIV Pop-up (25 November to 1 December 2013) and the fast-track HIV/STI screening service (Xpress) in a sexual health clinic immediately before the Pop-up (1 August to 22 November 2013). A comparison of all the HIV tests and results, tests per hour and characteristics of new clients (demographics, risk behaviour, testing history) was conducted using χ(2), Poisson distribution and Ranksum tests.

RESULTS

At the Pop-up service, 182 GBM had a rapid HIV test conducted over the 5-day period (average: seven HIV tests per hour) and no HIV tests were reactive (0%, 95% confidence interval: 0-1.8%). At the Xpress service, 1075 asymptomatic GBM had at least one STI test and 957 GMB had a HIV test (rapid or conventional) conducted over the 3-month period (average: four HIV tests per hour), with two positive HIV tests (0.2%, 95% confidence interval: 0.02-0.7) and 151 positive STI tests (14%, 95% confidence interval: 12-16.2). Compared with new patients at the Xpress service, GBM attending the Pop-up service were older (median of 39 vs 29 years, P<0.01); more likely to report ≥5 sexual partners in the past 3 months (P=0.02); more likely to reside in 'Gay Sydney' (P<0.01); and more likely to be tested for HIV (P<0.01).

CONCLUSIONS

Time-limited Pop-up community HIV testing is feasible and reached high-risk GBM, but compared with a clinic-based model, it only reached a smaller proportion of GBM who test infrequently or who have never been tested and are unaware of their HIV status. No STI testing was conducted through the Pop-up service, which allowed a higher throughput of HIV tests; however, a significant number of STIs may have been missed.

Psychosocial correlates of HIV testing among men who have sex with men in Italy: a cross-sectional study

The objective of this study was to understand the psychosocial correlates of men having sex with men (MSM) who have never been tested (never testers), MSM who have been tested in the last 12 months (recent testers), and MSM who have been tested before (remote testers). A sample of 14,409 Italian HIV-negative adult MSM was recruited via instant messages to the members of five international commercial websites and through clickable banner advertisements on different websites. The most important correlates of never testers compared to recent testers were younger age, sexual orientation concealment, unawareness of free HIV services, having had a partner of unknown serostatus, and lower levels of HIV testing self-efficacy (i.e. the belief in one’s own ability to get a test for HIV). The most important correlates of remote testers compared to recent testers were older age, homosexual orientation, having had a partner of unknown serostatus, unawareness of free HIV services, and lower level of HIV testing self-efficacy. There are different psychosocial correlates of MSM based on HIV testing history. Based on the findings of this study, prevention efforts should be directed toward increasing awareness about the availability of HIV testing services and HIV testing self-efficacy among MSM.

Antiretroviral therapy for prevention of HIV transmission: implications for Europe

The aim of this review is to summarise the evidence on the population-level effect of antiretroviral therapy (ART) in preventing HIV infections, and to discuss potential implications in the European context of recommending starting ART when the CD4 count is above 350 cells/mm3. The ability of ART to reduce the risk of HIV transmission has been reported in observational studies and in a randomised controlled trial (HPTN 052), in which ART initiation reduced HIV transmission by 96% within serodiscordant couples. As yet, there is no direct evidence for such an effect among men having sex with men or people who inject drugs. HPTN 052 led international organisations to develop recommendations with a higher CD4 threshold for ART initiation. However, there remains a lack of strong evidence of clinical benefit for HIV-positive individuals starting ART with CD4 count above 350 cells/mm3. The main goal of ART provision should be to increase ART coverage for all those in need, based on the current guidelines, and the offer of ART to those who wish to reduce infectivity; increased HIV testing is therefore a key requirement. Other proven prevention means such as condom use and harm reduction for people who inject drugs remain critical.

The informal use of antiretrovirals for preexposure prophylaxis of HIV infection among gay men in Australia

BACKGROUND

We aimed to describe the current use of antiretrovirals(ARVs) before unprotected anal intercourse (UAI) among Australian gay men, which may represent informal HIV preexposure prophylaxis (PrEP).

