Laia Ferrer

Undiagnosed HIV infection in a population of MSM from six European cities: results from the Sialon project

OBJECTIVES The purpose of this article is to assess the distribution of undiagnosed HIV infection in men who have sex with men (MSM) in Southern and Eastern European countries, to describe the differences in epidemiology and behaviour between undiagnosed, diagnosed HIV-positive and HIV-negative MSM and to identify factors associated with undiagnosed HIV infection in the study population. METHODS A multi-centre biological and behavioural cross-sectional study was conducted in 2008. Time-location sampling was used to recruit men attending different venues. A self-administered questionnaire was completed and oral fluid samples were collected to estimate HIV prevalence. RESULTS HIV prevalence was 17% in Barcelona, 12% in Verona, 6% in Bratislava, 5% in Ljubljana, 5% in Bucharest and 3% in Prague while undiagnosed HIV infection was 47, 62, 67, 83, 85 and 57%, respectively. Diagnosed HIV-positive men reported more casual partners than HIV-negative MSM (mean: 19 and 9, respectively) (P < 0.001), and they were more likely to self-reported condyloma in the last year than undiagnosed HIV-positive and HIV-negative men (15, 1 and 3%, respectively) (P < 0.001). Factors associated with undiagnosed HIV infection included attending sex-focused venues (OR = 2.49), reporting syphilis in the previous 12 months (OR = 2.56), using poppers at last sexual intercourse (OR = 3.36) and having had an HIV test in the previous year (OR = 2.00). CONCLUSIONS Many HIV infections remain undiagnosed, and there is evidence of the persistence of frequent risk behaviours and sexually transmitted infections (STI) despite knowledge of HIV-positive status, emphasising the need for a multidimensional approach to HIV/STI prevention. Access to HIV testing should be considered a priority in prevention programs targeted at MSM, especially in Eastern Europe.

High HIV incidence among men who have sex with men attending a community-based voluntary counselling and testing service in Barcelona, Spain: results from the ITACA cohort

Objectives To identify the HIV incidence and its associated factors (AFs) of the ITACA, a community-based cohort of HIV-negative men who have sex with men (MSM) established in Barcelona, Spain from 2008 to 2011. Methods Participants were men aged 18 years or older, having a negative HIV test result at baseline and agreeing to participate. Bio-behavioural data were collected by peers in each visit. HIV incidence rates using person-time measures and 95% CIs were calculated. Cox logistic regression models were used to identify AFs to seroconversion. Results Over the period, 3544 participants with at least one follow-up visit or those who had a first visit no longer than a year prior to the date of data censoring were included in the analysis contributing 3567.09 person-year (p-y) and 85 MSM seroconverted for an overall HIV incidence of 2.4 per 100 p-y (95% CI 1.9 to 2.9) ranging from 1.21/100 (2009) to 3.1/100 p-y (2011). Independent AF included: foreign origin, having more than five HIV tests at baseline, reporting in the preceding 6 months the following: condomless anal sex with the last steady partner of unknown serostatus, more than 10 casual partners, condomless anal sex with casual partner, self-reported gonorrhoea and entered in the cohort in 2010 or 2011. Conclusions The ITACA cohort revealed a high and increasing HIV incidence among MSM, especially important among foreign-born men. The findings underscore the need to implement multilevel interventions for MSM taking into account different types of partners, cultural origins and the exposure to other sexually transmitted infections.

Bio-behavioural HIV and STI surveillance among men who have sex with men in Europe: the Sialon II protocols

