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The UK has one of the most extensive HIV registry systems internationally. The study by Dougan and colleagues is an impressive exercise to explore what we can learn from such registries.1 Still, in the end it remains challenging to conclude whether increased uptake of HIV testing, a rising HIV incidence or both have contributed to the increasing number of HIV diagnoses among (older) men who have sex with men (MSM) using ecological comparisons. A useful addition that may shed more light on this issue would be to construct a mathematical model that incorporates observed data. Such models have been successfully used in the past to predict HIV spread and to assess the influence of strongly interlinked parameters.2,3,4
The data presented show a stable HIV incidence among MSM in the UK. A rise in HIV incidence is not unexpected considering ongoing high levels of risky sexual behaviour and sexually transmitted infection (STI) epidemics among MSM internationally. To measure the HIV incidence in a population, however, provides a methodological and logistical challenge. The current study uses the serologic testing algorithm for determining recent HIV seroconversion (STARHS) approach that, when incorporated in existing STI/HIV screening programmes at genitourinary medicine (GUM) clinics, is an easy tool to directly estimate HIV incidence. Its wider international (European) application, when standardised, would be of great benefit to HIV incidence surveillance, considering the puzzling discrepant incidence trends found in various countries.
The UK is like, for example, The Netherlands, a country with a historically conservative HIV testing policy. This likely resulted in the still lower testing rates than those found in MSM in, for example, the US or Australia, where testing has been promoted since the beginning of the epidemic.5,6,7 After the introduction of highly active antiretroviral therapy (HAART), the UK and The Netherlands changed to an active approach followed by higher testing uptake. Recently several countries, including the UK, have adopted or are planning to implement the opting‐out strategy for HIV testing. This strategy has been shown to drastically reduce the number of undiagnosed HIV infections.8,9,10 Considering that a substantial proportion of patients (one in five MSM in the UK and The Netherlands, and even higher among heterosexuals) are diagnosed late in their infection, the opting‐out strategy may also help to diagnose people earlier, when they have a better chance for optimal treatment.11,12,13
Finally, this study shows the importance of differentiating by age, and agrees with other reports showing an increase in the median age of MSM at HIV diagnosis and showing that HIV incidence is no longer highest in the younger age groups.14,15 Although conventionally attention is mainly focused towards the young, older MSM should be specifically targeted in HIV and STI prevention.