Trends in sexual behaviour among London homosexual men 1998-2003: implications for HIV prevention and sexual health promotion

Overcoming COVID-19 disruptions: Innovations in product provision in a multi-national clinical trial among cisgender men, transgender men and transgender women in five countries

Clinical trials often depend on participants receiving study product to meet objectives of the protocol. Vitally important are considerations for how sites receive and dispense study product during a study while ensuring appropriate handling, accountability and compliance. The process for provision of study product is detailed in Standard Operating Procedures (SOPs) which are adhered to by the research site throughout the trial. The COVID-19 pandemic unexpectedly affected the ability of study participants to receive study product. We report on the various methods implemented by trial sites to ensure timely provision of study product to participants during this unprecedented pandemic. In MTN-035, participants received 3 potential rectal microbicide formulations in randomized sequences to understand user preferences. Trial sites were permitted to revise dispensing methods to enable participants to continue to receive study product during COVID-19 restrictions. These actions mitigated disruption of study product administration and preserved the integrity of the trial. Out of the 78 participants expecting to receive study products on or after the onset of restrictions due to COVID-19, only four participants (5%) did not receive all three products. Adopting alternative methods to provide product to study participants in extraordinary circumstances was key to successful study completion and maintaining study integrity.

Underlying factors related to HIV/AIDS prevention: investigating the willingness to take pre-exposure prophylaxis among men-who-have-sex-with-men in Germany

BACKGROUND

This study investigates the willingness of men-who-have-sex-with-men (MSM) to use HIV pre-exposure prophylaxis (PrEP). Research in the HIV/AIDS field typically relies on clinical and epidemiological studies, thereby often excluding social dimensions of the illness as well as factors explaining its prevention. The current study analyzes HIV-prevention through an interdisciplinary theoretical approach. It aims to comprehensively understand the mechanisms associated with the willingness to take PrEP among MSM in terms of psychological, social, behavioral, cultural, and demographic factors.

METHODS

We analyze data from the survey "Gay Men and AIDS" conducted in Germany in 2013 prior to market approval for PrEP. Analyses were performed using the statistical software SPSS 25.0, while results were visualized using the R programming language.

RESULTS

We find that perceived risk of infection, social norms (anticipated HIV-stigma), practices (e.g. regular condomless sex), and socio-demographic factors (young age, being single) all have a positive effect on the willingness to take PrEP, while education reveals a negative, and income no effect.

CONCLUSIONS

Results indicate that beyond well-established socio-psychological mechanisms of health behavior, social factors play a crucial role in understanding the willingness of PrEP uptake. This study enriches existing health behavior theories with sociological concepts such as social norms and social practices.

As through a glass, darkly: the future of sexually transmissible infections among gay, bisexual and other men who have sex with men

The trajectory of sexually transmissible infection (STI) incidence among gay and other men who have sex with men (MSM) suggests that incidence will likely remain high in the near future. STIs were hyperendemic globally among MSM in the decades preceding the HIV epidemic. Significant changes among MSM as a response to the HIV epidemic, caused STI incidence to decline, reaching historical nadirs in the mid-1990s. With the advent of antiretroviral treatment (ART), HIV-related mortality and morbidity declined significantly in that decade. Concurrently, STI incidence resurged among MSM and increased in scope and geographic magnitude. By 2000, bacterial STIs were universally resurgent among MSM, reaching or exceeding pre-HIV levels. While the evidence base necessary for assessing the burden STIs among MSM, both across time and across regions, continues to be lacking, recent progress has been made in this respect. Current epidemiology indicates a continuing and increasing trajectory of STI incidence among MSM. Yet increased reported case incidence of gonorrhoea is likely confounded by additional screening and identification of an existing burden of infection. Conversely, more MSM may be diagnosed and treated in the context of HIV care or as part of routine management of pre-exposure prophylaxis (PrEP), potentially reducing transmission. Optimistically, uptake of human papillomavirus (HPV) vaccination may lead to a near-elimination of genital warts and reductions in HPV-related cancers. Moreover, structural changes are occurring with respect to sexual minorities in social and civic life that may offer new opportunities, as well as exacerbate existing challenges, for STI prevention among MSM.

Confronting Rising STIs in the Era of PrEP and Treatment as Prevention

PURPOSE OF REVIEW

This study aims to review the epidemiology of sexually transmitted infections (STIs) among men who have sex with men (MSM) and suggest control measures.

RECENT FINDINGS

Despite declines in new HIV diagnosis, bacterial STIs among MSM have dramatically risen since the late 1990s. This increase occurred concurrent with introduction of effective antiretroviral therapy, the advent of electronic mechanisms for meeting sex partners and population-level changes in sexual behavior, including decreased condom use. HIV pre-exposure prophylaxis (PrEP) is now further diminishing condom use, though its impact on STIs is uncertain. A plan to confront the MSM STI epidemic should include increased HIV/STI testing promoted through expanded public health clinical infrastructure, health care system reform to improve the care of gender and sexual minorities and promote low-barrier care, re-invigorated condom promotion, and scientific innovation. There is an urgent need to implement new STI control measures while continuing to expand PrEP use.

A randomised controlled trial of a telephone administered brief HIV risk reduction intervention amongst men who have sex with men prescribed post-exposure prophylaxis for HIV after sexual exposure in the UK: Project PEPSE

BACKGROUND

In western countries, men who have sex with men (MSM) are most affected by HIV and increasingly likely to engage in risky sexual behaviour. MSM who experience a potential sexual exposure to HIV (PEPSE) and receive a preventative regimen of anti-HIV treatment are at particularly high risk of acquiring HIV and could potentially benefit from targeted risk reduction behavioural interventions such as motivational interviewing (MI).

PURPOSE

The aim of this trial was to examine the impact of augmented MI (MI plus information provision and behavioural skills building), over and above routine care, on reducing risky sexual behaviour in MSM prescribed PEPSE. Secondary aims of the research were to examine whether the intervention reduced sexually transmitted infections (STI) and further requests for PEP.

METHODS

A parallel-group pragmatic randomised controlled trial was conducted with 175 MSM recruited from five sexual health (SH) clinics in the south east of England. The intervention was two fixed-duration sessions of telephone administered augmented MI. A manual guided the selection of individualised persuasive communication strategies based on underlying change mechanisms specified by the Information, Motivation and Behavioural Skills (IMB) model. Primary outcomes were the number of receptive and active anal intercourse (AI) partners, the use of condoms every time during receptive and active AI and the use of condoms sometimes during receptive and active AI.

RESULTS

There were no significant impacts on sexual risk behaviour or any of the psychological measures, and no discernible reduction in requests for repeat PEP or rates of STIs within a year.

CONCLUSION

Our behavioural intervention of augmented MI did not affect risky sexual behaviour, rates of further PEP and STIs, and psychological factors, in MSM prescribed PEPSE.

TRIAL REGISTRATION NUMBERS

UKCRN ID:11436; ISRCTN00746242.

The effects of free condom distribution on HIV and other sexually transmitted infections in men who have sex with men

BACKGROUND

HIV and other sexually transmitted infections remain a burden on men who have sex with men in the era of effective combination antiretroviral therapy. New prevention efforts are therefore needed. One of these approaches is the current country-wide free condom distribution at gay bars with darkrooms and gay saunas in the Netherlands. This study assessed the effects of free condom distribution on incidence and burden of disease of HIV and other sexually transmitted infections.

