Fernando Vallejo

Injecting and HIV prevalence among young heroin users in three Spanish cities and their association with the delayed implementation of harm reduction programmes

Objectives: To evaluate changes in the prevalence of HIV infection among young heroin users in three Spanish cities, and their association with harm reduction programmes (HRPs). Methods: Two cross sectional studies. The 1995 study included 596 users; half were street recruited and half were recruited at drug treatment centres. The 2001–03 study included 981 street recruited users. Face to face interviews were conducted using a structured questionnaire. Samples for HIV testing (saliva in 1995 and dried blood spot in 2001–03) were collected. Results: The proportion who had ever injected (IDUs) decreased in all three cities. HIV prevalence in IDUs decreased by half in Barcelona (44.1% to 20.8%) and Seville (44.2% to 22.2%), but remained constant in Madrid (36.8% and 34.9%). This difference was attributable to a decrease in HIV prevalence in long term IDUs in Barcelona and Seville, but not in Madrid. The crude odds ratio for HIV prevalence in Madrid compared with Barcelona in long term IDUs was 2.3 (95%CI 1.4 to 3.7), increasing to 3.1 (95%CI 1.5 to 6.2) after adjusting for sociodemographic and risk factors. HIV prevalence in short term IDUs was similar in all cities. In 1992 Barcelona already had 20 heroin users in methadone maintenance programmes (MMPs) per 10 000 population aged 15–49 years; Seville reached this rate in 1994, and Madrid, not until 1998. Conclusions: The prevalence of HIV infection did not decrease in long term injectors in Madrid. The delayed implementation of HRPs, especially MMPs, may be the most plausible hypothesis. This finding should shed light on decision making in countries in a similar epidemiological and sociological situation.

Impact of the demerit point system on road traffic accident mortality in Spain

Background To assess the effect of the Demerit Point System (DPS), introduced in Spain on 1 July 2006, on the number of fatalities due to road traffic accidents, using a methodology that controls for the seasonal variation and trend in the data series. Methods Time-series analysis by ARIMA models of 29 113 fatalities in road traffic accidents (at the accident scene or within 24 h thereafter), between January 2000 and December 2007. The model permitted estimation of an intervention parameter, together with its 95% CI, to calculate the number of fatalities that would have occurred if the DPS had not been implemented, after controlling for the effect of other measures introduced in 2004. Results It was estimated that 618 persons (95% CI 259 to 977) would have died in traffic accidents in the 18 months after implementation of the DPS had it not been in effect, which represents a reduction of 14.5% (95% CI 6.1% to 23.0%) from a total of 4252 deaths. Conclusion Implementation of the DPS in Spain has led to a significant reduction in the number of traffic accident deaths in the context of a downward trend after the implementation of the 2004 measures.

Mortality decrease according to socioeconomic groups during the economic crisis in Spain: a cohort study of 36 million people

BACKGROUND Studies of the effect of macroeconomic fluctuations on mortality in different socioeconomic groups are scarce and have yielded mixed findings. We analyse mortality trends in Spain before and during the Great Recession in different socioeconomic groups, quantifying the change within each group. METHODS We did a nationwide prospective study, in which we took data from the 2001 Census. All people living in Spain on Nov 1, 2001, were followed up until Dec 31, 2011. We included 35 951 354 people alive in 2001 who were aged between 10 and 74 years in each one of the four calendar years before the economic crisis (from 2004 to 2007) and in each one of the first four calendar years of the crisis (from 2008 to 2011), and analysed all-cause and cause-specific mortality in those people. We classified individuals by socioeconomic status (low, medium, or high) using two indicators of household wealth: household floor space (<72 m2, 72-104 m2, and >104 m2) and number of cars owned by the residents of the household (none, one, and two or more). We used Poisson regression to calculate the annual percentage reduction (APR) in mortality rates during 2004-07 (pre-crisis) and 2008-11 (crisis) in each socioeconomic group, as well as the effect size, measured by the APR difference between the pre-crisis and crisis period. FINDINGS The annual decline in all-cause mortality in the three socioeconomic groups was 1·7% (95% CI 1·2 to 2·1) for the low group, 1·7% (1·3 to 2·1) for the medium group, and 2·0% (1·4 to 2·5) for the high group in 2004-07, and 3·0% (2·5 to 3·5) for the low group, 2·8% (2·5 to 3·2) for the medium group, and 2·1% (1·6 to 2·7) for the high group in 2008-11 when individuals were classified by household floor space. The annual decline in all-cause mortality when people were classified by number of cars owned by the household was 0·3% (-0·1 to 0·8) for the low group, 1·6% (1·2 to 2·0) for the medium group, and 2·2% (1·6 to 2·8) for the high group in 2004-07, and 2·3% (1·8 to 2·8) for the low group, 2·4% (2·0 to 2·7) for the medium group and 2·5% (1·9 to 3·0) for the high group in 2008-11. The low socioeconomic group showed the largest effect size for both wealth indicators. INTERPRETATION In Spain, probably due to the decrease in exposure to risk factors, all-cause mortality decreased more during the economic crisis than before the economic crisis, especially in low socioeconomic groups. FUNDING None.

