Belgian 2024 guidance on the use of pre-exposure prophylaxis

OBJECTIVES

We aimed to develop a guidance on the use of pre-exposure prophylaxis (PrEP) for HIV tailored to the Belgian context.

METHODS

Different aspects of PrEP care were judged by an expert group of nine Belgian clinicians, seeking consensus for areas of controversies.

RESULTS

PrEP should be considered in HIV negative patients at high risk of acquiring HIV. Currently, only oral tenofovir/emtricitabine is available in Belgium for PrEP, which can be used daily, or also event-driven in cisgender men and trans women who are not taking exogenous estradiol-based hormones. Personal counselling directed at medication adherence and sexual health should have a central role in PrEP care. At the initial assessment clinicians should give attention to symptoms of an acute HIV infection, the patients' immunization status and renal function. A regular follow-up must be set up to diagnose HIV seroconversion, treat sexually transmitted infections, and manage side effects of PrEP.

CONCLUSION

The Belgian guidance on the use of PrEP provides a point of reference for standard PrEP care in Belgium and will be periodically updated.

PrEP Among Sub-Saharan African Diaspora Communities in Belgium - a Participatory Action Research Study

In Belgium, migrants from Sub-Saharan Africa (SSA) accounted for 45% of new heterosexual HIV infections in 2021, while only 1.5% of PrEP starters were of SSA descent. We explored the acceptance of PrEP and barriers towards PrEP uptake and use among SSA migrant and diaspora communities in Belgium using a participatory action research approach. Trained community researchers (CRs), involved in all phases of the study, co-designed and moderated group discussions (GDs) while simultaneously providing information on HIV and PrEP during workshops. Extensive summaries and field notes were analysed using reflexive thematic analysis. CRs were involved in data analysis, interpretation and reporting. We conducted seven GDs with 51 participants. We identified five major themes: (1) Participants had limited PrEP knowledge, which created feelings of surprise and annoyance about not being informed. This was partly explained by (2) the taboo and stigma that surrounds sexuality and HIV, which could shape PrEP acceptance. (3) Participants shared feelings of otherness due to experiences of racism and discrimination, also in relationship to HIV prevention. (4) PrEP was considered a high-threshold prevention tool, because of its perceived side-effects and its specialized service delivery. (5) Despite nuanced opinions about PrEP, all participants agreed that PrEP promotion should be mainstreamed, so everyone can make an informed decision. In conclusion, PrEP seemed acceptable among our participants. Our qualitative study provides insights into the intersecting barriers to accessing HIV services, showing that SSA diaspora communities are 'hardly reached' rather than 'hard to reach' by PrEP promotion messages.

Non-Consensual Sex and Help-Seeking Behavior Among PrEP Users in Belgium: Findings from an Online Survey

Non-consensual sex poses a threat not only to sexual health but also to mental and physical health in general. HIV pre-exposure prophylaxis (PrEP) users might be particularly vulnerable to non-consensual sex because of interplaying factors such as mental health disorders, a high number of sex partners, engagement in chemsex, and the widespread use of dating apps. The objectives of this study were to assess the occurrence of non-consensual sex, its associated factors, and related help-seeking behavior among PrEP users. We analyzed data from an online survey among PrEP users in Belgium (09/2020-02/2022). Almost one in five participants (34/187, 18.2%) reported having ever experienced non-consensual sex. The most reported form was having sex against one's will, followed by having been given drugs against one's will, and having had sex without a condom against one's will. The vast majority of those who had experienced non-consensual sex (29/34, 85.3%) did not seek help afterward, mostly due to a lack of perceived need (21/29, 72.4%). Reported barriers to seeking help were shame (6/29, 20.7%) and lack of awareness of help services (3/29, 10.3%). Having experienced non-consensual sex in the past five years was associated with younger age and suicidal ideation in a multivariable logistic regression model. We conclude that addressing barriers to non-consensual sex help services is crucial to maximize their use and minimize the consequences of non-consensual sex experiences. PrEP consultations also represent an opportunity to offer such help given PrEP users are already familiar with these PrEP services and engaged in care.

Patterns of PrEP and condom use among PrEP users in Belgium: a web-based longitudinal study

BACKGROUND

Tailoring pre-exposure prophylaxis (PrEP) service delivery is key to scaling-up PrEP uptake. Optimal implementation of tailored services requires, among other things, insights into patterns of PrEP use, sexual behaviours and condom use over time.