METHODS

Using data from Australian Gay Community Periodic Surveys conducted in 2011, we assessed the preventive use of ARVs before UAI and its association with sociodemographic characteristics, sexual practices, and drug use in the preceding 6 months. Associations were assessed using multivariate logistic regression analysis.

RESULTS

Of 3677 sexually active non-HIV-positive men, 2.5%reported taking ARVs before UAI. The likelihood of ARV use before UAI was significantly higher if any of the following behaviors were also reported: .1 sex partner; UAI with casual partners, irrespective of reporting UAI with regular partners [adjusted odds ratio (AOR) = 2.36; 95% confidence interval (CI): 1.24 to 4.48] or not (AOR = 2.71; 95% CI: 1.44 to 5.07); injecting drugs at least monthly (AOR = 2.56; 95% CI: 1.03 to 6.36); using “party” drugs,occasionally (AOR = 2.23; 95% CI: 1.33 to 3.73) or regularly(AOR = 5.34; 95% CI: 2.99 to 9.56); and group sex while using party drugs, occasionally (AOR = 2.42; 95% CI: 1.29 to 4.53) or regularly (AOR = 5.31; 95% CI: 2.62 to 10.76). Among non-HIV positive men in regular relationships with HIV-positive partners or partners of unknown HIV status, 1.7% and 4.7%, respectively, reported preventive ARV use before UAI.

CONCLUSIONS

Our findings illustrate sporadic use of ARVs before UAI among gay men in Australia, which was associated with high-risk casual sex and party drug use. These initial data contribute to a much needed understanding of the informal use of ARVs for HIV prevention.

Gay and bisexual men's views on rapid self-testing for HIV

Thirty-one gay and bisexual men were interviewed on the acceptability, potential use, benefits and limitations of rapid self-testing for HIV in Australia. The majority of men supported the introduction of rapid self-testing, and would be likely to, or would use the tests for home use. However, most reported they would use them for interim testing and not to replace conventional blood testing at health services as they could not detect other sexually transmitted infections or provide the professional expertise and support provided at health services.

Willingness to use couples voluntary counseling and testing services among men who have sex with men in seven countries

The willingness of male-male dyads to use couples voluntary HIV counseling and testing (CVCT) has not been previously investigated globally among men who have sex with men (MSM). Using online advertisements, data were collected from 3245 MSM in seven countries who were ≥ 18 years of age and had ≥1 male sex partner in the previous 12 months. The analysis examined associations between individual characteristics and willingness to utilize CVCT. The willingness to utilize CVCT was compellingly high, ranging from 79% in Australia and UK to 90% in Brazil. Older MSM and those who reported not knowing their sero-status reported lower odds of willingness to use CVCT. The relationship between being in a relationship and willingness to use CVCT varied across countries, perhaps reflecting varied local understandings of the nature and content of CVCT. Further work is required to examine willingness to use CVCT among a more heterogeneous population of MSM, and to examine how CVCT services are locally perceived in order to provide information vital for the development of locally appropriate messages to promote CVCT for MSM.

Understanding of norms regarding sexual practices among gay men: literature review

Since there is little evidence about gay community norms across the world, we reviewed published literature in this area and discuss implications for prevention and research. Eight databases were searched for articles and 16 were considered suitable for analysis. All used quantitative methodology and seven were based on a published theoretical framework. The most common theory employed by four out of the seven papers was the Theory of Reasoned Action. All papers reviewed examined norms on condom use but norms on other risk reduction practices were not explored in these papers. Seven (44 %) studies found those men who perceived strong social support from their peers, were less likely to engage in unprotected anal intercourse. This finding suggests that social support from partners and community members plays a role in shaping safe sex norms. Better understanding of norms may help to redress HIV behaviour change programmes, particularly at the time when HIV diagnoses rates are increasing in most gay communities across the world.

