Gay and MSM: more diagnosed + more undiagnosed = increasing HIV incidence
There were almost 2,400 new diagnoses of HIV in gay men and other men who have sex with men (MSM) in 2005, the highest ever recorded. Although this constitutes just one third of the total number of new diagnoses, gay men and other MSM continue to be the population who are most at risk of acquiring HIV within the UK.
In fact, the HPA report found that the annual incidence of new HIV diagnoses in gay and other MSM who attended sexual health clinics in 2005 was 3.2%.
Although new HIV infections are difficult to measure, the HPA reports that of every 200 young gay or MSM under the age of 25 who attended a sexual health clinic in London in 2005, at least three were newly diagnosed with HIV. This, says the report is “an indicator of relatively recent transmission.” The prevalence of previously undiagnosed HIV infection in gay and MSM aged under 25, which was 1.5% for London, was just slightly lower, at 1.3%, outside London
The summary at the start of the weighty HPA report suggests that one of the reasons for this increase is “earlier and increased HIV testing”. However, later on the report reveals that “uptake of voluntary confidential testing for HIV among MSM attending GUM clinics appears to have stabilised and was 80% in 2005 (compared to 79% in 2004).” This is lower than heterosexual HIV testing at GUM clinics, which the HPA reports to be 82%. It goes on to reveal that “of the [other] 20% [of gay and MSM] who could potentially have had their HIV infection status established, 36% were known to have refused a test.” Among the gay men and other MSM who refused an HIV antibody test, 7.5% were HIV-infected.
However, the report also reveals that 43% of HIV-infected gay and MSM who attended a sexual health clinic in 2005 remained undiagnosed. This correlates with the results of a recent study by the Medical Research Council (MRC) and University College London (UCL) which found that on average, of every five HIV-infected urban gay men in the UK, two are undiagnosed. Significantly, the MRC/UCL report found that more than half of the undiagnosed men had received a recent negative HIV antibody test and had perceived themselves to be HIV-negative.
Taken together, these data suggest that some gay and MSM are still not taking HIV antibody tests; some are not routinely being offered HIV testing at GUM clinics, and some are refusing; and that many new HIV diagnoses are, in fact, recent infections.
This is of grave concern, because not only is undiagnosed HIV infection the greatest driver of HIV transmission, but also because late diagnosis of HIV infection means a much lower probability of benefiting from the recent advances in HIV treatment and care.
The HPA report highlights that late HIV diagnosis is still very common in gay and MSM and that it is linked to increased mortality. The report found that in 2005 almost 500 gay and MSM were estimated to have been diagnosed with a CD4 cell count below 200 cells/mm3, the threshold when BHIVA's treatment guidelines suggest HIV treatment should begin. It found that gay and MSM who are diagnosed late are over ten times more likely to die within a year of their HIV diagnosis than those with higher CD4 cell counts (5.2% vs. 0.41%).
The report found that gay and MSM who are older, those who were diagnosed outside London, or those that belonged to an ethnic minority were the most likely to have been diagnosed late.
The Health Protection Agency's UK HIV/AIDS report, A Complex Picture notes that gay men and other men who have sex with men (MSM) as well as heterosexual women and men from black and ethnic minority (BME) communities continue to be disproportionately affected by HIV. It stresses that HIV, as well as other STIs, “remain a major public health concern in the UK” which “presents a substantial challenge to the sexual health strategies across the UK.” Consequently, the report highlights that “there is considerable scope for improvement, which includes…earlier HIV testing [and] more focussed prevention programmes for those at high sexual risk.”
Fewer Africans diagnosed, but more diagnosed late, and more acquiring HIV in the UK
Even more than in gay and MSM, late diagnosis amongst black Africans remains a major concern. The report says that “two in five (40%) black or ethnic minority (BME) adults were diagnosed late and they were seven times more likely to die within a year of their HIV diagnosis than those with higher CD4 counts (3% compared to 0.4%).”
The report notes that “only a minority of those diagnosed late had very recently arrived in the UK”. A previously published 2004 HPA-led community-based survey found that "fear of HIV and associated stigma and discrimination continues to deter African men and women from seeking HIV tests," and recommended that African community HIV organisations should do outreach work in order to motivate people to come forward for voluntary counselling and testing.
The report suggests that a significant proportion of the heterosexual BME population who think they might be infected are refusing HIV tests when attend a GUM clinic for a sexual health screen. “Among heterosexual clinic attendees who could potentially have had their HIV infection status established, 46% were known to have refused a test [and] “after leaving the clinic, 27% of the HIV-infected remained undiagnosed.”
Members of the diverse BME population accounted for two thirds of all new HIV diagnoses reported in 2005 (3,691 out of 5,902). Although the HPA report found that in 2005 there were fewer new HIV diagnoses of HIV in women and men who acquired their infection through heterosexual sex in Africa, it also notes that “the number of reports of HIV-infected black Africans who contracted their infection in the UK increased from 43 in 2000 to 182 in 2005.”
“Although the majority of these are contracted in countries of higher prevalence and particularly through links with Africa, more of these cases are now being contracted within the UK,” notes the HPA report. “Among the black Caribbean and the small proportion of HIV-infected black Africans born in the UK, over half (59%) had probably acquired their infection within the UK, and where reported, 10% of their partners had also probably been infected within the UK.”
The report warns that “as the number of BME heterosexuals living with HIV (diagnosed and undiagnosed) in the UK grows, the likelihood increases of expanding heterosexual HIV transmission chains within BME communities living in the UK.”
HPA and other public body recommendations
The report notes that “there is considerable scope for improvement” when it comes to preventing new infections and getting more at-risk people to test for HIV in a timely manner.
The most striking recommendation to reduce new infections comes from the National Institute for Health and Clinical Excellence (NICE) Public Health Interventions Advisory Committee. According to the HPA report, NICE recommends that “'one to one structured interventions'” should [be given] particular priority to MSM who engage in [unprotected anal intercourse] and to black African and black Caribbean heterosexuals at high risk of HIV and other STIs.” The HPA adds that “Primary Care Bodies should rapidly consider how to implement these recommendations as soon as they are finalised.”
Other interventions that also need to be looked into further include “group and peer-based programmes in a range of settings, specifically targeting those at high risk of acquiring or transmitting HIV and other STIs.”
The HPA report also stresses that an "an ongoing public health challenge" is “the need to reach individuals who remain undiagnosed and most at risk of HIV and other STIs and [to] target them with culturally sensitive and effective interventions.
The HPA recommends that HIV testing should be further expanded through “targeted promotion and opportunistic HIV testing in healthcare settings.” In particular, “primary care practitioners [GPs] should be supported to assess the health needs of migrants and gay men including discussing the need for HIV testing to ensure these groups are diagnosed as early as possible.”
Although its unlikely that the UK will follow the recent US lead for routine HIV testing of all adults, the move towards opt-out testing at all sexual health clinics as recently recommended by the British Association of Sexual Health and HIV (BASHH) is a signal that the UK is changing in the way it approaches HIV testing. The HPA adds that it “needs to work with professional and voluntary groups, the Expert Advisory Group on AIDS and the Department of Health to develop clearer recommendations on HIV testing in response to the changing epidemic.”