Sexual Risks and HIV amongst men who have sex with men . Professor Jane Anderson, PhD FRCP Health and Wellbeing Directorate Public Health England Birmingham November 2013

With thanks for help and support in preparation and for permission to use slides and data Professor Kevin Fenton, National Director of Health and Wellbeing Public Health England Dr. Alison Brown Health Protection Directorate

Sex and Risk : what do we mean? Risky sexual behaviour increases the likelihood of a negative outcome. In particular Contracting or transmitting disease A pregnancy that is not wanted Legal, financial, social consequences

HIV and STIs: markers for risk behaviours Black and ethnic minority populations Men who have sex with men People with multiple partners /overlapping relationships Those not using a condom with all partners People in short-term relationships Young people aged under 25 years Girls who had their first sexual experience before age 16 years Sonkin B et al 2007; Public Health England HIV and STI Surveillance data

Notes: Rate of acute STI diagnoses by LA of residence, England: 2012 In 2012, rates of acute STIs by Local Authority ranged from <90 to 3,210 per 100,000 population. Rates were highest among residents of urban areas, particularly in London, reflecting to a large extent the distribution of the core groups of the population who are at greatest risk of infection and areas of higher deprivation. Rates calculated by patient LA of residence may be slightly underreported due to incomplete residence data reported by some clinics. Presentation title - edit in Header and Footer

Prevalence of diagnosed HIV infection by area of residence among population aged 15-59 years: UK, 2012 In areas of high prevalence of diagnosed HIV infection (≥2 diagnosed infections per 1,000 population aged 15-59 years) UK national guidelines recommend expanding HIV testing among people admitted to hospital and new registrants to general practice. In 2012, 64 of 326 (20%) Local Authorities (LAs) had a diagnosed prevalence above the two per 1,000 threshold. All but one of the 33 London LAs had a prevalence above this threshold. Outside London, the five LAs with the highest prevalence and which are above ≥2 per 1,000 were: Brighton and Hove, Salford, Manchester, Blackpool and Luton. HIV in the United Kingdom: 2013

Estimated number of people living with HIV (both diagnosed and undiagnosed): UK, 2012 By the end of 2012, an estimated 98,400 (95% credible interval [CI] 93,500-104,300) people were living with HIV in the UK; approximately one in five (21,900, 22% [18%- 27%]) of whom were undiagnosed and unaware of their infection. HIV in the United Kingdom: 2013

New HIV diagnoses by exposure group: United Kingdom, 2002 – 2011 After adjusting for missing risk information, HIV infections acquired through heterosexual contact have accounted for 2,990 (48%) of all diagnoses in 2011. Among MSM, the number of new HIV diagnoses have surpassed those made among heterosexuals for the first time since 1999, accounting for 3010 (48%) of all new diagnoses made in 2011. Infections acquired through injecting drugs and through other routes have remained low over time, accounting for 140 new diagnoses each in 2011.

Men who have sex with Men (MSM) The people most affected by HIV in the UK are MSM (47:1,000) Approximately 2,400 MSM acquire HIV infection annually in the UK New diagnoses of HIV among MSM are rising: Reflection of more testing and on-going transmission The diagnosis of HIV for almost half of newly diagnosed MSM was made at the time of their first HIV test Presentation title - edit in Header and Footer

Recently acquired infections among people newly diagnosed with HIV by exposure group: England, Wales and Northern Ireland, 2011 The Recent Infection Testing Algorithm (RITA) incorporates results from an HIV antibody assay modified for the determination of HIV avidity as well as clinical biomarkers (CD4 cell count, ART and AIDS at diagnosis) to distinguish recent from long-standing HIV infection. This surveillance programme covered 51% of all people newly diagnosed in England, Wales and Northern Ireland in 2011. Sixteen percent of infections diagnosed were likely to have been recently acquired (i.e. infected in the previous 4 to 6 months). The proportion of likely recent infection was higher among MSM (23%; 350/1,500), compared to heterosexual men (8%; 50/550) and women (8%; 60/770) . The highest proportions of likely recent infections among heterosexuals were observed among women (21%; 20/80) and men (14%; 3/20) aged 15-24 years. In contrast, less than 6% (40/590) of newly diagnosed heterosexuals aged 35-49 years had probably acquired their HIV infection recently.

Late diagnosis of HIV infection by exposure group: United Kingdom, 2011 Late diagnosis is the most important predictor of morbidity and mortality among those with HIV infection. In 2011, 47% (2,950) of HIV diagnoses were made at a late stage of infection (with a CD4 cell count <350 cells/mm3 within three months of diagnosis) including 26% (1,630) who were severely immunocompromised at diagnosis (CD4 cell count <200 cells/mm3). The proportion diagnosed late was lowest among MSM (35%; 1,050), while 56% of heterosexual women (941) and 64% of heterosexual men (840) were diagnosed late. Late diagnosis was highest among black African men (65%; 460/700) and black African women (61%; 650/1070), followed by black Caribbean women (46%; 30/60) and black Caribbean men (42%; 40/100), and white women (42%; 160/370) and white men (41%; 1,210/2960).

