Trends in HIV testing, prevalence among first-time testers, and incidence in most-at-risk populations in Spain: the EPI-VIH Study, 2000 to 2009

High HIV/STI prevalence among cisgender men and transgender women sex workers attending community-based centres in Barcelona, Spain: The Sweetie Project

Background

The aim of this study was to describe the socio-demographics, and the sexual and health-seeking behaviours of cisgender men and transgender women sex workers (M & TWSW) attending community-based organisations (CBOs) in Barcelona, Spain, as well as to estimate the prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), Chlamydia Trachomatis (CT) and Neisseria gonorrhoeae (NG) among them at different anatomical sites.

Methods

The Sweetie Project was a community-based cross-sectional study of 147 M & TWSW recruited in two CBOs in Barcelona between 2017 and 2018. A nurse collected biological samples from rectum, pharynx and urethra from the subjects at each CBO and the participants self-completed an epidemiological questionnaire.

Results

The highest prevalence observed was for HIV infection (25.3%) followed by bacterial STIs (NG 19.2% and CT 10.3%). The most prevalent anatomical site was pharyngeal (17.7%) followed by rectal (13.8%). More than half of participants who had a pharyngeal infection presented an isolated pharyngeal infection (57.7%) and half of those who had a rectal or urethral infection presented an isolated infection respectively. The seroprevalence of HCV and HBV was 2.4% and 34.2% respectively. There was a poor but statistically significant correlation between HIV and rectal CT infection ( r = 0.31), previous exposure to HCV ( r = 0.27) or self-reported STI ( r = 0.23), as well as between previous exposure to HCV and rectal CT ( r = 0.21) or self-reported STI ( r = 0.20).

Discussion

The Sweetie Project confirms the high burden of HIV and bacterial STIs among a sample of M&TWSW recruited in CBOs and reinforces the need to routinely screen them at all exposed anatomical sites.

Awareness and Use of HIV Self-Testing Among Men Who Have Sex With Men Remains Low in Spain 2 Years After Its Authorization

Objectives

HIV self-testing has been available in Spain since 2017 as a diagnostic tool to promote earlier diagnosis. We aimed to assess awareness and previous use of HIV self-testing in a sample of men who have sex with men (MSM) recruited online more than 2 years after its legal authorization in Spain.

Methods

We analyzed 5,492 MSM recruited between May and July 2020 in gay dating apps/websites and other social networks. We estimated the proportion of participants who were aware of the existence of HIV self-testing and the proportion who reported previous use. To identify factors associated with both outcomes we built two Poisson regression models. Among those who reported previous use we described several aspects related to their last self-test.

Results

Awareness of HIV self-test was reported by 29.7% and its previous use by 5% of participants. Awareness was independently associated with recruitment in gay dating apps/websites, being ≥40 years old, born in Spain-other European countries, having higher educational level, living in medium-small municipalities and living sex life openly. Independent associations were also found with having received a sexually transmitted infection diagnosis (STI) or an HIV negative test in the last 12 months, and being HIV positive. Use was significantly higher among participants who were paid for sex or diagnosed with an STI in the last 12 months and who received their last HIV test in the preceding year. Self-testing occurred recently, with kits acquired at pharmacies and carried out alone.

Conclusion

Awareness and use probably have not increased sufficiently in order to make a relevant impact to the promotion of early HIV diagnosis. Additional efforts, mainly focused on less favored MSM, should be made to take better advantage of the possibilities offered by this testing option.

Knowledge and Prior Use of HIV Self-Testing in Madrid and Barcelona among Men Who Have Sex with Men More than One Year after Its Legal Authorization in Spain

