Introducing comprehensive sexuality education in Italian schools: from the co-construction to the evaluation of a pilot intervention

INTRODUCTION

School-based comprehensive sexuality education (CSE) is a powerful tool that provides young people with information on all aspects of sexuality and is aimed at protecting their sexual and reproductive health and well-being throughout their lives. Currently, CSE is not integrated within the schools' curriculum in Italy. This study describes the co-construction, implementation, and evaluation of a CSE project piloted among students attending lower secondary schools, in four regions of Italy. Evidence-based evaluation will be helpful in promote the inclusion of CSE programs in the Italian schools' curriculum.

METHODS

The pilot scheme was co-constructed by a multidisciplinary curriculum development group through a Delphi process, including educators who conducted the activities. The evaluation followed three directions: the program (based on a literature review of CSE principles and recommended characteristics), implementation (assessing the execution of the program through the analysis of the reflection tools used by the educators), and short-term outcomes (assessing critical thinking and conscious behavioural choices through pre-post and satisfaction surveys).

RESULTS

The main goal, learning modules and content were defined and structured in five interventions with the students, and two with families and teachers. A total of 638 students were involved in the activity, across 11 schools. Data analysis of pre/post surveys reported a significant increase in knowledge in 12 of the 15 items investigated (p < 0.05), and a high level of satisfaction with the topics addressed. Qualitative analysis added information on the pivotal role of educators in CSE.

CONCLUSIONS

The national piloting of this educational activity provided positive insights regarding the co-construction, implementation and short-outcome evaluation, suggesting potential for scalability and future inclusion of CSE in the curricula of Italian schools.

Sharp increase in gonorrhoea notifications among young people, EU/EEA, July 2022 to June 2023

Gonorrhoea cases increased steeply in women aged 20 to 24 years across 15 EU/EEA countries in July to December 2022 and January to June 2023 with, respectively, 73% and 89% more cases reported than expected, based on historical data from 2015 to 2019. Smaller increases among men due to heterosexual transmission were observed in nine EU/EEA countries. Interventions to raise awareness among young people about sexually transmitted infection risks are needed, emphasising the benefit of safe sexual practices and testing.

Prevalence of chronic HCV infection in EU/EEA countries in 2019 using multiparameter evidence synthesis

Background

Epidemiological data are crucial to monitoring progress towards the 2030 Hepatitis C Virus (HCV) elimination targets. Our aim was to estimate the prevalence of chronic HCV infection (cHCV) in the European Union (EU)/European Economic Area (EEA) countries in 2019.

Methods

Multi-parameter evidence synthesis (MPES) was used to produce national estimates of cHCV defined as: π = πrecρrec + πexρex + πnonρnon; πrec, πex, and πnon represent cHCV prevalence among recent people who inject drugs (PWID), ex-PWID, and non-PWID, respectively, while ρrec, ρex, and ρnon represent the proportions of these groups in the population. Information sources included the European Centre for Disease Prevention and Control (ECDC) national operational contact points (NCPs) and prevalence database, the European Monitoring Centre for Drugs and Drug Addiction databases, and the published literature.

Findings

The cHCV prevalence in 29 of 30 EU/EEA countries in 2019 was 0.50% [95% Credible Interval (CrI): 0.46%, 0.55%]. The highest cHCV prevalence was observed in the eastern EU/EEA (0.88%; 95% CrI: 0.81%, 0.94%). At least 35.76% (95% CrI: 33.07%, 38.60%) of the overall cHCV prevalence in EU/EEA countries was associated with injecting drugs.

Interpretation

Using MPES and collaborating with ECDC NCPs, we estimated the prevalence of cHCV in the EU/EEA to be low. Some areas experience higher cHCV prevalence while a third of prevalent cHCV infections was attributed to PWID. Further efforts are needed to scale up prevention measures and the diagnosis and treatment of infected individuals, especially in the east of the EU/EEA and among PWID.

Funding

ECDC.

