A summary report from Amsterdam: increase in sexually transmitted diseases and risky sexual behaviour among homosexual men in relation to the introduction of new anti-HIV drugs

Epidemiology of gonorrhoea: systematic review, meta-analyses, and meta-regressions, World Health Organization European Region, 1949 to 2021

BackgroundEpidemiology of Neisseria gonorrhoeae (NG) infection remains inadequately understood.AimWe aimed to characterise NG epidemiology in Europe.MethodsWe used Cochrane and PRISMA guidelines to systematically review, report, synthesise and analyse NG prevalence data from 1949 to 30 September 2021. Random-effects meta-analyses estimated pooled prevalence. Meta-regression analyses investigated associations and sources of heterogeneity.ResultsThe 844 included publications yielded 1,573 prevalence measures. Pooled prevalence of current urogenital infection was 1.0% (95% CI: 0.7-1.2%) among general populations, 3.2% (95% CI: 1.8-4.8%) among female sex workers, 4.9% (95% CI: 4.2-5.6%) among sexually transmitted infection clinic attendees and 12.1% (95% CI: 8.8-15.8%) among symptomatic men. Among men who have sex with men, pooled prevalence was 0.9% (95% CI: 0.5-1.4%), 5.6% (95% CI: 3.6-8.1%), and 3.8% (95% CI: 2.5-5.4%), respectively, for current urogenital, anorectal or oropharyngeal infection. Current urogenital, anorectal or oropharyngeal infection was 1.45-fold (95% CI: 1.19-1.77%), 2.75-fold (95% CI: 1.89-4.02%) and 2.64-fold (95% CI: 1.77-3.93%) higher among men than women. Current urogenital infection declined 0.97-fold (95% CI: 0.96-0.98%) yearly, but anorectal and oropharyngeal infection increased (1.02-fold; 95% CI: 1.01-1.04% and 1.02-fold; 95% CI: 1.00-1.04%), respectively.ConclusionsNeisseria gonorrhoeae epidemiology in Europe has distinct and contrasting epidemiologies for vaginal sex transmission in heterosexual sex networks vs anal and oral sex transmission in MSM sexual networks. Increased transmission may facilitate drug-resistant strain emergence. Europe is far from achieving the World Health Organization target of 90% incidence reduction by 2030.

Estimate of male urethritis incidences in France between 2007 and 2017 with a specific focus on Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis infections

Background

In a context of increasing use of Nucleic Acid Amplification Test, diagnoses of Neisseria gonorrhoeae and Chlamydia trachomatis infections among men increased in Europe and USA since 2007. We aimed to describe trends in the incidence of male urethritis in France between 2007 and 2017.

Methods

We analysed male urethritis clinical cases reported by the French GPs’ Sentinelles network.

Results

GPs reported 1944 cases of male urethritis during the study period. The estimated annual incidence rates in men aged 15 years and older remained stable between 226 cases per 100,000 seen in 2007 and 196 in 2017 (P value = 0.9). A third-generation cephalosporin with macrolide or tetracycline was prescribed in 17.5% of cases in 2009 (27/154) and 32.4% in 2017 (47/145) (P value = 0.0327).

Conclusions

The incidence rates for adult male urethritis diagnosed in primary care have remained stable since 2007 in France in contrast with the increasing trend of Neisseria gonorrhoeae and Chlamydia trachomatis infections based on microbiological surveillance. Using stable clinical definition for male urethritis seems essential to follow correctly epidemiological dynamic.

HIV-Infected Young Men Demonstrate Appropriate Risk Perceptions and Beliefs about Safer Sexual Behaviors after Human Papillomavirus Vaccination

The aim of this study was to identify risk perceptions after human papillomavirus (HPV) vaccination among HIV-infected young men who have sex with men. On average, participants appropriately perceived themselves to be at lower than neutral risk for HPV (mean subscale score 4.2/10), at higher than neutral risk for other sexually transmitted infections (7.0/10), and that safer sexual behaviors were still important (8.5/10). Higher perceived risk of HPV was associated with African-American race (p = .03); higher perceived risk of other sexually transmitted infections with White race (p = .01) and higher knowledge about HPV (p = .001); and higher perceived need for safer sexual behaviors with consistent condom use (p = .02). The study provides reassuring data that HIV-infected young men who have sex with men generally have appropriate risk perceptions and believe that safer sexual behaviors after vaccination are still important. These findings mirror the results of studies in HIV-infected young women and HIV-uninfected adolescents.

Estimating the Time to Diagnosis and the Chance of Spontaneous Clearance During Acute Hepatitis C in Human Immunodeficiency Virus-Infected Individuals

BACKGROUND

Hepatitis C virus (HCV) infection is often asymptomatic, and the date of infection is almost impossible to determine. Furthermore, spontaneous clearance (SC) may occur, but little is known about its time of occurrence.

