Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting?

BACKGROUND: Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised. OBJECTIVES: To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic. METHODS: The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre-existing DATA SOURCES: STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data. RESULTS: Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004. CONCLUSIONS: HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus.     

What is the potential impact of adult circumcision on the HIV epidemic among men who have sex with men in San Francisco?

With the help of a community-based survey, we assess the potential effect of circumcision on the HIV epidemic among men who have sex with men (MSM) in San Francisco. Only a small minority of MSM would both derive benefit from circumcision (i.e., were uncircumcised, HIV-negative, predominantly insertive, and reported unprotected insertive anal sex) and be willing to participate in circumcision trials (0.7%) or be circumcised if proven effective as a prevention strategy (0.9%). Circumcision would have limited public health significance for MSM in San Francisco.     

Understanding correlates of hepatitis B virus vaccination in men who have sex with men: what have we learned?

OBJECTIVES: Hepatitis B infection (HBV) is prevalent among men who have sex with men (MSM) and may lead to significant morbidity and death. Although an effective vaccine exists vaccination rates among MSM are low. We conducted a systematic review to synthesise the various findings from empirical correlational studies to understand HBV vaccination and series completion among MSM. METHODS: We systematically searched the Medline, PubMed, EMBASE, CINAHL, ERIC, and Web of Science databases to identify the breadth of published studies pertaining to HBV vaccination among MSM and to synthesise findings from these studies to better identify common themes that may direct future research and intervention approaches. RESULTS: Eight papers specifically addressed correlates of HBV vaccination among MSM. Six domains were identified as predictors of vaccination: (1) demographic variables such as younger age and higher education level; (2) knowledge of the vaccine; (3) access to health care; (4) level of "outness" regarding one's same sex sexual orientation; (5) behavioural factors including sexual and drug use behaviour; and (6) psychosocial variables. Three papers addressed predictors of vaccine series completion among MSM, observing two main domains: (1) demographic variables such as younger age and higher income level; and, (2) behavioural factors including sexual and health promotion behaviours. CONCLUSIONS: Continued educational efforts, creation of environments that facilitate proper risk factor evaluation, and access to low cost vaccine may facilitate vaccine uptake. Although we observed important trends in the studies we reviewed, there is a lack of empirical research regarding this important public health issue.     

Is screening for sexually transmitted infections in men who have sex with men who receive non‐occupational HIV post‐exposure prophylaxis worthwhile?

BACKGROUND/AIMS: Non-occupational HIV post-exposure prophylaxis (NPEP) is routinely prescribed after high risk sexual exposure. This provides an opportunity to screen and treat individuals at risk of concurrent sexually transmitted infections (STI). The aim of this study was to assess the efficacy of an STI screening programme in individuals receiving NPEP. METHODS: STI screens were offered to all individuals receiving NPEP from March 2001 to May 2004. Screen results were compared to type of sexual exposure and baseline patient characteristics. RESULTS: A total of 253 subjects were screened, representing 85% of the target population. All were men who have sex with men (MSM). Common exposure risks were receptive anal intercourse (RAI) in 61% and insertive anal intercourse (IAI) in 33%. 32 (13%) individuals had one or more STI. The most common STIs were rectal infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) in 11 (4.5%) and six (2.5%) individuals, respectively. Subjects with rectal CT were significantly more likely to be co-infected with rectal NG (p<0.001). There was no association between the presence of a rectal STI and age or exposure risk. Only six (19%) individuals with an STI were symptomatic at screening. CONCLUSION: In this cohort of MSM receiving NPEP, high rates of concomitant STIs are observed highlighting the importance of STI screening in this setting.     

Is use of antiretroviral therapy among homosexual men associated with increased risk of transmission of HIV infection?

