1. No magic bullet:
Moving forward with HIV prevention
for gay men in BC
Mark Gilbert
Travis Salway Hottes
8th BC Gay Men’s Health Summit
November 1, 2012
2. Diagnosis Rate per 100,000
BC Rate Canadian Rate
35
HIV Reportable
30
25
20
15
10
5
0
2011*
1993
1997
2001
2005
2009
1986
1987
1988
1989
1990
1991
1992
1994
1995
1996
1998
1999
2000
2002
2003
2004
2006
2007
2008
2010
Rate of new HIV diagnoses, BC and Canada, 1986-2011.
3. New infections Persons living with HIV
(total 380, range 260-500) (total 11,700, range 9,400-14,000)
3% 3% 1%
23% 19%
43%
54%
16%
31%
3% MSM MSM-IDU 3%
IDU Heterosexual (non-endemic)
Heterosexual (endemic) Other
Distribution of HIV in BC, 2011. Estimates provided by the Public Health Agency of Canada.
10. Why are we here today?
• In order to further decrease HIV incidence in BC, we need to
reduce incidence among gay men
• Time to take stock of recent trends and consider what we
know now about factors that influence the HIV epidemic in
gay men in BC
• Findings presented here are being used to inform the
development of a Provincial Health Officer’s Report on HIV
trends among gay, bisexual and other MSM in BC
• Springboard to discuss future directions to reduce HIV
incidence in gay men in BC
11. Snapshot of recent trends
• Many thanks to CBRC for collaborating on this
analysis of Sex Now Data:
– Historical trends over time (four rounds, 2007-2011)
– Snapshot for 2011
• Also drawing on provincial surveillance and treatment data
• Emphasis on understanding trends by birth cohort, and by
region of BC
13. Need to focus on more than behaviour
“Recent data suggest individual-level risks might be
insufficient to explain the high transmission dynamics
evident in MSM outbreaks, and that
biological, couple, network-level, and community-level
drivers might be crucial to understand why HIV transmission
rates remain so high in MSM populations.
…and why HIV prevalence rates in these men seem
to have increased in the HAART era.”
Beyrer et al. Global epidemiology of HIV infection in MSM. Lancet 2012; 380:367-77
20. Marginalization Development of Snowballing of Emergence of
Psychosocial Psychosocial Sexual Risks
Harassment Difficulties Difficulties into a
Physical Violence Syndemic Unprotected anal
Emotional Distress
Forced Sex intercourse with
Social Isolation
Career Affected an unknown
Substance Abuse
Suicidality status partner
Depression
Other Mental
Health Difficulties
Model of Syndemic production adapted from Stall et al. Olivier Ferlatte, CBRC, 2012. Report in Preparation
21. Percent
60
50
40 Harrasment
Physical Violence
30
Forced Sex
20
Career Affected
10
Suicidality
0
> 49 1950-59 1960-69 1970-79 1980-89
Year of birth
Lifetime experiences of marginalization by birth cohort, Sex Now, 2011. Olivier Ferlatte, CBRC, 2012. Report in Preparation
22. Relationship between Marginalization experiences and Psychosocial health Issues among Men < 30yrs, Sex Now, 2011.
Olivier Ferlatte, CBRC, 2012. Report in Preparation
23. Relationship to Unprotected
Number of Anal Sex with Unknown Status
Psychosocial issues Partner
Odds Ratio (95% CI)
None REF
One 1.2 (0.9-1.7)
Two 1.6 (1.2-2.2)
Three or more 2.0 (1.5-2.7)
Relationship between Mental Health and Unprotected Anal Sex among Men < 30yrs, Sex Now, 2011.
Olivier Ferlatte, CBRC, 2012. Report in Preparation
24. • Among sexually experienced gay and bisexual male youth in
schools in BC:
– Protective factors that reduce risk of HIV include family
caring and support, inclusive and safe schools, attitudes of
friends / peers, meaningful extracurricular activities
– However these may not be sufficient to offset the
increased risk that is associated with exposure to physical
and sexual abuse, having been in government care, and
discrimination on the basis of sexual orientation
Analysis of Adolescent Health Survey data, McCreary Centre Society. E. Saewyc, personal communication, 2012.
