Time trend in incidence of HIV seroconversion among homosexual men repeatedly tested in Madrid, 1988--2000

High HIV incidence among men who have sex with men attending a community-based voluntary counselling and testing service in Barcelona, Spain: results from the ITACA cohort

OBJECTIVES

To identify the HIV incidence and its associated factors (AFs) of the ITACA, a community-based cohort of HIV-negative men who have sex with men (MSM) established in Barcelona, Spain from 2008 to 2011.

METHODS

Participants were men aged 18 years or older, having a negative HIV test result at baseline and agreeing to participate. Bio-behavioural data were collected by peers in each visit. HIV incidence rates using person-time measures and 95% CIs were calculated. Cox logistic regression models were used to identify AFs to seroconversion.

RESULTS

Over the period, 3544 participants with at least one follow-up visit or those who had a first visit no longer than a year prior to the date of data censoring were included in the analysis contributing 3567.09 person-year (p-y) and 85 MSM seroconverted for an overall HIV incidence of 2.4 per 100 p-y (95% CI 1.9 to 2.9) ranging from 1.21/100 (2009) to 3.1/100 p-y (2011). Independent AF included: foreign origin, having more than five HIV tests at baseline, reporting in the preceding 6 months the following: condomless anal sex with the last steady partner of unknown serostatus, more than 10 casual partners, condomless anal sex with casual partner, self-reported gonorrhoea and entered in the cohort in 2010 or 2011.

CONCLUSIONS

The ITACA cohort revealed a high and increasing HIV incidence among MSM, especially important among foreign-born men. The findings underscore the need to implement multilevel interventions for MSM taking into account different types of partners, cultural origins and the exposure to other sexually transmitted infections.

Running in place: implications of HIV incidence estimates among urban men who have sex with men in the United States and other industrialized countries

Attempts to document changing HIV incidence rates among MSM are compromised by issues of generalizability and statistical power. To address these issues, this paper reports annualized mean HIV incidence rates from the entire published incidence literature on MSM from Europe, North America and Australia for the period 1995-2005. Publications that met the entry criteria were coded for region of the world, sampling method and year of study. From these reports, we calculated a mean incidence rate with confidence intervals for these variables. Although no differences in mean incidence rates were found for MSM from 1995 to 2005, HIV incidence rates are lower in Australia than either North America or Europe. We calculated a mean incidence rate of 2.39% for MSM in the United States, which if sustained within a cohort of MSM, would yield HIV prevalence rate of approximately 40% at age 40. These extrapolations overlap published HIV prevalence rates for MSM younger than age 40 in the United States. HIV incidence rates in the 2-3% range will adversely affect the health of gay male communities for decades to come. This analysis suggests that greater attention should be devoted to the question of how best to design prevention interventions that will lower HIV incidence rates among gay men.

Public sexual cultures: a systematic review of qualitative research investigating men's sexual behaviors with men in public spaces

Resurgent HIV and sexually transmitted infection incidence among men who have sex with men (MSM) requires an urgent re-examination of sexual transmission sites. To these ends, we systematically review qualitative literature concerning men's sexual behaviors within public sex environments (PSEs). Sex, therein, is negotiated by the highly codified, largely nonverbal practice of "cruising." A generic, shared PSE sexual culture emerges from the literature-across locations, countries, and decades-because of the importance of concealment and common structural constraints on sexual encounters in PSEs. However, differences in local geography and facilities may transform key features of this, resulting in specific, local sexual cultures emerging for each locale. We argue that, although sexual cultures developed to minimize nonsexual cruising risks, they may be exploited to improve contemporary in situ outreach work.

Sexual compulsivity and high-risk sex among Latino men: the role of internalized homonegativity and gay organizations

The objective of this study was to measure the correlation between compulsive sexual behavior (CSB) and internalized homonegativity (IH) and determine their association with unprotected anal intercourse in Latino men who have sex with men. Nine hundred sixty-three Latino men completed an Internet survey (MINTS study) in 2002 and provided data on two scale exposures. Logistic regression was used to test interactions and generate effect estimates. Higher IH and association with gay organizations modified the effect of CSB on high-risk sex. Drug and alcohol use also contributed to risk behavior for this subgroup. Overall, CSB had a strong association with high-risk sex. IH and gay organization membership may moderate this relationship, which illuminates an additional factor to consider in studying sexual risk-taking. Further work is needed to validate a path from IH and high-risk sex that incorporates drug or alcohol use.

