Articles

Sexual behaviours, HIV testing, and the proportion of men

at risk of transmitting and acquiring HIV in London, UK,
2000–13: a serial cross-sectional study
Adamma Aghaizu*, Sonali Wayal*, Anthony Nardone, Victoria Parsons, Andrew Copas, Danielle Mercey, Graham Hart, Richard Gilson,
Anne M Johnson

Summary
Background HIV incidence in men who have sex with men (MSM) in the UK has remained unchanged over the past Lancet HIV 2016; 3: e431–40
decade despite increases in HIV testing and antiretroviral therapy (ART) coverage. In this study, we examine trends Published Online
in sexual behaviours and HIV testing in MSM and explore the risk of transmitting and acquiring HIV. July 14, 2016
http://dx.doi.org/10.1016/
S2352-3018(16)30037-6
Methods In this serial cross-sectional study, we obtained data from ten cross-sectional surveys done between
See Comment page e400
2000 and 2013, consisting of anonymous self-administered questionnaires and oral HIV antibody testing in MSM
*Contributed equally
recruited in gay social venues in London, UK. Data were collected between October and January for all survey years up to
HIV and STI Department,
2008 and between February and August thereafter. All men older than 16 years were eligible to take part and fieldworkers National Infection Service,
attempted to approach all MSM in each venue and recorded refusal rates. Data were collected on demographic and sexual Public Health England, London,
behavioural characteristics. We analysed trends over time using linear, logistic, and quantile regression. UK (A Aghaizu MSc,
A Nardone PhD); and Centre for
Sexual Health and HIV
Findings Of 13 861 questionnaires collected between 2000 and 2013, we excluded 1985 (124 had completed the survey Research, University College
previously or were heterosexual reporting no anal intercourse in the past year, and 1861 did not provide samples for London, London, UK
antibody testing). Of the 11 876 eligible MSM recruited, 1512 (13%) were HIV positive, with no significant trend in HIV (S Wayal PhD, V Parsons MSc,
positivity over time. 35% (531 of 1505) of HIV-positive MSM had undiagnosed infection, which decreased non-linearly A Copas PhD, D Mercey FRCP,
Prof G Hart PhD, R Gilson FRCP,
over time from 34% (45 of 131) to 24% (25 of 106; p=0·01), while recent HIV testing (ie, in the past year) increased from Prof A M Johnson MD)
26% (263 of 997) to 60% (467 of 777; p<0·0001). The increase in recent testing in undiagnosed men (from 29% to 67%, Correspondence to:
p<0·0001) and HIV-negative men (from 26% to 62%, p<0·0001) suggests that undiagnosed infection might increasingly Prof Anne M Johnson, Centre for
be recently acquired infection. The proportion of MSM reporting unprotected anal intercourse (UAI) in the past year Sexual Health and HIV Research,
increased from 43% (513 of 1187) to 53% (394 of 749; p<0·0001) and serosorting (exclusively) increased from 18% University College London,
London WC1E 6JB, UK
(207 of 1132) to 28% (177 of 6369; p<0·0001). 268 (2%) of 11 570 participants had undiagnosed HIV and reported UAI in Anne.Johnson@ucl.ac.uk
the past year were at risk of transmitting HIV. Additionally 259 (2%) had diagnosed infection and reported UAI and
non-exclusive serosorting in the past year. Although we did not collect data on antiretroviral therapy or viral load,
surveillance data suggests that a small proportion of men with diagnosed infection will have detectable viral load and
hence might also be at risk of transmitting HIV. 2633 (25%) of 10 364 participants were at high risk of acquiring HIV
(defined as HIV-negative MSM either reporting one or more casual UAI partners in the past year or not exclusively
serosorting). The proportions of MSM at risk of transmission or acquisition changed little over time (p=0·96 for MSM
potentially at risk of transmission and p=0·275 for MSM at high risk of acquiring HIV). Undiagnosed men reporting
UAI and diagnosed men not exclusively serosorting had consistently higher partner numbers than did other MSM over
the period (median ranged from one to three across surveys in undiagnosed men reporting UAI, two to ten in diagnosed
men not exclusively serosorting, and none to two in other men).

Interpretation An increasing proportion of undiagnosed HIV infections in MSM in London might have been recently
acquired, which is when people are likely to be most infectious. High UAI partner numbers of MSM at risk of transmitting
HIV and the absence of a significant decrease in the proportion of men at high risk of acquiring the infection might
explain the sustained HIV incidence. Implementation of combination prevention interventions comprising both
behavioural and biological interventions to reduce community-wide risk is crucial to move towards eradication of HIV.

Funding Public Health England.

Introduction annual number of new HIV diagnoses (2800 new

In the UK, men who have sex with men (MSM) are at the
highest risk of acquiring HIV. The annual number of
new HIV diagnoses in MSM has increased from 1830 in
2000 to 3270 in 2013.1,2 Two studies have shown that
estimated HIV incidence over this period remained
stable (increasing slightly), and is now similar to the
infections estimated in 2013).3,4 One study3 used a back-
calculation approach based on CD4 cell count at
diagnosis; the other study is a dynamic model of sexual
behaviours.4 Given the greatly increased uptake of HIV
testing and antiretroviral therapy (ART) in the past
decade, which should reduce transmission by reducing

