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. 2000 Dec 16;321(7275):1531.
Increased high risk sexual behaviour in homosexual men
There is no evidence for a decreased incidence of HIV infection
Editor—Dodds et al began their paper1 with the statement
that the incidence of HIV infection among homosexual men in the United
Kingdom is increasing despite efforts to reduce high risk behaviour and
supported the statement of increasing incidence by referencing a report
from the Public Health Laboratory Service.2
This report, which featured national surveillance data on HIV infection
acquired through sex between men, does, however, not suggest that the
incidence in homosexual men is rising. Rather, together with the more
recent update,3 it highlights the number of new diagnoses
of HIV infection acquired through sex between men, which have remained
fairly constant at around 1500 a year throughout the 1990s. The
published erratum clarifies the situation (16 September, p 675), but
the statement caused us to re-examine our data to see what we are able
to say about recent trends in HIV among homosexual men.
Although trends in the diagnosis of HIV relate more closely to the
uptake of HIV testing than to the underlying incidence of infection,
the fact that there has been little change in the median age or median
CD4 lymphocyte count at diagnosis in this group over the past 10 years
suggests that new infections have occurred at similar rates to
diagnoses, through most of that period at least.4
At best, however, such indicators provide only a broad measure of past
incidence, and more sensitive and timely markers of likely changes in
HIV incidence may be found in the surveillance of acute sexually
transmitted infections and the type of monitoring of high risk sexual
behaviour covered in the paper by Dodds et al.
Increases in markers of HIV transmission risk may not, however, be
directly translated into increased transmission. The annual survey of
prevalent diagnosed HIV infections shows that in 1999 67% of
homosexual men with diagnosed HIV infection in England, Wales, and
Northern Ireland were receiving multiantiretroviral therapy.
Widespread use of treatment that is successfully reducing viral load
might well offset any increases in risky behaviour. Although measures
of the recent incidence of HIV infection are imprecise, there is clear
evidence that the numbers of prevalent HIV infections that are
diagnosed are increasing,5 and the messages concerning
safer sex practice among men who have sex with men need to be further
strengthened. The fact that we have no evidence of a decrease in the
incidence of HIV infection is a cause for concern at this stage in the
epidemic.
References
1.Dodds JP, Nardone A, Mercey DE, Johnson AM. Increase in high risk sexual behaviour among homosexual men, London 1996-8: cross sectional, questionnaire study. BMJ. 2000;320:1510–1512. doi: 10.1136/bmj.320.7248.1510. . (3 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Communicable Disease Surveillance Centre. AIDS and HIV infection in the UK: monthly report. Commun Dis Rep CDR Wkly. 1999;9:121–122. [PubMed] [Google Scholar]
3.Communicable Disease Surveillance Centre. AIDS and HIV infection in the UK: monthly report. Commun Dis Rep CDR Wkly. 2000;10:237–240. [Google Scholar]
4.Gupta SB, Gilbert RL, Brady AR, Livingstone SJ, Evans BG. CD4 cell counts in adults with newly diagnosed HIV infection: results of surveillance in England and Wales, 1990-1998. AIDS. 2000;14:853–861. doi: 10.1097/00002030-200005050-00012. on behalf of the CD4 Surveillance Advisory Group. [DOI] [PubMed] [Google Scholar]
5.Communicable Disease Surveillance Centre. Survey of diagnosed HIV infections shows prevalence is rising. Commun Dis Rep CDR Wkly. 1999;19:415. [PubMed] [Google Scholar]
Editor—Dodds et al report a significant increase in unsafe sexual
practices among homosexual men in London.1-1 However, such
activity, which predisposes to a risk of HIV infection, is not confined
to the capital. As the recent outbreak of infectious syphilis in
Manchester has shown,1-2 safer sexual practices seem to be
less rigidly adhered to in this high risk group.
In a survey of attenders at a dedicated sexual health clinic for
homosexual and bisexual men in south Manchester 70% of men had
practised unsafe sex, 45% within the previous 12 months. A higher
proportion of men under the age of 25 engaged in “at risk” sexual
behaviour (67% of those under 25 v 31% of those over 40),
and 69% of them had had casual sex in the previous three months.
Although rectal gonorrhoea has been cited as an indicator of at risk
sexual behaviour for HIV infection,1-3 we detected rectal
chlamydial infection using DNA amplification techniques in 11% of
attenders. We believe that rectal chlamydial infection could be equally
reflective of such behaviour.
Safer sex messages, common in the 1980s and early 1990s, have lost
their impact, especially among young homosexual and bisexual men.
Failure to associate themselves with being in a high risk group for HIV
infection may have contributed to unsafe sexual practices and the
emergence of the outbreak of infectious syphilis and revalence of
rectal chlamydial infection. Educational programmes specifically
targeting young homosexual and bisexual man are needed, otherwise a new
HIV epidemic is likely to ensue.
