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New diagnoses in gay men

Public Health England’s annual report on HIV diagnoses shows that 3250 men who have sex with men (MSM) were diagnosed in 2012 – the largest number of cases ever recorded in this group. (In most other recent years, between 2800 and 3000 MSM were diagnosed.)

There are several indications that efforts to improve the uptake of HIV testing are beginning to pay off. The proportion of gay men living with HIV who were unaware of their infection went down to 18%, the proportion of new diagnoses that were made late (with a CD4 cell count below 350 cells/mm3) went down to 34%, and the number of HIV tests in sexual health clinics went up – by 13% in England and Wales as a whole and by 19% in London. This all means that the rise in diagnoses is partly explained by improved testing, not more newly acquired infections.

But Public Health England also believes that HIV transmission continues at high levels – its estimations of HIV incidence suggest that around 2400 MSM newly acquired HIV during the year, a figure that has not changed in the past decade. The large majority of transmissions originate in men unaware of their own infection.

PHE also estimates that approximately one-in-five newly diagnosed MSM acquired HIV within the past six months, and that this figure is even higher among younger gay men and men in London.

New diagnoses in heterosexual men and women

Public Health England’s report also shows that there were 2880 new HIV diagnoses in heterosexual men and women in 2012, continuing the downward trend seen in recent years (there were as many as 4900 annual diagnoses a decade ago). Around six-in-ten diagnoses were in women.

Around half were in people of black African ethnicity.

Both amongst people born in the UK and people born elsewhere, around half the infections were probably acquired in the UK. (This estimate is based on the person’s CD4 cell count and date of arrival in the UK, if applicable.) The fact that the proportion of infections acquired in the UK has increased in recent years highlights the importance of prevention interventions with heterosexual people, especially black African people.

Whereas rates of late diagnosis and undiagnosed infection have improved noticeably in gay men over the past five years, there has been less improvement among heterosexual men and women.

Rise in HIV testing

As mentioned above, the Public Health England data for 2012 suggest an improvement in rates of HIV testing, at least among men who have sex with men (MSM) – a 13% rise in the number of sexual health clinic attendees who took an HIV test.

To put this in perspective, it is worth looking at the results of three very large studies, carried out in 1990, 2000 and 2010, which looked at a representative cross-section of the population, not just sexual health clinic attendees. The National Survey of Sexual Attitudes and Lifestyles (Natsal) has interviewed a total of 45,199 people over the past two decades and is more likely than most other studies to give an accurate picture of HIV testing behaviours across the population.

In the 1990 survey, 7% of men had taken an HIV test in the previous five years, rising to 17% in 2010. More women tested – rising from 11 to 28%.

The increase in testing was especially marked in people with more than ten sexual partners in the previous five years. In 2010, 56% of men and 66% of women with multiple partners had tested.

Although there was a strong rise in testing levels among men who have sex with men, this still fell far short of recommendations for all MSM to test at least once a year. Having taken a test in the previous five years was reported by 34% of MSM in 1990, 40% in 2000 and 52% in 2010. Only a quarter (27%) of men had tested within the previous year.

Testing increased in black African people, reaching 44% of men and 47% of women in the 2010 survey.

The results show how much further the UK needs to go in order to reduce rates of undiagnosed HIV – half of gay men and African people had not tested at all in the past five years.

Changing sexual behaviour

The National Survey of Sexual Attitudes and Lifestyles (Natsal) also contains a wealth of fascinating data on British people’s sexual behaviour and attitudes, including comparisons between the surveys in 1990, 2000 and 2010. It contains some of the most reliable data we have on the topic.

Among its findings:

  • The differences between women and men’s sexual behaviour are narrowing, for example in terms of partner numbers.
  • Sex has become increasingly detached from reproduction – more people are reporting oral sex, anal sex, sex at an older age, and other behaviours that have nothing to do with having children.
  • One-in-forty men and one-in-thirty women report having a partner of the same sex in the previous five years.
  • Public attitudes to homosexuality have become much more accepting, while there is less tolerance of adultery.
  • Across the population, HIV risk behaviours did not increase between the 2000 and 2010 surveys.
  • There are links between experiencing problems with sex (such as lack of libido or relationship problems) and having a sexually transmitted infection.
  • Non-consensual sex was reported by one-in-ten women and one-in-seventy men, but rates for MSM were as high as for women.