This study assessed the knowledge and prior use of HIV self-testing in a sample of men who have sex with men (MSM) recruited in a sexual health clinic and two community-based testing sites in Madrid and Barcelona, >12 months after its legal authorization. Between March 2019 and December 2020, we recruited 2044 MSM. Participants completed a self-administered questionnaire while waiting to be tested for HIV and other STIs. We built two Poisson regression models to assess factors associated with prior knowledge and with use. Among those who had used self-testing in the past we assessed frequency of use and several aspects related to the last testing episode. The proportion of participants that knew about the existence of self-testing and had already used it was of 26.3% and 5.1% respectively. Both, knowledge and use were independently associated with being born in Spain or other western European countries, university education and more recent HIV testing. Additionally, knowledge was associated with older age, having a more favorable economic situation, and not living sexuality in total secrecy. Use was also associated with having received money in exchange for sex. Most (69.5%) reported having self-tested once, 64.8% had self-tested <12 months ago, 63.8% self-tested alone and 71.4% acquired the kit at a pharmacy over the counter. In spite of its authorization and becoming legally available, knowledge and use of HIV self-testing remain low among MSM attending sites specialized in the diagnosis of HIV and other STIs. When designing scale-up strategies, lower levels of knowledge and use in less favored subgroups of MSM need to be factored in.

The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis

Introduction

Transgender individuals are at risk for HIV. HIV risks are dynamic and there have been substantial changes in HIV prevention (e.g., pre-exposure prophylaxis [PrEP]). It is thus time to revisit HIV prevalence and burden among transgender individuals. The objective of this systematic review and meta-analysis was thus to examine worldwide prevalence and burden of HIV over the course of the epidemic among trans feminine and trans masculine individuals.

Methods

We conducted an updated systematic review by searching PsycINFO, PubMed, Web of Science, and Google Scholar, for studies of any research design published in in a peer-reviewed journal in any language that reported HIV prevalence among transgender individuals published between January 2000 and January 2019. Two independent reviewers extracted the data and assessed methodological quality. We then conducted a meta-analysis, using random-effects modelling, to ascertain standardized prevalence and the relative burden of HIV carried by transgender individuals by country and year of data collection, and then by geographic region. We additionally explored the impact of sampling methods and pre-exposure prophylaxis (PrEP).

Results

Based on 98 studies, overall standardized HIV prevalence over the course of the epidemic, based on weights from each country by year, was 19.9% (95% CI 14.7% - 25.1%) for trans feminine individuals (n = 48,604) and 2.56% (95% CI 0.0% - 5.9%) for trans masculine individuals (n = 6460). Overall OR for HIV infection, compared with individuals over age 15, was 66.0 (95% CI 51.4–84.8) for trans feminine individuals and 6.8 (95% CI 3.6–13.1) for trans masculine individuals. Prevalence varied by geographic region (13.5% - 29.9%) and sampling method (5.4% - 37.8%). Lastly, PrEP effects on prevalence could not be established.

Conclusion

Trans feminine and trans masculine individuals are disproportionately burdened by HIV. Their unique prevention and care needs should be comprehensively addressed. Future research should further investigate the impact of sampling methods on HIV prevalence, and monitor the potential impact of PrEP.

Health care issues affecting transgender people living with HIV: an opportunity for improvement

The high vulnerability of transgender (TG) persons to HIV infection and the difficulties associated with access to health services can lead to delays in the diagnosis and treatment of HIV infection, thus increasing the risk of transmission of HIV by this population. We performed a retrospective study to analyze the main characteristics of TG living with HIV infection in a hospital in Madrid, Spain and to identify issues related to lack of access to the health care system and combination antiretroviral therapy (cART). We analyzed 28 TG, of whom 22 (78.6%) were TG women. Median age was 28 years (interquartile range [IQR]: 29-45), 24 (85.7%) were Latin American (all of them without health insurance), and 12 (42.8%) were sex workers. Accessibility to the health system was more difficult for 22 (78.6%) of foreign-born TG people living with HIV, with a median delay to initiation of cART of six months (IQR: 2-24). These values were greater than those recorded for the control group comprising other people living with HIV (16.9% and one month, respectively). At the first access to health care in our hospital, CD4+ cell count and HIV viral load (VL) were worse in TG patients, with a median baseline CD4+ cell count below 350 cells/µl and a higher median HIV VL, both in naïve patients (28.6%) and in pre-treated patients whose therapy was interrupted owing to access-related issues (46.4%). These data show high vulnerability to HIV infection among TG and highlight that issues associated with access to health care can cause delays in the diagnosis and treatment of HIV infection. Based on our results, we think that the health care system should adapt to the sociodemographic, clinical, and behavioral characteristics of TG people living with HIV and develop specific, targeted preventive programs to address the vulnerability of this group.