Trends in HIV incidence in homosexual men in developed countries

Objectives: To describe trends in HIV notifications and in other measures of HIV incidence in homosexual men in developed countries. Methods: A literature search was conducted using PubMed. In addition to the peer-reviewed literature, data on HIV surveillance trends were sought by searching websites of surveillance authorities in developed countries. Results: The availability of long-term HIV surveillance data varied considerably. However, in almost all jurisdictions in which such data were available, notifications of new HIV diagnoses among homosexual men have increased, mostly since the late 1990s. The magnitude of this increase varied, but was more than 50% in many countries. There were much fewer data available on trends in direct measures of HIV incidence in homosexual men, and increases in HIV testing rates may have contributed to the increases in HIV diagnoses in many countries. However, since the late 1990s, several clinic- and community-based cohort studies in Europe and North America reported increasing incidence. Conclusion: There were increases in HIV notifications in homosexual men in almost all developed countries, starting in the late 1990s and continuing to 2006. Although increases in HIV testing probably contributed to the increases in some settings, limited cohort data do support the existence of a true increase in HIV incidence in European and North American countries. Improved monitoring of HIV incidence in homosexual men at the population level is required to allow more timely assessment of the drivers underlying such trends.

[Elevated risk of HIV infection in homosexual men even after contact with the health system]

OBJECTIVE

To determine the incidence of HIV seroconversion and to evaluate the characteristics associated with a greater risk of seroconversion in homosexual men in the period 2000-2003.

METHODS

We performed a dynamic cohort study of all homosexual men tested for HIV in 20 ambulatory care centers specialized in diagnosing HIV, located in 19 cities in Spain. The characteristics of the men were analyzed and the seroconversion incidence rate was calculated among those who were followed up.

RESULTS

In the period 2000-2003, a total of 10,189 persons-year of follow-up were accumulated and 167 seroconversions were diagnosed with a seroconversion incidence rate of 16.4 per 1,000 persons-year. Most of the seroconversions (63%) occurred in men younger than 30 years old. The seroconversion rate was higher among homosexual men from Latin America and sub-Saharan Africa than among Spanish men.

CONCLUSIONS

In Spain, the risk of HIV transmission among men who have sex with men is still high. Therefore, this population continues to be a high priority group in HIV prevention. A proportion of HIV diagnoses among immigrants concern infections acquired after their arrival to Spain, probably due to conditions of greater social vulnerability. Reinforcing and renewing prevention strategies directed at this population would be timely.

Prevalence of HIV infection and predictors of high-transmission sexual risk behaviors among men who have sex with men

OBJECTIVES

We sought to determine the prevalence of HIV and novel cofactors of high-transmission-risk behavior in a probability sample of men who have sex with men (MSM).

METHODS

We performed a cross-sectional telephone survey of 1976 adult MSM in San Francisco.

RESULTS

We found an HIV prevalence of 25.2%. Predictors of unprotected insertive anal intercourse with a serodiscordant (not having the same HIV/AIDS serostatus) partner among HIV-infected men included use of Viagra and a greater number of partners in the past 12 months. Unprotected receptive anal intercourse with a serodiscordant partner among men not known to be HIV infected was independently associated with having lived in San Francisco for less than 1 year, use of crystal methamphetamine and amyl nitrites, a greater number of partners, and agreement with the statement, "You are less careful about being safe with sex or drugs than you were several years ago because there are better treatments for HIV now."

CONCLUSIONS

Strategies to prevent HIV for urban MSM should focus on new predictors of HIV transmission.

Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting?

BACKGROUND

Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised.

OBJECTIVES

To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic.

METHODS

The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre-existing

DATA SOURCES

STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data.

RESULTS

Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004.

CONCLUSIONS

HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus.

Characteristics and trends of newly diagnosed HIV-infections, 2000-2004

OBJECTIVE

To describe the characteristics and trends of newly diagnosed HIV-infections.

