Dr Kevin A Fenton HIV/STI Department Health Protection Agency

1. The evolution and impact of sexual networks on the transmission of HIV and STIs among MSM in Britain Dr Kevin A Fenton HIV/STI Department Health Protection Agency Communicable Disease Surveillance Centre London, United Kingdom

2. Objectives • Review the recent epidemiology of STIs and HIV among MSM in Britain • Examine some of the factors which may be driving the changing epidemiology • Critically examine the role of HIV prevention with MSM and explore options for enhancing interventions

3. STIs (including HIV infection) among MSM in Britain: What’s going on? • Key points: • Rising STIs among MSM • Rising gonorrhoea among MSM • Syphilis outbreaks ongoing • Viral STI rising at slower rate • New HIV diagnoses increasing • but HIV incidence rising but no statistically significant increases • Increases being observed among younger and older MSM; HIV positive MSM; those living in major metropolitan areas

4. Cases of acute STIs among MSM seen in GUM clinics,England, Wales & N.Ireland: 1996 to 2002 Data from reports of new HIV diagnoses received by end of December 2003. STI data from KC60. 1996 taken as baseline.

5. 1030 1996 baseline GC-1683 3285 HIV-1584 SY-84 1838 Proportional changes in total cases of gonorrhoea and syphilis, and number of new diagnoses of HIV by year among MSM for England. Data from KC60 and HIV AIDS Reporting. 1996 taken as baseline. Nb. Syphilis data are on a secondary axis.Reports of new HIV diagnoses received by end of December 2003. STI data from KC60.

6. n = 1414 Evidence of recent transmission of HIV in men who have sex with menDiagnosed and reported in 2003

7. Annual HIV incidence1 in homo/bisexual men2 1 Estimated using the serological test algorithm for recent HIV seroconversion (STARHS) Murphy G., et al. in press 2 Attendees at 15 GUM clinics in England, Wales and Northern Ireland (seven in London and eight elsewhere)

8. Why is this happening? Prevention & control interventions Efficacy? Effectiveness? Cost-effectiveness? Acceptability? Feasibility? STI/HIV Epidemics Individual factors Socio-demographic factors Health beliefs Health seeking behaviours High risk sexual behaviours Individual factors Socio-demographic factors Health beliefs Health seeking behaviours High risk sexual behaviours Environmental Factors Socio-economic deprivation Limitations to use of, and access to, curative services Racism, discrimination, stigma or other disadvantage Infectious agents Antimicrobial resistance Prevalence, incidence and duration of infectivity Disease susceptibility in new environment

9. Socio-demographic trends: Growth in MSM population • Increases in the proportion of British men reporting same sex contact • Data from the 2nd British National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) • 2.6% of men reported same sex contact in past 5 years (c.f. 1.5% 1990, p<0.001). An estimated population of 312,631 MSM aged 16-44yrs • Prevalent diagnosed HIV infection among MSM increased by 100% since 1997. • Currently19,500 MSM living with HIV in Britain today; • 15,100 (77%) diagnosed and attending services; 67% of men on HAART; • 4,400 (23%) still undiagnosed • In-migration of MSM from EU and other countries, many with higher prevalence of HIV infection • Migration within the UK from rural to urban areas, especially to Manchester, Brighton and London

10. Behavioural trends: Increasing rates of partner acquisition among MSM 1990 median: 2 partners 2000 median: 4 partners Source: 2nd British Survey of Sexual Attitudes and Lifestyles

11. Behavioural trends: Increasing high-risk sexual behaviours among MSM Source: *Dodds et al, Sexual Health survey of gay men, London, $Hickson et al, National Gay Men’s Sex Survey,

12. Behavioural trends: High risk behaviour in HIV+ MSM Behavioural surveillance data Source: Elford J. London GYM Survey, 2001. City University

13. Why is this happening? Prevention & control interventions Efficacy? Effectiveness? Cost-effectiveness? Acceptability? Feasibility? STI/HIV Epidemics Individual factors Socio-demographic factors Health beliefs Health seeking behaviours High risk sexual behaviours Environmental Factors Socio-economic deprivation Limitations to use of, and access to, curative services Racism, discrimination, stigma or other disadvantage Infectious agents Antimicrobial resistance Prevalence, incidence and duration of infectivity Disease susceptibility in new environment

14. Evolving sexual networks • Expansions in other sexual networks in the past decade • Saunas, bathhouses • Sex on premises venues (SOPV) and special events targeting partner acquisition • MSM selling or buying sex • Travel overseas with the acquisition of new sexual partners • Much evidence relating to the growth of the internet and its impact on HIV/STI transmission through • Facilitating partner acquisition, bridging transmission networks, as well as disassortative sexual mixing • More rapid transmission of new cultural and behavioural norms nationally and internationally • Facilitating on-line homosexual behaviour among off-line heterosexually identified individuals

