Annual HIV Testing for MSM May Not Be Enough
links to CDC reports below|
Published: June 02, 2011
"Although men who have sex with men (MSM) comprise an estimated 2% of the overall U.S. population aged ≥13 years (1), 59% of persons with diagnoses of human immunodeficiency virus (HIV) infection in the United States in 2009 were MSM, including MSM who inject drugs (2)......Given the high prevalence of new HIV infection among MSM who had been tested during the past year, sexually active MSM might benefit from more frequent HIV testing (e.g., every 3 to 6 months)......The findings from this analysis suggest that adherence to annual HIV testing recommendations for MSM is low and that even among MSM who reported being tested during the past 12 months, a substantial proportion were newly infected. Because persons often reduce their risk behaviors when they receive a diagnosis of HIV infection and persons who do not know they are infected are estimated to account for more than half of sexually transmitted HIV infections (10), increasing the frequency of HIV testing for MSM can reduce the time from HIV infection to diagnosis and reduce HIV transmission......Current CDC guidelines identify MSM who should be tested more frequently according to their risk behaviors (8). However, among MSM in this analysis, those who had high-risk behaviors were not more likely to be newly infected than those without high-risk behaviors, suggesting that self-reported risk behaviors might not determine which MSM should be tested more frequently......That MSM with less education and income were less likely to have been tested suggests that efforts to expand access to and use of HIV testing among MSM should concentrate on these populations. Additionally, although recent HIV testing did not vary by race/ethnicity, the high proportion of HIV-infected persons among minority MSM, particularly black MSM, who had not previously received a diagnosis of HIV infection and were tested during the past year underscores that testing among these populations should be a priority for HIV testing programs."
* Explain that a CDC study found that men who have sex with men are over-represented among HIV-infected individuals and that 7% tested positive despite having had a reported negative HIV test within 12 months.
* Note that the men included in the study who tested positive did not report engaging in riskier behavior than those who tested negative.
Yearly HIV testing for men who have sex with men may not be frequent enough, a CDC study suggests.
Although a majority of such men in a 21-city survey had had a negative test for the virus within the previous year, when re-tested as part of the survey, 7% were positive for HIV, the agency reported in the June 3 issue of Morbidity and Mortality Weekly Report.
So, the researchers noted, sexually active men who have sex with men "might benefit from more frequent HIV testing," perhaps every three or six months.
The report was the second in that issue of MMWR on the status of the HIV/AIDS epidemic in the U.S., 30 years after the first description of the consequences of HIV infection.
In the accompanying article, the CDC reported that an estimated 1,178,350 people were living with HIV at the end of 2008, with an additional 594,496 having died from AIDS since 1981.
Of those currently living with HIV, the agency reported, 20.1% do not know they are infected, which means they are more likely to pass on the virus.
The analysis also showed that HIV prevalence rates vary markedly by race and ethnicity. Among blacks or African Americans, there were 1,819 HIV-positive people per 100,000 population at the end of 2008, compared with 592.9 per 100,000 among Hispanics or Latinos and 238.4 per 100,000 among whites.
Most people with the virus are men -- some 75% -- and 65.7% of those were men who have sex with men, the agency noted.
Because of the high prevalence of HIV among men who have sex with men -- they accounted for 2% of the population over the age of 13 in 2009, but 59% of new infections -- the agency used data from the National HIV Behavioral Surveillance System to analyze their compliance with testing recommendations.
In 2008, researchers in 21 metropolitan areas with a high prevalence of AIDS collected cross-sectional behavioral risk data and conducted HIV testing among men who have sex with men.
The survey took place in bars, clubs, and other places frequented by men who have sex with men, the agency reported. Some 12,325 men were screened for participation and 11,074 were eligible for the survey -- they were 18 or older, spoke English or Spanish, and lived in the area.
For this analysis, the agency looked at men who said they had never had a positive HIV test Ð 7,271 men or 66% of those eligible.
* Of the 7,271 participants, 680 (9%) were HIV-infected, including 16% who had never been tested for the virus, and 29% who had been tested during the previous six months.
* Some 4,453 men (61%) had been tested during the previous year and had been negative.
* Despite that, 7% were HIV-positive when re-tested as part of the survey -- 15% of black participants, 7% of Hispanics, and 3% of whites.
* Prevalence rates were similar for those who reported or did not report high-risk behaviors, such as having sex in conjunction with illicit drug use.
The researchers cautioned that previous positive HIV tests might have been under-reported and recent testing might have been over-reported by participants. That would tend to inflate the number of new infections, the CDC noted.
