Men who have sex with men (MSM) living in London have particularly poor sexual health and this is worsening, Public Health England warn in a report published yesterday. The report calls on commissioners and providers of sexual health services to focus on the needs of this group: “Improving sexual health in MSM should be made the highest sexual health priority in London,” they recommend.
The report is published against a backdrop of highly variable funding for sexual health and HIV prevention in London, with some London boroughs investing very little.
Based on a recent large, household survey, 3.8% of adult male Londoners are gay or bisexual (higher than the 2.4% in other parts of the country). Gay and bisexual men therefore make up less than 2% of the adult population in London.
Nonetheless, MSM constituted 24% of all London residents diagnosed with a sexually transmitted infection (STI) last year. The proportion was even higher for gonorrhoea (65%) and syphilis (84%), and the number of these diagnoses is increasing, although this is partly due to improvements in testing technologies. In recent years, outbreaks of lymphogranuloma venereum (LGV), shigella and sexually transmitted hepatitis C have occurred almost exclusively in gay men and have been concentrated in certain London boroughs.
Similarly, 51% of new HIV diagnoses in London are in men who have sex with men. There were 1451 diagnoses amongst MSM in London in 2012, which represents a 28% increase compared to 2003.
Whereas it’s estimated that across the United Kingdom 1-in-34 gay men are living with HIV, the comparable figure for London gay men is 1-in-12.
The HIV-positive population is not evenly spread across the capital, reflecting to a great extent the areas in which gay men choose to live – and the priority areas for HIV prevention. The boroughs with the largest populations are Lambeth (2220 men, 14% of London MSM living with HIV), Southwark (1450 men, 9%), Westminster (1060 men, 7%), Camden (1000 men, 6%), Islington (940 men, 6%) and Tower Hamlets (870 men, 6%).
Several other boroughs have more than 500 MSM living with HIV: Kensington & Chelsea, Wandsworth, Hammersmith & Fulham, Hackney, Lewisham and Haringey.
In boroughs that are further from central London than this, somewhat fewer gay men are living with HIV, although almost all have a high overall prevalence of HIV infection.
Whereas the population of gay men living with HIV in London is progressively getting older – the largest age group is men in their forties – the average age at which men are diagnosed is dropping. The peak age at diagnosis has fallen from 30-34 years a decade ago to 25-29 years in recent years.
Moreover, 60% of London MSM newly diagnosed with HIV were born abroad, a proportion that has risen in recent years. A quarter of newly diagnosed men were born in other European countries (especially Spain, Italy and France) and a third were born elsewhere in the world (especially Brazil, United States and Australia).
“The factors behind the worsening of sexual health in MSM are complex and represent a challenge to tackle,” say Public Health England. They review the available evidence on a number of issues:
- Partnership patterns: a significant minority of gay men have large numbers of sexual partners, including concurrent or overlapping sexual partnerships.
- Unprotected anal intercourse: reported by around half of men who have sex with men.
- Serosorting and other seroadaptive behaviour: the data suggest that significant numbers of HIV-positive men do not use condoms when having sex with other HIV-positive men, contributing to the very high rates of STIs in men living with HIV. The data on HIV-negative men are less clear, but the authors believe that they should be told that serosorting is unsafe as partners may not have tested recently and could have undiagnosed HIV infection.
- Recreational drug use: rates of drug use are relatively high in London gay men and demand for specialist drug services has increased. While drug use during sex may be associated with risk taking, there are large gaps in the evidence.
- Engagement with sexual health services: access to services is good although few men take an HIV test often enough. Most men have received information from HIV prevention programmes.
Public Health England do not identify any magic bullets to deal with these issues. The ongoing risk behaviour in men who engage with health services shows that behaviour change is difficult to bring about in this population, they say; behavioural interventions are unlikely to be sufficient to improve Londoner’s sexual health.
“Tackling this is complex and challenging and a holistic life-course approach is needed,” they argue – pointing to the approach that will frame PHE’s strategy for improving the health of men who have sex with men.
In the meantime, they recommend a continued emphasis on expanding opportunities to test for HIV and increasing the frequency with which men test. Condoms should also to be provided “at scale”, backed up with strong communications.
Online interventions should be considered and evaluated, given their low cost and men’s use of the internet to find sexual partners. Work should also be done with sex-on-premises venues to help them provide a healthier environment (hygiene, lighting, access to condoms, staff training, access for outreach workers, etc.). Drug and alcohol services need to be able to meet the needs of gay men, and sexual health services should be able to offer harm reduction advice.
However, a discussion of the potential of pre-exposure prophylaxis (PrEP) is notable by its absence.
Public Health England. HIV and STIs in men who have sex with men in London, 2014.