Impact of COVID-19 epidemic on temporal pattern of new HIV diagnoses in Italy, 2021 database

BACKGROUND

New HIV diagnoses in Italy decreased drastically in 2020 due to COVID-19 related effects: 50% fewer diagnoses were reported by the National HIV Surveillance System. COVID-19 pandemic impact on HIV surveillance is unclear. We estimated the expected number of new HIV diagnoses in 2020 in order to isolate the impact of the COVID-19 pandemic.

METHODS

We analyzed 29 697 new HIV infections diagnosed from 2012 to 2020, reported to the National HIV Surveillance System. We assessed temporal trends of new HIV diagnoses applying negative binomial mixed effects models. We estimated the COVID-19 impact as the difference between the model-estimated slopes from 2012 to 2019 and the change reported in the diagnoses. The expected number of new HIV diagnoses in 2020 was also estimated and compared with the reported count.

RESULTS

Based on the historical trend, we expected a 15% (95% CI: 5-25%) decline of new HIV diagnoses in 2020. We reported, however, a 49% decrease, yielding to a 34% net decrease in the number of new diagnoses. The strongest impact was estimated in northern regions (-40%) and MSM (-38%). We estimated 761 (95% prediction interval: 350-1277) missed diagnoses during 2020, the majority of them occurring in the North (465 cases), among MSM (416) and heterosexual males (217).

CONCLUSIONS

In 2020, when excluding 15% decrease of new diagnoses attributable to the expected reduction, an additional 34% decrease was observed, representing a large decline in new HIV diagnoses associated with the COVID-19 pandemic.

Knowledge and behaviours associated with HIV infection and other sexually transmitted infections in blood donors in Italy

INTRODUCTION

Sexually transmitted infections (STIs) represent a group of widespread infectious diseases. The objective of this study is to investigate the knowledge on HIV and STIs as well as sexual risk behaviours among blood donors in Italy.

MATERIALS AND METHODS

The study was carried out in 2017 among blood donors who accessed social media of the Italian Association of Blood Donors (Associazione Volontari Italiani del Sangue, AVIS), and answered to a questionnaire posted online.

RESULTS

Participating blood donors were 9,021, median age 36 years (IQR 26-47), 53.9% males, 94.3% heterosexual, and 2.7% reported having a current occasional partner. Unprotected sex in the last 4 months was reported by 54.1% of participants. About half of the participants were not informed of most STIs, 11.0% reported never having searched for information on HIV and STIs, one third considered unlikely acquiring HIV through unprotected sex with a known person, 21.3% would stop having sex with a partner found to be HIV-positive, and 15.8% would be afraid to hug or kiss a person with HIV.

DISCUSSION

Our results show that most blood donors have a stable partner and search actively for information on HIV and STIs. However, there is a proportion of them who engage in high-risk behaviours, have misconceptions on HIV and STIs transmission, reporting a stigmatising attitude towards people with HIV.

CONCLUSION

A more comprehensive and updated information on various STIs, transmission modes and safe sex should be provided to blood donors, not only to prevent the spread of these infections but also to avoid unjustified discrimination.

Increased kidney disease mortality among people with AIDS versus the general population: a population-based cohort study in Italy, 2006-2018

OBJECTIVES

This study aimed to assess whether an excess mortality related to kidney and other urinary tract diseases exists among Italian people with AIDS (PWA), as compared with the general population without AIDS (non-PWA).

DESIGN

Population-based, retrospective cohort study.

SETTING AND PARTICIPANTS

We conducted a nationwide study including 9481 Italian PWA, aged 15-74 years, reported to the National AIDS Registry between 2006 and 2018.

METHODS

Vital status and causes of death were retrieved by record linkage with the National Register of Causes of Death up to 2018. Excess mortality for PWA versus non-PWA was estimated through sex-standardised and age-standardised mortality ratios (SMRs) with corresponding 95% CIs.