METHODS

Data on human immunodeficiency virus (HIV)-HCV coinfected individuals were used to inform a stochastic simulation model of HCV viral load kinetics, alanine aminotransferase (ALT), and HCV antibodies during acute hepatitis C. The dates of diagnosis and potential SC were estimated through a Bayesian approach. Hepatitis C virus diagnosis was assumed to be based on an elevated ALT level detected during a control visit for HIV-infected individuals, which occurred every 3 months (scenario A) or every 6 months (scenario B).

RESULTS

We found that HCV diagnosis occurred after a median of 115 days and 170 days of infection in scenarios A and B, respectively. Among spontaneous clearers, SC occurred after a median time of 184 days after infection. Seven percent (scenario B) to 10% (scenario A) of SCs appeared more than 6 months after diagnosis, and 3% (both scenarios) of SCs appeared more than 1 year after diagnosis.

CONCLUSIONS

Acute hepatitis C diagnosis occurs late in HIV-HCV coinfected individuals. Screening for HCV in HIV-infected individuals should be performed frequently to reduce delays. Our findings about late occurrence of SC support "wait and see" strategies for treatment initiation from an individual basis. However, early treatment initiation may reduce HCV transmission.

Implementation and Operational Research: Computer-Assisted Intervention for Safer Sex in HIV-Positive Men Having Sex With Men: Findings of a European Randomized Multi-Center Trial

OBJECTIVE

Men who have sex with men (MSM) are the key population most affected by HIV in Europe. We performed the first European multicenter, simple-randomized parallel-group study to test the effectiveness of a theory-guided computer-assisted intervention to improve safer sex among HIV-positive men who have sex with men.

METHODS

Between February, 2011 and February, 2013, 112 participants were enrolled in 8 different European HIV-care settings. Intervention participants received 3 individual counseling sessions facilitated by trained service providers using computer-assisted tools. The control-group received sexual health advice delivered as part of regular HIV care. Outcome behavior (self-reported condom use at last intercourse; combined HIV transmission risk score), its influencing factors, and mediating variables were assessed at baseline, and at 3 and 6 months follow-up. Mixed effects models were used to compare primary outcomes (condom use at last intercourse, HIV transmission risk score), and mediation analysis to explore intervention effects.

RESULTS

Condom use at last intercourse increased more among intervention than control participants at 3 months follow-up (odds ratio of 3.83; P = 0.03), but not significantly at 6 months follow-up. Intervention participants reported a lower transmission risk at 3 months follow-up than controls (odds ratio compared with baseline of 11.53 and 1.28, respectively; P = 0.008), but this effect became nonsignificant at 6 months. Intervention effects were mediated by the proximal variables, self-efficacy to negotiate condom use and condom attitudes.

CONCLUSIONS

This intervention showed short-term effectiveness. The intervention should be replicated in other settings, eventually investigating if booster-counseling sessions would yield a longer lasting effect.

Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: a systematic review and meta-analysis

BACKGROUND

Increased global access and use of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behavior. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behavior or diagnosis of sexually transmitted infections (STIs).

METHODS

A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared with no ART use in experimental or observational studies. Primary outcomes included (1) any unprotected sexual intercourse, (2) STI diagnoses, and (3) any unsafe injecting behavior.

RESULTS

Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; 11 studies containing 16 138 participants reported STI diagnoses; and 4 studies containing 1600 participants reported unsafe injecting behavior. All included studies were observational. Unprotected sex was lower in participants receiving ART than in those not receiving ART (odds ratio [OR], 0.73; 95% confidence interval [CI], .64-.83; P < .001; heterogeneity I(2) = 79%) in both high-income (n = 38) and low-/middle-income country (n = 18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR, 0.58; 95% CI, .33-1.01; P = .053; I(2) = 92%); however, there was no difference in injecting risk-taking behavior with antiretroviral use (OR, 0.90; 95% CI, .60-1.35; P = .6; I(2) = 0%).

CONCLUSIONS

Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests that unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, although self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.

High prevalence of sexually transmitted infections in HIV-infected men during routine outpatient visits in the Netherlands

BACKGROUND

In the Netherlands, no guidelines exist for routine sexually transmitted infection (STI) screening of human immunodeficiency virus (HIV)-infected men having sex with men (MSM). We assessed prevalence and factors associated with asymptomatic STI.

METHODS

MSM visiting HIV outpatient clinics of academic hospitals were tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), syphilis, and hepatitis B and C infection. Prevalence and risk factors were studied using logistic regression.