Also, the researchers noted, participants were recruited in specific venues and in high-prevalence areas, so the results might not represent all men who have sex with men.
The analysis of testing and prevalence was conducted by the CDC. The authors are employed by the agency.
The surveillance article was prepared by the CDC. Authors are employed by the agency or by a public health department.
Primary source: Morbidity and Mortality Weekly Report
Centers for Disease Control and Prevention "HIV testing among men who have sex with men -- 21 cities, United States, 2008." MMWR 2011; 60: 694-699.
Additional source: Morbidity and Mortality Weekly Report
Centers for Disease Control and Prevention "HIV surveillance -- United States, 1981Ð2008" MMWR 2011; 60: 689-693.
HIV Testing Among Men Who Have Sex with Men --- 21 Cities, United States, 2008
June 3, 2011 / 60(21);694-699
Although men who have sex with men (MSM) comprise an estimated 2% of the overall U.S. population aged ≥13 years (1), 59% of persons with diagnoses of human immunodeficiency virus (HIV) infection in the United States in 2009 were MSM, including MSM who inject drugs (2). CDC recommends HIV testing at least annually for sexually active MSM to identify HIV infections and prevent ongoing transmission (3). Results of HIV testing conducted as part of the National HIV Behavioral Surveillance System (NHBS) in 21 cities indicated that 19% of MSM who were tested in 2008 were HIV-positive; of these, 44% were unaware that they were infected (4). To assess whether MSM were tested as recommended and whether more frequent testing might be indicated, CDC analyzed NHBS data for 2008. This report describes the results of that analysis, which indicated that, of 7,271 MSM interviewed and tested who did not report a previous positive HIV test, 61% had been tested for HIV infection during the past 12 months; among these, 7% had a new, positive HIV test result when tested as part of NHBS. Given the high prevalence of new HIV infection among MSM who had been tested during the past year, sexually active MSM might benefit from more frequent HIV testing (e.g., every 3 to 6 months).
NHBS is a behavioral surveillance system used to monitor HIV-related risk, testing, and prevention behaviors and HIV prevalence among populations at high risk for acquiring HIV (5). In 2008, NHBS staff members in 21 metropolitan statistical areas (MSAs) with high prevalence of acquired immunodeficiency syndrome (AIDS)* collected cross-sectional behavioral risk data and conducted HIV testing among MSM (4). MSM were sampled using venue-based sampling methods (6). NHBS staff members identified venues (e.g., bars, clubs, organizations, and street locations) and days and times when MSM frequented those venues (7). Venues and days/times were selected using a computerized random selection process each month for interviews and supplemented by up to three nonrandom events (e.g., Gay Pride events) per site per month. Staff members systematically approached men at each venue, intercepting potentially eligible men in the order in which they entered a designated "counting area" (6). Men eligible to be interviewed were aged ≥18 years, residents of the MSAs, and able to complete the interview in English or Spanish. After participants gave informed consent, trained interviewers used a handheld computer to administer a standardized, anonymous questionnaire about sex, drug use, and HIV testing behaviors. All respondents were offered anonymous HIV testing, which was performed by collecting blood or oral specimens for either rapid testing at venues or laboratory-based testing. A nonreactive rapid test was considered a definitive negative result; a reactive (preliminary positive) rapid test result was considered a definitive positive result only when confirmed by Western blot or immunofluorescence assay. Incentives were offered for participating in the interview and HIV test.
This analysis excluded MSM who reported a previous positive HIV test. CDC determined the proportion of MSM who received an HIV test during the past 12 months and, of these, the proportion with a positive NHBS test result, stratifying by demographic and risk characteristics. Those testing positive were considered to be unaware of their infection. CDC sexually transmitted disease (STD) treatment guidelines recommend that MSM who have multiple or anonymous partners, have sex in conjunction with illicit drug use, use methamphetamine, or whose sex partners participate in these activities be screened for STDs and HIV more frequently (every 3 to 6 months) than those without such risk factors (8). To reflect these guidelines, MSM with high-risk behaviors were defined as those reporting at least one of the following: more than one male sex partner during the past 12 months, methamphetamine use during the past 12 months, sex in conjunction with illicit drug use at most recent sex, or a most recent male sex partner who definitely or probably had concurrent sex partners. CDC determined the proportion of HIV-infected men among MSM who did and did not report high-risk behaviors.
A multivariable Poisson model was used to create unadjusted and adjusted prevalence ratios to determine factors associated with being HIV-infected (9). The adjusted model controlled for various factors: race/ethnicity, age, annual household income, education, health insurance status, time since most recent HIV test, unprotected anal sex, and high-risk behaviors.