RESULTS

Among 2613 deceased PWA, 262 (10.0%) reported at least one urinary tract disease at death, including 254 (9.7%) non-cancer diseases-mostly renal failures (225 cases, 8.6%)-and 9 cancers (0.3%). The overall SMR for non-cancer urinary tract diseases was 15.3 (95% CI 13.4 to 17.3) with statistically significant SMRs for acute (SMR=22.3, 95% CI 18.0 to 27.4), chronic (SMR=8.4, 95% CI 6.0 to 11.3), and unspecified renal failure (SMR=13.8, 95% CI 11.2 to 16.8). No statistically significant excess mortality was detected for urinary tract cancers (SMR=1.7, 95% CI 0.8 to 3.3). The SMRs were particularly elevated among PWA aged <50 years, injecting drug users, or those with the first HIV-positive test >6 months before AIDS diagnosis.

CONCLUSIONS

The excess mortality related to non-cancer kidney and other urinary tract diseases reported among PWA highlights the importance of implementing the recommendation for screening, diagnosis and management of such conditions among this population.

Development and early results of a comprehensive sexuality education experience in Italian schools

Background

Comprehensive sexuality education (CSE) is an integrated approach to sexual health and wellbeing promotion, especially effective when performed in school settings, but it is not included in Italian school curricula. This study describes the creation and early results of a pilot experience targeting students attending 20 lower secondary schools (LSS) in 4 Italian regions within EduForIST project, funded by the Ministry of Health.

Methods

A literature review and a national survey were used to collect guidelines and best practices in the field of sexuality education (SE), along with focus groups and multisectorial expert consultations. The results informed the development of 4 modules of 2 hours each, addressing: changes in adolescence; emotions and relationships; sexual identities and diversity; sexual consent, pregnancy and sexually transmitted infection (STI) prevention, sexual health services. A final session was dedicated to evaluation.

Results

The pre-test results referred to 14 classrooms of 5 schools within 2 Regions, for a total of 266 students. A high level of uncertainty was reported, regarding the topics of personal identity development (37,4%), experiencing intense emotions during adolescence (18,1%), the definitions of gender identity, sexual orientation and stereotype (42,1%), STI symptoms (58,7%) and prevention (43,4%). The post-test results were available for 153 students. Pre/post analysis showed an increase of correct answers (p&lt;.05) for 12/15 items investigated. A total of 102 students responded to the satisfaction questionnaire, with positive results.

Conclusions

Preliminary results revealed knowledge gaps and high levels of uncertainty among LSS students. Early pre/post evaluation suggested that the pilot activity was effective in enhancing knowledge and decreasing uncertainty in all domains. Evidence collected through this study will foster awareness among policy makers on the value and urgency of introducing CSE in Italian school curricula.

Key messages

Implementing a school-based comprehensive sexual health education intervention in Italy: experiences from the field

Introduction

This study describes the preliminary results of a School-based sexuality education (SBSE) pilot activity developed and implemented within EduForIST project, funded by the Italian Ministry of Health.

Methods

The pilot activity (5 modules of 2 hours each delivered per classroom) targeted lower secondary schools students. A total of 20 schools located in 4 different Italian regions participated. The educators were staff of several HIV/AIDS civil society organisations operating in Italy. A 2-days intensive workshop for educators was performed. Pre and post tests were conducted.

Results

At the time of submission, pre-test results were available from 14 classrooms of 5 schools within 2 Italian Regions, for a total of 266 students. Among these, 37,4% were unsure that personal identity is built through social comparison; 21,8% reported that emotions don't get more intense during adolescence, while 18,1% were unsure about the response; 42,1% reported a higher level of uncertainty concerning the definitions of gender identity, sexual orientation and stereotype. The highest level of uncertainty were reported for STIs symptoms (58,7%), impact of treatment on HIV+ people (61,9%) and efficacy of contraceptive pills in preventing STIs (43,4%). The post-test results were available for 153 students. Pre/post analysis showed an increase of correct answers (p &lt; 0.05) for 12 of 15 items investigated. A total of 102 students responded to the satisfaction questionnaire, with preliminary positive results.