Outreach HIV testing using oral fluid and online consultation of the results: Pilot intervention in Catalonia

INTRODUCTION

The aim of the intervention was to describe the feasibility and cost-effectiveness of offering HIV testing in outreach interventions and subsequent consultation of the results through a secure web page.

METHODS

The HIV test was offered "in situ" to men who have sex with men (MSM), migrant sex workers and trans women recruited in places of leisure and sex. Four collaborating NGOs recruited the participants and assisted them to register on the study website (www.swab2know.eu) through a tablet or the smartphone of the same participant. The samples were sent to the reference laboratory and the results were published on the website.

RESULTS

834 participants (612 MSMs, 203 women sex workers and 19 trans women) were recruited. In total 22 reagent results (2.6%) were detected: 21 among MSMs (3.4%) and 1 in a trans women (5.3%). While 82.6% of MSMs consulted their outcome, only 39.9% and 26.3% of women sex workers and trans women respectively consulted their outcome CONCLUSIONS: Providing self-sampling in outreach activities, dispatch and analysis in a reference laboratory as well as online communication of test results is feasible. A high proportion of participants with a HIV reactive result were detected among MSMs and trans women.

HIV self-testing in Spain: A valuable testing option for men-who-have-sex-with-men who have never tested for HIV

BACKGROUND

We assessed the capacity of HIV self-testing to promote testing among untested men who have sex with men (MSM) and determined the most benefited subpopulations.

METHODS

An online questionnaire was disseminated on several gay websites in Spain from September 2012 to April 2013. We used Poisson regression to estimate factors associated with the intention to use self-testing if already available. Among those who reported intention of use, we assessed several aspects related to the testing and linkage to care process by type of barrier reported: low perceived risk (LR), structural barriers (SB) and fear of testing positive (FTP).

RESULTS

Of 2589 never-tested MSM, 83% would have used self-testing if already available. Intention of use was associated with age ≥30 (adj.PR, 95%CI: 1.05, 1.01-1.10), having had protected (adj.PR, 95%CI: 1.15, 1.02-1.30) or unprotected (adj.PR, 95%CI: 1.21, 1.07-1.37) anal intercourse and reporting FTP (adj.PR, 95%CI: 1.12, 1.05-1.20) or SB to access HIV testing (adj.PR, 95%CI: 1.23, 1.19-1.28). Among those who reported intention of using a self-testi, 78.3% declared it their preferred option (83.8% in the SB group; p<0.001), and 56.8% would always use this testing option (60.9% among the SB group; p = 0.001). In the case of obtaining a positive self-test, 69.3% would seek confirmatory testing, 15.3% would self-test again before taking any decision and 13.0% reported not being sure of what they would do.

CONCLUSION

HIV self-testing in Spain has the potential of becoming a highly used testing methodology for untested MSM and could represent the gateway to testing especially among older, at risk MSM who report SB or FTP as main barriers to testing.

Epidemiology and current control of sexually transmitted infections. The role of STI clinics

The burden of disease from sexually transmitted infections (STI) undermines sexual and reproductive health and the health of newborn infants. The presence of some STI facilitates the transmission of others, such as HIV, and cause cellular changes that precede some types of cancer. For all these reasons STIs are a first order uncontrolled public health problem. In Spain, gonococcal infection has been on rising since the beginning of 2000, while syphilis has remained stable at high levels since 2011. Both infections are more common in males. Chlamydia trachomatis is the most common STI, and principally affects females between the ages of of 20 and 40. STI units are an essential instrument to tackle this problem. They deal with populations that are particularly vulnerable to these infections and are essential for their control by means of interventions that reduce their transmission efficiency and infectivity duration. They are also the principal source of epidemiological information about these infections.

Genome-scale analysis of evolutionary rate and selection in a fast-expanding Spanish cluster of HIV-1 subtype F1

This work is aimed at assessing the presence of positive selection and/or shifts of the evolutionary rate in a fast-expanding HIV-1 subtype F1 transmission cluster affecting men who have sex with men in Spain. We applied Bayesian coalescent phylogenetics and selection analyses to 23 full-coding region sequences from patients belonging to that cluster, along with other 19 F1 epidemiologically-unrelated sequences. A shift in the overall evolutionary rate of the virus, explained by positively selected sites in the cluster, was detected. We also found one substitution in Nef (H89F) that was specific to the cluster and experienced positive selection. These results suggest that fast transmission could have been facilitated by some inherent genetic properties of this HIV-1 variant.

