Eurosurveillance - Volume 14, Issue 47, 26 November 2009

World Aids Day provides a good opportunity to take stock of the status of the HIV/AIDS epidemics in Europe and to reflect on achievements made and ongoing challenges.

HIV infections remain to be of major public health importance in Europe, with evidence of increasing transmission in several European countries. A total of 25,656 diagnosed cases of HIV infection were reported for 2008 by the countries of the European Union and European Economic Area (EU/EEA); data were not available from Austria, Denmark or Liechtenstein. The highest rates were reported by Estonia, Latvia, Portugal and the United Kingdom. In the EU/EEA, the predominant mode of transmission for HIV infection was sex among men who have sex with men (MSM, 40%) followed by heterosexual contact (29%), when cases in persons originating from countries with generalised epidemics were excluded. Injecting drug use accounted for 6% of the reported cases. Overall, despite incomplete reporting, the number of HIV cases in 2008 has increased while the number of reported AIDS cases continued to decline except in the Baltic States. The data presented have some limitations, due to missing data from a number of countries, limiting the conclusions that can be drawn with respect to the size of the HIV and AIDS epidemics in Europe.

An increase in HIV transmission among men who have sex with men (MSM) has been reported in eight regions of Spain from 2003 to 2007. In order to study the incidence of HIV-1 genetic forms in Galicia, northwest of Spain, in particular the spread of HIV-1 variants among MSM, 93 newly diagnosed HIV-1 patients, including those with acute and recently acquired infections, were studied for a year from August 2008 to August 2009. Thirty eight (41%) were MSM. Of them, nine (24%) were infected by non-B viruses, including seven different genetic forms. The analysis of transmission clusters showed that 23 (60%) MSM grouped in different clusters and mostly in large clusters. Resistance mutations were detected in six (16%) MSM.

This paper describes behavioural surveillance for HIV and sexually transmitted infections (STI) among men who have sex with men (MSM) in Europe, focusing on the methods and indicators used. In August 2008, questionnaires were sent to European Union Member States and European Free Trade Association countries seeking information on behavioural surveillance activities among eight population groups including MSM. Thirty-one countries were invited to take part in the survey and 27 returned a questionnaire on MSM. Of these 27 countries, 14 reported that there was a system of behavioural surveillance among MSM in their country while another four countries had conducted behavioural surveys of some kind in this subpopulation. In the absence of a sampling frame, all European countries used convenience samples for behavioural surveillance among MSM. Most European countries used the Internet for recruiting and surveying MSM for behavioural surveillance reflecting increasing use of the Internet by MSM for meeting sexual partners. While there was a general consensus about the main behavioural indicators (unprotected anal intercourse, condom use, number of partners, HIV testing), there was considerable diversity between countries in the specific indicators used. We suggest that European countries reach an agreement on a core set of indicators. In addition we recommend that the process of harmonising HIV and STI behavioural surveillance among MSM in Europe continues.

To evaluate the prevalence of sexual risk behaviours among men who have sex with men (MSM) in Catalonia and to identify sociodemographic, psychosocial, and behavioural factors associated with unprotected anal intercourse (UAI) with casual partners a convenience sample of 850 MSM was recruited in 2006. An anonymous questionnaire was used to explore risk behaviours during the previous 12 months. Logistic regression models were used to examine the variables associated with UAI. Mean age was 41 years and 20.4% were immigrants. Among those with casual partners (91.7% of all respondents), 31.4% had UAI. The multivariate analysis revealed that the likelihood of UAI was higher in men who were HIV-positive (OR: 1.77), used more than four drugs before sex (OR: 4.90 for +6), were not from Spain (OR: 2.10 for Latin American; OR: 1.86 for other immigrants), had more than 20 sexual partners (OR: 1.56), met casual sex partners on the Internet (OR:1.45) and presented a high level of internalised homophobia (OR: 2.40). HIV/STI prevention programmes for MSM in Catalonia should incorporate activities that strengthen self-esteem, take into account the impact of internalised homophobia, and adapt to the sociocultural reality of immigrants. Furthermore, these programmes should also address substance abuse and alert HIV-positive men about the risk of HIV re-infection and transmission of other STI.

We examined whether men who have sex with men (MSM) in France have adopted serosorting with their casual partners, serosorting being one strategy to reduce the risk of HIV transmission. We expected to see the same predictors of this practice with casual partners in France as in other similar MSM communities (HIV-seropositive, Internet dating). Data from a cross-sectional survey was used, based on a self-administered questionnaire conducted among readers of the gay press and users of gay websites in 2004. The study population consisted of MSM who reported their HIV status, as well as the practice of unprotected anal intercourse (UAI) with a casual partner at least once during the previous 12 months. Among 881 respondents included in the analysis, 195 (22%) had practiced serosorting: 14% among HIV-seropositive men and 26% among HIV-seronegative men. Serosorting was independently associated with the use of cruising venues (AOR 0.28, p=0.001) and Internet dating (AOR 2.16, p=0.051) among HIV-seropositive men, whereas it was independently associated with the use of cruising venues (AOR 0.59, p=0.013) and the fact of having less partners (AOR 1.50, p=0.046) among HIV-seronegative men. Serosorting requires an up-to-date knowledge of HIV serostatus for MSM and their UAI casual partners, and does not prevent from acquiring other sexually transmitted infections. Prevention campaigns are needed to underline the risks associated with serosorting.