Conclusions

Since activities are ongoing, further data will be soon available for more exhaustive analyses. Early pre/post evaluations suggested that the pilot experience was effective in enhancing knowledge and decreasing uncertainty in the different domains addressed in the pilot. Evidence collected through this study shall raise awareness among decision makers on the urgency of introducing CSE in Italian school curricula and inform future policy options.

Hepatitis of unknown aetiology in children - epidemiological overview of cases reported in Europe, 1 January to 16 June 2022

Following the report of an excess in paediatric cases of severe acute hepatitis of unknown aetiology by the United Kingdom (UK) on 5 April 2022, 427 cases were reported from 20 countries in the World Health Organization European Region to the European Surveillance System TESSy from 1 January 2022 to 16 June 2022. Here, we analysed demographic, epidemiological, clinical and microbiological data available in TESSy. Of the reported cases, 77.3% were 5 years or younger and 53.5% had a positive test for adenovirus, 10.4% had a positive RT-PCR for SARS-CoV-2 and 10.3% were coinfected with both pathogens. Cases with adenovirus infections were significantly more likely to be admitted to intensive care or high-dependency units (OR = 2.11; 95% CI: 1.18–3.74) and transplanted (OR = 3.36; 95% CI: 1.19–9.55) than cases with a negative test result for adenovirus, but this was no longer observed when looking at this association separately between the UK and other countries. Aetiological studies are needed to ascertain if adenovirus plays a role in this possible emergence of hepatitis cases in children and, if confirmed, the mechanisms that could be involved.

Mortality of people with AIDS in Italy: comparison of AIDS surveillance and multiple cause-of-death registries

AIMS

To assess whether the use of multiple cause-of-death data could improve reporting of AIDS mortality in Italy.

METHOD

Population-based, record-linkage study, on 3,975,431 deaths recorded in the National Registry of Causes of Death (RCoD) and 4,530 deaths recorded in the National AIDS Registry (RAIDS), during 2006-2012.

RESULTS

The record-linkage identified 3,646 AIDS-related deaths present in both registries, 884 deaths in the RAIDS without mention of HIV/AIDS in the RCoD, and 3,796 deaths in the RCoD with mention of HIV/AIDS that were not present in the RAIDS. In the latter, in-depth analysis of multiple cause-of-death allowed the identification of 1,484 deaths that were AIDS-related. On these results, we estimated 6,014 deceased people with AIDS. Of them, 14.7% (884) were not present in the RCoD and 24.7% (1,484) derived from the RCoD only.

CONCLUSIONS

The integration of different nationwide registries allowed a more comprehensive estimate of the impact of AIDS-associated mortality in Italy.

School-based sexuality education in Italy 2016-2020: a highly heterogeneous scenario

Background

In Italy, sexuality education (SE) is not part of school curricula. SE and, specifically, comprehensive SE (CSE), as defined by UNESCO, is one of the most important means of promoting sexual well-being among young people and a key component for sexually transmitted infections' (STI) prevention. School-based SE has the potential to reach most young people, is cost-effective and valued by students. The aim of this study was to describe school-based SE educational activities (EA) implemented in Italy during 2016-2020.

Methods

An online survey was developed and piloted to collect information on duration, content and methods used to implement the EA. The survey was disseminated at national and regional level between August-October 2020. IBM SPSS Statistics 26 was used to perform descriptive analysis of the data, while a framework from UNESCO was adapted to perform a qualitative analysis.

Results

A total of 219 reported EA were carried out in secondary schools. The analysis describes a highly heterogeneous scenario in terms of EA geographical coverage across the country (most EA delivered in 4/20 regions), providers (70% private, 30% public) and objectives. The qualitative analysis of content, objectives, and methodology identified 62 EA (29%) classifiable as CSE, with median duration of 3 days. The remainder EA had a risk-based approach, largely focussing on STI prevention (35%). Many EA (29%) were single-session interventions. Limited time availability for extra-curricular activities was reported as a key challenge. Only 97 EA performed evaluation (44%). In 53 EA (24%) both pre and post knowledge assessment were delivered and in 114 (52%) satisfaction was evaluated.

