Missed opportunities within the health system for the diagnosis of HIV infection in MSM in Spain: Greater commitment and action is required

In 2016, 1780 cases of HIV infection in men who have sex with men (MSM) were reported to the Spanish Information System on New HIV Diagnoses (SINVIH). Of these, 39.4% had fewer than 350 CD4/mm³ and less than 40% had more than 500 at the time of diagnosis.¹ For more than 10 years, MSMs have accounted for more than half of all new diagnoses of HIV in Spain. In 2016, 53% of all cases were MSM, although this may be underestimated, since it is based on the reported route of transmission at the time of diagnosis Unlike the clear decline in the number of cases of HIV transmitted via intercourse between men and women, injection drug use or vertical transmission, new diagnoses of MSM infection have remained stubbornly stable, after taking into account the delay in notification. Recommending HIV testing is, without a doubt, the best way to reduce the appearance of new infections, since it would allow clinicians to offer Pre-Exposure Prophylaxis (PrEP) to HIV-negative individuals at risk of becoming infected. It would also improve the clinical prognosis of HIV-positive individuals by linking them with health services and starting antiretroviral treatment, which would in turn help reduce the viral load in the community.

In an original article published in this edition of EIMC, Espinel et al. describe the extremely high (66%) rate of missed opportunities for early diagnosis of HIV in MSM between 2010 and 2013 in the Spanish public health system.² According to the authors, Primary Care physicians, and to a lesser extent A&E departments, are most likely to miss the signs and symptoms in MSM who present with sexually transmitted diseases and other HIV indicator conditions, such as repeated diarrhea, swollen lymph nodes or fever. The Spanish Ministry of Health, Social Services and Equality (MSSSI) 2014 Clinical Guidelines recommend a more proactive approach to HIV testing in the Primary Care setting, and include recommendations for individuals with HIV indicator conditions.³ Although these guidelines were released in 2014, after Espinel et al. had completed the field work for their study, the recommendation to perform an HIV test on individuals with a sexually transmitted disease had been widely accepted and known for more than 30 years. The authors show that, once the health professional was made aware that the patient had intercourse with other men, which occurred in fewer than 60% of cases, the offer of HIV testing increased significantly, with the rate of missed opportunities for diagnosis falling to “just” 40% vs 70% in cases where sexual practices were not specified.

The high rate of missed opportunities, together with the small number of cases in which sexual practices were specified, compels us to question the extent to which Primary Care is perceived by MSMs as a service capable of meeting their health needs and, therefore, what other opportunities could have been missed during access to this service? Public health policies that are proactive in their approach to gender and sexual diversity are needed in order reduce the health inequities suffered by the LGBT community.⁴

The subject of barriers to health care brings to mind Royal Decree 16/2010 (unfortunately known as the Royal Decree on Health Exclusion) which, through its administrative restrictions and power of dissuasion, succeeded in deepening the health inequities in the immigrant population.⁵ This is particularly alarming in the case of HIV, if we consider that 21% of participants in Espinel et al.’s study were immigrants.

More than half of all MSMs who answered the on-line survey presented by Espinel et al. reported having had unprotected anal sex in the 12 months prior to the survey, and having used the Internet as a means of contacting partners; one third were under 30 years old, 56% were university graduates and 41% lived in a city of more than 1 million inhabitants.

The data presented by Espinel et al. are consistent with the epidemiological figures released by the SINVIH. Only greater commitment and more action will allow us to reverse the status quo of annual HIV infections in MSM in Spain. What do we need to do that is not already being done? Some initiatives that have already been implemented need more impetus, commitment and resources. Among these is the need to promote the MSSSI Clinical Guidelines in the Primary Care setting. In addition to their recommendations regarding HIV and AIDS indicator conditions, the guidelines include a new recommendation to “routinely” offer HIV testing, at least once in their lifetime, to all sexually active individuals between 20 and 59 years of age who are asked to provide a blood sample for any other reason. This would circumvent the need for Primary Care staff to inquire about a patient's sexual practices. The Guidelines also explicitly recommend offering HIV testing to groups most exposed to infection, such as MSM, who should be asked to repeat the test each year. These recommendations are among the cost-effective HIV screening strategies proposed for Spain.⁶ Some centers in Catalonia and Madrid have already implemented a system of HIV testing alerts in the electronic medical records of patients with HIV indicator conditions. Taking action on the Primary Care level does not eliminate the need to set up centers offering sexual health strategies that target the specific needs of at-risk populations, where HIV testing is offered more frequently – for example, every three months. This has already been done in a few cities in Spain, the most interesting being the community-based Barcelona Checkpoint system, which has so far only been rolled out to Seville and Torremolinos. This system has been shown, in other contexts, to be able to provide comprehensive sexual health care, such as PrEP, for the LGBT community, and addresses emerging issues such as chemsex. The possibility of providing care to individuals who indulge in chemsex or – hopefully – to shortly offer PrEP in specific HIV prevention centers in Spain will undoubtedly help increase the number of HIV tests performed, promote early diagnosis and eventually reduce the incidence of HIV infection. PrEP is not currently offered by the Spanish public health system, although the indication has been approved by the Spanish Agency of Medicines and Medical Devices.⁷

History has shown us that over the past 37 years, only ambitious, cross-cutting, multidisciplinary anti-HIV strategies that are based on scientific evidence and respect for human rights have been successful. In Spain, at the beginning of 2018, we need more commitment and more action from political decision-makers. What are we waiting for?