Measuring Population Transmission Risk for HIV: An Alternative Metric of Exposure Risk in Men Who Have Sex with Men (MSM) in the US

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Abstract

Background

Various metrics for HIV burden and treatment success [e.g. HIV prevalence, community viral load (CVL), population viral load (PVL), percent of HIV-positive persons with undetectable viral load] have important public health limitations for understanding disparities.

Methods and Findings

Using data from an ongoing HIV incidence cohort of black and white men who have sex with men (MSM), we propose a new metric to measure the prevalence of those at risk of transmitting HIV and illustrate its value. MSM with plasma VL>400 copies/mL were defined as having ‘transmission risk’. We calculated HIV prevalence, CVL, PVL, percent of HIV-positive with undetectable viral loads, and prevalence of plasma VL>400 copies/ml (%VL400) for black and white MSM. We used Monte Carlo simulation incorporating data on sexual mixing by race to estimate exposure of black and white HIV-negative MSM to a partner with transmission risk via unprotected anal intercourse (UAI). Of 709 MSM recruited, 42% (168/399) black and 14% (44/310) white MSM tested HIV-positive (p<.0001). No significant differences were seen in CVL, PVL, or percent of HIV positive with undetectable viral loads. The %VL400 was 25% (98/393) for black vs. 8% (25/310) for white MSM (p<.0001). Black MSM with 2 UAI partners were estimated to have 40% probability (95% CI: 35%, 45%) of having ≥1 UAI partner with transmission risk vs. 20% for white MSM (CI: 15%, 24%).

Discussion

Despite similarities in other metrics, black MSM in our cohort are three times as likely as white MSM to have HIV transmission risk. With comparable risk behaviors, HIV-negative black MSM have a substantially higher likelihood of encountering a UAI partner at risk of transmitting HIV. Our results support increasing HIV testing, linkage to care, and antiretroviral treatment of HIV-positive MSM to reduce prevalence of those with transmission risk, particularly for black MSM.

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Most cited references 14

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Estimated HIV Incidence in the United States, 2006–2009

Joseph Prejean, Ruiguang Song, Ángela Hernández … (2011)

Background The estimated number of new HIV infections in the United States reflects the leading edge of the epidemic. Previously, CDC estimated HIV incidence in the United States in 2006 as 56,300 (95% CI: 48,200–64,500). We updated the 2006 estimate and calculated incidence for 2007–2009 using improved methodology. Methodology We estimated incidence using incidence surveillance data from 16 states and 2 cities and a modification of our previously described stratified extrapolation method based on a sample survey approach with multiple imputation, stratification, and extrapolation to account for missing data and heterogeneity of HIV testing behavior among population groups. Principal Findings Estimated HIV incidence among persons aged 13 years and older was 48,600 (95% CI: 42,400–54,700) in 2006, 56,000 (95% CI: 49,100–62,900) in 2007, 47,800 (95% CI: 41,800–53,800) in 2008 and 48,100 (95% CI: 42,200–54,000) in 2009. From 2006 to 2009 incidence did not change significantly overall or among specific race/ethnicity or risk groups. However, there was a 21% (95% CI:1.9%–39.8%; p = 0.017) increase in incidence for people aged 13–29 years, driven by a 34% (95% CI: 8.4%–60.4%) increase in young men who have sex with men (MSM). There was a 48% increase among young black/African American MSM (12.3%–83.0%; p<0.001). Among people aged 13–29, only MSM experienced significant increases in incidence, and among 13–29 year-old MSM, incidence increased significantly among young, black/African American MSM. In 2009, MSM accounted for 61% of new infections, heterosexual contact 27%, injection drug use (IDU) 9%, and MSM/IDU 3%. Conclusions/Significance Overall, HIV incidence in the United States was relatively stable 2006–2009; however, among young MSM, particularly black/African American MSM, incidence increased. HIV continues to be a major public health burden, disproportionately affecting several populations in the United States, especially MSM and racial and ethnic minorities. Expanded, improved, and targeted prevention is necessary to reduce HIV incidence.

