HIV resurges where it started three decades ago: MSM

MSM networks, lax condom use driving increases

Thirty years into an epidemic that began with cryptic reports of a new disease among gay American men, there is this discouraging finding: AIDs Studies and reports worldwide point to a resurgent HIV epidemic among men who have sex with men (MSM).

HIV incidence among MSM has been increasing worldwide, and condom use has been low in many areas around the world.1

"There have been multiple reports from countries both resource-rich and limited, and the major contextual factors are related to these increased rates of HIV among MSM," says Susan Little, MD, professor of medicine at the University of California — San Diego (UCSD).

The challenge is there has been an incomplete amount of research conducted and available in resource-limited settings, she adds.

"There's still a significant amount of stigma and discrimination in resource-limited settings," Little says. "A lot of the information available is from more recent studies in resource-rich countries."

In countries with high HIV prevalence, such as those in sub-Saharan Africa, the distinct risk associated with being gay is not as high as in resource-rich countries, she notes.

"In low prevalence countries, HIV is not as diffused," she explains.

"It's more concentrated in subpopulations," she adds. "So if you are in one of those sub-populations like men who have sex with men, then your risk of contracting HIV is much higher than if you are a heterosexual man."

One challenge is controlling for confounders of transmission, Little says.

"For instance, we looked at concurrent partnerships," she says. "There are many factors associated with HIV transmission in an HIV population, and one practice is linked to sexual concurrency, having multiple sexual partners that overlap in time."

Studies show that black and Latino MSM have no increased risk when you control for neighborhoods in which they live, so their increased risk for HIV infection could be most closely linked to their sexual network rather than their race or specific sexual practices, Little says.1

"Even if you engage in low-risk activities, if you engage in those activities within a sexual network with high HIV prevalence then you are much more likely to become infected than if you are engaging in high risk activities in a low network of HIV prevalence," she explains.

One of the key areas of future HIV research will be to find out what the predictors of infection are among sub-populations of sexual networks that have unique characteristics driving the epidemic forward, Little says.

"We need much more focused prevention strategies and multi-level prevention approaches that don't just target an individual," she says. "Because even if you target an individual and lower that person's risk behavior, it doesn't address the person's sexual network which could place the person at high risk for HIV infection."

There is a need for both individual-level and population-level prevention strategies.

"And, frankly, we're very limited in what those interventions might be," Little says. "The largest idea is using antiretroviral therapy as prevention, but that has huge resource issues tied up with it."

Still, some groups worldwide are proposing that governments scale up HIV screening and treatment, targeting populations at risk.

"One big strategy is to increase testing," Little says. "If people don't know their status they can escape medical attention and can unwittingly transmit HIV."

In the United States, an estimated 45% of people have ever been tested for HIV, and only 10% have been tested within the past year, Little says.

"We have a long way to go before we raise the level of awareness of how important testing is to limit transmission of disease within a population," she adds.

Although national public health guidelines have called for widespread HIV testing for five years now, routine HIV screening remains uncommon except among some communities of high risk, Little says.

Universal treatment is even more problematic. HIV providers remain uncertain about treating everyone who is infected, Little notes.

"I support universal treatment, but I understand their concerns," she says.

"My strong support of treatment is drawn from my own interpretation and extension of current studies," she adds. "There are no studies that address individual risk and risk to a population if you start ART significantly above 500 CD4 cell counts."

There is no consensus in the medical community about the best use of ART for individuals who are newly infected and have both high viral loads and high CD4 cell counts. These people are at high risk of transmitting HIV, so it would appear they're an ideal group to target for early treatment, Little explains.

"Some people believe those treatments are well-tolerated and the benefits to the population is quite high, and so they recommend treatment," Little says. "But even if we treat everyone who knows their HIV status today, that leaves potentially a large number of people who don't know their status and who have high rates of HIV in their blood and can transmit at a higher frequency than those with lower levels of virus."

Breaking down networks

How does one reach these people with unknown infection? One answer is literally door-to-door. Investigators in San Diego, CA, have begun an HIV screening and prevention project targeting populations of people who are at a high but unperceived risk for HIV infection, Little explains.

Called the Lead the Way Campaign, the project is funded through a one-year study of whether a comprehensive HIV screening approach will lead to increased testing in the general population.

"We've identified populations in two zip codes and are rolling out an aggressive, comprehensive marketing approach to HIV testing in the general community," she says.

"We're trying to normalize HIV testing, and we're not asking about HIV risk," she says. "We say, 'Just as you receive a cholesterol test when you pass a certain age, you should receive an HIV test when you're an adult.'"

The idea is to reach concentrated sexual networks of people who are at high risk of HIV transmission even when they engage in relatively low risk sexual behavior.

"We don't know where those concentrated networks are until we have a vast majority of people tested," Little says.

"A CDC statistic shows that 21% of the people in this country who are infected are untested," she explains. "If we're marketing testing and prevention to people who think they are at risk then we still have not made a huge impact on that number."

The project's goal is to get people tested early and into care and treatment to improve their own health and the health of the targeted population, Little says.

"It's non-risk-based testing, and we're marketing testing to adults of all races, ages, and socio-economic status with the hope that using more novel marketing techniques and role models will increase HIV testing," Little says.

"One of the things we're trying to make people in the general community aware of is we can't answer this question without your participation," Little says. "If they think it's a problem with distinct, well-characterized communities then we have a challenge controlling this epidemic."

The Lead the Way Campaign stresses that taking the HIV test is easy and fast.

"We hope the more people who take the test, the freer of stigma it becomes," Little says. "It should be part of a general health screening for every adult in the United States."

One of the zip code communities selected for the project has strong interest in HIV care, she adds.

"In this community, we believe the awareness and compassion and concern about controlling HIV as a disease is already quite high," Little says. "If we can demonstrate success in a population heavily engaged in HIV treatment and care, then our hope is we can take the tools and strategies we've learned to expand and generalize to other communities and metropolitan areas."

One of the biggest differences in the Lead the Way Campaign's marketing approach is that it will have trained health care professionals going door-to-door to do HIV testing.

"We're taking the lead from politicians who go door-to-door to engage community support for their cause," Little explains. "We'll ask people what are their beliefs and concerns about HIV testing and then offer them a test."

If people turn down the offer, that's fine, but the health care professional will ask them why not.

"We hope we can modify our approach to proposing or marketing testing within those communities, so we'll ask about their beliefs, motivators, and barriers surrounding HIV testing," Little says. "We hope to evaluate 10,500 people in one year."

The study has a long start-up period in which community education and marketing paves the way for the door-to-door visits.

"Our hope is that by the time we start door-to-door testing most people will have heard about it so they won't be caught off guard," Little says. "This is an amazing study and quite a challenge; it's something new, and we really are relying on the support and engagement of the community to get out the message."


  1. Morris SR, Little SJ. MSM: resurgent epidemics. Curr Opin HIV/AIDS 2011; [Epub ahead of print].