By: Eric Brus*
15% of U.S. MSM Are Living with HIV, But Prevalence Varies Widely by Region
Eli Rosenberg and colleagues from Emory University’s Rollins School of Public Health have used recent estimates of the number of gay, bisexual, and other men who have sex with men (MSM) and publicly available HIV surveillance data to estimate, for U.S. MSM, the prevalence of HIV diagnosis and infection and the rate of new diagnoses, at the national, state, Metropolitan Statistical Area (MSA), and county levels.
Their calculations indicate that, overall, HIV prevalence among MSM in the U.S. during 2012 was 15.0%, the diagnosed HIV prevalence among MSM in 2012 was 11.1%, and the new diagnosis rate for 2013 was 0.7 per 100 MSM. The diagnosed HIV prevalence rate among MSM was 57.5 times greater than among other U.S. men. The bulleted list below highlights geographic patterns in HIV prevalence among MSM at the state, MSA, and county level in 2012. Please note that the HIV prevalence rates and HIV case figures cited refer specifically to diagnosed cases of HIV infection among MSM only. Though not summarized here, the paper also contains estimates of the total HIV cases (both diagnosed and undiagnosed) among MSM, as well as HIV prevalence estimates that include undiagnosed cases.
- Georgia, with about 24,100 diagnosed HIV cases among MSM and a diagnosed HIV prevalence rate of 18.5%, was the only state with both more than 15,000 diagnosed HIV cases and a diagnosed prevalence rate above 15%.
- Five states, all in the South, and the District of Columbia (D.C.) had diagnosed HIV prevalence rates above 15% but fewer than 15,000 total diagnosed HIV cases among MSM. These states and their associated HIV prevalence rates were: Mississippi (23.3%); Louisiana (21.7%), South Carolina (21.6%), D.C. (21.0%), Alabama (15.8%), and Arkansas (15.0%).
- Five high-population states had more than 15,000 diagnosed HIV cases among MSM and diagnosed HIV prevalence rates between 10% and 15%. These states and their associated HIV prevalence rates were: New York (14.6%), Florida (14.4%), Texas (11.8%), California (10.9%), and Illinois (10.2%).
- Of the 25 MSAs with the highest diagnosed HIV prevalence rates in the U.S., 21 were in the South, and 6 had diagnosed HIV prevalence rates above 25% among MSM.
- County-level data showed high diagnosed HIV prevalence rates in both urban and rural counties of the South.
- The five states with the lowest diagnosed HIV prevalence rates were: North Dakota (3.3%), South Dakota (3.6%), Montana (3.7%), Vermont (4.0%), and Wyoming (4.0%).
The researchers conclude: “Surveillance data have been described as the conscience of the HIV epidemic, and the new insights provided here on the rates of HIV prevalence and new diagnoses for U.S. MSM constitute a call of conscience for heightened responses and improved monitoring of HIV epidemics among MSM, especially in the South. Across the U.S., MSM are affected by HIV at rates that are orders of magnitude higher than for other Americans. This health disparity is even more pronounced in the South. There is a need for increased resources for HIV prevention, treatment, and care for MSM. In the South, this must include expansion of access to health care through Medicaid expansion under the Affordable Care Act; increased access to comprehensive HIV prevention services, including for pre-exposure prophylaxis (PrEP); and increased resources for programs to support immediate referrals for antiretroviral therapy for those who are newly diagnosed with HIV.”
Denmark Is Nearing the “Elimination Threshold” for Their HIV Epidemic
The World Health Organization (WHO) has identified HIV treatment as prevention (TasP) as a key element in ending the HIV/AIDS epidemic. TasP refers to the reduction in HIV transmission rates arising from extensive access to, and use of, antiretroviral treatment (ART) among persons living with HIV. This occurs because effective ART suppresses HIV viral load to very low levels, dramatically decreasing the risk of HIV transmission – a 96% reduction in one major study. For infectious diseases, when the transmission rate falls below a level known as the “elimination threshold,” the disease is unable to maintain itself and will eventually be eliminated. For HIV, the elimination threshold has been calculated at one new HIV transmission per 1,000 individuals.