METHODS

A static model was constructed to calculate the impact of free condom distribution on HIV, hepatitis C, chlamydia, gonorrhoea, and syphilis among men who have sex with men visiting these venues. Outcomes included new infections averted and disability-adjusted life years averted. Scenario studies were performed to predict the effects of a further increase of condom use, condom effectiveness and coverage. Lastly, cost-effectiveness and sensitivity analyses were performed.

RESULTS

Our model showed that condom use at public sex venues increased after the intervention. Annual incidence risk decreased, ranging from 5.73% for gonorrhoea to 7.62% for HIV. The annual number of new infections averted was largest for chlamydia and gonorrhoea (261 and 394 infections, respectively), but 42 new HIV infections were averted as well. In scenarios where condom use and condom effectiveness were further increased, the number of infections reduced more extensively. Over 99% of the decrease in burden of disease was due to HIV. The intervention was cost-effective and cost-saving (for every €1 spent on condom distribution, €5.51 was saved) and remained this in all sensitivity analyses.

CONCLUSIONS

Free condoms at public sex venues could reduce the transmission of HIV and other sexually transmitted infections. Condom distribution is an affordable and easily implemented intervention that could reduce the burden of disease in men who have sex with men substantially.

Trends in condom use among MSM in the United States: the role of antiretroviral therapy and seroadaptive strategies

OBJECTIVE

Evaluate changes in condomless anal sex at last sex among men who have sex with men (MSM) and assess if these changes are associated with the adoption of serosorting and biomedical prevention.

DESIGN

The National HIV Behavioral Surveillance is a crosssectional survey done in up to 21 cities in 2005, 2008, 2011 and 2014.

METHODS

MSM were recruited through venue-based sampling. Among men reporting at least one male partner, we evaluated changes in condomless anal sex at last sex with a partner with (1) HIV-concordant (proxy for serosorting) or (2) HIV-discordant (discordant/unknown) status. We hypothesized that if concordant condomless sex was increasing while discordant was stable/declining, the increases could be driven by more men attempting to serosort. We used generalized estimating equations assuming a Poisson distribution and robust variance estimator to explore whether temporal changes in the outcomes varied by selected characteristics. We also assessed changes in condomless anal sex by antiretroviral therapy (ART) use among HIV-positive MSM.

RESULTS

Among 5371 HIV-positive MSM, there were increases in concordant (19% in 2005 to 25% in 2014, P < 0.001) and discordant condomless sex (15 to 19%, P < 0.001). The increases were not different by ART use. Among 30 547 HIV-negative MSM, concordant (21 to 27%, P < 0.001) and discordant condomless sex (8 to 13%, P < 0.001) increased.

CONCLUSION

Our data suggest that condom use decreased among MSM and that the trends are not explained by serosorting or ART. Promotion of condoms and increased access to preexposure prophylaxis are vital to ensure that the benefits of ART in reducing transmission of HIV are not undermined.

A Cross-Sectional Study on Attitudes to and Understanding of Risk of Acquisition of HIV: Design, Methods and Participant Characteristics

Background

The annual number of new human immunodeficiency virus (HIV) infections in the United Kingdom among men who have sex with men (MSM) has risen, and remains high among heterosexuals. Increasing HIV transmission among MSM is consistent with evidence of ongoing sexual risk behavior in this group, and targeted prevention strategies are needed for those at risk of acquiring HIV.

Objective

The Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) study was designed to collect information on HIV negative adults at risk of HIV infection in the United Kingdom, based on the following parameters: physical and mental health, lifestyle, patterns of sexual behaviour, and attitudes to sexual risk.

Methods

Cross-sectional questionnaire study of HIV negative or undiagnosed sexual health clinic attendees in the United Kingdom from 2013-2014.

Results

Of 2630 participants in the AURAH study, 2064 (78%) were in the key subgroups of interest; 580 were black Africans (325 females and 255 males) and 1484 were MSM, with 27 participants belonging to both categories.

Conclusions

The results from AURAH will be a significant resource to understand the attitudes and sexual behaviour of those at risk of acquiring HIV within the United Kingdom. AURAH will inform future prevention efforts and targeted health promotion initiatives in the HIV negative population.

A Pilot Trial of a Sexual Health Counseling Intervention for HIV-Positive Gay and Bisexual Men Who Report Anal Sex without Condoms

Background

Even in the presence of promising biomedical treatment as prevention, HIV incidence among men who have sex with men has not always decreased. Counseling interventions, therefore, continue to play an important role in reducing HIV sexual transmission behaviors among gay and bisexual men and other men who have sex with men. The present study evaluated effects of a small-group counseling intervention on psychosocial outcomes and HIV sexual risk behavior.

Method

HIV-positive (HIV+) peer counselors administered seven 2-hour counseling sessions to groups of 5 to 8 HIV+ gay and bisexual men. The intervention employed information provision, motivational interviewing, and behavioral skills building to reduce sexual transmission risk behaviors.

Results

There was a significant reduction in condomless anal sex (CAS) with HIV-negative and unknown HIV-status partners, from 50.0% at baseline to 28.9% of the sample at 3-month follow-up. Findings were robust even when controlling for whether the participant had an undetectable viral load at baseline. Significant reductions were also found in the two secondary psychosocial outcomes, loneliness and sexual compulsivity.

Conclusions

The findings provide preliminary evidence that this intervention may offer an efficient way of concurrently reducing CAS and mental health problems, such as sexual compulsivity and loneliness, for HIV+ gay and bisexual men.

Trial Registration

ClinicalTrials.gov NCT02546271

Effect of pre-exposure prophylaxis and combination HIV prevention for men who have sex with men in the UK: a mathematical modelling study

BACKGROUND

HIV transmission in men who have sex with men (MSM) in the UK has shown no sign of decreasing in the past decade. Additional prevention measures are needed. We aimed to estimate the effect of various potential interventions implemented individually and in combination on prevention of HIV infection.

METHODS

We extended a deterministic partnership-based mathematical model for HIV transmission, informed by detailed behavioural and surveillance data, to assess the effect of seven different HIV interventions implemented in MSM (aged 15-64 years) in the UK during 2014-20, including increasing rates of HIV testing, test-and-treat programmes, pre-exposure prophylaxis (PrEP), and sexual behavioural changes. We did sensitivity analyses on risk compensation.

FINDINGS

We predicted a baseline of 16 955 new infections (IQR 13 156-21 669) in MSM in the UK during 2014-20. At a coverage of ≤50%, testing twice a year outperformed all other interventions. Of all intervention combinations, only the combined effect of test and treat and annual HIV testing (61·8%, IQR 47·2-81·8, of total incidence) was greater than the sum of effects of the two interventions individually (32·6%, 23·7-46·0, and 23·9%, 16·5-33·3, respectively). Simultaneous PrEP, expansion of HIV testing, and initiation of test-and-treat programme in 25% of high-activity MSM could save 7399 (IQR 5587-9813) UK MSM from HIV infection (43·6%, IQR 32·9-57·9, of total incidence). An increase in unsafe sex or sexual partners to 50% or more could substantially reduce the effect of interventions, but is unlikely to negate the prevention benefit completely.

INTERPRETATION

PrEP could prevent a large number of new HIV infections if other key strategies including HIV testing and treatment are simultaneously expanded and improved. Without PrEP, HIV incidence in MSM in the UK is unlikely to decrease substantially by the end of this decade.

FUNDING

Health Protection Agency (now Public Health England).

"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.

Modelling the HIV epidemic among MSM in the United Kingdom: quantifying the contributions to HIV transmission to better inform prevention initiatives

OBJECTIVES

HIV is a major public health problem among MSM in the United Kingdom with around 2400 new infections annually. We quantified the contribution of biological and behavioural factors.

