Kevin A. Fenton

Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis

BACKGROUND We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA. METHODS We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106,148 black MSM relative to 581,577 other MSM. FINDINGS We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38-0·75, for Canada and 0·67, 0·50-0·92, for the USA). Black MSM in the UK (1·86, 1·58-2·18) and the USA (3·00, 2·06-4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23-1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes. INTERPRETATION Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes. FUNDING None.

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

PURPOSE To 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. METHODS We 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. RESULTS The 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. CONCLUSIONS After 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.

Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans

Although these health disparities are not unique to STIs; their nature, pattern, and distribution are complex. This complexity is not solely a result of individual risk behaviours. Increasing evidence indicates that disease epidemics, and, consequently, disparities in morbidity rates, are outcomes of the functioning of systems.

Infectious syphilis in high-income settings in the 21st century

In high-income countries after World War II, the widespread availability of effective antimicrobial therapy, combined with expanded screening, diagnosis, and treatment programmes, resulted in a substantial decline in the incidence of syphilis. However, by the turn of the 21st century, outbreaks of syphilis began to occur in different subpopulations, especially in communities of men who have sex with men. The reasons for these outbreaks include changing sexual and social norms, interactions with increasingly prevalent HIV infection, substance abuse, global travel and migration, and underinvestment in public-health services. Recently, it has been suggested that these outbreaks could be the result of an interaction of the pathogen with natural immunity, and that syphilis epidemics should be expected to intrinsically cycle. We discuss this hypothesis by examining long-term data sets of syphilis. Today, syphilis in western Europe and the USA is characterised by low-level endemicity with concentration among population subgroups with high rates of partner change, poor access to health services, social marginalisation, or low socioeconomic status.

Prevalence and Correlates of Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States

BACKGROUND Heterosexual anal and oral sex are related to the acquisition of sexually transmitted infections, including human immunodeficiency virus infection. We examined the correlates of heterosexual anal and oral sex in the general population, using data from the National Survey of Family Growth. METHODS The sample included 12,571 men and women aged 15-44 years (79% response rate). RESULTS One-third of men and women had ever had anal sex, and three-quarters had ever had oral sex. Condom use during last oral or anal sex was relatively uncommon. In separate models for men and women, having ever had anal sex was associated with white race, age of 20-44 years, and having had a non-monogamous sex partner. White race, age of 20-44 years, being married, and having higher numbers of lifetime sex partners were related to having ever given oral sex in men and women. Giving oral sex was associated with having a non-monogamous sex partner in men. Ever receiving oral sex was associated with white race and a non-monogamous sex partner in men and women. CONCLUSIONS It would be beneficial to track the prevalence of heterosexual anal and oral sex and associated condom use on a more frequent basis.

Opt-Out Testing for Human Immunodeficiency Virus in the United States: Progress and Challenges

The Centers for Disease Control and Prevention (CDC) has recommended human immunodeficiency virus (HIV) testing for all persons aged 13 to 64 years in all health care settings. Signed consent would not be required and counseling with referral would be managed as it is for other serious conditions. The goal of the recommendations is to promote earlier entry into care to reduce unnecessary mortality and facilitate prevention by behavioral changes that accompany knowledge of serostatus. Concerns about the change include laws in some states that mandate signed consent and counseling, a perception that counseling is an effective prevention strategy, variability in payment coverage for the test, concerns about the stigma and discrimination that may accompany the HIV diagnosis, and the possibility that other testing policies would be more effective. Eleven of 16 states have changed legislation to reduce barriers to testing, 35 of 74 national professional societies have endorsed the new recommendations, and multiple demonstration projects have shown feasibility. Metrics to evaluate the health outcomes of the CDCs recommendations for HIV testing have been defined, but the data necessary to determine the effects on early entry into care, the actual reduction in disease incidence, and the unanticipated consequences are not yet available.

