EDITORIAL
Surveillance of HIV in the United States and England, Wales, and Northern Ireland: What Have We Learned and What Do We Do About It? Cynthia Gay, MD MPH, Ada Adimora, MD, MPH, William Miller, MD, PhD, MPH, and Myron S. Cohen, MD
T
his issue of sexually transmitted disease includes 2 important articles focused on the detection of HIV, one from the United States1 and the second from England, Wales, and Northern Ireland.2 Together, they provide a sobering account of the status of HIV among men who have sex with men (MSM) and the pervasiveness of late HIV diagnosis. The first article used data from the National Health and Nutrition Examination Survey (NHANES) on a serial cross-sectional probability sample of the US population since 1999.3 The overall prevalence of HIV in the United States based on these data was 0.4%, consistent with earlier reports.4 The authors emphasize a higher prevalence of HIV within large metropolitan areas in the United States, twice as high relative to other areas. However, perhaps the most striking aspect of the report is the extreme risk for HIV in MSM and bisexual men. HIV prevalence among MSM was 10.1% and 13.4% in large metropolitan and metropolitan fringe areas, respectively, but remained high at 7% in medium and small metropolitan/nonmetropolitan areas. In contrast, HIV prevalence among heterosexuals in the United States did not vary by urbanicity, except among heterosexuals of low socioeconomic status in whom HIV prevalence was higher in large central metropolitan and fringe metropolitan areas. The prevalence of HIV among MSM in NHANES is similar to (but slightly lower) than that reported in the National HIV Behavioral Surveillance System, likely due to use of respondent driven sampling and HIV testing among high-risk populations in the latter.5 The report underscores the very high prevalence of HIV in MSM the United States. Although certainly not surprising, the results emphasize the truly urgent need for more resources and ideas about how to stop the spread of HIV in this patently vulnerable population. In addition, it must be noted that NHANES’ methods limit use of these data for the development of public health policy to prevent HIV infection. The NHANES samples only the civilian, noninstitutionalized US population in households, de facto missing substantial proportions of the nation’s HIV among individuals institutionalized in correctional facilities and psychiatric hospitals. Although the NHANES data support prior findings on the aggregation of HIV in large metropolitan centers, it does not account for regional variations and highly variable HIV prevalence in rural areas.6 For several years, HIV prevalence in the rural South and Midwest has been higher compared with the rural Northeast and West. In addition, the most rapid growth of HIV now occurs in the Southeastern United States, where HIV-infected individuals often reside in smaller towns, especially among African American men and some African American women.6 Finally, the survey is conducted in only 15 counties each year, and although data are aggregated, variations in HIV prevalence across regions and urbanicity (as reflected in the article) cannot be overlooked and limit the degree to which the findings from this report can inform HIV testing and care programs. The article from England, Wales, and Northern Ireland focuses on HIV prevalence and care in individuals reporting heterosexual behaviors. The results derive from data obtained from the National HIV and AIDS Reporting System, which has collected information on HIV-infected individuals older than 15 years since 1992, supplemented by complementary report of CD4 cell counts at diagnosis in 81% of the study population.2 The authors noted a rise in new diagnoses of HIV from 1992 through 2006, and a large fall in new HIV diagnoses in 2011. Most (72%) of HIV cases in heterosexuals occurred in blacks, 99% of whom had migrated from abroad. Importantly, the decrease in HIV diagnoses among black African adults over time was primarily due to declines in immigration of foreign From the Department of Medicine, Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Funding support: Cynthia Gay has received research support from Abbott Diagnostics, Argos Therapeutics, Gilead Sciences, Bristol Myers Squibb and Janssen Pharmaceuticals, Inc. Conflicts of interest: All other authors have no conflicts of interest to declare. Correspondence: Cynthia Gay, MD, UNC at Chapel Hill, Chapel Hill, NC 27599-7030. E-mail: [email protected]. Received for publication December 27, 2013, and accepted January 2, 2013. DOI: 10.1097/OLQ.0000000000000121 Copyright * 2014 American Sexually Transmitted Diseases Association All rights reserved.