The importance of accounting for testing and positivity in surveillance by time and place: an illustration from HIV surveillance in Japan

The number of tests performed is an important surveillance indicator. We illustrate this point using HIV surveillance data, focusing on Tokyo and Okinawa, two prefectures with high HIV notification rates in Japan. Restricting to data reported from local public health centres and affiliate centres where testing data are accessible, we assessed HIV surveillance data during 2007-2014, based on the annual HIV notification rate (per 100 000 population), HIV testing rate (per 100 000 population) and proportion testing HIV-positive (positivity). Nationally, testing activity and positivity showed an inverse relationship; in 2008, the testing rate peaked, but positivity was lowest. While notification rates were higher for Tokyo (median = 0.98, range = 0.89-1.33) than Okinawa (median = 0.61, range = 0.42-1.09), Okinawa had slightly higher testing rates (median = 187, range = 158-274) relative to Tokyo (median = 172, range = 163-210). Positivity was substantially lower in Okinawa (median = 0.34%, range = 0.24-0.45%) compared with Tokyo (median = 0.57%, range = 0.46-0.67%). Relative to the national testing rate (median = 85, range = 80-115) and positivity (median = 0.34%, range = 0.28-0.36%), Tokyo had higher positivity, despite more testing. In 2014 in Okinawa, all three indicators increased, providing a strong reason to be concerned as positivity increased despite more testing. Together with other information, accounting for testing and positivity improve interpretation of surveillance data to guide public health assessments.

Behavioural and demographic correlates of undiagnosed HIV infection in a MSM sample recruited in 13 European cities

Background

Reducing the number of people with undiagnosed HIV infection is a major goal of HIV control and prevention efforts in Europe and elsewhere. We analysed data from a large multi-city European bio-behavioural survey conducted among Men who have Sex with Men (MSM) for previously undiagnosed HIV infections, and aimed to characterise undiagnosed MSM who test less frequently than recommended.

Methods

Data on sexual behaviours and social characteristics of MSM with undiagnosed HIV infection from Sialon II, a bio-behavioural cross-sectional survey conducted in 13 European cities in 2013/2014, were compared with HIV-negative MSM. Based on reported HIV-testing patterns, we distinguished two subgroups: MSM with a negative HIV test result within 12 months prior to the study, i.e. undiagnosed incident infection, and HIV positive MSM with unknown onset of infection. Bivariate and multivariate associations of explanatory variables were analysed. Distinct multivariate multi-level random-intercept models were estimated for the entire group and both subgroups.

Results

Among 497 participants with HIV-reactive specimens, 234 (47.1%) were classified as previously diagnosed, 106 (21.3%) as incident, and 58 (11.7%) as unknown onset based on self-reported status and testing history. MSM with incident HIV infection were twice as likely (odds ratio (OR) = 2.22, 95% confidence interval (95%CI): 1.17–4.21) to have used recreational substances during their last anal sex encounter and four times more likely (OR = 3.94, 95%CI: 2.14–7.27) not to discuss their HIV status with the last anal sex partner(s). MSM with unknown onset of HIV infection were 3.6 times more likely (OR = 3.61, 95%CI: 1.74–7.50) to report testing for a sexually transmitted infection (STI) during the last 12 months.

Conclusions

Approximately one third of the study participants who are living with HIV were unaware of their infection. Almost two-third (65%) of those with undiagnosed HIV appeared to have acquired the infection recently, emphasizing a need for more frequent testing. Men with the identified behavioural characteristics could be considered as primary target group for HIV Pre-Exposure Prophylaxis (PrEP) to avoid HIV infection. The increased odds of those with unknown onset of HIV infection to have had an STI test in the past year strongly suggests a lost opportunity to offer HIV testing.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3249-8) contains supplementary material, which is available to authorized users.

Molecular evolution methods to study HIV-1 epidemics

Nucleotide sequences of HIV isolates are obtained routinely to evaluate the presence of resistance mutations to antiretroviral drugs. But, beyond their clinical use, these and other viral sequences include a wealth of information that can be used to better understand and characterize the epidemiology of HIV in relevant populations. In this review, we provide a brief overview of the main methods used to analyze HIV sequences, the data bases where reference sequences can be obtained, and some caveats about the possible applications for public health of these analyses, along with some considerations about their limitations and correct usage to derive robust and reliable conclusions.

