Increase in sexually transmitted infections among homosexual men in Amsterdam in relation to HAART

Incidence of Sexually Transmitted Diseases and HIV Infection Related to Perceived HIV/AIDS Threat Since Highly Active Antiretroviral Therapy Availability in Men Who Have Sex With Men

OBJECTIVE

Concerns have been expressed regarding increase in risky sex because of the availability of antiretroviral treatments in Western countries.

GOAL

The goal of this longitudinal study was to investigate the association between highly active antiretroviral therapy (HAART)- and postexposure prophylaxis-related beliefs and the incidence of sexually transmitted diseases (STDs) and new HIV infections in men who have sex with men (MSM).

STUDY

Data on the incidence of STDs and new HIV infection, and the level of agreement with different HAART- and PEP-related beliefs from 151 HIV-negative MSM were compiled.

RESULTS

Of all MSM, 65.6% tested negative for any STDs and 7 men HIV seroconverted. Perceiving less HIV/AIDS threat since HAART availability and younger age were significantly associated with a higher incidence of STDs. Perceiving less need for safe sex since HAART availability was significantly associated with an increased likelihood of HIV seroconversion.

CONCLUSIONS

The results support the assumption that there is an association between the incidence of STDs and a decreased perception of HIV/AIDS threat resulting from HAART availability. Less perceived need for safe sex since HAART availability was associated with HIV seroconversion.

Zunahme der Syphilis und STD-Koinfektionen bei HIV-Infizierten in Dresden

BACKGROUND

In the past few years, increased diagnoses of syphilis and other sexually transmitted diseases (STD) have been reported in the cities of the United States and Europe, including Germany. The majority of cases identified were men who have sex with men (MSM).

PATIENTS AND METHODS

A retrospective chart review of 144 HIV-infected patients from Dresden enrolled between 2000 and October 2003 was analyzed for the prevalence of syphilis and other STDs and compared with previous data of 104 patients collected between 1993 and 1999.

RESULTS

The seroprevalence of syphilis increased from 13.5% to 17.5%, mainly due to a marked increase of active early syphilis from 0% to 7% of patients, all of whom were MSM. 63% of the patients had clinical or serological signs of other STDs.

CONCLUSION

These data confirm previous reports on the increase of syphilis among MSM. The frequent occurrence of other STDs in HIV-infected patients outlines the need for special STD screening offers and adequate counseling.

Screening for syphilis among men who have sex with men in various clinical settings

OBJECTIVES

To assess the prevalence of syphilis infections among men who have sex with men (MSM) accessing the Brisbane Sexual Health Clinic during the period 1997 up to May 2003, data were collated through three clinical programmes conducted by the service-a large inner city mainstream sexual health clinic and two small outreach sessional clinics conducted on the site of male sex on premises venues (SOPV). Data analysis also provided the opportunity to evaluate the effectiveness of the smaller outreach clinics to access populations of MSM less likely to attend or identify at the larger mainstream clinic, and therefore enhance the detection of previously undiagnosed sexually transmissible infections.

METHODS

Computerised records from 1997-2003 were collated for a statistical analysis of syphilis and other STI pathology results for all MSM accessing the mainstream clinic, and two outreach clinics.

RESULTS

A review of client charts showed that 16 new syphilis diagnoses were made over the previous 5 years, but only two of these infections (both through the mainstream clinic) were early syphilis and therefore transmissible. All other cases were latent infections. A higher proportion of bisexual men was identified with positive syphilis serology but this was just below significance (p=0.06). Significantly, almost a third of syphilis diagnoses (all latent) were made at SOPV outreach clinics, despite the much lower proportion of clients seen overall through the SOPV clinics. For other sexually transmissible infections, the mainstream clinic demonstrated greater efficiency at case detection.

CONCLUSION

Outreach clinics located in male saunas may serve an effective function in syphilis screening by facilitating access for a particular subpopulation of MSM (bisexual, married men). These outreach clinics may provide important outlets for education and opportunistic screening of asymptomatic MSM and foster a greater willingness for men to honestly self identify. However, larger, mainstream clinics serve a more anonymous venue for the testing of symptomatic men.