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Volume 41, Number 4, April 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Editorial
born adults and not the success of HIV prevention within the region. As reflected in the report, linkage to care and treatment has improved in the United Kingdom. However, such improvement is perhaps overshadowed by the degree to which late diagnosis remains a major problem, with 60% of new cases presenting with a CD4 count less than 350 cells/mm3 in 2011. This degree of late diagnosis likely accounts for the static shortterm mortality in the region, despite overall declines in mortality due to ART.2 It should be noted that the prevalence of late diagnosis in England, Wales, and Northern Ireland is not so different from that found by the North AmericanYAIDS Cohort Collaboration on Research and Design, which reported that 54% of participating patients from the United States and Canada presented with a CD4 count less than 350 cells/mm3 in 2007.7 Because HIV treatment now requires only 1 pill once a day, the delay in treatment emphasized by these and other results8Y10 represents an especially disturbing failure to address such findings. Although not a focus in this report, the number of new HIV diagnoses among MSM in England, Wales, and Northern Ireland steadily increased over the study period and represented 50% of new cases in 2011, emphasized in other recent work by the UK research group where steady increases of HIV in MSM paralleled reports from the United States and Western Europe.11 These articles amplify our understanding of the distribution of HIV in the US and United Kingdom. However, how can we use the data they present to halt the spread of infection? In the absence of a vaccine, we have only 2 options. First, we must commit to widespread and, where appropriate, repeated HIV testing to allow prompt initiation of antiretroviral treatment (ART) for infected people. Because early ART preserves health and stops HIV transmission, maximizing treatment for individuals’ personal health as well as to prevent transmission is entirely justified and essential.12 Second, most people tested for HIV will be uninfected. Our biggest challenge is preventing those at highest risk for acquiring HIV. In recent years, we have seen the development of new behavioral tools13 and long-acting formulations of ART agents for preexposure prophylaxis, which, although still nascent, have great promise.14 These interventions, along with early ART as above, must be deployed with attention to the surveillance articles published in this issue of sexually transmitted disease. The most important purpose of this surveillance is to use the data as a baseline to monitor the interventions we deploy. Now is the time to use the data to justify the deployment of the best prevention
Sexually Transmitted Diseases
&
strategies available and to make predictions about the degree of benefit possible. REFERENCES 1. Oster AM, Sternberg M, Nebenzahl S, et al. Prevalence of HIV, STIs, and viral hepatitis by urbanicity, among MSM, IDUs, and heterosexuals in the United States. Sex Transm Dis 2014; 41:272Y279. 2. Rice B, Elford J, Yin Z, et al. Trends in HIV diagnoses, HIV care and uptake of antiretroviral therapy among heterosexual adults in England, Wales and Northern Ireland. Sex Transm Dis 2014; 41:257Y265. 3. McQuillan GM, Kruszon-Moran D, Granade T, et al. Seroprevalence of human immunodeficiency virus in the US household population aged 18Y49 years: The National Health and Nutrition Examination Surveys, 1999Y2006. J Acquir Immune Defic Syndr 2009. 4. Morris M, Handcock MS, Miller WC, et al. Prevalence of HIV infection among young adults in the United States: Results from the Add Health study. Am J Public Health 2006; 96:1091Y1097. 5. CDC. HIV testing and risk behaviors among gay, bisexual, and other men who have sex with menVUnited States. MMWR Morb Mortal Wkly Rep 2013; 62:958Y962. 6. Prejean J, Tang T, Hall HI. HIV diagnoses and prevalence in the southern region of the United States, 2007Y2010. J Community Health 2013; 38:414Y426. 7. Althoff KN, Gange SJ, Klein MB, et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis 2010; 50:1512Y1520. 8. Bamford LP, Ehrenkranz PD, Eberhart MG, et al. Factors associated with delayed entry into primary HIV medical care after HIV diagnosis. AIDS 2010;24:928Y930. 9. Schneider G, Juday T, Wentworth C 3rd, et al. Impact of health care payer type on HIV stage of illness at time of initiation of antiretroviral therapy in the USA. AIDS Care 2013; 25:1470Y1476. 10. Jenness SM, Myers JE, Neaigus A, et al. Delayed entry into HIV medical care after HIV diagnosis: Risk factors and research methods. AIDS Care 2012; 24:1240Y1248. 11. Birrell PJ, Gill ON, Delpech VC et al. HIV incidence in men who have sex with men in England and Wales 2001Y10: A nationwide population study. Lancet Infect Dis 2013; 13:313Y318. 12. Cohen MS, Smith MK, Muessig KE, et al. Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: Where do we go from here? Lancet 2013;382:1515Y1524. 13. Handa S, Halpern CT, Pettifor A, et al. The government of Kenya’s cash transfer program reduces the risk of sexual debut among young people age 15Y25. PLoS One 2014;9:e85473. 14. Spreen WR, Margolis DA, Pottage JC Jr. Long-acting injectable antiretrovirals for HIV treatment and prevention. Curr Opin HIV AIDS 2013;8:565Y571.