33. • In Sex Now 2011:
– 39% of men said they were not out to their primary care
provider
– 85% said that they were satisfied or very satisfied with
their health care
– 14% had ever dropped a health care provider because of
his or her negative attitude (homo-negative, sexist, anti-
gay)
34. Disclosing male sex partners (out) to a health care provider by postal code aggregated region, BC Sex Now 2011.
48. • Nationally, an estimated 19% of HIV positive MSM are
unaware of their HIV infection (PHAC 2009)
• Based on sero-surveys of gay men/MSM in BC:
• Victoria (2007): 4%
• Vancouver (2008): 13%
(Victoria M-Track report 2008, ManCount Sizes Up the Gaps Report 2010)
50. Number of Newly Diagnosed Persons
Years since last negative HIV test
Time since last negative HIV test among persons newly diagnosed in HIV in BC, by exposure category, 2006-2011
51. HIV testing in the past year among gay men, by birth cohort, BC. Sex Now 2011
52. HIV test in past 12 months by postal code aggregated region, BC, Sex Now 2011.
54. Having >=1 PVL>1500 cells/mL per year and median CD4+ at diagnosis, MSM, BC, 1996-2011.
Data provided by BC Centre for Excellence in HIV/AIDS.
55. Engagement in HIV Care, Vancouver
• In 2008, 72% of gay men in Vancouver who self-identified as
HIV positive indicated that they were currently taking anti-HIV
medication
• In 2010/12, 65% of newly diagnosed MSM were linked to care
within 30 days (increase from 56% in 2003/05)
• In 2012, 63% of MSM diagnosed with HIV since 2003 are
currently prescribed ARV and 74% are actively engaged in
care
ManCount Survey. VCH STOP HIV Quarterly Monitoring Report 2012.
57. • MSM are more likely to be diagnosed with acute HIV
compared to other people newly diagnosed with HIV in BC
• In 2011, 16% of all new diagnoses among MSM were men
with acute HIV infection
62. • 5,320 MSM living with HIV in BC in 2011 (range: 4,160 – 6,480)
• Based on sero-surveys of gay men/MSM in BC:
• Victoria (2007): 14%
• Vancouver (2008): 18% → 21% in residents of GVRD
• Self-identify as HIV positive in Sex Now, 2011:
• 4% if born after 1980
• 16% if born between 1960-1979
• 18% if born before 1960
66. It’s complicated.
• Dynamics and influences on HIV transmission in gay men are
similar yet fundamentally different from other populations
affected by HIV in BC.
• These influences on HIV trends do not operate in isolation,
but intersect and can be additive, and vary regionally
• Gay men in BC are not a uniform population and are
comprised of diverse social and sexual groups
67. Acknowledgements
• Rick Marchand, CBRC
• Terry Trussler, CBRC
• Olivier Ferlatte, CBRC
• Elizabeth Saewyc, McCreary Centre
• Bob Hogg, BCCFE
• Nada Gataric, BCCFE
• Chris Archibald, PHAC
Editor's Notes
Overall in the province of British Columbia we have been seeing a decline in the number of new diagnoses in the past five years. In 2011, the number of new HIV diagnoses was the lowest on record (289 cases) and the BC rate dropped below the Canadian Rate for the first time.
According to the most recent estimates of incidence (new infections) and prevalence (persons living with HIV) in BC in 2011, gay and bisexual men are clearly over-represented accounting for 57% of all new infections, and 46% of people living with HIV in BC. (Note: Here we have combined MSM and MSM-IDU, which is our practice in BC for surveillance reports).
When we break down recent trends in new HIV diagnoses further, and look at trends in different exposure categories, we see that the number of new HIV diagnoses in BC may have declined slightly over time, yet remain elevated with respect to other exposure categories – “critical, but stable”. Most notably, the decrease in new HIV diagnoses among IDU is not mirrored among MSM or any other exposure category.
Returning to British Columbia, we see very little differences in trends in new diagnoses of HIV in MSM by health authority. The uptick of new diagnoses in 2011 in Vancouver Coastal and to a lesser extent in Fraser Health may be related to expanded testing or earlier detection through STOP HIV or pooled NAAT testing (i.e., if these initiatives hadn’t been in place, we may have seen a decreasing trend in new HIV diagnoses during this time period).
The previous slides focused on new diagnoses of HIV, which are not the same as new infections (as a diagnosis can happen at a late stage of infection, for example). According to modeling from the Public Health Agency of Canada, HIV incidence among MSM rose to a peak in 1983, declined to 1995, increased to 2003 and has been relatively stable since then.