DESIGN

Modelling study.

METHODS

A partnership-based model of HIV transmission among UK MSM aged 15-64 years was developed and calibrated to time series HIV prevalence. The calibration was validated using multiple surveillance datasets. Population-attributable fractions were used to estimate the contribution of behavioural and biological factors to HIV transmission over the period 2001-2002, 2014-2015, and 2019-2020.

RESULTS

The contribution of most biological and behavioural factors was relatively constant over time, with the key group sustaining HIV transmission being higher-sexual activity MSM aged below 35 years living with undiagnosed HIV. The effect of primary HIV infection was relatively small with 2014-2015 population-attributable fraction of 10% (3-28%) in comparison with other subsequent asymptomatic stages. Diagnosed men who were not on antiretroviral therapy (ART) currently contributed 26% (14-39%) of net infections, whereas ART-treated MSM accounted for 17% (10-24%). A considerable number of new infections are also likely to occur within long-term relationships.

CONCLUSION

The majority of the new HIV infections among MSM in the United Kingdom during 2001-2020 is expected to be accounted for by a small group of younger and highly sexually active individuals, living with undiagnosed HIV in the asymptomatic stage. Bringing this group into HIV/AIDS care by improving testing uptake is a vital step for preventing onward transmission and will determine the success of using ART as prevention.

Where does treatment optimism fit in? Examining factors associated with consistent condom use among people receiving antiretroviral treatment in Rio de Janeiro, Brazil

In the era of highly active antiretrovirals, people living with HIV (PLWH) have resumed sexual activity in the context of longer and healthier lives, and thus the chances of transmitting the HIV virus, as well as the potential to be re-infected also increase. HIV treatment optimism has been found to be associated with sexual risk behaviors among PLWH in different settings. A cross sectional survey was conducted to examine the relationship between treatment optimism, safer sex burnout and consistent condom use as well as variables associated with treatment optimism in a sample of PLWH on antiretrovirals (ARVs) in Rio de Janeiro, Brazil (n = 604). Seventy-two percent of participants always used a condom in the last 6 months. Homosexual, bisexual, transexual persons were less likely to use condoms consistently than heterosexuals (AOR .58 CI .42-.78). Those who were treatment optimistic (AOR .46 CI .25-.88) were more likely not use a condom consistently in the past 6 months, as were participants who reported safer sex burnout (AOR .58 CI .36-.90). Sexual orientation, safer sex burnout, and lower education levels were significantly associated with higher treatment optimism in multivariate analysis. Study findings highlight the need to address psychosocial factors such as treatment optimism and safer sex burnout associated with lower consistent condom use among PLWH in Rio de Janeiro, Brazil.

Biomedical prevention: state of the science

Preexposure prophylaxis (PrEP) and treatment as prevention (TasP) involve the use of antiretroviral (ARV) drugs by human immunodeficiency virus (HIV)-negative and -positive individuals to reduce HIV acquisition and transmission, respectively. Clinical science has delivered a consistently high effect size for TasP and a range from 0%-73% reduction in incidence across placebo-controlled PrEP trials. However, the quality of evidence for PrEP compares favorably with evidence for postexposure prophylaxis (PEP). It is clear from treatment programs and PrEP trials that daily adherence presents challenges to a large proportion of the population. Although there are factors associated with inconsistent use (ie, younger age), they do not assist clinicians at the point of care. There are additional provider concerns about PrEP (covering cost of drug and delivery, undermining condom promotion, and facilitating resistant strains) that have delayed widespread acceptance. These issues need to be addressed in order to realize the full public health potential of antiretrovirals.

The 'Antiretrovirals, Sexual Transmission Risk and Attitudes' (ASTRA) study. Design, methods and participant characteristics

Life expectancy for people diagnosed with HIV has improved dramatically however the number of new infections in the UK remains high. Understanding patterns of sexual behaviour among people living with diagnosed HIV, and the factors associated with having condom-less sex, is important for informing HIV prevention strategies and clinical care. In addition, in view of the current interest in a policy of early antiretroviral treatment (ART) for all people diagnosed with HIV in the UK, it is of particular importance to assess whether ART use is associated with increased levels of condom-less sex. In this context the ASTRA study was designed to investigate current sexual activity, and attitudes to HIV transmission risk, in a large unselected sample of HIV-infected patients under care in the UK. The study also gathered background information on demographic, socio-economic, lifestyle and disease-related characteristics, and physical and psychological symptoms, in order to identify other key factors impacting on HIV patients and the behaviours which underpin transmission. In this paper we describe the study rationale, design, methods, response rate and the demographic characteristics of the participants. People diagnosed with HIV infection attending 8 UK HIV out-patient clinics in 2011-2012 were invited to participate in the study. Those who agreed to participate completed a confidential, self-administered pen-and-paper questionnaire, and their latest CD4 count and viral load test results were recorded. During the study period, 5112 eligible patients were invited to take part in the study and 3258 completed questionnaires were obtained, representing a response rate of 64% of eligible patients. The study includes 2248 men who have sex with men (MSM), 373 heterosexual men and 637 women. Future results from ASTRA will be a key resource for understanding HIV transmission within the UK, targeting prevention efforts, and informing clinical care of individuals living with HIV.

Circumcision and HIV infection among men who have sex with men in Britain: the insertive sexual role

The objective was to examine the association between circumcision status and self-reported HIV infection among men who have sex with men (MSM) in Britain who predominantly or exclusively engaged in insertive anal intercourse. In 2007-2008, a convenience sample of MSM living in Britain was recruited through websites, in sexual health clinics, bars, clubs, and other venues. Men completed an online survey which included questions on circumcision status, HIV testing, HIV status, sexual risk behavior, and sexual role for anal sex. The analysis was restricted to 1,521 white British MSM who reported unprotected anal intercourse in the previous 3 months and who said they only or mostly took the insertive role during anal sex. Of these men, 254 (16.7 %) were circumcised. Among men who had had a previous HIV test (n = 1,097), self-reported HIV seropositivity was 8.6 % for circumcised men (17/197) and 8.9 % for uncircumcised men (80/900) (unadjusted odds ratio [OR], 0.97; 95 % confidence interval [95 % CI], 0.56, 1.67). In a multivariable logistic model adjusted for known risk factors for HIV infection, there was no evidence of an association between HIV seropositivity and circumcision status (adjusted OR, 0.79; 95 % CI, 0.43, 1.44), even among the 400 MSM who engaged exclusively in insertive anal sex (adjusted OR, 0.84; 95 % CI, 0.25, 2.81). Our study provides further evidence that circumcision is unlikely to be an effective strategy for HIV prevention among MSM in Britain.

Guidance and practice on frequency of HIV and sexually transmitted infection testing in men who have sex with men - what is the European situation?

Men who have sex with men (MSM) are at particular risk for HIV/sexually transmitted infections (STI). To investigate the European guidance used for MSM STI and HIV screening, risk level profiling and how this translated to practice, we conducted a questionnaire survey of leading physicians in the European branch of the International Union against Sexually Transmitted Infections (IUSTI). We identified that most European countries have limited guidance on screening intervals for MSM. Where risk profiling is advised, it is often left to clinicians to weight different behaviours and decide on screening frequency. Our results suggest that European MSM STI and HIV testing guidelines be developed with clear and specific recommendations around screening intervals and risk profiling. These guidelines will be particularly helpful due to rapidly evolving models of sexual healthcare, and the emergence of new providers who may benefit from guidelines that require less interpretation.