www.thelancet.com/hiv Vol 3 September 2016 e431

 Articles
Research in context
Evidence before this study
We searched PubMed for articles published in English up to
May 3, 2016, with the terms “sexual behaviour”, “MSM”,
“homosexuality or male”, “trends”, “HIV”, “HIV infections” or
“HIV antibodies” or “HIV seropositivity” or “saliva” or “incidence”
or “prevalence”, “UK”, and “Great Britain”. Only one other study
has examined trends in sexual behaviours in UK men who have
sex with men (MSM; recruited from gyms across London)
between 1998 and 2008, which found lower rates of MSM
reporting unprotected anal intercourse (UAI) overall than in this
study, but also an increase in the proportion of men reporting UAI
and to serosort. No studies reported trends in sexual behaviours
in the UK in more recent years and none showed trends in
numbers of sexual partners in this population. One cross-
sectional study in HIV-positive MSM recruited from HIV clinics
between 2011 and 2012 showed a lower prevalence of UAI (38%)
and serosorting (28%). Another cross-sectional study in 2008
also found a lower prevalence of serosorting and strategic
positioning during UAI in MSM in Scotland with 11% in
HIV-positive and 13% in HIV-negative MSM. Three modelling
studies that used multiple national surveillance databases show
no reduction in undiagnosed HIV infection and an increase in
HIV testing. Additionally, similar patterns were found in
community-based surveys done in England and Scotland.
viral load, sustained HIV incidence supports the notion
that risk behaviours have increased over this period.5
Since the introduction of ART in the mid-1990s, studies
suggest the prevalence of high-risk sexual behaviours in
MSM is increasing (at least partly) because of treatment
optimism, relating both to the greatly reduced morbidity
and mortality associated with the infection, and the
reduced risk of transmission from a positive partner
(which was discovered after 2011).6,7 Few behavioural
studies are able to explore trends in sexual behaviours in
detail, in particular examining seroadaptive behaviours
relating to confirmed versus perceived HIV status.
Guidelines suggest that MSM should test for HIV once a
year and at least every 3 months if having unprotected
anal intercourse (UAI) with new or casual partners.1,8 In
this Article, we examine trends in both sexual risk and
HIV testing behaviours against a background of targeted
prevention and testing initiatives in MSM recruited from
community venues in London over the past 14 years.
With half of all new HIV diagnoses in the UK occurring
in London, these trends can be used to understand the
role of behavioural change and testing in driving
continued HIV transmission.
Methods
Study population and data collection
In this serial cross-sectional study, we obtained data from
the Gay Men’s Sexual Health Survey—a regular com-
munity-based survey done since 1996. The survey methods
e432
Added value of this study
Our data indicate changes in sexual risk behaviours with
increasing rates of UAI and serosorting, with serosorting
considered to be a risk reduction strategy. Our findings
emphasise the importance of core groups in the epidemiology
and control of HIV infection in MSM in the UK, with one in
20 MSM identified as being potentially at risk of transmitting
HIV and one in four at risk of acquiring HIV. An increasing
proportion of MSM with undiagnosed HIV infection might
have a recently acquired infection (ie, acquired within the past
12 months) during which the individual is most infectious.
This finding, coupled with the high partner numbers of a core
group of MSM potentially at risk of transmitting HIV, and the
sustained proportion at men at risk of acquiring the infection,
could explain the persistent HIV incidence in the UK, despite
increases in HIV testing and antiretroviral therapy coverage.
Implications of all the available evidence
Growing evidence shows that test-and-treat interventions
alone are not sufficient to reduce HIV incidence at the
population level. Combination prevention interventions will be
crucial for countries with similar epidemics in MSM.
have been described in detail elsewhere.9,10 Briefly, from
2000 to 2013, ten surveys were done. For each survey,
fieldworkers visited 38–58 bars, clubs, and saunas across
London, UK, over 3 months inviting MSM to self-complete
short, anonymous questionnaires on demographic and
sexual behaviour characteristics and to provide oral fluid
specimens for HIV antibody testing (OraSure Technologies,
Bethlehem, PA, USA). Participants were recruited between
October and January for all survey years up to 2008 and
between February and August in 2011 and 2013. A barcode
linked specimens to the corresponding questionnaire.
Participants were informed that the specimens would be
tested for research purposes only and results would not be
returned to them. All participants were advised to attend a
health-care setting for a named HIV test if they wanted to
know their status. All men aged 16 years and older in the
study venues were eligible to take part and fieldworkers
attempted to approach as many people as possible and
recorded refusal rates. Ethical approval was granted each
year by the UCL research ethics committee (00/0158).
Verbal consent for anonymous saliva samples and self-
completion of questionnaires was obtained to ensure
anonymity of all participants.
Procedures
Oral fluid samples, collected with the OraSure kit, were
tested for HIV-1 antibody at Public Health England
(London) with GACELISA (Abbott Laboratories,
Maidenhead, UK). All samples were tested for total
www.thelancet.com/hiv Vol 3 September 2016
 Articles

immunoglobulin (IgG) to assess the specimen quality,
apart from samples collected in 2011, when a two-stage
approach was used: first screening with a modified
enzyme immunoassay then by rescreening positive
specimens with an enzyme immunoassay and a
western blot (HIV blot 2.2; Genelabs, Redwood City,
CA, USA).
We defined undiagnosed infection as a participant who
had a positive OraSure specimen and reported that they
had never had an HIV test, or they perceived themselves
to be negative or didn’t know, or the result of their last
test was negative. We defined a casual partner as a
partner with whom UAI (condomless) was reported once
only and defined a regular partner as a partner with
whom the participant had had UAI more than once in
the past year. Exclusively serosorting was defined as
having UAI only with partners of presumed same HIV
status in the past year. Status is referred to as presumed
because the HIV status of partners was self-reported by
respondents, as established with the question, “In the
past year, how many men that you had active/passive
anal intercourse without a condom did you know had the
same HIV status as you?”
MSM potentially at risk of transmitting HIV were
defined as men with undiagnosed HIV reporting UAI in
the past year or with diagnosed HIV reporting UAI and
not exclusively serosorting in the past year. In the latter
group, most men might have had undetectable viral load
as a result of ART and might therefore not have been at
risk of transmitting, but information on ART and viral
load were not collected in this study. We discuss the
implications of the absence of these data for the
interpretation of our findings later. We defined MSM at
high risk of acquiring HIV as men who were HIV
negative and reported one or more casual UAI partners or
were not exclusively serosorting in the past year. All other
HIV-negative men were regarded as being at lower risk of
acquiring HIV than men at high risk.
Statistical analysis
We analysed data using Stata (version 13.0). Analyses were
stratified by HIV status. We examined the significance of
trends over time using linear, logistic, and quantile
regression, adjusted for age, with survey year modelled as
a linear term. For trends in HIV testing, overall HIV
positivity, and undiagnosed HIV, we also adjusted for
education, employment, and ethnicity, and assessed
linearity with a likelihood ratio test relative to a model with
survey year as a categorical variable. Characteristics of
MSM at potential risk of transmitting and at high risk of
acquiring HIV were explored with a multivariable model
controlling for the year of survey as a linear term (odds
ratios [OR] for year not shown). Factors significant to
p<0·05 in univariable analyses were included in the
multivariable model.
Role of the funding source
The funder contributed to the study design, data
collection, data analysis, data interpretation, and writing
of the report. The corresponding author had full access
to all the data in the study and had final responsibility for
the decision to submit for publication.

Total Year p value*

2000 2001 2002 2003 2004 2005 2006 2008 2011 2013
HIV positive
All MSM 13% 11% 11% 12% 12% 13% 13% 17% 15% 8% 14% p<0·001†
(1512/11 876) (132/1206) (150/1309) (126/1043) (177/1432) (177/1377) (195/1503) (200/1153) (167/1106) (82/965) (106/782)
HIV positive, 35% 34% 49% 33% 44% 41% 29% 35% 28% 29% 24% p=0·01†
undiagnosed (531/1505) (45/131) (74/150) (42/126) (78/177) (73/177) (56/193) (68/197) (46/166) (24/82) (25/106)
Tested for HIV (ever)
All MSM 79% 63% 69% 76% 78% 78% 80% 83% 89% 90% 91% p<0·004
(9184/11 568) (629/997) (900/1297) (788/1035) (1112/1420) (1065/1363) (1195/1487) (952/1142) (972/1092) (862/958) (709/777)
HIV negative 78% 62% 67% 75% 77% 76% 79% 81% 87% 89% 90% p<0·0001
(7886/10 161) (567/920) (770/1150) (683/912) (955/1248) (904/1189) (1024/1303) (770/950) (818/935) (787/880) (608/674)
HIV positive, 79% 57% 77% 57% 80% 82% 77% 85% 93% 88% 92% p<0·0001
undiagnosed (408/517) (20/35) (57/74) (24/42) (61/76) (60/73) (43/56) (58/68) (42/45) (21/24) (22/24)
% tested for HIV (in the past year)
All MSM 42% 26% 32% 36% 39% 42% 43% 44% 51% 56% 60% p<0·0001
(4891/11 568) (263/997) (421/1297) (375/1035) (550/1420) (576/1363) (634/1487) (504/1142) (560/1092) (532/958) (467/777)
HIV negative 42% 26% 32% 37% 39% 42% 43% 44% 52% 57% 62% p<0·0001
(4312/10 161) (241/920) (370/1150) (334/912) (482/1248) (498/1198) (563/1303) (422/950) (485/935) (501/880) (416/674)
HIV positive, 43% 29% 30% 21% 46% 49% 39% 56% 53% 50% 67% p<0·0001
undiagnosed (224/517) (10/35) (22/74) (9/42) (35/76) (36/73) (22/56) (38/68) (24/45) (12/24) (16/24)