METHODS

Between September 2020 and January 2022, we conducted a web-based, longitudinal study among PrEP users in Belgium. In three questionnaire rounds every six-months, we assessed PrEP and condom use, and sex with steady, casual and anonymous partners in the preceding three months. Based on the patterns of PrEP use in the preceding three months, we identified distinct PrEP use categories. We investigated differences in baseline socio-demographics and sexual behaviours by PrEP use category using Fisher's exact and one-way ANOVA tests. Patterns in PrEP and condom use over time were examined using descriptive analyses and visualised in alluvial diagrams.

RESULTS

In total, 326 participants completed the baseline questionnaire, and 173 completed all three questionnaires. We identified five distinct PrEP use categories: daily (≥ 90 pills), almost daily (75-89 pills), long period (> 7 consecutive days and < 75 pills) with or without additional short period use, short period (1-7 consecutive days and < 75 pills) and no PrEP use (0 pills). During the study, percentages of individuals in each PrEP use category varied, but did not change significantly over time. At baseline, daily and almost daily users were more likely to report five or more casual sex partners, ten or more anonymous sex partners and anal sex on a weekly basis with casual or anonymous partners compared to those using PrEP for long or short periods. Up to 12.6% (n = 16/127) of participants reporting anal sex with casual or anonymous partners, indicated always using condoms and PrEP with these partners. One in three (n = 23/69) participants who reported anal sex with steady partners had condomless anal sex and did not use PrEP with these partners; with casual or anonymous partners less than 3% reported this.

CONCLUSIONS

Our findings show that there is little variation in PrEP use over time and that PrEP use was associated with sexual behaviours, which could be taken into account when designing tailored PrEP care.

Pre-Exposure Prophylaxis Users' Attitudes About Sexually Transmitted Infections and Its Influence on Condom Use: A Mixed-Method Study in Belgium

Incidence rates of sexually transmitted infections (STIs) are rising among men who have sex with men (MSM). Since the rollout of HIV pre-exposure prophylaxis (PrEP), promoting condom use to prevent the spread of STIs has become more challenging. Using a mixed-method design, we explored MSM PrEP users' attitudes toward STIs, condoms, and condom use with nonsteady partners to prevent STIs. We triangulated data from 22 in-depth interviews conducted at a large HIV/STI clinic between August 2021 and January 2022 and an online survey among 326 PrEP users between September 2020 and January 2022. Interviews were analyzed iteratively using a thematic analysis approach. We used bivariate and multi-variate ordered logistic regression to analyze the online survey data. Themes identified in the qualitative data influencing condom use decisions to prevent STIs were as follows: (1) awareness (i.e., perceived severity of and susceptibility to STIs, condom counseling), (2) motivation (i.e., concerns about STIs, sexual pleasure and protection of own health), and (3) perceived social norms and practices (e.g., reduced condom use at community level). Overall, 10.7% of survey respondents consistently used condoms with nonsteady partners. Survey respondents who reported high or moderate levels of willingness to use condoms to prevent acquiring STIs were significantly more likely to use condoms for anal sex with nonsteady partners; those who initiated PrEP 6-12 months ago were less likely to use condoms. We found a wide variation in attitudes toward condom use for the prevention of STIs among MSM using PrEP. We recommend client-centered approaches, taking into account PrEP users' values and priorities toward STI prevention to help reduce the spread of STIs.

Quality of Life in People Living With HIV: An Exploratory Cross-Sectional Survey in Belgium

This cross-sectional survey explored the quality of life in 505 people living with HIV in Belgium. Several domains of quality of life were impaired: 26% had been diagnosed with depression and 43% had weak social support. HIV-related stigma is still widespread, with 49% believing most people with HIV are rejected and 65% having experienced discrimination due to HIV. The impact of HIV was limited on professional life, but 40% experienced a negative impact on life satisfaction and 41% a negative impact on sexual life. For several domains, people with a recent diagnosis of HIV and long-term survivors had significantly worse scores. This survey also uncovered strengths of people living with HIV, such as positive coping and HIV self-image. Expanding the scope of quality of life in people living with HIV may provide a more complete picture of relevant life domains that may be impacted by living with HIV, but this needs further validation.

Effectiveness of Depression-Suicidal Behaviour Gatekeeper Training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study

BACKGROUND

Gatekeeper training for community facilitators, to identify and respond to those at risk of suicide, forms an important part of multi-level community-based suicide prevention programmes.

AIMS

This study examined the effects of gatekeeper training on attitudes, knowledge and confidence of police officers in dealing with persons at risk of suicide.

METHODS

A total of 828 police officers across three European regions participated in a 4-hour training programme which addressed the epidemiology of depression and suicidal behaviour, symptoms of depression, warning signs and risk factors associated with suicidal behaviour, motivating help-seeking behaviour, dealing with acute suicidal crisis and informing bereaved relatives. Participants completed internationally validated questionnaires assessing stigmatising attitudes, knowledge about depression and confidence in dealing with suicidal persons pre- and post-training.

