Record numbers of UK gay men test positive for HIV

 

• Almost half of new cases are gay or bisexual males
• Up to 10,000 unaware of their infection, says study

The number of gay men being diagnosed with HIV has reached a record high in the UK, according to the Health Protection Agency (HPA).

One in 20 gay men and men who occasionally have sex with men are HIV positive in the UK – and in London, the ratio is as high as one in 12. Part of the reason for the observed rise is increased testing, but, says the HPA, it is also clear that too many men are unaware that they have HIV and are unknowingly infecting others.

“About 8,000 to 10,000 gay men are HIV positive and unaware of their status,” said Dr Valerie Delpech, the HPA’s head of HIV surveillance.

According to the HPA’s annual report, released on Thursday in advance of World Aids Day on Saturday, 3,010 men who have sex with men were newly diagnosed with HIV in 2011 – 47.9% of all new diagnoses in the UK. The numbers have remained high since 2007.

Men who have tested positive and been put on drug treatment, which can keep them healthy and give them a normal lifespan, are unlikely to be infectious. Trials have shown that treatment has a role to play in preventing the spread of the epidemic – the drugs reduce the levels of virus in somebody with HIV to such a low level that they are unlikely to transmit the infection to a sexual partner.

The HPA and organisations for those diagnosed with HIV are all advocating regular testing for anybody at risk. Gay men and other men who have sex with men should take an annual test, they say – and if they have new or casual partners, they should be tested every three months.

Living a long and healthy life with HIV depends on starting treatment early. “People are still starting late: they are infected for three to five years before they are diagnosed,” said Delpech. People who are diagnosed as HIV positive late are at 10 times the risk of dying within a year of discovering they have the infection. They are also more likely to infect people while they remain unaware of their status.

The black African community in Britain also faces a higher risk than average, with 37 out of every 1,000 living with HIV last year. Far more men and women in the black African community are diagnosed late than gay men – 68% and 61% respectively, compared with 35%.

The HPA is recommending safe-sex programmes promoting condom use and annual HIV testing as a priority for this community as well as for men who have sex with men. They want NHS clinicians to take every opportunity to offer testing to those at higher risk.

The total number of people in the UK living with HIV climbs steadily every year because treatment is keeping more people alive. Including both diagnosed and undiagnosed cases, it has now reached 96,000, with a total of 6,280 new diagnoses in 2011.

Nearly half of all new diagnoses were acquired heterosexually. More than half of all new UK infections were acquired while the subject was in Britain, compared with 27% in 2002: the small drop in new infections last year, from 6,400 in 2010 to 6,280 last year, was because of the drop in the number of people who had been infected abroad.

Deborah Jack, chief executive of the National Aids Trust, said: “What is striking about the HPA’s data is how it really shows both our successes and our shortcomings in tackling HIV in the UK. On the one hand, we can hail treatment as a real success story. Treatment is effective, people diagnosed with HIV can access it easily and it is working in keeping the virus under control.

“However, when it comes to increasing the uptake of testing – the gateway to treatment – our services are patchy, inconsistent and ultimately we are still failing to make any significant headway in tackling the high rates of undiagnosed HIV.

“A quarter of people living with HIV are unaware they have the virus. As long as this figure remains high, new infections will continue to occur. We must increase our efforts in encouraging people to test and making sure that the health service is taking advantage of every single avenue in offering an opportunity to test – something that isn’t happening at the moment.”

Sir Nick Partridge, the chief executive of the HIV/Aids charity the Terrence Higgins Trust, spoke up for safe sex and said that testing could add 40 years to a person’s life. “HIV is an entirely preventable condition, yet each year we see thousands more people across the UK receive this life-changing diagnosis,” he said. “While there is still no cure and no vaccine, that doesn’t mean we need to accept its continuing march.”

Original Story via Sarah Boseley, health editor at The Guardian

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US Regulators Vote For Approval of PrEP by Large Majority

The US Food and Drug Administration (FDA) took a decisive step yesterday towards approving the use of combination pill Truvada(tenofovir/FTC) as a prevention method for HIV-negative people.