Volume 41, Number 4, April 2014
267
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Surveillance of HIV in the United States and England, Wales, and Northern Ireland: What Have We Learned and What Do We Do About It? Cynthia Gay, MD MPH, Ada Adimora, MD, MPH, William Miller, MD, PhD, MPH, and Myron S. Cohen, MD
T
his issue of sexually transmitted disease includes 2 important articles focused on the detection of HIV, one from the United States1 and the second from England, Wales, and Northern Ireland.2 Together, they provide a sobering account of the status of HIV among men who have sex with men (MSM) and the pervasiveness of late HIV diagnosis. The first article used data from the National Health and Nutrition Examination Survey (NHANES) on a serial cross-sectional probability sample of the US population since 1999.3 The overall prevalence of HIV in the United States based on these data was 0.4%, consistent with earlier reports.4 The authors emphasize a higher prevalence of HIV within large metropolitan areas in the United States, twice as high relative to other areas. However, perhaps the most striking aspect of the report is the extreme risk for HIV in MSM and bisexual men. HIV prevalence among MSM was 10.1% and 13.4% in large metropolitan and metropolitan fringe areas, respectively, but remained high at 7% in medium and small metropolitan/nonmetropolitan areas. In contrast, HIV prevalence among heterosexuals in the United States did not vary by urbanicity, except among heterosexuals of low socioeconomic status in whom HIV prevalence was higher in large central metropolitan and fringe metropolitan areas. The prevalence of HIV among MSM in NHANES is similar to (but slightly lower) than that reported in the National HIV Behavioral Surveillance System, likely due to use of respondent driven sampling and HIV testing among high-risk populations in the latter.5 The report underscores the very high prevalence of HIV in MSM the United States. Although certainly not surprising, the results emphasize the truly urgent need for more resources and ideas about how to stop the spread of HIV in this patently vulnerable population. In addition, it must be noted that NHANES’ methods limit use of these data for the development of public health policy to prevent HIV infection. The NHANES samples only the civilian, noninstitutionalized US population in households, de facto missing substantial proportions of the nation’s HIV among individuals institutionalized in correctional facilities and psychiatric hospitals. Although the NHANES data support prior findings on the aggregation of HIV in large metropolitan centers, it does not account for regional variations and highly variable HIV prevalence in rural areas.6 For several years, HIV prevalence in the rural South and Midwest has been higher compared with the rural Northeast and West. In addition, the most rapid growth of HIV now occurs in the Southeastern United States, where HIV-infected individuals often reside in smaller towns, especially among African American men and some African American women.6 Finally, the survey is conducted in only 15 counties each year, and although data are aggregated, variations in HIV prevalence across regions and urbanicity (as reflected in the article) cannot be overlooked and limit the degree to which the findings from this report can inform HIV testing and care programs. The article from England, Wales, and Northern Ireland focuses on HIV prevalence and care in individuals reporting heterosexual behaviors. The results derive from data obtained from the National HIV and AIDS Reporting System, which has collected information on HIV-infected individuals older than 15 years since 1992, supplemented by complementary report of CD4 cell counts at diagnosis in 81% of the study population.2 The authors noted a rise in new diagnoses of HIV from 1992 through 2006, and a large fall in new HIV diagnoses in 2011. Most (72%) of HIV cases in heterosexuals occurred in blacks, 99% of whom had migrated from abroad. Importantly, the decrease in HIV diagnoses among black African adults over time was primarily due to declines in immigration of foreign From the Department of Medicine, Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Funding support: Cynthia Gay has received research support from Abbott Diagnostics, Argos Therapeutics, Gilead Sciences, Bristol Myers Squibb and Janssen Pharmaceuticals, Inc. Conflicts of interest: All other authors have no conflicts of interest to declare. Correspondence: Cynthia Gay, MD, UNC at Chapel Hill, Chapel Hill, NC 27599-7030. E-mail: [email protected]. Received for publication December 27, 2013, and accepted January 2, 2013. DOI: 10.1097/OLQ.0000000000000121 Copyright * 2014 American Sexually Transmitted Diseases Association All rights reserved.