Knowledge and Concern about STIs/HIV and Sociodemographic Variables Associated with Getting Tested for HIV Among the General Population in Spain

HIV testing is important in terms of prevention and treatment. However, HIV testing rates in the Spanish general population remains low. Therefore, HIV testing promotion constitutes a key issue. A high level of knowledge about HIV/AIDS is associated with having been tested for HIV. The general aim of this study was to determine the prevalence of people who had ever been tested for HIV in Spain. The sample consisted of 1,106 participants from the general population - 60.0% females and 40.0% males - aged between 17 and 55 years old. The assessment instruments were a questionnaire on sociodemographic data and HIV testing, a scale of knowledge about STIs and HIV/AIDS, and a scale of concern about STIs/HIV. Results showed that greater knowledge about STIs and HIV was associated with a greater likelihood of being tested for HIV (OR = .77; 95.0% CI = .73-.82; p < .05). In addition, higher concern about HIV/AIDS decreased the likelihood of not having been tested for HIV (OR = .87; 95.0% CI = .83-.92; p < .05). In fact, the higher participants concern about STIs was, the lower their likelihood of not having been tested for HIV was (OR = .87; 95.0% CI = .83-.91; p < .05). It is necessary to promote HIV testing in the general population as well as to consider their socio-demographic and psychological characteristics.

High levels of postmigration HIV acquisition within nine European countries

OBJECTIVE

We aimed to estimate the proportion of postmigration HIV acquisition among HIV-positive migrants in Europe.

DESIGN

To reach HIV-positive migrants, we designed a cross-sectional study performed in HIV clinics.

METHODS

The study was conducted from July 2013 to July 2015 in 57 clinics (nine European countries), targeting individuals over 18 years diagnosed in the preceding 5 years and born abroad. Electronic questionnaires supplemented with clinical data were completed in any of 15 languages. Postmigration HIV acquisition was estimated through Bayesian approaches combining extensive information on migration and patients' characteristics. CD4 cell counts and HIV-RNA trajectories from seroconversion were estimated by bivariate linear mixed models fitted to natural history data. Postmigration acquisition risk factors were investigated with weighted logistic regression.

RESULTS

Of 2009 participants, 46% were MSM and a third originated from sub-Saharan Africa and Latin America & Caribbean, respectively. Median time in host countries was 8 years. Postmigration HIV acquisition was 63% (95% confidence interval: 57-67%); 72% among MSM, 58 and 51% in heterosexual men and women, respectively. Postmigration HIV acquisition was 71% for Latin America and Caribbean migrants and 45% for people from sub-Saharan Africa. Factors associated with postmigration HIV acquisition among heterosexual women and MSM were age at migration, length of stay in host country and HIV diagnosis year and among heterosexual men, length of stay in host country and HIV diagnosis year.

CONCLUSION

A substantial proportion of HIV-positive migrants living in Europe acquired HIV postmigration. This has important implications for European public health policies.

Immunogenicity of a novel Clade B HIV-1 vaccine combination: Results of phase 1 randomized placebo controlled trial of an HIV-1 GM-CSF-expressing DNA prime with a modified vaccinia Ankara vaccine boost in healthy HIV-1 uninfected adults

Background

A phase 1 trial of a clade B HIV vaccine in HIV-uninfected adults evaluated the safety and immunogenicity of a DNA prime co-expressing GM-CSF (Dg) followed by different numbers and intervals of modified vaccinia Ankara Boosts (M). Both vaccines produce virus-like particles presenting membrane-bound Env.

Methods

Four US sites randomized 48 participants to receiving 1/10^th the DNA dose as DgDgMMM given at 0, 2, 4, 6 and 8 months, or full dose DgDgM_M or DgDgMM_M regimens, given at 0, 2, 4, and 8 months, and 0, 2, 4, 6, and 10 months, respectively. Peak immunogenicity was measured 2 weeks post-last vaccination.