RESULTS

In total, 659 MSM were included between 2007 and 2008. STI were found in 16.0% of patients, mostly anal CT and syphilis. One new hepatitis B and 3 new hepatitis C infections were identified. In multivariate analyses, any STI (syphilis, CT, or NG) was associated with patient's age below 40 years (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.3-5.0), having had sex with 2 or more sexual partners (OR 2.1, 95% CI: 1.2-3.5), the use of the same sexual toys with a sexual partner (OR 2.2, 95% CI: 1.0-4.9), and enema use before sex (OR: 2.3, 95% 1.2-4.2). Syphilis was independently associated with fisting with gloves versus no fisting (OR: 4.9, 95% CI: 1.7-13.7) and with rimming (OR: 5.0, 95% CI: 1.7-15.0). CT or NG were associated with age below 45 years (age 40-44 years: OR: 2.4, 95% CI: 1.1-5.3; age <40 years: OR: 2.4, 95% CI: 1.1-5.4), enema use before sex (OR: 2.4, 95% CI: 1.3-4.4) and drug use during sex (OR: 2.4, 95% CI: 1.4-4.0).

CONCLUSIONS

High-risk sexual behavior was very common, and 16% of HIV-infected MSM in HIV care had an asymptomatic STI, mostly anal CT and syphilis. Development of STI screening guidelines is recommended.

The syphilis epidemics in Hungary 1985-2004, before entering the European Union

In the decade prior to the turn of the millennium, great interest was raised, and rightly so, by the STD (syphilis and HIV/AIDS) epidemic that developed in the Eastern-Central European Region. Its coincidence with the far-reaching political and economic changes that took place at that time suggested a link between the two events.Hungary, where these infections had had low incidence before the period investigated, also experienced an increase in STD incidence. The trend in syphilis infection during the 20 years between 1985-2004, that preceded the turn of the millennium and when finally Hungary joined the European Union, have been analyzed. Due to the nature of venereological epidemiological surveillance in Hungary, syphilis prevalence data are appropriate for further analysis from socio-demographic aspects. Behavioural changes underlying the specific features of the epidemics in Hungary had developed several years earlier and cannot be linked to the political and economic changes that started in the early 90s. The only exception is the phenomenon of growing migration that appeared simultaneously with the political changes and had a decisive impact on the spread and level of infection in some areas in the country. As shown by our data, trends seen in specific demographic groups (females, rural population) preceded the suddenly occurring political changes by about 15 years.

Risk perceptions after human papillomavirus vaccination in HIV-infected adolescents and young adult women

PURPOSE

To examine risk perceptions (perceived risk of human papillomavirus [HPV], perceived risk of other sexually transmitted infections [STIs], and need for safer sexual behaviors) and to determine factors associated with these risk perceptions after HPV vaccination.

METHODS

Data were collected at the baseline visit of an HPV-6, -11, -16, -18 vaccine clinical trial in 16-23-year-old HIV-infected young women (N = 99). Immediately after receiving the first vaccine dose, participants completed a confidential questionnaire that included three 5-item scales measuring perceived risk of HPV, perceived risk of other STIs, and need for safer sexual behaviors. Linear and logistic regression models were used to examine associations between baseline characteristics (demographic characteristics; cluster of differentiation antigen 4 (CD4(+)) count; HIV viral load; knowledge about HPV and HPV vaccines; sexual behaviors; and STI diagnosis) and each measure of risk perceptions.

RESULTS

Most participants perceived themselves to be at lower risk for HPV (mean scale score = 19.5/50), most perceived that they were not at lower risk for other STIs (mean = 31.2/50), and the vast majority reported that there was still a need for safer sexual behaviors after vaccination (mean = 43.1/50). Multivariate analyses indicated that knowledge about HPV and HPV vaccines was associated with perceived need for safer sexual behaviors (OR = 1.05, 95% CI = 1.0-1.1).

CONCLUSIONS

Although almost all young women in this study believed that safer sexual behaviors were still important after HPV vaccination, a subset believed they were at less risk for STIs other than HPV. Educational interventions are needed to prevent misperceptions and promote healthy behaviors after vaccination.

Increasing risk behaviour can outweigh the benefits of antiretroviral drug treatment on the HIV incidence among men-having-sex-with-men in Amsterdam

Background

The transmission through contacts among MSM (men who have sex with men) is one of the dominating contributors to HIV prevalence in industrialized countries. In Amsterdam, the capital of the Netherlands, the MSM risk group has been traced for decades. This has motivated studies which provide detailed information about MSM's risk behavior statistically, psychologically and sociologically. Despite the era of potent antiretroviral therapy, the incidence of HIV among MSM increases. In the long term the contradictory effects of risk behavior and effective therapy are still poorly understood.