Versatility and HIV vulnerability: patterns of insertive and receptive anal sex in a national sample of older Australian gay men

According to mathematical modeling, HIV is more likely to spread through a population of men who have sex with men when high numbers practice versatile anal sex roles, that is, engage in both insertive (IAI) and receptive anal intercourse (RAI). Yet, actual patterns of versatility remain largely unknown, particularly among older men who currently face growing rates of HIV. In this study, 1,135 Australian gay men aged 40 years and older completed a national online survey of their sexual health and behavior over the past 12 months. Of men who had anal intercourse, 62 % engaged in both IAI and RAI. Factors associated with being versatile included younger age (P = 0.01), higher income (P = 0.009), and larger numbers of sexual partners (P = 0.003). Among men with multiple sexual partners, 20 % were highly versatile, that is, reported similar numbers of IAI and RAI partners. Having HIV (P = 0.003) and living in a rural area (P = 0.04) were significantly associated with being highly versatile. These data point to high rates of versatility among older Australian gay men, with implications for mathematical predictions of change in HIV epidemics and for the design of future HIV prevention strategies.

Considerations regarding antiretroviral chemoprophylaxis in MSM

PURPOSE OF REVIEW

HIV infection among MSM remains a significant issue. Data relevant to MSM populations from animal models, pharmacokinetic studies and clinical trials are summarized and challenges and potential consequences of use of preexposure prophylaxis (PrEP) by MSM are discussed.

RECENT FINDINGS

Rectal simian-human immunodeficiency virus transmission in macaque models can be prevented by intermittent PrEP dosing. The Preexposure Prophylaxis Initiative (iPrEx) study found that daily oral emtricitabine-tenofovir disoproxyl fumarate (TDF/FTC) decreased HIV infection by 44% among 2499 high-risk MSM. Men with detectable levels of TDF or FTC in plasma and peripheral blood mononuclear cells experienced more than 90% protective effect, emphasizing the importance of adherence. In iPrEX and other studies, PrEP was generally safe and well tolerated. However, it appears that TDF use is associated with a small but significant decrease in mean bone mineral density. No risk compensation has been demonstrated, but this remains an area of potential concern when PrEP is used outside the setting of a placebo-controlled trial. Numerous PrEP trials in MSM are currently underway.

SUMMARY

Oral FTC/TDF is effective in preventing HIV infection among MSM. Optimal PrEP agents and dosing regimens now need to be identified. Understanding the patterns of and impediments to PrEP use among MSM is vital and these should be monitored in ongoing demonstration projects and open-label studies.

Increased HIV testing will modestly reduce HIV incidence among gay men in NSW and would be acceptable if HIV testing becomes convenient

OBJECTIVE

Determine the acceptability and epidemiological impact of increases in HIV testing in gay men in New South Wales (NSW), Australia- particularly pertinent when considering treatment as prevention and the need to reduce undiagnosed infections.

METHODS

We conducted an online survey and focus groups to assess whether increases in HIV testing would be acceptable to gay men in NSW. In parallel, we assessed the potential impact of increases in testing coverage and/or frequency using an individual-based model of HIV transmission.

RESULTS

If sexual practices and the rate of initiating HIV treatment are unchanged then increasing HIV testing reduces infections. Increasing testing frequency has the largest impact, with a 13.8% reduction in HIV infections over 10 years if the ∼55-75% of men who test at least once per year increased their testing frequency to four times per year. If testing levels decrease from current levels then we expect an increase in HIV infections with a sharply rising trend over time. Increasing HIV testing would be acceptable if testing was more convenient. However, only ∼25% of men surveyed were 'very likely' to increase their level of HIV testing. Men delayed or avoided testing due to the slowness in obtaining results and if they believed they had not put themselves at risk.

CONCLUSIONS

An increase in HIV testing alone is unlikely to reduce HIV incidence substantially in NSW gay men- however, the relatively high testing levels need to continue to prevent an increase in HIV infections. In jurisdictions with lower levels of HIV testing, increases in testing coverage and frequency are likely to have a larger impact. Successful treatment as prevention interventions will require increases in testing rates; such increases would be acceptable to gay men in NSW but only if more convenient testing and rapid communication of results were available.