RESULTS

There were significant differences among countries in terms of previous exposure to suicidal persons and extent of previous training. Post-training evaluation demonstrated significant improvements in stigmatising attitudes, knowledge and confidence in all three countries.

CONCLUSION

The consistently positive effects of gatekeeper training of police officers across different regions support inclusion of this type of training as a fundamental part of multi-level community-based suicide prevention programmes and roll-out, nationally and internationally.

How to adjust media recommendations on reporting suicidal behavior to new media developments

This study examines the inclusion of preventive factors and new media developments in media recommendations on suicide reporting. Of the 193 member states of the United Nations screened for media recommendations, information was available for 74 countries. Similarities and differences in their contents were analyzed by cluster analysis. Results indicate that of these 74 countries, 38% have national suicide prevention programs, 38% have media recommendations, and 25% have press codes including suicide reporting. Less than 25% of the media recommendations advise against mentioning online forums, suicide notes, pacts, clusters, hotspots, details of the person, and positive consequences. No more than 15% refer to self-help groups, fictional and online reporting. We conclude that media recommendations need to be revised by adding these preventive factors and by including sections on new media reporting.

Patient suicide: the experience of Flemish psychiatrists

The experience of the most distressing patient suicide on Flemish psychiatrists is described. Of 584 psychiatrists, 107 filled a self-report questionnaire. Ninety-eight psychiatrists had been confronted with at least one patient suicide. Emotional suffering and impotence were the most common feelings reported. Changes in professional practice were described and included a more structured approach to the management of suicidal patients. Colleagues and contact with the patient's family were the most frequently used sources of help, whereas team case review and colleagues were rated as the most useful ones. Patient suicide leads to emotional suffering and has a considerable professional impact.

Nature and impact of European anti-stigma depression programmes

Stigma associated with depression is a major public health issue in the EU, with over 20 million people experiencing depression and its associated personal distress each year. While most programmes against stigma related to mental health problems are of a general nature, the knowledge about programmes tackling stigma against people with depression is limited. This study therefore aims to assess the nature and impact of depression-specific programmes in EU countries. Using a web-based tool, 26 programmes were identified across the 18 EU countries taking part in the study. Most were universal and targeted the whole population, while many also targeted specific population groups or settings, such as young people or health professionals. The most common programme aim was improving literacy, although reducing stigmatizing attitudes and discriminatory behaviour and promoting help-seeking were also common. Most programmes originated from professional bodies, or as grassroots initiatives from service user groups/NGOs, rather than as part of national and local policy. The approaches used were primarily different forms of education/information, with some, but very limited, use of positive personal contact. Overall, the quality and extent of impact of the programmes was limited, with few leading to peer-reviewed publications. Specific programmes were identified with evidence of positive impact, and we drew on these examples to develop a framework to be used for future programmes against stigma and discrimination associated with depression. These findings are provided in full in the Anti-Stigma Partnership European Network Toolkit available at www.antistigma.eu.

Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews

Background: Evidence-based best practices for incorporation into an optimal multilevel intervention for suicide prevention should be identifiable in the literature. Aims: To identify effective interventions for the prevention of suicidal behavior. Methods: Review of systematic reviews found in the Pubmed, Cochrane, and DARE databases. Steps include risk-of-bias assessment, data extraction, summarization of best practices, and identification of synergistic potentials of such practices in multilevel approaches. Results: Six relevant systematic reviews were found. Best practices identified as effective were as follows: training general practitioners (GPs) to recognize and treat depression and suicidality, improving accessibility of care for at-risk people, and restricting access to means of suicide. Although no outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies. Conclusions: A number of evidence-based best practices for the prevention of suicide and suicide attempts were identified. Research is needed on the nature and extent of potential synergistic effects of various preventive activities within multilevel interventions.

Community and health professionals' attitude toward depression: a pilot study in nine EAAD countries

BACKGROUND

Community facilitators (CFs), such as pharmacists, policemen, teachers and clergy, may be an important community resource for patients with depression in addition to (mental) health professionals. However, they are ill prepared for such a role and little is known about their attitudes toward depression, which may affect practice.

AIM

To investigate CFs' attitudes toward depression and compare them to those of (mental) health professionals and nurses.

METHOD

Attitudes were assessed in participants (n = 2,670) of training programmes about depression in nine countries of the European Alliance Against Depression (EAAD). The EAAD questionnaire included attitudes toward depression and its treatment, perceived causes, preferred treatment options, and knowledge of depression symptoms.