Background/objective: There is concern that use of highly active antiretroviral therapy (HAART) may be linked to increased sexual risk behaviour among homosexual men. We investigated sexual risk behaviour in HIV positive homosexual men and the relation between use of HAART and risk of HIV transmission. METHODS: A cross sectional study of 420 HIV positive homosexual men attending a London outpatient clinic. Individual data were collected from computer assisted self interview, STI screening, and clinical and laboratory databases. RESULTS: Among all men, sexual behaviour associated with a high risk of HIV transmission was commonly reported. The most frequently reported type of partnership was casual partners only, and 22% reported unprotected anal intercourse with one or more new partners in the past month. Analysis of crude data showed that men on HAART had fewer sexual partners (median 9 versus 20, p=0.28), less unprotected anal intercourse (for example, 36% versus 27% had insertive unprotected anal intercourse with a new partner in the past year, p=0.03) and fewer acute sexually transmitted infections (33% versus 19%, p=0.004 in the past 12 months) than men not on HAART. Self assessed health status was similar between the two groups: 72% on HAART and 75% not on HAART rated their health as very or fairly good, (p=0.55). In multivariate analysis, differences in sexual risk behaviour between men on HAART and men not on HAART were attenuated by adjustment for age, time since HIV infection. CD4 count and self assessed health status. CONCLUSION: HIV positive homosexual men attending a London outpatient clinic commonly reported sexual behaviour with a high risk of HIV transmission. However, behavioural and clinical risk factors for HIV transmission were consistently lower in men on HAART than men not on HAART. Although use of HAART by homosexual men with generally good health is not associated with higher risk behaviours, effective risk reduction interventions targeting known HIV positive homosexual men are still urgently needed.     

Who pays for sex? An analysis of the increasing prevalence of female commercial sex contacts among men in Britain

BACKGROUND: In the United Kingdom the incidence of sexually transmitted infections (STI) and risky sexual behaviours is increasing. The role of commercial sex in this trend is poorly understood. Little is known about the men who pay for sex. We examined the epidemiology of female commercial sex contacts reported by men in 1990 and 2000. METHODS: National probability sample surveys of sexual attitudes and lifestyles (Natsal) of men aged 16-44 resident in Britain in 1990 (n = 6000) and 2000 (n = 4762). RESULTS: The proportion of men who reported paying women for sex in the previous 5 years increased from 2.0% (95% CI 1.6 to 2.5) in 1990 to 4.2% in 2000 (95% CI 3.6 to 4.9). In both surveys, paying for sex was more frequent in men aged between 25 years and 34 years, who were never or previously married, and who lived in London. There was no association with ethnicity, social class, homosexual contact, or injecting drug use. Men who paid for sex were more likely to report 10 or more sexual partners in the previous 5 years; only a minority of their lifetime sexual partners (19.3%) were commercial. They were more likely to meet partners abroad and to report previous STI. Only 15% reported having had an HIV test. CONCLUSION: The proportion of men who reported paying for heterosexual sex has increased, and these men have multiple commercial and non-commercial partners. Their higher rates of STI and low level of HIV testing suggest the need for prevention interventions for clients as well as sex workers.     

Increased incidence of cervical cytological abnormalities in women with genital warts or contact with genital warts: a need for increased vigilance?

OBJECTIVE--To determine whether women who have a history of genital warts or whose sexual partners have such a history were more likely to have borderline or dyskaryotic cervical smears than other women. DESIGN--Prospective study conducted over a five month period. SETTING--A genitourinary medicine clinic in Cambridge, UK. PATIENTS--One hundred and eighty five women who attended the clinic during the study period, on whom cervical cytology was performed. Ninety-seven had a history of genital warts and twenty had partners with genital warts. METHODS--Cervical cytology taken by standard methods. Demographic data and sexual history obtained by questionnaire. Colposcopy was performed on patients with a history of warts or wart contact. OUTCOME MEASURED--Relative incidence of cytological abnormalities in the various groups of patients. RESULTS--"Borderline" nuclear change was the most frequent abnormality reported in the wart contact group (six cases) whereas mild dyskaryosis was the most frequent abnormal finding in those women with a history of warts (21 cases). CONCLUSIONS--Women with warts or contact with genital warts were more likely to have borderline or dyskaryotic cervical smears than women without such a history. Recommendations for follow-up of these patients are made.