AIDS Alert International: High-income countries see increase in epidemic

Italy sees increase in sexual transmission

The HIV/AIDS epidemic has grown to include about 1.6 million people who live in high-income countries, including the estimated 76,000 people who became infected with the virus in 2002.

Unlike the majority of the 42 million people infected worldwide, this small subset of people infected with HIV has access to the antiretroviral treatment.

However, this advantage has not stopped the epidemic from spreading to populations within high-income countries that largely were unaffected by the epidemic 20 years ago.

Italy’s HIV/AIDS epidemic’s shift from an injection-drug-using population to transmission through heterosexual intercourse is one good example of this trend.

UNAIDS of Geneva reports that complacency among people at risk and lackluster prevention efforts have led to increases in HIV transmission among heterosexuals. Between 1997 and 2001, the proportion of new HIV diagnoses occurring through heterosexual intercourse increased by 57%, according to UNAIDS.

In the United Kingdom, the number of new HIV infections resulting from heterosexual transmission increased from 33% in 1998 to more than 50% in 2001, UNAIDS states.

Frightening data

The data showing HIV increasing among heterosexuals and women are frightening, says Ingrid Kloet, a board member of the Global Network of People Living with HIV/AIDS (GNP+) in Amsterdam, The Netherlands.

In the United States between July 2000 and June 2001, for instance, the bulk of new HIV infections among youths (ages 13-39) were among females, according to data from 34 cities and regions reported to the Centers for Disease Control and Prevention of Atlanta.

Sexual transmission, especially among heterosexuals, has accounted for a much greater proportion of new HIV infections in Italy in recent years, says Giovanni Rezza, MD, director of AIDS and STD Unit, Lab of Epidemiology, Insituto Superiore di Sanita in Rome.

"Let’s say, 10 years ago, about 80% of cases were among drug users and less than 10% among heterosexuals," he says. "Now it’s the opposite: less than 20% are injection drug users, and more than 80% are due to sexual contact."

Male-to-male sexual contact probably amounts to about 15% of that total, Rezza adds.

The first phase of the epidemic in Italy was sustained by transmission among injection-drug users, he says.

"It was the same pattern as in Spain of a big epidemic among drug users and low [transmission] among homosexual men," Rezza explains. "Now the situation is changing as most injection drug users are heroin users, and the epidemic of heroin use is going down."

Most transmissions are sexual

Plus, there are fewer heroin users among Italy’s youth, who use other drugs, such as ecstasy, he adds. So now most of Italy’s new HIV cases are attributable to sexual transmission, both man to man and heterosexual, Rezza says.

"We have had a recent phenomenon of increased cases of syphilis, both primary and secondary syphilis. These increases have been reported especially among homosexual men, and there is a high proportion of cases diagnosed among HIV-infected people who are under highly aggressive antiretroviral treatment," he says.

Since the epidemic has shifted from the injection drug population to a heterosexual population, there also has been a shift in the median age of those infected. Unlike the trend reported in other high-income countries of the epidemic increasing among youths, in Italy the opposite has occurred, Rezza says.

"The median age of people affected by AIDS is increasing. And the median age of people who are being diagnosed with new infection is increasing," he adds. The explanation for this phenomenon is that the epidemic largely affected youths in the late 1980’s and early 1990’s when it was spread primarily through injection drug users, who mainly were in the 20- to 30-year-old range, he continues.

"Now the epidemic is through sexual transmission, and it affects all of the sexually active age classes, so it’s not only the young generation," Rezza says.

When the epidemic was limited primarily to one population it was easier to target prevention, testing, and treatment. However, Italy’s health officials now have to cope with several new obstacles to reducing new infection rates.

Despite the nation’s national health system which provides free access to HIV testing and treatment, there has been a surprising increase in the proportion of people diagnosed with AIDS who did not know they were infected with HIV before developing AIDS symptoms, Rezza says.

Most of the people who arrive late for treatment are those who were infected through sexual transmission, he adds. "I’m not surprised by heterosexual cases because they have a low perception of risk because they are not homosexuals or injection-drug users. But it’s surprising that a large proportion of cases diagnosed with AIDS among homosexual men did not get treatment before their diagnosis."

Change in perception

Early in the epidemic’s history in Italy, homosexual men were active in HIV testing and in finding out their diagnosis, and drug users typically were identified early as well, Rezza says.

So among the populations at risk for HIV, there apparently is a change in perception about HIV infection, and this means the Italian government has some work to do with regard to HIV education and intervention, he says.

"We are thinking we need to give information again [to at risk groups] or at least try to raise the risk perception among the general population who are at risk for sexual transmission of HIV," Rezza says.

"I think the information-level is not bad, but the problem is it seems these people have not seen their friends die from AIDS, and so are removed from the risk of HIV," he explains.

To better address this perception problem, Italy has launched a new information campaign targeting the general population, in conjunction with smaller campaigns aimed at special groups, including youths and foreigners, he explains. "Special attention is given to particular media used by young people, like MTV, for example."

Also, Italy’s minister of education has begun to distribute a leaflet with AIDS information directed toward youths.

While some critics of the educational campaign say it doesn’t provide direct information about condom use, the government’s plan is to assess the success of this particular campaign and then make changes if needed, Rezza says.