Transcript slides - astda

The evolution and impact of
sexual networks on the
transmission of HIV and STIs
among MSM in Britain
Dr Kevin A Fenton
HIV/STI Department
Health Protection Agency
Communicable Disease Surveillance Centre
London, United Kingdom
Objectives
Review the recent epidemiology of STIs and HIV
among MSM in Britain
Examine some of the factors which may be
driving the changing epidemiology
Critically examine the role of HIV prevention
with MSM and explore options for enhancing
interventions
2
STIs (including HIV infection)
among MSM in Britain: What’s
going on?
Key points:
Rising STIs among MSM
• Rising gonorrhoea among MSM
• Syphilis outbreaks ongoing
• Viral STI rising at slower rate
New HIV diagnoses increasing
• but HIV incidence rising but no statistically significant increases
Increases being observed among younger and older
MSM; HIV positive MSM; those living in major
metropolitan areas
3
Cases of acute STIs among MSM
seen in GUM clinics,England,
Wales & N.Ireland: 1996 to 2002
New HIV diagnoses
4,000
infectious syphilis
3,500
uncomplicated gonorrhoea
genital chlamydial infection
Number of diagnoses
3,000
genital warts (first attack)
2,500
2,000
1,500
1,000
500
0
1996
1997
1998
1999
2000
2001
2002
Year of diagnosis
Data from reports of new HIV diagnoses received by end of December 2003.
STI data from KC60. 1996 taken as baseline.
4
Proportional changes in total cases of gonorrhoea
and syphilis, and number of new diagnoses of HIV
by year among MSM for England.
120%
1030
1200%
100%
Syphilis
80%
60%
1000%
HIV
3285
800%
600%
1996 baseline
GC-1683
40%
400%
HIV-1584
SY-84
1838
20%
200%
0%
0%
-20%
Proportional difference from 1996
(syphilis)
Proportional difference from 1996
(HIV and gonorrhoea)
Gonorrhoea
-200%
1996
1997
1998
1999
2000
2001
2002
Year of diagnosis
Data from KC60 and HIV AIDS Reporting. 1996 taken as baseline.
Nb. Syphilis data are on a secondary axis.
Reports of new HIV diagnoses received by end of December 2003. STI data from KC60.
5
Evidence of recent transmission of
HIV in men who have sex with men
Diagnosed and reported in 2003
n = 1414
date last negative within 12
months
89%
2%
5%
4%
reported with
"seroconversion" symptoms
with clinician comment
mentioning "seroconversion"
no reported evidence of
recent transmission
6
Annual HIV incidence1 in
homo/bisexual men2
5%
London
Outside London
HIV Incidence
4%
3%
2%
1%
0%
1995
1996
1997
1998
1999
2000
2001
2002
Year of survey
1 Estimated
using the serological test algorithm for recent HIV
seroconversion (STARHS) Murphy G., et al. in press
2 Attendees
at 15 GUM clinics in England, Wales and Northern Ireland
(seven in London and eight elsewhere)
7
Why is this happening?
Prevention & control interventions
Efficacy? Effectiveness?
Cost-effectiveness? Acceptability?
Feasibility?
Individual factors
Socio-demographic factors
Health beliefs
Health seeking behaviours
High risk sexual behaviours
Environmental Factors
STI/HIV
Epidemics
Socio-economic deprivation
Limitations to use of, and access to,
curative services
Racism, discrimination, stigma or
other disadvantage
Infectious agents
Antimicrobial resistance
Prevalence, incidence and duration of infectivity
Disease susceptibility in new environment
8
Socio-demographic trends: Growth
in MSM population
In-migration
of the
MSMproportion
fromHIV
EU infection
andofother
countries,
many
Prevalent
among
Increases diagnosed
in
British
men MSM
with
higher prevalence
of HIV 1997.
infection
increased
by 100% since
reporting same sex contact
Currently19,500
MSM
livingNational
with HIVSurvey
in Britain
today;
•Migration
Data from
the
2nd
British
of
Sexual
within the UK from rural to urban areas,
Attitudes
andManchester,
Lifestylesand
(Natsal
2000)
especially
to
Brighton
and
London
15,100
(77%)
diagnosed
attending
services;
67% of
men
on HAART;
- 2.6%
of men reported same sex contact in past 5 years
(c.f.