Of 28,468 men approached, 12,325 were screened for participation at 626 venues. Of men screened, 11,074 (90%) were eligible for the survey. Men who were surveyed were excluded from analysis if they did not complete both the survey (n = 396 [4%]) and the HIV test (n = 1,535 [14%]), did not report sex with a man during the preceding 12 months (n = 1,744 [16%]), had an indeterminate HIV test result (n = 85 [0.8%]), or reported being HIV-positive (n = 1,214 [11%]). These reasons were not mutually exclusive. Of eligible men, 7,271 (66%) were included in this analysis.
Of men included in this report, 44% were white, 25% were Hispanic, and 23% were black. Mean age was 34 years (range: 18--85 years); 62% had less than a college education, 29% reported an annual household income <$20,000, and 34% had no health insurance (Table 1).
Among the 7,271 MSM, 680 (9%) were HIV-infected. Of these, 16% had never been tested for HIV, and 29% had been tested during the past 6 months (Figure).
Among the 7,271 MSM, 4,453 (61%) had tested for HIV infection during the past 12 months and did not receive a positive HIV test result. The proportion tested was higher among MSM in younger age groups and those with higher levels of education and income but did not vary by race/ethnicity (Table 1). Among 5,864 (81%) MSM with high-risk behaviors, 44% had been tested for HIV infection during the past 6 months.
Among the 4,453 MSM who had not received a diagnosis of HIV infection previously and were tested for HIV during the past 12 months, 7% (15% of blacks, 7% of Hispanics, and 3% of whites) were found to be HIV-infected when tested by NHBS (Table 2). Of 3,672 MSM with high-risk behaviors who were tested for HIV in the past 12 months and did not receive a positive HIV test result, 7% were HIV-infected when tested by NHBS, compared with 8% of those who did not report any high-risk behaviors. Prevalence of HIV infection among these two groups remained similar after adjusting for time since most recent HIV test. After adjusting for risk and testing behaviors, substantial and significant differences between black, Hispanic, and white MSM persisted (Table 2).
Alexandra M. Oster, MD, Isa W. Miles, ScD, Binh C. Le, MD, Elizabeth A. DiNenno, PhD, Ryan E. Wiegand, MS, James D. Heffelfinger, MD, Richard Wolitski, PhD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Alexandra M. Oster, CDC, firstname.lastname@example.org, 404-639-6141.
The findings from this analysis suggest that adherence to annual HIV testing recommendations for MSM is low and that even among MSM who reported being tested during the past 12 months, a substantial proportion were newly infected. Because persons often reduce their risk behaviors when they receive a diagnosis of HIV infection and persons who do not know they are infected are estimated to account for more than half of sexually transmitted HIV infections (10), increasing the frequency of HIV testing for MSM can reduce the time from HIV infection to diagnosis and reduce HIV transmission.
Current CDC guidelines identify MSM who should be tested more frequently according to their risk behaviors (8). However, among MSM in this analysis, those who had high-risk behaviors were not more likely to be newly infected than those without high-risk behaviors, suggesting that self-reported risk behaviors might not determine which MSM should be tested more frequently. The 7% prevalence of new HIV infection detected through NHBS among MSM who had been tested for HIV during the past year and the similar prevalence of new HIV infection among MSM with and without high-risk behaviors suggests that more frequent testing, perhaps as often as every 3 to 6 months, might be warranted among all sexually active MSM, regardless of their risk behaviors. In considering revising guidelines regarding frequency of testing among MSM, public health officials also should weigh other factors, including the acceptability and cost effectiveness of testing MSM more frequently and the sensitivity of tests in the early stages of infection.
That MSM with less education and income were less likely to have been tested suggests that efforts to expand access to and use of HIV testing among MSM should concentrate on these populations. Additionally, although recent HIV testing did not vary by race/ethnicity, the high proportion of HIV-infected persons among minority MSM, particularly black MSM, who had not previously received a diagnosis of HIV infection and were tested during the past year underscores that testing among these populations should be a priority for HIV testing programs.
The findings in this report are subject to at least three limitations. First, positive HIV status might have been underreported, and recent HIV testing might have been overreported during this interviewer-administered survey, thereby inflating estimates of the proportion of MSM in the sample with new HIV infections. Likewise, MSM might have underreported high-risk behaviors, resulting in some MSM being miscategorized as not having high-risk behaviors. This social-desirability bias also can influence response in HIV testing settings, which suggests that identifying persons for more frequent testing based on self-reported risk might not be effective because it might miss those at risk who underreport risk behaviors. Second, MSM with high-risk behaviors who were tested in the past 12 months might have been more likely to receive a positive HIV test result and be excluded from this analysis compared with MSM without high-risk behaviors, which might have resulted in an underestimation of HIV risk among those with high-risk behaviors. Finally, participants were recruited at venues, most of which were bars and clubs, in 21 cities with high AIDS prevalence and might not represent all MSM; data have not been weighted to account for the unequal selection probabilities of venues or frequency of venue attendance.