Emergence in Japan of an HIV-1 variant associated with transmission among men who have sex with men (MSM) in China: first indication of the International Dissemination of the Chinese MSM lineage

A survey of HIV-1 strains circulating in the Tokyo-Kanagawa metropolitan area of Japan during 2004 to 2011 (n = 477) identified six Japanese males (patients 1 to 6), who harbored viruses with genome segments derived from a distinct CRF01_AE variant uniquely found among men who have sex with men (MSM) in China (designated CN.MSM.01-1). These six HIV infections were diagnosed in 2010 and 2011 among MSM (3 of 75) and men with unknown risk factors (3 of 63) and differed from the vast majority of HIV infections among MSM in Japan, which are overwhelmingly characterized by subtype B (239 of 246 [97.2%]). Approximately one-third (91 of 239 [38.1%]) of subtype B strains from MSM in Japan belong to a large monophyletic cluster (designated JP.MSM.B-1). In addition, we identified a smaller subtype B cluster (n = 8) (designated JP.MSM.B-2) that also contains strains from two Chinese MSM living in Japan. Interestingly, patients 5 and 6 were found to be coinfected with CRF01_AE (CN.MSM.01-1) and subtype B (JP.MSM.B-2 or JP.MSM.B-1) variants that are unique to the HIV-1 epidemics among MSM in China and Japan, respectively. Our study demonstrates for the first time the effect of the expanding HIV epidemic among MSM in China on transmission in neighboring countries and shows the ongoing mixing of CRF01_AE and subtype B lineages unique to HIV-1 that cocirculate in MSM populations in East Asia. This finding highlights the importance of strengthening epidemiological surveillance in the region and the need for effective measures to limit transmission among MSM in East Asia.

HIV Testing and HIV Serostatus-Specific Sexual Risk Behaviour Among Men Who Have Sex with Men Living in England and Recruited Through the Internet in 2001 and 2008

Using data from two large internet-recruited surveys in England in 2001 and 2008, we examine HIV status-specific patterns of unprotected anal intercourse (UAI). In adjusted comparisons between our 2008 and 2001 samples, there was evidence of a greater proportion of men living with diagnosed HIV, a reduction in sexual partners and in UAI with partners of unknown HIV status among men not tested HIV positive, increases in anal intercourse and UAI among men with diagnosed HIV and an increase in insertive UAI with HIV-positive men among men never tested for HIV. However, we found no evidence for increases in negotiated safety or sero-sorting. The data are compatible with a concentration of sexual risk among men with diagnosed HIV, countering an overall trend towards less risk taking among men not tested HIV positive.

Stop the drama Downunder: a social marketing campaign increases HIV/sexually transmitted infection knowledge and testing in Australian gay men

INTRODUCTION

Since 2000, notifications of HIV and other sexually transmitted infections (STIs) have increased significantly in Australian gay men. We evaluated the impact of a social marketing campaign in 2008-2009 aimed to increase health-seeking behavior and STI testing and enhance HIV/STI knowledge in gay men.

METHODS

A convenience sample of 295 gay men (18-66 years of age) was surveyed to evaluate the effectiveness of the campaign. Participants were asked about campaign awareness, HIV/STI knowledge, health-seeking behavior, and HIV/STI testing. We examined associations between recent STI testing and campaign awareness. Trends in HIV/STI monthly tests at 3 clinics with a high case load of gay men were also assessed. Logistic and Poisson regressions and χ tests were used.

RESULTS

Both unaided (43%) and aided (86%) campaign awareness was high. In a multivariable logistic regression, awareness of the campaign (aided) was independently associated with having had any STI test within the past 6 months (prevalence ratio = 1.5; 95% confidence interval = 1.0-2.4. Compared with the 13 months before the campaign, clinic data showed significant increasing testing rates for HIV, syphilis, and chlamydia among HIV-negative gay men during the initial and continued campaign periods.

CONCLUSION

These findings suggest that the campaign was successful in achieving its aims of increasing health-seeking behavior, STI testing, and HIV/STI knowledge among gay men in Victoria.

Participation of HIV prevention programs among men who have sex with men in two cities of China--a mixed method study

Background

Although various HIV prevention programs targeting men who have sex with men (MSM) are operating in China, whether and how these programs are being utilized is unclear. This study explores participation of HIV prevention programs and influencing factors among MSM in two cities in China.