1.5%still
1990,
p<0.001). An estimated population of
4,400
(23%)
undiagnosed
312,631 MSM aged 16-44yrs
9
Behavioural trends: Increasing
rates of partner acquisition among
MSM
50
Natsal 2000, Reported numbers of male
sexual partners in past 5 years, 1990 and
2000
40
%
30
20
10
0
1
2
3-4
5-9
10+
Number of partners
1990 median: 2 partners
2000 median: 4 partners10
Source: 2nd British Survey of Sexual Attitudes and Lifestyles
Behavioural trends: Increasing
high-risk sexual behaviours among
MSM
UAI: any partners * UCL survey
Percentage
60
UAI: Partners of unknown or
serodiscordant serostatus - UCL survey*
40
20
0
1996
1997
1998
1999
2000
2001
2002
Year of survey
Source: *Dodds et al, Sexual Health survey of gay men, London,
$Hickson et al, National Gay Men’s Sex Survey,
11
Behavioural trends: High risk
behaviour in HIV+ MSM
Behavioural surveillance data
Reported UAI with a casual partner in the past year:
1998 - 2002
40
Percentage
41%
HIV positive
p<0.001
30
20
12%
15%
10
HIV negative
p<0.01
8%
7%
Never-tested
p<0.01
2%
0
1998
1999
2000
2001
2002
Survey year
Source: Elford J. London GYM Survey, 2001. City University
12
Why is this happening?
Prevention & control interventions
Efficacy? Effectiveness?
Cost-effectiveness? Acceptability?
Feasibility?
Individual factors
Socio-demographic factors
Health beliefs
Health seeking behaviours
High risk sexual behaviours
Environmental Factors
STI/HIV
Epidemics
Socio-economic deprivation
Limitations to use of, and access to,
curative services
Racism, discrimination, stigma or
other disadvantage
Infectious agents
Antimicrobial resistance
Prevalence, incidence and duration of infectivity
Disease susceptibility in new environment
13
Evolving sexual networks
Expansions
Much
evidence
in other
relating
sexual
to the
networks
growth in
of the
the past
internet and its impact on HIV/STI transmission
decade
through
- Saunas, bathhouses
-- Facilitating
partnervenues
acquisition,
bridging
transmission
Sex on premises
(SOPV)
and special
events
networks,
as wellacquisition
as disassortative sexual mixing
targeting partner
-- More
of new cultural and behavioural
MSM rapid
sellingtransmission
or buying sex
norms nationally and internationally
- Travel overseas with the acquisition of new sexual
- Facilitating
partners on-line homosexual behaviour among off-line
heterosexually identified individuals
14
How are social networks evolving? Data
from BSS among MSM
Between 1999 and 2001 reported internet use by MSM doubled.
Use of other sexualised settings fell, especially cottages and
cruising grounds
In 2001, the most popular settings for meeting new sex partners
were gay pubs (62%); internet (51%); saunas (34%); cruising
grounds (28%)
Among MSM use of backrooms were associated with sdUAI
• Men who met a new partner in a backroom in the last year were twice as
likely to report sdUAI compared to those who had not. Irrespective of HIV
status.
• For HIV+ MSM the internet and social groups were associated with UAI and
among HIV– MSM, the gym.
Data from Weatherburn P, Hickson F, Reid D. Net benefits. Gay men’s use of the
internet and other settings where HIV prevention occurs. 2003. London, Sigma
research. Available online from http://www.sigmaresearch.org.uk/reports
15
Changing sexual networks
STI and Behavioural surveillance data
Place social
of meeting lastnetworks
sexual
Relevant
by
Proportion/ sexual
of MSM who reportreported
using
partner
by HIVthe
status
MSM with
syphilis,
HIV
setting in by
paststatus.
month London
Percentage
2.9
Cruising
38.9
50% Cottage/cruising
HIV
positive
(n=213)
27.9
Ground
5.2
ground
45%
HIV negative (n=125)
40%
Cottage
35%
Gay Pub
30%
25%
25%
20%
15%
Sauna
5%
31% 31%
Gay Club
Gay
Pub
Sauna
18%
10%
22.7
Backroom
Backroom
39%
56.2
46.1 68.8
65.5
85
82.7
9.4
19.1
23.7
22.1
1.7
5.2 13.5
13.3
0%
Internet
Internet
Internet
1999
2001
46%
9.5Sauna
8.7
5% 5%
HIV negative
HIV48.1
positive
Bar
66.2
CSW contact
Site where most recent partners acquired
Data from Weatherburn P, Hickson F, Reid D. Net benefits. Gay men’s use of the
internet and other settings where HIV prevention occurs. 2003. London, Sigma
Source: Available
Dodds et online
al. London
Men's Survey, 2001. UCL
research.
fromGay
http://www.sigmaresearch.org.uk/reports
16
What are the implications for
HIV/STI prevention with MSM?
Prevention & control interventions
Efficacy? Effectiveness?
