Changes in the profile of newly HIV-diagnosed men who have sex with men, Madrid, 2014 to 2019

with HIV infection. Methods: We carried out an observational, descriptive, study on all MSM newly diagnosed with HIV infection in one clinic for sexually transmitted infections (STI) and HIV clinic in Madrid between 2014 and 2019. Information on sociodemographic, clinical, and behavioural characteristics of participants per year of diagnosis was collected. Results: We detected a total of 1,398 people with HIV infection, 253 of whom were recent seroconverters (rSCV) with a median dura-tion of documented seroconversion of 6 months. From the total, 97.9% infections were sexually transmitted and 2.1% involved injected drugs, i.e. slam practices. The average age was 32.9 years (range: 15.6–74.9), 51.8% were Spanish and 40% Latin American. These diagnoses decreased in Spanish people and increased in Latin Americans during the study period. Of the rSCV, 73.9% had condomless sex under the influence of drugs and 28.9% participated in chemsex sessions. Apps were used by 92.6% rSCV for sexual encounters and 70.4% of them attributed HIV transmission to their use. Conclusions: Combination of HIV prevention strategies, as pre-exposure prophylaxis, should be reinforced among young MSM, especially those born in Latin America, those who use drugs for sex, and those who use apps in search of sexual contacts.


Introduction
Since the start of the AIDS epidemic, the interest in knowing the factors associated with the transmission of infection of the human immunodeficiency virus (HIV) has been constant in order to establish up-to-date prevention strategies aimed particularly at the most affected groups [1].
Numerous studies show that HIV transmission is higher in infected subjects who are unaware of their serostatus [2]. Thus, early diagnosis and highly active antiretroviral therapy (HAART) are essential tools for prevention. In 1987, the sale of the first drug, Zidovudine (AZT), was approved, but it was not until 1996 that the greater efficacy of combination ART changed the history of the infection [3,4]. Since then, advances in ART have dramatically improved the survival and quality of life of infected people [5]. Several studies have confirmed that seropositive patients with undetectable viral load under ART did not transmit the infection to their sexual partners [6,7]. Therefore, the reduction of the time between the transmission of HIV and the diagnosis and treatment of the infection is a priority in all prevention programmes for this disease. Several preventive measures have been used against HIV, such as the promotion of consistent condom use, sex education, screening for sexually transmitted infections (STI) and HIV, post-exposure prophylaxis (PEP) or early diagnosis and immediate ART, which is probably the measure that has had the greatest impact in recent years. In 2016, another preventive measure known as pre-exposure prophylaxis (PrEP) was approved in Europe, recommended by different health agencies and scientific societies such as the United States (US) Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the European AIDS Clinical Society (EACS) or the Spanish AIDS Study Group (GeSIDA) [8][9][10][11][12][13]. In November 2019, the Ministry of Health announced the funding of PrEP in Spain as an additional measure of prevention against HIV within the National Health System [14]. According to UNAIDS data, there has been a 16% reduction in new HIV diagnoses globally, from 2.1 million in 2010 to 1.7 million in 2018 [15]. In some high-income countries, the implementation of preventive strategies in a combined manner and directed at target populations has been associated with an important decrease in new cases of HIV, even in men who have sex with men (MSM) for the first time in years [16][17][18] [20].
The objective of this work was to describe the sociodemographic, clinical and behavioural characteristics of MSM newly diagnosed with HIV infection between 2014 and 2019 in a reference centre for STI/HIV in Madrid and to analyse changes during that period.

Methods
We carried out an observational, descriptive study in a reference clinic for STI/HIV in Madrid between 2014 and 2019. That centre offers universal care without administrative barriers, attends to more than 30,000 consultations a year and is located in the heart of the city. All MSM with new HIV diagnosis during the 6-year period were invited by the health professional, on the same day or close to the diagnosis, to participate in the study; they were also offered linkage for immediate ART and STI screening. The treating physician compiled a complete clinical history of each patient based on the information on sociodemographic, clinical and Cop: genome copies; GHB: gamma hydroxybutyrate; PEP: post-exposure prophylaxis; PrEP: pre-exposure prophylaxis; STI: sexually transmitted disease. a HIV recent seroconverters were considered to be those who had a documented negative HIV serology in the 12 months before diagnosis or who were in the process of seroconversion. b STI included Neisseria gonorrheae infection, Chlamydia trachomatis infection/lymphogranuloma venereum, syphilis, herpes simplex virus infection, anogenital condylomas, scabies, pediculosis pubis and hepatitis A, B and C. We defined two categories of late presentation: late diagnosis with 350-500 cells/µL CD4+ T-cell count; and advanced disease with less than 200 cells/µL. behavioural characteristics collected STI/HIV clinic. The collected variables are described in Table 1.

Statistical analysis
The qualitative variables are presented as absolute and relative frequencies. The quantitative variables are expressed as the mean and standard deviation (SD

Ethical statement
All data derived from medical histories were fully anonymised before access. The study protocol was approved by the IRB of Hospital Clínico San Carlos, approval number 20/795-E. The ethics committee waived the need for informed consent because the information obtained for the study was collected in routine clinical practice.

Results
Between 2014 and 2019, 1,398 new infections of HIV were diagnosed among MSM. For 253 of them, a recent seroconversion could be documented. During that period, we observed a downward trend in the number of cases and of recent seroconverters (rSCV) (p = 0.034) ( Figure 1).