METHODS

We analysed all newly diagnosed HIV-infections among residents of the Canary Islands, Ceuta, La Rioja, Navarre and the Basque Country (Spain) between 2000 and 2004.

RESULTS

In total, 1,807 HIV-infections -74.4 per million inhabitants, per year- were diagnosed. The heterosexual transmission category was the most frequent (48.6%), followed by that of homo/bisexual men (23.0%) and injecting drug users (IDU) (22.5%). From 2000 to 2004, the rate of new diagnoses of HIV infection decreased by 29.8% (p < 0.0001). The rate of diagnoses of infections acquired by IDU diminished by 58.5% (p < 0.0001), and the rate of infections associated with homo/bisexual practices in men descended by 33.9% (p = 0.0318). Nevertheless, the rate of diagnoses of infections by heterosexual transmission has not undergone significant changes. In the period 2002-2004, 28.7% of cases were diagnosed in foreigners, but the rate of diagnoses in the population of non-Spanish origin diminished by 24% (p = 0.0534). 39.7% of HIV diagnoses were delayed (with CD4 < 200 cells/microlitre or coinciding with the diagnosis of AIDS). This situation was less frequent in women (odds ratio = 0.5; p < 0.001) and increased with age amongst people over 30. The proportion of delayed diagnoses reached a maximum in 2001 (47.5%) and then declined until 2004 (38.6%; p = 0.022).

CONCLUSIONS

Although none of the analysed indicators evolved unfavourably, it is important to insist on the prevention of sexual transmission, the early diagnosis of HIV infection, and the need to adapt preventive activities and focus them on people from other countries.

Cruising for sex: Sexual risk behaviours and HIV testing of men who cruise, inside and outwith public sex environments (PSE)

This paper describes sexual risk behaviours and HIV testing amongst men who cruise an urban public sex environment (PSE) in southern England. Data were collated using a cross-sectional survey (response rate = 56%; n=216), sampling men from directly within the PSE. As such, this represents the first peer-review study generalizable to the wider population of urban PSE users. The current sample reflect a highly sexually active population, almost one-third (31%) reported over 50 sex partners in the last year. However, just one-quarter (26%) reported unprotected anal intercourse (UAI) with at least one partner outside of a 'safer sexual strategy'. Almost 1 in 12 (7%) reported UAI within the PSE. Over two-thirds (71%) had had a named HIV test of whom 16% had tested HIV positive. Just one-third (34%) of negative/untested PSE users had tested within the previous two years. Positive men were significantly more likely to report unsafe sex within the PSE in the last year. PSE users report lower levels of UAI than men in the local gay community but higher HIV prevalence. PSE-based UAI remains an HIV (re)infection risk. In concert, these findings suggest the importance of in situ targeted health promotion to prevent PSE-based risks.

Trends in HIV testing, serial HIV prevalence and HIV incidence among people attending a Center for AIDS Prevention from 1988 to 2003

AIM

To analyse trends in HIV testing, serial HIV prevalence and HIV incidence among people who underwent voluntary testing in a Center for AIDS Prevention in Valencia, Spain.

METHODS

Open cohort study including all subjects who went to the Center for AIDS Prevention from 1988 to 2003. Information on sociodemographic variables and HIV test results was collected. Serial prevalence and incidence rates were calculated, and joinpoint regression was used to identify changes in trends over time.

RESULTS

21,241 subjects were analysed; 67% men, 27% injecting drug users (IDUs), 43% heterosexuals and 13% men who have sex with men (MSM). From 1988 to 1990, IDUs accounted for 57% of clinic attenders, decreasing to 14% by 1997-2003, accompanied by an increase in heterosexuals. Overall, HIV prevalence for the whole period was 15%, dropping from 35% to <10% after 1999 and to 3% by 2003, when HIV prevalence was 26% in IDUs, 6% in MSM and 2% in heterosexuals. Total HIV incidence was 2.5%. From 1988 to 1990, HIV incidence ranged from 6% to 8%, and a gradual and progressive decline observed from 1990 onwards. From 1995 onwards, HIV incidence was <2%. The highest incidence rate is seen in IDUs, 7-12% in the first period and 4-5% at the end. Among MSM, a change in the decreasing trend is seen by 1998, and increases in incidence are detected by 2002-3.

