Preliminary review of surveillance data suggests that there has been a significant increase in HIV and sexually transmitted infections (STIs) among men who have sex with men (MSM) in Ireland. Between 2014 and 2015, reported diagnoses of HIV among MSM increased by 21%, while diagnoses of early infectious syphilis (EIS) among MSM increased by 53%. While data validation is ongoing and more complete information is awaited, an increasing trend is already clear. While the increasing trend in syphilis amongst MSM is consistent with trends in other countries, a number of western European countries have seen decreases in HIV amongst MSM in recent years (1, 2). A multi-disciplinary multi-sectoral group has been established to respond to this increase in HIV and STIs among MSM in Ireland.
HIV
During 2015, 491 new HIV diagnoses were notified in Ireland, an increase of 30% from the previous year. This compares with an increase in new diagnoses of 11% between 2013 and 2014 (3). A previously reported outbreak of HIV amongst people who inject drugs (PWID) and a change in the laboratory notification criteria for one region account for some of this increase (4). However, there was also a significant increase in new diagnoses amongst MSM.
In 2015, 58% (223) of new diagnoses, where the probable mode of transmission was known, were in MSM. This compares to 49% (184) of diagnoses in 2014. This constitutes a 21% increase in the number of HIV diagnoses amongst MSM between 2014 and 2015. At the same time, diagnoses amongst heterosexuals decreased by 16% from 125 to 105 (figure 1). The route of transmission is not yet known for 23% (112) of diagnoses notified in 2015.
Figure 1: Number of HIV notifications in Ireland by reported probable route of transmission, 2012-2015
In 2015, the median age of cases amongst MSM was 32 years (range: 18 to 74 years). The highest proportion of new diagnoses (52%) was amongst 25 to 34 year olds. The highest proportion of cases (77%) resided in HSE East.
Where information on stage of infection was known, 75% (143) of diagnoses in MSM in 2015 were asymptomatic, 11% (21) were symptomatic (non-AIDS), 7% (13) had an AIDS defining illness, and 4% (7) had an acute seroconversion illness.
Amongst MSM, where region of origin was known, 36% (74) of diagnoses in 2015 were Irish-born and 64% (133) were born abroad. This represents a 52% increase in the number of diagnoses in MSM born abroad, and a 16% decrease in the number of diagnoses in Irish-born MSM when compared to 2014. There has been a particular increase in diagnoses amongst MSM from Latin America. The trend in number of notifications amongst MSM by region of origin between 2012 and 2015 is shown in figure 2.
Figure 2: Number of notifications of HIV among MSM in Ireland by region of origin, 2012-2015.
Notifications of HIV include all people who test HIV positive in Ireland and this includes people who previously tested positive abroad. In 2015, there was an increase in the number of MSM who had previously tested positive abroad, with 30% (66) of MSM reported to have previously tested positive abroad compared to 21% (39) in 2014.
Overall, the number of MSM who reported that they acquired infection in Ireland has remained stable between 2014 and 2015 (104 and 102). However, there is an increasing trend in reported acquisition of infection within Ireland amongst MSM from particular regions. The number of Latin American MSM who reported acquiring infection in Ireland doubled between 2014 and 2015. In 2015, 32% of the HIV diagnoses reported in Latin American MSM were reported to have been acquired in Ireland.
Early infectious syphilis
There has also been an increasing trend in diagnoses of early infectious syphilis (EIS) amongst MSM. Again, data validation is ongoing and numbers may change as further information becomes available. Reported diagnoses of EIS amongst MSM increased by 53% between 2014 and 2015, from 140 to 214. During the same period heterosexual transmission remained stable. In 2015, MSM accounted for 87% of diagnoses of EIS. Figure 3 shows the trend in the number of all diagnoses (male and female) of EIS in Ireland by the mode of transmission.
Figure 3: Number of notifications of EIS in Ireland by probable mode of transmission, 2012-2015
In 2015, the majority (73%) of cases of EIS among MSM resided in HSE East region, followed by HSE South (8%). EIS in MSM increased between 2014 and 2015 in all but one HSE region.
EIS increased amongst Irish, Latin American and European MSM living in Ireland (figure 4). While diagnoses amongst European and Latin American MSM doubled between 2014 and 2015, 44% of diagnoses of EIS in MSM in 2015 were amongst men born in Ireland. Where the probable country of acquisition is reported, 85% of diagnoses amongst MSM in 2015 reported being infected in Ireland. Thirty percent of MSM diagnosed with EIS in 2015 were HIV positive.
Figure 4: Trend in notifications in Ireland of EIS by region of origin among MSM, 2012-2015
Other sexually transmitted infections
For other STIs, mode of transmission is not available or is incomplete, limiting the accurate analysis of trends amongst MSM. The proportion of notifications of gonorrhoea, where mode of transmission is known, amongst MSM remained stable between 2014 (73%; n=357) and 2015 (68%; n=362). However, to date in 2016 the number of diagnoses of gonorrhoea has increased by 30% compared to the same period in 2015, with an increase in the male-to–female ratio from 4.9 to 7.9, suggesting that the increase is amongst MSM. In addition, there have been two reported lymphogranuloma venereum (LGV) outbreaks amongst MSM since 2015, and the first shigellosis outbreak in MSM in Ireland was reported in 2015 (5, 6).
Discussion
The increasing trends in HIV and EIS amongst MSM in Ireland is of concern and calls for a coherent, effective response. While recent increases in immigration to Ireland may partly explain the increasing representation of MSM born abroad in HIV and EIS data, the disproportionate increases in HIV and EIS acquired within Ireland amongst MSM born in certain regions is of particular concern. Also of concern is the transmission of other STIs amongst HIV positive MSM.