15. How are social networks evolving? Data from BSS among MSM • Between 1999 and 2001 reported internet use by MSM doubled. • Use of other sexualised settings fell, especially cottages and cruising grounds • In 2001, the most popular settings for meeting new sex partners were gay pubs (62%); internet (51%); saunas (34%); cruising grounds (28%) • Among MSM use of backrooms were associated with sdUAI • Men who met a new partner in a backroom in the last year were twice as likely to report sdUAI compared to those who had not. Irrespective of HIV status. • For HIV+ MSM the internet and social groups were associated with UAI and among HIV– MSM, the gym. Data from Weatherburn P, Hickson F, Reid D. Net benefits. Gay men’s use of the internet and other settings where HIV prevention occurs. 2003. London, Sigma research. Available online from http://www.sigmaresearch.org.uk/reports

16. Data from Weatherburn P, Hickson F, Reid D. Net benefits. Gay men’s use of the internet and other settings where HIV prevention occurs. 2003. London, Sigma research. Available online from http://www.sigmaresearch.org.uk/reports Source: Dodds et al. London Gay Men's Survey, 2001. UCL Changing sexual networksSTI and Behavioural surveillance data

17. What are the implications for HIV/STI prevention with MSM? Prevention & control interventions Efficacy? Effectiveness? Cost-effectiveness? Acceptability? Feasibility? STI/HIV Epidemics Individual factors Socio-demographic factors Health beliefs Health seeking behaviours High risk sexual behaviours Environmental Factors Socio-economic deprivation Limitations to use of, and access to, curative services Racism, discrimination, stigma or other disadvantage Infectious agents Antimicrobial resistance Prevalence, incidence and duration of infectivity Disease susceptibility in new environment

18. MSM HIV Prevention in England…what's happening now? • In England, key prevention activities are provided through a nationally coordinated programme, the Community HIV/AIDS Prevention Scheme (CHAPS) led by the Terrence Higgins Trust • Partnership working between regional and local agencies in London and 5 other cities in England and Wales • A single planning Framework (Making it Count) endorsed by the Department of Health and adopted by nearly all NHS and Social care prevention providers in prevention work with MSM • Relatively flexible

19. Other frameworks influencing HIV/STI prevention work with MSM • The DH (England) National Strategy for sexual health and HIV • A 10 year programme providing researchers and providers with a wide range of service delivery and public health oriented goals and aims against which prevention successes may be measured • Health service reorganisation • Sexual health promotion devolved to local Primary Care Trusts • Sexual Health Service investment and redevelopment • Research • CHAPS has a strong evaluative component built into it. • Additional investment available though Medical Research Council`

20. What then are the challenges facing MSM HIV prevention? • How to ensure maximal effectiveness from the DH funded £1.2m national CHAPS programme? • How to ensure a strengthening of locally funded and led gay men’s HIV prevention work (local funding estimated at £10m)? • How to maximise access to HIV & STI diagnostic and treatment services for gay men?

21. Implementation of evidence based prevention interventions • Evidence from well-designed controlled trials clearly demonstrate that HIV prevention can work • Recent review of reviews by Ellis (2003) and Johnson (2002) • Group- and community level behavioural interventions can bring significant reductions in risk-behaviour • Particularly effective in younger participants and populations with higher background of UAI • Elford and Hart (2003) identify factors which limit successful implementation • Repeatability and transferability from research to practice; experiment to intervention • Poor understanding of why interventions work or fail • Changing risk environments compared with the early 1990s

22. Targeting highly sexually active gay men who use Sex on Premises venues (SoPVs) • There is a need to increase the level, profile, and visibility of work within SoPVs. • The current London Gay Men’s Health Promotion Partnership contracts do not contain the capacity to target these venues often enough either through • detached work • appropriately targeted materials • or availability of condoms and lube in places where sex happens.

23. Targeting venue owners of SoPVs • Early work with SOPV owners proved extremely useful in facilitating venue outreach and testing in the syphilis outbreaks in Brighton and London. • Venues might need to feel prevention providers have a 'special relationship' with them • Clever marketing – e.g., specific interventions for specific clubs, possibly with joint branding. • Identifying and working within the legislative framework • Care however to avoid “endorsement” of high-risk activities

24. Targeting people who provide HIV health promotion services to gay men • Huge gaps exist in the abilities of the gay men's health promotion sector to deal with changes, skills needs, training etc. • Reasons for this are many: declining volunteers, declining interest in MSM health promotion, high turnover, unclear career pathways • This suggests significant capacity building requirements to be addressed.

25. Summary • Changes in the epidemiology of STIs (including HIV infection) among MSM in Britain • Demographic, social and behavioural trends are all contributing,however many individual level factors are being enhanced by a rapidly changing social environment • Prevention interventions should respond to the emerging epidemiological and social trends

26. Acknowledgements • John Imrie, Julie Dodds, Neil MacDonald, Ian Simms, Christine McGarrigle • Behavioural Surveillance Collaborators: Centre for Sexual Health and HIV Research, UCL; City University; Sigma Research • Clinical, laboratory and policy colleagues who participate in and support our programmes. • Colleagues from the Terrence Higgins Trust CHAPS programme • HIV/STI Department, Health Protection Agency Communicable Disease Surveillance Centre

27. Summary • Changes in the epidemiology of STIs (including HIV infection) among MSM in Britain • Demographic, social and behavioural trends are all contributing,however many individual level factors are being enhanced by a rapidly changing social environment • Prevention interventions should respond to the emerging epidemiological and social trends • However, this response must be tempered with strengthening of the relationship between public health and health promotion; community and statutory sector approaches to prevention