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HIV Notification "Rate": A More Accurate and Useful Indicator to Measure the HIV Epidemic.

To the Editors: Most public and professional commentary on issues relating to the success or failure of HIV control centers on the number of notifications that have increased in most of the highincome countries over the last decade. However, notifications do not take account of the large increase in the number of people living with HIV (PLHIV) after the introduction of highly active antiretroviral therapy. For example, in Australia, the annual HIV notification increased by 41.0% (876 in 2003 to 1235 in 2013), while the number of PLHIV increased by 96.6% (13,630 to 26,800). We argue that, given that the main driver of HIV notifications in any community is the number of PLHIV, any discussion of notifications should include the number of individuals living with HIV. Our early work suggested that when notifications were expressed as a proportion of those living with HIV, a different picture of HIV emerges, with declines, year after year, rather than rises. The majority of high-income countries usually report the annual number of HIV notification and PLHIV as part of routine HIV surveillance. However, to our knowledge, San Francisco (SF) in the United States is the only place that calculated and reported HIV notification rate per 100 PLHIV by dividing the total number of notification by the number of PLHIV. To test whether our early observations are still valid, we have calculated the trends in notification rate per 100 men who have sex with men (MSM) living with HIV and compared this with notification rates in several regions. We restricted the analysis to MSM because the majority of HIV transmission in high-income countries occurs among MSM. If the notification per 100 MSM living with HIV is falling, then it implies that the reproductive rate is falling despite stable or rising notifications. This proposition holds true only if HIV testing rates remain stable over time and that notifications and the number of PLHIV in the area who are at risk of HIV transmission are correct. Two states [Victoria (VIC) and New South Wales (NSW)] in Australia and 2 cities [New York City (NYC) and SF] in the United States were selected because these places provided relatively complete data on PLHIV and MSM diagnoses. Annual HIV notification rates per 100 MSM living with HIV were calculated by the number of HIV-notified cases in MSM divided by the estimated number of MSM living with HIV in each year. The number of MSM living with HIV was estimated by multiplying the total number of PLHIV and the proportion of HIV diagnoses in MSM. We acknowledge that the estimates used in this analysis are imperfect. Notifications may not necessarily reflect incidence, and estimating the number of PLHIV is difficult and provided by few regions. The number of notifications of HIV in MSM increased 3.6% from 639 cases in 2003 to 662 cases in 2013 in VIC and NSW. The number of HIV notifications in MSM also increased in NYC from 1488 cases in 2002 to 1609 cases in 2013 (a 8.1% increase) but not in SF (Fig. 1). All places, except VIC, had a significant increase in the proportion of HIV diagnoses in MSM over the study period (see Table S1, Supplemental Digital Content, http://links.lww.com/ QAI/A715). In addition, we found that if the notifications were expressed as a proportion of cases per 100 MSM living with HIV, such proportions declined significantly over time in VIC (41.0% decline, from 8.3 to 4.9, 2002– 2013), NSW (50.9% decline, from 5.5 to 2.7, 2003–2013), NYC (38.3% decline, from 6.0 to 3.7, 2002–2013), and SF (36.1% decline, from 3.6 to 2.3, 2006– 2013). We found that the number of notifications per 100 MSM living with HIV declined significantly in all 4 areas, but the notification rate rose in 3 of the 4 areas. The magnitude of the fall in notifications was substantial and of the order of 40%–50% decline in contrast to notifications, which changed little except for SF. It could be argued that the change in HIV testing rate may play an important role to interpret the increase of new HIV notification. However, a large Australian gay community survey shows that there was no observable change in HIV testing rate among MSM from 2003 to 2012. These data suggest that the reproductive rate for HIV among MSM is falling significantly possibly due to increases in HIV treatment uptake. Although these encouraging falls should not deter funding for prevention in any way, they do recognize the substantial success of current control measures and might remove some of the unhelpful and stigmatized comments about the sexual practices of MSM. However, the relationship between this proposed notification “rate” and the existing measures of HIV surveillance are not well understood, further extensive modeling studies are required to evaluate the value of using this new notification rate as a measure of HIV epidemic.