BackgroundGlobally, the HIV epidemic continues to represent a pressing public health issue in Europe and elsewhere. There is an emerging and progressively urgent need to harmonise HIV and STI behavioural surveillance among MSM across European countries through the adoption of common indicators, as well as the development of trend analysis in order to monitor the HIV-STI epidemic over time. The Sialon II project protocols have been elaborated for the purpose of implementing a large-scale bio-behavioural survey among MSM in Europe in line with a Second Generation Surveillance System (SGSS) approach.Methods/DesignSialon II is a multi-centre biological and behavioural cross-sectional survey carried out across 13 European countries (Belgium, Bulgaria, Germany, Italy, Lithuania, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the UK) in community settings. A total of 4,966 MSM were enrolled in the study (3,661 participants in the TLS survey, 1,305 participants in the RDS survey). Three distinct components are foreseen in the study protocols: first, a preliminary formative research in each participating country. Second, collection of primary data using two sampling methods designed specifically for ‘hard-to-reach’ populations, namely Time Location Sampling (TLS) and Respondent Driven Sampling (RDS). Third, implementation of a targeted HIV/STI prevention campaign in the broader context of the data collection.DiscussionThrough the implementation of combined and targeted prevention complemented by meaningful surveillance among MSM, Sialon II represents a unique opportunity to pilot a bio-behavioural survey in community settings in line with the SGSS approach in a large number of EU countries. Data generated through this survey will not only provide a valuable snapshot of the HIV epidemic in MSM but will also offer an important trend analysis of the epidemiology of HIV and other STIs over time across Europe. Therefore, the Sialon II protocol and findings are likely to contribute significantly to increasing the comparability of data in EU countries through the use of common indicators and in contributing to the development of effective public health strategies and policies in areas of high need.

Hepatitis C virus infection and its relationship to certain sexual practices in men-who-have-sex-with-men in Spain: Results from the European MSM internet survey (EMIS)

OBJECTIVES To compare sexual practices and risk behaviours between MSM who were first diagnosed with hepatitis C (HCV) in the previous 12 months and those who were never diagnosed; and, to identify factors associated with a diagnosis of HCV. METHODS The European-MSM-Internet-Survey (EMIS) was implemented for 3 months during 2010, mainly on websites for MSM. Data on socio-demographic characteristics, sexual behaviour, drug use, STI history, and other sexual health variables were collected. The Chi-square test and logistic regression analysis were used to analyse the data. RESULTS Data from 13,111 respondents were analysed. The proportion of MSM who had ever been diagnosed with HCV infection was 1.9% (n=250), and of those currently infected with the virus was 0.6% (n=78). The percentage of those first diagnosed in the last 12 months was 0.4% (n=46), of whom 70% were HIV-negative and 22% had HIV coinfection. Having a first diagnosis of HCV in the last 12 months was more common among HIV-positive than among HIV-negative MSM (0.9% vs 0.4%) and among MSM born abroad than among Spanish-born (0.7% vs 0.3%). MSM diagnosed with HCV in the last 12 months were more likely to have had: more than 10 sexual partners, sex abroad, receptive anal intercourse, insertive/receptive fisting, and unprotected anal intercourse with non-steady partners of unknown or discordant HIV-status. Likewise, they reported more frequent visits to sex-focused venues, higher drug use, as well as a higher proportion of STI diagnosis. In the multivariate model, visiting a public sex-focused venue, practicing receptive fisting, using erection enhancing medication and having a diagnosis of syphilis were independently associated with a first diagnosis of HCV in the last 12 months. CONCLUSIONS HCV infection does not seem to be restricted to HIV-infected MSM. Certain sexual behaviour (fisting, visiting sex-focused venues), drug use, and ulcerative STI seem to be associated with a diagnosis of HCV.

Female sex workers and access to social and health services in Catalonia: Influence of region of origin and place of work

The objectives of the study were to describe the use of social and health services (SHS) of female sex workers (FSW) in Catalonia according to place of work and region of origin, and explore the barriers these women encountered when accessing these services. Quantitative and qualitative methods were combined. A questionnaire-based survey (n = 400) was conducted from October 2009 to January 2010, and complemented by focus group discussions technique (n = 23). More than 60% of FSW had used health services (HS) in the last 6 months (no differences by context of work and region of origin). Nevertheless, there were differences in the characteristics of health resources used. Although all women in clubs contracted the private HS provided by the club itself, they were those who least benefited from social services (SS), in particular Eastern-Europe women (24.6% in the last 6 months). The stigma and discrimination that FSW women suffer were one of the main barriers to access SHS. Women from Eastern Europe who worked in clubs were the most isolated and vulnerable women. Access to the public health system must continue to be provided for all FSW, assuring confidentiality and diminishing the burden associated with discrimination which they generally feel.