Results

All regimens were well tolerated and safe. Full dose DgDgM_M and DgDgMM_M regimens generated Env-specific IgG to HIV-1 Env in >90%, IgG3 in >80%, and IgA in <20% of participants. Responses to gp140 and gp41 targets were more common and of higher magnitude than to gp120 and V1V2. The gp41 antibody included reactivity to the conserved immunodominant region with specificities known to mediate virus capture and phagocytosis and did not cross-react with a panel of intestinal flora antigens. The 3^rd dose of MVA increased the avidity of elicited antibody (7.5% to 39%), the ADCC response to Bal gp120 (14% to 64%), and the one-year durability of the IgG3 responses to gp41 by 4-fold (13% vs. 3.5% retention of peak response). The co-expressed GM-CSF did not enhance responses over those in trials testing this vaccine without GM-CSF.

Conclusion

This DNA/MVA prime-boost regimen induced durable, functional humoral responses that included ADCC, high antibody avidity, and Env IgG1 and IgG3 binding responses to the immunodominant region of gp41. The third, spaced MVA boost improved the overall quality of the antibody response. These products without co-expressed GM-CSF but combined with protein boosts will be considered for efficacy evaluation.

Trial registration

ClinicalTrials.gov NCT01571960

Differences between migrants and Spanish-born population through the HIV care cascade, Catalonia: an analysis using multiple data sources

Migrants are considered a key group at risk for HIV infection. This study describes differences between migrants and the Spanish-born population as they progress through the HIV care cascade in Catalonia, Spain. This study found that among people reached by prevention activities, migrants had a higher number of barriers to access HIV testing services than Spanish-born people, driven primarily by shared risk factors. Between 2001 and 2013, 9829 new HIV diagnoses were reported in Catalonia, the proportion of migrants increasing from 24% in 2001 to 41% in 2013. Compared with Spanish-born people, migrants had a higher proportion of women at diagnosis (24·6% vs. 16·7%), and were younger (median age of 33 vs. 37). The most frequent at-risk population was MSM (men who have sex with men) in both migrants and Spanish-born people, (40% and 43%, respectively), although there were significant differences by region of origin. People from sub-Saharan Africa had the highest proportion of late diagnosis (63·7%). Compared with the Spanish-born population, migrants on follow-up had a lower proportion of people on antiretroviral therapy (ART) (93·7% vs. 90·8%, P < 0·001) and with viral suppression (87·2% vs. 82·9%, P < 0·001). Migrants have higher number of barriers to access HIV testing services, lower retention rates and proportions on ART as compared with Spanish-born people, these differences not being uniform between migrants from different regions.

Executive summary: Pre-exposure prophylaxis for prevention of HIV infection in adults in Spain: July 2016

Administration of antiretroviral drugs to individuals exposed to, but not infected by, HIV has been shown to reduce the risk of transmission. The efficacy of pre-exposure prophylaxis (PrEP) makes it obligatory to include it in an integral program of prevention of HIV transmission, together with other measures, such as use of the condom, training, counseling, and appropriate treatment of infected individuals. In this document, the AIDS Study Group (GeSIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology (Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica [SEIMC]) provides its views on this important subject. The available evidence on the usefulness of PrEP in the prevention of transmission of HIV is presented, and the components that should make up a PrEP program and whose development and implementation are feasible in Spain are set out.

Identification of a large, fast-expanding HIV-1 subtype B transmission cluster among MSM in Valencia, Spain

We describe and characterize an exceptionally large HIV-1 subtype B transmission cluster occurring in the Comunidad Valenciana (CV, Spain). A total of 1806 HIV-1 protease-reverse transcriptase (PR/RT) sequences from different patients were obtained in the CV between 2004 and 2014. After subtyping and generating a phylogenetic tree with additional HIV-1 subtype B sequences, a very large transmission cluster which included almost exclusively sequences from the CV was detected (n = 143 patients). This cluster was then validated and characterized with further maximum-likelihood phylogenetic analyses and Bayesian coalescent reconstructions. With these analyses, the CV cluster was delimited to 113 patients, predominately men who have sex with men (MSM). Although it was significantly located in the city of Valencia (n = 105), phylogenetic analyses suggested this cluster derives from a larger HIV lineage affecting other Spanish localities (n = 194). Coalescent analyses estimated its expansion in Valencia to have started between 1998 and 2004. From 2004 to 2009, members of this cluster represented only 1.46% of the HIV-1 subtype B samples studied in Valencia (n = 5/143), whereas from 2010 onwards its prevalence raised to 12.64% (n = 100/791). In conclusion, we have detected a very large transmission cluster in the CV where it has experienced a very fast growth in the recent years in the city of Valencia, thus contributing significantly to the HIV epidemic in this locality. Its transmission efficiency evidences shortcomings in HIV control measures in Spain and particularly in Valencia.