Data are % (n/N), unless otherwise specified. Denominators vary because of incomplete data on all variables. Percentages might not add up to totals because of rounding. MSM=men who have sex with men.
*Adjusted for age, education, ethnicity, and employment. †p value for association between outcome and survey year (categorical) because data showed evidence of departure from linearity.

Table 1: HIV status and HIV testing in MSM in London, 2001–13

www.thelancet.com/hiv Vol 3 September 2016 e433

e434
Articles

Total Year p value*

2000 2001 2002 2003 2004 2005 2006 2008 2011 2013
UAI in the past year
HIV negative 46% 42% 45% 42% 46% 43% 49% 46% 47% 50% 51% p<0·0001
(4651/10 139) (448/1058) (510/1138) (378/907) (567/1235) (502/1173) (633/1291) (431/927) (430/920) (423/843) (329/647)
HIV positive, diagnosed 60% 49% 47% 58% 62% 66% 54% 66% 64% 62% 64% p=0·002
(556/934) (41/84) (35/74) (46/79) (58/94) (65/98) (70/129) (82/125) (74/116) (34/55) (51/80)
HIV positive, undiagnosed 54% 53% 59% 54% 44% 57% 62% 56% 43% 52% 64% p=0·93
(268/497) (24/45) (42/71) (21/39) (33/75) (38/67) (32/52) (35/63) (18/42) (11/21) (14/22)
All 47% 43% 46% 43% 47% 45% 50% 49% 48% 51% 53% p<0·0001
(5475/11 570) (513/1187) (587/1283) (445/1025) (658/1404) (605/1338) (735/1472) (548/1115) (522/1078) (468/919) (394/749)
Exclusively serosorted in the past year
HIV negative 21% 18% 18% 17% 21% 19% 23% 23% 24% 27% 27% p<0·0001
(1942/9166) (181/1007) (178/1015) (143/844) (242/1144) (198/1067) (271/1155) (186/817) (200/838) (193/725) (150/554)
HIV positive, diagnosed 26% 22% 19% 21% 30% 30% 24% 27% 30% 23% 30% p=0·06
(225/862) (18/83) (13/68) (15/72) (26/88) (28/92) (30/124) (31/114) (32/105) (11/47) (21/69)
HIV positive, undiagnosed 15% 19% 9% 9% 12% 10% 20% 13% 21% 18% 38% p=0·033
(64/438) (8/42) (6/64) (3/34) (8/67) (6/60) (9/46) (7/53) (8/39) (3/17) (6/16)
All 21% 18% 17% 17% 21% 19% 23% 23% 24% 26% 28% p<0·0001
(2231/10 466) (207/1132) (197/1147) (161/950) (267/1299) (232/1219) (310/1325) (224/984) (240/982) (207/789) (177/639)
Reported UAI with partners of unknown or discordant HIV status in the past year
HIV negative 19% 22% 21% 21% 21% 19% 20% 17% 18% 16% 16% p<0·0001
(1748/9166) (218/1007) (211/1015) (173/844) (235/1114) (200/1067) (229/1155) (136/817) (148/838) (112/725) (86/554)
HIV positive, diagnosed 30% 27% 24% 33% 30% 34% 28% 35% 30% 32% 28% p=0·433
(259/862) (22/83) (16/68) (24/72) (26/88) (31/92) (35/124) (40/114) (31/105) (15/47) (19/69)
HIV positive, undiagnosed 33% 31% 45% 38% 25% 43% 37% 34% 18% 24% 13% p=0·012
(146/438) (13/42) (29/64) (13/34) (17/67) (26/60) (17/46) (18/53) (7/39) (4/17) (2/16)
All 21% 22% 22% 22% 21% 21% 21% 20% 19% 17% 17% p<0·0001
(2153/10 466) (253/1132) (256/1147) (210/950) (278/1299) (257/1219) (281/1325) (194/984) (186/982) (131/789) (107/639)
Number of UAI partners in the past year
HIV negative 1·4 (6·8) 0·9 (3·2) 1·6 (5·9) 1·2 (5·0) 1·4 (4·9) 1·3 (7·1) 1·7 (11) 1·3 (4·3) 1·3 (4·6) 1·4 (3·6) 1·9 (12·5) p=0·073
0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1)
HIV positive, diagnosed 9·2 (30·7) 4·7 (12·8) 4·6 (14·7) 8·3 (24·9) 7·9 (22·5) 7·1 (15·6) 9·3 (45·0) 13·5 (36·8) 11·8 (42·1) 12·6 (31·8) 9·7 (22·5) p=0·008
1 (0–5) 0 (0–2) 0 (0–2) 1 (0–7) 1 (0–4) 2 (0–5) 1 (0–5) 1 (0–5) 1 (0–5) 1 (0–11) 1 (0–10)
HIV positive, undiagnosed 4·1 (17·5) 1·6 (3·5) 3·8 (6·5) 2·9 (8·4) 5·3 (34·6) 6·5 (22·4) 4·5 (7·8) 4·0 (13·9) 1·5 (3·3) 1·2 (2·2) 7·4 (13·9) p=0·77
1 (0–2) 1 (0–1) 1 (0–3) 1 (0–1) 0 (0–2) 1 (0–2) 1 (0–4·5) 1 (0–2) 0 (0–2) 1 (0–1) 1 (0–5)
All 2·1 (11·6) 1·2 (4·7) 1·9 (6·9) 1·8 (8·7) 2·0 (11·0) 2·0 (9·5) 2·5 (17·0) 2·8 (13·8) 2·4 (14·8) 2·0 (8·9) 2·9 (14·2) p=0·0001
0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 0 (0–1) 1 (0–1) 1 (0–1)

Data are % (n/N), mean (SD), or median (IQR), unless otherwise reported. Denominators vary because of incomplete data on all variables. Percentages might not add up to totals because of rounding. MSM=men who have sex with men.
UAI=unprotected anal intercourse. *Adjusted for age.