A Longitudinal Study of the Association Between Treatment Optimism and Sexual Risk Behavior in Young Adult Gay and Bisexual Men

To determine whether optimism about highly active antiretroviral therapy is associated with sexual risk behavior among young adult HIV-negative gay and bisexual men, and to test 2 alternative explanations for this association: that treatment optimism leads to increased sexual risk or that treatment optimism is the result of previous sexual risk. Data on sexual risk behavior, treatment optimism, and perceived susceptibility to HIV infection were obtained from a sample of 538 HIV-negative or untested gay and bisexual men (ages 18-30) who were not in monogamous relationships. Follow-up data were collected 18 months later. In the cross-sectional data, treatment optimism was associated with the 2-month cumulative incidence of unprotected anal intercourse (UAI) with nonprimary partners; however, this effect was observed only among men who felt highly susceptible to HIV infection. Longitudinal analyses revealed that treatment optimism did not predict subsequent UAI, but UAI did predict later treatment optimism. Treatment optimism is associated with sexual risk behavior among young adult gay and bisexual men. However, these data suggest that optimism may result from, rather than precede, sexual risk.

A Case–Control Study of Syphilis Among Men Who Have Sex With Men in New York City

OBJECTIVE

The objective of this study was to determine factors associated with syphilis among men who report sex with other men in New York City. DESIGN, SETTING AND STUDY SUBJECTS: We conducted a case-control study among 88 men who reported sex with men in the previous year, 18 to 55 years old and diagnosed with primary or secondary syphilis during 2001; and 176 control subjects frequently matched by age and type of health provider.

RESULTS

HIV prevalence among syphilis cases was 48% compared with 15% among control subjects (P <0.001). Variables associated with syphilis in a multivariate model were HIV infection (odds ratio [OR], 7.3; 95% confidence interval [CI], 3.5-15.4), income >$30,000 per year (OR, 2.7; CI, 1.4-5.2), and barebacking (OR, 2.6; CI, 1.4-4.8). The median time since HIV diagnosis for HIV-positive was 6 years for cases and 7 years for control subjects (P = 0.70). Among HIV-infected participants, syphilis cases were more likely than control subjects to report being on antiretroviral therapy (69% vs. 44%, P = 0.05) and to report having undetectable viral load (58% vs. 24%, P = 0.02).

CONCLUSION

HIV infection was strongly associated with syphilis in this study. High-risk behavior reported by both cases and control subjects indicates the potential for increased HIV transmission.

Perceived viral load, but not actual HIV-1-RNA load, is associated with sexual risk behaviour among HIV-infected homosexual men

BACKGROUND

Increases in sexual risk behaviour and sexually transmitted infections among HIV-infected homosexual men after the introduction of highly active antiretroviral therapy (HAART) confirm the need for innovative prevention activities. The present study focused on time trends in sexual risk behaviour and predictors for unprotected anal intercourse in the HAART era among HIV-infected homosexual men.

METHODS

In 2000-2003, 57 HIV-infected homosexual men (mean age 45 years) were interviewed in three serial data waves. Logistic regression, correcting for repeated measurements, was used to assess time trends in risky sex, and the association between HAART-related beliefs, and both the perceived and actual viral load level and CD4 cell counts and subsequent risky sex.

RESULTS

Risky sex with casual partners increased from 10.5% in 2000 to 27.8% in 2003 (P < 0.01), and with steady partners of negative or unknown HIV status from 5.3% to 10.7% (P = 0.6). Homosexual men with a favourable perception of their viral load were more likely to engage in subsequent risky sex with steady partners of negative or unknown HIV status than men with a less favourable perception of their viral load; this association was independent of the actual HIV-1-RNA load and CD4 cell counts.

CONCLUSION

Risky sex increased in this group of HIV-infected homosexual men. The perceived viral load, but not the actual load, is associated with subsequent risky sex with steady partners of negative or unknown HIV status. Care givers should discuss with patients not only their actual viral load and CD4 cell count but also their perceived viral load.

Syphilis in the HIV-infected patient: An update on epidemiology, diagnosis, and management

After a decade of unprecedented declines, incidence of early-stage syphilis in the United States and Europe has increased significantly since 2000. These cases have occurred at disproportionately elevated rates among people infected with HIV. Speculation continues as to whether the clinical spectrum of syphilis is qualitatively different among those individuals who are HIV infected. Recent data suggest that individuals who are immune compromised because of HIV have a higher likelihood of developing neurosyphilis. Recommendations for treatment of syphilis remain the same for patients with and without HIV.

Is unsafe sexual behaviour increasing among HIV-infected individuals?

BACKGROUND

The number of new diagnoses of HIV infection is rising in the northwestern hemisphere and it is becoming increasingly important to understand the mechanisms behind this trend.