When we look globally, we see that the stable Canadian trend in new diagnoses is similar to trends from other countries, which are increasing or stable. According to a global review of the epidemiology of HIV among MSM by Beyrer (Lancet 2012), inmany high-income settings, overall HIV epidemic trends are in the decline except among MSM, where they have been expanding in the era of highly active antiretroviral therapy as what have been described as re-emergent epidemics in MSM. Incidence continues to be sustained at levels sufficient for epidemics in the MSM population to continue.
One of the most notable trends when looking at recent trends in new HIV diagnoses among MSM in BC are the different trends by birth cohort. Here we see that the numbers of new HIV diagnoses in cohorts of men currently in their 30’s-50’s, and men over 50, have been decreasing over time – while new diagnoses in the cohort of men currently 30 years or less has been increasing slowly over time. These trends may be related to the natural lifecourse of gay men (e.g., the increase in new diagnoses among younger men reflecting this cohort aging into a period of greater sexual activity and exposure to HIV). However these cohorts have also had different life experiences – most notably the experience of the mortality associated with the peak of the HIV epidemic.
Comments on Sex Now Data: We focused on 4 rounds of the survey which were all done online, at approximately 12-18 months apart, between 1200-1800 men participating in BC per year. While convenience sampling and there may be differences from year to year, participants in these four rounds of the survey are very similar in terms of age, residence, ethnicity and income.
How do we approach understanding the trend in new diagnoses? First we need to consider what may be influencing the trends. First arrow: A stable trend line may be related to stable influences, where there has been no change over this time period.Second arrow: A stable trend may also be a mix of opposing influences, including factors that increase HIV diagnoses, such as HIV testing (for example, the upswing in 2011 in BC and particularly in VCH may be related to increased testing through STOP HIV). Third arrow: Factors may also be acting which decrease HIV diagnosis. For example, increased uptake of HAART over time would have a downward effect on this trend due to preventing new HIV infections.
The theme of this Summit is on Social Determinants of Gay Men’s Health, and the importance of thinking about determinants definitely to HIV. At previous summits as well as in community dialogues, this is not a new idea and we have examples of MSM-focused strategies deliberately adopting this approach (for example, the UK’s “Making it Count” strategy). Increasingly – and finally! - given HIV trends in gay men globally, this dialogue is emerging in scientific literature and among government public health leaders as evidenced by this recent quotation in the Lancet as part of the MSM and HIV series presented at AIDS2012. We definitely need to shift our focus from an emphasis on behaviour to a more nuanced understanding of factors influencing HIV among gay men.
Our approach for the PHO report is to consider factors influencing HIV trends in gay men in BC at multiple levels, proximal to distal. We examined factors which are considered to have an influence on HIV transmission in gay men because of: plausibility (resonance with community & providers), availability of data, amenable to intervention, and perceived importance.
Connection to other gay men or the gay community is considered to be a protective factor that may reduce risk of infection; for example, by providing more opportunity to learn about safer sex techniques. Probably more important is whether men have social supports or not – which may be friends, family, gay men, or others.
The percentage of free time that gay men are spending with other gay guys is decreasing over time. 42% of men in 2007 said that they spent at least 50% of free time with other gay guys, down to 25% in 2011.
This varied by region - outside of the city of Vancouver, <20% of men reported spending most free time with other gay guys. This may reflect differences in terms of gay venues, different social norms, or smaller gay populations less urban parts of the province.
Social Support in general (regardless of whether it is other gay men, friends, family, co-workers, etc) is a key determinant of health, particularly for gay men. A clear gradient is seen around the province from urban to rural areas in terms of men in sex now reporting poor social support (i.e., when asked if they have people to turn to for support answering “no” or “few”).Overall, when this was looked at by birth cohort, fewer younger men reported poor social support compared to older men (16% among 1980+, 25% among 1960-79, 24% among <1960).
Ron Stall’s concept of “syndemics” – co-occurring epidemics in this case of experiences of marginalization, mental health, and HIV risk – have immediate resonance. Olivier looked at whether syndemics exist in Canada through Sex Now data, presented at last year’s Summit and with his permission I am reprising briefly here. Under this theoretical model, experiences of marginalization contribute to the development of psychosocial issues/poor mental health, which then contribute to increase sexual risk (and risk of HIV).
In Olivier’s analysis, it was evident that experiences marginalization affect all generations of gay men in Canada. Most troubling is that reported experience of marginalization is even higher among younger cohorts of men – for example, half of gay men between 20-30 years reported experiencing harassment and suicidal ideation in their lifetime (in this analysis, suicidality is conceptualized as a manifestation of the oppression experienced by gay men).
