When AIDS first appeared among men who have sex with men (MSM) in New Zealand in the 1980s, a comprehensive approach to prevention was initiated from within the gay community.1 This not only informed MSM of the risks of HIV—and how to reduce them—but also successfully advocated for homosexual law reform that resulted in a more tolerant environment. These activities were supported by the Department of Health that also undertook its own campaign aimed at the wider population, and initiated changes in the law to allow the distribution of clean needles and syringes for injecting drug users.

These approaches showed appreciation that while individual behaviours are key to the spread of HIV, the right social and structural environment is necessary to enable an effective response. The actions were successful; in the early 1990s, the number of people being diagnosed with HIV was declining, and New Zealand was one of the first countries to experience a levelling of AIDS cases.2 The latter occurred before the new era of treatment of HIV that started in 1996, when it became clear that appropriate antiretroviral therapy could have a major beneficial effect on the progression of HIV.

However, in 2005, more people were diagnosed with HIV in New Zealand than in any previous year, an extension of the trend noted since 2000. Indeed, from 2000 to 2005, the number of people diagnosed with HIV doubled.3 The increase was fuelled not only by more infections among MSM, but also infections among heterosexual men and women.

There is an important difference between the MSM and heterosexual groups with HIV. Nearly three-quarters of the MSM diagnosed in 2005 were infected in New Zealand, and most of the increase since 2000 was made up of infections acquired here. In contrast, most (88%) heterosexuals diagnosed in 2005 were infected overseas, and the recent rise is predominantly made up of people infected outside New Zealand.3

New Zealand is not alone in experiencing a rise in infections among MSM. In Western Europe, the number of diagnoses in this group increased between 2000 and 2004 by 45%.4 There have also been increases in the US and Australia.

In many countries, behaviour surveillance has shown that from the mid-1990s until recently, high-risk sexual behaviour among MSM increased.5 Internationally, while some have argued that there has been some relaxation in the culture of safer sex among MSM because of optimism about treatment,6 this alone does not appear to explain all the behaviour change.5 Two of the other factors that may have impacted on this increase over the past decade are more use of the Internet to find sexual partners, and of recreational drugs such as methamphetamine, that reduce inhibitions and increase sexual desire.7

While increases in sexual risk taking may well have played some part in the increasing number of new HIV infection among MSM in New Zealand, it is important to remember an underlying tenet of infectious disease epidemiology: prevalence drives incidence. Of particular relevance to the spread of HIV is that people are more infectious soon after infection, so an increase in the prevalence of recent infections has the potential to accelerate a further rise. Thanks to the new treatments, people are living longer with HIV, rather than dying of AIDS. Although this will impact on prevalence, and hence incidence, it must also be remembered that being on treatment makes people less infectious.

Other sexually tract infections increase the risk of HIV transmission. If the increase in people attending sexual health clinics with sexually transmitted infections reflects a rise among MSM, this may have contributed to HIV more spread in this group.8

In 2003, the Ministry of Health’s HIV/AIDS Action Plan was published.9 The continuing increase in HIV diagnoses makes it imperative that the implementation of this be examined, and action expedited if it has not occurred. In addition, consideration of new initiatives may be required.

The Action Plan highlighted the importance of societal attitudes to HIV, and people at risk, which are known to impact on the potential success of prevention strategies. Major efforts need to be made to ensure people at risk of HIV—whether infected or not—are not subject to stigma and discrimination.10 Where such barriers exist, uptake of measures needed to control HIV spread is inhibited. As one commentator put it, HIV should now be considered a “normal misfortune”.11

Progress in de-stigmatisation, as promised in the Action Plan, should be reviewed in the light of research on how to monitor and manage this problem.12 In New Zealand, new migrant populations are particularly vulnerable, and some have been particularly affected by HIV. As well as addressing this issue, it is important to involve these groups in HIV prevention planning and delivery, as was investigated in the Mayisha Project in the UK.13

We believe that the New Zealand control strategy should be more explicit about the importance of professionally delivered HIV testing. There are many good reasons why HIV should be diagnosed as soon after infection as possible. Diagnosis allows infected people not only to benefit from early effective care, but also reduces the risk of others being infected. Indeed, those diagnosed with HIV tend to reduce their risk behaviour,14 and treating individuals early reduces their infectivity. However the environment must be safe enough for people to be tested. The amnesty that was recently announced for Zimbabweans who came here before October 2004, which means that HIV infection will not now prevent them gaining New Zealand residency if this is sought soon, should be applauded.

A recent study confirmed that MSM most at risk are those having multiple partners, unprotected anal intercourse, and alcohol and drug use before sex.15 The results support the argument for promoting universal condom use during anal intercourse for MSM. They also show the need to acknowledge the role of multiple partners, because condoms will sometimes fail. We support the argument that reducing partner numbers should be given greater prominence in HIV prevention.16

The New Zealand Primary Health Care Strategy emphasises prevention in primary care. General practice is where testing occurred most commonly among people diagnosed with HIV, and is likely to be where most testing takes place. It is therefore an important site for individualised health promotion. While many primary care practitioners may not yet be skilled as health promoters in this field, well designed education programmes can help staff address such sensitive issues.17 The newly formed primary health care organisations could have a crucial role in this area.

To conclude, there is an urgent need to reinforce HIV/AIDS prevention in New Zealand. While programmes should cover the entire range of people at risk, MSM continue to warrant specific consideration, as most new infections in New Zealand still occur in this group. However, there are others that also have specific prevention needs, particularly heterosexuals from high prevalence countries. Progress on the 2003 HIV/AIDS Action Plan must be reviewed, and new initiatives for prevention considered. While individual behaviour must be targeted, the success of these initiatives will only be maximised when full consideration is given to the social and psychological contexts in which people live.

Author information: Nigel Dickson, Director, AIDS Epidemiology Group, Department of Preventive and Social Medicine; Oliver Davidson, Associate Professor, Department of Psychological Medicine; Dunedin School of Medicine, University of Otago, Dunedin

Correspondence: Dr Nigel Dickson, AIDS Epidemiology Group, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin. Fax: (03) 479 7298; email: nigel.dickson@stonebow.otago.ac.nz