The FDA’s Antiviral Drugs Advisory Committee (ADAC) voted by a majority of 19 to 3 in favour of recommending Truvada as PrEP (pre-exposure prophylaxis) for men who have sex with men, and by 19 to 2 with one abstention for an approval for use by the HIV-negative partner in serodiscordant couples.

There was a close vote, however, when it came to recommending its use generally in individuals for people at risk of HIV infection: 12 to 8, with two abstentions, voted for a general recommendation for any person at risk of HIV.

The ADAC decision was taken after an all-day meeting on 10 May. This meeting discussed the findings of a written report and also heard submissions from a large number of community prevention and treatment advocates. Interest was such that the FDA extended the time for submissions from advocates and community members from one hour to two and had to organise a ballot for access to the hearings.

The written report had concluded that concerns about safety and HIV drug resistance were not sufficient to delay the introduction of PrEP. It also decided that concerns about poor adherence levels seen in some randomised controlled trials, and about whether PrEP would negatively influence behaviour to such a degree that people ended up at greater risk of HIV, were beyond the remit of the FDA.

“I don’t think it’s our charge to judge whether people will take the medicine,” panellist Dr Tom Giordano told the Los Angeles Times. “Our charge is to judge whether it works when taken.”

Considerations of cost are also explicitly ruled out of the FDA’s remit when it comes to approving a new drug or indication.

The FDA is not bound to follow the recommendations of its advisory committees and will make a final decision by 15 June. However it is very rare for it not to do so and the large majority in favour of its approval for gay men and in serodiscordant couples makes this unlikely.

PrEP has always excited controversy amongst HIV prevention advocates and people affected by HIV. Some organisations have opposed its introduction and the AIDS Healthcare Foundation, in particular, has mounted a provocative campaign against its approval. “If you love Vioxx you’ll love PrEP,” read one poster displayed on bus shelters near the White House, referring to the painkilling drug that was withdrawn in 2004 when it was linked to heart attacks.

The majority of HIV prevention advocates, however, has supported PrEP. Mitchell Warren of the AIDS Vaccine Advocacy Coalition (AVAC) commented: “Some funders and policy makers have been awaiting a signal from the FDA before launching demonstration projects or developing implementation plans.

“The time for waiting is over. We need to get on with the work of setting priorities and rolling out PrEP to people who can benefit the most.”
The controversy was if anything reinforced when the randomised controlled trials (RCTs) of PrEP that have reported in the last 18 months –iPrEX, Fem-PrEP, Partners PrEP and TDF2 – produced strikingly different results, with headline efficacy levels ranging from zero (in Fem-PrEP) to 83% (for men in Partners PrEP). Studies of drug levels found that these results could be explained by different levels of adherence in trial participants. PrEP was 92% efficacious in participants in iPrEx who had detectable levels of drug in their blood, and it is clear that adherence levels will crucially determine whether it protects the people who take it.

At present randomised controlled trials have only tested daily doses of PrEP, though a study in France, IPERGAY, is currently testing its efficacy in gay men when taken on a before-and-after-sex basis.
In contrast concerns about negative behaviour change and participants putting themselves at greater risk of HIV have not been supported by RCT findings, but it is recognised that these will only be answered by an open-label study in which people know for sure that they are taking the drug and not a placebo.

Such a study, called PROUD, has been suggested for the UK and is awaiting a decision on approval. In this study gay men attending genitoruinary medicine clinics in the UK who are at significant risk of HIV will be offered TruvadaPrEP plus a package of behavioural support and counselling, but will be randomised to receive the PrEP component either immediately or a year later.

Principal Investigator of the proposed study, Dr Sheena McCormack of the UK Medical Research Council (MRC), told Aidsmap: “It is unusual for the MRC to talk publicly about a trial before it receives approval, but in the case of PrEP it is so important that the trial involves and is supported by its target community.”

Original article by Gus Cairns at Nam

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PrEP acceptable to UK gay men, studies find

Pre-exposure prophylaxis (PrEP) would be an acceptable HIV prevention strategy for large numbers of gay, bisexual and other men who have sex with men in major UK cities, according to two studies presented to the British HIV Association (BHIVA) conference in Birmingham this week.

The conference also heard details of a small pilot PrEP study, likely to start recruiting later this year.

