Factors related to condomless anal intercourse between men who have sex with men: results from a European bio-behavioural survey

Background

Relationship status is an important factor associated with condomless anal intercourse (CAI) amongst men who have sex with men (MSM).

Methods

A multi-centre bio-behavioural survey with MSM was conducted in 13 European cities (n = 4901) exploring factors associated with CAI via bivariate and multivariate multilevel logistic regression analyses.

Results

Likelihood of CAI with casual partners was associated with being ‘out’ to a majority (AOR = 1.19;95% CI 1,1.42); knowing their HIV status (AOR = 1.86; 95% CI 1.25,2.76); using substances (1–2 AOR = 1.39; 95% CI 1.16,1.63, 2+ AOR = 1.81; 95% CI 1.35,2.42); being older (AOR = 0.98; 95% CI 0.97,0.99); successful sero-communication (AOR = 0.79; 95% CI 0.67,0.94); and, not having a recent HIV test (AOR = 0.78; 95% CI 0.66,0.92). CAI with steady partners was associated with successful sero-communication (AOR = 2.72; 95% CI 2.72,3.66); not having a recent HIV test (AOR = 1.26; 95% CI 1.09,1.46), and; being older (AOR = 0.99; 95% CI 0.98,0.99).

Conclusions

Understandings of partner type and/or relationship status in relation to CAI amongst MSM can potentially play an important role in the development of culturally appropriate HIV/STI prevention and risk-reduction efforts targeting at-risk MSM. Our results speak to the need to consider segmented and tailored public health and health promotion initiatives for MSM with differing CAI behaviours and relationship profiles.

Are men who have sex with men in Europe protected from hepatitis B?

Hepatitis B vaccination is recommended for men who have sex with men (MSM) in many countries, but information on vaccine coverage is scarce. We studied hepatitis B vaccination programmes and coverage among MSM in Europe to guide prevention. From a large (N = 174 209) pan-European MSM survey (EMIS-2010), we used data on self-reported hepatitis B vaccination, age, education, settlement size and disclosure of the same-sex sexual orientation ('outness'). We excluded participants with a history of hepatitis B. In multilevel (participants, countries) logistic regression models, we calculated adjusted odds ratios (aOR) with 95% confidence intervals (95% CI). We analysed data of 163 987 MSM in 38 European countries: 38.3% were 'out' to all or almost all, 56.4% reported vaccination against hepatitis B and 65.5% lived in countries with free recommended hepatitis B vaccination for MSM. In the final model the odds for being vaccinated increased with outness ('out to all or almost all': aOR 1.76, 95% CI 1.70-1.83 vs. 'out to no one') and with living in countries, where hepatitis B vaccination was recommended and free-of-charge for MSM (aOR 2.21, 95% CI 1.47-3.32 vs. 'no or unclear recommendation'). To increase hepatitis B vaccination coverage among MSM, implementation of MSM-specific recommendations and improvement of the societal climate for MSM is needed.

Infektionen mit dem humanen Immundefizienzvirus bei Kindern in Deutschland, 1999–2016

Hintergrund

Mutter-Kind-Übertragungen von humanem Immundefizienz Virus (HIV) sind durch antiretrovirale Therapie der Schwangeren und weitere medizinische Maßnahmen (Sectio-Entbindung, Postexpositionsprophylaxe beim Neugeborenen, Stillverzicht) verhinderbar. Weiterhin erfolgende Übertragungen sind überwiegend Folge mangelhafter Umsetzung der bekannten wirksamen Maßnahmen. Stand und Probleme bei der Erreichung einer Eliminierung von Mutter-Kind-Übertragungen von HIV in Deutschland werden beschrieben.

Methoden

Hauptquelle der Daten sind pseudonymisierte Meldedaten des HIV-Melderegisters am Robert Koch-Institut (RKI). Mittels einer intensivierten Surveillance für HIV-Meldungen zu Kindern werden Angaben zum Geburtsland, zum mütterlichen Herkunftsland und zur Kenntnis und zum Management der mütterlichen HIV-Infektion in der Schwangerschaft bei seit 1999 geborenen, mit HIV infizierten Kindern erhoben.

