JAIDS Journal of Acquired Immune Deficiency Syndromes:
Letters to the Editor
Recent Increase in High-Risk Sexual Behaviors Among Sexually Active Men Who Have Sex With Men Living With AIDS in Los Angeles County
Wohl, Amy Rock MPH, PhD*; Johnson, Denise F. MPH*; Lu, Sharon MPH*; Frye, Douglas MD, MPH*; Bunch, Gordon MA*; Simon, Paul A. MD, MPH†
*HIV Epidemiology Program, Los Angeles County Department of Health Services, Los Angeles, CA
†Office of Health Assessment and Epidemiology, Los Angeles County Department of Health Services, Los Angeles, CA
To the Editor:
Recent reports have documented a significant increase in high-risk sexual behaviors and sexually transmitted diseases among men who have sex with men (MSM) in urban settings in the United States and worldwide. 1–7 In Los Angeles County (LAC), which includes one of the largest urban MSM populations in the United States, an outbreak of syphilis was reported in 1999 among MSM, 50% of whom were also HIV infected. 8,9 Despite rapidly instituted outbreak control efforts, 8 reported cases of syphilis among MSM in the county remain high. 10 Few data are available on sexual risk behaviors in this population, however. We present trends in the reported number of male sexual partners and unprotected anal intercourse (UAI) in a population-based sample of sexually active MSM living with AIDS interviewed from 1998 to 2003 in LAC.
These data were collected as part of the Centers for Disease Control and Prevention (CDC)–funded Supplement to HIV/AIDS Surveillance Project (SHAS), a cross-sectional population-based survey of persons diagnosed with AIDS. 11 Patients are contacted through their medical providers within 2 years of an AIDS diagnosis and are administered a standardized questionnaire on risk behaviors by trained interviewers. For this analysis, MSM were defined as men who reported having sex with a man in the prior 12 months. From 1998 through August 2003, 568 MSM were asked how many male sexual partners they had had during the previous 12 months. From September 2000 through August 2003, 249 MSM were also asked about UAI during their most recent sexual intercourse with a male partner.
Although the percentage of MSM with AIDS who reported 10 or more partners during the previous 12 months remained fairly stable from 1998 through 2001 at 8% to 11%, the percentage increased to 20% in 2002 and to 25% in 2003 (χ2 test for trend = 6.4; P = 0.00005;Fig. 1). Although the proportion of MSM with AIDS who reported UAI during their last sexual intercourse increased each year, from 11% in 2000, to 16% in 2001, to 21% in 2002, to 26% in 2003, the trend was not statistically significant because of small numbers (χ2 test for trend = 2.3; P = 0.13; see Fig. 1).
A limitation to these data is the inclusion of only sexually active men who reported sex with a man in the previous 12 months, which is likely to lead to an overestimate of sexual risk behaviors for all MSM in LAC diagnosed with AIDS. When the analysis included men who self-identify as gay or bisexual, however, a similar increase in reported risk behaviors was observed. Also, there was insufficient power to conduct an analysis of trends in sexual risk behaviors for men whose male partners were HIV-negative or of unknown HIV status, which would have resulted in a better estimate of potential HIV transmission. Small numbers also prevented an analysis of these trends by race/ethnicity, age, and history of injection drug use.
Although the data are limited to sexually active MSM diagnosed with AIDS, these population-based findings are consistent with the recent increase in reported syphilis among MSM in the county and suggest that sexual risk behaviors are continuing to increase in HIV-infected MSM. Possible explanations for these increases include safe sex fatigue, 12,13 improved health because of highly active antiretroviral treatment resulting in increased sexual activity, 13,14 increased sexual activity between seropositive men without the possibility of new transmissions, 12,13,15 and shifts in attitudes regarding the severity of HIV infection. 12–14 Urgent efforts are needed to conduct more effective prevention, including community-level interventions to change cultural norms around sexual behavior in the MSM population and individual level prevention services for those already HIV infected to reduce the ongoing spread of HIV and other sexually transmitted diseases. 16
Amy Rock Wohl, MPH, PhD
Denise F. Johnson, MPH
Sharon Lu, MPH
Douglas Frye, MD, MPH
Gordon Bunch, MA
Paul A. Simon, MD, MPH
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2. US Centers for Disease Control and Prevention. Increases in unsafe sex and rectal gonorrhea among men who have sex with men—San Francisco, California, 1994–1997. MMWR Morb Mortal Wkly Rep. 1999; 48:45–48.
3. Stolte IG, Dukers NHTM, de Wit JBF, et al. A summary report for Amsterdam: increase in sexually transmitted diseases and risky sexual behavior among homosexual men in relation to the introduction of new anti-HIV drugs. Eurosurveillance. 2002; 7:19–22.
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5. Chen SY, Gibson S, Katz MH, et al. Continuing increases in sexual risk behavior and sexually transmitted diseases among men who have sex with men: San Francisco, California, 1999–2001. Am J Public Health. 2002; 92:1387.
6. Johansen JD, Smith E. Gonorrhoea in Denmark: high incidence among HIV-infected men who have sex with men. Acta Derm Venereol. 2002; 82:365–368.
7. US Centers for Disease Control and Prevention. Primary and secondary syphilis among men who have sex with men, New York City, 2001. MMWR Morb Mortal Wkly Rep. 2002; 51:853–856.
8. Chen JL, Kodagoda D, Lawrence AM, et al. Rapid public health interventions in response to an outbreak of syphilis in Los Angeles. Sex Trans Dis. 2002; 29:277–284.
9. US Centers for Disease Control and Prevention. Outbreak of syphilis among men who have sex with men—Southern California, 2000. MMWR Morb Mortal Wkly Rep. 2001; 50:117–120.
10. Sexually Transmitted Disease Program, Los Angeles County Department of Health Services, Los Angeles, CA. Early Syphilis Surveillance Summary.
11. Diaz T, Chu S, Conti L, et al. Risk behaviors of persons with heterosexually acquired HIV infection in the United States: results of a multistate surveillance project. J Acquir Immune Defic Syndr Hum Retrovirol. 1994; 7:958–963.
12. Wolitski RJ, Valdiserri RO, Denning PH, et al. Are we headed for a resurgence of the HIV epidemic among men who have sex with men. Am J Public Health. 2001; 91:883–888.
13. Stall RD, Hays RB, Waldo CR, et al. The gay `90s: a review of research in the 1990s on sexual behavior and HIV risk among men who have sex with men. AIDS. 2000; 14(Suppl):S1–S14.
14. Katz MH, Schwarcz SK, Kellogg TA, et al. Impact of highly active antiretroviral treatment on HIV seroincidence among men who have sex with men: San Francisco. Am J Public Health. 2002; 92:388–394.
15. Parsons JT, Halkitis PN, Wolitski RJ, et al. Correlates of sexual risk behaviors among HIV-positive men who have sex with men. AIDS Educ Prev. 2003; 15:383–400.
16. Janssen RS, Holtgrave DR, Valdiserri RO, et al. The serostatus approach to fighting the HIV epidemic: prevention strategies for infected individuals. Am J Public Health. 2001; 91:1019–1024.
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