CONCLUSIONS

Serial HIV prevalence has markedly decreased from 1988 in all transmission categories, although it is still high. With regard to HIV incidence, the drop has been marked too, although a worrying increase, that requires further follow-up, has been detected in MSM in the past 2 years.

Factors associated with unprotected sexual intercourse with steady male, casual male, and female partners among men who have sex with men in Barcelona, Spain

To increase understanding of the HIV epidemic among MSM in Barcelona, anonymous questionnaires were completed by 640 MSM recruited in the city in 2002. The prevalence of unprotected anal intercourse (UAI) with casual male partners in the prior 12 months was higher among self-reported HIV-positive men (confirmed through saliva testing) than among men who were HIV-negative or of unknown serostatus (35% vs. 20%, p < .01). The prevalence of UAI with steady male partners was substantially lower among HIV-positive men than other men (28% vs. 60%, p < .01). In multivariate analyses, UAI with casual partners was more likely among HIV-positive individuals; those who used drugs before sex; perceived less acceptance of their sexual orientation by family, friends, or coworkers; and were less concerned about HIV prevention because of antiretroviral therapy (ART). UAI with steady partners was more likely among HIV-negative men with seroconcordant partners, those living with a partner, and men less concerned about HIV prevention because of ART. Findings indicate a need for prevention programs targeting HIV-positive MSM in Barcelona. Attention to substance use and attitudes about HIV prevention are needed for MSM in general.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Evolución de la prevalencia de infección por el VIH y de las conductas de riesgo en varones homo/bisexuales

OBJECTIVES

To describe trends in the prevalence of HIV infection, in risk behaviors and in knowledge and attitudes related to antiretroviral therapy (ART) among men who have sex with men (MSM) recruited in Barcelona (Spain) between 1995 and 2002.

METHODS

Cross-sectional surveys were conducted twice yearly from 1993. MSM were recruited in saunas, sex-shops, a cruising site in a public park and by a mailing sent to all members of a gay organization, using an anonymous self-administered questionnaire. From 1995 saliva samples were requested to determine the prevalence of HIV infection.

RESULTS

The prevalence of HIV infection remained stable from 14.2% in 1995 to 18.3% in 2002 (p > 0.05). The proportion of men who had more than 10 sexual partners in the previous 12 months showed an increasing trend (from 45.2% in 1995 to 55.7% in 2002, p < 0.0001). Unprotected anal intercourse (UAI) with casual partners did not change significantly between 1995 and 2002 (25.8% en 2002). In 2002, 55.8% of steady couples in which one or both members did not know their serological status and 27.5% of serodiscordant couples reported UAI. The proportion of men who believed that "HIV-positive persons taking ART (7.7% in 2002) or with undetectable viral load (6.4% in 2002) cannot transmit the virus" remained steady since 1998 (p > 0.05).

CONCLUSIONS

The prevalence of HIV and risk behaviors continues to be high among MSM in Barcelona. A strategic objective in the control of the HIV epidemic must be to continue the decrease in the number of occasions on which UAI takes place between men with discordant serological status.

Men who have sex with men (MSM) in public sex environments (Pses): a systematic review of quantitative literature

We systematically review quantitative research relating to the sexual behaviours of MSM in PSEs. We examine the methodological rigour of these studies to determine an appropriate framework for future PSE-based research and quantify sexual behavioural trends therein. Medline, BIDS, Web of Science and recent HIV/AIDS conferences were searched according to a systematic inclusion criteria. Nine papers were included for review. Recruitment of participants' outwith PSE settings, and low response rates (6%) of participants contacted in situ, question the validity and generalizability of current evidence. Most PSE users were gay or bisexually identified and half of men in the gay community reported recent PSE use. Around 10% of men reported casual status-unknown/serodiscordant unprotected anal intercourse (UAI) within PSEs. HIV testing rates amongst PSE users were similar to the wider gay community, though the proportion of men who tested positive was twice as high. Rates of casual UAI suggest that PSEs represent important sites for HIV prevention. However, since extant evidence is scant and methodologically flawed, further research is urgent. Such work must recruit participants in situ, and obtain satisfactory response rates, to be generalizable to the wider population of men who cruise.