Ergebnisse

Bis Ende 2018 wurden bei zwischen dem 01.01.1999 und dem 31.12.2016 geborenen Kindern im Alter unter 15 Jahren in Deutschland 331 HIV-Diagnosen gemeldet. Bei 313 war eine Mutter-Kind-Übertragung der wahrscheinlichste Übertragungsweg. Von diesen 313 Kindern wurden 162 (52 %) in Deutschland geboren, aber nur 26 % der Mütter waren deutscher Herkunft. Die HIV-Übertragungshäufigkeit bei in Deutschland geborenen Kindern sank von 1,8/100.000 Lebendgeburten im Zeitraum 1999–2007 auf 0,8/100.000 im Zeitraum 2008–2016. Bei 59 % der in Deutschland geborenen Kinder war der HIV-Status der Mutter den betreuenden Ärzt*innen zum Zeitpunkt der Geburt nicht bekannt.

Schlussfolgerung

Ein fehlendes HIV-Testangebot für die Schwangere war Hauptursache für Übertragungen bei bis 2007 geborenen Kindern; bei später geborenen Kindern waren die Gründe vielfältiger und hingen oft mit mütterlicher Migration und Zugangsbarrieren in das Versorgungssystem zusammen.

Monitoring the HIV continuum of care in key populations across Europe and Central Asia

OBJECTIVES

The aim of the study was to measure and compare national continuum of HIV care estimates in Europe and Central Asia in three key subpopulations: men who have sex with men (MSM), people who inject drugs (PWID) and migrants.

METHODS

Responses to a 2016 European Centre for Disease Prevention and Control (ECDC) survey of 55 European and Central Asian countries were used to describe continuums of HIV care for the subpopulations. Data were analysed using three frameworks: Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; breakpoint analysis identifying reductions between adjacent continuum stages; quadrant analysis categorizing countries using 90% cut-offs for continuum stages.

RESULTS

Overall, 29 of 48 countries reported national data for all HIV continuum stages (numbers living with HIV, diagnosed, receiving treatment and virally suppressed). Six countries reported all stages for MSM, seven for PWID and two for migrants. Thirty-one countries did not report data for MSM (34 for PWID and 41 for migrants). In countries that provided key-population data, overall, 63%, 40% and 41% of MSM, PWID and migrants living with HIV were virally suppressed, respectively (compared with 68%, 65% and 68% nationally, for countries reporting key-population data). Variation was observed between countries, with higher outcomes in subpopulations in Western Europe compared with Eastern Europe and Central Asia.

CONCLUSIONS

Few reporting countries can produce the continuum of HIV care for the three key populations. Where data are available, differences exist in outcomes between the general and key populations. While MSM broadly mirror national outcomes (in the West), PWID and migrants experience poorer treatment and viral suppression. Countries must develop continuum measures for key populations to identify and address inequalities.

A large proportion of people who inject drugs are susceptible to hepatitis B: Results from a bio-behavioural study in eight German cities

BACKGROUND

People who inject drugs (PWID) are at high risk of hepatitis B virus (HBV) infection by sharing needles and drug use paraphernalia. In Germany, no routine surveillance of HBV prevalence and vaccination coverage among PWID exists.

METHODS

Socio-demographic and behavioural data were collected between 2011 and 2014 through face-to-face interviews, during a bio-behavioural survey of PWID recruited in eight German cities. Dried blood spots (DBS) prepared with capillary blood were tested for HBV markers. Factors associated with past/current HBV infection and vaccination status were analysed by univariable and multivariable analysis using logistic regression. The validity of self-reported HBV infection and vaccination status was analysed by comparison to the laboratory results.