OBJECTIVE

To evaluate whether reported unsafe sexual behaviour among HIV- infected individuals is changing over time.

DESIGN

Participants in the Swiss HIV Cohort Study were asked about their sexual practices every 6 months for 3 years during regular follow-up of the cohort beginning on 1 April 2000.

METHODS

: Logistic regression models were fit using generalized estimating equations assuming a constant correlation between responses from the same individual.

RESULTS

At least one sexual behaviour questionnaire was obtained for 6545 HIV-infected individuals and the median number of questionnaires completed per individual was five. There was no evidence of an increase in reported unsafe sex over time in this population [odds ratio (OR), 1.0; 95% confidence interval (CI), 0.96-1.05]. Females (OR, 1.38; 95% CI, 1.19-1.60), 15-30 year olds (OR, 1.26; 95% CI, 1.09-1.47), those with HIV-positive partners (OR, 12.58; 95% CI, 10.84-14.07) and those with occasional partners (OR, 3.25; 95% CI, 2.87-3.67) were more likely to report unsafe sex. There was no evidence of a response bias over time, but individuals were less willing to leave questions about their sexual behaviour unanswered or ambiguous (OR, 0.93; 95% CI, 0.90-0.97).

CONCLUSIONS

There was no evidence of a trend in unsafe sex behaviour over time. However, several subgroups were identified as being more likely to report unsafe sex and should be targeted for specific interventions.

Missed Opportunities: Prevention With HIV-Infected Patients in Clinical Care Settings

OBJECTIVE

To assess current practices related to prevention with HIV-positive patients in Ryan White-funded primary care settings and the barriers to providing such services.

METHOD

Exit surveys about HIV prevention services were conducted with 618 HIV-infected patients at 16 primary HIV care clinics receiving Ryan White CARE Act funding. To place the exit survey findings in context, qualitative in-depth interviews were conducted with 16 clinic administrators, 32 primary care providers, 32 support service providers, and 64 patients.

RESULTS

One quarter of patients reported having had a general discussion of "safer sex and ways to prevent transmission to others" during that day's primary care visit. However, only 6% reported discussing specific sexual activities. HIV prevention counseling was less common than counseling for adherence to antiretroviral therapy, emotional issues, and diet and nutrition (P < 0.001). Patients in clinics with established procedures for HIV prevention counseling were significantly more likely to report receiving such services (odds ratio = 2.17). Qualitative interviews identified barriers to providing prevention services as lack of time, training, funding for staffing, and providers' understanding of their roles and responsibility.

CONCLUSIONS

HIV prevention counseling is not routine in most clinics, and the low frequency of such services represents missed opportunities for HIV prevention.

The changing face of the HIV epidemic in western Europe: what are the implications for public health policies?

In this review, we describe changes in dynamics of HIV transmission and shifts in affected populations in western Europe using HIV/AIDS surveillance data and published and unpublished reports. Despite substantial reductions in HIV-related morbidity and mortality since the introduction of highly active antiretroviral treatment, HIV continues to pose a major public health problem in western Europe. More than half a million people are living with an infection that remains incurable and requires costly lifelong treatment; many people remain unaware of their infection, and thousands of new infections continue to occur every year. Migrants from countries with a high prevalence of HIV/AIDS, notably sub-Saharan Africa, bear a disproportionate and increasing share of HIV throughout western Europe and, in most countries, account for the majority of heterosexually acquired HIV infections diagnosed in recent years. Prevention, treatment, and care must be adapted to reach migrant populations. Following a resurgence of risky sexual behaviour, HIV transmission may now be increasing among homosexual and bisexual men, and renewed safer sex campaigns are urgently needed.

Long-term effects of syringe exchange on risk behavior and HIV prevention

The purpose of this study was to assess stability of population-level injection risk behavior over time among participants in a syringe exchange program and compare factors affecting syringe sharing at two points in time. Participants of the Tacoma Syringe Exchange Program were interviewed in 1997 and 2001 using audio computer assisted self-interviewing technology. In each wave of data collection, a random cross section of participants was recruited and interviewed, with no attempt made to follow respondents over time. Rates of injection risk behavior remained stable across the 4-year period, despite increases in factors associated with syringe sharing. Homelessness, rates of depression symptoms, and injection of amphetamines all increased from 1997 to 2001. The central factors associated with syringe sharing in both 1997 and 2001 were depression symptoms and the interaction of younger age with amphetamine injection. The data indicate that the exchange has been able to stabilize risk among a high-risk population for a substantial period of time. This study confirms previous findings that SEPs can play a significant role in the prevention of HIV in marginal and impoverished communities in the United States.