Sexual Health, HIV, and Sexually Transmitted Infections among Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

The sexual health of gay, bisexual, and other men who have sex with men (MSM) in the United States is not getting better despite considerable social, political and human rights advances. Instead of improving, HIV and sexually transmitted infections (STIs) remain disproportionately high among MSM and have been increasing for almost two decades. The disproportionate and worsening burden of HIV and other STIs among MSM requires an urgent re-assessment of what we have been doing as a nation to reduce these infections, how we have been doing it, and the scale of our efforts. A sexual health approach has the potential to improve our understanding of MSM’s sexual behavior and relationships, reduce HIV and STI incidence, and improve the health and well-being of MSM.

The accuracy of reported sensitive sexual behaviour in Britain: exploring the extent of change 1990–2000

Objectives: The 1990–1 British national probability sample survey of sexual attitudes and lifestyles (Natsal 1990) was repeated in 1999–2001 (Natsal 2000) to update population estimates of risk behaviours, and assess change over time. We examine whether changes in prevalence estimates may partly result from changes in measurement accuracy. Methods: Taking Natsal 2000 (11 161 respondents) and Natsal 1990 (13 765 respondents aged 16–44) we compared the response rate, sample representativeness, reporting of abortion last year (relative to official statistics), and selected attitudes. Among the common birth cohort eligible for both surveys (aged 16–34 Natsal 1990, 26–44 Natsal 2000), we compared reporting of experiences before 1990. Results: The response rate (66.8% Natsal 1990, 65.4% Natsal 2000) and completeness of reporting abortion were unchanged (84% Natsal 1990, 86% Natsal 2000). Attitudes were significantly changed in Natsal 2000 relative to Natsal 1990—for example, increased tolerance of male homosexual sex, OR (95% CI) 2.10 (1.93–2.29) men and 2.95 (2.74 to 3.18) women. In the common birth cohort reporting of heterosexual intercourse before 16 (OR 1.15 (1.02 to 1.29) men, 1.49 (1.31 to 1.69) women), and homosexual experience (OR 1.80 (1.46 to 2.21) men, 2.00 (1.61 to 2.48) women) were significantly increased. Conclusions: The results are consistent with improved reporting accuracy for some sensitive behaviours in Natsal 2000, in line with greater social tolerance and improved survey methodology. However, the evidence is not conclusive, and may not be generalisable to all such behaviours. The increase found in the reported prevalence of STI risk behaviours between Natsal 1990 and Natsal 2000 is likely to be somewhat overstated.

HIV, Homelessness, and Public Health: Critical Issues and a Call for Increased Action

Homelessness and housing instability are significant public health issues that increase the risks of HIV acquisition and transmission and adversely affect the health of people living with HIV. This article highlights the contributions of selected papers in this special issue of AIDS and Behavior and considers them within the broader context of prior research on the associations between housing status and HIV risk, use of HIV medical care, adherence to HIV treatment, and the physical health of HIV-seropositive persons. Special recognition is given to the roles of interrelated health problems, such as substance abuse, poor mental health, and physical and sexual abuse, that often co-occur and exacerbate the challenges faced by those who are homeless or unstably housed. Taken as a whole, the findings indicate a critical need for public health programs to develop strategies that address the fundamental causes of HIV risk among homeless and unstably housed persons and, for those living with HIV, contribute to their risk of disease progression. Such strategies should include “mid-stream” and “upstream” approaches that address the underlying causes of these risks. The successful implementation of these strategies will require leadership and the formation of new partnerships on the part of public health agencies. Such efforts, however, may have significant effects on the individuals and communities most affected by HIV/AIDS.

Common roots: a contextual review of HIV epidemics in black men who have sex with men across the African diaspora

Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection. Nevertheless, black MSM across the African diaspora share common experiences such as discrimination, cultural norms valuing masculinity, concerns about confidentiality during HIV testing or treatment, low access to HIV drugs, threats of violence or incarceration, and few targeted HIV prevention resources.