RESULTS

Among 2077 participants, the prevalence of current HBV infection was 1.1%, of past HBV infection was 24%, and of vaccine-induced HBV antibodies was 32%. No detectable HBV antibodies were found in 43%. HBV infection status was significantly associated with study city, age, years of injecting, use of stimulants, migration status, and homelessness; HBV vaccination status was significantly associated with study city, age, and level of education. Correct infection status was reported by 71% and correct vaccination status by 45%.

CONCLUSIONS

HBV seroprevalence among PWID was about five times higher than in the general population in Germany, confirming PWID as an important risk group. Targeted information campaigns on HBV and HBV prevention for PWID and professionals in contact with PWID need to be intensified. Routinely offered HBV vaccination during imprisonment and opioid substitution therapy would likely improve vaccination rates among PWID.

Shigellosis — a re-emerging sexually transmitted infection: outbreak in men having sex with men in Berlin

In December 2001, the Robert Koch-Institut (RKI) was informed about a cluster of 10 Shigella sonnei infections in men who have sex with men (MSM), diagnosed in Berlin since September 2001. A retrospective investigation on sexual risk factors for infection in all shigella cases from Berlin from 2001 was initiated by sending a questionnaire to all patients without known travel history. Simultaneously laboratories were asked to send new shigella isolates from patients to the National Reference Centre at the RKI. Out of 29 responders, 24 self-identified as MSM. Seventeen of these reported sexual contacts as the most likely potential risk of infection. Almost all MSM reported direct or indirect oral–anal sexual contacts in the week before they fell ill. Fifteen of 27 shigella isolates collected during the prospective sampling period showed identical plasmid profiles, PFGE- and resistance patterns and can therefore be regarded as clonally identical. Asymptomatic and/or prolonged shedding in the reconvalescent phase may contribute to the transmission risk of shigella infection during oral–anal sexual practices. Awareness among practitioners and among MSM about the risk of sexual transmission of orally transmitted agents needs to be raised.

The impact of meeting locations for men having sex with men on the risk for bacterial sexually transmitted infections: analyses from a cross-sectional online survey

OBJECTIVES

Opportunities for men having sex with men (MSM) to meet each other have very much improved by new communication technologies. Meeting venue-based characteristics can impact how many partners are met and how much sexual risk is taken. We analysed the association between physical and virtual venues and the risk for bacterial sexually transmitted infections (bSTIs) among participants in an MSM online survey.

METHODS

Data were collected during 2013/2014 with a survey targeting MSM living in Germany. The impact of the meeting place with the last non-steady anal sex partner on diagnosis with a bSTI in the previous year was analysed using bivariate and multivariate regression analysis, taking into account self-reported HIV status, serostatus communication, condom use, partner number, age and city size.

RESULTS

The study sample consisted of 8878 respondents (7799 not diagnosed with HIV; 1079 diagnosed with HIV). Meeting partners online was most common (62% HIV-/51% HIV+), followed by sex venues (11% HIV-/25% HIV+); other venues were each reported by 2-6% of the respondents. Venue-dependent proportions reporting bSTIs in the recent year were 2-4 folds higher among men diagnosed with HIV. In multivariate analysis, HIV status was the strongest predictor for bSTIs (OR=5.0; 95% CI 2.8 to 8.7). Compared with meeting partners online, sex (OR 1.6; 95% CI 1.0 to 2.5) and social venues (OR 1.9; 95% CI 1.4 to 2.6) were associated with increased bSTI risk for men not diagnosed with HIV, but the risk when meeting partners by smartphone apps was only of borderline significance (OR 1.5; 95% CI 0.9 to 2.3). For men diagnosed with HIV, bSTI risk increased for sex venues (OR 1.5; 95% CI 1.1 to 2.1), and was lower for non-gay/other venues (OR 0.2; 95% CI 0.1 to 0.5).

CONCLUSIONS

Venues are connected to social-behavioural facets of corresponding sexual encounters, and may be important arenas for differential HIV and STI education, treatment and prevention.