Methods

This is a mixed-method study conducted in Beijing and Chongqing. A qualitative study consisting of in-depth interviews with 54 MSM, 11 key informants, and 8 focus group discussions, a cross-sectional survey using respondent-driven sampling among 998 MSM were conducted in 2009 and 2010 respectively to elicit information on MSM’s perception and utilization of HIV prevention programs. Qualitative findings were integrated with quantitative multivariate factors to explain the quantitative findings.

Results

Fifty-six percent of MSM in Chongqing and 75.1% in Beijing ever participated in at least one type of HIV prevention program (P=0.001). Factors related to participation in HIV prevention programs included age, ethnicity, income, HIV risk perception, living with boyfriend, living in urban area, size of MSM social network, having talked about HIV status with partners, and knowing someone who is HIV positive. Reasons why MSM did not participate in HIV prevention programs included logistical concerns like limited time for participation and distance to services; program content and delivery issues such as perceived low quality services and distrust of providers; and, cultural issues like HIV-related stigma and low risk perception.

Conclusions

The study shows that there is much room for improvement in reaching MSM in China. HIV prevention programs targeting MSM in China may need to be more comprehensive and incorporate the cultural, logistic and HIV-related needs of the population in order to effectively reach and affect this population’s risk for HIV.

Gay men who are not getting tested for HIV

Using data from Australian Gay Community Periodic Surveys 1998-2010, we assessed the prevalence, trends and characteristics of gay men not tested for HIV. In 2010, one in eight Australian gay socially-engaged men were never tested for HIV, most of them sexually active and 56.5 % reporting unprotected anal intercourse. The proportion of not tested men was significantly higher in men younger than 30, of non-European origin and living outside of gay metropolitan areas. Although frequency of testing was associated with sexual practices, significant proportions of men with multiple sex partners and reporting unprotected anal intercourse were not tested as recommended. There were issues with using gay-friendly testing services in gay metropolitan areas. Despite Australia's success in HIV testing, improvement is needed for early detection of HIV infections. Interventions should encourage regular testing, engage with young gay men, improve access and convenience of testing, train service providers and expand testing options.

Is back-projection methodology still relevant for estimating HIV incidence from national surveillance data?

Accurate estimates of HIV incidence are crucial to understand the extent of transmission of the infection, evaluate intervention strategies and effectively plan new public health control measures. HIV/AIDS surveillance systems in numerous industrialised countries record the number of known new HIV and/or AIDS diagnoses, which are often used as a surrogate marker for HIV incidence. HIV/AIDS diagnosis data have been used to reconstruct historical HIV incidence trends using modified back-projection methods. Estimates of HIV incidence are most robust when reliable data on the number of incident infections, a subset of all diagnoses, is widely available, and surveillance systems should prioritise the collection of these data. Back-projection alone provides reliable estimates of HIV incidence in the past, but is not useful when estimating current or future HIV incidence. However, back-projection methodology should be used in conjunction with other corroborative methods to estimate current HIV incidence, and methods to combine the various techniques should be investigated.

A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men

In the United States, there continues to be high incidence of HIV infection among men who have sex with men (MSM), who represent 57% of new infections in 2009. While many studies report associations between non-injection substance use and sexual risk behavior among MSM, overall results are mixed. Summarizing these studies is difficult because researchers have used a variety of assessment periods for substance use and sexual behavior. We review the scientific literature on event-level measures, which assess substance use and sexual risk behavior immediately before or during a sexual encounter and provide the most precise link between these two behaviors. From January 2009 through March 2010, we searched four databases: Ovid (MEDLINE and PsycINFO), Web of Knowledge, and Sociofile. Across studies, results varied by substance with little within substance consistency or a lack of research except for two notable exceptions: methamphetamine and binge alcohol use. The findings underscore the importance of providing HIV risk-reduction interventions for substance-using MSM.