Table 2: Sexual behaviour in MSM by HIV status, 2000–13

www.thelancet.com/hiv Vol 3 September 2016


Results
13 861 questionnaires were collected between 2000 and
2013. The proportion of MSM who responded ranged
between 50% and 70% each year. Venue data were
missing for 930 participants (two participants in 2002,
three participants in 2008, and all 925 participants
in 2013). In the 12 931 participants for whom data were
available, 10 578 (82%) were recruited from bars, 1636 (13%)
from clubs, and 717 (6%) from saunas. We excluded
124 questionnaires from men who completed the survey
previously or were heterosexual reporting no anal
intercourse in the past year, leaving 13 737 questionnaires.
Additionally, questionnaires from 1861 men (13%) were
excluded because they did not provide samples for
antibody testing, resulting in 11 876 questionnaires. Men
who did and did not give samples were similar in age,
education, and employment status (data not shown), but
differed slightly by ethnic origin: 105 (6%) of 1856 men
who did not provide a sample were black compared with
374 (3%) of 11 841 men who did. The demographic
characteristics of 11 876 men included were similar in
each of the ten surveys (data not shown). Overall, the
median age was 33 years (range 16–82 years) and
10 201 (86%) of 11 841 men were white.
Across all study years, 1512 (13%) of 11 876 of
participants were HIV positive, the proportion ranged
from 8% in 2011 to 17% in 2006 (table 1). 35% of
HIV-positive MSM (4% of the entire sample) were
undiagnosed, which decreased (non-linearly) over the
period from 34% in 2000 to 24% in 2013. During this
period, recent HIV testing (in the past year) in all men
increased from 26% to 60%. Recent testing increased in
undiagnosed MSM at a similar rate, from 29% to 67%.
The proportion of MSM ever having had an HIV test
increased from 63% in 2000 to 91% in 2013. HIV
positivity varied by recruitment venue type with a similar
prevalence in MSM in bars (8% [740 of 9100] diagnosed,
4% [387 of 9100] undiagnosed) and clubs (6% [89 of 1375]
diagnosed, 5% [62 of 1375] undiagnosed), and the highest
prevalence in saunas (12% [71 of 617] diagnosed, 9%
[57 of 617] undiagnosed).
The proportion of MSM reporting UAI in the past year
increased from 43% in 2000 to 53% in 2013 (table 2,
figure). This increase was significant in HIV-negative
MSM, increasing from 42% to 51% and in HIV-positive,
diagnosed MSM, increasing from 49% to 64%. Numbers
in undiagnosed MSM were small and no clear change
was recorded (table 2); prevalence of UAI in undiagnosed
MSM varied between 43% and 64%.
The proportion of MSM who exclusively serosorted
increased overall from 18% in 2000 to 28% in 2013; in
HIV-negative men (with other presumed HIV-negative
men) this increased from 18% to 27%. In HIV-positive,
diagnosed men and in HIV-positive undiagnosed men
(who reported UAI with presumed HIV-negative men)
the numbers were small and changes in the proportion
serosorting were not significant (table 2). Notably, 3%
www.thelancet.com/hiv Vol 3 September 2016
Articles
(18 of 653) of men who perceived themselves to be HIV
negative had undiagnosed HIV in 2013, with no
significant trend over time (data not shown).
The proportion of men reporting UAI with partners of
unknown or discordant status decreased from 22% in
2000 to 17% in 2013 overall, from 22% to 16% in HIV-
negative men, and from 31% to 13% in HIV-positive,
undiagnosed men. In HIV-positive, diagnosed men the
changes were not significant.
Over the 14 years of study, the mean number of sexual
partners in the past year was consistently highest in
diagnosed HIV-positive MSM and increased significantly
from 4·7 (SD 12·8) partners in 2000 to 9·7 (22·5) in 2013,
having peaked at 13·5 (36·8) in 2006.
Between 2000 and 2013, 259 diagnosed MSM reported
UAI (table 3) and were not exclusively serosorting, some
of whom might have been at risk of transmitting HIV.
A further 268 undiagnosed HIV-positive MSM reported
UAI (table 3). Together, they represented 5% of MSM
overall (table 3). The overall proportion of MSM
potentially at risk of transmitting HIV remained stable
over the 14 year period, as did the proportion of men in
this group who were diagnosed and undiagnosed. Both
diagnosed and undiagnosed MSM potentially at risk of
transmitting HIV had consistently higher numbers of
UAI partners than did all other MSM, but the mean
number of partners increased over time for all groups.
In 2013, undiagnosed men at risk of transmitting
reported a mean of 11·6 UAI partners (SD 16·1) and
median of 2·5 (IQR 1–20) UAI partners in the past year;
diagnosed MSM, of whom some might be at risk of
transmitting, reported a mean of 22·4 UAI partners
(SD 30·0) and median of ten UAI partners (IQR 2–28)
compared with other MSM with 2·2 UAI partners
(SD 13·1) and one UAI partner (IQR 0–1). This shows
2000 2013
0·7% 1·9% 0·8% 4·0%
1·3% 1·1%
1·5% 2·8%
22·5%
23·9%
47·4%
56·8%
15·2%
20·0%
No unprotected anal intercourse
Diagnosed (exclusively serosorting)
Undiagnosed (exclusively serosorting with presumed negative partners)
Diagnosed (not exclusively serosorting)
Undiagnosed (not exclusively serosorting with presumed negative partners)
HIV–negative MSM (exclusively serosorting)
HIV–negative MSM (not exclusively serosorting)
Figure: Population prevalence of unprotected anal intercourse and
serosorting by HIV status in MSM in London, 2000 and 2013
MSM=men who have sex with men.
e435
 Articles