A cluster of invasive meningococcal disease in young men who have sex with men in Berlin, October 2012 to May 2013

Between October 2012 and May 2013, five cases of invasive meningococcal disease in young men who have sex with men (MSM) living in Berlin were notified to local health authorities in Germany. Three of the five cases died. All were caused by serogroup C variants with the finetype P1.5-1,10-8:F3-6. Awareness was increased through the use of community networks; an extension of the existing vaccination recommendation to all MSM is currently being considered.

Syphilis on the rise again in Germany--results from surveillance data for 2011

In Germany, syphilis is notified anonymously. In 2011, 3,698 cases (incidence 4.5/100,000 inhabitants) were notified, an increase of 22% over 2010. The increase was higher in men (23%) than women (13%) and 94% of the cases were male. Information on the possible way of transmission was available for 72% of cases. Of these, 84% were men who have sex with men, who seem to play a major role in the renewed increase in syphilis cases.

Syphilis on the rise again in Germany – results from surveillance data for 2011

In Germany, syphilis is notified anonymously. In 2011, 3,698 cases (incidence 4.5/100,000 inhabitants) were notified, an increase of 22% over 2010. The increase was higher in men (23%) than women (13%) and 94% of the cases were male. Information on the possible way of transmission was available for 72% of cases. Of these, 84% were men who have sex with men, who seem to play a major role in the renewed increase in syphilis cases.

Late presentation for HIV diagnosis and care in Germany

OBJECTIVES

Antiretroviral therapy reduces mortality and morbidity in HIV-infected individuals most markedly when initiated early, before advanced immunodeficiency has developed. Late presentation for diagnosis and care remains a significant challenge. To guide public health interventions effectively it is crucial to describe the factors associated with late presentation.

METHODS

Case surveillance data for all individuals newly diagnosed with HIV infection in Germany in the years 2001-2010 and data for the years 1999-2010 from the German Clinical Surveillance of HIV Disease (ClinSurv) cohort study, a large multicentre observational study, were analysed. Factors associated with late presentation (CD4 count < 350 cells/μL or clinical AIDS) were assessed using descriptive statistics and multivariable logistic regression methods.

RESULTS

Among 22 925 eligible patients in the national surveillance database, 49.5% were late presenters for HIV diagnosis. Among 6897 treatment-naïve patients in the ClinSurv cohort, 58.1% were late presenters for care. Late presenters for care were older (median 42 vs. 39 years for early presenters), more often heterosexuals from low-prevalence countries (18.1% vs. 15.5%, respectively) and more often migrants (18.2% vs. 9.7%, respectively; all P < 0.005). The probability of late presentation was >65% throughout the observation period in migrants. The probability of late presentation for care clearly decreased in men who have sex with men (MSM) from 60% in 1999 to 45% in 2010.

CONCLUSIONS

In Germany, the numbers of late presenters for HIV diagnosis and care remain high. The probability of late presentation for HIV diagnosis seems to be particularly high for migrants. These results argue in favour of targeted test promotion rather than opt-out screening. Late presentation for care seems to be an additional problem after HIV diagnosis.

Verlauf der HIV-Epidemie in Deutschland

The course of the HIV epidemic in Germany can be modelled by back calculation until the beginning of the nineties. The recent course of the epidemic can only be derived from surveillance data of newly diagnosed HIV infections in conjunction with other data sources. Based on these surveillance data HIV incidence in Germany can be estimated to have been stable with 2000 to 2500 new infections per year since the early nineties, after having peaked in the early eighties. The most affected group are men who have sex with men followed by persons infected by heterosexual contact and migrants from high prevalence countries. The number of intravenous drug users has declined over the years and is now in fourth place. There are indications that increased risk behaviour and rising numbers of other sexually transmitted infections together with a change towards later initiation of antiretroviral therapy has led to an increase in new HIV infections in Germany in recent years. An improvement of the epidemiological surveillance for "indicator" STIs in combination with the assessment of risk behaviours in high risk groups would be desirable steps towards a second generation surveillance in Germany.