Men who pay for sex in Spain and condom use: prevalence and correlates in a representative sample of the general population

Objective: To estimate the percentage of men who have paid for heterosexual sex in Spain and the percentage who used condoms. To identify the main factors associated with these behaviours and to describe opinions about condoms. Methods: Sexual behaviour probability sample survey in men aged 18–49 years resident in Spain in 2003 (n = 5153). Computer-assisted face to face and self interview was used. Bivariate and multivariate logistic regression analyses were performed. Results: 25.4% (n = 1306) of the men had paid for heterosexual sex at some time in their lives; 13.3% (n = 687) in the last 5 years and 5.7% (n = 295) in the last 12 months. In the logistic analysis this behaviour was associated with older age, lower education, being unmarried, foreign birth, being a practicing member of a religious group, unsatisfactory communication with parents about sex, age under 16 years at first sexual intercourse and having been drunk in the last 30 days. Of the men who had paid for sex in the previous 5 years, 95% (n = 653) had used a condom in the most recent paid contact. In the multivariate analysis, not using a condom was associated with age over 30 years and first sexual intercourse before age 16 years. Men who did not use condoms in the last commercial intercourse had more negative opinions about condoms. Conclusions: The prevalence of paying for heterosexual sex among Spanish men is the highest ever described in developed countries. The many variables associated with paying for sex and condom use permit the characterisation of male clients of prostitution and should facilitate targeting HIV prevention policies.

Prevalence of HIV infection among young adult injecting and non-injecting heroin users in Spain in the era of harm reduction programmes: gender differences and other related factors

The aims were to assess the prevalence of HIV infection among young adult heroin users, including injecting heroin users (IHUs) and non-injecting heroin users (NIHUs), and to explore the differences by gender and other factors. The design was a cross-sectional cohort study between April 2001 and December 2003, which included 961 current heroin users (HU), aged 18-30 years: 422 in Madrid, 351 in Barcelona and 188 in Seville; 621 were IHUs and 340 were NIHUs. All were street-recruited by chain referral methods. Face-to-face interviews were conducted using a structured questionnaire with computer-assisted personal interviewing (CAPI). Samples for HIV testing (dried blood spot) were collected and tested with ELISA and Western Blot. Bivariate, logistic regression, and classification and regression tree analyses were performed. The overall prevalence of HIV infection among IHUs was 25.8% (95% CI 22.3-29.3) [32.4% (95% CI 26.6-38.1) in Madrid, 20.5% (95% CI 15.6-25.4) in Barcelona, and 20.6% (95% CI 9.8-31.4) in Seville], whereas in NIHUs it was 4.0% (95% CI 2.1-6.7), with no differences among cities. The prevalence was significantly higher in women than in men in NIHUs (10.9%, 95% CI 4.3-17.5 vs. 1.7%, 95% CI 0.5-4.2) and was non-significantly higher in IHUs (30.4%, 95% CI 23.0-37.8 vs. 24.1%, 95% CI 20.1-28.1). HIV prevalence in short-term IHUs was 12.9% (CI 8.8-17.02), with no differences among cities. In the logistic analysis, the variables associated with infection in IHUs were ever having injected with used syringes (OR 3.4, 95% CI 2.2-5.3), ever having been in prison (OR 2.6, 95% CI 1.6-4.0), and heroin as the first drug injected at least weekly (OR 2.3, 95% CI 1.1-4.5). Factors positively associated with HIV infection in NIHUs were female sex (OR 8.7, 95% CI 2.6-29.2) and age >25 years (OR 3.1, 95% CI 0.9-11.1), while primary educational level was inversely associated (OR 0.26, 95% CI 0.1-0.9). Although there are important geographic differences, HIV prevalence in IHUs remains high, even in short-term IHUs, whereas it was almost six times lower in NIHUs. The prevalence in women is higher than in men, particularly among NIHUs. A wide range of preventive strategies should be developed, aimed primarily at empowering women to negotiate safe sex.

