Sexual Health, HIV, and STDs

Sexual Health, HIV, and STDs Richard J. Wolitski, PhD Deputy Director, Behavioral and Social Science Division of HIV/AIDS Prevention Centers for Disease Control & Prevention Fenway Institute, Boston, MA April 27, 2010 The findings and conclusions expressed in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Acknowledgments John Douglas Irene Hall David Purcell

Sexual Health, HIV, and STDs Sexual health is not merely the absence of disease But sexually transmitted disease can have a profound effect on sexual health Physical health Mental health Sexual function, satisfaction, and relations Marker for sexual and other health problems

Sexual Health of MSM Long history of sexual health disparities Exist within broader context of health inequities Unprotected sex among MSM is increasing HIV and other STDs among MSM are increasing across the US as a whole and elsewhere in the world Access and utilization of prevention services is not optimal Low uptake of Hepatitis A/B vaccine National HIV Behavioral Surveillance About 1 in 5 MSM had participated in an HIV intervention in past year 30% not tested for HIV in past year

STD in MSM Now account for majority of U.S. cases of syphilis 46 times as likely to have syphilis than other men 71 times as likely to have syphilis than women (Purcell et al., National STD Prevention Conference, 2010) Evidence of growing role in other STDs GC (20+% of cases in CDC s GISP) Prevalence of GC, CT underestimated due to limited rectal, pharyngeal screening Outbreaks of Lymphogranuloma Venereum (LGV) HPV and anal cancer High rates of HIV co-infection Syphilis 40-60%, GC 5-10%

Primary and secondary syphilis, by year and sex: reported rates and male-to-female rate ratios, United States, 1981-2007 25 Males 7 Females 20 Male-Female Rate Ratio 15 10 5 6 5 Rate (per 100,000 males / females) Male-Female Rate Ratio 4 3 2 1 0 0 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 MSM est. 65% of cases Black MSM est. 20% of cases

Primary and secondary syphilis among MSM by race/ethnicity in 23 states, Number of cases 2000 2005-2007* 1500 1000 White African American Hispanic 500 0 2005 2006 2007 * 2007 data are preliminary

Gonorrhea Rates: Total and by sex: United States, 1988 2007 and the Healthy People 2010 target Rate (per 100,000 population) 400 320 240 Male Female Total 2010 Target 160 80 0 1988 90 92 94 96 98 2000 02 04 06 Note: The Healthy People 2010 target for gonorrhea is 19.0 cases per 100,000 population.

Gonococcal Isolate Surveillance Project (GISP) Percent of urethral Neisseria gonorrhoeae isolates obtained from men who have sex with men attending STD clinics, 1988 2007 Percent 25 20 15 10 5 0 1988 90 92 94 96 98 2000 02 04 06 GC in men --est. 22% MSM

STD in MSM Sexually Transmitted Hepatitis C Of HIV+ MSM STD clinic patients in Amsterdam 15% HCV+ in May 2007 21% in April 2008 Associated with: Being HIV-positive IDU (1 in 5 had ever injected) Fisting GHB use Urbanus et al., AIDS, 2009.

Estimated Percentage of New HIV Infections, by Transmission Category, 2006* N=56,300 Men who have sex with men and inject drugs, 4% Heterosexual contact, 31% Men who have sex with men, 53% Injection drug users, 12% *50 States and District of Columbia

HIV diagnosis rates among MSM, other men, and women--34 states, 2007 HIV/AIDS Rate per 100,000 pop 44x as likely to have HIV dx than other men 40x as likely to have HIV dx than women MSM Other Men Women Purcell et al., National STD Conference, 2010.

Estimated HIV Infections by Risk, Race/Ethnicity, and Gender---US, 2006

Estimated HIV Infections among MSM by Race/Ethnicity & Age, 2006

Estimated Number of New HIV Infections by Transmission Category, 1977-2006 *50 States and District of Columbia MSM 32,000 infections each year IDU HET

Estimated proportion of HIV transmissions among MSM, 2003-2005 Sullivan et al. AIDS 2009, 23:1153-1162.

Population-based survey of MSM conducted in San Francisco in 1997 (n = 915) and 2002 (n = 879) Self-reported HIV prevalence increased from 19.6% in 1997 to 26.8% in 2002 Sexual risk behavior also increased Men between ages of 30 and 50 reported largest increase in unprotected anal sex Men between ages of 18-29 reported largest increase in serosorting

Summary Epi shows increasing risk and sexually transmitted infections Underlying factors driving these increases worldwide are poorly understood Clear and urgent need for better and more timely longitudinal epi data for MSM Individual behavior as well as interpersonal, social, and community context Need to understand differences by race/ethnicity, age, and HIV status Protective factors/resilience

Questions to Consider What do STD and HIV epidemiological data tell us about the overall sexual health of MSM? What other questions do they raise? What sexual health data are missing? Why do inequities in HIV/STD rates exist? What factors are driving increases in STD and HIV infections? What are most effective actions that can be taken (by individuals and public health) to support and improve sexual health of MSM?