A cross-sectional survey of 842 HIV-negative gay and bisexual men, recruited at bars, clubs and saunas in London, suggested that half the respondents would be interested in taking PrEP.

Respondents were given information about pre-exposure prophylaxis and asked: “If PrEP were available, how likely is it that you would take a pill (oral dose) on a daily basis to prevent HIV infection?”.

Half said yes, with 16% saying they were likely to take PrEP and 34% saying they were very likely to. Men interested in PrEP were slightly more likely to be under the age of 35 (AOR adjusted odds ratio 1.58), have attended a sexual health clinic in the past year (AOR 1.59) and to have previously taken post-exposure prophylaxis (PEP) (AOR 1.96). After statistical adjustment, various measures of risky sex were no longer associated with interest in PrEP.

In this survey, 17 men (2.1% of those answering the question) said that they had previously taken antiretroviral drugs to reduce their risk of HIV infection.

Secondly, clinicians at the Manchester Centre for Sexual Health surveyed HIV-negative men attending their service who reported unprotected receptive anal intercourse. Of the 121 men who responded, 36% said they would be “very willing” to take PrEP while only 14% said they would not take the treatment. Daily dosing was perceived as a better option by four fifths of respondents – just one fifth would prefer taking a dose before sexual activity.

These data confirm and reinforce findings from a study reported in November 2011, which found that half the gay men surveyed would consider taking PrEP. Once again, daily dosing was preferred to taking a dose before sex. In the qualitative data, men commented that sex is often spontaneous and that they felt daily dosing would facilitate adherence.

However these data are all based on giving men a few key facts about PrEP and presenting it as a hypothetical option. In real-life circumstances, where men think more seriously about PrEP as an option and hear friends’ experience of taking it, actual uptake and sustainability may be very different.

While the Manchester respondents largely assured the researchers that they would take all their doses of PrEP and wouldn’t have more risky sex, real-life experience needs to be tested in research.

To this end, the Medical Research Council are seeking funding for a 5000-participant, two-year study which would randomise HIV-negative gay men who report unprotected anal intercourse to either take PrEP (Truvada) and attend motivational interviewing (intervention group) or to be put on a one-year waiting list for PrEP and to have motivational interviewing in the meantime (control group).

For the researchers, it is crucial that this is an open label but randomised study, in which participants know whether they are receiving the actual drug. This unusual research design would, they argue, tell us more about the real-world effectiveness of PrEP than a blinded study as it would take into account the possible impact of participants taking more sexual risks because they felt that PrEP afforded some protection. (Researchers call this ‘risk compensation’ or ‘behavioural disinhibition’).

Rather than test efficacy in artificial conditions, the study would therefore test effectiveness in more realistic UK conditions.

So far, however, the potential funders of this costly study have not been persuaded by this argument and it is unclear whether the study will be able to go ahead.

What will, however, start recruiting later this year is a pilot version of the same study, aiming to include 500 men who attend one of around twelve sexual health clinics.

As well as allowing the researchers to have a dry run of the main trial and identify teething problems with its strategy, it should also provide valuable information on the number of men who actually follow through on a clinician’s offer of PrEP. Data on the characteristics of men who seek PrEP, drop-out rates and risk compensation will also be collected.

The researchers intend to take some of these data back to the main study’s potential funders, in order to support a revised application.

Acceptability of taking HIV treatment for prevention purposes

As well as asking people hypothetical questions about PrEP, researchers have also been asking people waiting for an HIV test result hypothetical questions about treatment as prevention.

Individuals from high-risk groups attending the Jefferiss Wing at St Mary’s Hospital for HIV testing were given an explanatory paragraph about treatment, infectiousness and safer sex. They were then asked: “If you were diagnosed with HIV would you consider taking treatment to reduce the risk of passing on infection (even if you did not need to take treatment for your own health)?”.

Four out of five respondents said ‘yes’. Encouragingly, gay men who reported unprotected anal intercourse in the past three months were more likely than others to be interested in the idea. Less encouragingly, people who had had a sexually transmitted infection or who had previously taken PEP were slightly less likely to say that they would take treatment for prevention.