When focusing just on men < 30 years of age, when experiences of marginalization were compared to reported mental health / psychosocial issues, the gradient is clear and dramatic. The greater the number of experiences of marginalization reported by young gay men, the greater the proportion reporting each of these outcomes.
The same relationship held true for young men and risk of HIV, as a having an increasing number of psychosocial issues was associated with a greater odds of reporting unprotected anal sex.
This data is from the BC Adolescent Health Survey (combining last three rounds spanning over a decade of data), with an exclusive focus on gay and bisexual male youth in the data.
I am not going to focus on differences in these trends by sexual identity (gay, bisexual, or straight). What we do see clearly in Sex Now 2011 is that the proportion of participants identifying as gay decreases with distance from metro Vancouver. There are important differences between men of different identities that will be touched on by Terry later in the Summit. For HIV related risk, there is a clear gradient, between men identifying as gay having the highest prevalence, testing rates, and risk sex.
Overall in BC see an increasing proportion of new HIV diagnoses among Men of Colour since 2008.
See a gradient in ethnicity by birth cohort among cases diagnosed in BC since 2006, with men of colour comprising 44% among 1980+, 31% among 1960-79+, 14% among <1960.
When looking at trends over time in SN data among all participants see little change over time. However we do see differences by birth cohort.Relationship between substance use and HIV may be through several pathways:Substance use/abuse as intermediary on pathway between marginalization experiences/mental distress and unprotected sexSubstance use in the context of sex that impairs judgment and may lead to risk sexSexual enhancement drugs (poppers and viagra) which have demonstrated association with risk sex – use of viagra may also be related to true erectile dysfunction in older cohorts.
Being out to your primary care provider (i.e., having told him/her that you have sex with men) is an important indicator for accessing appropriate health care as a gay man – not least of which for HIV is access to appropriate sexual health including testing. Overall ~40% of men are not “out” to their primary care provider, and while most are satisfied 1 in 7 man had dropped a health care provider because of his or her homophobic attitude.
There are clear differences in access to appropriate health care for gay men in BC – outside of Vancouver between 35-50% of men have come out to their primary care provider.
How sexual networks form, dissolve, and re-form is a key determinant of how HIV spreads in a population. Here we have an illustration of a group of gay men, and then we can see the various kinds of networks that men have – including no sex, having a relationship and partners on the side, multiple partners, being part of active sexual networks. These sexual relationships are not static either – they are in flux and change, as men move in and out of different kinds of networks at different stages of their lives.
In Sex Now we can see that gay guys are into a variety of things sexually, with some key differences by birth cohort. For example, younger guys are more into dating and sex with a primary partner only compared to older men.
Relationship networks overlap on sexual networks. Relationships between positive and negative gay men are common – seen here by the fact that 1 in 20 HIV negative men say they have a primary partner who is HIV positive, and 1 in 2 HIV positive guys have a negative primary partner.
What hasn’t changed over time is that condoms are the best protection against acquiring or transmitting HIV. This is a risk reduction strategy which is part of gay sexual culture at all ages - overall 71% of participants in Sex Now 2010 said that they used condoms for anal sex on casual dates “almost every time” or “all the time”.
In these past four rounds of the Sex Now survey it is evident that we have not seen any big changes in individual sexual risk, as evidenced by these traditional indicators of risk behaviour. This generally held true when we looked at risk by birth cohort as well.
What is striking is that there is very little variation in risk sex (UAI with unknown status partners) by region.
The knowledge that gay man employ other risk reduction strategies besides condom use is not new, and there is evidence that these strategies do reduce an individual’s risk of infection – some (such as strategic positioning) more than others (such as viral load). This data comes from the ManCount survey in 2008-09, showing that the majority of positive and negative men use risk reduction strategies. It would be interesting to repeat this survey now to see if these frequencies have changed – particularly to see if there are changes in the percent reporting use of low viral load as a risk reduction strategy.
Most men who report risk sex (UAI with an unknown status partner) also report that they had sex which risked HIV transmission. By this traditional measure of risk, for most men there is congruence between risk perception and type of sex. However, not all men reporting risk sex consider the sex they have had to risk HIV transmission, and the proportion perceiving their own sex as risky is declining over time.
