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Sex Transm Infect. 2007 April; 83(2): 125–126.
PMCID: PMC2598615

COMMENTARY

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.

References

1. Dougan S, Elford J, Chadborn T. et al Does the recent increase in HIV diagnoses among men who have sex with men in the United Kingdom reflect a rise in HIV incidence or increased uptake of HIV testing? Sex Transm Infect 2007. 83120–125.125 [PMC free article] [PubMed]
2. Xiridou M, Geskus R, de Wit J. et al Primary HIV infection as source of HIV transmission within steady and casual partnerships among men who have sex with men. AIDS 2004. 181311–1320.1320 [PubMed]
3. Porco T C, Martin J N, Page‐Shafer K A. et al Decline in HIV infectivity following the introduction of highly active antiretroviral therapy. AIDS 2004. 1881–88.88 [PMC free article] [PubMed]
4. Bezemer D O, de Wolf F, Boerlijst M C. et al Despite HAART, HIV‐1 is once again spreading epidemically amongst men having sex with men in the Netherlands [V‐143]. 14th Conference on Retroviruses and Opportunistic Infections (CROI 2007). Los Angeles, CA, USA
5. Stolte I G, de Wit J B F, Kolader M. et al Low HIV‐testing rates among younger high‐risk men who have sex with men in Amsterdam. Sex Transm Infect 2007. In press [PMC free article] [PubMed]
6. Jin F Y, Prestage G, Law M G. et al Predictors of recent HIV testing in homosexual men in Australia. HIV Med 2002. 3271–276.276 [PubMed]
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8. Weiser S D, Heisler M, Leiter K. et al Routine HIV testing in Botswana: a population‐based study on attitudes, practices, and human rights concerns. PLoS Med 2006. 3e261 [PMC free article] [PubMed]
9. Mulder‐Folkerts D K, van den Hoek J A, van der Bij A K. et al Less refusal to participate in HIV screening among pregnant women in the Amsterdam region since the introduction of standard HIV screening using the opting‐out method [in Dutch]. Ned Tijdschr Geneeskd 2004. 1482035–2037.2037 [PubMed]
10. Centers for Diseases Control and Prevention Advancing HIV prevention: new strategies for a changing epidemic, 2003. Morb Mortal Wkly Rep 2003. 52329–332.332 [PubMed]
11. Van Leth F, Andrews S, Grinsztejn B. et al for the 2NN study group. The effect of baseline CD4 cell count and HIV‐1 viral load on the efficacy and safety of nevirapine or efavirenz‐based first‐line HAART. AIDS 2005. 19463–471.471 [PubMed]
12. Siddique M A, Hartman K E, Dragileva E. et al Low CD4+ T cell nadir is an independent predictor of lower HIV‐specific immune responses in chronically HIV‐1 infected subjects receiving highly active antiretroviral therapy. J Infect Dis 2006. 194661–665.665 [PubMed]
13. Egger M, May M, Chene G. et al Prognosis of HIV‐1‐infected patients starting highly active antiretroviral therapy: a collaborative analysis of prospective studies. Lancet 2002. 360 pp 119-29 [Correction appears in: Lancet 2002;3601178] [PubMed]
14. Annual report HIV Monitoring Foundation [Stichting HIV Monitoring] Amsterdam 2006. http://www.hiv‐monitoring.nl/_site1134/images/Jaarverslag2005.pdf (accessed 11 Feb 2007)
15. Dukers H T M, Fennema S A, van der Snoek E M. et al Trends in HIV incidence and HIV testing behaviour in men who have sex with men: an overview using three incidence sources, The Netherlands, 1984–2005. AIDS 2007. 21491–499.499 [PubMed]

Articles from Sexually Transmitted Infections are provided here courtesy of BMJ Group