Comparison of three methods to measure HIV incidence among persons seeking voluntary, anonymous counseling and testing

OBJECTIVES

The authors compared 3 practical methods to estimate human HIV incidence rates using existing data from persons seeking anonymous testing in San Francisco between 1996-2002. Each method was assessed for strengths and limitations.

METHODS

Three different approaches were used to determine HIV incidence: one based on self-reported dates of prior tests, one based on linking records of prior tests using an anonymous unique testing code, and one based on the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS).

RESULTS

The 3 methods found comparable rates of seroconversion overall (1.0, 1.2, and 1.3 per 100 person-years) and among men who have sex with men (1.4, 1.6, and 2.0 per 100 person-years). Incidence for all 3 methods saw a peak during 1999 followed by a decline. Greatest variability of incidence was observed among lower-risk populations, in whom few infections were expected.

CONCLUSIONS

The 3 methods had complementary strengths and limitations, which may prevent proper interpretation of HIV incidence if any one method is analyzed alone. HIV incidence rates among persons seeking HIV testing should be interpreted cautiously using corroborative data on risk behavior and sexually transmitted diseases and other contextual information.

Patrón epidemiológico de la infección por el VIH en 15 hospitales españoles: casos de nuevo diagnóstico incluidos en la cohorte VACH en 2001 y 2002

BACKGROUND

Studying the changing trends of HIV epidemics is a useful means of evaluating the results of current preventive plans as well as of defining future needs and objectives.

METHODS

We performed a cross-sectional study of the newly-diagnosed cases of HIV infection included in the Spanish VACH cohort. New HIV cases were defined as those diagnosed between January 2001 and December 2002. Their epidemiologic characteristics were compared with those of patients included in the same cohort who had been diagnosed between January 1998 and December 2000.

RESULTS

We studied 603 new cases (27% women). In 146 (24.4%) HIV infection had been acquired by sharing material for intravenous drug use (IVDU), 171 (28,6%) were men who had had sex with other men (MSM) and 247 (41.3%) acknowledged some risk for heterosexual HIV transmission. The median age was 36 years (range: 18-80). Only 1.5% of the patients were younger than 20 years while 32.1% were older than 40 years. This percentage was significantly higher than that corresponding to 1998-2000 (27.5%; p < 0,05). HIV infection was diagnosed simultaneously with an AIDS-defining condition in 13.3% of patients and an AIDS-defining disease was diagnosed in the first month after HIV-diagnosis in another 40 patients (6.6%).

CONCLUSIONS

We confirm the trends observed in previous studies: a growing proportion of newly diagnosed cases among women, a decreasing proportion of IVDU, a growth of MSM, and a trend toward diagnosis at a later age.

Increase of sexually transmitted infections, but not HIV, among young homosexual men in Amsterdam: are STIs still reliable markers for HIV transmission?

OBJECTIVES

The incidence of HIV and STIs increased among men who have sex with men (MSM) visiting our STI clinic in Amsterdam. Interestingly, HIV increased mainly among older (> or =35 years) MSM, whereas infection rates of rectal gonorrhoea increased mainly in younger men. To explore this discrepancy we compared trends in STIs and HIV in a cohort of young HIV negative homosexual men from 1984 until 2002.

METHODS

The study population included 863 men enrolled at < or =30 years of age from 1984 onward in the Amsterdam Cohort Studies (ACS). They had attended at least one of the 6 monthly follow up ACS visits at which they completed a questionnaire (including self reported gonorrhoea and syphilis episodes) and were tested for syphilis and HIV. Yearly trends in HIV and STI incidence and risk factors were analysed using Poisson regression.

RESULTS

Mean age at enrollment was 25 years. The median follow up time was 4 years. Until 1995 trends in HIV and STI incidence were concurrent, however since 1995 there was a significant (p<0.05) increase in syphilis (0 to 1.4/100 person years (PY)) and gonorrhoea incidence (1.1 to 6.0/100 PY), but no change in HIV incidence (1.1 and 1.3/100 PY).

