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

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

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

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 HIV antibody test introduced

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 HIV antibody test introduced Antiretroviral treatment introduced

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

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

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

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.

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 % 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

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, New & emerging infections (syphilis; hep C; LGV)

SEXUAL BEHAVIOUR & PARTNER NUMBERS

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

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

% Effect of serosorting?

‘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

HIV positive men - London Serosorting, casual partners: %

% p<0.01

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

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

(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”

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

Mercer et al ISSTDR Amsterdam, 2005

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

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

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

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

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

SEXUAL BEHAVIOUR: OVERVIEW Increase in sexual risk behaviour, Increased HIV+ serosorting Clustering of sexual risk

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

“Sex Pig”

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

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

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

CONCLUSIONS Pre-ART ( ) 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 ( ) 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

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?

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