Mj Belza

Sociodemographic characteristics and HIV risk behaviour patterns of male sex workers in Madrid, Spain.

This paper describes the sociodemographic and work characteristics, prevalence of HIV infection and associated risk behaviours among male sex workers (MSWs) in Madrid (Spain). Using an anonymous semi-structured questionnaire, educators attached to a mobile unit under a street-based prostitution programme surveyed 84 MSWs from several Madrid areas. Of the total surveyed: 35% were immigrants, mean age was 23 years, mean period in prostitution was four years; 21% had no primary education; 16% had injected drugs at some time; 11% reported private sexual relationships exclusively with women; 89% always used condoms in anal practices with clients; and 41% were in sexual relationships with their partners. Only 11% had ever used fortified condoms. In the preceding month, 37% had experienced condom failure, 82% without having used any lubricant. In all, 67% reported having undergone HIV testing, with a higher percentage of positive results among injecting (60%) versus non-injecting drug users (17%). Immigrants had a lower level of education, made less use of condoms, had more condom failures and, in their private lives, a greater proportion reported sexual relationships exclusively with women. In Spain, MSWs should be included in HIV prevention programmes, which ought to be specifically adapted to immigrants. Priority should be given to reducing the condom failure rate in anal intercourse, by improving access to fortified condoms.

Increasing Early Diagnosis of HIV through Rapid Testing in a Street Outreach Program in Spain

Our goal was to analyze the results of a multicity program offering rapid HIV testing in a mobile unit in central locations. Between October 2006 and December 2007, 7138 persons were tested, providing a finger-prick blood sample and filling out a brief questionnaire while waiting for the results of the Determine((R)) test. Seventy people were classified as reactive and 3 as indeterminate. Confirmatory test results were obtained for 83.6%. Of the 56 reactive persons contacted, 2 were confirmed as negative, giving a positive predictive value of 96.6%. Those tested were primarily men (60.6%), persons with university education (47.4%), and included a large percentage of immigrants (26.2%), especially from Latin America, and 37.3% were men who have sex with men (MSM). Forty-seven percent had ever been tested for HIV. Global HIV prevalence was 0.98% (confidence interval [CI]: 0.75-1.21), 1.59%, (CI: 1.21-1.97) in men and 0.19%, (CI: 0.02-0.35) in women. In the tree analysis the high prevalence node included Latin Americans with only primary studies (study level finished at least at the age of 12). Of the 64% HIV-positive tests in 2007 with available CD4 counts, 18.75% had CD4 counts under 350. Street-based mobile units offering rapid HIV testing in selected sites, may diagnose HIV at an earlier stage of infection than clinic-based sites, and have a low rate of false-positives.

Are Participants in a Street-Based HIV Testing Program Able to Perform Their Own Rapid Test and Interpret the Results?

Objective Availability of over-the-counter rapid HIV tests could improve access to testing those reluctant or unable to use current services. We aimed to evaluate the feasibility of HIV self-testing using a finger-stick whole-blood rapid test (Determine™ HIV Combo) to detect both antigen and antibody. Methods Before being tested, 313 participants in a street-based testing program were given adapted instructions and a test kit, and performed the self-test without supervision. These participants, together with another 207 who performed supervised self-testing, received additional instructions on how to interpret the test results shown in six colour photos and filled out a questionnaire. Logistic regression and generalized estimating equations (GEE) were used in the statistical analysis. Results About 8.0% (95%CI:4.8%–11.2%) obtained an invalid self-test. An invalid result was inversely associated with male participants who had sex with men (OR = 0.3;95%CI:0.1–1.0). Of the 3111 photos interpreted,4.9% (95%CI:4.1–5.7) were incorrect. Only 1.1% (95%CI:0.3–1.8) of the positive results were interpreted as negative. Age 30 or older (OR = 2.1; 95%CI:1.2–3.7), having been born in Latin America (OR = 1.6; 95%CI:1.1–2.2),and not having university education (OR = 2.1;95%CI:1.2–3.7) were associated with misinterpreting test results in the GEE. Participants perceptions of both their proficiency when conducting the test and interpretation were related with actual outcomes. Most participants (83.9%) were more motivated than before to use the self-test in the future, and 51.7% would pay >10 Euros for the test if it was sold in pharmacies. Conclusions This is the first study showing that blood-based self-testing with current technology is feasible in HIV-negative participants demanding the test and without prior training or supervision. Bearing in mind that it was conducted under difficult weather conditions and using a complex kit, over-the-counter tests could be a feasible option to complement current diagnostic strategies. More studies are needed to accommodate technology, minimise interpretation mistakes and provide on-line support.

Características sociales y conductas de riesgo para el VIH en un grupo de travestis y transexuales masculinos que ejercen la prostitución en la calle

Objetivo: Describir las condiciones de vida y de trabajo, las practicas asociadas a la transmision del VIH, la cobertura y los resultados autoinformados de la prueba de VIH, en un grupo de travestis y transexuales que ejercen la prostitucion en la calle. Metodos: Estudio descriptivo de serie de casos de travestis y transexuales masculinos que ejercian la prostitucion en la calle, en Madrid, y que fueron atendidas por la unidad movil de un programa de reduccion de danos en 1998. Se recogieron datos sobre caracteristicas sociodemograficas, condiciones de trabajo, consumo de drogas ilegales, conductas de riesgo sexual y estado serologico frente al VIH autoinformado. Resultados: Se entrevistaron 132 travestis y transexuales masculinos, de las cuales 56% eran espanolas. La mediana de edad era de 30 anos. El 50% tenia un nivel de estudios de EGB o inferior. El 11% se habia inyectado drogas ilegales alguna vez. La mediana de anos de prostitucion era de 8 anos y el 66% habia ejercido solo en la calle. En el ultimo mes, todas dijeron utilizar el preservativo en las practicas anales insertivas con los clientes, el 98% en las anales receptivas y el 49% lo utilizaron siempre con la pareja en el ultimo ano. El 39% tuvieron algun accidente con el preservativo en el ultimo mes. El 73% se habia realizado la prueba del VIH, siendo positivas el 22% (el 16% entre las que nunca se habian inyectado drogas y el 58% entre las que se habian inyectado alguna vez). Conclusiones: En travestis y transexuales que ejercen la prostitucion la prevalencia de VIH es elevada, incluso entre las no inyectoras. El uso del preservativo en el medio laboral es alto, pero tambien su accidentabilidad. Los programas de prevencion del VIH en prostitucion deberian adaptarse mas especificamente a los distintos grupos que la ejercen.