Estimating HIV incidence and the correlates of recent infection in venue-sampled men who have sex with men in New York City

In a cross-sectional study, MSM aged ≥18 years were venue-sampled in New York City in 2008, interviewed, and tested for HIV using oral fluids. Participants who reported testing HIV negative at their last test in the previous 24 months were analyzed (n = 287 of 550 sampled). Those testing positive at the interview were defined as recently infected. HIV incidence was estimated using person-time at-risk methods and correlates of recent infection using proportional hazards regression. Thirty-two (11.1%) were recently infected. HIV incidence was 5.67/100 person-years at-risk. Independent correlates included: study recruitment in parks vs. bars, and in other venues vs. bars; black vs. non-black race/ethnicity; and reporting a last sex partner with a positive or unknown vs. negative HIV status. When assay-based methods are not feasible, cross-sectional HIV test results and self-reported HIV testing history and risk factor data can be used to estimate HIV incidence and the correlates of recent infection.

HIV prevalence among men who have sex with men in New Zealand 1985–2009: 25 years of public health monitoring

Annual population-based estimates of the number of men who have sex with men (MSM) with diagnosed HIV infection (HIV prevalence pool), and the proportion of all MSM this represents (HIV prevalence), have been insufficiently described over the long term. We investigated the dynamic effects of ongoing HIV diagnoses, lower mortality due to treatment and growth in the MSM population over time on these two epidemic indicators using national HIV/AIDS surveillance data in New Zealand, 1985–2009. The diagnosed HIV prevalence pool rose 79% between 1989 and 1999, and 137% between 1999 and 2009. Estimates of diagnosed HIV prevalence as a proportion of MSM were 0.2% of MSM in 1985, and were between 1.5% and 5.0% of MSM by 2009. New Zealand continues to have a relatively low-prevalence HIV epidemic among MSM; however, the number of MSM living with diagnosed infection is growing rapidly 25 years after HIV testing was introduced.

Would gay men change their sexual behavior to reduce syphilis rates?

BACKGROUND

The community at which public health strategies for reducing syphilis epidemics are potentially targeted may have different considerations with regards to their sexual and health priorities. We aimed to elicit information on the acceptability of behavior change interventions among gay men for reducing syphilis transmission.

METHODS

We conducted an online survey (n = 2306 participants) and focus groups to determine whether further sexual behavior change to reduce syphilis is likely to be acceptable to gay men in Australia.

RESULTS

One quarter of survey respondents (26%) indicated that they would be highly likely to reduce partner acquisition rates in order to reduce their chances of syphilis infection. However, among the 475 (21%) men who reported greater than 10 partners in the previous 6 months, only 11% indicated being "highly likely" to reduce partner numbers to avoid syphilis. Among 606 (26%) survey respondents who reported not always using condoms in the previous 6 months, 34% indicated being highly likely to always use condoms with casual partners to avoid syphilis. In the focus groups, men indicated little commitment to sexual behavior change but some willingness to consider short-term changes to reduce community syphilis levels.

CONCLUSIONS

Interventions promoting partner reduction or increased condom use are unlikely to be adopted on a long-term basis by men at greatest risk. Behavioral interventions alone are unlikely to materially contribute to syphilis prevention among gay men.

The rate of HIV testing is increasing among men who have sex with men in China

OBJECTIVES

HIV infection is spreading relatively quickly among men who have sex with men (MSM) in China. Accurate knowledge of HIV status is of high importance for public health prevention.

METHODS

We conducted a systematic review of literature published in either English or Chinese to collate available HIV testing data among MSM in China. Linear regression and Spearman's rank correlation were used to study factors associated with HIV testing rates.

RESULTS

Fifty-five eligible articles were identified in this review. The proportion of MSM who had ever been tested for HIV has significantly increased, from 10.8% in 2002 to 51.2% in 2009. In comparison, reported rates of HIV testing in the past 12 months have also significantly increased, from 11.0% in 2003 to 43.7% in 2009.

CONCLUSIONS

Chinese MSM have relatively low HIV testing rates compared with MSM in other settings. It is important to continue to promote HIV testing among MSM in China.