Conclusions

Italy is one of a few European countries still lacking a dedicated policy for school-based SE. According to available data, SE is not systematically and equally delivered across the country. Action is urgently needed to incorporate SE in school curricula. (Funding: Italian Ministry of Health)

Key messages

This study shows the absence of a comprehensive and shared approach to SE in Italy, with heterogeneous geographical coverage and providers and a lack of systematic objectives and evaluation. The results highlight the need to develop theoretical and practical guidelines for the implementation of CSE in Italy and the integration of sexuality education in school curricula.

[The professional skills of the nurse involved in the care of individuals with sexually transmitted infections]

INTRODUCTION

Accurate pain assessment and management in critically ill patients withcognitive alterations who are unable to communicate constitute a major challenge for themedical and nursing staff of Intensive Care Units (ICUs). This study want assess the impact of Critical Care Pain Observation Tool (CCPOT) scale in ICU practice and evaluate the effects on pain assessment and management in brain-injured critically ill adult patients.

METHODS

This before-and-after study was carried out in an Italian ICU, where data were collected before (T0) and after (T1) implementation of the CCPOT in brain-injured critically ill adults.

RESULTS

The study population consisted of 81 patients (35 before and 46 after intervention). The use of propofol fell significantly (propofol: t(80) = 1.83) and at the same time the use of morphine increase significantly (morphine: t(80) = 1.51) after intervention.Analysis of the data with respect to pain relief and prevention during some nursing care activities revealed a significant increase in the use of fentanyl citrate (x2(1)= 4.04, p =.04) and paracetamol (x2(1)= 5.30, p =.02). Pain management was in line with the protocol, which envisaged administration of pain medications to patients with CCPOT scores > 3 in 76.8% of cases.

CONCLUSION

The present findings strongly support the value of the CCPOT scale in managing ICU patient pain in conjunction with medical and nursing staff training. However, further studies of larger patient samples should be performed.

Post-migration acquisition of HIV: Estimates from four European countries, 2007 to 2016

BackgroundThe assumption that migrants acquire human immunodeficiency virus (HIV) before migration, particularly those from high prevalence areas, is common.AimWe assessed the place of HIV acquisition of migrants diagnosed in four European countries using surveillance data.MethodsUsing CD4+ T-cell count trajectories modelled to account for seroconversion bias, we estimated infection year of newly HIV-diagnosed migrants residing in the United Kingdom (UK), Belgium, Sweden and Italy with a known arrival year and CD4+ T-cell count at diagnosis. Multivariate analyses identified predictors for post-migration acquisition.ResultsBetween 2007 and 2016, migrants constituted 56% of people newly diagnosed with HIV in the UK, 62% in Belgium, 72% in Sweden and 29% in Italy. Of 23,595 migrants included, 60% were born in Africa and 70% acquired HIV heterosexually. An estimated 9,400 migrants (40%; interquartile range (IQR): 34-59) probably acquired HIV post-migration. This proportion was similar by risk group, sex and region of birth. Time since migration was a strong predictor of post-migration HIV acquisition: 91% (IQR: 87-95) among those arriving 10 or more years prior to diagnosis; 30% (IQR: 21-37) among those 1-5 years prior. Younger age at arrival was a predictor: 15-18 years (81%; IQR: 74-86), 19-25 years (53%; IQR: 45-63), 26-35 years (37%; IQR: 30-46) and 36 years and older (25%; IQR: 21-33).ConclusionsMigrants, regardless of origin, sex and exposure to HIV are at risk of acquiring HIV post-migration to Europe. Alongside accessible HIV testing, prevention activities must target migrant communities.

Human Immunodeficiency Virus Continuum of Care in 11 European Union Countries at the End of 2016 Overall and by Key Population: Have We Made Progress?

Background

High uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region.