Gonorrhoea surveillance system in France: 1986-2000

OBJECTIVE

The objectives of this study were to monitor epidemiologic trends in Neisseria gonorrhoeae (NG) infections and to assess antimicrobial resistance patterns of NG.

METHODS

RENAGO, a voluntary-based laboratory surveillance system, including private and public laboratories, was set up in France in 1986. Every NG strain isolated by the participating laboratories was sent to the National Reference Center, Institut Alfred Fournier, Paris, where susceptibility to 6 antibiotics was tested. These laboratories reported monthly numbers of positive NG isolates and associated epidemiologic data. Because the number of laboratories varied every year, the average number of NG isolates per laboratory per year was computed to monitor annual trends in gonorrhea incidence.

RESULTS

The average number of NG isolated per laboratory per year decreased steadily from 10.6 in 1986 to 0.6 in 1997 but then yearly increased and reached 1.9 in 2000. Increasing gonorrhea was observed mostly in men and in the Paris area. The proportion of rectal strains increased significantly from 0.9% in 1986 to 9.2% in 2000. From 1998 to 2000, 5.3% of the isolates had reduced susceptibility or were resistant to ciprofloxacin, 7.3% were PPNG strains and 27.4% were resistant to tetracycline, 18.5% had a reduced susceptibility to thiamphenicol, and 1 strain was resistant to the latter. Neither strain was resistant to ceftriaxone or to spectinomycin.

CONCLUSION

From 1998 to 2000, gonorrhea markedly increased in France and seemed to affect mainly gay men in Paris, which suggests relapses to risky sexual behaviors and highlights the need for strengthening prevention. During the same period, NG ciprofloxacin resistance has sharply increased and should be carefully monitored because of the wide use of ciprofloxacin single-dose treatment.

Changes in the transmission dynamics of the HIV epidemic after the wide-scale use of antiretroviral therapy could explain increases in sexually transmitted infections: results from mathematical models

BACKGROUND

Recent increases in bacterial sexually transmitted infections (STI) and risk behavior have coincided with the introduction of antiretroviral therapy (ART) in homosexual communities of industrialized countries. The reasons for these increases are not fully understood.

GOAL

The goal of this study was to understand the various effects of ART on risk behaviors and STI.

OBJECTIVE

The objective of this study was to assess the independent impact of the change in the transmission dynamics of HIV/AIDS as a result of the wide-scale use of ART on a bacterial STI.

STUDY DESIGN

We developed a mathematical model of bacterial STI and treated/untreated HIV/AIDS infection for an open homosexual population. At the individual level, we assume that susceptible and healthy HIV-positive individuals do not increase their risk behavior as a result of ART over time. However, individuals with AIDS, who are successfully treated with ART, can resume sexual activity. The impact of the wide-scale use of ART on risky behavior, STI, and HIV/AIDS was evaluated over a wide range of assumptions on treatment use, ART efficacy, and population characteristics.

RESULTS

Over 10 years, 0% to 55% new bacterial STI could be attributed to the wide-scale use of ART as a result of more modest increases (0-25%) in risky sex occurring at the population level rather than at the individual level. These increases have a negative impact on HIV if coverage is too low. Increasing treatment coverage helps to prevent more HIV infections despite larger increases in risky sex and STI that is predicted to ensue.

CONCLUSION

Taking the differential impact of wide-scale use of ART into account helps to interpret recent behavioral and STI trends. Our results have implications for prevention strategies and for the formulation of public health policies. A better understanding of the differential impact of ART on sexual network over time is required.

Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: a longitudinal study

OBJECTIVE

To investigate longitudinally the association between highly active antiretroviral therapy (HAART)-related beliefs and the change from protected to unprotected anal intercourse with casual partners on an individual level.

METHODS

The study population included 217 HIV-negative homosexual men participating in the Amsterdam Cohort Study from September 1999 to May 2002, including five data waves with a 6-month interval. The selection criteria were: being under 31 years of age, having had anal sex with casual partners in the preceding 6 months, and participating in at least two data waves. Information was collected on the individual change from protected to unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI) and the level of agreement with different HAART-related beliefs.