The researchers suggested that the latter factor may be associated with PEP users’ experience of side-effects. It contrasts with the findings of the London PrEP attitudes study described above which found people who had previously taken PEP more likely to be interested in PrEP.

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Charities criticise London ‘failing’ HIV prevention programme

Charities have criticised the way HIV services in London are commissioned following the release of a report which highlights “significant management failings” and a “lack of strategy”.

The report said there was "an urgent need to address HIV prevention in London"

The Pan London HIV Prevention Programme (PLHPP) Needs Assessment report highlights “failings” of the pan London HIV commissioning group, which spends £2.3m a year.

HIV treatment in London costs £500m with almost 30,000 people accessing care and that number rising by 5% annually.  The PLHPP provides prevention work targeting gay men and African communities and treatment information for people with HIV.

HIV prevention charity African Health Policy Network (AHPN) chief Francis Kaikumba said he was “shocked, annoyed and heads need to roll” in light of the report.  Meanwhile, Caspar Thomson, director of the National Aids Manual, which provides information on HIV and Aids, said: “The whole process is moving too slowly. There’s an urgent need to address HIV prevention in London.”

But Mark Creelman, director of strategy at Inner North West London Primary Care Trusts (INWL PCTs), which leads the pan London HIV commissioning group, said: “We are working to ensure the programme has the right leadership and the right governance in place to be as effective as possible.”
‘Crisis level’

The needs assessment report was prepared by the INWL PCTs on behalf of the Pan London HIV commissioning group and will be used to guide future commissioning intentions.

It identified “significant failings with the management of the programme” and said “providers have fallen far short of their activity targets”.

HIV IN LONDON

•     Almost 30,000 people with HIV accessing care in London
•     About 26% of Londoners affected with HIV remain undiagnosed
•     People diagnosed with HIV rising by 5% annually
•     46% of those diagnosed in London are men who have sex with men
•     Black Africans make up 5.5% of London population but 32% of those newly diagnosed with HIV
•     Treatment costs are £500m per year.

Failings identified by the report included “a lack of clarity over leadership” and “inconsistent direction from commissioners”.  The programme “appears to have evolved over time without any explicit strategic direction”, the report said.

Mr Thomson responded to the report saying: “Over the course of the years of the programme, I think the strategic direction was lost.”

Mr Kaikumba said: “HIV prevention work in London is at an all-time crisis level. Where is the accountability? Why has there been a lack of leadership?” he asked.

“Heads need to roll in terms of what the PLHPP is going to do about it.”

But Mr Creelman said: “The basis for the needs assessment was to give us a more strategic direction.

“Across commissioning and providers, we have a joint responsibility to ensure we’re spending taxpayers’ money effectively.”  Francis Kaikumba, head of the AHPN AHPN chief Francis Kaikumba says the proportion of money going towards Black Africans is “poor”

The report highlights the need for an “urgent” exercise “to inform commissioning intentions”.  Another report, entitled PLHPP Final Evaluation Report, published last February, showed of 17 projects commissioned, only two “merited continued commissioning”.

A total of 11 were said to “merit no further investment” while four needed “fundamental restructuring”.  Nevertheless, these projects all continue to receive funding through the programme, nearly a year after the report was published.

Mr Thomson stressed the need for urgent action, saying: “Organisations are under threat because of the delays and if some of them go a huge amount of knowledge and expertise will be lost.”

But Mr Creelman said: “The needs assessment is very much the start of the process.  We understand the urgency but we wanted to make absolutely sure within the evidence that has been collected, that organisations look at the needs assessment.”

Contributors to the report now have until 6 February to comment further, before new commissioning intentions are “developed”.

The needs assessment report also highlighted that the PLHPP spends £320,000 per year on the black African community, compared with £1.3m on “men who have sex with men”.

“Spend targeted at the black African population appears disproportionately low” the report said.

Mr Kaikumba said: “The amount of money that goes towards Black African work is ridiculous – it’s really poor.  We’re shocked and annoyed how few pennies are being spent to support black Africans with HIV,” he said.

But Mr Creelman said: “The needs assessment supports that Black African work is much better served by being done at a local level.  Lots of PCTs have Black African HIV prevention programmes and those programmes were set up to address their local needs.”