Total Year p value*

2000 2001 2002 2003 2004 2005 2006 2008 2011 2013

Potentially at risk of transmitting HIV†

Undiagnosed HIV-positive MSM reporting UAI in the past year
All MSM 2% 2% 3% 2% 2% 3% 2% 3% 2% 1% 2% 0·09
(268/11 570) (24/1187) (42/1283) (21/1025) (33/1404) (38/1338) (32/1472) (35/1115) (18/1078) (11/919) (14/749)
MSM reporting UAI 5% 5% 7% 5% 5% 6% 4% 6% 3% 2% 4% 0·005
(268/5475) (24/513) (42/587) (21/445) (33/658) (38/605) (32/735) (35/548) (18/522) (11/468) (14/394)
Mean (SD) number 7·6 3 6·5 5·5 12 11·4 7·4 7·1 3·5 2·4 11·6 0·62
of UAI partners‡ (23·2) (4·4) (10·2) (11·0) (51·8) (28·9) (8·9) (18·2) (4·4) (2·7) (16·1)
Median (IQR) of UAI 2 1 3 1 2 2 3 2 2 1 3 1·0
partners‡ (1–5) (1–2) (1–10) (1–5) (1–4) (1–3) (1–10) (1–4) (1–4) (1–3) (1–20)
Diagnosed MSM reporting UAI and not exclusively serosorting in the past year§
All MSM 2% 2% 1% 2% 2% 2% 2% 4% 3% 2% 3% 0·07
(259/11 570) (22/1187) (16/1283) (24/1025) (26/1404) (31/1338) (35/1472) (40/1115) (31/1078) (15/919) (19/749)
MSM reporting UAI 5% 4% 3% 5% 4% 5% 5% 7% 6% 3% 5% 0·47
(259/5475) (22/513) (16/587) (24/445) (26/658) (31/605) (35/735) (40/548) (31/522) (15/468) (19/394)
Mean (SD) number 17·8 13·4 16·1 13·8 13·9 12 9·5 28·8 24·0 22·7 22·4 0·05
of UAI partners‡ (39·5) (21·3) (27·6) (17·4) (23·4) (23·0) (11·5) (56·0) (71·5) (51·6) (30·0)
Median (IQR) of UAI 5 7 4 7 4 4 5 5 5 2 10 0·45
partners‡ (2–15) (2–15) (1–14) (3–16) (2–8) (2–15) (2–10) (2–16) (2–15) (1–20) (2–28)
Total
All MSM 5% 4% 5% 4% 4% 5% 5% 7% 5% 3% 4% 0·96
(527/11 570) (46/1187) (58/1283) (45/1025) (59/1404) (69/1338) (67/1472) (75/1115) (49/1078) (26/919) (33/749)
No reported risk of transmitting HIV¶
All MSM 95% 96% 95% 96% 96% 95% 95% 93% 95% 97% 96% 0·96
(11 043/11 570) (1141/1187) (1225/1283) (980/1025) (1345/1404) (1269/1338) (1405/1472) (1040/1115) (1029/1078) (893/919) (716/749)
MSM reporting UAI 90% 91% 90% 90% 91% 89% 91% 86% 91% 94% 92% 0·13
(4948/5475) (467/513) (529/587) (400/445) (599/658) (536/605) (668/735) (473/548) (473/522) (442/468) (361/394)
Mean (SD) number of 1·6 1·0 1·5 1·4 1·5 1·5 2·2 1·7 1·7 1·7 2·2 0·004
UAI partners‡ (9·2) (3·3) (5·8) (8·1) (6·9) (7·3) (17·2) (7·0) (8·1) (5·6) (13·1)
Median (IQR) of UAI 0 0 0 0 0 0 0 0 0 0 1 1·0
partners‡ (0–1) (0–1) (0–1) (0–1) (0–1) (0–1) (0–1) (0–1) (0–1) (0–1) (0–1)
At high risk of acquiring HIV||
All MSM 23% 24% 23% 23% 24% 22% 26% 19% 22% 22% 21% 0·275
(2633/11 570) (280/1187) (299/1283) (236/1025) (341/1404) (288/1338) (377/1472) (217/1115) (238/1078) (203/919) (154/749)
All HIV-negative MSM 25% 26% 26% 26% 27% 24% 29% 23% 25% 23% 23% 0·16
(2633/10 364) (280/1074) (299/1159) (236/917) (341/1255) (288/1200) (377/1308) (217/953) (238/939) (203/883) (154/676)
Mean (SD) of UAI 4·2 2·8 5·1 3·4 3·8 4·5 4·8 4·2 3·7 3·8 6·1 0·252
partners‡ (12·8) (5·7) (10·8) (9·0) (8·2) (13·9) (20·0) (8·1) (8·4) (6·0) (25·2)
Median (IQR) of UAI 2 2 2 1 1 2 2 2 2 2 2 1·0
partners‡ (1–3) (1–2) (1–4) (1–3) (1–3) (1–3) (1–4) (1–3) (1–3) (1–3) (1–4)
Tested for HIV in the 50% 34% 37% 44% 47% 50% 53% 51% 58% 70% 73% <0·001
past year (1288/2573) (79/234) (108/297) (102/234) (157/337) (141/284) (199/376) (110/217) (138/238) (143/203) (111/153)

Data are % (n/N), mean (SD), or median (IQR), unless otherwise specified. Denominators vary because of incomplete data on all variables. Percentages might not add up to totals because of rounding.
MSM=men who have sex with men. UAI=unprotected anal intercourse. *Adjusted for age. †MSM with undiagnosed HIV who reported UAI in the past year or MSM with diagnosed HIV who reported UAI and
not exclusively serosorting. ‡In the past year. §Data on antiretroviral therapy or viral load not available, so we were unable to ascertain if men in this group were on treatment and had undetectable viral loads
and therefore not at risk of transmitting HIV. ¶All MSM not including those who were potentially at risk of transmitting HIV who provided information on number of UAI partners. ||HIV-negative MSM
reporting one or more casual UAI partner or not exclusively serosorting in the past year.

Table 3: Proportion of MSM potentially at risk of transmitting and acquiring HIV, the number of UAI partners in the past year, and recent testing (in the past year) in men at high risk of
acquiring HIV, 2000–13

the skewed distribution of partner numbers, with no
increase over time for most men (medians largely
unchanged), but an increase in partners for the
proportion at the upper end of the distribution, which
increased the mean. Multivariable analyses revealed
that MSM were more likely to be at risk of transmitting
HIV (than were all other MSM) if they were older, of
black ethnic origin, had a higher number of casual UAI
partners in the past year, or had attended a genitourinary
medicine clinic during the past year (table 4).