[Prevention strategies to control the HIV epidemic. Successes, problems, and perspectives]

After the recognition of AIDS as a new disease entity and isolation of HIV as the causative agent in the early 1980s, a controversial debate about adequate measures to reduce the spread of HIV developed. In all developed countries a strategy based on education about modes of HIV transmission, condom promotion and harm reduction approaches to intravenous drug use finally succeeded and became instrumental for the relative containment of HIV within most at risk populations. However, in most developing countries as well as in the countries of Eastern Europe, the success of HIV pre vention remained limited for various reasons. In addition, for several years now, in the western developed countries sexual risk behaviour, newly diagnosed HIV infections, and the incidence of various other sexually transmitted infections seem to re-increase, especially among men who have sex with men (MSM). These increases coincide with a dramatic improvement of therapeutic options for the treatment of HIV infection. The relationship between improvement of therapy and changes in sexual risk behaviour has to be further defined. It is hypothesized that HIV serosorting as a predominant risk management strategy among MSM results in an accumulation of health risks in the HIV-positive MSM population. In addition to and beyond established condom promotion, additional biomedical approaches to reduce transmissibility and susceptibility for HIV will be necessary to regain control of the spread of HIV in highly sexually active populations.

German-Austrian recommendations for HIV-therapy in pregnancy and in HIV-exposed newborn - update 2005

In Germany during the last years about 200-250 HIV infected pregnant women delivered a baby each year, a number that is currently increasing. To determine the HIV-status early in pregnancy voluntary HIV-testing of all pregnant women is recommended in Germany and Austria as part of prenatal care. In those cases, where HIV infection was known during pregnancy, since 1995 the rate of vertical transmission of HIV was reduced to 1-2%. - This low transmission rate has been achieved by the combination of anti-retroviral therapy of pregnant women, caesarean section scheduled before onset of labour, anti-retroviral post exposition prophylaxis in the newborn and refraining from breast-feeding by the HIV infected mother. To keep pace with new results in research, approval of new anti-retroviral drugs and changes in the general treatment recommendations for HIV infected adults, in 1998, 2001 and 2003 an interdisciplinary consensus meeting was held. Gynaecologists, infectious disease specialists, paediatricians, pharmacologists, virologists and members of the German AIDS Hilfe (NGO) were participating in this conference to update the prevention strategies. A third update became necessary in 2005. The updating process was started in January 2005 and was terminated in September 2005. The guidelines provide new recommendations on the indication and the starting point for therapy in pregnancies without complications, drugs and drug combinations to be used preferably in these pregnancies and updated information on adverse effects of anti-retroviral drugs. Also the procedures for different scenarios and risk constellations in pregnancy have been specified again. With these current guidelines in Germany and Austria the low rate of vertical HIV-transmission should be further maintained.

HIV incidence increasing in MSM in Germany: factors influencing infection dynamics

After an initial peak in the mid-1980s, HIV incidence in men who have sex with men (MSM) declined in most western industrialised countries and then levelled off during the 1990s. Since the late 1990s, increasing numbers of newly diagnosed HIV infections in MSM have been observed in the majority of countries with large and visible MSM communities. Based on a review of national and international behavioural surveillance studies of MSM and national HIV surveillance data, we propose a model for the HIV epidemic in MSM in Germany. The model includes aspects such as individuals' increasing numbers of sexual partners and increasing frequency of unprotected anal intercourse, conditional condom use based on real or perceived HIV status of sexual partners (HIV "serosorting") and sexual role assignments (insertive versus receptive based on HIV status (HIV "seropositioning"), selection of partners and formation of sexual networks through seeking sexual partners on the internet, the introduction of HAART and changing HAART treatment strategies. All these aspects have been shown or are suspected to increase or decrease HIV transmission risk in MSM. We conclude that increasing HIV incidence in MSM in recent years has been fuelled by a spread of HIV in high-risk sexual networks with an increasing proportion of infections transmitted during highly infective early HIV infection, acquired mostly from casual sexual partners.