HCV seroconversion among never-injecting heroin users at baseline: no predictors identified other than starting injection

BACKGROUND Heroin users who do not inject constitute a large pool of drug users with a potentially important impact on public health. We aimed to estimate the incidence of hepatitis C virus (HCV) among heroin users who had never injected (NIDUS) at baseline, and the effect of starting injecting during follow-up, other percutaneous exposures, sharing snorting paraphernalia, cocaine/crack use, and risky sexual behaviour on HCV-seroconversion. METHODS Prospective cohort of 305 HCV-negative NIDUs at baseline, aged 18-30 and street-recruited in three Spanish cities in 2001-2003. Computer-assisted personal interviews were conducted and dried blood-spot samples were collected. Bivariate and multivariable Poisson models were used. RESULTS Among the 305 never-injectors who were HCV-negative at baseline, 197 (64.6%) were followed-up and 21 seroconverted [HCV-incidence rate=5.8/100 person-years at risk (pyar) (95% CI: 3.6-8.9)]. HCV incidence in new-injectors was 28.4/100 pyar [(95% CI, 14.7-49.7) vs. 2.8/100 pyar (95% CI, 1.3-5.4)] among NIDUs. Of the risk exposures considered, starting injecting was the only predictor of HCV-seroconversion [adjusted relative risk=10.1, 95% CI: 3.8-26.7]. CONCLUSION The HCV-seroconversion rate was 10 times higher among new-injectors than never-injectors. No predictors other than starting injecting were found for HCV-seroconversion. Harm reduction interventions to prevent HCV infection should include prevention of drug injection.

Human immunodeficiency virus testing uptake and risk behaviours in Spain

Background: The purpose of this study was to estimate the prevalence of human immunodeficiency (HIV) testing in the general population; to analyse factors related to voluntary testing; and to describe the main reasons for testing, the kinds of health services where testing takes place and the relations between self-risk perception and HIV testing. Methods: A probability sample survey of health and sexual behaviour in men and women aged 18–49 years and resident in Spain in 2003 (n = 10 980) was used. A combination of face-to-face and computer-assisted self-interview was used, and bivariate and multivariate logistic regression analyses were performed. Results: Some 39.4% (40.2% in men and 38.5% in women) had ever been tested, blood donation being the main reason for men and pregnancy for women. In the multivariate analysis, HIV testing was associated with foreign nationality, high educational level, having injected drugs and having a large number of sexual partners. In men, it was also associated with age 30–39 years, having had sex with other men and having paid for sex. About 29.3% of men and 32.8% of women had their last voluntary HIV test in primary healthcare centres, whereas only 3.4% of men and 3.6% of women had last been tested in sexually transmitted infection/HIV diagnostic centres. About 20.2% of men and 5.5% of women with risk behaviours had never been tested. Conclusion: The proportion of men with risk behaviours who have never had an HIV test is unacceptably high in Spain. Scaling up access to HIV testing in this population group remains a challenge for health policies and research.

