Men who have sex with men

Men Still Drive STD Increases.

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The CDC’s annual snapshot of sexually transmitted diseases (STDs) has both good news and bad news for 2013.

On the positive side, the rate of reported cases of chlamydia fell for the first time since national reporting of the disease began, the agency said in the report, “Sexually Transmitted Disease Surveillance 2013.”

On the down side, the 2013 rate of reported primary and secondary syphilis cases rose nearly 11% over 2012 — the highest rate since 1995.

The third of the nationally notifiable STDs for which there are federal control programs is gonorrhea, where the incidence rate was slightly down in 2013, after several years of increases.

For all three infections, the agency found, rates among men were increasing, while those for women were falling or stable.

That continues the pattern the CDC reported in last year’s snapshot in which men were driving increased STD rates.

The data come from notifiable disease reporting by state and local STD programs, as well as projects that monitor STDs in various settings, and other national surveys by federal and private organizations, the agency said.

But incomplete diagnosis and reporting means the numbers are an underestimate even for the notifiable diseases, the CDC said, adding that for other STDs, such as human papillomavirus, national estimates aren’t available.

Data on chlamydia show 1,401,906 reported infections from 50 states and the District of Columbia, the report said, corresponding to a rate of 446.6 cases per 100,000 population.

From 1993 through 2011, the rate rose from 178.0 to 453.4 cases per 100,000 population and then was stable in 2012 at 453.3 cases per 100,000. The 1.5% decrease in 2013 represents the first drop since national reporting began.

Women continue to have the most reported infections — some 993,348 cases in 2013 for a rate of 623.1 per 100,000 — at least partly because they are more likely to be screened for the disease, the report said. The rate was a 2.4% decline from 2012.

On the other hand, there were 408,558 cases among males for a rate of 262.6 cases per 100,000 males, up 0.8% from 2012.

 The report notes that reported figures for chlamydia, which is mostly asymptomatic, can be affected by changes in the actual incidence, as well as by variation in diagnostic, screening, and reporting practices.

For syphilis, the driving factor is men — and mainly men who have sex with men — the report said.

The annual rate of reported primary and secondary syphilis in the U.S. reached an all-time low in 2000, and rose in the following decade, before decreasing slightly in 2010 and stabilizing in 2011.

But the rate rose in 2012 and again in 2013, when the number of reported syphilis cases increased from 15,667 in 2012 to 17,535 in 2013, an increase of 10.9%. The rate from 5.0 to 5.5 cases per 100,000 population, making both the 2013 case count and rate the highest since 1995.

Among men, the rate of primary and secondary syphilis rose 12% in 2013, compared with 2013 — from 9.2 to 10.3 cases per 100,000 men — while the rate among women remained unchanged at 0.9 cases per 100,000 women.

Men accounted for 91% of all reported primary and secondary disease cases; in the 49 states and the District of Columbia that reported the sex of partners of patients, men who have sex with men accounted for 75% of cases.

In jurisdictions where information for both sex of partner and HIV status was relatively complete — defined as 70% or greater for all cases — 52% of men who have sex with men with syphilis also had HIV. The co-infection rates for men who have sex with women and for women were 9.9% and 5.2%, respectively.

For gonorrhea, there were 333,004 reported cases yielding a rate of 106.1 cases per 100,000 population, which was down 0.6% over 2012. On the other hand, the rate still represented an 8.2% increase over 2009.

Compared with 2012, the 2013 gonorrhea rate among men increased 4.3%, and the rate among women decreased 5.1% — a difference that suggests either increased transmission or increased case ascertainment among gay, bisexual, and other men who have sex with men.

  • Primary Source

    Centers for Disease Control and Prevention

The cultural challenge of HIV/AIDS.

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As the HIV epidemic enters its fourth decade, HIV transmission in several parts of the world shows no sign of abating—for example, in sub-Saharan Africa an estimated 1·9 million people became newly infected in 2010.1 Certain affected populations in the epidemic are more marginalised than others, notably gay men and other men who have sex with men. A biologically heightened vulnerability to HIV and the limited uptake and use of barrier methods, especially among younger cohorts of men who have sex with men, fuelled by stigma and in some parts of the world criminalisation, makes addressing the issue of HIV/AIDS in men who have sex with men complex, as this Lancet Series shows.2—9

In the past year, the dialogue around HIV/AIDS has centred on ending the epidemic after release of the HPTN052 study findings, which showed that early initiation of antiretroviral therapy reduced the risk of HIV transmission to uninfected partners by 96%.10 Several studies have confirmed the potential of similar interventions to help prevent HIV infection. These scientific advances have to some extent prompted a renewal in efforts towards achieving an AIDS-Free Generation. Indeed, last year Hillary Clinton announced the US Government’s commitment towards this goal,11 one that builds on the global programmatic successes of treatment and prevention technologies to date. And from a research perspective, the HIV cure agenda has had a recent resurgence of interest and optimism with the launch of a global scientific strategy.12 Although these efforts are welcome, there is a sense that the HIV/AIDS response is taking the wrong road.

The power of science has been, and continues to be, a huge benefit to the AIDS response. But science is also the Achilles’ heel of HIV prevention and control. The science of HIV can mislead us into thinking there are technical solutions to the epidemic. If we could only roll out more antiretrovirals in the developing world, develop the right regimen for treatment as prevention, or develop an effective vaccine or the right microbicide all will be well. But, in truth, the underlying challenge of HIV is only partly technical. A more important barrier is cultural: stigma and alienation apply not only to the HIV epidemic among men who have sex with men but also among heterosexuals.