Selected STI diagnoses among MSM: England 2001-2010 FROM HPA: Since 2001, diagnoses of primary, secondary and early latent infectious syphilis among MSM in England have increased from 440 to 1,490 in 2010, although most of this increase was during the first half of the decade. After a drop between 2007 and 2008, gonorrhoea diagnoses in MSM have risen again to reach ~4,500 diagnoses in 2010. Chlamydia diagnoses increased from 1,300 in 2001 to 5,100 in 2010. Unsafe sexual behaviour has probably driven much of the rise in new diagnoses of STIs in MSM, although increased testing of non-genital (rectal and pharyngeal) sites using highly sensitive Nucleic Acid Amplification Tests (NAATs) is likely to have contributed to the rise in chlamydia and gonorrhoea diagnoses. In addition, there are about 5000 diagnoses of non-specific urethritis among MSM each year. Genital herpes diagnoses have increased from 390 in 2001 to 970 in 2010 and genital warts diagnoses have increased from 1,700 to 2,500.

Health disparities affecting MSM TITLE OF TALK Health disparities affecting MSM There is growing recognition that MSM are at risk for multiple health disparities These disparities are the result of combinations of individual, cultural, behavioral, and biomedical factors as well as discrimination, and stigma Childhood sexual abuse, substance use, mental health disorders, STDs, and partner violence exist at higher levels among MSM, and associated with HIV risk The combined effects of these problems may be greater than their individual effects Slide Courtesy of Professor Kevin Fenton PHE

Driving factors? STIs and Sexual risk behaviours Specific practices put MSM at risk for diverse STIs Anal sex: HIV, rectal GC/CT, HBV, HPV, HSV; Anal trauma →HCV, Syphilis, LGV Oral sex: Syphilis; Penile sex: HPV, HSV; Epidemiologic synergy with other STIs Syphilis: ↑ associated with HIV+ serosorting and substance use GC and CT: Frequently asymptomatic rectal infections Increasing MDR GC, including quinolone resistance HSV2: More common among MSM and facilitates HIV transmission. Acyclovir prophylaxis was not effective Slide Courtesy of Professor Kevin Fenton PHE

Driving factors? Substance Use Many studies suggest that substance use is common Among substance using MSM, poly-drug use is common Smoking rates range from 27 to 66%, higher than matched controls Heavy alcohol use (14-39%) though lower than general population Episodic recreational use is common; drug addiction is uncommon There are many reasons why gay men use substances Coping with homophobia, depression/anxiety Substance use may ↑ libido, sense of invulnerability; impair negotiation skills, select high risk network partners Substance use lowers pain thresholds, allowing for more traumatic sex, and possibly impairing host immunity Slide Courtesy of Professor Kevin Fenton PHE

Driving factors? Mental Health Issues 40% of MSM become depressed, 2X the lifetime rate of heterosexual men Predictors of major depression are: not having a partner, experiencing anti-gay threats or violence, non- identification as gay Panic disorder, social phobia, generalized anxiety disorder are more common among MSM (20% lifetime incidence) Culturally-tailored treatment may involve groups that enhance community identification Slide Courtesy of Professor Kevin Fenton PHE

Driving factors? Culturally Competent Care MSM often receive suboptimal care and are often reluctant to disclose to providers because of fears of stigmatization Many health care providers are unaware of the diversity of MSM and their different acute and chronic health conditions Ironically, health care providers may be uniquely able to assist MSM in their coming out process because of their social role Culturally-competent care is a basic human right, and is essential for optimal clinical management Slide Courtesy of Professor Kevin Fenton PHE

Enhancing MSM HIV Prevention Optimise use of new prevention technologies Adapted from Cohen et al. J. Clin. Invest. 118:4, 2008. Courtesy of C. Hankins

Enhancing MSM HIV prevention Scaling HIV testing HIV testing now gateway for more tailored approach, and access to, behavioral and biomedical interventions Key challenge will be optimising HIV testing programmes Increase HIV testing frequency by providing acceptable options Test groups of men who are at high risk, but currently not testing Use new testing options to leverage networks Use internet-based technologies to reach men who are in rural areas, or who don’t want to use MSM NGOs Integrate HIV testing into routine care Slide Courtesy of Professor Kevin Fenton PHE

Enhancing MSM HIV Prevention Promote sexual health across the lifecourse Increase use of high-quality, coordinated educational, clinical, and other preventive services Increase knowledge, communication, and respectful attitudes regarding sexual health Promoting opportunities to discuss role of pleasure, satisfaction and ability to have the best sex with the least harm Increase healthy, responsible, and respectful sexual behaviors and relationships Decrease adverse health outcomes, including HIV/STDs, viral hepatitis, and sexual violence Source: Douglas JM Jr, Fenton KA. Public Health Rep. 2013 Mar-Apr;128 Suppl 1:1-4 Slide Courtesy of Professor Kevin Fenton PHE

Enhancing MSM HIV Prevention Comprehensive Clinical Care Work with providers to address stigma, discrimination and provide comprehensive care MSM are entitled to culturally competent health care that addresses their health needs As major sources of information and vital services, health providers play a key role, and must be trained to provide supportive, non-judgmental care Well-trained clinicians who understand MSM realities and contexts Use provider engagement can to enable youth and older MSM to develop healthier lifestyles Adapted from Mayer et al 2012 Slide Courtesy of Professor Kevin Fenton PHE

Summary Men who have sex with men are disproportionately affected by HIV and rates of acquisition continue to rise Closely linked with risk taking in a number of areas Underlying reasons for risk complex and multifactorial Multiple effective modalities for combination prevention and treatment approaches now exist. Utilising the available tools in ways that address social and structural drivers is crucial for them to be maximally effective Presentation title - edit in Header and Footer

With thanks for help and support in preparation and for permission to use slides and data Professor Kevin Fenton, National Director of Health and Wellbeing Public Health England Dr. Alison Brown Health Protection Directorate