RESULTS

The majority of men disagreed with the three treatment-belief factors that resulted from the principal component analysis: perceiving less HIV/AIDS threat since HAART, perceiving less need for safe sex since HAART, and perceiving high effectiveness of HAART in curing HIV/AIDS. Multivariate analyses revealed that the more men inclined to agree with the belief 'perceiving less HIV/AIDS threat', the more likely they were to change to URAI (adjusted OR 1.60; 95% CI 1.16-2.22).

CONCLUSION

Homosexual men are quite realistic about the effectiveness of HAART, the continued need for condom use, and the HIV/AIDS threat since HAART. However, a tendency towards agreement with 'perceiving less HIV/AIDS threat' was found to predict an individuals' change to URAI. This finding supports the hypothesis of a causal relationship between decreased HIV/AIDS threat since HAART and a change to URAI.

Epidemiología de la infección por el VIH/sida y su relación con otras infecciones de transmisión sexual. Perspectivas de futuro

Over the last decade, different cross-sectional and case-control studies have shown the relationship between HIV and Sexually Transmitted infections (STI). In this sense, different reasons are found: a modification of the clinical manifestations of some STI as well as an increase of HIV infectiousness and susceptibility to HIV. The main objective of HIV/AIDS and STI surveillance includes: to assess its temporal trends, to define high risk groups and high-risk behaviours and to plan and to evaluate public health programmes. Nevertheless, classical surveillance systems are not enough to describe the real situation of HIV/AIDS and STI. Thus, an enhanced surveillance system which includes complementary resources should be implemented.

Risk Factors for Rectal Gonococcal Infection Amidst Resurgence in HIV Transmission

BACKGROUND

Rectal gonorrhea in men has been increasing in San Francisco since 1995.

GOAL

The goal was to determine behavioral risk factors associated with rectal gonorrhea (RGC) among men who have sex with men (MSM) by HIV serostatus.

STUDY DESIGN

All men reporting receptive anal sex in the last 6 months are screened for RGC, regardless of reported condom use, at San Francisco's municipal sexually transmitted disease (STD) clinic. We surveyed a convenience sample of men screened for RGC at the clinic.

RESULTS

Among 564 MSM surveyed, 7.1% had RGC. HIV-positive MSM were significantly more likely (relative risk, 3.5, 95% confidence interval, 1.9-5.8) to have RGC. Behavioral risks for RGC infection varied significantly by HIV serostatus. HIV-positive MSM engaging in anonymous sex were at highest risk for RGC infection. Drug use during anal sex was the strongest risk factor for RGC infection among HIV-negative or unknown HIV status MSM.

CONCLUSION

Our data suggest that STD and HIV prevention efforts among MSM in San Francisco must consider the role that HIV serostatus plays in acquisition of new infections.

If HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM?

Systematic reviews of HIV prevention research provide clear evidence that behavioral interventions can influence the sexual behavior of men who have sex with men (MSM). However, if HIV prevention works, why are rates of high-risk sexual behavior increasing among MSM in major European, Australian, Canadian, and U.S. cities? The evidence generated by systematic reviews alone may not provide a clear answer to this question. This is because (a) it is uncertain whether experimental interventions shown to be effective in one setting, place, or moment in time can be repeated successfully in another; (b) we have limited understanding of the processes that underlie the interventions; (c) interventions shown to work in an experimental study may not necessarily be effective in everyday life. To answer the question, we need to be alert to the changing risk environment in which men have sex with other men. We also need to develop a new program of research addressing the transferability, sustainability, and effectiveness of sexual health promotion among MSM. Randomized controlled trials will remain one of the optimal means of evaluating behavioral interventions in such a program. By further strengthening the evidence base, we may identify opportunities for innovative as well as effective HIV prevention initiatives.

Prevalence of unsafe sexual behavior among HIV-infected individuals: the Swiss HIV Cohort Study