When risk perception is looked at by birth cohort, while in 2011 Sex Now data there were no clear differences between cohorts in terms of reporting risk sex in the past 12 months (left hand side of graph), there were differences by cohort when looking at perceived risk among men who reported risk sex. A greater proportion of younger men having risk sex identified that they had sex with risked HIV transmission, with a gradient towards a lower proportion of older men.
This does not mean that men with undiagnosed infections are not getting tested. In the ManCount survey, of men who were unaware that they were HIV+ most had previously tested, most in the past two years. Likely these are men who have been infected between tests – not an “untested” population.(Note that in the survey 13% of HIV+ men were unaware of their status – which translated to 2.5% of all men (HIV+ and HIV-) in the survey.
This is further evident when looking at provincial HIV surveillance data, comparing the time elapsed since last negative HIV test for MSM (in light blue) who have a new diagnosis of HIV in BC. While many men have a short interval (as curve is skewed to the right) suggesting that many men test frequently, there are men for whom a long interval has elapsed. These findings speak to the importance of increasing the frequency of HIV testing among gay men in BC.
However we do see that testing rates are high – and consistent over time, among gay men of all ages, with generally 50% or more reporting having tested in the past year.
There are regional differences, with lower (yet similar) testing rates outside of Vancouver.
Community viral load among MSM is decreasing over time, as was observed in IDU populations in the previous PHO report. The same trend (and similar %) for PVL is seen in all health authorities (data not shown). Median CD4+ when starting treatment among MSM has shifted over time depending on changes in treatment guidelines, with the most recent trend being towards starting treatment at a higher CD4+ (e.g., at an earlier stage of infection). These trends have likely contributed to preventing new HIV infections to date among MSM in BC (downward influence on diagnosis trends – i.e., if eligibility for treatment hadn’t expanded, we may have observed a greater number of new HIV diagnoses). We will be looking at this data in collaboration with BCCFE by birth cohort to see if there are differences by sub-group where targeted approaches may be of benefit. Note: The documentation of a man in the provincial treatment registry as MSM is not considered complete (i.e., ascertainment bias), and there is misclassification of MSM as other males in the data. So this data is from participants known to be MSM, and may be an underestimate of true trends.
Through STOP HIV as reported in the VCH STOP HIV Quarterly Monitoring Report, VCH has been able to look at engagement in care for newly diagnosed MSM in Vancouver, and have demonstrated high and improving linkage to care over time, and high levels of engagement in care among diagnosed men.
Acute HIV infection may play a greater role in sustaining HIV among gay men compared to other populations, and is thought to be one of the reasons that may limit the impact that HAART has on HIV transmission. We have previously shown in BC that MSM are more likely to be diagnosed with HIV in BC, and most recently 16% of all new diagnoses among MSM were men with acute HIV infection. This has increased, primarily due to the use of pooled NAAT testing for acute HIV implemented at six clinics in Vancouver accessed by gay men.
Another “syndemic” related to HIV transmission in gay men is the co-occurring epidemics of STIs which either facilitate acquisition or transmission of HIV. Over the past ten years, we have not seen an increase in chlamydia or gonorrhea among MSM (based on data from BCCDC clinics where any increases would be expected to be seen). The exception is infectious syphilis which has clearly increased (including a recent resurgence in 2011 and continuing in 2012). While syphilis trends may be contributing to spread of HIV, it’s important to note that the majority of syphilis cases are among HIV positive MSM, and are thought in part to be a result of sero-sorting, which would limit the impact on HIV spread. (In 2011, ~70% of all provincial infectious syphilis cases were HIV+).
This means that purely on the basis of prevalence alone, chances are high that a man’s sex partners – and relationships, as we saw earlier – will be HIV positive. This is a driver that will continue to have an upwards influence on diagnosis trends, as the number of gay men living with HIV in BC will slowly increase over time, unless incidence rates drop.
When looking at participants who self-identified as being HIV positive in the Sex Now Survey in 2011, the gradient is clear that prevalence is highest in Vancouver and lowest in more rural parts of BC. However, as we saw earlier, testing rates are also lower in these regions so that is also an influence on these trends.
A simple title but I think an important concept to acknowledge – the HIV epidemic in gay men in BC is complex and evolving over time and neither are the solutions simple. Much as we would like, there is no magic bullet that will end the epidemic. Epidemiology is reductionist by nature, and this presentation – which has shed more light on influences on trends – is still overly simplistic and doesn’t speak to the nuances and realities of gay men’s lives and relationship to HIV.
Finally before moving to the panel discussion I would like to acknowledge the following people who provided data for this presentation.