[Practices and perception of risk in human immunodeficiency virus infected males who have sex with other males]

INTRODUCTION

The incidence of human immunodeficiency virus (HIV) and other sexually transmitted diseases increases in males who have sex with males (MSM), despite the knowledge on how to prevent them. To determine the mechanisms that are driving this lack of prevention is important to reverse the trend.

PATIENTS AND METHODS

An anonymous, voluntary and self-reporting questionnaire was completed by HIV+ MSM patients who were seen in a hospital clinic, with the aim of finding out the sexual risk practices and behaviour, as well as their perceptions and assessment as regards this risk. The questionnaire included 58questions, divided into 10sections, to explore the knowledge, attitudes, and behaviour as regards HIV. The questionnaires were also given to the physicians, with the aim of exploring their perceptions, attitudes and opinions as regards the situation of the epidemic, prevention, perception of the diseases and the patient, and values in clinical practice.

RESULTS

A total of 495 questionnaires from the patients were analysed. Most of them (87%) said they knew how HIV was acquired, and 97% knew how to prevent it, but 69% knew they were in a risk situation, and 43% had little concern of contracting HIV. Almost two-thirds (65%) had sex with ≥2persons on the same day, 47% met on the Internet and 26% had group sex. The same percentage of those surveyed considered that they acted impulsively. They highlighted a lack of information (33%), bad luck (32%), assumed excessive risk (36%), and lake of concern (25%), as the main reasons for acquiring the infection. When confronted with diagnosis 41% of patients answered «I never thought that it would happen to me», and 32% said «I had bad luck». Of the 121 physicians who completed the questionnaire, 24% considered that infection due to HIV/AIDS was out of control in Spain, and 65% responded that there was an image that HIV/AIDS was a controlled disease and of little concern. A large majority (71%) of those surveyed, considered that the increase in new infections showed that there was no suitable preventive plan.

CONCLUSIONS

The management of the risk of acquiring HIV maintains a low level of concern, due to the optimism produced by the advances in the fight against the disease and the current toning down of the discussion. The trivialisation of the risk, on distorting the idea of risky behaviour, is a determining factor of attitudes that makes it impossible to adopt effective preventive behaviour and to take sensible and anticipated decisions.

Circumcision among men who have sex with men in London, United Kingdom: an unlikely strategy for HIV prevention

OBJECTIVES

To explore attitudes toward circumcision among men who have sex with men (MSM) in London and the feasibility of conducting research into circumcision and HIV prevention in this population.

METHODS

A convenience sample of MSM visiting central London gyms completed a confidential, self-administered questionnaire between May and June 2008. Information was collected on participants' demographic characteristics, self-reported HIV status, sexual behavior, circumcision status, attitudes toward circumcision, and willingness to participate in research on circumcision and HIV prevention.

RESULTS

Of 653 MSM, 29.0% reported that they were circumcised. Overall, HIV prevalence was 23.3%; this did not differ significantly between circumcised and uncircumcised men (18.6% vs. 25.2%, respectively; adjusted odds ratio 0.79, 95% confidence interval: 0.50-1.26). A similar proportion of circumcised and uncircumcised men reported unprotected anal intercourse in the previous 3 months (38.8% vs. 36.7%, adjusted odds ratio 1.06, 95% confidence interval: 0.72-1.55). Uncircumcised men were less likely to think that there were benefits of circumcision than circumcised men (31.2% vs. 65.4, P < 0.001). Only 10.3% of uncircumcised men said that they would be willing to participate in research on circumcision as an HIV prevention strategy.

CONCLUSIONS

Most uncircumcised MSM in this London survey were unwilling to participate in research on circumcision and HIV prevention. Only a minority of uncircumcised men thought that there were benefits of circumcision. It is unlikely that circumcision would be a feasible strategy for HIV prevention among MSM in London.

Increased HIV incidence in men who have sex with men despite high levels of ART-induced viral suppression: analysis of an extensively documented epidemic

BACKGROUND

There is interest in expanding ART to prevent HIV transmission, but in the group with the highest levels of ART use, men-who-have-sex-with-men (MSM), numbers of new infections diagnosed each year have not decreased as ARTcoverage has increased for reasons which remain unclear.

METHODS

We analysed data on the HIV-epidemic in MSM in the UK from a range of sources using an individual-based simulation model. Model runs using parameter sets found to result in good model fit were used to infer changes in HIV-incidence and risk behaviour.

RESULTS

HIV-incidence has increased (estimated mean incidence 0.30/100 person-years 1990-1997, 0.45/100 py 1998-2010), associated with a modest (26%) rise in condomless sex. We also explored counter-factual scenarios: had ART not been introduced, but the rise in condomless sex had still occurred, then incidence 2006-2010 was 68% higher; a policy of ART initiation in all diagnosed with HIV from 2001 resulted in 32% lower incidence; had levels of HIV testing been higher (68% tested/year instead of 25%) incidence was 25% lower; a combination of higher testing and ART at diagnosis resulted in 62% lower incidence; cessation of all condom use in 2000 resulted in a 424% increase in incidence. In 2010, we estimate that undiagnosed men, the majority in primary infection, accounted for 82% of new infections.

CONCLUSION

A rise in HIV-incidence has occurred in MSM in the UK despite an only modest increase in levels of condomless sex and high coverage of ART. ART has almost certainly exerted a limiting effect on incidence. Much higher rates of HIV testing combined with initiation of ART at diagnosis would be likely to lead to substantial reductions in HIV incidence. Increased condom use should be promoted to avoid the erosion of the benefits of ART and to prevent other serious sexually transmitted infections.

HIV infection among ethnic minority and migrant men who have sex with men in Britain

OBJECTIVE

To examine human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) from different ethnic and migrant groups living in Britain.

METHODS

In 2007-2008, a diverse national sample of MSM living in Britain was recruited through Web sites, in sexual health clinics, bars, clubs, and other venues. Men completed an online survey that included questions on HIV testing, HIV status, and sexual behavior.

RESULTS

Nine hundred and ninety-one ethnic minority MSM, 207 men born in Central or Eastern Europe (CEE), 136 men born in South or Central America, and 11,944 white British men were included in the analysis. Self-reported HIV seropositivity was low for men of South Asian, Chinese, and "other Asian" ethnicity (range, 0.0%-5.8%) and for men born in CEE (4.5%) but elevated for men born in South or Central America (18.7%), compared with white British men (13.1%) (P < 0.001). There were no significant differences between these groups in high-risk sexual behavior (P = 0.8). After adjusting for confounding factors in a multivariable model, substantial differences in the odds of HIV infection remained for South Asian and Chinese MSM as well as for migrants from CEE, but not for other groups, compared with white British men; for example, South Asian men, adjusted odds ratio 0.43, 95% confidence interval 0.23, 0.79, P = 0.007.

CONCLUSION

There were marked differences in self-reported HIV seropositivity between ethnic minority, key migrant, and white British MSM in this study but not in high-risk sexual behavior. This highlights the importance of health promotion targeting MSM from all ethnic and migrant groups in Britain.