RESULTS

CFs and nurses had a more negative attitude toward patients with depression and toward antidepressants, and more limited knowledge of depression symptoms than (mental) health professionals. CFs more frequently supported non-standard treatment for depression. Nurse assistants clearly differed from registered nurses with their attitudes being among the least favourable and their knowledge the most limited of all groups.

CONCLUSIONS

CFs and nurses had less favourable attitudes and more limited knowledge regarding depression when compared to mental health professionals and doctors. This may negatively affect professional collaboration, challenge optimal treatment and stigmatize patients. CFs' and nurses' knowledge and attitudes may be similar to those of the general population and be related to a lack of training in mental health issues.

Drug suicide: a sex-equal cause of death in 16 European countries

Background

There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84).

Methods

Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated.

Results

No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk.

Conclusions

Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Suicide intervention skills and related factors in community and health professionals

Health and community professionals have considerable exposure to suicidal people and need to be well skilled to deal with them. We assessed suicide intervention skills with a Dutch version of the SIRI in 980 health and community professionals and psychology students. Suicide intervention skills clearly differed among professional groups and were strongly related to experience, especially suicide-specific experience. Some community professionals scored below acceptable levels on their ability to respond appropriately to suicidal people they encounter, and tended to overestimate their skills level. Training is therefore indicated for these groups, and may be useful to more highly experienced groups too.

Pharmacists' role in depression care: a survey of attitudes, current practices, and barriers

OBJECTIVE

Pharmacists may be well placed to take up a role in depression care, complementing the role of general practitioners. However, depression care is a relatively new role for pharmacists, and little is known of their attitudes, current practices, and barriers toward it.

METHODS

A random sample of 200 community pharmacists in Belgium was surveyed about the care of patients with depression in comparison with patients with other, physical conditions.

RESULTS

The 69 pharmacists who responded to the survey generally endorsed a very positive attitude toward their potential role in depression care. This willingness was, however, not reflected in current practice, and fulfilling this role appeared to be more difficult with patients with depression in comparison with patients with other, physical conditions. A lack of training in mental health issues was the most important barrier reported. Cooperation with general practitioners in depression care was desired, but the current level of cooperation was rather low.

CONCLUSIONS

For pharmacists to effectively take up depression care, perceived barriers need to be addressed through specific training programs and increased cooperation with general practitioners.

Pharmacists' role in depression care: a survey of attitudes, current practices, and barriers

OBJECTIVE

Pharmacists may be well placed to take up a role in depression care, complementing the role of general practitioners. However, depression care is a relatively new role for pharmacists, and little is known of their attitudes, current practices, and barriers toward it.

METHODS

A random sample of 200 community pharmacists in Belgium was surveyed about the care of patients with depression in comparison with patients with other, physical conditions.

RESULTS

The 69 pharmacists who responded to the survey generally endorsed a very positive attitude toward their potential role in depression care. This willingness was, however, not reflected in current practice, and fulfilling this role appeared to be more difficult with patients with depression in comparison with patients with other, physical conditions. A lack of training in mental health issues was the most important barrier reported. Cooperation with general practitioners in depression care was desired, but the current level of cooperation was rather low.

CONCLUSIONS

For pharmacists to effectively take up depression care, perceived barriers need to be addressed through specific training programs and increased cooperation with general practitioners.

Suicide methods in Europe: a gender-specific analysis of countries participating in the "European Alliance Against Depression"

OBJECTIVE

To identify the most frequent gender-specific suicide methods in Europe.

DESIGN

Proportions of seven predominant suicide methods utilised in 16 countries participating in the European Alliance Against Depression (EAAD) were reported in total and cross-nationally. Relative risk (RR) relating to suicide methods and gender was calculated. To group countries by pattern of suicide methods, hierarchical clustering was applied.

SETTING AND PARTICIPANTS

Data on suicide methods for 119,122 male and 41,338 female cases in 2000-4/5 from 16 EAAD countries, covering 52% of European population were obtained.

RESULTS

Hanging was the most prevalent suicide method among both males (54.3%) and females (35.6%). For males, hanging was followed by firearms (9.7%) and poisoning by drugs (8.6%); for females, by poisoning by drugs (24.7%) and jumping from a high place (14.5%). Only in Switzerland did hanging rank as second for males after firearms. Hanging ranked first among females in eight countries, poisoning by drugs in five and jumping from a high place in three. In all countries, males had a higher risk than females of using firearms and hanging and a lower risk of poisoning by drugs, drowning and jumping. Grouping showed that countries might be divided into five main groups among males; for females, grouping did not yield clear results.

CONCLUSIONS

Research on suicide methods could lead to the development of gender-specific intervention strategies. Nevertheless, other approaches, such as better identification and treatment of mental disorders and the improvement of toxicological aid should be put in place.