Ann McDonald

Reemergence of the HIV epidemic among men who have sex with men in North America, Western Europe, and Australia, 1996-2005.

PURPOSEnTo describe and contextualize changes in rates of human immunodeficiency virus (HIV) notifications in men who have sex with men (MSM) in eight countries (Australia, Canada, France, Germany, Netherlands, Spain, United Kingdom, and United States) from 1996-2005.nnnMETHODSnWe analyzed trends in HIV notification rates from 1996-2000 and 2000-2005 by generalized linear regression and estimated annual percentage change (EAPC) in rates of HIV notifications. To interpret trends, we visually examined graphs of primary and secondary syphilis reports among MSM and the prevalence of recent HIV testing.nnnRESULTSnThe rate of HIV notifications among MSM declined 5.2% per year (95% confidence interval [CI]: -5.8%, -4.7%) from 1996-2000, and increased 3.3% per year (95% CI: +2.9%,+3.7%) from 2000-2005. During the period of increasing HIV diagnoses, increases in primary and secondary syphilis diagnoses occurred among MSM, but recent HIV testing among MSM did not seem to increase.nnnCONCLUSIONSnAfter declining in the second half of the 1990s, HIV notification rates for MSM increased beginning in 2000. Increased HIV notifications in MSM are not wholly explained by changes in HIV testing. Urgent efforts are required to develop effective HIV prevention interventions for MSM, and implement them broadly in these countries.

The role of initial AIDS-defining illness in survival following AIDS.

ObjectiveTo examine the role of initial AIDS-defining illness in survival following AIDS and survival trends over time. DesignStates and Territory Health Departments notified new diagnoses of AIDS to the National AIDS Registry. Information on vital status and date of last medical contact was sought annually. MethodsSurvival was calculated for all adult and adolescent AIDS cases (n = 3204) in Australia diagnosed until 1 November 1991 and reported to the National AIDS Registry by 31 March 1994. The Cox regression method was used to identify independent predictors for survival. ResultsAge < 50 years, a CD4+ cell count >100 × 106/l and an initial diagnosis of Kaposis sarcoma were independently associated with longer survival (P<0.05). Acquisition of HIV through blood transfusion and the AIDS-defining illness non-Hodgkins lymphoma were significantly associated with shorter survival. Survival improved substantially from 1986 to 1987, but did not improve further thereafter. A further study of initial AIDS-defining illnesses in a subgroup of individuals, i.e., men aged <50 years at diagnosis who acquired HIV infection through homosexual or bisexual contact and diagnosed after 1987, showed that Kaposis sarcoma, Pneumocystis carinii pneumonia, oesophageal candidiasis and herpes simplex virus as initial AIDS-defining illnesses had a relatively better prognosis than other single illnesses. Furthermore, patients with multiple illnesses did not have a worse prognosis than patients with a single illness, provided all illnesses were those with a better prognosis. ConclusionsInitial AIDS-defining illness, as well as age at diagnosis, year of diagnosis, HIV exposure and CD4+ cell count at diagnosis, plays an important role in survival following AIDS in Australia.

Characteristics of HIV diagnoses in Australia, 1993-2006.

OBJECTIVEnTo describe recent trends in the diagnosis of HIV infection in Australia.nnnMETHODSnNational HIV surveillance data from 1993 to 2006 were analysed with a focus on geographic differences by HIV exposure route and late presentation (HIV within 3 months of a first AIDS-defining illness or a CD4 count of less than 200 cells muL(-1)).nnnRESULTSnIn 1993-99, the number of HIV diagnoses declined by 32%, and then increased by 39% from 1999 to 2006. From 2000 onwards, rates increased significantly in Victoria, Queensland, South Australia and Western Australia. The most frequently reported routes of HIV exposure were male to male sex (71%) and heterosexual contact (18%), and the population rate of diagnoses have increased in both categories. Among the cases reported as heterosexually acquired (n = 2199), 33% were in people born in a high-prevalence country and 19% in those with partners from a high-prevalence country. Late presentation was most frequent in heterosexually acquired infections in persons who had a partner from a high-prevalence country: 32% compared with 20% overall.nnnCONCLUSIONSnRecent increases in annual numbers of HIV diagnoses in Australia underline the continuing need for HIV-prevention programs, particularly among men having male to male sex. Early diagnosis and access to care and treatment should also be emphasised, as a substantial proportion of people with HIV infection are unaware of their status until late in the course of disease.