Cost-effectiveness? Acceptability?
Feasibility?
Individual factors
Socio-demographic factors
Health beliefs
Health seeking behaviours
High risk sexual behaviours
Environmental Factors
STI/HIV
Epidemics
Socio-economic deprivation
Limitations to use of, and access to,
curative services
Racism, discrimination, stigma or
other disadvantage
Infectious agents
Antimicrobial resistance
Prevalence, incidence and duration of infectivity
Disease susceptibility in new environment
17
MSM HIV Prevention in
England…what's happening now?
In England, key prevention activities are provided
through a nationally coordinated programme, the
Community HIV/AIDS Prevention Scheme (CHAPS) led
by the Terrence Higgins Trust
Partnership working between regional and local
agencies in London and 5 other cities in England and
Wales
A single planning Framework (Making it Count)
endorsed by the Department of Health and adopted by
nearly all NHS and Social care prevention providers in
prevention work with MSM
Relatively flexible
18
Other frameworks influencing
HIV/STI prevention work with MSM
The DH (England) National Strategy for sexual health
and HIV
• A 10 year programme providing researchers and providers with a
wide range of service delivery and public health oriented goals and
aims against which prevention successes may be measured
Health service reorganisation
• Sexual health promotion devolved to local Primary Care Trusts
• Sexual Health Service investment and redevelopment
Research
• CHAPS has a strong evaluative component built into it.
• Additional investment available though Medical Research Council`
19
What then are the challenges
facing MSM HIV prevention?
How to ensure maximal effectiveness from the
DH funded £1.2m national CHAPS programme?
How to ensure a strengthening of locally funded
and led gay men’s HIV prevention work (local
funding estimated at £10m)?
How to maximise access to HIV & STI
diagnostic and treatment services for gay men?
20
Implementation of evidence based
prevention interventions
Evidence from well-designed controlled trials clearly
demonstrate that HIV prevention can work
• Recent review of reviews by Ellis (2003) and Johnson (2002)
• Group- and community level behavioural interventions can bring
significant reductions in risk-behaviour
• Particularly effective in younger participants and populations with
higher background of UAI
Elford and Hart (2003) identify factors which limit
successful implementation
• Repeatability and transferability from research to practice; experiment
to intervention
• Poor understanding of why interventions work or fail
• Changing risk environments compared with the early 1990s
21
Targeting highly sexually active
gay men who use Sex on Premises
venues (SoPVs)
There is a need to increase the level, profile,
and visibility of work within SoPVs.
The current London Gay Men’s Health Promotion
Partnership contracts do not contain the capacity to target
these venues often enough either through
• detached work
• appropriately targeted materials
• or availability of condoms and lube in places where sex
happens.
22
Targeting venue owners of SoPVs
Early work with SOPV owners proved extremely
useful in facilitating venue outreach and testing
in the syphilis outbreaks in Brighton and
London.
Venues might need to feel prevention providers
have a 'special relationship' with them
• Clever marketing – e.g., specific interventions for specific
clubs, possibly with joint branding.
• Identifying and working within the legislative framework
• Care however to avoid “endorsement” of high-risk
activities
23
Targeting people who provide HIV
health promotion services to gay
men
Huge gaps exist in the abilities of the gay men's health
promotion sector to deal with changes, skills needs,
training etc.
Reasons for this are many: declining volunteers,
declining interest in MSM health promotion, high
turnover, unclear career pathways
This suggests significant capacity building
requirements to be addressed.
24
Summary
Changes in the epidemiology of STIs (including HIV
infection) among MSM in Britain
Demographic, social and behavioural trends are all
contributing,however many individual level factors
are being enhanced by a rapidly changing social
environment
Prevention interventions should respond to the
emerging epidemiological and social trends
25
Acknowledgements
John Imrie, Julie Dodds, Neil MacDonald, Ian Simms,
Christine McGarrigle
Behavioural Surveillance Collaborators: Centre for
Sexual Health and HIV Research, UCL; City University;
Sigma Research
Clinical, laboratory and policy colleagues who
participate in and support our programmes.
Colleagues from the Terrence Higgins Trust CHAPS
programme
HIV/STI Department, Health Protection Agency
Communicable Disease Surveillance Centre
26
Summary
Changes in the epidemiology of STIs (including HIV
infection) among MSM in Britain
Demographic, social and behavioural trends are all
contributing,however many individual level factors are being
enhanced by a rapidly changing social environment
Prevention interventions should respond to the emerging
epidemiological and social trends
However, this response must be tempered with
strengthening of the relationship between public health and
health promotion; community and statutory sector
approaches to prevention
27