Sexual Health Promotion & HIV Prevention for HIV Positive MSM: Issues & Challenges

1. Centre for Sexual Health & HIV Research Research Department of Infection & Population Health Sexual Health Promotion & HIV Prevention for HIV Positive MSM: Issues & Challenges Professor Graham J Hart PhD

2. OVERVIEW • Epidemiology • Sexual behaviour & partner numbers • Sexual market place • Challenges to prevention

3. HIV and AIDS diagnoses and deaths for MSM, UK Numbers will rise for recent years as further reports are received Clinician reports of new HIV/AIDS diagnosis

4. HIV and AIDS diagnoses and deaths for MSM, UK HIV antibody test introduced Numbers will rise for recent years as further reports are received Clinician reports of new HIV/AIDS diagnosis

5. HIV and AIDS diagnoses and deaths for MSM, UK Antiretroviral treatment introduced HIV antibody test introduced Numbers will rise for recent years as further reports are received Clinician reports of new HIV/AIDS diagnosis

6. Estimated HIV incidence in MSM attending STD clinics Estimated using the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) Trend not significant

7. Estimated HIV incidence in MSM attending STD clinics 3.8% incidence Estimated using the Serological Testing Algorithm for Recent HIV Seroconversion (STARHS) Trend not significant

8. Undiagnosed HIV infection in MSM in community samples in the UK, 2003-5 (Williamson et al, AIDS 2008, 22:1063–1070)

9. England and Wales: HIV & STI • MSM in general disproportionately affected by HIV and other STIs: • 44% of diagnosed HIV infections • 23% of gonorrhea diagnoses • 68% of syphilis diagnoses Source: Health Protection Agency, 2004.

10. England and Wales: HIV & STI • MSM in general disproportionately affected by HIV and other STIs: • 44% of diagnosed HIV infections • 23% of gonorrhea diagnoses • 68% of syphilis diagnoses • 7 - 11% of MSM are HIV-positive, but bear disproportionate burden of STI compared to HIV negative men • ~50% of gonorrhoea • ~50% syphilis • ~80% of LGV Source: Health Protection Agency

11. EPIDEMIOLOGY: OVERVIEW • No reduction in new HIV diagnoses among MSM • MSM remain the group at most risk of HIV acquisition - no decrease in incidence despite ART • High proportion living with undiagnosed HIV infection • Increase in STIs, 1997 - 2006 • New & emerging infections (syphilis; hep C; LGV)

12. SEXUAL BEHAVIOUR & PARTNER NUMBERS

13. Unprotected anal intercourse in the last year with 1 or more casual partners* *excludes men reporting no UAI Dodds & Mercey, 2006

14. HIV positive men - High risk sexual behaviour 1998 - 2005 (Gym survey, Elford et al) %

15. HIV positive men - High risk sexual behaviour 1998 - 2005 (Gym survey, Elford et al) % Effect of serosorting?

16. ‘Serosorting’: The practice of seeking to engage in sexual activities with partners who are of the same HIV status to you HIV positive serosorting in MSM permits UAI without the risk of primary transmission of HIV

17. HIV positive men - LondonSerosorting, casual partners: 1998 - 2005 %

18. HIV positive men - London Serosorting, casual partners: 1998 - 2005 % p<0.01

19. HIV positive men - London Serosorting, casual partners: 1998 - 2005 % p<0.01 Internet?

20. HIV positive men surveyed in clinics, community & online: number of concordant UAI partners by where met p<0.01 p=0.02 p=0.03 Elford et al, 2004

21. (HIV positive man, London) Davis et al, Culture, Health & Sexuality 2006; 8: 161–174 “Yes, his username is ‘Poz…’ So it was very clear that he is positive … … and he wrote in the profile that he liked barebacking. So we did talk about it … … And, so there wasn’t any need for any negotiation, it had already been negotiated before … … When you hear the newspaper reports ‘Oh, people have been infecting people deliberately’ it’s not like that at all. It’s all consenting adults doing something quite honestly, by an informed decision. I mean the guy was a solicitor, he knew exactly what he was doing and so did I. So, nobody was using anybody and nobody was putting anybody in risks that they didn’t know they were taking”

