1. Re-Emerging HIV Epidemics among MSM in the United States and Other Industrialized Nations Ron Stall, Thomas C. Mills and Michael Marshal University of Pittsburgh Pittsburgh USA

2. Presentation Goals To summarize the literature on incidence rates among MSM in North America, Europe and Australia To predict what current published incidence rates will yield in terms of expected prevalence rates of HIV infection across the life course To identify MSM most at risk of HIV infection

3. Why Is Incidence Important? Incidence measures how quickly a disease is spreading in a population. By studying incident cases within an evolving epidemic, emerging risk factors for infection can be identified.

4. Summarizing Incidence Estimates among MSM Computerized literature review : Google Scholar, PubMed, ISI Web of Science, Scopus HIV incidence, MSM, Gay Men, HIV seroconversion Correspondence with leading researchers in the field to identify unpublished data

5. Inclusion Criteria MSM or Gay/Bi male study population, or sub-population, from 1995 to the present Incidence reports from cohort studies using test/retest methods STARHS (detuned ELISA) assay to identify incident HIV infections North America (USA and Canada), Western Europe, Australia and New Zealand

6. Exclusion Criteria Incidence data from a behavioral or vaccine trial Reports from populations at dual risks (IDU/MSM or co-occurring STIs) Duplicative reports from the same data set Estimates based on >4 years of observation

7. 22 Independent Studies 90 Annual Incidence Estimates Community-Based Samples – 10 independent studies; 32 incidence estimates HIV Test Site Samples – 5 independent studies; 31 incidence estimates STD Clinic Samples – 7 independent studies; 27 incidence estimates

9. Mean Published Incidence Estimates among MSM, 1995-- Community-Based Estimates1.93% HIV Test Site Estimates2.24% STD Clinic Estimates2.93%

10. With 1.9% incidence, what will the burden of HIV disease be within a cohort of MSM now aged 20? 8% prevalence rate of HIV infection at age 20 (MMWR, 2001) No mortality due to HIV through age 60 Identical non-HIV mortality rates to other men in the US population MMWR (2001) HIV incidence among young MSM – 7 US Cities, 1994-2000.

11. Limits of the Projections Publication bias? Cannot be applied to any specific city or sub-population of MSM Cannot control for future events: – development of effective vaccines/ microbicides – greater commitment to evidence-based HIV prevention among MSM by funders

12. Burden of HIV Disease Among MSM: HIV Incidence Rate of 1.9%

13. Which MSM at Greatest Risk of HIV Seroconversion? Demographic: African American race, Unstable Housing, Prison history, No Health Insurance, Lower educational levels, Younger Age Sexual Behaviors: Sex work, URAI, UIAI, Selection of partners from high risk venues (bars, bathhouses, internet)

14. Which MSM at Greatest Risk of HIV Seroconversion? Substance Use : Cocaine, Meth, Heavy Alcohol Use, Poppers Psychological : Psychiatric hospitalization, Sub- Clinical Depression Other Variables : Uncircumcised, other STIs, residence in a city with high HIV prevalence?

15. Substance Use & HIV Incidence HIV Seroconverter HIV Negative p (n=38) (n=120) Methamphetamine42%14%<.01 Poppers4722.05 Viagra21 8.05 Ecstasy16 1.01 Ketamine13 1.01 GHB21 4.01 Thiede, et al., (2006) Determinants of Recent HIV Infection among Seattle-Area MSM, Congress of Epidemiology, Seattle.

16. High Rates of HIV infection among African American MSM are NOT News Samuel, M. and Winkelstein, W., “Prevalence of HIV in Ethnic Minority Homosexual/ Bisexual Men” JAMA, 1987 257: 1901-2. HIV Prevalence African American66% White (non-Hispanic)49% Hispanic50% Asian/PI27% Other 6%

17. HIV Incidence is High Among African American MSM HIV incidence among African American men aged 15-22 4% HIV incidence among African American men aged 23-29 15% MMWR, HIV incidence among young MSM – 7 US Cities, 1994-2000, June 01, 2001

18. African-American MSM Cohort: HIV Incidence Rates of 4.0%

19. African American MSM have very high HIV prevalence rates HIV infection and Unrecognized Infection among MSM, 5 US Cities, aged >18: Black, Non-Hispanic46%(67%) White, Non-Hispanic21%(18%) Multiracial19%(50%) Hispanic17%(48%) Other13%(50%) MMWR, HIV Prevalence, unrecognized infection and HIV Testing among MSM – 5 US Cities, June 2005, April, 2005, June 24, 2005.

20. African American MSM suffer among the highest HIV prevalence and incidence rates of any risk group in the world.

21. Conclusions HIV incidence rates within the published literature cluster near the 2% range among HIV testing and community based samples; at about 3% for STD clinic samples. Ongoing incidence rates at this level will yield very high HIV prevalence rates within each new generation of gay men.

22. Conclusions We have known that African American MSM and substance abusing MSM are a high risk for HIV infection for about 20 years. Despite this knowledge, we have yet to identify a proven method to reduce incident HIV infection rates in either of these populations.

23. Recommendations Create a rigorous HIV surveillance system Haphazard reporting and analysis of HIV incidence has hindered our ability to characterize the spread of new infections among MSM. Use of the STAHRS assay with large samples of newly-identified HIV seropositives may help identify newly-evolving risk groups. National HIV Behavioral Surveillance System at the CDC as a model?

24. Recommendations Use social justice criteria to guide funding of HIV prevention and science. Groups that are known to have high HIV incidence rates should be accorded the highest priority in HIV prevention efforts.

25. Re-Emerging HIV Epidemics among MSM in the United States and Other Industrialized Nations Ron Stall, Thomas C. Mills and Michael Marshal University of Pittsburgh Pittsburgh USA

26. HIV Prevalence among MSM: 5 US Cities AgeHIV Prevalence 18-2414% 25-2917 30-3929 40-4937 50+31 MMWR, HIV prevalence, unrecognized infection and HIV testing among MSM: 5 US Cities, June, 2004-April, 2005, June 24, 2005

27. An Example of Age-Adjusted HIV Incidence Rates

30. HIV Test Site Samples of MSM: HIV Incidence Rate of 2.2%

31. STD Clinic Samples of MSM: HIV Incidence Rates of 2.9%