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Setting the stage: host invasion by HIV.

M McElrath, Florian Hladik (2008)

For more than two decades, HIV has infected millions of people worldwide each year through mucosal transmission. Our knowledge of how HIV secures a foothold at both the molecular and cellular levels has been expanded by recent investigations that have applied new technologies and used improved techniques to isolate ex vivo human tissue and generate in vitro cellular models, as well as more relevant in vivo animal challenge systems. Here, we review the current concepts of the immediate events that follow viral exposure at genital mucosal sites where most documented transmissions occur. Furthermore, we discuss the gaps in our knowledge that are relevant to future studies, which will shape strategies for effective HIV prevention.

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Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities.

Patrick Sullivan, Laura Salazar, Susan Buchbinder … (2009)

HIV incidence in the United States among men who have sex with men (MSM) has been increasing since 2000, and MSM remain the most heavily impacted risk group in the US HIV epidemic. We modeled HIV transmissions, using data from MSM in five US cities from the National HIV Behavioral Surveillance System, the HIVNET Vaccine Preparedness Study, and other published data. Annual HIV transmissions were estimated by partner type (main or casual) and by sex type (receptive anal intercourse, insertive anal intercourse, or oral sex). Sixty-eight percent [95% confidence interval (CI) 58-78) of HIV transmissions were from main sex partners because of a higher number of sex acts with main partners, more frequent receptive roles in anal sex with main partners, and lower condom use during anal sex with main partners. By sex type, 69% (95% CI 59-79) of infections were from receptive anal intercourse, 28% (95% CI 19-38) were from insertive anal intercourse, and 2% (95% CI 0-5) were from oral sex. The model-based estimated HIV incidence rate was 2.2% (95% CI 1.7-2.7) per year. Sensitivity analyses demonstrated estimates of transmission from main sex partners as low as 52% (95% CI 41-62) and as high as 74% (95% CI 68-80). According to our model, most HIV transmissions among MSM in five US cities are from main sex partners. HIV prevention efforts should take into account the risks of HIV transmissions in male partnerships, and couples-based HIV prevention interventions for MSM should be given high priority in the US HIV prevention research portfolio.

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Author and article information

Contributors

Rupert Kaul: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2012

Publication date (Electronic): 28 December 2012

Volume: 7

Issue: 12

Electronic Location Identifier: e53284

Affiliations

[1 ]Department of Medicine, Emory University, Atlanta, Georgia, United States of America

[2 ]Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America

[3 ]Department of Behavioral Science and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America

[4 ]Department of Psychology, Georgia State University, Atlanta, Georgia, United States of America

[5 ]Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America

University of Toronto, Canada

Author notes

* E-mail: colleen.kelley@ 123456emory.edu

Competing Interests: Patrick S. Sullivan is an Editorial Board member for PLOS ONE. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Conceived and designed the experiments: CFK ESR PSS. Performed the experiments: CFK ESR BMO. Analyzed the data: CFK ESR BMO. Wrote the paper: CFK ESR BMO PMF JLP THS CDR PSS.

Article

Publisher ID: PONE-D-12-21673

DOI: 10.1371/journal.pone.0053284

PMC ID: 3532405

PubMed ID: 23285274

SO-VID: 1fd8baed-4a2b-4791-b441-8f66f08b1cca

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 17 July 2012

Date accepted : 28 November 2012

Page count

Pages: 8

Funding

The study was supported by the National Institutes of Health R01-MH085600 and R01-HD067111 to PSS, KL2 RR025009 to CFK, and the Emory Center for AIDS Research P30 AI050409. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Measuring Population Transmission Risk for HIV: An Alternative Metric of Exposure Risk in Men Who Have Sex with Men (MSM) in the US

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Abstract

Background

Methods and Findings

Discussion

Related collections

PLOS Climate

Most cited references 14

Estimated HIV Incidence in the United States, 2006–2009

Setting the stage: host invasion by HIV.

Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities.

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