Methods

Using a previously presented Complex Agent Network model, we describe steady and casual partnerships to predict the HIV spreading among MSM. Behavior-related parameters and values, inferred from studies on Amsterdam MSM, are fed into the model; we validate the model using historical yearly incidence data. Subsequently, we study scenarios to assess the contradictory effects of risk behavior and effective therapy, by varying corresponding values of parameters. Finally, we conduct quantitative analysis based on the resulting incidence data.

Results

The simulated incidence reproduces the ACS historical incidence well and helps to predict the HIV epidemic among MSM in Amsterdam. Our results show that in the long run the positive influence of effective therapy can be outweighed by an increase in risk behavior of at least 30% for MSM.

Conclusion

We recommend, based on the model predictions, that lowering risk behavior is the prominent control mechanism of HIV incidence even in the presence of effective therapy.

Occurrence, risk factors, diagnosis and treatment of syphilis in the prospective observational Swiss HIV Cohort Study

BACKGROUND

Annual syphilis testing was reintroduced in the Swiss HIV Cohort Study (SHCS) in 2004. We prospectively studied occurrence, risk factors, clinical manifestations, diagnostic approaches and treatment of syphilis.

METHODS

Over a period of 33 months, participants with positive test results for Treponema pallidum hemagglutination assay were studied using the SHCS database and an additional structured case report form.

RESULTS

Of 7244 cohort participants, 909 (12.5%) had positive syphilis serology. Among these, 633 had previously been treated and had no current signs or symptoms of syphilis at time of testing. Of 218 patients with newly detected untreated syphilis, 20% reported genitooral contacts as only risk behavior and 60% were asymptomatic. Newly detected syphilis was more frequent among men who have sex with men (MSM) [adjusted odds ratio (OR) 2.8, P < 0.001], in persons reporting casual sexual partners (adjusted OR 2.8, P < 0.001) and in MSM of younger age (P = 0.05). Only 35% of recommended cerebrospinal fluid (CFS) examinations were performed. Neurosyphilis was diagnosed in four neurologically asymptomatic patients; all of them had a Venereal Disease Research Laboratory (VDRL) titer of 1:>or=32. Ninety-one percent of the patients responded to treatment with at least a four-fold decline in VDRL titer.

CONCLUSION

Syphilis remains an important coinfection in the SHCS justifying reintroduction of routine screening. Genitooral contact is a significant way of transmission and young MSM are at high risk for syphilis. Current guidelines to rule out neurosyphilis by CSF analysis are inconsistently followed in clinical practice. Serologic treatment response is above 90% in the era of combination antiretroviral therapy.

Public sexual cultures: a systematic review of qualitative research investigating men's sexual behaviors with men in public spaces

Resurgent HIV and sexually transmitted infection incidence among men who have sex with men (MSM) requires an urgent re-examination of sexual transmission sites. To these ends, we systematically review qualitative literature concerning men's sexual behaviors within public sex environments (PSEs). Sex, therein, is negotiated by the highly codified, largely nonverbal practice of "cruising." A generic, shared PSE sexual culture emerges from the literature-across locations, countries, and decades-because of the importance of concealment and common structural constraints on sexual encounters in PSEs. However, differences in local geography and facilities may transform key features of this, resulting in specific, local sexual cultures emerging for each locale. We argue that, although sexual cultures developed to minimize nonsexual cruising risks, they may be exploited to improve contemporary in situ outreach work.

Trends in hepatitis A, B, and shigellosis compared with gonorrhea and syphilis in men who have sex with men in Amsterdam, 1992-2006

BACKGROUND

Since the mid-1990s, sexually transmitted infections (STIs) among men who have sex with men (MSM) have increased and appear to be related to more risky sexual behavior. We compare trends in hepatitis A, acute hepatitis B, and shigellosis with the trends of gonorrhea and infectious syphilis in Amsterdam MSM more than a period of 15 years.

METHODS

We used data of all reported hepatitis A, acute hepatitis B, and shigellosis, and from all patients newly diagnosed with gonorrhea and infectious syphilis who visited the Public Health Service STI outpatient department in Amsterdam between January 1, 1992 and December 31, 2006.

RESULTS

Hepatitis A incidence remained unchanged in MSM (mean 0.97 per 1000 MSM, range 0.04-2.27), who had 21% of all 1697 infections. Hepatitis B likewise remained unchanged in MSM (mean 0.47 per 1000 MSM, range 0.19-0.77), who had 41% of all 448 infections. Most shigellosis is travel-related (657/974), and 16% of the infections occurred in MSM. Its incidence dropped in general, but not in MSM. Both gonorrhea and infectious syphilis in MSM show a steep increase, mainly after 1998.

DISCUSSION

Hepatitis A, B, and shigellosis do not follow the rising trends of conventional STI in MSM, which are believed to result from increased risky sexual behavior. This disparity in trends implies differences in transmission dynamics. Recent molecular epidemiologic studies suggest that clustered transmission in social MSM networks plays a major role.