Sociodemographic and clinical characteristics of men who have sex with men and who had newly diagnosed HIV infection
The most relevant characteristics of MSM with new HIV diagnoses are described by year in Table 2, from 2014 to 2019. Most transmissions (97.9%) were sexual and 2.1% occurred in people who inject drugs (PWID). Intravenous drugs were used in a sexual context by all 2.1%. This practice, known as slam, remains infrequent but has increased during the study period. The average age was 32.9 years (± 8.8), ranging from 15.6 to 74.9 years. Diagnoses decreased among people born in Spain and increased among those born in Latin America, with a statistically significant trend (p linear trend < 0.001). Diagnosis of HIV occurred at a younger age among Latin American compared with Spanish MSM, with a significant trend (p linear trend < 0.001) ( Figure 2). The majority were early diagnoses but, starting in 2016, the number of late diagnoses and

Behavioural characteristics of men who have sex with men and who were newly diagnosed with HIV infection
The majority of newly diagnosed MSM began sexual relations at an age between 16 and 18 years, had more than 10 sexual partners in the year before diagnosis and more than 100 sexual partners in their lifetime. Consistent condom use was 0.4% (

Sociodemographic, clinical and behavioural characteristics among men who have sex with men and with recent HIV seroconversion
Among the 253 HIV rSCV, 80.2% (n = 203) were between 20 and 39 years-old; 65.6% (n = 166) were of Spanish

Discussion
In our study, the percentage of people born in Latin America was higher and presented an upward trend, 25 If we compare the CD4 + T-lymphocyte counts at the time of HIV diagnosis between the Spanish national registry against in our study among MSM they were, in 2019, 378 vs 533 cells/mL on average. There were 20.5% vs 9.2% of diagnoses with < 200 cells/mL advanced disease and 20.8% vs 27.6% with 201-350 cells/mL late diagnosis [20]. This difference between the data from Madrid and the governmental data reflect an earlier diagnosis in our STI/HIV clinic, probably related to the follow-up of seronegative people with risky practices. However, in the years 2017 to 2019, the CD4 + T-cell counts at the time of diagnosis have been lower. This may be explained by later diagnosis among foreigners and the numerous diagnoses of acute infection, coinciding with the decrease in CD4 + T-cells.
The WHO points out that MSM are highly vulnerable to acquiring HIV infection [22]. In this work, MSM presented clinical and behavioural markers considered to indicate high risk: history of STI (69.8%), high number of sexual partners, condomless sexual practices under the effect of recreational substances (64.5%) and the use of apps to search for sexual contacts (77.4%). Several publications have associated the use of recreational drugs with an increased incidence of HIV and other STI [23]. Among the MSM analysed, 64.5% had condomless sexual relations under the influence of drugs, while among the rSCV, this percentage was higher (73.9%) and similar to that found in a meta-analysis carried out among HIV-positive people and including 38 publications from 2000 to 2018 [24]. The USEX-Study, a study conducted in 22 hospitals in Madrid with 2,916 HIV-positive MSM, found that 29.1% used drugs for sex and, in our study, 28.9% of the rSCV participated in chemsex sessions [25]. It is fundamental to know the type of drug used and the route of administration. Substances such as mephedrone, methamphetamine, GHB, ketamine and poppers were strongly related to condomless sex and, as Pakianathan et al. noted, were identified as facilitating drugs for HIV transmission [26]. Even though their use by the parenteral route is uncommon, it is increasing, from 0.4% in 2014 to 4.3% in 2019. All PWID In our study used substances in a sexual context, data which are in line with Bui et al. who recorded that 4.7% of MSM monitored in an Australian Clinic practiced slam [27]. The growing popularity of chemsex coincides with a decrease in new HIV diagnoses, which could be explained by the high preventive efficacy of ART and PrEP. However, the use of preventive strategies such as PEP (3.8%) or PrEP (1.1%) was very rare in our study. The comparatively late funding in the implementation of PrEP in Spain could be one of the factors that explains the slow decline in new cases compared with other European or North American countries [14,28]. Funding of PrEP, combined with the other measures used in our country, may represent an opportunity to achieve a more substantial reduction in the number of new cases.
The use of apps to search for sexual contacts was high among MSM, especially among rSCV, and, as has been published elsewhere, the use of some social networks has been linked to risk behaviours for acquiring HIV and others STI [29]. In our work, 70.4% of HIV rSCV   attributed the transmission of the virus to the use of these apps.
Our work could be limited by the fact that it was a monocentric study and analysed MSM, since most of the diagnoses in our centre were made among them. These data could not be extrapolated to heterosexual men and women or transgender women with very different sociodemographic, clinical and behavioural characteristics. It is an important line of research that should be studied. Despite this limitation, this is a study carried out at a reference STI/HIV clinic where care is offered without administrative barriers. Half of the people attended to are MSM, and many of them are of foreign origin, mainly Latin American. Because of the fact that it is the reference centre for PrEP in the Community of Madrid and because of its particular characteristics, it is considered a sentinel centre prepared to detect the epidemiological changes that accompany an HIV epidemic at an early stage. Knowing the profile of people newly infected with HIV allows for the design of preventive strategies specifically aimed at each individual or population group.

Conclusion
Our results reflect a reduction in new cases of HIV, in particular among MSM born in Spain, although the trend is not as significant as it is in other countries. Combination of HIV prevention strategies with the inclusion of PrEP and frequent HIV testing, should be reinforced among young MSM, especially those born in Latin America, those that use drugs for sex and those that use apps in search of sexual contacts.