STI tests and proportion of positive tests in female sex workers attending local public health departments in Germany in 2010/11

BACKGROUND

In Germany, local public health departments (LPHD) are required to offer low-threshold access to confidential counselling and testing for sexually transmitted infections (STI) for sex workers. We collected data from LPHD in Germany to estimate the number of performed STI tests and the proportion of positive STI tests among attending female sex workers (FSW) in order to formulate recommendations for improving STI testing and care for FSW in Germany.

METHODS

We recruited LPHD across Germany to collect aggregated data on attending FSW between January 2010 and March 2011. Baseline characteristics, the number of attending FSW, STI tests (HIV, Chlamydia trachomatis, Neisseria gonorrhoea, syphilis and Trichomonas vaginalis) and the number of positive results were provided by participating LPHD. We described the number of STI tests per FSW visit and the proportion of positive test results, including interquartile range (IQR). We tested whether baseline characteristics of LPHD were associated with the proportion of positive test results.

RESULTS

Overall, 28 LPHD from 14 of the 16 federal states reported 9284 FSW visits over the study period, with a median of 188 FSW visits (IQR 45-440) per LPHD. Overall, a median of 77.1% (IQR 60.7-88.0) of visiting FSW received a test for Neisseria gonorrhoea, followed by HIV (66.0%, IQR 47.9-86.8), Chlamydia trachomatis (65.4%, IQR 50.7-83.6) and syphilis (61.6, IQR 48.6-78.6). In total, 22,914 STI tests were performed. The proportion of positive tests was 3.1% (IQR 1.3-4.8), with the highest proportion of positive tests for Chlamydia trachomatis (6.8%, IQR 2.5-10.4), followed by Neisseria gonorrhoea (3.2%, IQR 0.0-5.3), Trichomonas vaginalis (3.0%, IQR 0.0-15.4), syphilis (1.1%, IQR 0.0-1.3) and HIV (0.2%, IQR 0.0-0.4). The proportion of positive tests varied between 0 and 13.9% between LPHD, with a higher variation of proportion of positive tests in LPHD with a smaller number of reported STI tests.

CONCLUSIONS

Participating LPHD varied in terms of performed STI tests and FSW visits. The proportion of positive STI tests was low, but varied between LPHD. This variation likely reflects different testing strategies. Existing testing guidelines should be used by all LPHD to ensure high quality care for FSW.

Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People

INTRODUCTION

Transgender populations have been underrepresented in HIV epidemiologic studies and consequently in HIV prevention, care, and treatment programs. Since 2012, there has been a dramatic increase in research focused on transgender people. Studies highlight the burden of HIV and risk determinants, including intersecting stigmas, as drivers of syndemics among transgender populations. This review synthesizes the most recent global epidemiology of HIV infection and describes current gaps in research and interventions to inform prioritization of HIV research for transgender populations.

METHODS

A systematic review was conducted of the medical literature published between January 1, 2012 and November 30, 2015. The data focused on HIV prevalence, determinants of risk, and syndemics among transgender populations.

RESULTS

Estimates varied dramatically by location and subpopulation. Transfeminine individuals have some of the highest concentrated HIV epidemics in the world with laboratory-confirmed prevalence up to 40%. Data were sparse among trans masculine individuals; however, they suggest potential increased risk for trans masculine men who have sex with men (MSM). No prevalence data were available for transgender people across Sub-Saharan Africa or Eastern Europe/Central Asia. Emerging data consistently support the association of syndemic conditions with HIV risk in transgender populations.

DISCUSSION

Addressing syndemic conditions and gender-specific challenges is critical to ensure engagement and retention in HIV prevention by transgender populations. Future research should prioritize: filling knowledge gaps in HIV epidemiology; elucidating how stigma shapes syndemic factors to produce HIV and other deleterious effects on transgender health; and understanding how to effectively implement HIV interventions for transgender people.