Prevalence of and Risk Factors for Hepatitis B Virus Infection among Street-Recruited Young Injection and Non-Injection Heroin Users in Barcelona, Madrid and Seville

Background: To evaluate the prevalence of hepatitis B virus (HBV) and associated factors in 949 heroin users (HU): injectors (IHUs) and non-injectors (NIHUs). Methods: Cross-sectional study; structured questionnaire administered by computer-assisted personal interviewing and audio computer-assisted self-interviewing; dry blood samples analysed for the hepatitis B core antigen and hepatitis B surface antigen; bivariate analysis and logistic regression. Results: The prevalence of infection was significantly higher in IHUs (22.5%) than in NIHUs (7.4%) in the three cities. In the logistic analysis of male IHUs, infection was found to be associated with living in Seville, age over 25, foreign nationality, having had a sexual partner who traded sex, hepatitis C virus infection, and having injected for more than 5 years. In female IHUs, HBV infection was associated with age over 25, having injected as the first main route of administration, and having begun to inject before 18 years of age. In NIHUs, the associated factors were female gender, foreign nationality and having been tattooed. In young IHUs, the prevalence of HBV infection remains four times higher than in the general population of the same age group. Conclusion: The vaccination strategy urgently needs to be reinforced and redesigned to achieve acceptable control of the HBV infection in the most vulnerable groups, with special attention to immigrants.

Injecting, Sexual Risk Behaviors and HIV Infection in Young Cocaine and Heroin Users in Spain

Aim: To evaluate differences between young cocaine users and heroin users (HUs) regarding the prevalence of sexual and injection risk behavior, and HIV, HCV and HBV infection. Methods: Two community cohorts were recruited in Madrid, Barcelona and Seville; 720 cocaine users, of whom 586 had never used heroin (CUs), and 991 HUs were interviewed. Dried blood spot samples were tested. Results: CUs were less marginalized socially than HUs. Only 0.9% had ever injected versus 64.3%; none had ever injected with borrowed syringes versus 25%; 2.2% had an injecting steady partner in the last 12 months versus 24.9%; 4.8% had ever traded sex versus 16.0%. However, 31.0 versus 12.7% had unprotected sex with more than two occasional partners in the last 12 months; 45.0 versus 21.9% had sniffed through tubes used by more than 10 persons. Only 32.3% knew their HIV status versus 80.3%; 0.4 versus 18.1% were HIV positive; 0.9 versus 51.9% were HCV positive, and 1.5 versus 17.0% were HBV positive. Conclusions: The intense cocaine epidemic has hitherto had little impact on either HIV, HBV or HCV in Spain. However, surveillance should be intensified given the high percentage of CUs having unprotected sex with occasional partners.

High hepatitis C virus prevalence and incidence in a community cohort of young heroin injectors in a context of extensive harm reduction programmes

Background Cohort studies on hepatitis C virus (HCV) among drug injectors are scarcer than studies on HIV. Combined harm reduction interventions (HRIs) can prevent HCV infection. Spain has a medium–high coverage of HRIs. Methods 513 young heroin users who injected drugs in the past 12 months (recent injectors) were street-recruited in 2001–2003 and followed until 2006 in three Spanish cities; 137 were anti-HCV seronegative, 77 of whom had ≥1 follow-up visit. Dried blood spots were tested for anti-HCV. HCV incidence and predictors of infection were estimated using Poisson models. Results At baseline, 73% were anti-HCV positive. Overall incidence (n=77) of HCV seroconversion was 39.8/100 person-years (py) (95% CI 28.7 to 53.8). Excluding non-injectors during follow-up from the analysis (n=57), HCV incidence was 52.9/100 py (95% CI 37.4 to 72.5). Injecting at least weekly (incidence rate ratio (IRR)=5.2 (95% CI 2.5 to 11.1)) and having ≥2 sexual partners (IRR=2.2 (95% CI 1.1 to 4.7)) were independent predictors of HCV seroconversion; drug-injection history <2 years was marginally associated (IRR=2.4 (95% CI 0.9 to 4.7)). HCV incidence may have been underestimated due to differential attrition. Conclusions Despite fairly high HRI coverage among Spanish drug injectors, a distressingly high incidence of HCV in a context of high HCV prevalence was found among young heroin injectors.