J del Romero

Absence of hepatitis C virus transmission in a prospective cohort of heterosexual serodiscordant couples

Objective: To analyse hepatitis C virus (HCV) transmission in a cohort of heterosexual couples who are discordant both for HIV and for HCV. Methods: We followed an open cohort of 171 people, 152 women and 19 men, who were not initially infected by either HIV or HCV, and whose steady heterosexual partner presented antibodies to both viruses (index case). Other risk exposures were excluded. Every 6 months clinical, epidemiological, and risk behaviour information was collected, and antibodies to both viruses were determined. Results: During 529 person years of follow up more than 40 000 vaginal or anal penetrations were recorded. 74 partners (43.3%) had vaginal and/or anal intercourse without condoms with the index case; another 15.8%, who always used condoms, declared breaking or slipping episodes during intercourse; and another 22.2% had unprotected orogenital exposures. During the follow up, over 5800 unprotected vaginal and anal contacts with the index case were estimated, as well as more than 25 000 unprotected orogenital contacts. 31 women became pregnant (two were index cases), and seroconversion to HIV occurred for one woman (1.7 per 10 000 unprotected contacts; 95% CI, 0 to 9.5), but there was no seroconversion to HCV (95% CI, 0–6.3 per 10 000 unprotected contacts). Conclusion: These results are consistent with a low or null transmissibility of HCV in heterosexual relations, even when the index case is HIV co-infected.

Influence of age and geographical origin in the prevalence of high risk human papillomavirus in migrant female sex workers in Spain.

Objectives: To estimate the prevalence and risk factors of high risk human papillomavirus (HPV) infection in migrant female sex workers (FSW) according to age and geographical origin. Methods: Cross sectional study of migrant FSW attending a sexually transmitted infection (STI) clinic in Madrid during 2002. Information on sociodemographic characteristics, reproductive and sexual health, smoking, time in commercial sex work, history of STIs, HIV, hepatitis B, hepatitis C, syphilis, and genitourinary infections was collected. High risk HPV Infection was determined through the Digene HPV Test, Hybrid Capture II. Data were analysed through multiple logistic regression. Results: 734 women were studied. Overall HPV prevalence was 39%; 61% in eastern Europeans, 42% in Ecuadorians, 39% in Colombians, 29% in sub-Saharan Africans, and 24% in Caribbeans (p = 0.057). HPV prevalence showed a decreasing trend by age; 49% under 20 years, 35% in 21–25 years,14% over 36 years% (p<0.005). In multivariate analyses, area of origin (p = 0.07), hormonal contraception in women not using condoms (OR 19.45 95% CI: 2.45 to 154.27), smoking, age, and an interaction between these last two variables (p = 0.039) had statistically significant associations with HPV prevalence. STI prevalence was 11% and was not related to age or geographical origin. Conclusions: High risk HPV prevalence in migrant FSW is elevated and related to age, area of origin, and use of oral contraceptives in women not using condoms. These data support the role of acquired immunity in the epidemiology of HPV infection and identifies migrant FSW as a priority group for sexual health promotion.

Prevalence and distribution of Hhv-8 in different subpopulations, with and without Hiv infection, in Spain

ObjectiveTo estimate the seroprevalence of HHV-8 in several Spanish subpopulations with different risk levels of acquiring HIV-1 infection and from different geographical regions. DesignCross-sectional seroprevalence study. MethodsA total of 1699 serum samples from blood donors (613), children under the age of 12 years (100), injecting drug users (IDU) (382), heterosexuals attending a sexually transmitted disease (STD) clinic (273) and homosexual men attending a STD clinic or a HIV-based hospital unit (331) were analysed for anti-HHV-8 antibodies. The presence of antibodies against HHV-8 was tested with an indirect immunofluorescence assay (IFA). A subsample of HHV-8-positive samples was also tested for antibody titre against HHV-8. ResultsThe overall seroprevalence of antibodies against HHV-8 for the blood donor population was 6.5% (7.0% in Andalusia, 8.0% in Catalonia and 4.5% in the Basque Country). None of the children tested positive for HHV-8. The HHV-8 prevalence was 86.7% in HIV-positive homosexual men and 28.0% in HIV-negative homosexual men (P < 0.001). Of heterosexual men attending STD clinics, 17.2% tested positive for HHV-8; 11.5% of IDU tested positive for HHV-8. HHV-8 antibody titres by groups parallel the distribution of HHV-8 prevalence. No association between HHV-8 antibody titres and CD4 cell count or HIV viral load was identified. ConclusionsThe HHV-8 prevalence among blood donors in Spain is higher than in Northern Europe and the USA, but is similar to that in Northern Italy. The distribution of HHV-8 is compatible with a sexually transmitted agent. The distribution of HHV-8 correlates with that of Kaposis sarcoma but factors other than HHV-8 seem to explain the Kaposi sarcoma distribution.