Mr Kaikumba said the report showed: “We’re spending such a tiny amount on prevention.”  Can we get away with spending so little?” he asked.

But Mr Creelman stressed: “This is a programme within a wider prevention portfolio. The local PCTs also fund localised services”.  Meanwhile, with 26% of Londoners affected with HIV remaining undiagnosed, there appear to be no plans to reduce the amount spent on HIV prevention.

“Chief executives are absolutely committed to not taking any money out of prevention in this programme,” Mr Creelman said.

Original Article By Andy Dangerfield at BBC News

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HIV stigma divides and fragments gay communities

A review of research studies has identified a growing division within gay communities, in which HIV-negative gay men associate mainly with other HIV-negative men, and vice versa. Moreover stigma has negative impacts on the health of both HIV-positive and HIV-negative men, say the authors, writing in the online edition of AIDS Care.

Stigma has been defined as ‘‘a process of devaluation of people either living with, or associated with, HIV and AIDS’’. The majority of the research literature on stigma deals with the attitudes of the general population, but the authors wished to draw attention to and pull together reports concerning the stigmatisation of HIV-positive men within communities of gay men.

They describe this literature as “fragmented and largely anecdotal” – and call for more empirical research – but have identified multiple references to stigma that affects gay and bisexual men.

• Seven out of ten gay male respondents to a Dutch survey had experienced stigma on the gay scene.
• HIV-positive men perceive a ‘‘rift’’ based on HIV status within their gay community.
• Fear of rejection by potential sexual partners is widely reported and causes long-lasting harm to the self-confidence and self-esteem of men with HIV.
• Older men with HIV feel particularly under-valued, believing that they are at the “lowest rung” of the “gay social hierarchy”, resented for supposedly being dependent on social benefits that are no longer available to younger men with HIV.
• Body fat changes and other physical manifestations of HIV and its treatment are regarded as unattractive. Men with such symptoms report a loss of intimacy and the avoidance of particular social spaces because they feel self-conscious or fear rejection.
• In the United States, black gay men are perceived to be at higher risk of having HIV compared to men of other ethnicities, and are sometimes avoided as sexual partners for that reason.
• Stigma has a considerable impact on mental and emotional well-being, leading to anxiety, loneliness, depression, thoughts of suicide and avoidance strategies such as social withdrawal.
• Men who only disclose their HIV-status to a limited support network often feel socially isolated.
• Some gay men with HIV report keeping social and sexual distance from other HIV-positive men, feeling that being associated with HIV-positive sexual spaces (either online or offline) would compound stigma directed against them.
• HIV-positive men who identify as ‘barebackers’ tend to report greater stigma, gay-related stress, self-blame and substance abuse coping.
• Men reporting discrimination from sexual partners and breaches of confidentiality are less likely to adhere to their medication.

The authors note that stigma has negative effects on the health of HIV-negative men too. HIV-negative men who rely on trying to avoid sexual contact with HIV-positive men as a way of avoiding HIV infection put themselves at risk – due to infrequent HIV testing, undiagnosed infection and non-disclosure of HIV status.Moreover stigmatising beliefs are associated with lower rates of HIV testing and poorer knowledge about HIV transmission.

They say that effective strategies, validated by research, to reduce stigma are urgently needed. “Such initiatives should foster a renewed dialogue about living with HIV as a gay man, create opportunities to share understanding and experience among HIV positive and HIV-negative men, and aim to reunite gay communities by reducing stigma and offering integrated medical and social support.”

Original Article by Roger Pebody at NAM

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UK’s battle with HIV goes into reverse, prompting calls for more testing

The HIV 1 virus. The numbers infected with HIV within the UK are on the rise, the Health Protection Agency says. Photograph: Institut Pasteur/AFP/Getty Images

More than 100,000 people in Britain are predicted to be living with HIV by the end of this year, according to an official report that warns that the virus is on the rise again in the UK.

While there is a continuing drop in new cases among people who have acquired HIV abroad, the numbers infected within the UK are on the rise, the Health Protection Agency says in the report on Tuesday. New diagnoses of HIV in men who have sex with men have hit a record high.