Educational differences in mortality and the relative importance of different causes of death: a 7-year follow-up study of Spanish adults

Background The evidence on mortality patterns by education in Spain comes from regional areas. This study aimed to estimate these patterns in the whole Spanish population. Methods All citizens aged 25 years and over and residing in Spain in 2001 were followed during 7 years to determine their vital status, resulting in a total of 196 470 401 person-years and 2 379 558 deaths. We estimated the age-adjusted total and cause-specific mortality by educational level—primary, lower secondary, upper secondary and university education—and then calculated the relative and absolute measures of inequality in mortality and contribution of the leading causes of death to absolute inequalities. Results Except for some cancer sites, the mortality rate for the leading causes of death shows an inverse gradient with educational level. The leading causes of death with the highest relative index of inequality ratios were HIV disease (9.81 in women and 11.61 in men), diabetes in women (4.02) and suicide in men (3.52). The leading causes of death that contribute most to the absolute inequality in mortality are cardiovascular diseases (48.8%), respiratory diseases (9.3%) and diabetes mellitus (8.8%) in women, and cardiovascular diseases (20.8%), respiratory diseases (19.8%) and cancer (19.6%) in men. Conclusions Although the causes of death with the strongest gradient in mortality rate are HIV disease in both sexes, diabetes mellitus in women and suicide in men, most of the absolute education-related inequalities in total mortality are due to cardiovascular diseases, respiratory diseases and diabetes mellitus in women and to cardiovascular diseases, respiratory diseases and cancer in men.

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.

Awareness and use of nonoccupational HIV post-exposure prophylaxis among people receiving rapid HIV testing in Spain.

This paper examines the awareness and use of nonoccupational HIV post‐exposure prophylaxis (nPEP) in Spain, and the factors that influence this awareness.

Assessment of an outreach street-based HIV rapid testing programme as a strategy to promote early diagnosis: a comparison with two surveillance systems in Spain, 2008-2011.

We assess the added value of a multisite, street-based HIV rapid testing programme by comparing its results to pre-existing services and assessing its potential to reduce ongoing transmission. Between 2008 and 2011, 8,923 individuals underwent testing. We compare outcomes with those of a network of 20 sexually transmitted infections (STI)/HIV clinics (EPI-VIH) and the Spanish National HIV Surveillance System (SNHSS); evaluate whether good visibility prompts testing and assess whether it reaches under-tested populations. 89.2% of the new infections were in men who have sex with men (MSM) vs 78.0% in EPI-VIH and 56.0% in SNHSS. 83.6% of the MSM were linked to care and 20.9% had <350 CD4 HIV prevalence was substantially lower than in EPI-VIH. 56.5% of the HIV-positive MSM tested because they happened to see the programme, 18.4% were previously untested and 26.3% had their last test ≥2 years ago. The programme provided linkage to care and early diagnosis mainly to MSM but attendees presented a lower HIV prevalence than EPI-VIH. From a cost perspective it would benefit from being implemented in locations highly frequented by MSM. Conversely, its good visibility led to reduced periods of undiagnosed infection in a high proportion of MSM who were not testing with the recommended frequency.

Inequalities in mortality at older ages decline with indicators of material wealth but persist with educational level

OBJECTIVE This study aimed to investigate the relationship between education and different indicators of material wealth with mortality, and to analyze whether this relationship varies with the leading causes of death. METHODS All persons aged 65 and older residing in Spain in 2001 were followed up for 7 years to determine their vital status. The relationship between mortality and four indicators of socioeconomic position (education, number of rooms in home, surface area of home and number of vehicles) was estimated in three age groups: 65-74, 75-84 and 85 and older. Rate ratios and relative index of inequality (RII) were calculated for general mortality and for the leading causes of death by Poisson regression. RESULTS In women, the mortality rate ratio for low vs. high educational level was 1.48 for persons aged 65-74, 1.43 for those aged 75-84 and 1.40 for those aged 85 and older. The respective rates for men were 1.30, 1.25 and 1.29. For the indicators of material wealth, the differences between morality rates in the lower vs. the higher socioeconomic categories decline with age. Mortality differences by the leading causes of death decline with age, except in the case of cancer in women and cardiovascular and digestive mortality in men according to educational level. CONCLUSIONS Relative socioeconomic differences in mortality in the older Spanish population decrease with age using indicators of material wealth but not using educational level. The variation in the pattern of mortality by cause of death by level of education may be responsible for these findings.

The rapid test in Spanish pharmacies: a novel programme to reach heterosexual men?†

Spain has been a pioneer in the implementation of rapid HIV testing programmes in pharmacies to increase access to testing. However, no formal evaluation of the effectiveness of these programmes has been carried out to date. Our aim was to evaluate the ability of a novel in‐pharmacy rapid HIV testing programme to promote diagnosis and reach vulnerable populations.