Socio-demographic Characteristics, Sexual and Test-Seeking Behaviours Amongst Men Who have Sex with Both Men and Women: Results from a Bio-behavioural Survey in 13 European Cities

Within the MSM population, men who have sex with both men and women (MSMW) are identified as a high-risk group both worldwide and in Europe. In a multi-centred bio-behavioural cross-sectional study, we aimed to assess the relationship(s) between socio-demographic factors, stigma, sexual behavioural patterns, test seeking behaviour and sero-status amongst MSMW. A multi-level analysis was conducted to identify factors associated with being MSMW versus Men who have Sex with Men Only (MSMO). A total of 4901 MSM were enrolled across the 13 study sites. Participants were categorised as MSMW in the 12.64% of the cases. Factors such as educational status, perceived homonegativity, testing facilities knowledge and HIV testing lifetime seem to be relevant factors when characterising the MSMW group. The results highlight the vulnerability of MSMW and the wide spectrum of risky behavioural and psycho-social patterns, particularly in terms of HIV testing, ‘outness’, and perceived stigma.ResumenLos Hombres que tienen Sexo con Hombres y Mujeres (HSHM) son un grupo de población de alto riesgo dentro de los HSH. Evaluar la relación entre factores socio-demográficos, estigma, patrones de conducta sexual y de búsqueda de la prueba y el estado serológico de los HSHM. Estudio bio-conductual multicéntrico transversal. Análisis multinivel para identificar factores asociados con ser HSHM respecto a los Hombres que Sólo tienen Sexo con Hombres. Se reclutaron 4.901 HSH en 13 ciudades, siendo un 12,64% HSHM. El nivel educativo, la homonegatividad percibida, el conocimiento de los lugares de realización de la prueba y la prueba del VIH alguna vez son factores relevantes para caracterizar los HSHM. Los resultados subrayan la vulnerabilidad de los HSHM y la diversidad de conductas y patrones psicosociales de riesgo, particularmente en términos de la prueba del VIH, visibilidad de la identidad sexual y estigma percibido.

CONDOM USE AMONG FEMALE SEX WORKERS IN CATALONIA: WHY DO THEY USE A CONDOM, WHY DON'T THEY USE IT?

The present study, based on social representation theory (Moscovici, 1961), aimed to identify the social representation of condom use (CU) in a collective of female sex workers (FSW) in Catalonia, considering both their work and private life. It involved 124 FSW and combined both qualitative and quantitative methodologies. Results suggest that both CU and non-CU represent strategies that FSW use mainly when confronted by threats to things they consider important. In work life, where CU is widespread, the most important thing is health protection, and the threat is represented by sexually transmitted infections. In private life, where non-CU is widespread, the most important thing is that their relationships adhere to an idealized relationship model, based on love, trust, and sexual gratification; this model lies in contrast to the status of the women as FSW. The threats are represented by both partner infidelity and their FSW status (symbolic threats).

S15.3 European MSM Internet Survey (EMIS): differences in sexually transmissible infection testing in European countries

Background Comparing rates of sexually transmissible infections (STIs) among men who have sex with men (MSM) in different European countries is challenging due to national differences in reporting systems, healthcare systems, infectious disease surveillance methods, quality of data, and/or levels of social acceptance of homosexual behaviours and openness about homosexuality. Methods From June through August 2010, the European MSM Internet Survey (EMIS) mobilised more than 180 000 respondents from 38 European countries to complete an online questionnaire in one of 25 languages. The questionnaire covered sexual happiness, HIV and STI-testing and diagnoses, unmet prevention needs, intervention performance, HIV-related stigma and gay-related discrimination. Recruitment was organised predominantly online, through gay social media, and links and banners on more than 100 websites for MSM all over Europe. Results Perceptions on access to free/affordable STI-testing differed across Europe (median: 80%; range: 40–95%); and was substantially correlated with reported recent STI-testing (R2=0.27). Quality of STI-testing was highly diverse: While blood-testing was common in all participating countries, only Ireland, Malta, and the UK seem to offer penile or particularly anal examinations as standard of care. In all participating countries HIV-positive respondents reported higher rates of both STI-testing and diagnosis. Self-reported STI-screening among men without HIV diagnosis ranged from 10% (Turkey) to 37% (Netherlands). Substantial correlations between rates of testing procedures appropriate for MSM (such as anal or genital swabs) and diagnosed gonorrhoea (R2HIV-pos=0.24) or Chlamydia infections were observed (R2HIV-pos=0.50; R2others=0.29). Conclusion Self-reported testing and diagnosis rates for bacterial STIs suggest high levels of under-diagnosis and unmet sexual healthcare needs in most European countries. In Europe, there is an urgent need to implement or improve sexual healthcare tailored to MSM-specific needs.