Sexual mixing and HIV risk among ethnic minority MSM in Britain

We conducted a cross-sectional online survey of men who have sex with men (MSM) living in Britain in 2007-2008 to examine sexual mixing among ethnic minority MSM. The sample comprised 115 black, 112 South Asian, 47 Chinese and 4,434 white MSM who reported unprotected anal intercourse (UAI) in the previous 3 months. In each ethnic minority group, MSM were three times more likely to report UAI with a partner of the same ethnicity than would be expected by chance alone (χ(2) > 8.43, p < 0.05). Nonetheless, most (>80 %) ethnic minority MSM reported UAI with men from an ethnic group other than their own. In multivariable analysis there was statistical evidence that, compared with white British MSM, self-reported HIV seropositivity remained low for South Asian and Chinese MSM after adjusting for UAI with partners of the same ethnicity (e.g. South Asian MSM, adjusted odds ratio 0.35, 95 % CI 0.19-0.66). This analysis suggests that differences in self-reported HIV seropositivity between ethnic minority and white MSM in Britain cannot be explained by sexual mixing with partners from the same ethnic group.

Multicentre RCT and economic evaluation of a psychological intervention together with a leaflet to reduce risk behaviour amongst men who have sex with men (MSM) prescribed post-exposure prophylaxis for HIV following sexual exposure (PEPSE): a protocol

Background

Post-exposure prophylaxis (PEP) following sexual exposure to HIV has been recommended as a method of preventing HIV infection in the UK. Men who have sex with men (MSM) are the group most affected by HIV in the UK and their sexual risk taking behaviour is reported to be increasing. One-to-one behavioural interventions, such as motivational interviewing (MI) have been recommended to reduce HIV in high risk groups. The Information, Motivation and Behavioral skills (IMB) model has been shown to provide a good basis for understanding and predicting HIV-relevant health behaviour and health behaviour change, however the IMB has yet to be applied to PEP after risky sexual exposure. The primary aim of this trial is to examine the impact of MI augmented with information provision and behavioural skills building (informed by the IMB Model), over and above usual care, on risky sexual behaviour in MSM prescribed PEP after potential sexual exposure. A secondary aim of this research is to examine the impact of the intervention on adherence to PEP. This study will also provide estimates of the cost-effectiveness of the intervention.

Methods

A manualised parallel group randomised controlled trial with economic evaluation will be conducted. The primary outcome is the proportion of risky sexual practices. Secondary outcomes include: i) Levels of adherence to PEP treatment; ii) Number of subsequent courses of PEP; iii) Levels of motivation to avoid risky sexual behaviours; iv) Levels of HIV risk-reduction information/knowledge; v) Levels of risk reduction behavioural skills; vi) Diagnosis of anal gonorrhoea, Chlamydia and/or HIV. 250 participants will be asked to self-complete a questionnaire at four time points during the study (at 0,3,6,12 months). The intervention will consist of a two-session, fixed duration, telephone administered augmented MI intervention based on the IMB model. A newly developed treatment manual will guide the selection of persuasive communication strategies as appropriate for each participant and will be based on underlying change mechanisms specified by the IMB theoretical framework. Information provision and skills building will also be included in the intervention package through the use of information leaflets and tailored action plans. Fidelity of intervention delivery will be assessed.

Discussion

The results from this NIHR funded study will identify whether it is appropriate and cost-effective to intervene using one-to-one telephone calls with MSM seeking PEP. If the intervention is effective, further work will be needed on training staff to deliver the intervention competently.

Trial registration numbers

UKCRN ID:11436; ISRCTN00746242.

Substance use and sexual risk behaviour among HIV-positive men who have sex with men in specialized out-patient clinics

OBJECTIVES

Unprotected sexual intercourse between men who have sex with men (MSM) is the most common route of HIV infection in Germany. Approximately 70% of newly infected people are MSM. Substance use is a determinant of sexual risk behaviour in the general population, but also in the MSM subpopulation. There are only a few studies, from the USA, on the correlation between substance use and sexual risk behaviour in HIV-infected MSM in specialized care.

METHODS

In a German sample of 445 HIV-infected MSM treated in specialized out-patient clinics, the influence of substance use on sexual risk behaviour was investigated. Information was obtained from subjects using self-report questionnaires and a structured interview.

RESULTS

Recreational drug use was common. The prevalences of cannabis addiction (4.5%), harmful use of cannabis (4.3%) and harmful use of dissociative anaesthetics (0.4%) were higher than in the general German male population. A substantial proportion of patients reported unprotected insertive (32.9%) and receptive (34.6%) anal intercourse during the last 12 months. Use of cannabis, amyl nitrite, dissociative anaesthetics, cocaine, amphetamines and erectile dysfunction medication was significantly correlated with unprotected sexual contacts. Substance use in the context of sexual activity significantly increased sexual risk behaviour.

CONCLUSIONS

Substance use, especially in the context of sexual activity, should be taken into account when developing new prevention and intervention programmes aimed at reducing sexual risk behaviour in HIV-infected MSM currently in specialized care.

Self-screening for Neisseria gonorrhoeae and Chlamydia trachomatis in the human immunodeficiency virus clinic--high yields and high acceptability

BACKGROUND

Despite antiretroviral therapy (ART), incident human immunodeficiency virus (HIV) continues to rise, and sexually transmitted infections (STI) are well known for their part in HIV transmission. National guidelines recommend routine STI screening in HIV-positive individuals, but despite this, reported uptake remains low.

METHODS

We implemented a nurse-led self-screening program for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) in asymptomatic HIV patients. Self-collected samples were tested for CT and GC using the GenProbe Aptima Combo 2 assay. Clinical records were reviewed for ART history, CD4 T-cell count, and plasma viral load. A screening service evaluation questionnaire was handed out.

RESULTS

During an 8-month period, 976 screens were performed. In all, 143 infections were detected which would have been missed without the screening program. Overall prevalence of infection among men who have sex with men was 17.4%: rectal CT and GC, 9.8% (56/571) and 4.2% (24/571), respectively; urethal CT and GC, 2.6% (16/605) and 1.3% (8/605), respectively; and pharyngeal CT and GC, 1.7% (10/589) and 3.9% (23/589), respectively. Among heterosexual men and women, the rates of CT were 2.1% (3/141) and 1.5% (3/201), and there was no GC. Transient viremia was observed at the time of STI diagnosis in 6 patients on ART. All men who have sex with men and most women found self-swabbing acceptable, and most patients indicated that they would like to be offered testing in future.

CONCLUSION

These findings highlight the need for the introduction of similar screening approaches in HIV clinics. Self-collected specimens using sensitive and specific GC and CT nucleic acid amplification tests are a convenient and acceptable way of testing, and it may address some of the barriers to screening in this population.

Less decrease in risk behaviour from pre-HIV to post-HIV seroconversion among MSM in the combination antiretroviral therapy era compared with the pre-combination antiretroviral therapy era

OBJECTIVE

To gain insight in the ongoing HIV transmission, we compared sexual risk behaviour pre-HIV and post-HIV seroconversion in 206 MSM participating in the Amsterdam Cohort Studies (1984-2008) before and after the introduction of combination antiretroviral therapy (cART).

DESIGN AND METHODS

MSM completed behavioural questionnaires and were tested for HIV antibodies every 6 months. Trends in anal intercourse and number of sex partners from 4 years before HIV seroconversion until 4 years after diagnosis were analysed with latent class random effects logistic regression models.

RESULTS

The risk of having unprotected anal intercourse (UAI) 1 year after HIV diagnosis decreased significantly when compared with 1 year before diagnosis in both the pre-cART era [difference, 30%; 95% confidence interval (CI), 22-36%] and cART era (difference, 19%; 95% CI, 9-30%). In contrast to a continuing decrease of UAI in the pre-cART era, the probability of UAI in the cART era increased again to preseroconversion levels (61%; 95% CI, 48-74%)) 4 years after diagnosis.