The objective was to investigate herpes simplex virus (HSV) epidemiology amongst HIV-positive and HIV-negative men who have sex with men (MSM) in England and Wales. Unlinked anonymous sera from 3,968 MSM attending 12 sexual health clinics in 2003 were tested for HIV, HSV-2 and HSV-1 antibodies. Fifty-five percent of HIV-positive MSM were HSV-2-seropositive, compared to 17% of HIV-negative MSM (Adj RR: 2.14 [CI: 1.92-2.37]). Amongst HIV-positive individuals, there was no significant difference in HSV-2 seroprevalence by knowledge of HIV status or whether the HIV infection was recently acquired (determined through STARHS). HIV infection was also independently associated with HSV-1 serostatus (Adj RR 1.19 [CI: 1.14-1.24)]). Four of the twelve attendees who received a diagnosis of recurrent anogenital herpes at the clinic visit were HSV-1-seropositive but not HSV-2-seropositive at the time, although no cultures or PCR results were available to type the cause of the ano-genital presenting disease. It is of concern that one in two HIV-positive MSM and one in six HIV-negative MSM may be infected with HSV-2, given increasing evidence of its impact on HIV progression, onward transmission and acquisition. To date results have been disappointing from trials aimed at reducing HIV onward transmission and HIV acquisition using HSV antiviral medication. However, recent research in an African context demonstrates the efficacy of HSV antivirals in delaying HIV progression. The high prevalence of HSV-2 amongst HIV-positive MSM suggests that an increased focus on HSV control in the management of HIV amongst MSM in the United Kingdom (UK) may be warranted. Given this and existing research on the high prevalence of genitally acquired HSV-1 amongst MSM in the UK, further research is also warranted into the role of HSV-1 in the HIV epidemic in this context.

This paper describes recent trends in the epidemiology of syphilis and gonorrhoea infections in Europe among men who have sex with men (MSM). Routine surveillance data submitted to the European Surveillance of Sexually Transmitted Infections (ESSTI) network from 24 European countries for the period 1998-2007 were analysed. Data on whether syphilis and gonorrhoea infections were in MSM were available for 12 and 10 countries respectively. The number of syphilis cases reported to be MSM increased considerably in all Western European countries. While in some Central and Eastern European countries the male to female ratio remained relatively stable at around 1:1, in Slovenia and the Czech Republic the proportion of male cases increased and so did the percentage of cases reported to be MSM. More cases of gonorrhoea were seen in men than women, but the percentage of male cases reported to be MSM was lower than for syphilis. The findings suggest MSM are at high risk of STI in Western Europe and appear to be an increasingly important risk group in Central Europe. Despite this, data on infections among MSM are not collected routinely in many countries. The introduction of standardised data collection including data on diagnoses in MSM should be prioritised for monitoring STI in this population.

The report presents data on HIV infection among men who have sex with men (MSM) in Slovenia during 1999-2008. HIV surveillance was based on universal mandatory reporting of HIV/AIDS cases, monitoring HIV infection prevalence among sentinel populations of MSM and STI patients and selected behaviour indicators in a sentinel population of MSM. Among 48 newly diagnosed HIV cases reported for 2008, 34 were MSM. Since 1999, the annual reported rate of HIV diagnoses in MSM rose from 7.1 to 46.8 per million men aged 15-64 years (an increase of more than six times). During 1999-2008, the proportion of MSM diagnosed with AIDS within three months of HIV diagnosis declined from 60% to 21%, however, the corresponding rate per million men aged 15-64 increased from 4.3 to 9.6. During 1999-2008, HIV prevalence among male clients of STI outpatient services tested for syphilis (including a substantial proportion of MSM) increased from 0% to 3.4%, and it remained below 5% in a sentinel population of MSM in Ljubljana. In the same sentinel population of MSM, the proportion reporting HIV test last year increased from 29% in 2003 to 38% in 2008 while the proportion reporting condom use at last anal intercourse decreased from 81% in 2004 to 66% in 2008. The burden of HIV among MSM in Slovenia is disproportionately high and increasing fast. Promotion of safer sexual behaviour and HIV testing among MSM as well as positive prevention among MSM with diagnosed HIV infection are urgently needed.

Belgium is currently experiencing an upward trend in the number of new HIV diagnoses characterised by a continuous increase in the number of cases among men who have sex with men (MSM). Based on surveillance data, in the past decade the yearly number of newly diagnosed HIV cases in MSM increased more than threefold, from 101 cases diagnosed in 1999 to 332 cases in 2008. During this period, the majority of new HIV infections in MSM were diagnosed among Belgians citizens (72%), followed by other European nationalities (13%). The increase in HIV diagnoses does not reflect an increase in HIV testing since the number of tests performed nationwide remained remarkably stable over time. The steady increase in the number of newly diagnosed HIV cases among MSM, and the high proportion of MSM among HIV-positive patients co-infected with other sexually transmitted infections (STI) (95.6% in 2008) indicate increases in unsafe sex practices in this group. Development of behavioural surveillance and more qualitative research on reasons for unsafe sex are needed in order to develop more effective prevention strategies.

Viral hepatitis causes major disease burden worldwide, due to the chronic hepatitis sequelae: cirrhosis and primary liver cancer. Transmission of viral hepatitis is a problem not only in low-income countries, but also in high-income ones where viral hepatitis is a frequently occurring infection among men who have sex with men (MSM). Although the transmission routes of the three main hepatitis viruses, A, B and C, differ, MSM mainly acquire viral hepatitis during sexual contact. Vaccination programmes (only available for hepatitis A and B), raising awareness, and screening can be used to prevent transmission. However, despite the introduction of such methods in many high-income countries, the spread of viral hepatitis among MSM is still ongoing. This paper provides an overview of sexually acquired hepatitis A, B, and C among MSM in high-income countries, using recent insights obtained through molecular epidemiology, with the aim to raise awareness, improve vaccination coverage, and stimulate prevention programs.