e436 www.thelancet.com/hiv Vol 3 September 2016


HIV-negative MSM were considered at high risk of
HIV if they reported UAI with one or more casual
partners or reported not exclusively serosorting in the
past year. Overall, 25% of HIV-negative men were at high
risk (table 3). HIV testing in the past year increased in
MSM in this group (table 3). Men at higher risk of
acquiring HIV were more likely to have had a higher
number of casual partners or have been diagnosed with a
sexually transmitted infection in the past year than other
HIV-negative MSM (table 4).
Discussion
We report that the prevalence of HIV remains high at
13% in MSM in our London surveys. The uptake of HIV
testing increased substantially in the period 2000–13, and
the proportion of HIV that is undiagnosed decreased
concomitantly. Despite these changes, which might have
been expected, combined with improved uptake of
treatment to reduce transmission, HIV incidence
remains high and unchanged.3,4 Our data show that
irrespective of the positive changes in testing uptake, risk
behaviour has increased over this period characterised by
increased UAI and increasing numbers of sexual
partners, particularly in HIV-positive men and men who
are at risk of transmission. Serosorting, which has
increased substantially over the past 14 years, is a risky
practice, particularly in HIV-negative men, because 3%
(in 2013) of men who perceive themselves to be
HIV negative are HIV positive, inadvertently putting
others at risk. We have identified and characterised a
subgroup at risk of transmitting infection, particularly
undiagnosed men reporting UAI (one in 43 MSM) and a
larger group at risk of acquiring infection (one in five
HIV-negative MSM) in whom maintenance of the
epidemic could be occurring. Because not all diagnosed
MSM are on treatment (69% in 2000 [Yin Z, Public
Health England, personal communication], 90% in 20132)
and not all men on treatment have undetectable viral
loads (94% in 2013),2 a proportion of individuals
diagnosed reporting UAI and not exclusively serosorting
are also likely to be at risk of transmission. Furthermore,
increased uptake of recent testing (in the past year),
combined with evidence of undiagnosed HIV-positive
men who have recently tested negative, suggest that an
increasing proportion of the undiagnosed men might
have been recently infected and could pose a high risk of
transmission.
This study examined long-term trends in undiagnosed
HIV, testing, UAI, serosorting, and partner numbers by
HIV status in MSM in London. We report on the changes
in behaviours and testing alongside other available
information on testing and ART uptake.1,2 Some
HIV-positive individuals have been reported to change
their behaviour shortly after diagnosis11 and we have
presented differences in behaviour by HIV infection
status and further explore a large group of undiagnosed
MSM. Additionally, we were able to identify HIV-positive
www.thelancet.com/hiv Vol 3 September 2016
Articles
(particularly undiagnosed) MSM reporting behaviours
conducive to transmission. These data will be useful in
modelling studies, because we are able to provide key
variables such as rate of partner change and the
proportion of the population at risk.
One limitation of the study is that we had no
information on the timing of infection in relation to
contact with sexual partners, or how many diagnosed
individuals were on treatment and had undetectable viral
load for MSM at risk of transmitting HIV. In HIV
diagnosed men potentially at risk of transmitting, the
proportion diagnosed with a sexually transmitted
infection in the past year was double that of other MSM
(39% vs 17%), which might have increased their risk of
transmission. Second, the increase in recent testing in
undiagnosed MSM is only suggestive of undiagnosed
infection being increasingly recently acquired, because
we do not know the length of infection in men that were
not tested.
Third, the surveys were convenience samples and might
not be generalisable, comparable or both, over time. This
might also have restricted the ability to detect trends over
time. Response rates varied between 50% and 70% and we
are unable to say how non-responders differed in risk. The
demographic characteristics of the 13% of men who
refused a test were broadly the same as men who did take
a test, although we are unable to infer differences in HIV
status. Also, the self-reported behaviour and testing data
could be subject to recall bias. Furthermore, new web-
based or app-based methods to meet partners have become
increasingly popular,12 and MSM who use these services
could differ from individuals visiting bars, clubs, and
saunas. A study comparing MSM recruited to online and
offline behavioural surveillance studies showed that
individuals using web-based methods were younger, less
likely to identify as gay, less likely to use condoms with
casual partners, and less likely to be tested for HIV.13
Additionally, London-based MSM might not be
representative of MSM in the UK; the estimated HIV
prevalence in London is one in 11 MSM compared with
one in 28 in England and Wales outside London.14 However,
because of the low MSM population prevalence, it is not
feasible to obtain a true probability sample. Unlike many
convenience samples or internet samples, we did have a
clear sampling frame and calculated a response rate. Data
from the National Survey of Sexual Attitudes and Lifestyles
(NATSAL) show that in 2000, 61·6% (95% CI 52·8–69·7)
of MSM had attended a gay club or bar in the past year, and
in 2010, the proportion was 55% (44·7–64·9; Mercer C,
UCL, personal communication). 77·5% (64·3–86·8) of gay
MSM, had attended such venues in the past year.
Comparison of data from MSM in convenience sample
surveys and the 2010 NATSAL show that convenience
sample surveys are likely to overestimate rates of sexually
transmitted infection diagnoses and HIV testing, but that
these differences are smaller in MSM who identify
themselves as gay,15 which suggests that our findings
e437
 Articles

MSM potentially at risk of transmitting HIV* MSM at higher risk of acquiring HIV†
% (n/N)‡ OR (95% CI)§ AOR (95% CI)¶ % (n/N)‡ OR (95% CI)§ AOR (95% CI)¶
Age, years
16–24 3% (40/1583) 1 1 30% (469/1554) 1 1
25–34 5% (217/4735) 1·85 (1·32–2·60) 2·11 (1·45–3·08) 27% (1146/4317) 0·84 (0·74–0·95) 0·94 (0·79–1·12)
35–44 5% (195/3635) 2·19 (1·55–3·09) 2·67 (1·82–3·92) 24% (745/3090) 0·74 (0·64–0·85) 0·83 (0·69–1·00)
45–64 5% (70/1455) 1·94 (1·31–2·89) 2·55 (1·64–3·97) 20% (250/1245) 0·59 (0·49–0·70) 0·62 (0·49–0·80)
≥65 1% (1/82) 0·48 (0·06–3·50) 0·89 (0·11–7·21) 11% (9/80) 0·30 (14·6–59·6) 0·39 (0·15–1·04)
p value ·· 0·0002 <0·0001 ·· <0·0001 0·003
Ethnic origin
White 4% (434/9973) 1 1 25% (2269/8912) 1 ··
Black 12% (41/356) 2·86 (2·04–4·01) 2·60 (1·73–3·90) 26% (76/287) 1·06 (0·81–1·38) ··
Asian 3% (10/314) 0·72 (0·38–1·37) 0·83 (0·43–1·64) 24% (73/310) 0·90 (0·69–1·18) ··
Southeast Asian 2% (5/204) 0·55 (0·23–1·35) 0·71 (0·28–1·81) 18% (36/197) 0·65 (0·45–0·94) ··
Mixed/other 5% (36/689) 1·21 (0·85–1·71) 1·21 (0·82–1·79) 27% (168/628) 1·09 (0·90–1·31) ··
p value ·· <0·0001 0·0001 ·· 0·14 ··
Years education after age 16 years
None 5% (69/1325) 1 1 28% (314/1116) 1 1
Up to 2 years 6% (119/1888) 1·22 (0·90–1·66) 1·32 (0·94–1·85) 28% (459/1648) 0·99 (0·84–1·17) 0·91 (0·72–1·13)
3 years or more 4% (306/7459) 0·77 (0·59–1·01) 0·91 (0·68–1·23) 24% (1637/6741) 0·83 (0·72–0·95) 0·82 (0·68–0·99)
Still in full-time education 4% (30/820) 0·69 (0·44–1·06) 0·99 (0·60–1·63) 27% (213/779) 0·97 (0·79–1·19) 0·85 (0·64–1·14)
p value ·· 0·0002 0·03 ·· 0·003 0·18
Employed
No 6% (87/1508) 1 1 27% (342/1247) 1 1
Yes 4% (437/10 021) 0·75 (0·59–0·95) 0·97 (0·74–1·27) 25% (2289/9091) 0·89 (0·78–1·02) 1·02 (0·84–1·24)
p value ·· 0·011 0·81 ·· 0·09 0·96
Age at first anal intercourse <16 years
No 4% (410/9393) 1 1 26% (2176/8429) 1 1
Yes 8% (110/1463) 1·78 (1·43–2·22) 1·27 (1·00–1·63) 33% (406/1218) 1·44 (1·26–1·64) 1·11 (0·94–1·33)
p value ·· <0·0001 0·054 ·· <0·0001 0·42
Casual UAI partners in the past year
<2 2% (168/9264) 1 1 15% (1227/8380) ·· 1
2–5 11% (180/1633) 6·73 (5·42–8·37) 5·50 (4·37–6·91) 77% (1046/1360) 19·7 (17·1–22·7) 17·9 (15·4–20·9)
6–10 19% (64/343) 12·49 (9·15–17·06) 9·83 (7·08–13·64) 89% (218/245) 48·0 (32·0–71·9) 54·4 (33·3–88·8)
>10 35% (115/330) 29·29 (22·26–38·51) 21·77 (16·23–29·19) 92% (142/154) 70·2 (38·8–127·0) 69·8 (35·3–138·2)
p value ·· <0·0001 <0·0001 ·· <0·0001 <0·0001
Sexually transmitted infection in the past year
No 3% (321/9391) 1 1 23% (1938/8610) 1 1
Yes 10% (202/2083) 3·05 (2·54–3·67) 1·24 (0·99–1·55) 40% (671/1661) 2·32 (2·08–2·59) 1·43 (1·22–1·68)
p value ·· <0·0001 0·058 ·· <0·0001 <0·0001
Attended a genitourinary medicine clinic in the past year
No 2% (154/6199) 1 1 21% (1275/5937) 1 1
Yes 7% (367/5256) 2·97 (2·45–3·60) 1·81 (1·45–2·26) 31% (1330/4327) 1·65 (1·50–1·80) 1·10 (0·97–1·25)
p value ·· <0·0001 <0·0001 ·· <0·0001 0·12