CONCLUSION

This study provides evidence that recently seroconverted MSM reduce their sexual risk behaviour following HIV diagnosis both in the pre-cART as well as the cART period. However, in the cART period this reduction in sexual risk behaviour is less and returns to pre-cART levels within 4 years. These findings not only confirm the need for early HIV testing but also make it clear that much more effort should go into identifying, counselling, and possibly treating recently seroconverted MSM who have been found to be one of the most important drivers of HIV transmission among MSM.

HIV serosorting among HIV-positive men who have sex with men is associated with increased self-reported incidence of bacterial sexually transmissible infections

BACKGROUND

We aimed to quantify the frequency of HIV serosorting among men who have sex with men (MSM) in Germany, and evaluate the association of serosorting with other sexual risk management approaches (RMA) and with the frequency of bacterial sexually transmissible infections (STI).

METHODS

An anonymous, self-administered questionnaire was distributed through German online sexual networking sites and medical practices in 2006. The analysis was based on 2985 respondents who reported an HIV test result. Based on two questions on RMA, serosorting was classified as tactical (an event-based decision) or strategic (a premeditated search for a seroconcordant partner). The analysis was stratified by HIV serostatus and seroconcordant partnership status.

RESULTS

HIV serosorting patterns were different for HIV-positive and HIV-negative participants. Tactical serosorting ranked second after RMA based on condom use (HIV-positive: 55.1%, HIV-negative: 45.1%; P < 0.001). While the overlap of strategic and tactical HIV serosorting among HIV-positive MSM was substantial (58.0%), HIV-negative strategic and tactical serosorting were more distinct (18.1% overlap). Among HIV-positive and HIV-negative respondents, tactical serosorting was associated with reduced condom use. Compared with respondents using RMA other than serosorting, HIV-positive men reporting serosorting had a three-fold increased risk for bacterial STI (strategic: odds ratio (OR) = 2.62; 95% confidence interval (CI): 1.76-3.89; tactical: OR = 3.19; 95% CI: 2.14-4.75; both for respondents without HIV seroconcordant partners).

CONCLUSIONS

HIV serosorting has emerged as a common RMA among MSM. For HIV-positive MSM, it may contribute to high rates of bacterial STI that may lead to elevated per-contact risks for HIV transmission.

Sexual protection behavior in HIV-positive gay men: testing a modified information-motivation-behavioral skills model

This study on determinants of sexual protection behavior among HIV-positive gay men used the empirically tested information-motivation-behavioral skills (IMB) model. HIV-specific variables were added to the model to determine factors decisive for condom use with steady and casual partners. Data were collected using an anonymous, standardized self-administered questionnaire. Study participants were recruited at HIV outpatient clinics associated with the Eurosupport Study Group and the Swiss HIV Cohort Study. To identify factors associated with condom use, backward elimination regression analyses were performed. Overall, 838 HIV-infected gay men from 14 European countries were included in this analysis. About 53% of them reported at least one sexual contact with a steady partner; 62.5% had sex with a casual partner during the last 6 months. Forty-three percent always used condoms with steady partners and 44% with casual partners. High self-efficacy and subjective norms in favor of condom-use were associated with increased condom use with casual and steady partners, whereas feeling depressed was associated with decreased condom use with casual partners. Condoms were used less often with HIV-positive partners. Self-efficacy as an important behavioral skill to perform protection behavior was influenced by lower perceived vulnerability, higher subjective norms, and more positive safer sex attitudes. The IMB-model constructs appeared to be valid; however, not all the model predictors could be determined as hypothesized. Besides the original IMB constructs, HIV-specific variables, including sexual partners' serostatus and mental health, explained condom use. Such factors should be considered in clinical interventions to promote "positive prevention."

Men who have sex with men: estimating the size of at-risk populations in London primary care trusts

The objective of this study was to estimate local at-risk populations of men who have sex with men (MSM) in London primary care trusts (PCTs) to inform the commissioning of targeted health interventions. Estimated population size and prevalence of diagnosed HIV in MSM in all of London were calculated using data from the British National Survey of Sexual Attitudes and Lifestyles (NATSAL), Greater London Authority population estimates and the annual survey of diagnosed MSM (Survey of Prevalent HIV Infections Diagnosed [SOPHID]). Estimated MSM population sizes at the PCT level were calculated using un-weighted and SOPHID-weighted methods and methods discussed. Four-fifths of MSM with diagnosed HIV infection in Greater London lived in inner London. Estimated population size of MSM 16-44 years in inner London was 66,000; estimated overall prevalence of diagnosed HIV infection among MSM was 9.5%. Our models show substantial variation at the PCT level between the two methods. Using the SOPHID-weighted method MSM account for up to 16% of the male population in some London PCTs, compared with as low as 3% in others. We provide a novel method of estimating at-risk MSM populations living in inner London PCTs indicating that proportions of MSM vary widely between PCTs. Significant proportions of MSM among the resident populations in several PCTs warrant inclusion of MSM health needs in core PCT prevention and service programming. In light of data source limitations further validation studies are needed.

Anorectal syphilis mimicking Crohn's disease

Anorectal syphilis, one of the great masqueraders in medicine, can be difficult to diagnose not only because of its variable symptoms but also because it is hard to think of unless a detailed history about sexual preferences and practices, including homosexuality, has been gathered. With increasing acceptance of sexual activity in our culture, despite moral and religious issues, various forms of sex have led to many different clinical conditions of sexually transmitted diseases. In this report, we describe a rare case of primary anorectal syphilis with clinical, endoscopic and histologic features that was misdiagnosed as Crohn's disease.

Stable sexual risk behavior in a rapidly changing risk environment: findings from population-based surveys of men who have sex with men in Seattle, Washington, 2003-2006

We assessed trends in behavioral risk for HIV infection among men who have sex with men (MSM). Seattle MSM participated in random digit dial telephone surveys in 2003 (n = 400) and 2006 (n = 400). Fourteen percent in 2003 and 9% in 2006 reported unprotected anal intercourse with a partner of different or unknown HIV status (non-concordant UAI; odds ratio [OR] = 0.7; 95% confidence interval [CI]: 0.5, 1.2). Compared to participants in 2003, participants in 2006 met a greater proportion of their anal sex partners through the Internet (OR = 2.0; 95% CI: 1.2, 3.1). Although the proportion of anal sex partnerships formed online increased between 2003 and 2006, Internet partnerships were not more risky than those initiated elsewhere. While the emergence of the Internet as a venue through which men meet partners demonstrates that sexual risk among MSM remains highly dynamic, our findings suggest that sexual risk behavior among MSM is currently stable.

Responses from the Lesbian & Gay Psychology Section to Crossley's Making sense of barebacking

The aim of the present study is to summarize key responses to Crossley's (2004) article 'Making sense of barebacking' from members of the British Psychological Society's Lesbian & Gay Psychology Section. These responses are assembled into four main themes: (1) terminology, including descriptions of sexual behaviour that are inaccurate and pejorative; (2) representations that endorse culturally dominant and stigmatizing stereotypes of gay men as hedonistic, promiscuous, morally irresponsible and interested in sex rather than relationships; (3) methodology, particularly the use of autobiographical and fictional accounts as reliable sources of data about HIV risk; (4) ethics, especially the infringement of the dignity and the worth of those researched or represented. We welcome attempts to address the continuing problems of HIV/AIDS but recommend that authors and editors enter into dialogue with colleagues who are members of sexual minority communities as part of the research process.