Our Series aims to unite two vital elements in the fight against AIDS. One is the application of science to defeat the epidemic, and the second neglected, yet crucial, element is the cultural dimension of stigma and homophobia. Men who have sex with men have been, and continue to be, pushed to the margins of the HIV/AIDS response. Our Series not only aims to put men who have sex with men back into the centre of those debates, but to reassert the importance of the cultural and political dimensions of HIV/AIDS, which have been neglected in our fascination with technical breakthroughs.

Although there are many countries that should be credited for showing enlightened responses to HIV/AIDS in communities of men who have sex with men, such as Brazil and South Africa, the extraordinary global polarisation around basic human rights for these men—in what Dennis Altman and colleagues9 in this Series call “political homophobia”—points to the existence of deeply rooted cultural barriers. While South Africa led the world in recognising sexual rights in its Constitution, about 80 countries still criminalise homosexual behaviour. In many African and Caribbean countries, the former Soviet Union, and most of the Middle East, citizens face persecution for discussing safe sex behaviour, are unable to access harm reduction services, are unable to talk openly about their lives, and cannot get tested for HIV without the fear of being stigmatised.

There is no technical solution to HIV that is a panacea for all communities and all countries. There is only going to be a solution that involves a broad understanding and acceptance of diverse sexual behaviours among men and women. Achieving this goal will mean discussing matters that people often wish to avoid. These issues invite us all to ask challenging questions about human sexuality and behaviour. Whether it is the Catholic Church or academia, aid donors or recipient countries, these predicaments are not being prioritised as they should be. These attitudes towards men who have sex with men combine to create a cultural crisis faced by other communities—for example, women, injecting drug users, and sex workers. If we are to succeed in this fourth decade of the HIV/AIDS response, we must show our commitment to this welcome human diversity as well as to gender equity.

Source: Lancet

 

Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals.

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More than 30 years into the global HIV/AIDS epidemic, infection rates remain alarmingly high, with over 2.7 million people becoming infected every year. There is a need for HIV prevention strategies that are more effective. Oral antiretroviral pre-exposure prophylaxis (PrEP) in high-risk individuals may be a reliable tool in preventing the transmission of HIV.

Objectives

To evaluate the effects of oral antiretroviral chemoprophylaxis in preventing HIV infection in HIV-uninfected high-risk individuals.

Search methods

We revised the search strategy from the previous version of the review and conducted an updated search of MEDLINE, the Cochrane Central Register of Controlled Trials and EMBASE in April 2012. We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov for ongoing trials.

Selection criteria

Randomised controlled trials that evaluated the effects of any antiretroviral agent or combination of antiretroviral agents in preventing HIV infection in high-risk individuals

Data collection and analysis

Data concerning outcomes, details of the interventions, and other study characteristics were extracted by two independent authors using a standardized data extraction form. Relative risk with a 95% confidence interval (CI) was used as the measure of effect.

Main results

We identified 12 randomised controlled trials that meet the criteria for the review. Six were ongoing trials, four had been completed and two had been terminated early. Six studies with a total of 9849 participants provided data for this review. The trials evaluated the following: daily oral tenofovir disoproxil fumarate (TDF) plus emtricitabine (FTC) versus placebo; TDF versus placebo and daily TDF-FTC versus intermittent TDF-FTC. One of the trials had three study arms: TDF, TDF-FTC and placebo arm. The studies were carried out amongst different risk groups, including HIV-uninfected men who have sex with men, serodiscordant couples and other high risk men and women.

Overall results from the four trials that compared TDF-FTC versus placebo showed a reduction in the risk of acquiring HIV infection (RR 0.51; 95% CI 0.30 to 0.86; 8918 participants). Similarly, the overall results of the studies that compared TDF only versus placebo showed a significant reduction in the risk of acquiring HIV infection (RR 0.38; 95% CI 0.23 to 0.63, 4027 participants). There were no significant differences in the risk of adverse events across all the studies that reported on adverse events. Also, adherence and sexual behaviours were similar in both the intervention and control groups.

Authors’ conclusions

Finding from this review suggests that pre-exposure prophylaxis with TDF alone or TDF-FTC reduces the risk of acquiring HIV in high-risk individuals including people in serodiscordant relationships, men who have sex with men and other high risk men and women.

 

Plain language summary

Antiretroviral pre-exposure prophylaxis (PrEP) for preventing HIV in high-risk individuals

This review evaluated the effects of giving people at high risk for HIV infection drugs to prevent infection (called antiretroviral pre-exposure prophylaxis, or PrEP). We found six randomised controlled trials that assessed the effects of oral tenofovir disoproxil fumarate (TDF) plus emtricitabine (FTC) versus placebo; TDF versus placebo, and daily TDF-FTC versus intermittent TDF-FTC. One of the trials had three study arms (TDF, TDF-FTC and placebo arm). The trials were carried out amongst different risk groups, including HIV-uninfected men who have sex with men, people in serodiscordant sexual relationships where one partner is infected and the other is not, and other high risk men and women. The findings suggests that the use of TDF alone or TDF+FTC reduces the risk of becoming infected with HIV. However, further studies are need to evaluate the method of administration (daily versus intermittent dosing), long-term safety and cost effectiveness of PrEP in different risk groups and settings.

Source: Cochrane Library.