CONCLUSIONS

The incidence of syphilis and gonorrhoea has increased among young homosexual men since 1995, while HIV incidence has remained stable. Increasing STI incidence underscores the potential for HIV spread among young homosexual men. However, several years of increasing STIs without HIV, makes the relation between STI incidence and HIV transmission a subject for debate.

Studies relying on passive retrospective cohorts developed from health services data provide biased estimates of incidence of sexually transmitted infections

OBJECTIVE

Passive retrospective cohorts composed of persons who have tested 2 or more times for a sexually transmitted infection (STI) of interest during clinical visits have been used to estimate STI incidence. We hypothesized that the analytic period of a passive cohort might affect the estimate of STI incidence, with shorter periods yielding higher estimates of incidences of infection.

STUDY

We analyzed data collected from women, 12 to 24 years of age, tested for chlamydia 2 or more times at 6 sites in San Francisco between January 1997 and December 2000. Incidence was calculated for 10 different analytic periods.

RESULTS

The calculated incidence of chlamydial infection during 1997 was 16.8 (95% confidence interval [CI], 10.9-24.0) per 1000 person-months of follow up. The calculated incidence dropped markedly as the analytic period lengthened, with the incidence estimated to be 9.7 (95% CI, 8.6-10.9) using a study period of 4 years (1997-2000). Estimates of incidence were similar when using the same analytic period, regardless of calendar year, and there was a similar decline in estimated incidence using longer analytic periods.

CONCLUSIONS

Estimates of STI incidence based on passive cohort data may have limited epidemiologic value because incidence measures may be highly dependent on the analytic period.

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.

Negotiated Safety Relationships and Sexual Behavior Among a Diverse Sample of HIV-Negative Men Who Have Sex With Men

OBJECTIVE

To examine the prevalence of negotiated safety (NS) in a diverse sample of HIV-negative men who have sex with men (MSM), characteristics of MSM practicing NS, and adherence to NS.

METHODS

This was a cross-sectional survey of San Francisco MSM recruited from venues and community organizations. NS relationships were defined as those in which HIV-negative men were in seroconcordant primary relationships for >/=6 months, had unprotected anal intercourse (UA) together, and had rules prohibiting UA with others. Adherence to NS was determined from self-reported sexual behavior in the prior 3 months. Presence of an agreement with NS partners to disclose rule breaking was also determined.

RESULTS

Of 340 HIV-negative participants, 76 (22%) reported a current seroconcordant primary relationship for >/=6 months. Of these 76 men, 38 (50%) had NS relationships, 30 (39%) had no UA with primary partners, and 8 (11%) had UA with primary partners without rules prohibiting UA with others. In multivariate analysis, NS was more common than no UA with primary partners in younger men. Among 38 NS men, 29% violated their NS-defining rule in the prior 3 months, including 18% who reported UA with others, and 18% reported a sexually transmitted infection (STI) in the prior year. Only 61% of NS men adhered fully to rules and agreed to disclose rule breaking.

CONCLUSIONS

Although NS was commonly practiced among HIV-negative men in seroconcordant relationships, some men violated NS-defining rules, placing themselves and potentially their primary partners at risk for HIV infection. Prevention efforts regarding NS should emphasize the importance of agreement adherence, disclosure of rule breaking, and routine STI testing.

Estimation of HIV incidence among repeat anonymous testers in Catalonia, Spain

A retrospective cohort study of 2124 repeat HIV testers attending at anonymous testing sites (ATS) of Catalonia between 1995 and 2001 registered 3273 person-years (PY) of follow-up and 76 seroconversions (incidence density of 2.32 per 100 PY; 95% CI: 1.83, 2.90). The highest HIV infection incidence was observed among heterosexual injection drug users (IDU) (9.25 per 100 PY; 95% CI: 6.77, 12.25) and the lowest was among heterosexual non-IDU (0.69 per 100 PY; 95% CI: 0.35, 1.24). In multivariate Cox regression, factors independently associated with seroconversion were men having sex with men, IDU, and having sex with a known HIV-infected person. In spite of some limitations, such results suggest that prevention interventions targeting specific groups attending at ATS in Catalonia should be prioritized.

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.

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.