266
Sexually Transmitted Diseases
&
Volume 41, Number 4, April 2014
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Editorial
born adults and not the success of HIV prevention within the region. As reflected in the report, linkage to care and treatment has improved in the United Kingdom. However, such improvement is perhaps overshadowed by the degree to which late diagnosis remains a major problem, with 60% of new cases presenting with a CD4 count less than 350 cells/mm3 in 2011. This degree of late diagnosis likely accounts for the static shortterm mortality in the region, despite overall declines in mortality due to ART.2 It should be noted that the prevalence of late diagnosis in England, Wales, and Northern Ireland is not so different from that found by the North AmericanYAIDS Cohort Collaboration on Research and Design, which reported that 54% of participating patients from the United States and Canada presented with a CD4 count less than 350 cells/mm3 in 2007.7 Because HIV treatment now requires only 1 pill once a day, the delay in treatment emphasized by these and other results8Y10 represents an especially disturbing failure to address such findings. Although not a focus in this report, the number of new HIV diagnoses among MSM in England, Wales, and Northern Ireland steadily increased over the study period and represented 50% of new cases in 2011, emphasized in other recent work by the UK research group where steady increases of HIV in MSM paralleled reports from the United States and Western Europe.11 These articles amplify our understanding of the distribution of HIV in the US and United Kingdom. However, how can we use the data they present to halt the spread of infection? In the absence of a vaccine, we have only 2 options. First, we must commit to widespread and, where appropriate, repeated HIV testing to allow prompt initiation of antiretroviral treatment (ART) for infected people. Because early ART preserves health and stops HIV transmission, maximizing treatment for individuals’ personal health as well as to prevent transmission is entirely justified and essential.12 Second, most people tested for HIV will be uninfected. Our biggest challenge is preventing those at highest risk for acquiring HIV. In recent years, we have seen the development of new behavioral tools13 and long-acting formulations of ART agents for preexposure prophylaxis, which, although still nascent, have great promise.14 These interventions, along with early ART as above, must be deployed with attention to the surveillance articles published in this issue of sexually transmitted disease. The most important purpose of this surveillance is to use the data as a baseline to monitor the interventions we deploy. Now is the time to use the data to justify the deployment of the best prevention
Sexually Transmitted Diseases
&
strategies available and to make predictions about the degree of benefit possible. REFERENCES 1. Oster AM, Sternberg M, Nebenzahl S, et al. Prevalence of HIV, STIs, and viral hepatitis by urbanicity, among MSM, IDUs, and heterosexuals in the United States. Sex Transm Dis 2014; 41:272Y279. 2. Rice B, Elford J, Yin Z, et al. Trends in HIV diagnoses, HIV care and uptake of antiretroviral therapy among heterosexual adults in England, Wales and Northern Ireland. Sex Transm Dis 2014; 41:257Y265. 3. McQuillan GM, Kruszon-Moran D, Granade T, et al. Seroprevalence of human immunodeficiency virus in the US household population aged 18Y49 years: The National Health and Nutrition Examination Surveys, 1999Y2006. J Acquir Immune Defic Syndr 2009. 4. Morris M, Handcock MS, Miller WC, et al. Prevalence of HIV infection among young adults in the United States: Results from the Add Health study. Am J Public Health 2006; 96:1091Y1097. 5. CDC. HIV testing and risk behaviors among gay, bisexual, and other men who have sex with menVUnited States. MMWR Morb Mortal Wkly Rep 2013; 62:958Y962. 6. Prejean J, Tang T, Hall HI. HIV diagnoses and prevalence in the southern region of the United States, 2007Y2010. J Community Health 2013; 38:414Y426. 7. Althoff KN, Gange SJ, Klein MB, et al. Late presentation for human immunodeficiency virus care in the United States and Canada. Clin Infect Dis 2010; 50:1512Y1520. 8. Bamford LP, Ehrenkranz PD, Eberhart MG, et al. Factors associated with delayed entry into primary HIV medical care after HIV diagnosis. AIDS 2010;24:928Y930. 9. Schneider G, Juday T, Wentworth C 3rd, et al. Impact of health care payer type on HIV stage of illness at time of initiation of antiretroviral therapy in the USA. AIDS Care 2013; 25:1470Y1476. 10. Jenness SM, Myers JE, Neaigus A, et al. Delayed entry into HIV medical care after HIV diagnosis: Risk factors and research methods. AIDS Care 2012; 24:1240Y1248. 11. Birrell PJ, Gill ON, Delpech VC et al. HIV incidence in men who have sex with men in England and Wales 2001Y10: A nationwide population study. Lancet Infect Dis 2013; 13:313Y318. 12. Cohen MS, Smith MK, Muessig KE, et al. Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: Where do we go from here? Lancet 2013;382:1515Y1524. 13. Handa S, Halpern CT, Pettifor A, et al. The government of Kenya’s cash transfer program reduces the risk of sexual debut among young people age 15Y25. PLoS One 2014;9:e85473. 14. Spreen WR, Margolis DA, Pottage JC Jr. Long-acting injectable antiretrovirals for HIV treatment and prevention. Curr Opin HIV AIDS 2013;8:565Y571.
Volume 41, Number 4, April 2014
267
Copyright © 2014 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