Inequalities in HIV disease management and progression in migrants from Latin America and sub-Saharan Africa living in Spain

The objective of the study was to analyse key HIV‐related outcomes in migrants originating from Latin America and the Spanish‐speaking Caribbean (LAC) or sub‐Saharan Africa (SSA) living in Spain compared with native Spaniards (NSP).

Factors influencing HIV progression in a seroconverter cohort in Madrid from 1985 to 1999

Objective: To study HIV progression from seroconversion over a 15 year period and measure the population effectiveness of highly active antiretroviral therapy (HAART). Methods: A cohort study of people with well documented dates of seroconversion. Cumulative risk of AIDS and death were calculated by extended Kaplan-Meier allowing for late entry. Cox proportional hazards models were used to study variables associated with HIV progression. To assess the impact of HAART, calendar time was divided in three periods; before 1992, 1992–6, and 1997–9. Results: From January 1985 to May 2000, 226 seroconverters were identified. The median seroconversion interval was 11 months, median seroconversion date was March 1993. 202 (89%) were men, 76% of whom were homo/bisexual. A 66% reduction in progression to AIDS was observed in 1997–9 compared to 1992–96 (HR 0.34 95% CI: 0.16 to 0.70). People with primary education appeared to have faster progression to AIDS compared to those with university studies (HR 2.69 95%CI: 1.17 to 6.16). An 82% reduction in mortality from HIV seroconversion was observed in 1997–9 (HR 0.18 95% CI: 0.05 to 0.68) compared to 1992–6. Progression to death for people with primary education was twice as fast as for those with university education (p 0.0007). People without confirmation of an HIV negative test had faster progression (HR 4.47 95% CI: 1.18 to 16.92). Conclusions: The reduction in progression to AIDS and death from seroconversion from 1992–6 to 1997–9 in Madrid is likely to be attributable to HAART. HIV progression was faster in subjects with primary education; better educational level may be associated with better adherence to medication.

Recently acquired HIV infection in Spain (2003-2005): introduction of the serological testing algorithm for recent HIV seroconversion.

Background: Identification of recent HIV infections provides a description of the current pattern of HIV transmission and, consequently, can help to design better preventive interventions. Our study shows the first implementation in Spain of the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) strategy. We assess the viability of introducing STARHS in our setting and describe the frequency and epidemiological characteristics of recent infections (RIs). Methods: Between 2003 and 2005, HIV-positive blood samples drawn for diagnostic purposes were collected from 28 Spanish laboratories to be tested using STARHS. Samples from patients with a previous HIV diagnosis, age <18 years, <200 CD4 cells/μL or clinical AIDS criteria were excluded from the analysis. Results: A total of 660 (19.2%) samples were classified as RI. Most people identified with RI were male (79.8%) with a median age of 33.1 years, and 62.5% occurred among men who have sex with men (MSM). Immigrants made up 26.5% of individuals identified with RIs, with 48.7% coming from South America. Among the individuals with RI, at least 16.5% had reported another sexually transmitted infection (STI) during the year before the HIV diagnosis. Conclusion: The study shows that the implementation of STARHS in our setting is feasible and has highlighted important features of the local HIV epidemic, such as the ongoing spread of HIV among MSM, the potential role of STIs in RIs and the vulnerability of immigrants as a new target population.

Effect of ignoring the time of HIV seroconversion in estimating changes in survival over calendar time in observational studies: results from CASCADE

ObjectiveTo compare estimates of changes in HIV survival over time derived from seroconverter and prevalent cohorts. Design and methodsUsing pooled data from 19 seroconverter cohorts (CASCADE), the relative risk of death from HIV seroconversion by calendar time at risk from 1 January 1991 was examined. The analyses were repeated, ignoring knowledge of the time of seroconversion, but adjusting for the CD4 cell count at the time the participant came under observation, thus mimicking a prevalent cohort. Estimates from the ‘prevalent’ cohort approach were compared with those obtained from the seroconverter cohort. ResultsOf 5428 subjects at risk on 1 January 1991 or later, 1312 (24.2%) had died. In the analysis based on time from seroconversion, estimates of the effect of calendar year showed marked reductions in mortality in 1997–1999 only, with no evidence of a linear trend over the period 1991–1996 (P-trend = 0.85). Using the prevalent cohort approach a decrease in the relative risk of death was observed from 1991 to 1998–1999, with a statistically significant trend of a decrease in risk from 1991 to 1996 (P-trend = 0.002). Similar findings were observed when the analyses was repeated taking the start date of the cohort as 1 January 1988. ConclusionLack of knowledge of HIV infection duration may lead to biased and exaggerated estimates of survival improvements over time. The adjustment for duration of infection in prevalent HIV cohorts through laboratory markers may compensate inadequately for this.