HIV treatment as prevention: the utility and limitations of ecological observation

Results from several observational studies of HIV-discordant couples and a randomized controlled trial (HIV Prevention Trials Network 052) show that antiretroviral therapy (ART) can greatly reduce heterosexual HIV transmission in stable HIV-discordant couples. However, such data do not prove that ART will reduce HIV incidence at the population level. Observational investigations using ecological measures have been used to support the implementation of HIV treatment for the specific purpose of preventing transmission at the population level. Many of these studies note ecological associations between measures of increased ART uptake and decreased HIV transmission. Given the urgency of implementing HIV prevention measures, ecological studies must de facto be used to inform current strategies. However, the hypothesis that widespread ART can eliminate HIV infection may have raised expectations beyond what we may be able to achieve. Here we review and discuss the construct of the exposure and outcome measures and analysis methods used in ecological studies. By examining the strengths and weaknesses of ecological analyses, we aim to aid understanding of the findings from these studies to inform future policy decisions regarding the use of ART for HIV prevention.

HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention

There is growing enthusiasm for increasing coverage of antiretroviral treatment among HIV-infected people for the purposes of preventing ongoing transmission. Treatment as prevention will face a number of barriers when implemented in real world populations, which will likely lead to the effectiveness of this strategy being lower than proposed by optimistic modelling scenarios or ideal clinical trial settings. Some settings, as part of their prevention and treatment strategies, have already attained rates of HIV testing and use of antiretroviral therapy--with high levels of viral suppression--that many countries would aspire to as targets for a treatment-as-prevention strategy. This review examines a number of these "natural experiments", namely, British Columbia, San Francisco, France, and Australia, to provide commentary on whether treatment as prevention has worked in real world populations. This review suggests that the population-level impact of this strategy is likely to be considerably less than as inferred from ideal conditions.

Increase in HIV diagnoses among men who have sex with men in New Zealand from a stable low period

OBJECTIVES

To describe trends in HIV diagnoses among men who have sex with men (MSM) in New Zealand 1996-2008, and to identify characteristics associated with HIV diagnoses in the resurgent phase.

METHODS

Data collected through routine surveillance of HIV infection, where the mode of transmission included homosexual contact, were analysed over the period 1996-2008.

RESULTS

Annual HIV diagnoses were low during 1996-2000, rose sharply between 2001 and 2005, and remained at an elevated plateau between 2006 and 2008. Over a quarter were attributed to HIV infection acquired overseas (28.6%). Trends in diagnoses of locally acquired HIV infection closely mirrored the trend of three diagnosis phases. Increases in locally acquired HIV occurred among virtually all characteristics of MSM. However, compared with MSM diagnosed in the low phase 1996-2000, individuals diagnosed in the resurgent phase 2001-05 were more likely to be aged 30-39, to have tested HIV-negative within the previous 2 years, to live in the Northern region encompassing Auckland, and to be of non-European ethnicity. The per capita HIV diagnosis rate among MSM was lowest in 1997, at 22.0 per million males aged 15-64, and highest in 2005 at 66.7 per million.

CONCLUSION

The increase in HIV diagnoses among MSM in New Zealand was primarily due to an increase in locally acquired HIV infection, which disproportionately affected some groups of MSM. Factors driving this change in local epidemic conditions need to be identified. The rate of new HIV diagnoses among MSM remains low by international standards.

Behavioural surveillance among gay men in Australia: methods, findings and policy implications for the prevention of HIV and other sexually transmissible infections

BACKGROUND

The Australian HIV and sexually transmissible infection (STI) behavioural surveillance system (the repeated cross-sectional Gay Community Periodic Surveys, GCPS) has been conducted since 1998 and covers six main Australian jurisdictions. In this paper, we review its history and methodology, and the available indicators, their trends and their use.

METHODS

We describe the design and history of GCPS. For analyses of indicators, we use Pearson's χ²-test and test for trend where appropriate.

RESULTS

About 90% of gay men in Australia have been tested for HIV (60% to 70% of men who were not HIV-positive) have been tested as recommended in the preceding 12 months. STI testing levels (≈ 70% in the preceding 12 months) are high, but remain insufficient for STI prevention. In general, unprotected anal intercourse with regular (UAIR) and casual (UAIC) sex partners has increased over time. The prevalence and increasing trends in UAIR were similar across jurisdictions (P-trend <0.01), while trends in UAIC differed across the states: during 2001-08, UAIC declined in NSW (P-trend <0.01) and increased elsewhere (P-trend <0.01). Trends in UAIC were associated with HIV diagnoses.

