Latest update to the National Outbreak Response group on recent trends in HIV, STIs and Hepatitis among men who have sex with men (MSM) in Ireland June 2018

For longer term trends in STIs/HIV in MSM please see This slide set provides the most up to date epidemiological data (including provisional information) which was presented to the National Outbreak Response group for increase in STI/HIV in men who have sex with men (MSM) in Ireland on 5th June 2018. For longer term trends in STIs/HIV in MSM please see http://www.hpsc.ie/a- z/hivstis/sexuallytransmittedinfections/dataonhivandstisamongmenwhohavesexwithmen msm/

The Outbreak Response group was established in response to increasing notifications of STI/HIV in MSM in order to: Review the epidemiological, clinical and microbiological trends in notifications among MSM nationally Develop, agree and implement an evidence-based action plan to control the outbreak and reverse the trends http://www.hpsc.ie/a-z/specificpopulations/MSM Outbreak Response Action Plan 2017

Technical notes Data were extracted from the Computerised Infectious Disease Reporting System (CIDR) in May 2018 and were correct at the time of publication Data in CIDR are updated on an ongoing basis, updated data will be presented in subsequent reports Data are provisional and should be interpreted with caution as many datasets are incomplete, particularly for 2017 and 2018 data Increased notifications of HIV and STIs may be attributed, in part, to increased HIV/STI testing, however testing rates by risk group are not currently available

Acknowledgements This slideset was produced on behalf of the Epidemiology Subgroup of the National Outbreak Response group for increase in STI/HIV in MSM in Ireland. We would like to sincerely thank all who provided data for this update; the UCD National Virus Reference Laboratory (NVRL),  Microbiology Laboratories, Departments of Public Health, Consultants in Infectious Disease/Genitourinary Medicine, STI clinics, GPs and all other clinicians involved.

HIV update 2016 provisional data

HIV notifications in 2017 Total number of HIV notifications in 2017 = 504, similar to 2016 (n=506) Rates are stable since the change in case definition in 2015 377 HIV notifications in males during 2017, 4% lower than 2016 (n=393) An average of 32 HIV notifications among males, per month in 2017, compared to 33 per month in 2016 2016 provisional data

HIV notifications among males and men who have sex with men (MSM) Note: Notifications among MSM in 2017/2018 will increase as additional information on mode of transmission is returned 2016 provisional data

HIV notifications among MSM - 2017 HIV in MSM did not increase in 2017 (n=236) when compared to 2016 (n=272). However, risk group data is missing for 29% in 2017 versus 13% in 2016. This percentage is likely to fall as information is received. Of HIV notifications among MSM in 2017: 40% were diagnosed as HIV positive previously in another country (91% transferred their HIV care to Ireland) Country of birth was Ireland for 28%; Latin America for 30%; Europe for 17%; South and South East Asia for 5% (missing/unknown for 20%) Probable country of infection was Ireland for 25%, outside Ireland for 41% (missing/unknown for 34%) 10% were co-infected with acute infectious syphilis, 10% with chlamydia, 6% with gonorrhoea (22% co-infected with acute STI) 2016 provisional data

Hepatitis A and Hepatitis C update

Hepatitis A among MSM Reports of increased numbers of hepatitis A cases in MSM in a number of European countries since mid-2016. 3 circulating strains identified through sequencing. No cases of hepatitis A identified in MSM in Ireland in 2016 20 cases (30% of all hepatitis A cases) identified in 2017 2018 - 1 MSM case notified between Jan and mid-May (MSM status unknown for 2 other male cases) Country of infection for MSM cases: 13 Ireland, 6 outside Ireland & not reported for 2 Age range: 20-42 years, median 32, mean 31.8 29% (n=6) had HIV, gonorrhoea and/or chlamydia co-infections Outbreak appears to be under control 2016 provisional data

Hepatitis A notifications among MSM (January 2017 to 11th May 2018), by month of onset

Hepatitis C

Hepatitis C among MSM Reports of increased numbers of MSM being diagnosed with hepatitis C (HCV) since late 2015: 8 cases identified as MSM in 2015, 29 in 2016, 17 in 2017 and 3 in 2018 (up to May 11th) - Hepatitis C appears to be decreasing Of hepatitis C notifications among MSM: Age range: 20-61 years (median: 36, mean: 37) Region/country of birth: 38% Ireland, 23% Latin America, 19% Central and Eastern Europe & 13% Western Europe 67% HIV positive at time of HCV diagnosis (38/57) 63% of HIV positive cases and 47% of HIV negative cases diagnosed with syphilis, gonorrhoea, chlamydia or herpes in same year or year prior to hepatitis C diagnosis 2016 provisional data

Hepatitis C notifications among MSM, breakdown by acute/chronic status, 01st Jan 2015 – 11th May 2018

Hepatitis C notifications among MSM, by HIV status (at HCV diagnosis) and recent STI status, 01st Jan 2012-11th May 2018 *Gonorrhoea, syphilis, chlamydia, lymphogranuloma venereum or genital herpes simplex in the same year as hepatitis C notification or in the year prior to hepatitis C notification 2016 provisional data