Rapidly ageing HIV epidemic among men who have sex with men in Australia

BACKGROUNDnAntiretroviral therapy has increased survival for individuals living with HIV and has led to an ageing of this population in developed countries. To date the rate of ageing has been unquantified, giving rise to uncertainty in the treatment emphasis and burden in this population.nnnMETHODSnA mathematical model was used in conjunction with HIV/AIDS data from the Australian National HIV/AIDS Registry to estimate numbers and ages of Australian men who have sex with men (MSM) living with HIV infection from 1980 to 2005.nnnRESULTSnThe average age of HIV-infected Australian MSM is estimated to exceed 44 years of age by the year 2010 and has increased by 1 year of age for each two calendar years since the mid-1980s. HIV-infected MSM over 60 years of age have been increasing in number by 12% per year since 1995. A consequence of successful therapy with subsequent ageing of those infected has meant that from 2001 estimated deaths from other causes exceed AIDS deaths in Australia.nnnCONCLUSIONSnIn summary, our analyses indicate an increasing and rapidly ageing population living with HIV in Australia. This will inevitably lead to more serious non-AIDS conditions in ageing patients living with HIV, and to increased treatment complexity.

Late HIV presentation among AIDS cases in Australia, 1992-2001.

Objective: To describe time trends and demographic, exposure and clinical factors associated with late HIV presentation among notified AIDS cases diagnosed in Australia in 1992–2001.

Trend in HIV incidence in a cohort of homosexual men in Sydney: data from the Health in Men Study.

OBJECTIVESnTo determine the incidence of HIV seroconversion in a community-based cohort of homosexual men in Sydney from 2002 to 2006.nnnMETHODSnParticipants were recruited between 2001 and 2004 from community-based events and venues. They were tested for HIV annually at follow-up interviews. Each year, the study database was matched against the national HIV register to identify additional HIV seroconversions among men lost to active follow up. The trend in HIV incidence over time was examined using Cox regression.nnnRESULTSnAmong 1426 participants, 52 cases of HIV seroconversion were identified between 2002 and 2006, an incidence of 0.87 per 100 person-years (95% CI: 0.65-1.14). HIV incidence varied from 1.67 per 100 person-years in 2002 to 0.39 in 2006 (P trend = 0.282). The median age of HIV seroconversion was 36.9 years, ranging from 22 to 63 years.nnnCONCLUSIONnIn this community-based cohort of highly sexually active homosexual men in Sydney, HIV incidence was close to 1% each year and declined non-significantly between 2002 and 2006. These data are consistent with surveillance data suggesting no increase in recent HIV incidence in homosexual men in New South Wales.

The pattern of diagnosed Hiv infection in Australia, 1984–1992

Objective:To describe the pattern of newly diagnosed HIV infection in Australia, between 1984 and 1992. Methods:State and Territory health authorities reported cases of newly diagnosed HIV infection to the national HIV surveillance centre. Information sought on each case included the State or Territory of diagnosis, the case identifying number, the sex, date of birth and postcode of residence of the person with newly diagnosed HIV infection, the source of exposure to HIV and the date of specimen collection for the diagnosis of infection. Results:By the end of December 1992, a total of 16 765 cases of newly diagnosed HIV infection had been reported in Australia. The annual number of cases declined between 1985 and 1992. Most diagnoses were among males, and exposure to HIV was attributed to male homosexual contact for more than 80% of cases for which information on exposure to HIV was available. Cases of HIV infection attributed to heterosexual contact represented an increasing proportion of the annual number of diagnoses over the period 1985–1992, among both men and women. Conclusion:National surveillance for newly diagnosed HIV infection has complemented national surveillance for diagnoses of AIDS as a key mechanism for monitoring the course of the HIV epidemic in Australia. The pattern of newly diagnosed HIV infection was similar to the pattern of AIDS diagnoses, with the overwhelming majority of diagnoses of infection being in adult males whose exposure to HIV was attributed to homosexual contact. Limitations of HIV surveillance include the lack of information on HIV testing patterns, incomplete information on HIV exposure histories and duplication of reported diagnoses.