Awareness of Pre-exposure Prophylaxis for HIV, Willingness to Use It and Potential Barriers or Facilitators to Uptake Among Men Who Have Sex with Men in Spain

There is a lack of data on pre-exposure prophylaxis (PrEP) effectiveness in Spain. We described the awareness of and willingness to use PrEP and examined potential barriers and facilitators to their use among men who have sex with men recruited either online or in voluntary HIV testing centers in Spain. Nearly a third of men (28.7 %) were aware of PrEP and 57.6 % said they would be willing to use it if available, 16.6 % saying they would be unwilling to use PrEP and 25.8 % not being sure. Men who had heard of PrEP were more forceful in their opinions on willingness to use PrEP (willing/not willing: 29.8 %/32.6 % vs. don't know: 21.8 %). The greatest consensus regarding more acceptable PrEP attributes was in the mode of delivery and its cost. Doctors (91 %) or pharmacists (85.3 %) were the preferred providers. The results confirm the need to inform and educate on PrEP and define implementation strategies.

Provider-Initiated HIV Testing for Migrants in Spain: A Qualitative Study with Health Care Workers and Foreign-Born Sexual Minorities

Introduction

Provider-initiated HIV testing (PITC) is increasingly adopted in Europe. The success of the approach at identifying new HIV cases relies on its effectiveness at testing individuals most at risk. However, its suitability to reach populations facing overlapping vulnerabilities is under researched. This qualitative study examined HIV testing experiences and perceptions amongst Latin-American migrant men who have sex with men and transgender females in Spain, as well as health professionals’ experiences offering HIV tests to migrants in Barcelona and Madrid.

Methods

We conducted 32 in-depth interviews and 8 discussion groups with 38 Latin-American migrants and 21 health professionals. We imported verbatim transcripts and detailed field work notes into the qualitative software package Nvivo-10 and applied to all data a coding framework to examine systematically different HIV testing dimensions and modalities. The dimensions analysed were based on the World Health Organization “5 Cs” principles: Consent, Counselling, Connection to treatment, Correctness of results and Confidentiality.

Results

Health professionals reported that PITC was conceptually acceptable for them, although their perceived inability to adequately communicate HIV+ results and resulting bottle necks in the flow of care were recurrent concerns. Endorsement and adherence to the principles underpinning the rights-based response to HIV varied widely across health settings. The offer of an HIV test during routine consultations was generally appreciated by users as a way of avoiding the embarrassment of asking for it. Several participants deemed compulsory testing as acceptable on public health grounds. In spite of—and sometimes because of—partial endorsement of rights-based approaches, PITC was acceptable in a population with high levels of internalised stigma.

Conclusion

PITC is a promising approach to reach sexual minority migrants who hold high levels of internalised stigma but explicit extra efforts are needed to safeguard the rights of the most vulnerable.

Effects of region of birth, educational level and age on late presentation among men who have sex with men newly diagnosed with HIV in a network of STI/HIV counselling and testing clinics in Spain

This paper analyses late presentation (LP) of HIV infection, and its determinants, among men who have sex with men (MSM) in Spain, newly diagnosed with HIV (2003-2011) in 15 sexually transmitted infection/HIV counselling and testing clinics. LP was defined as <350 CD4 cells/µL or AIDS. In total, 3,081 MSM were included (2,499 having CD4/AIDS); overall LP was 25.3%. LP was higher in men older than 34 years, those not previously HIV-tested (adjusted odds ratio (aOR):3.1; 95% confidence intervals (CI):2.3-4.2) , and those tested > 12 months before diagnosis (12-24 months (aOR:1.4; 95% CI:1.0-2.0); > 24 months (aOR:2.2; 95% CI:1.7-3.0)). LP was less likely in MSM reporting a known HIV-infected partner as infection source or symptoms compatible with acute retroviral syndrome. 'Region of birth' interacted with 'educational level' and 'steady partner as infection source': only African and Latin-American MSM with low educational level were more likely to present late; Latin-American men attributing their infection to steady partner, but no other MSM, had LP more frequently. In Spain, HIV testing among MSM should be promoted, especially those > 34 years old and migrants with low educational level. The current recommendation that MSM be tested at least once a year is appropriate.