Sexually transmitted infections in Western Europe among HIV-positive men who have sex with men

BACKGROUND

Since 1996, there has been a resurgence in sexually transmitted infections (STIs) among men who have sex with men (MSM) in Western Europe. This has coincided with a significant decrease in HIV-associated mortality following the introduction of highly active antiretroviral therapies (HAART) and a corresponding increase in the number of MSM living with HIV. Levels of unprotected anal intercourse have also increased. In this article, we use STI surveillance data from a number of Western European countries to better understand the contribution of HIV-positive MSM to the recent increase in STIs.

METHODS

Published literature, surveillance reports, and ad hoc publications relating to HIV prevalence trends and STIs among HIV-positive MSM in Western Europe were reviewed.

RESULTS

Post-HAART, HIV prevalence among community samples of MSM ranged from 5% to 18%. HIV prevalence among MSM diagnosed with an STI was substantially higher. On average, HIV prevalence among MSM diagnosed with syphilis in 11 countries was 42% (range 14%-59%). Most HIV-positive MSM with syphilis were aware of their HIV status. In England and Wales, 32% of MSM with gonorrhea were HIV-positive in 2004. Outbreaks of lymphogranuloma venereum have been documented in 9 countries; HIV-positive MSM accounted for 75% of cases on average (range 0%-92%). Cases of sexually transmitted hepatitis C have been predominantly identified among HIV-positive MSM in Rotterdam, Paris, Amsterdam, and the United Kingdom.

CONCLUSIONS

In Western Europe, STIs have been disproportionately diagnosed among HIV-positive MSM post-HAART. Improved survival coupled with serosorting among HIV-positive MSM appears to explain the high prevalence of HIV among MSM with STIs. STI transmission among HIV-positive men will have contributed substantially to increasing STI trends seen among MSM in Western Europe, since 1996. These findings highlight the need for routine STI testing among HIV-positive MSM as well as safer sex messages highlighting the implications of STI coinfection.

Association between risk of acquiring HIV and beliefs and perceptions about the lived experience of HIV/AIDS among HIV-negative or untested men who have sex with men

The study aim was to assess whether the sexual behaviour of HIV-negative or untested men who have sex with men (MSM) was related to their perceptions of what it is like to live with HIV/AIDS, their beliefs or their attitudes to highly active antiretroviral treatments. Any unprotected anal intercourse (UAI) with casual partners was used as the sexual-risk indicator. The study enrolled 261 MSM. There were no significant differences between beliefs, attitudes and perceptions about HIV/AIDS, knowledge of post-exposure prophylaxis (PEP) or exposure to the HIV/AIDS epidemic among those who had had UAI with casual partners and those that had not (P>0.12). Those who considered that low levels of viral load and withdrawing before ejaculation reduced the risk of HIV transmission were significantly more likely to have had UAI with a casual partner (P=0.03). Only a minority of MSM engaging in UAI were optimistic about antiretroviral therapy. The study participants were in general pessimistic about life with HIV/AIDS despite their risk-taking sexual behaviour.

Cruising for sex: Sexual risk behaviours and HIV testing of men who cruise, inside and outwith public sex environments (PSE)

This paper describes sexual risk behaviours and HIV testing amongst men who cruise an urban public sex environment (PSE) in southern England. Data were collated using a cross-sectional survey (response rate = 56%; n=216), sampling men from directly within the PSE. As such, this represents the first peer-review study generalizable to the wider population of urban PSE users. The current sample reflect a highly sexually active population, almost one-third (31%) reported over 50 sex partners in the last year. However, just one-quarter (26%) reported unprotected anal intercourse (UAI) with at least one partner outside of a 'safer sexual strategy'. Almost 1 in 12 (7%) reported UAI within the PSE. Over two-thirds (71%) had had a named HIV test of whom 16% had tested HIV positive. Just one-third (34%) of negative/untested PSE users had tested within the previous two years. Positive men were significantly more likely to report unsafe sex within the PSE in the last year. PSE users report lower levels of UAI than men in the local gay community but higher HIV prevalence. PSE-based UAI remains an HIV (re)infection risk. In concert, these findings suggest the importance of in situ targeted health promotion to prevent PSE-based risks.

