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Surveillance of HIV in the United States and England, Scotland, and Northern Ireland: what have we learned and what do we do about it?

This issue of sexually transmitted disease includes 2 important articles focused on the detection of HIV, one from the United States and the second from England, Wales, and Northern Ireland. Together, they provide a sobering account of the status of HIV among men who have sex with men (MSM) and the pervasiveness of late HIV diagnosis. The first article used data from the National Health and Nutrition Examination Survey (NHANES) on a serial cross-sectional probability sample of the US population since 1999. The overall prevalence of HIV in the United States based on these data was 0.4%, consistent with earlier reports. The authors emphasize a higher prevalence of HIV within large metropolitan areas in the United States, twice as high relative to other areas. However, perhaps the most striking aspect of the report is the extreme risk for HIV in MSM and bisexual men. HIV prevalence among MSM was 10.1% and 13.4% in large metropolitan and metropolitan fringe areas, respectively, but remained high at 7% in medium and small metropolitan/nonmetropolitan areas. In contrast, HIV prevalence among heterosexuals in the United States did not vary by urbanicity, except among heterosexuals of low socioeconomic status in whom HIV prevalence was higher in large central metropolitan and fringe metropolitan areas. The prevalence of HIVamong MSM in NHANES is similar to (but slightly lower) than that reported in the National HIV Behavioral Surveillance System, likely due to use of respondent driven sampling and HIV testing among high-risk populations in the latter. The report underscores the very high prevalence of HIV inMSM the United States. Although certainly not surprising, the results emphasize the truly urgent need for more resources and ideas about how to stop the spread of HIV in this patently vulnerable population. In addition, it must be noted that NHANES’ methods limit use of these data for the development of public health policy to prevent HIV infection. The NHANES samples only the civilian, noninstitutionalized US population in households, de facto missing substantial proportions of the nation’s HIV among individuals institutionalized in correctional facilities and psychiatric hospitals. Although the NHANES data support prior findings on the aggregation of HIV in large metropolitan centers, it does not account for regional variations and highly variable HIV prevalence in rural areas. For several years, HIV prevalence in the rural South and Midwest has been higher compared with the rural Northeast and West. In addition, the most rapid growth of HIV now occurs in the Southeastern United States, where HIV-infected individuals often reside in smaller towns, especially among African American men and some African American women. Finally, the survey is conducted in only 15 counties each year, and although data are aggregated, variations in HIV prevalence across regions and urbanicity (as reflected in the article) cannot be overlooked and limit the degree to which the findings from this report can inform HIV testing and care programs. The article from England, Wales, and Northern Ireland focuses on HIV prevalence and care in individuals reporting heterosexual behaviors. The results derive from data obtained from the National HIVand AIDS Reporting System, which has collected information on HIV-infected individuals older than 15 years since 1992, supplemented by complementary report of CD4 cell counts at diagnosis in 81% of the study population. The authors noted a rise in new diagnoses of HIV from 1992 through 2006, and a large fall in new HIV diagnoses in 2011. Most (72%) of HIV cases in heterosexuals occurred in blacks, 99% of whom had migrated from abroad. Importantly, the decrease in HIV diagnoses among black African adults over time was primarily due to declines in immigration of foreign EDITORIAL