US CDC study: 77% of young urban HIV-positive gay/bisexual men have unrecognised HIV infection

A 1994-2000 study of gay and bisexual men aged between 15 and 29 has found that in five of six US cities, three-quarters of the men who were HIV-positive were unaware of their HIV status, and were unknowingly exposing their male and female sexual partners to HIV. The US Centers for Disease Control and Prevention (CDC) published the data in the April 15^th issue of the Journal of AIDS.

The CDC’s Young Men’s Survey was a two-phase, cross-sectional anonymous survey that took place in Baltimore, Dallas, Los Angeles, Miami, New York and Seattle between 1994 and 1998 (men aged 15-22), and 1998 and 2000 (men aged 23-29) in order to evaluate the magnitude and distribution of unrecognised HIV infection among young gay and bisexual men.

At 263 gay venues (including dance clubs, street locations within the ‘gay neighbourhood’, bars, health clubs, cafés, shops, gay youth organisations, parks, adult bookstores, bathhouses and Pride events) in the six cities, 11,156 men met the study’s eligibility criteria. These included being under 30, living locally, and having never previously participated in the current research phase. Of these, 6,556 (59%) participated in the study, which included answering a standard questionnaire, and giving blood specimens for HIV testing. Participants were counselled on HIV prevention, reimbursed $40-50 for their time, and scheduled to receive their test results within two weeks.

The following analysis was restricted to 5649 participants. Reasons for removal from the analysis included duplication (n=178), invalid data (n=52), never having had sex (n=116), never having had sex with men (n=489) and incomplete HIV test results (n=72).

Demographics of unrecognised infection

Of the 5649 men, 573 (10%) tested positive for HIV. Of these, 439 (77%) were unaware of their HIV infection, although this varied by city, age group, and ethnicity: 91% of black, 69% of Hispanic and 60% of white participants were unaware they were HIV-positive. The authors termed these men ‘infected-unaware’. Compared with the HIV-negative participants, infected-unaware men were more likely to live in any city other than Seattle; be aged 23-29 (Adjusted Odds Ratio [AOR] 1.7, 95% CI 1.3-2.2); black (AOR 6.8, 95% CI 5.0-9.2), mixed-race (AOR 3.7, 95% CI 2.1-6.5) or Hispanic (AOR 1.8, 95% CI 1.3-2.4); and not currently studying at college or university. Although the data are not shown in the paper, the authors say, “within each study phase, older age remained significantly associated with being infected-unaware”.

Previous HIV testing

Of the 4037 men who had previously taken an HIV test, 8% were found to be HIV-positive, although this varied by ethnicity (21% among black men, 7% among Hispanics, and 4% among white men). Of the 439 infected-unaware men, 360 (82%) had ever taken an HIV test and 323 (74%) reported that their most recent test was negative. The researchers also discovered during the second phase of the study that high proportions of both infected-unaware men and HIV-negative men reported that they did not receive any counselling at their most recent HIV test.

Delayed HIV testing

Participants who had never tested, or whose most recent test was more than a year ago, were called ‘delayed testers’ by the researchers. They found that delayed testing among infected-unaware men was associated with several factors: a perceived moderate-high risk of being infected, not using a regular source of healthcare, and less than monthly attendance at gay meeting places. Importantly, among the men who had never tested, proportionally more infected-unaware men than HIV-negative men reported that they hadn’t tested due to a fear of knowing the results (65 vs. 38%, p

Perceptions of Low HIV Risk

Of the 439 infected-unaware men, 258 (59%) perceived themselves to be at low risk of currently being infected, and 193 (44%) thought they were at low risk of ever being infected. These perceptions were associated with being younger, having previously tested HIV-negative, never being diagnosed with an STI, having fewer lifetime male partners, and not having unprotected anal intercourse (UAI) in the six months preceding the interview.

Risk Behaviour

Proportionally more infected-unaware than HIV-negative men reported having more than five male partners in their lifetime, as well as having anal sex and/or injecting drugs. In the six months preceding the interview, 51% of the infected-unaware men reported having insertive and/or receptive UAI with men, and 7% reported having UAI or unprotected vaginal intercourse with women. Of those who engaged in UAI, 48% said they hadn’t used condoms because either they “knew” they were HIV-negative, “knew” their partners were HIV-negative, or perceived that their partners were at low risk for infection. Significantly, among infected-unaware men, UAI was more highly associated with having a steady partner (AOR 4.3, 95% CI 2.4-7.6). Compared with the men who knew they were HIV-positive in the six months prior to the survey, proportionally more infected-unaware men reported having UAI because they thought their partners were HIV-negative or at low risk for infection (AOR 2.7; p

The authors state that “these finding underscore the urgency of improving federal, state, and local prevention programs for [gay and bisexual men] through interventions that help clarify perceived risk for infection and by increasing the availability of and demand for HIV testing services.” They go on to make the following recommendations:

• Health-care providers should routinely recommended HIV testing for all patients in health-care settings where HIV prevalence is 1% or greater; where HIV prevalence is below 1%, at-risk gay and bisexual men should be routinely assessed for HIV and STI testing at least annually. Rapid tests should be used.
• Expansion of outreach HIV testing at clubs, bars, bathhouses and other locations in the ‘gay neighbourhood’ may reach more men with unrecognised infection.
• Since this and other studies have found that a large majority of new infections among younger gay and bisexual men are likely occurring within primary relationships, partner counselling and referral services might be an effective strategy to reach gay and bisexual men with unrecognised infection.
• Demand for HIV testing might be increased by efforts that increase awareness of personal risks for infection, as well as by efforts that address concerns about testing positive. These include marketing the benefits of early diagnosis and advancement in HIV treatments, emphasising that access to treatment is often available to those without insurance, and publicising that laws and organisations exist to help protect against discrimination.
• Prevention counsellors should inform gay and bisexual men that many men are HIV infected despite perceiving themselves to be negative. In addition, gay and bisexual men should be encouraged to use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have recently tested HIV negative.

The authors conclude that their findings “suggest that the HIV epidemic among young [gay and bisexual] men in the United States continues unabated, in part, because many young HIV-infected [gay and bisexual] men are unaware of their infection and unknowingly expose many of their partners to HIV… To advance HIV prevention in the third decade of HIV/AIDS, national, state, and local prevention efforts must take advantage of opportunities to increase the demand for and availability of testing to reduce the burden of unrecognised HIV infection among young [gay and bisexual] men.”