Methods

A CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit.

Results

We estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries.

Conclusions

The EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control.

Demographic and socio-economic determinants of poor HIV-risk perception at first HIV diagnosis: analysis of the HIV Surveillance data, Italy 2010-2016

INTRODUCTION

HIV infections in Italy has not undergone a substantial decline over recent years. For this reason, we analysed risk-factors and socio-economic indicators of HIV-risk perception in HIV surveillance data.

METHODS

An observational study was conducted and HIV-risk perception was estimated on the basis of reasons for undergoing testing. Ordinal logistic models were applied with three groups of response corresponding to three ordered levels of HIV-risk perception.

RESULTS

The study included 18 055 individuals: 27% with low, 40% moderate and 33% with high perception. A low risk perception was estimated in both areas, least deprived and highly deprived [Adjusted Odds Ratio (AOR) = 1.58, CI: 1.14-2.18 and AOR = 2.33, CI: 1.39-3.90]; for heterosexuals (AOR = 1.96, CI: 1.83-2.11), Injecting Drug Users (IDU) (AOR =1.82, CI: 1.59-2.08), low education (AOR = 1.74. CI: 1.20-2.54), age > 40 years (AOR = 1.59, CI: 1.50-1.69), males (AOR = 1.30, CI: 1.20-1.40).

CONCLUSIONS

In Italy there is a high percentage of HIV-infected people with poor HIV-risk perception. Poorer HIV-risk perception was associated with both, least and high deprivation, low education, older age, male gender, heterosexual and IDU groups. Our results could be relevant to address targeted HIV testing policies at both local and national levels.

Excess liver-related mortality among people with AIDS compared to the general population: an Italian nationwide cohort study using multiple causes of death

OBJECTIVES

Liver diseases have become a leading cause of death among people with AIDS (PWA). This study aimed to investigate whether PWA experienced excess mortality related to liver diseases as compared to the general population (non-PWA), using a multiple cause of death (MCoD; i.e. all conditions reported on death certificates) approach.

METHODS

A population-based, nationwide, retrospective cohort study was conducted among Italian people, aged 15-74 years, who had been diagnosed with AIDS since 2006. Date of death and MCoD data were retrieved, up to December 2015, by individual record linkage with national mortality data. Sex- and age-standardized mortality ratios (SMRs), with 95% confidence intervals (CIs), were estimated by dividing the observed number of deaths related to a specific condition among PWA to the expected number, based on non-PWA mortality rates.

RESULTS

Among 7912 PWA (34 184 person-years), 2076 deaths occurred. The number of death certificates reporting liver diseases among MCoDs was 583 (28.1%), including 382 (18.4%) reporting viral hepatitis, 370 (17.8%) reporting nonviral liver diseases, and 41 (2.0%) reporting liver cancers. The corresponding SMRs were 40.4 (95% CI 37.2-43.8) for all liver diseases, 131.1 (95% CI 118.3-145.0) for viral hepatitis, 29.9 (95% CI 27.0-33.1) for nonviral liver diseases, and 11.2 (95% CI 8.1-15.3) for liver cancers. Particularly elevated SMRs emerged among PWA aged 15-49 years and those infected by injecting drug use.

CONCLUSIONS

The high excess liver-related mortality observed among PWA warrants preventive actions to limit the burden of viral hepatitis coinfections, alcohol abuse, and metabolic disorders, especially among younger PWA and injecting drug users.