Changes in the transmission dynamics of the HIV epidemic after the wide-scale use of antiretroviral therapy could explain increases in sexually transmitted infections: results from mathematical models

BACKGROUND

Recent increases in bacterial sexually transmitted infections (STI) and risk behavior have coincided with the introduction of antiretroviral therapy (ART) in homosexual communities of industrialized countries. The reasons for these increases are not fully understood.

GOAL

The goal of this study was to understand the various effects of ART on risk behaviors and STI.

OBJECTIVE

The objective of this study was to assess the independent impact of the change in the transmission dynamics of HIV/AIDS as a result of the wide-scale use of ART on a bacterial STI.

STUDY DESIGN

We developed a mathematical model of bacterial STI and treated/untreated HIV/AIDS infection for an open homosexual population. At the individual level, we assume that susceptible and healthy HIV-positive individuals do not increase their risk behavior as a result of ART over time. However, individuals with AIDS, who are successfully treated with ART, can resume sexual activity. The impact of the wide-scale use of ART on risky behavior, STI, and HIV/AIDS was evaluated over a wide range of assumptions on treatment use, ART efficacy, and population characteristics.

RESULTS

Over 10 years, 0% to 55% new bacterial STI could be attributed to the wide-scale use of ART as a result of more modest increases (0-25%) in risky sex occurring at the population level rather than at the individual level. These increases have a negative impact on HIV if coverage is too low. Increasing treatment coverage helps to prevent more HIV infections despite larger increases in risky sex and STI that is predicted to ensue.

CONCLUSION

Taking the differential impact of wide-scale use of ART into account helps to interpret recent behavioral and STI trends. Our results have implications for prevention strategies and for the formulation of public health policies. A better understanding of the differential impact of ART on sexual network over time is required.

Seroprevalence of HIV Among Sexually Transmitted Infections Clinic Attenders Voluntarily Tested for HIV in Barcelona, 1998–2001

BACKGROUND

Spain has been the European country most affected by the AIDS epidemic, and sexual transmission now accounts for the majority of cases of HIV.

GOAL

The goal was to describe HIV prevalence and risk profiles among people tested for HIV in Barcelona in 1998 to 2001.

STUDY DESIGN

We studied cross-sectional HIV surveys among sexually transmitted infection clinic attenders. We performed quantification of risk factors for HIV infection through odds ratios (ORs) and logistic regression.

RESULTS

The prevalence of HIV among the 4993 persons tested was 1.8% (95% confidence interval, 1.5-2.2) without significant changes across the years. HIV prevalence in homo-/bisexual men was higher (P<0.001) at 4.8% than heterosexuals. Although men aged older than 30 compared with those younger were at increased risk, 2.56), young homosexual men were at higher risk (OR, 17.84) to be infected than young heterosexuals.

CONCLUSION

HIV prevalences were relatively low among all heterosexuals, but much higher among homosexual and bisexual men. The potential exists for ongoing sexual HIV transmission among homo-/bisexual men in Barcelona.

Viagra use in a community-recruited sample of men who have sex with men, San Francisco

The authors conducted a community-based anonymous survey of 837 men who have sex with men (MSM) to gauge the extent of Viagra (sildenafil citrate) use, its association with high-risk sexual behavior, and its combination with other drugs. Participants' mean age was 35 years, 67% were white, and 66% had a college degree. The majority (76%) reported anal sex in the past 6 months, with 49% reporting always using condoms. Overall, 32% had ever used Viagra (CI: 29%-36%). Significant independent predictors of Viagra use were white race, older age, HIV positivity, illicit drug use, and having had unprotected anal sex with potentially serodiscordant partners. Over one third of Viagra users had combined Viagra with other drugs, 18% with amyl nitrate. Only a minority (44%) obtained Viagra under the care of a physician. For some MSM, Viagra appears to be an emerging contributing factor to unsafe sex, potentially increasing HIV transmission. HIV care and prevention providers should target Viagra users for enhanced education on safer sex and potentially harmful drug interactions.

Risk behaviour and sexually transmitted diseases are on the rise in gay men, but what is happening with HIV?

Increases in sexually transmitted diseases and sexual risk behaviour among men who have sex with men in the Western world have raised concern with regard to the HIV/AIDS epidemic in this group. The aim of this review is to give an overview of possible explanations for these alarming increases and to indicate what impact they might have on this epidemic.