CONCLUSION

This review of the design, implementation and findings of the Australian HIV/STI behavioural surveillance highlights important lessons for HIV/STI behavioural surveillance among homosexual men, particularly the need for consistent data collection over time and across jurisdictions. Investment in systematic behavioural surveillance appears to result in a better understanding of the HIV epidemic, the availability of a warning system and a better targeted HIV prevention strategy.

Treatment for prevention of HIV transmission in a localised epidemic: the case for South Australia

BACKGROUND

Discussion is currently taking place among international HIV/AIDS groups around increasing HIV testing and initiating earlier use of antiretroviral therapy (ART) among people diagnosed with HIV as a method to reduce the spread of HIV. In this study, we explore the expected epidemiological impact of this strategy in a small population in which HIV transmission is predominantly confined to men who have sex with men (MSM).

METHODS

A deterministic mathematical transmission model was constructed to investigate the impacts of strategies that increase testing and treatment rates, and their likely potential to mitigate HIV epidemics among MSM. Our novel model distinguishes men in the population who are more easily accessible to prevention campaigns through engagement with the gay community from men who are not. This model is applied to the population of MSM in South Australia.

RESULTS

Our model-based findings suggest that increasing testing rates alone will have minimal impact on reducing the expected number of infections compared to current conditions. However, in combination with increases in treatment coverage, this strategy could lead to a 59-68% reduction in the number of HIV infections over the next 5 years. Targeting men who are socially engaged with the gay community would result in the majority of potential reductions in incidence, with only minor improvements possible by reaching all other MSM.

CONCLUSIONS

Investing in strategies that will achieve higher coverage and earlier initiation of treatment to reduce infectiousness of HIV-infected individuals could be an effective strategy for reducing incidence in a population of MSM.

Characteristics of HIV epidemics driven by men who have sex with men and people who inject drugs

PURPOSE OF REVIEW

To highlight the latest developments in mathematical transmission modelling of HIV epidemics among men who have sex with men (MSM) and people who inject drugs (PWID).

RECENT FINDINGS

Mathematical approaches have been applied to a wide range of topics in recent HIV research. Epidemiological models have evaluated past and forecasted future trends in prevalence and incidence, evaluated innovative behaviour modification strategies and public health programmes aimed at minimizing risk, and explored the potential impact of various biomedical interventions. MSM have developed new risk reduction strategies which models have deemed to be effective at a population level only in certain settings, such as when there are high rates of HIV testing. Modelling has also indicated that persistent circulation of drug-resistant HIV strains is likely to become an inevitable public health issue in the near future in resource-rich settings among MSM. Models have also recently been used to demonstrate that needle and syringe programmes for harm reduction among PWID are effective and cost-effective.

SUMMARY

Mathematical modelling is particularly amenable to single population groups of concentrated HIV epidemics, such as among MSM and PWID. Models have been utilized to evaluate innovative areas in clinical, biomedical and public health research that cannot be conducted in other population groups. Future directions are likely to include evaluation of specific public health programmes and providing understanding of the importance of specific treatment regimens and incidence and interaction of comorbid conditions associated with HIV.

Recent decline in the incidence of human immunodeficiency virus infection among California men who have sex with men

Monitoring the incidence of human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) is imperative for developing targeted prevention programs and evaluating their effectiveness. The authors used California counseling and testing data to estimate the temporal trend in HIV incidence among MSM in California. HIV incidence rates were retrospectively calculated among MSM who had received at least 1 HIV test at a public California counseling and testing site between 1997 and 2007 and had a prior HIV-negative test from any HIV testing source. All study subjects were weighted on the basis of the interval between the last HIV-negative test and the current HIV test to account for the right-truncation bias introduced by more frequent testers. The authors observed that the HIV incidence rate among MSM in California increased from 2.0/100 person-years (95% confidence interval (CI): 1.8, 2.2) in 1997 to 2.4/100 person-years (95% CI: 2.2, 2.6) in 2003 and then decreased to 1.9/100 person-years (95% CI: 1.7, 2.0) in 2006. Trend analyses showed that both the increase (P < 0.001) and the decrease (P < 0.01) were statistically significant. The study showed that HIV incidence among MSM in California had decreased since 2003.