Lymphogranuloma venereum emerging in men who have sex with men in Germany

A resurgence of lymphogranuloma venereum (LGV) has been observed in several European countries. LGV is not a mandatorily notifiable disease in Germany. Reports of LGV cases have actively been collected by the Robert Koch-Institut since 2004 to describe the outbreak and estimate the extent of the LGV problem in Germany. Updates on the LGV outbreak were published in the German national epidemiological bulletin. Physicians were asked to send their samples to a laboratory for genotyping. A possible case was defined as a person with symptoms of proctitis and/or inguinal lymph node swelling and a positive chlamydia serology. A probable case had in addition a positive chlamydia rectal or urinary PCR test. A case was confirmed if the genotype L1-L3 was identified based on sequence analysis of omp1 gene sequences. Since 2003, LGV has been reported in 78 male patients in Germany. Of these, 61 patients were confirmed as genotype L2. Fifty eight out of 78 patients (74%) are known to be men who have sex with men (MSM). Fifty five patients (71%) had rectal symptoms and 49 (63%) knew they were HIV positive. Sixty two (79%) of the patients were residents of Berlin or Hamburg. LGV has emerged in MSM in Germany at the same time as in other European countries. It is thought that LGV may become endemic in the MSM community in German metropolitan areas, because the number of reported patients with LGV continues to increase. The increase in the number of LGV cases and the high HIV prevalence in LGV patients are of great public health concern. Clinicians and MSM may not be sufficiently aware of the disease, and existing efforts to promote awareness and prevention of sexually transmitted infections and HIV need to be strengthened.

HIV incidence increasing in MSM in Germany: factors influencing infection dynamics

After an initial peak in the mid-1980s, HIV incidence in men who have sex with men (MSM) declined in most western industrialised countries and then levelled off during the 1990s. Since the late 1990s, increasing numbers of newly diagnosed HIV infections in MSM have been observed in the majority of countries with large and visible MSM communities. Based on a review of national and international behavioural surveillance studies of MSM and national HIV surveillance data, we propose a model for the HIV epidemic in MSM in Germany. The model includes aspects such as individuals’ increasing numbers of sexual partners and increasing frequency of unprotected anal intercourse, conditional condom use based on real or perceived HIV status of sexual partners (HIV ‘serosorting’) and sexual role assignments (insertive versus receptive based on HIV status (HIV ‘seropositioning’), selection of partners and formation of sexual networks through seeking sexual partners on the internet, the introduction of HAART and changing HAART treatment strategies. All these aspects have been shown or are suspected to increase or decrease HIV transmission risk in MSM. We conclude that increasing HIV incidence in MSM in recent years has been fuelled by a spread of HIV in high-risk sexual networks with an increasing proportion of infections transmitted during highly infective early HIV infection, acquired mostly from casual sexual partners.

Lymphogranuloma venereum emerging in men who have sex with men in Germany

A resurgence of lymphogranuloma venereum (LGV) has been observed in several European countries. LGV is not a mandatorily notifiable disease in Germany. Reports of LGV cases have actively been collected by the Robert Koch-Institut since 2004 to describe the outbreak and estimate the extent of the LGV problem in Germany. Updates on the LGV outbreak were published in the German national epidemiological bulletin. Physicians were asked to send their samples to a laboratory for genotyping. A possible case was defined as a person with symptoms of proctitis and/or inguinal lymph node swelling and a positive chlamydia serology. A probable case had in addition a positive chlamydia rectal or urinary PCR test. A case was confirmed if the genotype L1-L3 was identified based on sequence analysis of omp1 gene sequences. Since 2003, LGV has been reported in 78 male patients in Germany. Of these, 61 patients were confirmed as genotype L2. Fifty eight out of 78 patients (74%) are known to be men who have sex with men (MSM). Fifty five patients (71%) had rectal symptoms and 49 (63%) knew they were HIV positive. Sixty two (79%) of the patients were residents of Berlin or Hamburg. LGV has emerged in MSM in Germany at the same time as in other European countries. It is thought that LGV may become endemic in the MSM community in German metropolitan areas, because the number of reported patients with LGV continues to increase. The increase in the number of LGV cases and the high HIV prevalence in LGV patients are of great public health concern. Clinicians and MSM may not be sufficiently aware of the disease, and existing efforts to promote awareness and prevention of sexually transmitted infections and HIV need to be strengthened.

