The EMIS survey of nearly 180,000 gay men in Europe has found that, while HIV prevalence in the richer countries of western Europe is twice as high as in eastern Europe, similar proportions of gay men were diagnosed with HIV last year in eastern and western Europe, suggesting rising HIV incidence in eastern Europe.
This could be due to increased rates of testing in eastern Europe, but HIV testing rates in gay men in that region are in fact not much lower than they are in western Europe, and the fact that the average age of respondents in eastern Europe was lower may indicate increased incidence there. Either way, without changes in behaviour or HIV prevention methods, HIV prevalence rates in gay men in eastern Europe are likely to catch up with HIV prevalence in western Europe in years to come.
EMIS is by far the largest survey of sexual health and sexual risk behaviour ever conducted in gay men. There were a total of 174,209 valid responses from men in 38 European countries to the survey, which was translated into 25 European languages. Aidsmap has already reported on the survey’s findings on sexual health services, HIV testing and internalised homophobia, and rates of risky sex.
Axel Schmidt of Germany’s Robert Koch institute, which oversaw the survey’s scientific co-ordination, told the Future of European Prevention among MSM (FEMP) conference in Stockholm earlier this month that HIV seropositivity among the survey respondents was in general higher in western than in eastern Europe. It was 13.2% in the west Europe group which included France, the Netherlands and the UK; 11.2% in the west-central group which includes Germany, Austria and Switzerland, 10.9% in the so-called PIGS countries (Portugal, Italy, Greece and Spain) and somewhat lower at 7% in Scandinavia. This means overall prevalence in the region was 10.6%.
In contrast HIV prevalence was 5.1% in the Baltic states, 3.8% in Romania and Bulgaria, 4% in Turkey and the former Yugoslav states, and 6% in the central-east states (Poland, Czech Republic, Slovakia and Hungary). Prevalence was higher in the former USSR states of Russia and Ukraine at just over 8%, though half of this in Belarus and Moldova. Overall in the eastern European region 5.4% of respondents were HIV positive: half the rate in western Europe.
In individual countries, HIV prevalence ranged from 15.6% in the Netherlands (which, at an average of 40 years was also the country with the oldest respondents) to none of the 163 respondents from Bosnia (average age 26) and 1% of 605 respondents from Slovakia.
When it comes to newly diagnosed infections, however, the proportion of respondents who had tested positive for HIV in the last year was similar throughout Europe, with some local variations. The highest rates were in the former USSR (3.4%), west Europe (3.1%) and the PIGS group (3.1%) followed by the central-east countries (2.8%) and central-west (2.6%). Romania and Bulgaria reported middling rates of new infections (2.1%) while Scandinavia (1.4%), former Yugoslavia and Turkey (1.3%) and the Baltic states (0.6%) had lower rates. Regionally, the rate of newly diagnosed infections was 1.8% in western Europe and 2% in eastern Europe.
Respondents, whose average age was 30 overall, were younger in eastern Europe - where the average age was 28, with only five out of 20 countries with an average age over 29 - than in western Europe (average age 33.4, and no country with an average age below 30). The comparative youth of respondents suggests that these diagnoses are likely to be actual recent infections rather than infections acquired a long time ago but only recently diagnosed. The finding that rates of risky sex are higher in eastern than western Europe may also indicate that HIV infections are significantly increasing in eastern European gay men.
Estimating actual HIV prevalence from the EMIS data
To what extent do the HIV prevalence and new-infection rates reported by EMIS respondents actually reflect the true situation amongst gay men in Europe? Self-selected groups like the EMIS respondents may not represent gay men in general. As better-connected gay men, they may have higher-than-average rates of risky sex and HIV than more isolated men; conversely, HIV rates reported in national surveys, which are based on diagnoses in sexual health centres, may overestimate the HIV-positive population.
The degree to which reported HIV status predicts true prevalence depends on a number of factors: the proportion of each country’s gay men who responded to the survey; the proportion who have access to the internet in that country; the proportion who are sexually active; and the age structure in the gay population (given that seropositivity rises with age, one would expect countries with older respondents to report more HIV cases than younger countries).
EMIS estimated that 3% of the adult male population aged 15-64 was actively having sex with other men in western Europe, and 2% of the population in eastern Europe, not because of differences in sexual orientation, but to lack of opportunity and more homophobic environments there. This led to an estimate that the proportion of each country’s gay men who responded to the survey ranged from 0.3% in Turkey to 6.9% in Germany. When adjusted for internet access, some of the smaller countries such as Estonia, Cyprus and Slovenia had higher response rates, amongst those who could respond, than Germany. The proportion of men having sex that might expose them to HIV was 32% overall, and ranged from 21% in Luxembourg to 49% in Turkey.
EMIS also compared seropositivity rates in its survey to two national sets of data. It compared its HIV prevalence rates to the adjusted HIV rates in country reports submitted to the United Nations General Assembly Special Session (UNGASS) on HIV, and it compared its new-diagnosis rates to new diagnoses reported to national surveillance systems. National prevalence rates in EMIS agreed with UNGASS for lower-prevalence countries, but were somewhat lower for high-prevalence countries. In contrast new-diagnosis rates for high-incidence countries were higher in EMIS than in national surveillance. There was, however strong correlation between EMIS figures and the prevalence and new-diagnosis rates (high prevalence in EMIS meant high prevalence in UNGASS, and vice versa).
Combining all these various figures allowed EMIS to adjust its figures and make an adjusted estimate of the ‘true’ HIV prevalence in the 38 countries. They estimate that prevalence amongst the MSM population in general ranges from a low of about 0.25% in Moldova to 6.2% in France. Thirteen countries, all in eastern Europe, had an adjusted HIV prevalence of 1% or below, while four – Belgium, the Netherlands, the United Kingdom and France – came out with an adjusted HIV prevalence of over 5%. The UK had both the second-highest prevalence amongst EMIS respondents (14.2%) and the second-highest adjusted prevalence (5.7%).
Schmidt A. The European MSM Internet Survey (EMIS). The Future of European Prevention amongst men who have sex with men (FEMP) conference,Stockholm. 2011. See www.femp2011.eu
Data also from:
Marcus U et al. The European MSM Internet Survey (EMIS) 2010. A large network approach for harmonising European 2nd generation surveillance and for identifying unmet prevention needs among gay and other men who have sex with men (MSM) in 38 countries. Tenth AIDS Impact Conference, Santa Fe. Abstract #167. 2011.
Community reports nos 1 and 2, European MSM internet survey (EMIS): see www.emis-project.eu