Late Diagnosis and Entry to Care after Diagnosis of Human Immunodeficiency Virus Infection: A Country Comparison

Background Testing for HIV infection and entry to care are the first steps in the continuum of care that benefit individual health and may reduce onward transmission of HIV. We determined the percentage of people with HIV who were diagnosed late and the percentage linked into care overall and by demographic and risk characteristics by country. Methods Data were analyzed from national HIV surveillance systems. Six countries, where available, provided data on two late diagnosis indicators (AIDS diagnosis within 3 months of HIV diagnosis, and AIDS diagnosis within 12 months before HIV diagnosis) and linkage to care (≥1 CD4 or viral load test result within 3 months of HIV diagnosis) for people diagnosed with HIV in 2009 or 2010 (most recent year data were available). Principal Findings The percentage of people presenting with late stage disease at HIV diagnosis varied by country, overall with a range from 28.7% (United States) to 8.8% (Canada), and by transmission categories. The percentage of people diagnosed with AIDS who had their initial HIV diagnosis within 12 months before AIDS diagnosis varied little among countries, except the percentages were somewhat lower in Spain and the United States. Overall, the majority of people diagnosed with HIV were linked to HIV care within 3 months of diagnosis (more than 70%), but varied by age and transmission category. Conclusions Differences in patterns of late presentation at HIV diagnosis among countries may reflect differences in screening practices by providers, public health agencies, and people with HIV. The percentage of people who received assessments of immune status and viral load within 3 months of diagnosis was generally high.

Kaposi's sarcoma as a sexually transmissible infection: an analysis of Australian AIDS surveillance data. The National HIV Surveillance Committee.

OBJECTIVEnTo further examine the hypothesis that Kaposis sarcoma (KS) among people with AIDS is caused by a sexually transmissible infectious agent.nnnDESIGNnAnalysis of Australian AIDS surveillance data for the period 1982-1991 by sex, age, exposure category, country of birth, year and place of diagnosis.nnnMAIN OUTCOME MEASURESnPercentage of people with AIDS who had KS.nnnRESULTSnIn Australia, by November 1991, 17.2% (527 out of 3067) of individuals with AIDS aged > or = 13 years had presented with KS as their AIDS-defining illness: men, 17.6% (524 out of 2977); women, 3.4% (three out of 87) (P < 0.001). KS was predominantly reported in people aged 20-49 years and there were no cases in children < 13 years of age. In general, KS was more common in those who had acquired HIV by sexual contact rather than parenterally. Among people aged > or = 13 years, the proportion with KS ranged from 0.0% (none out of 41) in men with haemophilia to 1 Iford 9.0% (483 out of 2542) in men reporting homosexual contact. Between 1984-1985 and 1990-1991, the percentage of men with AIDS reporting homosexual contact who presented with KS declined from 30% (37 out of 124) to 15% (145 out of 995) (chi 2 for a linear trend, P < 0.001). For men with AIDS reporting homosexual contact, the percentage with KS in New South Wales and Victoria (20.3%) was higher than in the other States and Territories (12.5%) (P < 0.001). New South Wales and Victoria have also reported the highest incidence of AIDS in Australia.nnnCONCLUSIONnThe epidemiological characteristics of KS among people with AIDS in Australia are broadly consistent with those reported from the United States and Europe. This provides further evidence that KS may be caused by a sexually transmissible infectious agent. The nature of the infectious agent and its mode of transmission have yet to be determined.

Could sexually transmissible infections be contributing to the increase in HIV infections among men who have sex with men in Australia

BACKGROUNDnTo review existing data on sexually transmissible infections (STI) in men who have sex with men in Australia in order to determine the possible contribution of STI to diverging trends in HIV notifications in different states.nnnMETHODSnWe reviewed data from multiple sources, including routine national surveillance data, laboratory surveillance data, self-reported information on STI testing in men who have sex with men and ad hoc reports of STI prevalence.nnnRESULTSnWe found increasing rates of gonorrhoea and infectious syphilis notifications in urban men in Australia between 1997 and 2006, and increasing rates of chlamydia notifications in men aged 30-49 years. There was little difference in these trends by state. Differences in the population groups sampled meant we were unable to gain further information on trends in men who have sex with men from these studies. Data on STI testing showed an increase in anal STI testing between 2003 and 2006, which may have increased the number of diagnoses of chlamydia and gonorrhoea for men who have sex with men during this period.nnnCONCLUSIONSnOver the past 10 years, there has been a substantial increase in diagnoses of gonorrhoea and infectious syphilis, and probably chlamydia, in men who have sex with men in Australia. However, it is unlikely that changes in the pattern of STI transmission are responsible for the recent divergence in HIV rates between Australian states because there is little evidence that trends in STI also differ by state.