References
1-1.Dodds JP, Nardone A, Mercey DE, Johnson AM. Increase in high risk sexual behaviour among homosexual men, London 1996-8: cross sectional, questionnaire study. BMJ. 2000;320:1510–1511. doi: 10.1136/bmj.320.7248.1510. . (3 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2.Higgins SP, Sukthankar A, Mahto M, Jarvis RR. Syphilis increases in Manchester, UK. Lancet. 2000;355:1466. doi: 10.1016/S0140-6736(05)74666-3. [DOI] [PubMed] [Google Scholar]
1-3.Lewis DA, Forster GE, Goh B. Gonorrhoea in HIV seropositive homosexual men attending an East London genitourinary medicine clinic. Genitourin Med. 1996;72:74. doi: 10.1136/sti.72.1.74. [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Dec 16;321(7275):1531.
Clarity may have been lost through including too much information
Editor—Dodds et al2-1 offered evidence of increasing high
risk sexual behaviour among homosexual men. This followed shortly after
a polemical article in the Guardian.2-2 That
article, which drew on one in the Pink Paper (which is
published by and for gay people),2-3 seemed critical of an
apparent rise in irresponsible sexual behaviour among homosexual men.
The research by Dodds et al is important. What a pity that in reporting
it they are less clear than they might have been. The article seems to
promote unprotected anal intercourse for all men, whether homosexual or
not, as a way of reducing HIV, by saying that HIV transmission can be
reduced by ensuring that men have unprotected anal intercourse only
with partners of a concordant HIV status. This is surely a linguistic
mistake. More worrying is the fact that this statement fails to take
account of other possible infections and of the difficulty in knowing
whether a potential partner has the same HIV status.
Even more concerning is the lack of clarity in the figures Dodds et al
present. When they say, for example, that in every year high risk
sexual behaviour (for example, unprotected anal intercourse in the
previous year) was significantly associated with younger age (occurring
among 108/252 (43%) of those aged under 25 and 103/340 (30%) of those
over 40, P<0.01 in 1998) and recruitment from a genitourinary medicine
clinic (odds ratio 1.39, 95% confidence interval 1.13 to 1.71, P<0.01
in 1998), this is unclear on many points. How many patients came from
clinics for genitourinary medicine? Are the figures for participants
aged under 25 totalled from all three years?
The method of selecting venues was undefined. The report claims to
describe the behaviour of gay men, when the research sampled only those
in London who attend genitourinary clinics and attend night clubs,
saunas, etc. The sample was narrowly based and self selected. Gay men
who do not frequent the selected social and clinical venues were
excluded. The veracity of answers from men present at or queuing to
enter a venue must be questioned. How much can be ascribed to bravado?
How much to concealment? Dodds et al had to work within the limits of a
short report. Clarity may, however, have been lost through including
too much information. This survey is interesting and important, and we
hope that they have the opportunity to produce a fuller report soon.
References
2-1.Dodds JP, Nardone A, Mercey DE, Johnson AM. Increase in high risk sexual behaviour among homosexual men, London 1996-8: cross sectional, questionnaire study. BMJ. 2000;320:1510–1511. doi: 10.1136/bmj.320.7248.1510. . (3 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2-2.Wells M. Sex on the edge. Guardian 2000;March 14:2-3.
2-3.Wrench N. Lust and life. Pink Paper 2000 March 3:29.
Editor—We agree with the letter from Macdonald et al. The incorrect
statement at the beginning of our paper was the result of editorial
changes at the proof stage [see editorial footnote below]. We are
interested and concerned to hear of similar findings to ours among men
attending a clinic for genitourinary medicine in Manchester.
We thank Fairburn et al for their appreciation of the
difficulties of condensing such a large repeated cross sectional survey
into a short report. More detailed methods are to be found in our third
reference, and a full report is available from the authors. We disagree
that our paper seems to promote unprotected anal intercourse for all
men and are surprised that Fairburn et al should infer this conclusion.
Recent health promotion campaigns have encouraged men who have
unprotected anal intercourse to undergo HIV testing and reach
agreements to have unprotected anal intercourse only with men of the
same HIV status as themselves, as one method among many (including the
use of condoms, reducing numbers of partners, and safer sexual
practices) of reducing the transmission of HIV.
We appreciate that our population is a selected one, constrained by the
methodological difficulties of obtaining a large random population
sample of men who have sex with men. The crucial point is, however,
that this allows repetition of the survey, among comparable groups,
over time, permitting trends to be examined. Any self reported sexual
behaviour may be subject to measurement error, but we attempt to reduce
this by the use of a short, self completion questionnaire that is
completely anonymous. Any measurement error is likely to apply equally
to each year of the survey and is therefore an implausible explanation
of the observed trends.
Footnotes
An error crept into this short report at the proof
stage, for which we apologise. A correction has been
published.3-1
References
3-1.Corrections and clarifications. BMJ. 2000;321:675. . (16 September.) [Google Scholar]