Factors associated with unprotected sexual intercourse with steady male, casual male, and female partners among men who have sex with men in Barcelona, Spain

To increase understanding of the HIV epidemic among MSM in Barcelona, anonymous questionnaires were completed by 640 MSM recruited in the city in 2002. The prevalence of unprotected anal intercourse (UAI) with casual male partners in the prior 12 months was higher among self-reported HIV-positive men (confirmed through saliva testing) than among men who were HIV-negative or of unknown serostatus (35% vs. 20%, p < .01). The prevalence of UAI with steady male partners was substantially lower among HIV-positive men than other men (28% vs. 60%, p < .01). In multivariate analyses, UAI with casual partners was more likely among HIV-positive individuals; those who used drugs before sex; perceived less acceptance of their sexual orientation by family, friends, or coworkers; and were less concerned about HIV prevention because of antiretroviral therapy (ART). UAI with steady partners was more likely among HIV-negative men with seroconcordant partners, those living with a partner, and men less concerned about HIV prevention because of ART. Findings indicate a need for prevention programs targeting HIV-positive MSM in Barcelona. Attention to substance use and attitudes about HIV prevention are needed for MSM in general.

The impact of the transmission dynamics of the HIV/AIDS epidemic on sexual behaviour: a new hypothesis to explain recent increases in risk taking-behaviour among men who have sex with men

Increases in sexually transmitted infections and related high-risk behaviours have been reported among men who have sex with men (MSM) in industrialised countries when effective antiretroviral therapy against HIV infection has become widely available, in the mid-nineties. The reasons for these increases are not fully understood and often conflicting. Prevention fatigue, relapses to unsafe sex, as well as optimism toward the risk of developing AIDS among people living with HIV are not unique to the era of antiretroviral therapy (ART). This has led researchers to highlight the need to investigate other potential reasons that could explain the increase in high-risk taking following the ART introduction. We put forward the hypothesis that the change in the transmission dynamics of the HIV/AIDS epidemic before and after the introduction of ART has contributed to this change in high-risk behaviour. It is suggested that a decline in sexual risk activities has occurred at the population-level following the initial spread of the HIV/AIDS epidemic because AIDS mortality and severe morbidity disproportionately depleted the pool of high-risk taking individuals. As a result, non-volitional changes may have occurred at the individual-level over time because the depletion of this pool of high-risk individuals made it more difficult for the remaining high-risk taking individuals to find partners to engage in risky sex with. Following its introduction, ART has facilitated the differential replenishment of the pool of individuals willing to engage in high-risk taking behaviours because ART reduces AIDS mortality, and morbidity. Consequently, high-risk taking individuals who had previously reduced their level of risky sex non-volitionally (i.e., as a result of the reduced availability of high-risk partners) were able to resume their initial high-risk practices as the pool of high-risk taking individuals replenished over time. Thus, a fraction of the recently reported increase in high-risk sexual activities may be secondary to the fact that those MSM who were unable to engage in their desired high-risky sexual activities (because of reduced availability) are now able to revert to them as the availability of men willing to engage in risky sexual behaviours increases partly due to ART. Therefore, we suggest that a fraction of the changes in individual behaviour are non-volitional and can be explained by a change in "sexual partner availability" due to the transmission dynamics of HIV/AIDS before and after ART. The hypothesis is formulated and explained using simple social network diagrams and the Theory of Planned Behaviour. We also discuss the implication of this hypothesis for HIV prevention.

Increasing rates of sexually transmitted diseases in homosexual men in Western europe and the United States: why?

The recent increases in acute STDs among MSM must be viewed in the context of a post-AIDS era that is characterized by demographic shifts,changing sexual attitudes, and rapidly changing social contexts. A key driver seems to be the growing prevalent pool of HIV-positive MSM for whom the crucial motivator for safer sex (primary HIV prevention) no longer exists and where, given the prevalence of seroconcordant sexual mixing, consider-able uncertainty and conflicting advice regarding the rationale and benefits for continued safer-sex practice are unclear [105,106]. Although it is tempting to ascribe these changes to increases in risk behavior, it is essential that the contexts in which the changes are occurring are also considered. It may also be appropriate to contemplate whether further changes to the social environment (eg, structural interventions) are a suitable adjunct to our traditional prevention activities that operate largely in isolation from each other. It seems natural to advocate that interventions that adopt holistic approaches to the sexual health of MSM and that address upstream factors such as mental health, drug use, discrimination, and internalized homophobia should be included in the efforts to create more healthy environments for MSM. However, there is still some way to go in identifying which of these upstream interventions are effective, how they may be implemented within or alongside existing health care systems, and what impact, if any, they are likely to have on STD transmission. Such interventions are also likely to belong on implementation time, require consider political will, and be extremely hard to evaluate, and the benefits may not be seen within the same generation in which they are implemented. Therefore, there must be confidence that this is the appropriate route of travel. The consistency of findings from across industrialized countries confirms an increasing connectivity within the global MSM community;a community that is decreasingly defined by geographic boundaries and, in the era of the Internet and easier foreign travel, increasingly linked by shared interests and social and sexual networks. This is powerfully demonstrated in the near-simultaneous syphilis and LGV outbreaks among MSM in Europe and the United States [29]. In this regard, greater collaboration between researchers and providers working with MSM indifferent countries is now required. More specifically, consideration should be given to creating closer partnerships between sentinel cities, such as London, New York, San Francisco, Berlin, Paris, and Amsterdam, that have large MSM populations and are likely to be emerging, or rapid diffusion sites for new social and sexual trends that may impact on disease transmission. There are many benefits to such cross-national working,including earlier recognition and improved response to emerging threats,sharing innovative practice, avoiding duplication of effort, and creating a united front for dealing with what must be considered a cause for concern domestically and globally.

