The Health Protection Agency (HPA) in the UK has issued a bleak report on the state of the nation’s sexual health. Titled, Testing Times it notes an increase in HIV prevalence, a high incidence of syphilis and increases in new cases of herpes and genital warts.
Continuing high rates of HIV diagnoses in gay men and increases in diagnoses of many sexually transmitted infections in this population prompt the report’s authors to write, “current prevent efforts directed towards…MSM [men who have sex with men] are not succeeding adequately.” The report also calls for a review of HIV prevention campaigns targeted at gay men to make sure that they “are based upon proven interventions and authoritative recommendations”.
The report did find that more people attending sexual health clinics are being offered and accepting an HIV test, but an estimated third of all HIV infections in the UK are still undiagnosed.
Gay men, HIV and sexually transmitted infections
HPA figures suggest that 2,700 gay men were newly diagnosed with HIV in 2006, a total similar to the highest ever annual number of new diagnoses recorded in 2005.
Annual incidence of HIV amongst gay men attending sexual health services in 2006 was just over 2%. Almost three-quarters of new HIV diagnoses in gay men in 2006 were located in those aged 25 – 44.
Investigators estimate that there are 31,000 gay men living with HIV (diagnosed and undiagnosed) in the UK, and that almost 9% of gay men in London are HIV-positive, with the HIV prevalence amongst gay men elsewhere in the UK being 5%.
New diagnoses of gonorrhoea also increased amongst gay men, from just under 4,000 cases in 2004 to 4,524 cases in 2006, a 13% increase.
In all gay men accounted for 58% of all syphilis cases diagnosed in 2006. However, there was a small fall in the number of new syphilis cases amongst gay men in 2006 (1,417) compared to 2005 (1,438 cases).
Transmission of lymphogranuloma venereum (LGV) amongst gay men continued in 2006. But the number of cases diagnosed per quarter fell to an average of 32 compared to a peak of 45 per quarter in 2005.
Gay men living with HIV were particularly likely to be diagnosed with a sexually transmitted infection. Over a third of syphilis cases were in HIV-positive gay men, as were 75% of LGV cases and approximately 20% of all gonorrhoea diagnoses.
There has been a move to offer gay men ‘opt-out’ HIV tests as part of a sexual health screen to help cut the rate of undiagnosed HIV. But the investigators found there was no real difference in the proportion of gay men accepting HIV tests at ‘op-out’ and ‘opt-in clinics (87% vs. 83%). Anonymous blood testing showed that 47% of gay men with undiagnosed HIV who attended a sexual health clinic left the clinic without being tested for HIV, suggesting that those most likely to be HIV-positive are disproportionately likely to turn down the offer of an HIV test when they attend a sexual health clinic.
Late diagnosis of HIV continued to be a problem, with 20% of gay men diagnosed with HIV in 2006 having a CD4 cell count below 200 cells/mm3. However the median CD4 cell count at diagnosis in gay men has remained stable since 2003, at around 400 cells/mm3.
HIV and black Africans
The HPA estimates that 4% of black Africans in the UK are HIV-positive, and that almost 50% of new HIV diagnoses in 2006 were amongst this population. The total number of HIV-positive black Africans in the UK (diagnosed and undiagnosed) is estimated to be 24,800. There were just over 3,000 new HIV diagnoses in black Africans in 2007.
Late diagnosis continued to be a problem for black Africans with 41% of this population diagnosed in 2006 having a CD4 cell count below 200 cells/mm3.
HIV prevalence in 2006 amongst pregnant black African women was 2.4%.
HIV and black Caribbeans
The report also included data on HIV in the UK’s Caribbean population. Investigators estimate that 3% of new HIV diagnoses in 2006 were in this population. HIV was diagnosed late in 25% of these individuals and HIV prevalence was under 1% amongst pregnant Caribbean women.
There is evidence of heterosexual transmission of HIV in UK’s black African and black Caribbean populations. In 1997, 26 HIV diagnoses were thought to involve black African transmission in the UK, but this had increased to 191 in 2006, partially reflecting the increase in the black African population in the UK over the last ten years. Similarly in 1997 28 new diagnoses involved Caribbean transmission in the UK, but this had increased to 118 cases in 2006.
HIV and UK-born heterosexuals
HIV prevalence amongst UK-born women was 0.05% in 2006. Prevalence was highest amongst women with male partners born in the Caribbean or South America (0.47%) and sub-Saharan Africa (0.33%). HIV prevalence amongst UK-born heterosexuals attending sexual health services was 0.17%, unchanged on recent years.
HIV and injecting drug users
HIV prevalence amongst injecting drug users in 2006 was higher in London (4%) than elsewhere in the UK (0.65%). High rates of risk behaviour were found amongst injecting drug users, with almost a quarter (23%) of current injectors reporting sharing injecting equipment in the previous month.
Other infections
New cases of syphilis fell in gay men and heterosexual women in 2006 compared to 2005, but there was an increase in heterosexual men.
There was a 3% increase in new diagnoses of genital warts in 2006 compared to 2005. Although most cases of genital warts were diagnosed in heterosexuals, the investigators note that there has been a 64% increase in diagnoses of this infection in gay men since 1997.
Increases were also noted in new diagnoses of genital herpes with a total of 21,698 infection in 2006. Only 7% of these were amongst gay men.
Young adults
Along with gay men, young adults remain the group most affected by sexually transmitted infections.
In 2006, 55% of genital warts diagnoses, along with 48% of gonorrhoea infections were located in the under-25s.
Resistance
In 2006, 27% of gonorrhoea samples were resistant to the antibiotic ciprofloxacin, the former standard of care, including 43% of isolates from gay men and 35% of isolates in Scotland.
Recommendations
The HPA make 15 specific recommendations including a call for a “priority consideration” of “primary prevention policy and programmes directed towards MSM.”
Furthermore, the HPA recommends “all relevant bodies should give priority to supporting effective ways of addressing the steadily increasing problem of heterosexual HIV transmission within the UK, which disproportionately affects members of black ethnic communities.”
To help lower the rate of undiagnosed HIV, the HPA recommend that all sexual health clinics should have a policy of ‘opt-out’ HIV testing and studies should be encouraged to “establish the feasibility and acceptability of offering and recommending HIV tests to migrants from sub-Saharan Africa in general practice soon after registration.”
Improved needle-exchange services and heroin substitution services should be a priority, the HPA recommends. And to better understand sexual risk behaviours a new national survey of sexual attitudes and lifestyle, similar to those conducted in 1990 and 2000, should be undertaken in 2010.
Health Protection Agency. Testing times. HIV and other sexually transmitted infections in the United Kingdom: 2007.