Partner notification is highly effective

Systematically contacting the sexual partners of people newly diagnosed with HIV is a very efficient way of identifying people with undiagnosed HIV, according to an audit conducted by the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA).

Clinicians across the UK were asked to check the case notes of just under 3000 people who had been newly diagnosed with HIV. In the majority of cases, the process of partner notification was started – the newly diagnosed person was asked about their past and present sexual partners and, where possible, partners were asked to come to the clinic for advice and HIV testing.

The audit looked in detail at 1399 partners (contacts) who were tested as a result of partner notification. There was an extremely high prevalence of undiagnosed HIV – 293 people (21%) were newly diagnosed as a result. Amongst regular partners, the rate was even higher (27%).

For each ten newly diagnosed individuals, an additional person was diagnosed following partner notification.

But the audit shows that it needs to be carried out more systematically at some clinics. For one-in-eight newly diagnosed people, no partner notification at all took place. And a significant number of ex-partners and casual partners were missed out, even when contact details were provided – only two thirds were contacted, and only half actually took an HIV test.

Harm reduction works

Incidence of new HIV infections among people who inject drugs in Australia is extremely low, a new study shows. Australia introduced needle and syringe exchanges early in the epidemic, has a higher rate of syringe distribution than most other countries, and has introduced other forms of harm reduction, such as opioid substitution therapy.

Researchers examined new HIV infections (incidence) among people who inject drugs who had repeat HIV tests between 1995 and 2012. The annual rate was very low throughout the study period at just 0.11 per 100 person-years – in other words, for every 1000 people, one person acquired HIV each year.

And it’s possible that some of the infections were actually acquired through sex – most of those becoming HIV positive were gay men who injected drugs.

Like Australia, the UK has good provision of harm-reduction services and low rates of HIV infection in people who inject drugs – 111 diagnoses in 2012 and a prevalence of 1.3% in people attending drug services. Continued support for harm reduction is vital.

At the same time, there is evidence that there are new groups of drug users, such as people injecting mephedrone and crystal meth, and evidence of anabolic steroid injectors acquiring HIV. At present, not all drugs services have the skills and experience to meet the needs of these groups.

Other recent news headlines

Urgent need to address "resurgent" gay global epidemic, says English public health chief

There is an increasing and potentially catastrophic HIV and sexual health epidemic in gay men and men who have sex with men (MSM) in every part of the world, Professor Kevin Fenton, the National Director of Health and Wellbeing at Public Health England, told the BHIVA autumn conference last month.

Good adherence to HIV treatment, undetectable viral load, reduce the risk of anal infection with high-risk HPV types for MSM with HIV

Prevalence of anal HPV (human papillomavirus) infection is significantly higher among men with HIV than HIV-negative men who have sex with men (MSM), investigators from the United States report in PLOS ONE. Overall, men with HIV had higher rates of infections with the HPV types strongly and weakly associated with anal cancer, and also lower risk HPV types. For men with HIV, high levels of adherence to antiretroviral therapy and an undetectable viral load were protective against high-risk HPV types.

Church attendance associated with late HIV diagnosis among US MSM

Church attendance is associated with late HIV diagnosis among men who have sex with men (MSM), according to US research published in the online edition of Clinical Infectious Diseases. The study was conducted in Alabama and showed that church-attending MSM were more than twice as likely to have a CD4 cell count below 200 cells/mm3 at the time of HIV diagnosis than MSM who did not attend church. There was also some evidence that church attendance was associated with less frequent HIV testing among MSM.

After diagnosis of hepatitis C, some gay men willing to consider risk-reduction practices

HIV-positive gay men living with HIV in France need better information about the sexual transmission of hepatitis C, according to a researcher who interviewed 31 men about their experience of living with hepatitis C.