Rate of Increase Slows Dramatically Among American MSM
To date in the U.S., HIV-related illness and death have had the greatest impact on MSM. And MSM continue to account for the largest number of AIDS cases reported annually. But the rate of increase in AIDS incidence among MSM has slowed overall. Between 1993 and 1994, AIDS incidence increased only 6% among MSM. But at the same time, heterosexual AIDS incidence increased 17%.
The overall stabilization among MSM reflects declines in some groups -- most notably older white MSM -- but increases in others. Data suggest that the highest rate of new infection is among minority MSM. These findings emphasize that prevention is not a "one-shot deal." Sustained, targeted prevention will be needed to reduce the stable -- but still high -- rate of AIDS cases among MSM.
Disturbing Sub-Trends Point To the Need for Ongoing, Targeted Prevention
Although the overall proportion of AIDS cases related to all MSM is declining, the proportion continues to increase among young MSM. Among male adolescents ages 13-19 with AIDS, the proportion related to MSM increased from 29% in 1994 to 34% in 1995. Recent studies -- to be presented in Vancouver -- show that both HIV prevalence and risk behaviors remain high among young MSM. In a sample of young MSM ages 15-22 in 6 urban counties, researchers found that between 5% and 9% were infected with HIV. A higher percentage of blacks (8-13%) and Hispanics (5-9%) were infected than were whites (4-6%).
From 1989 to 1994, across the U.S., 20 metropolitan statistical areas (MSAs) accounted for most of the young MSM with AIDS. During that time, AIDS incidence decreased in 16 of those MSAs, with decreases ranging from 5% to 49% and increased in only 4 MSAs (with increases ranging from 3% to 33%). Trends in incidence varied by MSA size. During that time, AIDS incidence fell 12% in larger MSAs (with populations of 1 million or more); it fell 4% in medium-sized MSAs with populations ranging from 250,000 to 999,999. But AIDS incidence rose 3% in MSAs with fewer than a quarter of a million people and rose 4% in rural areas.
A study of clients at 10 sexually transmitted disease (STD) clinics from 1988-1995 shows that 101 out of 96,692 seroconverted after an initial negative test. Of those 101, 47 were MSM, even though they represented a far smaller portion of the total number of clients than did heterosexuals. Among MSM, incidence ranged widely by clinic -- from 2.1 per 100 person-years to 9.8 per 100 person-years ("person-years" is the rate of new HIV infections divided by a given amount of time an individual is at risk, in this case, a year, times 100). MSM's seroincidence rate was significantly higher than was heterosexuals', which was less than 1 per 100 person-years in every clinic.
Sustained, Targeted Prevention Works
When AIDS emerged in the U.S. in the early 1980s, prevention programs were first targeted to those hardest hit -- MSM in New York City, Los Angeles, and San Francisco. Due in part to sustained prevention efforts, the rate of new AIDS diagnoses among white gay and bisexual men has decreased dramatically in those cities. From 1989 to 1994, rates declined by 20% in New York City, 16% in Los Angeles, and 3% in San Francisco.
But in these same cities, at the same time, the rates of new AIDS diagnoses among African-American MSM increased dramatically -- by 49% in New York, 48% in Los Angeles, and 53% in San Francisco.
Sustaining behavior change over time has proven to be a great challenge among all populations; making it vital that communities continue to target prevention to those populations where the epidemic is stabilizing in addition to the those populations where the epidemic appears to be growing.
CDC Support for Community Action
The challenge for the future is to ensure each community has the tools to address the evolving epidemic. AIDS has evolved from a period of explosive growth in a few geographic areas, primarily among gay and bisexual men and injection drug users, to the development of diverse local subepidemics, where the dynamics of AIDS vary by community and region. CDC's role is to provide data, research and support for effective community action. Because each community faces unique challenges, HIV prevention strategies must be locally determined and relevant.
CDC will continue to provide surveillance data, biomedical and behavioral prevention research, evaluation of prevention programs, technical assistance in communications and other aspects of prevention to communities so that their prevention efforts -- for all groups -- are infused with the best science possible. For more information on research specific to MSM, see the following Vancouver presentations.
The AIDS Community Demonstration Projects(ACDP): A Successful Multi-Site Community-Level Behavioral Intervention, Martin Fishbein.
Condom Carrying and its Relationship to Condom Use among High Risk Populations, Carolyn Guenther-Grey.
Incidence Trends in AIDS-related Opportunistic Illnesses in Men Who Have Sex with Men and Injecting Drug Users, Jeffrey L. Jones.
HIV Seroincidence Among Persons Attending Sexually Transmitted Disease Clinics In The United States, 1988-1995, Hillard Weinstock.
HIV/STD High Risk Behavior Surveys-Where Are the Gaps and What Needs to Be Done? Robert Brackbill.
Current Trends in AIDS Incidence among Young Men Who Have Sex with Men-- United States, Paul Denning.
Trends in AIDS Associated with Injecting Drug Use, United States, 1985-1995, Allyn K. Nakashima.
The Decision to Participate in HIV Vaccine Efficacy Trials: An Assessment of Changing
Willingness Among Homosexual Men, Bradford N. Bartholow.
The Relationship Between Perceived Exposure to HIV and Actual Risk in a Cohort of Gay and Bisexual Men, Kathleen M. MacQueen.
HIV Prevention Programs for Gay and Bisexual Men of Color: A National Initiative, Stephen E. Schindler.
Geographical Variation of AIDS Associated Kaposi's Sarcoma (KS) in Europe, Shahul H. Ebrahim.