Relation between the HIV and the re-emerging syphilis epidemic among MSM in Germany: an analysis based on anonymous surveillance data

In 2003, for the first time since the introduction of highly active antiretroviral therapy (HAART), the number of newly diagnosed HIV infections in Germany increased considerably compared to the previous year. The increase was largely restricted to men who have sex with men (MSM) from larger cities. In this group the number of newly diagnosed HIV infections increased about 30% compared to 2002. Since the late 1990s syphilis infections among MSM also increased in Germany, concentrated in larger cities.

European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus

Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, &gt;10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs &gt;50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs &gt;10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus

Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, >or=10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs >or=50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs >or=10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

Building a sentinel surveillance system for sexually transmitted infections in Germany, 2003

BACKGROUND/OBJECTIVES

Increases in STIs have been reported from the United States and Europe. Since 2001, only syphilis and HIV are notifiable in Germany. A sentinel surveillance system has been set up to assess the occurrence and trends of STIs and identify risk groups.

METHODS

Through the sentinel system data are collected from local health offices (LHO), hospital based STI clinics and private practitioners (dermato-venerology, urology, gynaecology, or HIV). For every newly diagnosed laboratory confirmed infection of HIV, gonorrhoea, chlamydia, syphilis, or trichomoniasis physicians complete a standardised questionnaire regarding diagnosis, source of infection, and demographic information. Patients complete a questionnaire about sexual risk behaviour. The patient form is matched with the diagnosis form using a unique identifier number. Characteristics of sentinel patients were compared with those reported through the HIV and syphilis national notification system.

RESULTS

58 LHO, 14 hospital based STI clinics, and 160 private practitioners (53.1% dermato-venerologists) from all federal states participated in the study. 176 (75.9%) sentinel sites are located in cities of >100 000 inhabitants. From 1 March 2003-29 February 2004, a total of 1833 STIs have been reported, among them 452 chlamydia, 321 syphilis (10.9% of notified syphilis), 343 gonorrhoea, 269 HIV (15.7% of notified HIV). 925 (50.5%) of the patients were male, the median age was 31 years. Female patients were more often of foreign origin (chi(2) test; 70.0% v 26.3%; p<0.001).

CONCLUSIONS

Our sentinel system will provide a base for detection of STI trends in Germany. In addition, information about sexual risk behaviour will enable us to target prevention at those most at risk for STIs.

Syphilis auf dem Vormarsch

New public health laws in Germany require the reporting of some infectious agents directly but anonymously to the Robert Koch Institute (RKI). Included in this group are Treponema pallidum und HIV. Reporting responsibility lies with the director of the establishment where the causative agent was identified, usually a laboratory. The doctor who submits the clinical material for diagnosis is required to support the laboratory director in obtaining relevant information. The reporting form is filled out with the available information by the laboratory, sent to the RKI and a copy is sent to the submitting physician, who provides additional information and then sends the second form to the RKI, meeting his legal responsibilities. This new reporting system has provided reliable data about syphilis infections in Germany. In order to accumulate accurate data and plan effective prevention strategies, it is essential that all physicians comply with the new regulations.

Syphilis surveillance and trends of the syphilis epidemic in Germany since the mid-90s

Recent surveillance reports from Europe and the United States show an increase in syphilis cases. Accurate epidemiological information about the distribution of syphilis is important for targeting screening and intervention programmes. The German syphilis notification system changed in 2001 from physician to laboratory-based reporting, which is complemented by a newly introduced sexually transmitted infection (STI) sentinel system. After reaching an all time low during the 1990s, syphilis notifications have increased significantly since 2001, coinciding with the introduction of the new reporting system. However, the increased reported incidence is reflecting a true rise in the number of cases and is not predominantly determined by more underreporting through the previous reporting system. The increase reflects syphilis outbreaks among men who have sex with men (MSM). The first of these outbreaks was observed in Hamburg in 1997. In 2003, incidence in men was ten times higher than in women. An estimated 75% of syphilis cases are currently diagnosed among MSM. A high proportion (according to sentinel data, up to 50%) of MSM diagnosed with syphilis are HIV positive. The continuously high number of syphilis cases diagnosed among heterosexuals in Germany in recent years compared with other western European countries may reflect the higher population movement between Germany and syphilis high incidence regions in south-east and eastern Europe.

