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1 figure, 2 tables omitted
Well into the third decade of the human immunodeficiency virus (HIV)
epidemic, rates of HIV infection remain high, especially among minority populations.
Of newly diagnosed HIV infections in the United States during 2003, CDC estimated
that approximately 63% were among men who were infected through sexual contact
with other men, 50% were among blacks, 32% were among whites, and 16% were
among Hispanics.1 Studies of HIV infection
among young men who have sex with men (MSM) in the mid to late 1990s revealed
high rates of HIV prevalence, incidence, and unrecognized infection, particularly
among young black MSM.2-4 To
reassess those findings and previous HIV testing behaviors among MSM, CDC
analyzed data from five of 17 cities participating in the National HIV Behavioral
Surveillance (NHBS) system. This report summarizes preliminary findings from
the HIV-testing component of NHBS, which indicated that, of MSM surveyed,
25% were infected with HIV, and 48% of those infected were unaware of their
infection. To decrease HIV transmission, MSM should be encouraged to receive
an HIV test at least annually, and prevention programs should improve means
of reaching persons unaware of their HIV status, especially those in populations
disproportionately at risk.
NHBS is an ongoing behavioral surveillance system that collects cross-sectional
data among populations at high risk for acquiring HIV, including MSM, injection-drug
users, and heterosexuals at high risk. Men aged ≥18 years were sampled
systematically from randomly selected venues where MSM congregated (e.g.,
bars/clubs, organizations, and street locations). Formative research was conducted
to identify venues and days and times when MSM frequented these venues.2-4 Men eligible for the
survey were aged ≥18 years and residents of the metropolitan statistical
area (MSA). Using a standardized questionnaire, men were interviewed about
their sexual and drug-use behaviors, HIV-testing behavior, and use of HIV-prevention
services. During June 2004–April 2005, participants in five NHBS cities
(Baltimore, Maryland; Los Angeles, California; Miami, Florida; New York, New
York; and San Francisco, California) were also tested for HIV infection after
The OraQuick® rapid test or an enzyme immunoassay (EIA) was used
to screen blood specimens for HIV antibody, and initially reactive specimens
were tested by Western blot for confirmation. To estimate HIV incidence, CDC
used a serologic testing algorithm for recent HIV seroconversion (STARHS).5 Specimens that were confirmed positive were tested
further with the Vironostika-Less Sensitive (LS) EIA, which detects HIV infection
approximately 170 days after initial infection by using a 1.0 standard optical
density cutoff (95% confidence interval [CI] = 145-200 days).6 A
specimen confirmed positive by Western blot and nonreactive on the Vironostika-LS
assay was categorized as an incident infection. Persons self-reporting a previous
positive test result and HIV-positive participants reporting use of antiretroviral
therapy were excluded from the incidence estimate.
Participants were asked about the date and result of their most recent
HIV test before having their blood drawn as part of NHBS. Men who had not
been tested during the preceding year were asked about their reasons for not
being tested. MSM with unrecognized infection were defined as those who reported
being HIV negative, indeterminate, or not knowing their HIV status, but who
tested HIV positive at the time of their interview. Prevalence ratios and
95% CIs were calculated to evaluate characteristics associated with testing
during the preceding year. Differences in reasons for not testing between
HIV-negative MSM and MSM with unrecognized infection were assessed by using
chi-square tests (p<0.05).
In the five cities, 2,261 men sampled from 258 venues participated in
NHBS. The participation rate among eligible men was 83% (range by city: 69%-99%).
A total of 1,767 (78%) were men who had one or more male sex partners and
agreed to the survey, HIV test, and STARHS test (range by city: 222-462).
Of these 1,767 participants, the median age was 32 years (range: 18-81 years);
35% were white, 27% Hispanic, 25% black, 7% multiracial/other, and 6% Asian/Pacific
Islander. Participants were recruited at bars (30%), street locations (20%),
dance clubs (19%), cafes/retail stores (10%), Gay Pride events (6%), social
organizations (5%), gyms (5%), sex establishments (3%), and parks (1%).
Of the 1,767 MSM, 450 (25%) tested positive for HIV (range by city:
18%-40%). HIV prevalence was 46% among blacks, 21% among whites, and 17% among
Hispanics. A total of 340 (76%) of those who were HIV positive were aged ≥30
years. Of the 449 HIV-antibody–positive specimens tested by Vironostika-LS,
80 were nonreactive; of these, 31 were considered incident infections, and
49 were excluded from the incidence estimate. HIV incidence among MSM by city
was as follows: Baltimore, 8.0% (95% CI = 4.2%-11.8%); Los Angeles, 1.4% (95%
CI = 0.0%-2.9%); Miami, 2.6% (95% CI = 0.0%-5.6%); New York City, 2.3% (95%
CI = 0.28%-4.2%); and San Francisco, 1.2% (95% CI = 0.0%-2.6%).