New infections of the virus, which eventually causes Aids if not kept in check by drugs, had been falling in the UK but that trend seems to have levelled off, according to the agency’s annual HIV report. At the end of 2010, there were an estimated 91,500 people with HIV in the UK, up from 86,500 the previous year. The figure includes estimates for those who have not had a test and do not know they are infected – thought to be around a quarter of the total.

In 2010, according to the HPA’s data, there were 3,000 new infections among men who have sex with men, 81% of which occurred in the UK. Most of the men were white (83%) and two-thirds (67%) were born in the UK. Some had been HIV-positive for years without knowing, but a third of those who were recently infected were under 35. The figures suggest that one in 20 gay men are living with HIV, the ratio rising to one in 12 in London.

When the epidemic began 30 years ago, people with HIV swiftly became sick, developed Aids and died of infections such as pneumonia that their bodies could not fight off. Today, combinations of antiretroviral drugs keep people alive and healthy and can give them a normal lifespan as long as they stay on the medication. That means the number living with the virus continues to rise.

Of the 91,500 people estimated to have HIV in the UK, just over 40,000 of the total are men who have sex with men. Around 2,300 are injecting drug users. Of the 47,000 infected through heterosexual sex, around 19,300 were African-born women and 9,900 African-born men. The prevalence rate in the black African community is one in 32 among men and one in 15 women.

Half of those who are diagnosed with HIV have gone to a doctor years after infection, at the point when they have fallen ill. Those people have a much worse prognosis: they are 10 times more likely to die within a year of diagnosis than people who were diagnosed earlier.

In 2010, 680 HIV-positive people died, 510 of them men. Two-thirds were people who had been diagnosed late. Most died within a year of being tested.

People who have not been diagnosed risk infecting others. The HPA says that there is a need to introduce routine HIV tests around the country beyond the traditional confines of sexually transmitted infection and antenatal clinics.

There have been pilot projects in the last two years in London, Brighton, Leicester and Sheffield. Testing was successfully introduced in two general practices, the acute care units of three hospitals and two community settings without opposition from staff or patients.

Greater efforts to test people and prevent infection would save the NHS money, because treating people is expensive, the HPA says. Because HIV has become a chronic, manageable condition instead of a fatal illness, the costs of providing specialist treatment and care are substantial and accelerating.

“It is difficult to calculate the true expenditure on HIV in the UK. However, of the £1.9bn spent by the Department of Health on infectious diseases in England in 2009-10, an estimated 40% was allocated to the treatment of HIV and Aids. This total does not include the costs of psychosocial care or HIV testing, so in fact the total amount spent on HIV treatment is much higher,” the report says.

The amount spent on prevention, the HPA adds, was £2.9m, just 1% of the overall HIV budget in 2010. The report says: “Investing in prevention should be a priority because of its potential for cost savings. We estimate that each infection prevented would save between £280,000 and £360,000 in lifetime treatment costs.

“If the 3,640 UK-acquired HIV diagnoses made in 2010 had been prevented, between £1bn and £1.3bn lifetime treatment and clinical care costs would have been saved.”

Original Article by Sarah Boseley at The Guardian

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New MSM Panel report from Sigma Research

This month Sigma Research have undertaken the ninth monthly survey in the Sigma Panel of gay men, bisexual men and other men that have sex with men (MSM) in England and released the fifth Insight BLAST – their fast feedback mechanism to get essential planning data into the public domain.

Insight Blasts have a short turnaround for analysis and output to health
promoters developing and delivering sexual health interventions with, or for
men who have sex with men. The fifth Insight Blast is about “STI screening before your next sexual partner”. It describes how recently MSM have had an asymptomatic STI screen, why they had their last STI screen, and the perceived costs and benefits of screening for STIs when you have no symptoms. The data was collected as part of the eighth Sigma Panel questionnaire in August 2011.

This new Insight Blast and the first four – addressing “HIV testing”: “The
next sexual partner”; “Alternatives to unprotected anal intercourse”; and
“Notifying former sex partners about STI diagnoses” – are all available via
their homepage or at http://www.sigmapanel.org.uk

At http://www.sigmaresearch.org.uk you will also find a
link to the second EMIS Community Report.