Percentages might not add up to totals because of rounding. MSM=men who have sex with men. UAI=unprotected anal intercourse. OR=odds ratio. AOR=adjusted odds ratio. NA=not applicable. *Includes MSM
with undiagnosed HIV who reported UAI in the past year and MSM with diagnosed HIV who reported UAI and not exclusively serosorting in the past year, compared with all other MSM. †Includes HIV-negative
MSM who either report one or more UAI casual partners or not exclusively serosorting in the past year, compared with all other HIV-negative MSM. ‡Denominators vary because of incomplete data on all
variables. §Adjusted for age and year of survey. ¶Multivariable model includes variables that were significant (ie, p<0·05) in the univariable analysis.

Table 4: Factors associated with potential risk of transmitting and high risk of acquiring HIV in MSM, 2000–13 data combined

might be generalisable to MSM who identify as gay. By disclosed their status, which could potentially have inflated
obtaining trends from similar venues over an extended our estimate of undiagnosed participants. However, we
timeframe, we were able to make comparisons over time. believe non-disclosure was kept to a minimum because
Lastly, some participants might not have accurately the self-completed survey was entirely anonymous.

e438 www.thelancet.com/hiv Vol 3 September 2016


To our knowledge, few UK studies exist that examine
trends in sexual behaviours in MSM in the community
by HIV status, and none that have reported trends in
MSM partner numbers in detail by HIV transmission
risk. Most are cross-sectional data from earlier rounds
of surveys included in this study.10,16,17 In a study of
sexual behaviour of gay men who used gyms in London
between 1998 and 2008, Lattimore and colleagues18
found a lower proportion of MSM reporting UAI (37%)
than we did (50% in 2008), but also an increase in UAI
with partners of the same status, particularly in
HIV-negative MSM, from 12% in 1998 to 21% in 2008.
A study by McDaid and colleagues19 on serosorting and
strategic positioning during UAI in MSM in Scotland
found that, although these behaviours were occurring
(in 11% of HIV-positive and 13% of negative MSM in
2008), they were inconsistently performed. Both of
these studies found increased HIV testing (ever and
recent) in MSM. Continuing high levels of undiagnosed
infection in MSM in the community have also been
reported in Scotland—25% of HIV-positive MSM in
Scotland were undiagnosed in 2011.20 Notably, the
characteristics of HIV epidemics in MSM in several
other countries are similar to that in the UK. For
example, reports show that despite increases in ART
coverage and testing, transmission in France and the
USA is sustained at a high level,21,22 probably because of
increased risk behaviours similar to those shown in
this study.
This study emphasises the importance of core groups
in the epidemiology and control of HIV infection in the
MSM community in the UK. The data show changes in
sexual risk behaviours of MSM in London over the past
14 years with more reporting UAI and an increase in
serosorting as a risk reduction strategy. As expected,
distinct differences in risk behaviours of MSM by HIV
status exist, with HIV-positive men describing the
highest risk. A subgroup of these men are infectious,
particularly those who are undiagnosed. Coupled with
high partner numbers and the one in five HIV-negative
men at high risk of acquisition, this subgroup of men are
likely to disproportionately be the drivers of the sustained
incidence over the past decade. The benefits of
serosorting might be outweighed by increased partner
numbers, inconsistent practice, and incorrect perceived
serostatus, as shown by the high proportion of
undiagnosed men who incorrectly perceive their HIV
status as negative. Additionally, the rise in testing rates
in undiagnosed men suggests these infections are
increasingly recently acquired, when people might be
most infectious.
Modelling studies have shown that reducing the
number of undiagnosed infections and subsequently
treating these individuals will have the greatest effect on
HIV incidence.23,24 Undiagnosed HIV infection is
prevalent in the MSM community, particularly in saunas
where nearly one in ten men were undiagnosed.
www.thelancet.com/hiv Vol 3 September 2016
Articles
Community-level interventions in settings such as bars,
clubs, and saunas have been shown to be successful.25
Furthermore, self-sampling and self-testing are
acceptable to MSM26 and now available in the UK, which
could promote testing at more regular intervals, and
would be important in earlier detection of infection to
reduce transmission, particularly in men who do not
attend sexual health clinics often. Anecdotal evidence
suggests that an increase in new diagnoses and infections
in London1 could also partly be attributable to other
behaviours not studied here, such as an increase in
recreational drug use.27 MSM attending the central
London CODE clinic (a clinic that specialises in sexual
health for men who use drugs for sex—chemsex) prefer
to use internet sites and apps that specialise in
barebacking (the common term for UAI) to find partners,
with an average of five partners per encounter.27 Further
work is needed to design interventions that reach the
users of these sites.
Although HIV testing is increasing1 and the coverage
of ART is high in people diagnosed, the prevalence of
high-risk behaviours in MSM visiting gay social venues
remains high. Treatment as prevention strategies alone
are unlikely to have a substantial effect on HIV incidence
in the UK because of transmission from men with
primary infection and undiagnosed cases.28 We have
shown here that a large proportion of undiagnosed
infections are now recently acquired infections and
some of these infections are probably primary infections.
Additionally, modelling studies have found the
epidemiological effect of earlier diagnosis and treatment
to be offset by increases in risk behaviours.29,30 Pre-
exposure prophylaxis (PrEP) might help prevent
outbreaks. However, PrEP relies on MSM perceiving
themselves at risk and choosing to test. In our study, a
third of undiagnosed MSM had not been tested in the
past year. Finally, serosorting, in which the status of the
partner is presumed, is unsafe because of incorrect
perception of serostatus. Thus, public health authorities
urgently need to focus on implementing and evaluating
combined behavioural and biomedical interventions
(such as test-and-treat and PrEP programmes) that focus
on the group of men potentially at risk of HIV
transmission and HIV-negative men with behavioural
patterns that put them at high risk of acquisition. The