Sexual contact is the major mode of HIV transmission. Increased sexual risk taking has been described in HIV-infected individuals receiving potent antiretroviral therapy. A new questionnaire on sexual behavior was introduced into the Swiss HIV Cohort Study on April 1, 2000. We evaluated sexual behavior in all individuals who completed the questionnaire for the first time within 1 year after its introduction. Our primary hypothesis was that self-reported unsafe sexual behavior would be more prevalent among individuals with optimal viral suppression. On April 1, 2000, 4948 individuals were registered in the study, and 4723 (95%) completed the questionnaire. Of these individuals, 12% reported unsafe sex, 78% received antiretroviral therapy, and 25% had optimal viral suppression (HIV RNA level always <50 copies/mL during the preceding 12 months). During the preceding 6 months, 55% of individuals had stable and 19% had occasional partners, and 6% had both types of partners. Sexual intercourse was reported by 82% of individuals with stable and 87% of individuals with occasional partners, and of those reporting sexual intercourse in each group, 76% and 86%, respectively, said that they always used condoms. After adjustment for covariates, reported unsafe sex was not associated with optimal viral suppression (odds ratio, 1.04; 95% confidence interval, 0.81-1.33) or antiretroviral therapy (odds ratio, 0.83; 95% confidence interval, 0.65-1.07), but it was associated with gender, age, ethnicity, HIV transmission group, HIV status of partner, having occasional partners, and living alone. There is no evidence that self-reported unsafe sexual behavior is more prevalent among HIV-infected individuals with optimal viral suppression. However, unsafe sex is associated with other factors.

Increases in gonorrhea and sexual risk behaviors among men who have sex with men: a 12-year trend analysis at the Denver Metro Health Clinic

BACKGROUND

Recent increases in rates of sexually transmitted diseases (STDs) and decreases in safe sex behaviors among men who have sex with men (MSM) in several American and European cities have been noted by researchers. It has been suggested that these trends are the result of perceptions that HIV/AIDS is less serious because of the availability of highly active antiretroviral therapy (HAART).

GOAL

The goal of the study was to examine trends in STD rates and risk behaviors among MSM and men who have sex with women (MSW) visiting a public STD clinic in Denver and to determine whether there is an ecological association with the availability of HAART.

STUDY DESIGN

This is a two-part retrospective analysis of male visits to the Denver Metro Health Clinic (DMHC). The first part describes gonorrhea and early (primary and secondary) syphilis trends among MSM between 1982 and 2001. For the second part, data were grouped into two 6-year time periods to represent pre-HAART and post-HAART time frames, 1990 to 1995 and 1996 to 2001.

RESULTS

Gonorrhea and early syphilis cases among MSM declined precipitously between 1982 and 1988 and then stabilized at low rates. The proportion of male visits to the clinic made by MSM decreased from 14.1% in 1990 to 7.2% in 1995 and then increased to 13.0% in 2001. Gonorrhea positivity rates among MSM increased after 1995 and were significantly higher in the period 1996 to 2001 (12.9%) than in the period 1990 to 1995 (8.1%; P<0.0001). Conversely, gonorrhea rates among MSW dropped from 11.2% in the first period to 6.9% in the second (P<0.0001). Among MSM known to be HIV-infected, gonorrhea rates increased from 11.6% in the first time period to 24.0% in the second period (P<0.0001). Reports of anal sex among MSM increased from 64.4% to 70.9% (P<0.0001). Reporting more than one sex partner increased for MSM from 65.2% to 70.3% (P<0.0001), but it significantly decreased from 52.6% to 46.2% for MSW (P<0.0001). No or inconsistent condom use increased from 60.9% to 63.0% for MSM (P=NS) and decreased from 85.1% to 82.4% among MSW (P<0.0001).

CONCLUSIONS

These trends appear to reflect a change toward higher risk-taking behaviors among MSM but not MSW since the time HAART became available and raise concerns about the potential for increased HIV transmission in this group.

Unprotected anal intercourse between potentially HIV-serodiscordant men who have sex with men, San Francisco

BACKGROUND

Increasing trends in high-risk sexual behavior are noted among men who have sex with men (MSM) worldwide. Less information is available on unprotected sex between persons of different HIV serostatus.

METHODS

From 1999 through 2001, volunteers of a community-based organization conducted interviews of 10,579 MSM at gay-oriented venues in San Francisco and in neighborhoods with high-volume MSM pedestrian traffic. The questionnaire recorded demographic and risk behavior information, including self-reported and partners' HIV serostatus.

RESULTS

Potentially serodiscordant unprotected anal intercourse (UAI) with at least 2 anal sex partners was reported by 12.7% and increased from 11.0% in 1999 to 16.2% in 2001. Stratifying by self-reported HIV serostatus, 20.8% of HIV-positive respondents, 12.1% of HIV-negative respondents, and 13.4% of MSM who did not know or report their own HIV serostatus had potentially serodiscordant UAI. Older MSM of white race were more likely to report potentially serodiscordant UAI among HIV-positive respondents, whereas younger MSM of white race were more likely to report potentially serodiscordant UAI among HIV-negative respondents. Among those with unknown HIV serostatus, MSM of color were more likely to engage in potentially serodiscordant UAI.