Evolución de la prevalencia de infección por el VIH y de las conductas de riesgo en varones homo/bisexuales

OBJECTIVES

To describe trends in the prevalence of HIV infection, in risk behaviors and in knowledge and attitudes related to antiretroviral therapy (ART) among men who have sex with men (MSM) recruited in Barcelona (Spain) between 1995 and 2002.

METHODS

Cross-sectional surveys were conducted twice yearly from 1993. MSM were recruited in saunas, sex-shops, a cruising site in a public park and by a mailing sent to all members of a gay organization, using an anonymous self-administered questionnaire. From 1995 saliva samples were requested to determine the prevalence of HIV infection.

RESULTS

The prevalence of HIV infection remained stable from 14.2% in 1995 to 18.3% in 2002 (p > 0.05). The proportion of men who had more than 10 sexual partners in the previous 12 months showed an increasing trend (from 45.2% in 1995 to 55.7% in 2002, p < 0.0001). Unprotected anal intercourse (UAI) with casual partners did not change significantly between 1995 and 2002 (25.8% en 2002). In 2002, 55.8% of steady couples in which one or both members did not know their serological status and 27.5% of serodiscordant couples reported UAI. The proportion of men who believed that "HIV-positive persons taking ART (7.7% in 2002) or with undetectable viral load (6.4% in 2002) cannot transmit the virus" remained steady since 1998 (p > 0.05).

CONCLUSIONS

The prevalence of HIV and risk behaviors continues to be high among MSM in Barcelona. A strategic objective in the control of the HIV epidemic must be to continue the decrease in the number of occasions on which UAI takes place between men with discordant serological status.

Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study

BACKGROUND

Infection with human papillomavirus (HPV) is causally linked to the development of anal and cervical cancer. In the United States, the incidence of anal cancer among men who have sex with men (MSM) is higher than the incidence of cervical cancer among women. Anal squamous intraepithelial lesions (ASILs) are anal cancer precursors comprising low-grade squamous intraepithelial lesions (LSILs) and high-grade squamous intraepithelial lesions (HSILs). The prevalence of cervical cancer precursor lesions peaks at around 30 years of age. The age-related prevalence of ASILs in HIV-negative MSM is unknown.

METHODS

We conducted a cross-sectional analysis of the prevalence and determinants of ASILs in 1262 HIV-negative MSM aged 18-89 years recruited from four U.S. cities. Anal cytology and behavioral data were obtained. Anal HPV infection status was assessed by polymerase chain reaction. Independent predictors of ASILs were identified using logistic regression. All statistical tests were two-sided.

RESULTS

The prevalences of LSILs and HSILs were 15% and 5%, respectively, and did not change with age. In a multivariable analysis, the risk of LSILs was associated with having more than five male receptive anal sex partners (P = .03), any use of poppers (alkyl nitrites) in the previous 6 months [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.1 to 2.5; P = .03] or use of injection drugs two or more times per month during the previous 6 months [OR = 19, 95% CI = 1.3 to 277; P = .03], older age at first receptive anal intercourse (P = .004), and infection with a greater number of HPV types (P < .001 for linear trend). The risk of HSILs was associated with any anal HPV infection (OR = 3.2, 95% CI = 1.1 to 9.4; P = .039) and infection with an increasing number of HPV types (P < .001 for linear trend).

CONCLUSIONS

Sexually active HIV-negative MSM in all age groups have a high prevalence of ASILs, possibly reflecting their ongoing sexual exposure to HPV.

Men who have sex with men (MSM) in public sex environments (Pses): a systematic review of quantitative literature

We systematically review quantitative research relating to the sexual behaviours of MSM in PSEs. We examine the methodological rigour of these studies to determine an appropriate framework for future PSE-based research and quantify sexual behavioural trends therein. Medline, BIDS, Web of Science and recent HIV/AIDS conferences were searched according to a systematic inclusion criteria. Nine papers were included for review. Recruitment of participants' outwith PSE settings, and low response rates (6%) of participants contacted in situ, question the validity and generalizability of current evidence. Most PSE users were gay or bisexually identified and half of men in the gay community reported recent PSE use. Around 10% of men reported casual status-unknown/serodiscordant unprotected anal intercourse (UAI) within PSEs. HIV testing rates amongst PSE users were similar to the wider gay community, though the proportion of men who tested positive was twice as high. Rates of casual UAI suggest that PSEs represent important sites for HIV prevention. However, since extant evidence is scant and methodologically flawed, further research is urgent. Such work must recruit participants in situ, and obtain satisfactory response rates, to be generalizable to the wider population of men who cruise.