Sampling methods used in developed countries for behavioural surveillance among men who have sex with men

The aim of this review was to develop an overview of the sampling methods used in developed countries for behavioural surveillance among men who have sex with men. We abstracted information from peer-reviewed and non-peer-reviewed publications and, when needed, contacted first authors and surveillance authorities. Out of the 40 developed countries, 26 surveillance systems were identified in 23 countries. These surveillance systems made use of one or a combination of: venue-based sampling (n = 16); web-based sampling (n = 11); gay press/mail-out (n = 8); or respondent-driven sampling (n = 4). Differences in the sampling methods used were found by year of implementation and by region. More information is needed to better assess the strengths and limitations of the range of sampling methods. There was substantial variation in the way sampling methods were applied, most especially in venue-based sampling. To improve the ability to compare indicators across countries, key elements of the sampling methods should be standardized.

Sexual health of ethnic minority MSM in Britain (MESH project): design and methods

Background

Men who have sex with men (MSM) remain the group most at risk of acquiring HIV infection in Britain. HIV prevalence appears to vary widely between MSM from different ethnic minority groups in this country for reasons that are not fully understood. The aim of the MESH project was to examine in detail the sexual health of ethnic minority MSM living in Britain.

Methods/Design

The main objectives of the MESH project were to explore among ethnic minority MSM living in Britain: (i) sexual risk behaviour and HIV prevalence; (ii) their experience of stigma and discrimination; (iii) disclosure of sexuality; (iv) use of, and satisfaction with sexual health services; (v) the extent to which sexual health services (for treatment and prevention) are aware of the needs of ethnic minority MSM.

The research was conducted between 2006 and 2008 in four national samples: (i) ethnic minority MSM living in Britain; (ii) a comparison group of white British MSM living in Britain; (iii) NHS sexual health clinic staff in 15 British towns and cities with significant ethnic minority communities and; (iv) sexual health promotion/HIV prevention service providers. We also recruited men from two "key migrant" groups living in Britain: MSM born in Central or Eastern Europe and MSM born in Central or South America.

Internet-based quantitative and qualitative research methods were used. Ethnic minority MSM were recruited through advertisements on websites, in community venues, via informal networks and in sexual health clinics. White and "key migrant" MSM were recruited mostly through Gaydar, one of the most popular dating sites used by gay men in Britain. MSM who agreed to take part completed a questionnaire online. Ethnic minority MSM who completed the online questionnaire were asked if they would be willing to take part in an online qualitative interview using email.

Service providers were identified through the British Association of Sexual Health and HIV (BASHH) and the Terrence Higgins Trust (THT) CHAPS partnerships. Staff who agreed to take part were asked to complete a questionnaire online.

The online survey was completed by 1241 ethnic minority MSM, 416 men born in South and Central America or Central and Eastern Europe, and 13,717 white British MSM; 67 ethnic minority MSM took part in the online qualitative interview. In addition 364 people working in sexual health clinics and 124 health promotion workers from around Britain completed an online questionnaire.

Discussion

The findings from this study will improve our understanding of the sexual health and needs of ethnic minority MSM in Britain.

Rectal syphilis mimicking rectal cancer

Rectal syphilis, known as a great masquerader, can be difficult to diagnose because of its variable symptoms. Gastroenterologists should be aware of the possibility of rectal syphilis when confronted with anorectal ulcers, and should gather a detailed history about sexual preferences and practices, including homosexuality. We report a case of primary rectal syphilis mimicking rectal cancer on radiologic imaging. In this report, we described the clinical, endoscopic, and radiologic features of this rare case.

Advances in sexually transmitted infections of the gastrointestinal tract

The gastrointestinal mucosa is a target of many sexually transmitted infections, and major advances have increased our understanding of the consequences of such infections within the gastrointestinal system. HIV-1 is associated with a marked loss of mucosal CD4(+) T cells that express CC-chemokine receptor 5. This process seems to be more rapid and more severe in mucosa-associated lymphoid tissue than in the peripheral blood. Mechanistic insights into the underlying cause of acute and chronic gastrointestinal damage with HIV infection-microbial translocation, defects in intestinal epithelial barrier function and activation of a systemic immune response-have also been achieved. Increased understanding of the pathogenesis of mucosal HIV-1 infection may identify therapeutic targets to restore immunological function and the integrity of the intestinal mucosal epithelial barrier. The increasing prevalence of lymphogranuloma venereum in Europe, mostly in HIV-positive men who have sex with men, suggests a change in the epidemiology of what was previously considered to be a 'tropical' disease. The increasing incidence of acute HCV infection transmitted via sexual contact has also been fueled by high-risk sexual behaviors among men who have sex with men, many of whom are also HIV-positive. The first part of this Review discusses the pathogenesis and gastrointestinal complications of HIV infection, and the second part summarizes advances in our understanding of other sexually transmitted infections of the gastrointestinal system.

Predictors and confounders of unprotected sex: A UK web-based study

OBJECTIVES

To evaluate the effects of gender, sex orientation, age, relationship status, age at first sex education, age at first sex, frequency of sex and number of sexual partners on the likelihood of unprotected sex in the United Kingdom (UK).

METHODS

A web-based survey was conducted in the UK in 2004 with 10,138 respondents. Eight variables were chosen as potential predictors of unprotected sex. Responses from sexually active participants were combined and crude/adjusted odds ratios (AORs) were calculated for binary/categorical variables.

RESULTS

No differences were found in AOR for gender, sex orientation, relationship status and frequency of sex. Differences were found in AOR for age, sex education, age at first sex and number of sexual partners, e.g. AOR 21-24 years of age versus under 16 (1.92, CI 1.38-2.68; p-value < 0.001); AOR sex education never received versus first sex education under 10 years of age (1.45, CI 1.12-1.87; p-value < 0.01); AOR first sex at 20 years versus at 14 years (0.56, CI 0.40-0.79; p-value < 0.01); and AOR 11-20 partners versus one partner (24.91, CI 20.02-30.98; p-value < 0.001). The association of sex orientation and relationship status with unprotected sex is confounded by the number of sexual partners.

CONCLUSIONS

UK health and education authorities should develop strategies to provide sex education starting in primary school and continuing throughout secondary school. Prevention programs and policies should focus on particular sexual behaviours. Furthermore, an understanding of sexual diversity and reducing stigmatisation of sexual orientation is necessary.

Circuits, networks, and HIV risk management

Drawing on a survey of men who have sex with men conducted at Toronto's largest gay and lesbian event (N = 947), this study examines the characteristics of men who report that they like to participate in the "bareback scene" and cruise "bareback Web sites" by comparing them with men who (a) report having had at least one incident of unprotected anal intercourse but no bareback connections, or (b) report consistently protected anal intercourse (UAI). Overall, 62.0% of the surveyed men reported having had a casual male partner in the last 6 months, 14.2% of whom reported having had UAI. Including these men, with men who report UAI with or without ejaculation, with casual or regular partners, accounts for 40.6% of the sample. MSM in bareback scenes or Web sites form a circuit insofar as they are significantly overrepresented in a set of bars, baths, parks, and Web sites, that aligns closely with one of the circuits identified in a factor analysis of venues attended by men in the sample. They also show a distinctive pattern of beliefs and perceptions of appropriate norms for sexual conduct, and are more likely to have had five or more partners in the last 6 months.

