Reemergence of the HIV Epidemic Among Men Who Have Sex With Men in North America, Western Europe, and Australia, 1996–2005
Introduction
From the earliest case reports of rare opportunistic illnesses among men in Los Angeles and New York 1, 2, men who have sex with men (MSM) have been the predominantly impacted risk group in many countries with concentrated human immunodeficiency virus (HIV) epidemics. In Canada (3), the United States (4), and Australia (5), MSM continue to represent the risk group diagnosed most frequently with HIV infection, and recent population-based HIV incidence estimates indicate that in the United States, MSM accounted for the majority (53%) of new HIV infections in that country in 2006 (6). In Western Europe, MSM were the risk group diagnosed most commonly through 1998, after which persons with heterosexual contact have been diagnosed more commonly (7). Importantly, however, MSM remain the group most at risk of acquiring HIV in Western Europe, whereas most cases acquired through heterosexual contact were among migrant populations who may have acquired their infection abroad. In Catalonia (8) and Spain as a whole (9), MSM were initially the second largest group of reported AIDS cases until 1998, and male–male sex is currently the most common exposure mode for AIDS cases among men. Through the late 1980s and early 1990s, MSM in many communities decreased the risk behaviors most commonly associated with HIV infection, and the growth in the HIV epidemic among MSM slowed in at least some subpopulations of MSM during this time (10). However, beginning in 1998, increasing rates and local outbreaks of syphilis raised concerns that sexual risk behaviors among MSM might be increasing 11, 12, 13, 14, 15, 16, 17, 18, and that increases in risk behaviors might herald a new period of increasing HIV infections among MSM 15, 19.
Surveillance systems for HIV (with or without acquired immune deficiency syndrome [AIDS]) have been in place since early in the HIV epidemic in many industrialized countries, and represent important sources of data for identifying trends in local HIV epidemics. Surveillance data have important advantages for monitoring high-level trends in HIV epidemiology, most notably that they are population-based, are ongoing, and use systematic methods and common case definitions. However, case surveillance data are also limited, because they collect somewhat limited information on each reported case, and because their reports are subject to changes in diagnostic testing or screening practices, and in surveillance operating procedures. Therefore, surveillance data should be interpreted in the context of other indicators of risk behaviors, knowledge of surveillance practices, and data on HIV testing or screening intensity.
This analysis grew out of an observation that HIV notifications (first-time notifications to surveillance systems of HIV diagnoses; in some countries, this may also be called HIV surveillance case reports) in MSM seemed to be increasing during the early 2000s in many countries; this observation was made by participants in the 2005 and 2006 annual meetings of the Annecy Group, an informal group of HIV surveillance scientists from countries with concentrated HIV epidemics and case-based HIV surveillance systems. To evaluate the significance of these observations and to allow a comparative analysis of trends in HIV notifications among MSM, we used data from HIV and syphilis surveillance systems from 1996–2005, as well as data on the prevalence of recent HIV testing among MSM during the same period.
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Data Sources
Data were obtained from national HIV and syphilis surveillance systems in eight participating countries: Australia, Canada, France, Germany, the Netherlands, Spain, the United Kingdom, and the United States (25 states with confidential name-based HIV surveillance since 1994, representing 23.6% of AIDS notifications in 2006). In the case of Spain, data were obtained from the Integrated STI/HIV/AIDS Surveillance System (SIVES) of Catalonia (8). AIDS rates in Catalonia during 2006 were 30/million
Trends In HIV Rates
HIV notification rates are presented in Fig. 1. For the period 1996–2000 (n = 6 countries), HIV notification rates decreased by an estimated 5.2% per year (95% CI: −5.8%, −4.7%). The combined annual rate of HIV notifications in 1996 was 19.1/100,000 men (range: 3.5–24.5). The combined annual rate of HIV notifications in 2000 was 14.6/100,000 men (range: 4.1–19.1). The country-specific EAPCs for five of six countries with data available from 1996–2000 showed significantly decreasing year-to-year
Discussion
Individual countries participating in this analysis have reported trends in MSM notifications within their countries using various methods 24, 25, 26 and published literature has been surveyed on this topic (27). Our report differs from earlier reports in that we conducted a combined analysis of HIV surveillance data on MSM using consistent analytic methods across continents. Surveillance data from eight countries with concentrated HIV epidemics and methodologically similar HIV case
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The Annecy MSM Epidemiology Study Group is comprised of Debra Hanson, Rongping Zhang, Hillard Weinstock, Timothy D. Mastro, and Richard Wolitski, Centers for Disease Control and Prevention, Atlanta, GA; Rafa Muñoz, and Nuria Vives, Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissión Sexual i Sida de Catalunya, Barcelona, Spain; Rossie Lugo, Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissión Sexual i Sida de Catalunya and Ciber Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Annie M. Velter, Institut de Veille Sanitaire, Paris, France; Azhar Nizam, Emory University, Atlanta, GA.
Required disclaimer: The findings and conclusions in this study are those of the authors and do not necessarily represent the views of the authors' organizations.