CONCLUSION

Recent increases in UAI among MSM in San Francisco are not only the result of increases in UAI between persons of the same HIV serostatus. Prevention messages must address disclosure of HIV serostatus to sexual partners specifically tailored to groups according to age, community, and HIV serostatus.

Sexually Transmitted Diseases in Men Who Have Sex with Men: An Epidemiologic Review

The introduction of highly active antiretroviral therapy (HAART) has led to dramatic reductions in morbidity and mortality due to HIV infection. However, the resulting optimism and improved health status produced by HAART appears to have contributed to unanticipated consequences in men who have sex with men (MSM): loss of fear of acquiring and transmitting HIV, an increase in high-risk sex, decreased use of condoms, and a resurgence of gonorrhea and syphilis. Other factors, such as lack of knowledge of sexually transmitted diseases (STDs), use of the Internet as a venue to find sex partners, the increasing use of Viagra (Pfizer, New York, NY) as a recreational drug, and the apparent expanding role of oral sex in STD transmission are fueling these trends. Since ulcerative and inflammatory STDs facilitate HIV transmission, a new wave of HIV infection in MSM may be on the horizon. The rising STD rates and relapses in high-risk sexual behaviors in MSM, both HIV-infected and -uninfected MSM, have profound implications for public health and the clinical management of these patients. Clinicians should be aware of this turn of events, and implement new screening and counseling guidelines that have been issued in response to these alarming reports.

Results of an enhanced-outreach programme of hepatitis B vaccination in the Netherlands (1998-2000) among men who have sex with men, hard drug users, sex workers and heterosexual persons with multiple partners

BACKGROUND/AIMS

The Dutch Ministry of Health funded a pilot vaccination project targeting groups at high risk for sex- and drug-related hepatitis B transmission.

METHODS

In seven Municipal Health Service (MHS) areas, three-part hepatitis B vaccination was offered free to men who have sex with men (MSM), drug users (DUs), and heterosexuals with multiple partners, including sex workers (SWs). Four intervention areas recruited participants through care-givers and opinion leaders and offered vaccination at non-MHS sites. Three control areas only used flyers to offer vaccination at MHS during regular hours.

RESULTS

Over 18 months, 13808 persons enrolled for the first vaccination, representing 63% of the targeted population in the intervention areas and 23% in control areas. In intervention areas, only 19% of DUs enrolled, versus 4% in control areas. In both areas, enrollment of the targeted heterosexual population (64%) was satisfactory. MSM were most compliant in having the full series. Of vaccination sources, general practitioners (GPs) attained highest compliance (71%, odds ratio 1.82).

CONCLUSIONS

Dutch MHS facilities can reach high-risk individuals, but DUs require additional outreach. Vaccine coverage was disappointing, but our experience will be deployed nationwide and successful strategies might be employed elsewhere in countries of low endemicity.

High-risk sexual behaviour increases among London gay men between 1998 and 2001: what is the role of HIV optimism?

OBJECTIVE

To examine whether HIV optimism (i.e. optimism in the light of new HIV drug therapies) can account for the recent increase in high-risk sexual behaviour among London gay men.

METHODS

Gay men (n = 2938) using London gyms were surveyed annually between 1998 and 2001. Information was collected on HIV status, unprotected anal intercourse (UAI) in the previous 3 months, and agreement with two statements concerning the severity of and susceptibility to HIV infection. Those who agreed were classified as 'optimistic'.

RESULTS

Between 1998 and 2001, the percentage of men reporting high-risk UAI (i.e. UAI with a casual partner of unknown or discordant HIV status) increased: HIV-positive men 15.3-38.8%; HIV-negative men 6.8-12.1%; never-tested men 2.1-7.7%; (P < 0.01). Overall, less than a third were optimistic. In cross-sectional analysis, optimistic HIV-positive and -negative men were more likely to report high-risk UAI than other men (P < 0.05). However, the increase in high-risk UAI between 1998 and 2001 was seen in those who were optimistic and those who were not (P < 0.05). In multivariate analysis, the modelled increase in high-risk UAI over time remained significant after controlling for HIV optimism (P < 0.01), with no significant interaction between optimism and time.