22. Distribution of total new sexual contacts in last year among HIV+ MSM (n=361)

23. Distribution of total new sexual contacts in last year among HIV+ MSM (n=361) Mercer et al ISSTDR Amsterdam, 2005

24. Distribution of total new sexual contacts in last year among HIV+ MSM (n=361) 75% of men reported <35 sexual contacts in the last year n=271 Median: 12 Mercer et al ISSTDR Amsterdam, 2005

25. Distribution of total new sexual contacts in last year among HIV+ MSM (n=361) 75% of men reported <35 sexual contacts in the last year n=271 Median: 12 25% of men reported 35 or more sexual contacts in the last year n=90 Median: 98 Mercer et al ISSTDR Amsterdam, 2005

26. 25% (90/361) reported 35 or more sexual partners in last year HIV+ MSM reporting 35 or more sexual contacts in the last year (n=361)

27. 25% (90/361) reported 35 or more sexual partners in last year HIV+ MSM reporting 35 or more sexual contacts in the last year (n=361) OR

28. 25% (90/361) reported 35 or more sexual partners in last year HIV+ MSM reporting 35 or more sexual contacts in the last year (n=361) OR 79.3% of the ALL reported sexual contacts in sample ( 11,077/13,969) Source: Mercer et al., ISSTDR, Amsterdam, 2005

29. SEXUAL BEHAVIOUR: OVERVIEW • Increase in sexual risk behaviour, 1996 - 2005 • Increased HIV+ serosorting • Clustering of sexual risk

30. Evolution of the sexual marketplace • Rapid rise of the internet • Increased international travel and ‘sex tourism’ • Globalisation of community events (‘circuit parties’) • Prevalence of recreational (poly) drug use • Increase in sex-on-premises bars & clubs • Emergence of hyper-sexual HIV positive identity

31. “Sex Pig”

32. Evolution of the sexual marketplace • Rapid rise of the internet • Increased international travel and ‘sex tourism’ • Globalisation of community events (‘circuit parties’) • Prevalence of recreational (poly) drug use • Increase in sex-on-premises bars & clubs • Emergence of hyper-sexual HIV positive identity

33. Evolution of the sexual marketplace • Rapid rise of the internet • Increased international travel and ‘sex tourism’ • Globalisation of community events (‘circuit parties’) • Prevalence of recreational (poly) drug use • Increase in sex-on-premises bars & clubs • Emergence of hyper-sexual HIV positive identity Facilitate expansion of social & sexual networks & rapid acquisition of new partners

34. Established, new & emerging technologies for HIV prevention Primary prevention • Behaviour change • Condom use • Male circumcision • Rectal microbicides • Pre-exposure prophylaxis with antiretroviral drugs (PREP) • Post-exposure prophylaxis with antiretroviral drugs (PEP) • Suppression of concurrent viral STIs; control of bacterial infection Secondary prevention • Individual antiretroviral therapy • Early identification of recently infected • Partner notification • Map & access sexual networks

35. CONCLUSIONS • Pre-ART (1981-1995) characterised by marked declines in bacterial STIs among MSM • Broad agreement that this was the result of • effective generalised & targeted health promotion • widespread adoption of condom use, & fewer new sexual partners • selective mortality of individuals with high-risk sexual lifestyles • Post-ART (1996 - 2006) these declines no longer sustained • many bacterial STI rates returning to pre-HIV levels or higher • new and emerging infections • Incident HIV infection • Comparable to hyperendemic settings in Sub-Saharan Africa • increasing pool of infection

36. Unsafe Sex in HIV Positive MSM: Challenges • Initiating/increasing condom use in HIV positive men • Serosorting • Got ‘the big one’ - other STIs ‘benign’ • Changed sexual environment (internet; venues) • Identification & focused interventions for those recently infected • Partner notification in HIV positive MSM for secondary prevention? • ‘Core group within the core’: partner numbers?

37. Acknowledgements Danielle Mercey & Julie Dodds Lisa Williamson Jonathan Elford Valerie Delpech & colleagues