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.

Predictors of substance use frequency and reductions in seriousness of use among persons living with HIV

AIMS

To examine predictors of the current level of substance use and reductions in seriousness of substance use among adults living with HIV.

DESIGN

Cross-sectional survey.

SETTING

Four major metropolitan areas of the United States.

PARTICIPANTS

Three thousand eight hundred six adults living with HIV.

MEASUREMENT

Self-reported substance use, depression, and quality of life from audio computer assisted self-interviewing and computer assisted personal interviewing structured assessments.

FINDINGS

Recent substance use of persons living with HIV was classified as frequent (40%), occasional (32%), or abstinent (28%). Participants using drugs at a frequent level identified as heterosexual, had public insurance, and had higher levels of depression. Participants who reduced from a lifetime high seriousness in substance use were female, older, and knew their HIV status for a longer period of time.

CONCLUSIONS

Screening and identification of substance use should be included in all treatment settings and community-based organizations serving adults living with HIV.

Resurgence of Lymphogranuloma Venereum in Western Europe: An Outbreak ofChlamydia trachomatisSerovar L2Proctitis in The Netherlands among Men Who Have Sex with Men

BACKGROUND

Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) and is rare in the Western world. Recently, 3 men who have sex with men presented with LGV proctitis at the Erasmus Medical Center, Rotterdam, The Netherlands. We investigated a possible outbreak in a sexual network of men who have sex with men (MSM).

METHODS

After active case finding, a total of 15 men presented and were investigated. Serum antibody titers to Chlamydia trachomatis were determined. Urine and rectum specimens were analyzed by polymerase chain reaction (PCR) for the presence of C. trachomatis. C. trachomatis-positive specimens were genotyped to detect the specific C. trachomatis serovars. All subjects underwent routine STD screening. Sociodemographic, clinical, and endoscopic characteristics were evaluated.

RESULTS

Thirteen subjects had high immunoglobulin (Ig) G and IgA titers to C. trachomatis, suggesting an invasive infection. Rectal specimens of 12 subjects were PCR-positive for C. trachomatis. All urine specimens were negative. Genotyping revealed serovars L(2) (n=8) and L(1) (n=1). An ulcerative proctitis was found in all subjects obtaining sigmoidoscopy (n=9). Eleven of 13 subjects with an LGV diagnosis were seropositive for human immunodeficiency virus (HIV), 6 had another concomitant STD, and 1 had recently acquired a hepatitis C virus infection. Further sexual contacts were reported from The Netherlands, Germany, Belgium, the United Kingdom, and France.

CONCLUSIONS

We revealed an outbreak of LGV proctitis among MSM in The Netherlands. The ulcerous character favors transmission of HIV, other STDs, and blood-borne diseases. From a public health perspective, it seems important to increase the awareness of possible LGV in MSM with symptomatic proctitis.

Recent trends in the epidemiology of sexually transmitted infections in the European Union

Sexually transmitted infections (STIs) are a major public health problem in Europe. We review recent trends in the epidemiology of the major acute STIs in the European Union and Norway, their key determinants, and opportunities for enhancing STI prevention interventions in the region.

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.

An outbreak no longer: factors contributing to the return of syphilis in Greater Manchester

BACKGROUND

In the past few years, increased diagnoses of syphilis have been reported in cities around Britain and Europe. Enhanced surveillance of cases began in 1999 to identify the epidemiology of this increase in Greater Manchester.

METHODS

Information was collected on all cases of syphilis newly diagnosed in genitourinary medicine (GUM) clinics in Greater Manchester between January 1999 and November 2002. The data collected included demographic information and information about other sexually transmitted infections, sexual behaviour, perception of risk of infection, and awareness of syphilis transmission.

RESULTS

The majority of cases identified were white homosexual men resident in Greater Manchester. Of the 414 cases diagnosed, 74% had either a primary or secondary stage of syphilis infection and 37% of cases were HIV positive. High numbers of individuals practised unprotected oral sex despite good awareness of the risk of infection with syphilis. There is evidence that the way people are meeting sexual contacts is changing, with increasing numbers meeting most of their partners through the internet.

CONCLUSIONS

These findings have implications for targeting interventions. The provision of rapid diagnostic and treatment services is likely to be key for the control of syphilis and potentially of subsequent increases in HIV in the region.