2017 provisional data Syphilis update 2017 provisional data

Early infectious syphilis (EIS): Summary 2017 2017 provisional data Early infectious syphilis (EIS): Summary 2017 401 notifications of confirmed EIS in 2017 (n=305 during 2016) Laboratory criteria for notifying EIS were updated, increasing the sensitivity of reporting from 01st July 2016 onwards, so 2016 and 2017 data are not comparable 96% (n=383) of cases were male (97% in 2016) Median age among males: 34 years (range: 17-71 years) Where mode of transmission is known (n=277; 69%), 88% (n=243) of cases were among MSM and 12% among heterosexuals (this is a similar to proportion in 2016) 2017 provisional data

EIS notifications among males 01st July 2016 – 30th April 2018 2017 provisional data EIS notifications among males 01st July 2016 – 30th April 2018 2017 provisional data

EIS notifications among MSM - 2017 Of EIS notifications among MSM in 2017: 10% were consistent with reinfection Where HIV status is known (n=199; 82%), 34% of cases among MSM were HIV positive (also 34% in 2016), though the proportion of cases missing mode of transmission is high at 31% Where region of origin is known (n=195; 80%): 51% of MSM originated from Ireland 25% from Latin America 18% from Eastern, Central or Western Europe 6% Other regions

Majority of EIS notifications in HSE East Note: Quarter 2 2018 data is up to 30th April

Gonorrhoea update

Gonorrhoea trends 2017 – 2018 2254 gonorrhoea notifications in 2017 60% (n=901) were MSM (where mode of transmission is known) - Number of notifications remain high but proportion MSM has not increased 771 notifications to end of week 19 2018 3% increase on same period last year Mode of transmission known for 51% (n=395) of cases in 2018: of those, 60% (n=238) were MSM Median age among MSM: 29 years (range: 16 – 66 years) 25 – 29 year olds age group most affected among MSM

Gonorrhoea trends 2017 - 2018

MSM are older than heterosexuals

Gonorrhoea antimicrobial resistance (AMR) AMR gonorrhoea is an international concern; WHO have warned gonorrhoea may become untreatable in the future First global reports of multi-drug resistant gonorrhoea in early 2018 (1 case in the UK and 2 cases in Australia) In Ireland a multi-disciplinary committee for monitoring gonorrhoea AMR has been established, the committee will work to improve surveillance and reporting of gonorrhoea AMR

Lymphogranuloma venereum (LGV)

LGV trends 2017 – 2018 20 cases of LGV in 2017 9 cases to week 19 2018 95% (n=19) were MSM 9 cases to week 19 2018 125% increase in cases compared to same period in 2017 Mode of transmission known for 89% (n=8) cases – all MSM 78% (n=7) cases from HSE-East and 1 case each from HSE- Northeast and HSE-Southeast Age range: 22 – 58 years Median age: 32 years LGV will continue to be closely monitored during 2018

Majority of LGV notifications in HSE East

Sexually transmitted enteric infections (STEIs) among MSM: Shigella update

Shigellosis in males and MSM 2017 – 2018 81 cases of Shigellosis notified in males aged >18 years, in 2017 (n=62) and 2018 (n=19) 24 were reported as MSM, according to comments in CIDR 18 in 2017 (29%) 6 in 2018 (32%) 96% of MSM (n=23) notified in HSE East and one in the Northeast Country of infection was: 58% Ireland (n=14), 4% Spain (n=1) and 38% were unknown (n=8) (all cases with unknown country of infection were notified as non-travel) June 2017 marked beginning of a cluster that is continuing into 2018

Shigellosis trends among all males >18 years and MSM 01st Jan 2017 – 11th May 2018

Shigella species among MSM 2017 – 2018 Shigella sonnei and Shigella flexneri 2a are most prevalent species among MSM in Ireland (species known for 96% of MSM cases). Species are more diverse among females, males under 18 years of age, and travel- associated cases. From 01st January 2017 to 11th May 2018, 58% (n=14) of cases among MSM were S. sonnei and 33% (n=8) were S. flexneri 2a. Two largely MSM-specific clusters have emerged since June 2017: S. sonnei SH-B/17 cluster of 18 cases (15 reported in HSE East) 12 MSM 4 male cases with no risk factor data reported 1 non‑MSM male 1 female S. flexneri 2a SH-D/17 cluster of 4 cases (3 reported in HSE East) 3 MSM 1 male with no risk factor data reported

Shigella species and clusters among MSM

Overall Summary Overall notifications of HIV are stable – numbers slightly down among males High proportion previously diagnosed abroad, majority are virally suppressed One in ten co-infected with acute infectious syphilis Need for more complete data Hepatitis A in MSM decreased at end of 2017 – outbreak appears to be under control May be due, in part, to increased awareness and increased vaccine uptake Hepatitis C among MSM appears to be decreasing Syphilis numbers remain high but proportion of MSM has not increased Gonorrhoea numbers remain high but proportion MSM has not increased LGV in MSM increased in 2018, compared to same time period in 2017 – will continue to be monitored STEIs such as Shigellosis are an emerging issue among MSM Cohort of MSM with multiple STIs and repeat STIs remain of concern

Please note This slide set focuses on the latest epidemiological, clinical and microbiological trends in notifications among MSM nationally, provided to the MSM outbreak response group in June 2018. This this data is provisional and subject to change. More detailed reports on HIV and STIs in Ireland, and longer term trends can be found at http://www.hpsc.ie/a-z/hivstis/