This analysis demonstrates that MSM remain a key population for expanded HIV testing efforts. Efforts to increase the proportion of HIV-infected MSM who are aware of their infection should include 1) enhanced outreach of HIV testing to sexually active MSM, particularly populations with higher HIV incidence, in clinical and nonclinical settings, and 2) reexamination of existing recommendations and consideration of HIV testing every 3 to 6 months for all sexually active MSM regardless of self-reported risk behaviors.
HIV Surveillance --- United States, 1981--2008
June 3, 2011 / 60(21);689-693
Within 1 year of the initial report in 1981 of a deadly new disease that occurred predominantly in previously healthy persons and was manifested by Pneumocystis carinii pneumonia and Kaposi's sarcoma, the disease had a name: acquired immune deficiency syndrome (AIDS). Within 2 years, the causative agent had been identified: human immunodeficiency virus (HIV). On the 30th anniversary of the epidemic, to characterize trends in HIV infection and AIDS in the United States during 1981--2008, CDC analyzed data from the National HIV Surveillance System. This report summarizes the results of that analysis, which indicated that, in the first 14 years, sharp increases were reported in the number of new AIDS diagnoses and deaths among persons aged ≥13 years, reaching highs of 75,457 in 1992 and 50,628 in 1995, respectively. With introduction of highly active antiretroviral therapy, AIDS diagnoses and deaths declined substantially from 1995 to 1998 and remained stable from 1999 to 2008 at an average of 38,279 AIDS diagnoses and 17,489 deaths per year, respectively. Despite the decline in AIDS cases and deaths, at the end of 2008 an estimated 1,178,350 persons were living with HIV, including 236,400 (20.1%) whose infection was undiagnosed. These findings underscore the importance of the National HIV/AIDS Strategy focus on reducing HIV risk behaviors, increasing opportunities for routine testing, and enhancing use of care (1).
HIV infection is notifiable in all 50 states and the District of Columbia (DC); AIDS is now notifiable as stage 3 HIV infection. For this report, AIDS data reported to CDC by the end of June 2010 from 50 states and DC were analyzed to determine the annual number of AIDS diagnoses, deaths among persons with AIDS, and persons living with AIDS from 1981 through 2008. Surveillance data were adjusted for reporting delays and missing risk-factor information, but not for incomplete reporting (2). Additionally, by using 1) HIV and AIDS data for persons aged ≥13 years at diagnosis from 40 states that have had confidential name-based HIV infection reporting since at least January 2006 and 2) AIDS data from 11 areas, CDC estimated the annual number of persons living with HIV infection using extended back-calculation (3). The estimated number of undiagnosed HIV infections was calculated by subtracting the number of diagnosed infections from the estimated overall HIV prevalence. HIV prevalence rates per 100,000 population were calculated for 2008 based on postcensal estimates from the U.S. Census Bureau.
From 1981 to 1992, the estimated annual number of persons aged ≥13 years with newly diagnosed AIDS grew rapidly, from 318 to 75,457. From 1981 to 1995, the estimated annual number of deaths among persons with AIDS increased from 451 to 50,628 (Figure). These increases were followed by declines of 45% in AIDS diagnoses, from 1993 (75,263) to 1998 (41,462) and 63% in deaths, from 1995 (50,628) to 1998 (18,851). The declines began to level off in 1999, and AIDS diagnoses and deaths remained fairly stable at an average of 38,279 AIDS diagnoses and 17,489 deaths per year during 1999--2008. As a result, the estimated number of persons aged ≥13 years living with AIDS more than doubled from 1996 (219,318) to 2008 (479,161) (Figure).
At the end of 2008, an estimated 1,178,350 persons aged ≥13 years were living with HIV infection, including 236,400 (20.1%) whose infections had not been diagnosed (Table). Most (75.0%) persons living with HIV were male, and 65.7% of the males were men who have sex with men (MSM). HIV prevalence rates among blacks or African Americans (1,819.0 per 100,000 population) and Hispanics or Latinos (592.9) were approximately eight times and two and a half times the rate among whites (238.4) (Table). Greater percentages of those living with HIV infection had undiagnosed HIV among persons aged 13--24 years (58.9%) and 25--34 years (31.5%) than among those aged 34--44 years (18.0%), 45--54 years (13.8%), 55--64 years (11.9%), and ≥65 years (10.7%). Greater percentages of undiagnosed HIV also were observed among males with high-risk heterosexual contact (25.0%) and MSM (22.1%) than among those in other transmission categories. Greater percentages of undiagnosed HIV also were observed among Asians or Pacific Islanders (26.0%), and American Indians or Alaska Natives (25.0%), than among blacks or African Americans (21.4%), whites (18.5%), and Hispanic or Latinos (18.9%) (Table).