Thanks to broad access to ART, the HIV epidemic among Danish gay, bisexual, and other men who have sex with men (MSM) is now close to the elimination threshold, according to a new study from the University of California-Los Angeles (UCLA) and the Copenhagen University Hospital. The study researchers used an approach called CD4-staged Bayesian back-calculation to determine the number of Danish MSM who had become infected with HIV each year between 1995 and 2013, as well as the number of MSM who had undiagnosed HIV infection.
They found that the number of new HIV infections among MSM has been decreasing since 1996, the year that effective ART regimens were introduced in Denmark. When the researchers examined the relationship between this declining HIV incidence and the growth in ART use during the period, they found that these two variables were highly correlated.
By 2013, the number of new HIV infections among Danish MSM had declined to just 1.4 per 1,000 – very close to the elimination threshold for HIV. “The Danes have done what nobody else in the world has been able to do,” according to UCLA researcher Sally Blower. “They have almost eliminated their HIV epidemic, and they have achieved this simply by providing treatment.”
The Danish experience may be difficult to replicate, however, because both HIV treatment access and adherence are exceptionally high there. In fact, 98% of Danish MSM have achieved HIV viral suppression – a key goal of HIV treatment. The paper concludes on a sobering note: “Unless these extremely challenging conditions [very high treatment coverage, and an exceptionally high viral suppression rate] can be met in sub-Saharan Africa, the WHO’s global elimination strategy is unlikely to succeed.”
CDC Report Finds Progress in Reducing Sexual Risk Behaviors Among U.S. Youth
The newly released national Youth Risk Behavior Survey (YRBS) for 2015 indicates that progress continues to be made in reducing some sexual risk behaviors among U.S. high school students. Every two years, the YRBS monitors the following six main categories of priority health-risk behaviors among youth and young adults nationwide in grades 9 through 12: 1) sexual behaviors related to unintended pregnancy and sexually transmitted infections (STIs), including HIV; 2) behaviors that contribute to unintentional injuries and violence; 3) tobacco use; 4) alcohol and other drug use; 5) unhealthy dietary behaviors; and 6) physical inactivity. In this brief feature, we focus on the YRBS report’s findings on sexual behavioral risks, HIV/AIDS education, and HIV testing.
Sexual Risk Behaviors and HIV Testing
According to the 2015 YRBS report, for 9th through 12th grade students:
- about 41% had ever had sexual intercourse – decreasing from about 47% in 2013 and 54% in 1991 (the year when the YRBS was first conducted);
- about 30% were currently sexually active – decreasing from about 34% in 2013 and 37.5% in 1991;
- about one in nine (11.5%) had had sexual intercourse with four or more people during their life – decreasing from about 15% in 2013 and 19% in 1991;
- about one in 25 (3.9%) had sexual intercourse for the first time before age 13 – decreasing from 5.6% in 2013 and 10.2% in 1991; and
- about one in 10 (10.2%) had ever been tested for HIV, compared to 12.9% in 2013 and 11.9% in 2005 (the first year for which this information was compiled in the YRBS).
Health Education, Health Services, and Supportive Environments
A related survey, the School Health Policies and Practices Study 2014, indicates that, among U.S. high school students:
- 75% had been taught in school about preventing HIV infection;
- 76% had been taught about preventing STIs;
- 65% had been taught how to find valid information or services related to HIV or HIV testing;
- 70% were taught how to find valid information or services related to STIs or STI screening;
- 50% were taught how to obtain condoms; and
- 35% were taught how to correctly use a condom.
Further, among U.S. high schools:
- 50% provided HIV or STI prevention services at school in one-on-one or small-group sessions;
- 7% made condoms available to students at school;
- 40% provided HIV counseling, testing, and referral services at school;
- 54% provided identification, treatment of, or referral for STIs at school;
- 16% provided identification, treatment of, or referral for STIs to students through arrangements with providers not located on school property;
- 35% provided services specifically for gay, lesbian, or bisexual students at school; and
- 38% had a gay/straight alliance.
*Eric Brus is the Director of Health Information at AIDS Action Committee. This report is produced by the Health Library of the AIDS Action Committee in collaboration with the New England AIDS Education and Training Center Minority AIDS Initiative Project. The full version is available online.