social and cultural mixing of these groups will need to
be considered as part of the design of risk reduction
strategies (eg, targeting of younger MSM who might be
less aware of the risks and less able to protect
themselves). The findings presented in this Article are
an important contribution to the growing evidence that
testing and treatment strategies alone are not sufficient
to reduce HIV incidence at the population level.
Combination prevention working closely with affected
communities to reduce community-wide risk by both
behavioural and biological interventions is crucial if we
are to move towards eradication of HIV.
e439
 Articles
Contributors
All authors contributed to the design of the study. AA and SW analysed
the data and drafted the manuscript. All authors commented on drafts of
the manuscript and approved the final version.
Declaration of interests
We declare no competing interests.
Acknowledgments
This study was funded by Public Health England. We thank
Gary Murphy and Bharati Patel for doing the laboratory testing,
Catherine Mercer for providing the NATSAL statistics, Zheng Yin for
providing data on proportion of diagnosed men on antiretroviral therapy
with detectable viral load in 2000, and all participants for their valuable
contributions.
References
1 Aghaizu A, Brown AE, Nardone A, et al. HIV in the United Kingdom
2013 report: data to end 2012. London: Public Health England, 2013.
2 Public Health England. National HIV surveillance data tables.
London: Public Health England, 2013.
3 Birrell PJ, Gill ON, Delpech VC, et al. HIV incidence in men who
have sex with men in England and Wales 2001–10: a nationwide
population study. Lancet Infect Dis 2013; 13: 313–18.
4 Phillips AN, Cambiano V, Nakagawa F, et al. Increased HIV
incidence in men who have sex with men despite high levels of
ART-Induced viral suppression: analysis of an extensively
documented epidemic. PLoS One 2013; 8: e55312.
5 Elford J. Changing patterns of sexual behaviour in the era of highly
active antiretroviral therapy. Curr Opin Infect Dis 2006; 19: 26–32.
6 Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy
and sexual risk behavior: a meta-analytic review. JAMA 2004;
292: 224–36.
7 Elford J. HIV treatment optimism and high-risk sexual behaviour
among gay men: the attributable population risk. AIDS 2016;
18: 2216–17.
8 British HIV Association, British Association of Sexual Health and
HIV, British Infection Society. UK national guidelines for HIV
testing 2008. London: British HIV Association, 2008.
9 Aghaizu A, Mercey D, Copas A, et al. Who would use PrEP?
Factors associated with intention to use among MSM in London:
a community survey. Sex Transm Infect 2013; 89: 207–11.
10 Dodds JP, Mercey DE, Parry JV, Johnson AM. Increasing risk
behaviour and high levels of undiagnosed HIV infection in a
community sample of homosexual men. Sex Transm Infect 2004;
80: 236–40.
11 Fox J, White PJ, MacDonald N, et al. Reductions in HIV
transmission risk behaviour following diagnosis of primary HIV
infection: a cohort of high-risk men who have sex with men.
HIV Med 2009; 17: 432–38.
12 Bolding G, Davis M, Hart G, Sherr L, Elford J. Where young MSM
meet their first sexual partner: the role of the Internet. AIDS Behav
2007; 11: 522–26.
13 Saxton P, Dickson N, Hughes A. Who is omitted from repeated
offline HIV behavioural surveillance among MSM? Implications for
interpreting trends. AIDS Behav 2013; 17: 3133–44.
14 Skingsley A, Yin Z, Kirwan P, et al. HIV in the UK: situation report
2015. Incidence, prevalence and prevention. London: Public Health
England, 2015.
e440
15 Prah P, Hickson F, Bonell C, et al. Men who have sex with men in
Great Britain: comparing methods and estimates from probability
and convenience sample surveys. Sex Transm Infect 2016; published
online March 10. DOI:10.1136/sextrans-2015-052389.
16 Dodds JP, Johnson AM, Parry JV, Mercey DE. A tale of three cities:
persisting high HIV prevalence, risk behaviour and undiagnosed
infection in community samples of men who have sex with men.
Sex Transm Infect 2014; 83: 392–96.
17 Williamson LM, Dood JP, Mercey DE, Johnson AM, Hart GJ.
Increases in HIV-related sexual risk behavior among community
samples of gay men in London and Glasgow: how do they compare?
J Acquir Immune Defic Syndr 2006; 42: 238–41.
18 Lattimore S, Thornton A, Delpech V, Elford J. Changing patterns of
sexual risk behavior among London gay men: 1998–2008.
Sex Transm Dis 2011; 38: 221–29.
19 McDaid LM, Hart GJ. Serosorting and strategic positioning during
unprotected anal intercourse: are risk reduction strategies being
employed by gay and bisexual men in Scotland? Sex Transm Dis
2013; 39: 735–38.
20 Wallace LA, Li J, McDaid LM. HIV prevalence and undiagnosed
infection among a community sample of gay and bisexual men in
Scotland, 2005–2011: implications for HIV testing policy and
prevention. PLoS One 2014; 9: e90805.
21 Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in
the United States, 2006–2009. PLoS One 2011; 6: e17502.
22 Le Vu S, Le Strat Y, Barin F, et al. Population-based HIV-1 incidence
in France, 2003–08: a modelling analysis. Lancet Infect Dis 2010;
10: 682–87.
23 Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of
HIV from persons aware and unaware that they are infected with
the virus in the USA. AIDS 2006; 26: 1447–50.
24 Granich RM, Gilks CF, Dye C, De Cock KM, Williams BG.
Universal voluntary HIV testing with immediate antiretroviral
therapy as a strategy for elimination of HIV transmission:
a mathematical model. Lancet 2009; 373: 48–57.
25 Godin G, Naccache H, Cote F, Leclerc R, Frechette M, Alary M.
Promotion of safe sex: evaluation of a community-level intervention
programme in gay bars, saunas and sex shops. Health Educ Res
2008; 23: 287–97.
26 Wayal S, Llewellyn C, Smith H, et al. Self-sampling for
oropharyngeal and rectal specimens to screen for sexually
transmitted infections: acceptability among men who have sex with
men. Sex Transm Infect 2015; 85: 60–64.
27 Kirby T, Thornber-Dunwell M. High-risk drug practices tighten grip
on London gay scene. Lancet 2013; 381: 101–02.
28 Brown AE, Nardone A, Delpech VC. WHO “Treatment as
Prevention” guidelines are unlikely to decrease HIV transmission
in the UK unless undiagnosed HIV infections are reduced.
AIDS 2014; 28: 281–83.
29 van Sighem A, Vidondo B, Glass T, et al. Resurgence of HIV
infection among men who have sex with men in switzerland:
mathematical modelling study. PLoS One 2012; 7: e44819.
30 Bezemer D, de Wolf F, Boerlijst MC, et al. 27 years of the HIV
epidemic amongst men having sex with men in the Netherlands: an in
depth mathematical model-based analysis. Epidemics 2010; 2: 66–79.
www.thelancet.com/hiv Vol 3 September 2016