Syphilis surveillance and trends of the syphilis epidemic in Germany since the mid-90s

Recent surveillance reports from Europe and the United States show an increase in syphilis cases. Accurate epidemiological information about the distribution of syphilis is important for targeting screening and intervention programmes. The German syphilis notification system changed in 2001 from physician to laboratory-based reporting, which is complemented by a newly introduced sexually transmitted infection (STI) sentinel system. After reaching an all time low during the 1990s, syphilis notifications have increased significantly since 2001, coinciding with the introduction of the new reporting system. However, the increased reported incidence is reflecting a true rise in the number of cases and is not predominantly determined by more underreporting through the previous reporting system. The increase reflects syphilis outbreaks among men who have sex with men (MSM). The first of these outbreaks was observed in Hamburg in 1997. In 2003, incidence in men was ten times higher than in women. An estimated 75% of syphilis cases are currently diagnosed among MSM. A high proportion (according to sentinel data, up to 50%) of MSM diagnosed with syphilis are HIV positive. The continuously high number of syphilis cases diagnosed among heterosexuals in Germany in recent years compared with other western European countries may reflect the higher population movement between Germany and syphilis high incidence regions in south-east and eastern Europe.

German-Austrian recommendations for the antiretroviral therapy of HIV-infection (status May 2004)

The availability and application of effective antiretroviral combination therapies have now almost become routine. More than 20 antiretroviral substances in four classes have been approved. Although an almost incalculable number of combinations can be conceived, it must be stressed, that only a small number of the theoretically possible combinations are actually applicable. As a result of the broad therapeutic armamentarium, HIV infection can be better treated. However, the decisions to start, monitor and change therapy have become even more difficult because the indication for treatment, the selection of the most suitable therapy for an individual, the information and counselling of the patient, and the monitoring of the success of treatment all demand a high level of knowledge and experience. This guideline evaluates the indication and selection of the initial antiretroviral therapy for HIV infection.

["Emerging infectious diseases". Dengue-fever, West-Nile-fever, SARS, avian influenza, HIV]

Some emerging infectious diseases have recently become endemic in Germany. Others remain confined to specific regions in the world. Physicians notice them only when travelers after infection in endemic areas present themselves with symptoms. Several of these emerging infections will be explained. HIV is an example for an imported pathogen which has become endemic in Germany. SARS and avian influenza are zoonoses with the potential to spread from person to person. Avian influenza in humans provides a possibility for the reassortment of a potential new pandemic strain. Outbreaks of dengue fever in endemic areas are reflected in increased infections in travelers returning from these areas. Currently, West-Nile-virus infections are only imported into Germany. The timely implementation of diagnostic, therapeutic and infection control measures requires physicians to include these diseases in their differential diagnosis. To achieve this goal, good cooperation between physicians, laboratories and the public health service is essential.

Results from laboratory-based reporting of syphilis in Germany, 2001-2002

From the beginning of 2001 to mid-2002, 2783 cases of syphilis were notified to the Robert Koch-Institut (RKI) in Germany (1). Of these notifications, 1681 were for cases diagnosed in 2001, and 1102 were for cases diagnosed so far in the first half of 2002 (a 50% increase on the first half of 2001). The annual number of syphilis notifications in Germany between 1995 and 2000 was between 1120 and 1150. The recent rise in reported cases follows a major change in the German syphilis notification system, from physician- to laboratory-based reporting, which was introduced at the beginning of 2001.