Of the 450 HIV-infected MSM, 217 (48%) were unaware of their HIV infections.
The proportion of unrecognized HIV infection was highest among MSM who were
aged <30 years, nonwhite, and surveyed in the four cities other than San
Francisco. Of the 217 MSM with unrecognized HIV infections, 64% were black,
18% Hispanic, 11% white, and 6% multiracial/other. The majority (184 [84%])
of the 217 MSM with unrecognized HIV infection had previously been tested
for HIV; 145 (79%) reported that their most recent test result was negative,
33 (18%) were unknown, and six (3%) were indeterminate. Approximately 58%
of MSM with unrecognized infections had not been tested during the preceding
year. Compared with MSM who were HIV negative, proportionally more MSM with
unrecognized infections had not been tested during the preceding year because
they were afraid of learning they had HIV (34% versus 68%; p<0.0001) and
were worried others would find out the result (14% versus 35%; p<0.0001).
Nearly all participants (92%) reported previously being tested for HIV,
and 64% reported being tested during the preceding year. MSM were more likely
to have been tested during the preceding year if they had visited a health-care
provider and their provider recommended an HIV test. Sexual and drug-use behaviors
were not associated with testing during the preceding year.
F Sifakis, PhD, Johns Hopkins Bloomberg School of Public Health, Baltimore;
CP Flynn, ScM, Maryland Dept of Health and Mental Hygiene. L Metsch, PhD,
Univ of Miami; M LaLota, MPH, Florida Dept of Health. C Murrill, PhD, New
York City Dept of Health; BA Koblin, PhD, New York Blood Center, New York.
T Bingham, MPH, Los Angeles County Dept of Health Svcs; W McFarland, MD, H
Raymond, San Francisco Dept of Public Health, California. S Behel, MPH, A
Lansky, PhD, B Byers, PhD, D MacKellar, MPH, A Drake, MPH, K Gallagher, DSc,
Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention,
CDC Editorial Note:
Consistent with previous studies of young MSM conducted in the same
cities using similar sampling methods,2-4,7,8 this
study revealed that (1) prevalence and incidence of HIV infection in this
population were high; (2) many HIV-infected MSM, particularly younger and
black MSM, were unaware they were HIV-infected; and (3) among MSM with unrecognized
infection, nearly half presumably acquired HIV during the preceding year,
and many had not been tested recently because of fears of testing positive.
These findings underscore the need to increase testing and improve primary
prevention practices for MSM.
Although a majority of MSM had been tested during the preceding year,
more than half with unrecognized infections had not had an annual test. The
results of this study support CDC guidelines recommending at least annual
testing for sexually active MSM,8 especially
among younger MSM and minority populations.7
The findings in this report are subject to at least four limitations.
First, the date of a participant’s most recent HIV test is self-reported
and might be subject to reporting inaccuracies. Second, given the sensitive
nature of some questions, HIV status might have been underreported during
the interview, thereby inflating estimates of unrecognized infections. Third,
these findings are limited to men who frequented MSM-identified venues in
the five selected cities during the survey period. Although similar rates
of HIV incidence were observed compared with previous surveys,2 the
limited number of incident cases prevents comparisons by race and age. Finally,
data are preliminary and have not been weighted by venue-selection probability.
The 2004 NHBS system was conducted in 17 MSAs with the highest AIDS
prevalence. Although this report focuses on testing results from five selected
cities, behavioral data are forthcoming from all participating cities. NHBS
is an important tool for monitoring the impact of the HIV epidemic and informing
HIV incidence and prevalence are high among MSM, and many are unaware
they are HIV positive. The high level of unrecognized HIV infections among
MSM is a public health concern. Persons aware of their HIV infection often
take steps to reduce their risk behaviors, which could reduce HIV transmission.9 To increase the proportion of HIV-positive persons
who know they are infected, sexually active MSM should be encouraged to have
an HIV test at least annually. Corresponding efforts should be developed to
address barriers to testing, particularly those related to fear, and to increase
the availability of testing in clinical and nonclinical settings.10 Testing programs should target both younger MSM and
black MSM to reach populations disproportionately unaware they are HIV positive.
HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who
Have Sex With Men—Five U.S. Cities, June 2004–April 2005. JAMA. 2005;294(6):674–676. doi:10.1001/jama.294.6.674
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