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Big increase in HIV and syphilis diagnoses in US among young black gay men

HIV and syphilis diagnoses among  young gay and other men who have sex with men (MSM) increased in most metropolitan areas of the US between 2004 and 2008, investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

The increase in diagnoses was especially marked in young (13-24) black men, among whom HIV diagnoses increased by 85% and syphilis diagnoses by 203%.

“Young black MSM have disproportionately high rates of HIV diagnoses…highlighting the need for prevention efforts which address the behavioral and structural factors that place these men at risk,” write the investigators.

A recent study using data from the Centers for Disease Control and Surveillance showed that although rates of new HIV diagnoses in the US are steady, they are increasing in young gay men and black men. Diagnoses of HIV and syphilis are especially high in younger black MSM.

However, it is possible that recent increases in reported rates of both infections have been skewed by large numbers of diagnoses in a few large cities. In 2008, two cities accounted for 20% of all cases of syphilis in gay men and a fifth of all HIV diagnoses in gay and other MSM were located in three cities.

Therefore, investigators analysed reported HIV and syphilis diagnoses in gay and other MSM from 73 metropolitan areas across the US. All had a population of at least 500,000, and to be included in the analysis the areas had to have a population of at least 500 black individuals aged between 13 and 14.

Rates of HIV and syphilis diagnoses between 2004 and 2008 were monitored. The results were stratified according to age and race.

The total number of HIV diagnoses in gay and other MSM increased between 2004 and 2008 in all 73 areas by an average of 11%. Over the same period syphilis diagnoses almost doubled (88%).

However, the largest percentage increase in HIV diagnoses was among black men aged 13 to 24. HIV diagnoses in all other age and race groups remained relatively stable.

A comparison of the 2004 and 2008 data showed that increases in HIV diagnoses in black MSM aged 13 to 24 occurred in 85% of the areas included in the study. Increases were observed in more areas for black men in this age group than for Hispanic (62%) or white (58%) MSM of a similar age.

The number of HIV diagnoses among young black MSM was 69% higher in 2008 compared to 2004.

Similar patterns were present for syphilis diagnoses. These increased in 70% of areas among black men aged 13 to 24. Overall, the number of syphilis diagnoses in young black gay men increased by 203% between 2004 and 2008.

The majority of areas (79%) had increases in both HIV and syphilis diagnoses in black men aged 13 to 24. Concurrent increases in HIV and syphilis diagnoses among Hispanic MSM in the same age group were recorded in 73% of areas, but concurrent increases in both infections among young white men occurred in only 50% of areas.

“These findings document that increases in HIV and syphilis diagnoses among young black men are not limited to a few large areas, but are widespread among areas with different population sizes,” comment the investigators.

They believe that some of the increase could be due to changes in US testing guidelines. In 2006, opt-out HIV testing was introduced and all individuals at high risk of HIV were recommended to have an annual HIV test. Moreover, in 2007 a major programme commenced designed to increase testing among African Americans.

However, the investigators also suggest: “increases in transmission may also explain the observed increases in diagnoses of HIV and syphilis.” They add: “the observed increase in HIV diagnoses among MSM aged 13-24 years suggests an increase in transmission.”

The investigators further argue that the massive increases in syphilis diagnoses point to high rates of risky sexual behaviour, commenting: “syphilis diagnoses can serve as a ‘real-time’ marker of unprotected sexual intercourse that may result in the transmission of syphilis or HIV.”

The authors were especially concerned about the especially large increase in new HIV diagnoses among younger gay men. They write: “young MSM report being unprepared for their first sexual encounter, such as being ill-equipped to negotiate safer sex or not knowing how to use lubricant to reduce tearing and bleeding during anal sex.”

Separate research has shown that sexual risk behaviour in among US is similar across racial groups. The investigators suggest that the especially large increase in new diagnoses among young black men in their study could be due to “social factors, such as sexual network configurations (e.g. sex with black and older partners).” They also note that rates of undiagnosed HIV are especially high among African Americans.

“Infections among young MSM are unacceptably high,” conclude the investigators, “as the underlying causes of the epidemic are likely to be multifactorial, combining multiple strategies may prove most beneficial in improving the sexual health of this increasingly vulnerable population.”

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