Lucia Torian, PhD, New York City Dept of Health and Mental Hygiene. Mi Chen, MS, Philip Rhodes, PhD, H. Irene Hall, PhD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: Mi Chen, CDC, email@example.com, 404-639-8336.
Three decades after the first cases were reported in the United States, HIV infection is no longer inevitably fatal. Highly active antiretroviral therapy suppresses viral replication for decades, allowing patients to enjoy longer and healthier lives and making them less infectious to others (4). A recent study of 3,400 heterosexual couples in Africa found that use of antiretroviral therapy reduced HIV transmission risk by 92% (4). HIV-related mortality, perinatal transmission, and the number of new HIV diagnoses among injection drug users have plummeted (2). Nucleic acid testing now can detect HIV as early as 9 days after infection, enhancing the safety of the blood and organ supply and providing opportunities for early detection and disease intervention, including partner notification (5). Preexposure prophylaxis and topical microbicides are promising biomedical interventions (6). The scientific progress in immunology, virology, pharmacology, and clinical management that led to these successes occurred at a faster pace than was imaginable in 1981, when the first cases of AIDS were identified.
HIV prevention efforts averted an estimated 350,000 HIV infections during 1991--2006 and saved $125 billion in medical care costs (7). However, despite these efforts and widespread knowledge of how to prevent HIV, CDC estimates that 50,000 persons are infected each year in the United States. More than half of the newly infected are MSM, and nearly half are black or African American (3). In addition, the findings in this report indicate that, of the estimated 1,178,350 living with HIV infection in the United States, 20.1% had undiagnosed HIV infections.
Surveillance data show that the proportion of HIV diagnoses occurring in MSM continues to grow. HIV incidence among MSM has increased steadily since the early 1990s (3). In 2009, MSM accounted for 57% of all persons and 75% of men with a diagnosis of HIV infection in the 40 states with longstanding, confidential, name-based HIV infection reporting (2). Syphilis and gonorrhea are endemic among MSM; outbreaks or hyperendemic sexually transmitted infections have been reported from many communities where HIV infection also is prevalent, further increasing the risk for acquiring and transmitting HIV (8).
Late diagnosis of HIV infection is common. Among persons with newly diagnosed HIV in 2008, 33% developed AIDS within 1 year of initial HIV diagnosis (2). These persons likely were infected an average of 10 years before diagnosis. During this period, they missed opportunities to obtain medical care and to prevent unwitting transmission of HIV to others. Persons with a late diagnosis of HIV infection also are at greater risk for short-term mortality than those who receive an HIV diagnosis earlier in the course of infection. Initiation of care soon after diagnosis is recommended, yet a meta-analysis of 28 studies from multiple U.S. regions found that 28% of persons did not enter care within 4 months of HIV diagnosis (9). In addition, an estimated 41% of HIV-infected persons did not average at least two care visits in a year (9), as recommended by the U.S. Department of Health and Human Services (10).
The findings in this report are subject to at least three limitations. First, reported HIV data used in the extended back-calculation method represent only a portion of persons in the United States who received a diagnosis of HIV infection; some areas with high incidence, including Maryland and DC, did not contribute HIV data. Availability of HIV data from these areas will increase accuracy of future prevalence estimates. Second, not all persons with HIV have received a diagnosis of HIV infection, and so, have not been reported to the public health surveillance system; data must be estimated for persons with undiagnosed HIV. Finally, the data have been adjusted statistically to account for delays in reporting new cases and deaths and for missing risk factor information, which might result in less stable results (2).
The National HIV/AIDS Strategy (1) has three primary goals: 1) reduce HIV incidence, 2) increase access to care and improve health outcomes for persons living with HIV, and 3) reduce HIV-related health disparities. The strategy refocuses efforts toward intensified HIV prevention in communities where HIV infection is most prevalent, using a combination of effective strategies that seek to optimize entry into and retention in care and maintenance of viral suppression. CDC, in partnership with state and local health departments, will use surveillance data to evaluate the measurable outcomes of this strategy, including new diagnoses, early detection, entry into care, retention in care, and viral suppression, as well as progression to AIDS and death.