HIV in gay and bisexual men in the United Kingdom: 25 years of public health surveillance

It is more than 25 years since the first case of AIDS was reported in the United Kingdom. In December 1981 a gay man was referred to a London hospital with opportunistic infections indicative of immunosuppression. National surveillance began the following year, in September 1982, with the notification of deaths and clinical reports of AIDS and Kaposi's sarcoma plus laboratory reports of opportunistic infections. Since then epidemiological surveillance systems have evolved, adapting to, and taking advantage of advances in treatments and laboratory techniques. The introduction of the HIV antibody test in 1984 led to the reporting of HIV-positive tests by laboratories and the establishment of an unlinked anonymous survey in 1990 measuring undiagnosed HIV infection among gay men attending sexual health clinics. The widespread use of highly active antiretroviral therapies (HAART) since 1996 has averted many deaths among HIV-positive gay men and has also resulted in a large reduction in AIDS cases. This led to a need for an enumeration of gay men with HIV accessing NHS treatment and care services (1995 onwards), more clinical information on HIV diagnoses for epidemiological surveillance (2000 onwards) and the routine monitoring of drug resistance (2001 onwards). Twenty-five years after the first case of AIDS was reported, gay and bisexual men remain the group at greatest risk of acquiring HIV in the United Kingdom. Latest estimates suggest that in 2004, 26 500 gay and bisexual men were living with HIV in the United Kingdom, a quarter of whom were undiagnosed. In this review, we examine how national surveillance systems have evolved over the past 25 years in response to the changing epidemiology of HIV/AIDS among gay and bisexual men in the United Kingdom as well as advances in laboratory techniques and medical treatments. We also reflect on how they will need to continue evolving to effectively inform health policy in the future.

Sexually transmitted infections in Western Europe among HIV-positive men who have sex with men

BACKGROUND

Since 1996, there has been a resurgence in sexually transmitted infections (STIs) among men who have sex with men (MSM) in Western Europe. This has coincided with a significant decrease in HIV-associated mortality following the introduction of highly active antiretroviral therapies (HAART) and a corresponding increase in the number of MSM living with HIV. Levels of unprotected anal intercourse have also increased. In this article, we use STI surveillance data from a number of Western European countries to better understand the contribution of HIV-positive MSM to the recent increase in STIs.

METHODS

Published literature, surveillance reports, and ad hoc publications relating to HIV prevalence trends and STIs among HIV-positive MSM in Western Europe were reviewed.

RESULTS

Post-HAART, HIV prevalence among community samples of MSM ranged from 5% to 18%. HIV prevalence among MSM diagnosed with an STI was substantially higher. On average, HIV prevalence among MSM diagnosed with syphilis in 11 countries was 42% (range 14%-59%). Most HIV-positive MSM with syphilis were aware of their HIV status. In England and Wales, 32% of MSM with gonorrhea were HIV-positive in 2004. Outbreaks of lymphogranuloma venereum have been documented in 9 countries; HIV-positive MSM accounted for 75% of cases on average (range 0%-92%). Cases of sexually transmitted hepatitis C have been predominantly identified among HIV-positive MSM in Rotterdam, Paris, Amsterdam, and the United Kingdom.

CONCLUSIONS

In Western Europe, STIs have been disproportionately diagnosed among HIV-positive MSM post-HAART. Improved survival coupled with serosorting among HIV-positive MSM appears to explain the high prevalence of HIV among MSM with STIs. STI transmission among HIV-positive men will have contributed substantially to increasing STI trends seen among MSM in Western Europe, since 1996. These findings highlight the need for routine STI testing among HIV-positive MSM as well as safer sex messages highlighting the implications of STI coinfection.

Beliefs about treatments for HIV/AIDS and sexual risk behaviors among men who have sex with men, 1997-2006

Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.

[Prevention practices of primary health care physicians in Switzerland in the context of the HIV/Aids epidemic: changes between 1990 and 2002]

BACKGROUND

Individual preventive counseling offered to the general public by private doctors working in primary health care is an essential component of the Swiss National Aids Prevention strategy. Surveys were conducted to assess to what extent they fulfill this role and how this may have changed over time.

METHODS

Three cross-sectional surveys were conducted in 1990, 1995, and 2002 by anonymous mailed questionnaire in a random sample of primary health care physicians. Dimensions of the physicians HIV prevention practices investigated were: practice of HIV risk assessment, content and frequency of HIV pretest counseling, and, in 2002 only, care of patients living with HIV/AIDS. Trends over the 12-year period were calculated; logistic regressions were performed to investigate factors associated with the frequency of counseling given to HIV positive patients.

RESULTS

Risk assessment has increased dramatically over the period for certain groups of patients (patients requesting contraception, young people and new patients). In 2002, routine screening is often or always performed by 93% of physicians for intravenous drug patients or patients with a sexually transmitted infection; 77% for homosexuals; 76% for patients requesting contraception; 63% for young people. It is less frequent in other groups (migrants: 40%; separated/divorced patients: 29%). More than half of physicians care for patients with HIV. Around two-thirds of physicians regularly discuss with their HIV positive patients issues related to patients' professional, social and private life. There are few differences among specialties regarding the propensity to discuss these topics.

CONCLUSION

Prevention activities by primary care physicians have increased in the last decade. Nonetheless, potential for increased prevention still exists in some areas of risk assessment and counseling.

HIV Prevalence and Undiagnosed Infection Among a Community Sample of Gay Men in Scotland

OBJECTIVE

To examine HIV prevalence among men in gay bars in Glasgow and Edinburgh, Scotland.

METHODS

Self-complete questionnaires and Orasure oral fluid collection kits (OraSure Technologies, Inc., Bethlehem, PA), to collect samples to be tested anonymously for HIV antibodies, were distributed. A total of 1744 men completed questionnaires (66.1% response rate), and 1350 provided samples (51.6% response rate).

RESULTS

HIV prevalence was 4.4% (95% confidence interval: 3.5% to 5.7%). Positivity was associated with older age (mean of 36 years for positive men vs. 32 years for negative men), having 10 or more anal intercourse (AI) partners (12.8% positive vs. 3.4% of men with <10 AI partners, P < 0.05), and self-reported sexually transmitted infections (STIs) in the previous year (12.3% positive vs. 3.5% of men without STIs in the previous year; P < 0.05). Of the HIV-positive men, 41.7% were undiagnosed. More than half had had a negative HIV test result and perceived themselves to be HIV-negative. Men who had not used a genitourinary medicine clinic or had an STI in the previous year were more likely to be undiagnosed (65.0% and 52.5%, respectively).

CONCLUSIONS

This is the first study to assess HIV prevalence among a community sample of gay men in Scotland. There is an urgent need for HIV prevention efforts to address the high level of undiagnosed infection and incorrect assumptions of status.

Postexposure prophylaxis after sexual exposure to HIV

Increasing numbers of international, national and state/provincial health organizations in the developed and developing world recommend postexposure prophylaxis (PEP) following potential sexual exposure to HIV. The evidence for these policies is extrapolated from occupational healthcare worker, perinatal prophylaxis and animal studies. There is no direct evidence of PEP efficacy after sexual exposures. Studies addressing potential increases in risk behavior, toxicities and cost–effectiveness are encouraging. Considerations for offering PEP include the timing and characteristics of the exposure and the HIV status of the source and exposed individuals. PEP includes 28 days of a combination antiretroviral drug regimen containing two or more drugs and associated laboratory testing, counseling and referrals. PEP service delivery challenges include ensuring adequate access to services, optimizing PEP adherence and facilitating follow-up HIV testing and counseling. Men who have sex with men, sexual assault survivors, children and adolescents, and individuals in resource-limited settings present unique needs and challenges.