In response, a national multidisciplinary multisectoral group has been established with representation from the Sexual Health and Crisis Pregnancy Programme, STI and Infectious Disease services, Public Health Departments, the Health Protection Surveillance Centre, Laboratory services, the Gay Health Network, HSE Gay Men's Health Service (GMHS), and Positive Now. The response involves three main strands of work covering epidemiology, interventions, and communications.
Ongoing analysis is being undertaken by an epidemiological subgroup to inform the development of an appropriate response. Timely provision of accurate surveillance data by stakeholders is important to monitor the increase, and the effectiveness of implemented interventions.
Knowledge and understanding of the community and cultural backgrounds of groups affected by HIV and STIs is vital for provision of appropriate information and support. Since 2006, GMHS has produced reports on the ethnic and cultural identity of MSM attending the GMHS clinic; the “Men from Afar” reports and the annual GMHS reports (7, 8). In 2014 51% (of the 926 new attendees), were born abroad (from 57 countries), an increase of 23% over 2013. Currently, the HSE and the Gay Health Network provide sexual health information, including information on HIV and STIs, in multiple languages for MSM through the Man2Man website (9). The GMHS offers an interpreter service and also have onsite Latin American health workers. Further development of services to meet the needs of MSM living in Ireland, will be informed by the work of the response group. An intervention subgroup is reviewing current HIV and STI services for MSM and is preparing an evidence informed action plan to address the increasing trends. Interventions being reviewed include education, outreach and peer led initiatives, testing services, clinical assessment, and partner notification procedures.
A communications subgroup is coordinating the development and implementation of evidence informed health promotion and communications strategies.
Eve Robinson1, Kate O’Donnell1, Gillian Cullen1, Fiona Lyons2,3, Mick Quinlan4, Fionnuala Cooney5, Sarah Doyle6, Cillian De Gascun7, Paul Holder7, Sarah Hennessy1, Orla Ennis5, Philomena Downes5, Joanne Moran7, Aileen Kitching8, Margaret Morris Downes9, Dominic Rowley3, Linda Dalby3, Derval Igoe1 on behalf of the MSM HIV and STI Response Group
- Health Protection Surveillance Centre, HSE, Dublin
- Sexual Health and Crisis Pregnancy Programme, HSE, Dublin
- St James’s Hospital, Dublin
- Gay Health Network, Dublin
- Department of Public Health, HSE East, Dublin
- Department of Public Health, HSE Southeast, Kilkenny
- National Virus Reference Laboratory, University College Dublin, Dublin
- Department of Public Health, HSE South, Cork
- Department of Public Health, HSE Midwest, Limerick
MSM HIV and STI Response Group members:
Cork University Hospital: Dan Corcoran, Arthur Jackson, Mary Horgan, Elizabeth Murphy
Department of Public Health, HSE East: Niamh Byrne, Fiona Cianci, Fionnuala Cooney, Orla Ennis, Philomena Downes, Gabriel Fitzpatrick
Department of Public Health, HSE South: Aileen Kitching
Department of Public Health, HSE Midwest: Rose Fitzgerald, Margaret Morris Downes
Department of Public Health, HSE Southeast: Sarah Doyle
Gay Men’s Health Service: Siobhan O’Dea
Gay Health Network: Noel Sutton, Mick Quinlan
Health Protection Surveillance Centre: Gillian Cullen, Derval Igoe, Kate O’Donnell, Aoibheann O’Malley, Eve Robinson
Mater Misericordiae University Hospital: John Lambert
National Virus Reference Laboratory: Cillian De Gascun
Positive Now: Peter Kellegher, Lysander Preston
STI Clinic, Cork: Suzanne Cremin, Aileen Harte, Deirdre McCarthy, Daniel Quealey
Sexual Health and Crisis Pregnancy Programme, HSE: Helen Deely, Fiona Lyons
St James’s Hospital: Susan Clarke, Brendan Crowley, Linda Dalby, Dominic Rowley
Assistant National Director, Health and Wellbeing Directorate, HSE: Kevin Kelleher
Note:
Data are preliminary and data validation is ongoing. Data were correct at the time of publication and were extracted from CIDR on 21/04/2016.
References
1. European Centre for Disease Prevention and Control, WHO Regional Office for Europe. HIV/AIDS surveillance in Europe 2014. Stockholm: ECDC; 2015.
2. European Centre for Disease Prevention and Control. Sexually transmitted infections in Europe 2013. Stockholm: ECDC; 2015.
3. Health Service Executive. HIV in Ireland - 2014 Report. Dublin: Health Protection Surveillance Centre; 2015. Available here
4. Glynn R, Giese C, Ennis O, Gibbon Z, O’Donnell K, Hurley C, et al. Increase in diagnoses of recently acquired HIV in people who inject drugs. Epi-Insight; 2015; 16(7). Available here
5. Cullen G, Igoe D, Quinlan M, Cooney F, on behalf of the Shigella Outbreak Control Team. Shigellosis among men who have sex with men in Ireland. Epi-Insight; 2015; 16(11). Available here
6. Cooney F, ÓhAiseadha C, Downes P, on behalf of the LGV Outbreak Control Team. LGV outbreak in Ireland. Epi-Insight; 2015; 16(2). Available here
7. Gay Men's Health Service. GMHS 22; The annual report 2014. Dublin: Health Service Executive; 2015. Available here
8. Gay Men's Health Service. "Men from afar"; Report on the diversity of men attending the Gay Men’s Health Service (GMHS) HSE 2009 to 2012. Health Service Executive. Available here
9. Gay Health Network and Health Service Executive. Man2Man.ie; Sexual health information for men for who sex with men. Available here