CONCLUSION

Among London gay men, no difference was detected between those who were optimistic and those who were not in the rate of increase in high-risk sexual behaviour between 1998 and 2001. Our findings suggest that HIV optimism is unlikely to explain the recent increase in high-risk sexual behaviour in these men.

HIV incidence on the increase among homosexual men attending an Amsterdam sexually transmitted disease clinic: using a novel approach for detecting recent infections

OBJECTIVE

Dramatic increases have occurred in sexually transmitted diseases (STD) and in sexual risk behaviour among homosexual men in Amsterdam and internationally. We investigated whether these trends indicate a resurgence of the HIV epidemic.

METHODS

HIV incidence was determined among homosexual attendees of an STD clinic in Amsterdam, who had participated in semi-annual anonymous unlinked cross-sectional HIV prevalence studies from 1991 to 2001. Stored HIV-seropositive samples were tested with a less-sensitive HIV assay and, if non-reactive, were further tested for the presence of antiretroviral drugs, indicative of the use of highly active antiretroviral therapy. Seropositive men who tested non-reactive on the less-sensitive assay and had not used antiretroviral drugs were classified as recently infected (< 170 days). Annual HIV incidence and its changes were examined.

RESULTS

Among 3090 homosexual participants (median age 34 years), 454 were HIV infected, of whom 37 were recently infectioned. From 1991 to 2001 the overall incidence was 3.0 infections/100 person-years. Incidence increased over time (P = 0.02) and, strikingly, the increase was evident in older (> or = 34 years) men (P < 0.01), but not in the young. Of men recently infected, 84% (n = 31) were unaware of their infection and 70.3% (n = 26) had a concurrent STD. These 26 men reportedly had sex with a total of 315 men in the preceding 6 months.

CONCLUSION

HIV incidence is increasing among homosexual attendees of an STD clinic. It is imperative to trace recently infected individuals, because they are highly infectious, and can thus play a key role in the spread of HIV.

No increase in HIV incidence observed in a cohort of men who have sex with other men in Montreal

To monitor HIV incidence we tested a cohort of men who have sex with men in Montreal for HIV every 6 months. Between 1996 and 2001, 17 out of 1244 participants seroconverted, for an HIV incidence of 0.56 per 100 person-years (py) (95% CL 0.29, 0.83). The incidence decreased over the study period, from 0.75 to 0.34 per 100 py; which was not statistically significant. An in-depth evaluation of the situation in Montreal could identify useful lessons for prevention efforts elsewhere.

Can antiretroviral therapy be used to prevent sexual transmission of human immunodeficiency virus type 1?

Approximately 5 million people annually are newly infected with human immunodeficiency virus (HIV). Although education, behavior modification, and promotion of condom use are effective transmission-prevention measures, the severity of the pandemic demands that all possible prevention strategies be explored. Antiretroviral therapy has the potential to decrease sexual transmission of HIV type 1 by reducing levels of HIV RNA and thus decreasing the risk that infected persons will transmit the disease or by its use as preexposure or postexposure prophylaxis. In this article, we explore the rationale for using antiretroviral therapy to prevent sexual transmission of HIV, as well as the limitations of this approach.

Risk behaviour and sexually transmitted diseases are on the rise in gay men, but what is happening with HIV?

Increases in sexually transmitted diseases and sexual risk behaviour among men who have sex with men in the Western world have raised concern with regard to the HIV/AIDS epidemic in this group. The aim of this review is to give an overview of possible explanations for these alarming increases and to indicate what impact they might have on this epidemic.

The great pretender returns to Dublin, Ireland

BACKGROUND

An outbreak of syphilis has been identified primarily in Dublin, Ireland. On a background of a stable low incidence of syphilis, a significant increase in the number of cases of syphilis has been observed over the past 18 months.

RESULTS

181 cases of syphilis were seen in this period. 121 were defined as early syphilis. These cases were mainly among men who have sex with men (92%). A high rate of HIV co-infection was present; 16 patients who regularly attended HIV clinics were diagnosed with early syphilis. Nine patients were co-diagnosed with HIV and early syphilis. High risk behaviour and concurrent diagnoses with other sexually transmitted infections were prevalent in this cohort. Sexual networks were also investigated.

CONCLUSION

An education campaign, widespread advertisements, and on-site testing in commercial venues have revealed further cases. Safer sex messages need to be emphasised particularly among the HIV population. Further innovative strategies continue to be explored.