Imputación del instante de seroconversión al VIH en cohortes de hemofílicos

Objectives: To describe the methods used to impute HIV seroconversion date in the haemophiliac cohorts from GEMES project and to validate its use. Method: 632 haemophiliacs coming from three hemophilia units identified as HIV+ and 1.092 individuals coming from 5 project GEMES cohorts with a seroconversion window (time among test HIV‐ and HIV+) less than 3 years where mid point (PM) was assumed as seroconversion date. For both groups, seroconversion date was imputed after estimating the probability distribution of seroconversion by means of the EM algorithm. Two imputation methods are used: one obtained from the expected value and the other from the geometric mean of 5 random samples. from the estimated distribution. Imputations have been validated in the non haemophiliacs cohorts comparing with the PM seroconversion date. Also AIDS free time and survival from the different seroconversion imputed dates were compared. Results: Median seroconversion date is located in May of 1993 for the non haemophiliacs and in 1982 for the haemophiliacs. Not big differences are observed among the imputed seroconversion dates and the mid-point seroconversion date in the non-haemophiliac cohorts. Similar results are found for the haemophiliac cohorts. Also no differences are observed in the estimated AIDS-free time for both groups of cohorts. Conclusions: Geometric mean imputation from several random samples provides a good estimate of the HIV seroconversion date that can be used to estimate AIDS-free time and survival in haemophiliac cohorts where seroconversion date is ignored.

Categorías de exposición y seroprevalencia del VIH en adolescentes que se realizaron voluntariamente la prueba. Madrid, 1986–2000

Objetivos: Describir los cambios en los tipos de exposicion y en la prevalencia del VIH en adolescentes que se hicieron la prueba voluntaria entre 1986 y 2000. Metodos: Se incluyo a todos los adolescentes de 13 a 19 anos que se hicieron por primera vez la prueba del VIH en una clinica de enfermedades de transmision sexual de Madrid. Se determinaron anticuerpos en suero mediante ELISA y se confirmaron con Western blot. Se analizaron los cambios en los tipos de exposicion y en la seroprevalencia del VIH. Resultados: De los 1.327 adolescentes analizados (un 52% de mujeres) el 22% eran menores de 18 anos. El numero de adolescentes analizados anualmente se mantuvo, aunque descendieron los usuarios de drogas por via parenteral (UDVP) y las parejas de UDVP, y aumentaron las mujeres que ejercen la prostitucion. Se diagnosticaron 108 infecciones, el 71% en UDVP. La seroprevalencia fue del 8,1%, alcanzando el 31,3% en UDVP. Descendio desde 18,2% en 1986 al 1,5% en 1995, manteniendose desde entonces por debajo del 4%. En varias categorias de exposicion se observaron descensos, que alcanzaron significacion estadistica en varones homo/bisexuales y en mujeres que ejercen la prostitucion. El analisis de regresion logistica evidencio una reduccion anual de la seroprevalencia (odds ratio [OR] = 0,87; intervalo de confianza [IC] del 95%: 0,81-0,94) tras ajustar por los cambios en las categorias de exposicion. Conclusiones: La prevalencia del VIH ha descendido debido a la disminucion de nuevos UDVP y de la prevalencia en varias categorias de exposicion. Siguen produciendose conductas de riesgo e infecciones por el VIH en adolescentes.

Imputation of the date of HIV seroconversion in cohorts of haemophiliacs

OBJECTIVES To describe the methods used to impute HIV seroconversion date in the haemophiliac cohorts from GEMES project and to validate its use. METHOD 632 haemophiliacs coming from three hemophilia units identified as HIV+ and 1.092 individuals coming from 5 project GEMES cohorts with a seroconversion window (time among test HIV and HIV+) less than 3 years where mid point (PM) was assumed as seroconversion date. For both groups, seroconversion date was imputed after estimating the probability distribution of seroconversion by means of the EM algorithm. Two imputation methods are used: one obtained from the expected value and the other from the geometric mean of 5 random samples. from the estimated distribution. Imputations have been validated in the non haemophiliacs cohorts comparing with the PM seroconversion date. Also AIDS free time and survival from the different seroconversion imputed dates were compared. RESULTS Median seroconversion date is located in May of 1993 for the non haemophiliacs and in 1982 for the haemophiliacs. Not big differences are observed among the imputed seroconversion dates and the mid-point seroconversion date in the non-haemophiliac cohorts. Similar results are found for the haemophiliac cohorts. Also no differences are observed in the estimated AIDS-free time for both groups of cohorts. CONCLUSIONS Geometric mean imputation from several random samples provides a good estimate of the HIV seroconversion date that can be used to estimate AIDS-free time and survival in haemophiliac cohorts where seroconversion date is ignored.