Estimated burden of Chlamydia trachomatis female infection and consequent severe pelvic inflammatory disease, Italy, 2005-2016

Chlamydia trachomatis (Ct) is the leading sexually transmitted infection (STI) across Europe. In Italy, Ct prevalence is low in general population, but predominance of asymptomatic infections, passive voluntary reporting, variable diagnostic criteria and coding practices can lead to considerable underestimation, preventing assessment of real burden of disease and health intervention. We analysed data on female genital Ct infection registered in STI sentinel surveillance systems in Italy from 2005 through 2016 and found 3305 women. Among them, those aged 20-24 years had the highest disability-adjusted life years (DALYs) estimation equal to 106.77 DALYs per 100 000-stratum specific population. Through the study period, incidence rate (IR) for female Ct infection increased significantly from 2.9 to 7.1 per 100 000 resident population. Besides, we analysed data on pelvic inflammatory disease (PID) reported from the National Hospital Information system (NHIS) in the same period. We found 287 women hospitalised with concurrent PID and Ct infection. We recommend targeted screening programmes in women aged 20-24, definition of nationwide active surveillance system, standardisation of diagnostic criteria and ICD-9CM coding practices.

Quantifying unmet prevention needs among MSM in Europe through a multi-site bio-behavioural survey

Introduction

The HIV epidemic represents an important public health issue in Europe particularly among men who have sex with men (MSM). Global AIDS Monitoring indicators (GAM) have been widely and jointly promoted as a set of crucial standardised items to be adopted for monitoring and responding to the epidemic.

Methods

The Sialon II study, implemented in 13 European cities (2013-14), was a complex multi-centre integrated bio-behavioural cross-sectional survey targeted at MSM, with a concomitant collection of behavioural and biological (oral fluid or blood specimens) data. Rigorous sampling approaches for hard-to-reach populations were used (time-location sampling and respondent-driven sampling) and GAM indicators were calculated; sampling frames were adapted to allow weighted estimates of GAM indicators.

Results

4,901 MSM were enrolled. HIV prevalence estimates ranged from 2.4% in Stockholm to 18.0% in Bucharest. When exploring city-level correlations between GAM indicators, prevention campaigns significantly correlated with levels of condom use and level of HIV testing among MSM.

Conclusion

The Sialon II project has made an important contribution to the monitoring and evaluation of the HIV epidemic across Europe, integrating the use of GAM indicators within a second generation HIV surveillance systems approach and in participatory collaboration with MSM communities. It influenced the harmonisation of European data collection procedures and indicators via GAM country reporting and contributed essential knowledge informing the development and implementation of strategic, evidence-based HIV prevention campaigns for MSM.

People living with undiagnosed HIV infection and a low CD4 count: estimates from surveillance data, Italy, 2012 to 2014

Background and aims

Late HIV diagnosis is associated with onward HIV transmission, higher morbidity, mortality and healthcare costs. In Italy, more than half of people living with HIV were diagnosed late during the last decade, with a CD4 count < 350 cells/mm³ at diagnosis. We aimed to determine the number and characteristics of people living with undiagnosed HIV infection and low CD4 counts in Italy.

Methods

Data on newly reported HIV diagnoses from 2012 –2014 were obtained from the national HIV surveillance system. We used the European Centre for Disease Prevention and Control HIV modelling tool to calculate the undiagnosed prevalence and yearly diagnosed fraction (YDF) in people with low CD4 count.

Results

The estimated annual number undiagnosed HIV infections with low CD4 count was on average 6,028 (95% confidence interval (CI): 4,954–8,043) from 2012–2014. In 2014, most of the undiagnosed people with low CD4 count were men (82.8%), a third acquired HIV through sex between men (MSM) (35.0%), and heterosexual transmission (33.4%), respectively. The prevalence of undiagnosed HIV infection was 11.3 (95% CI: 9.3–14.9) per 100,000 residents ranging from 0.7 to 20.8 between Italian regions. Nationally the prevalence rate was 280.4 (95% CI: 173.3–450.2) per 100,000 MSM, 8.3 (95% CI: 4.9–13.6) per 100,000 heterosexual men, and 3.0 (95% CI: 1.4–5.6) per 100,000 women. The YDF was highest among heterosexual women (27.1%; 95% CI: 16.9–45.2%).

Conclusions

These findings highlight the importance of improving efforts to identify undiagnosed HIV infections primarily among men, both MSM and heterosexual men.

Allergy screening in a schoolchildren-based population

BACKGROUND

Schoolchildren screening for allergic diseases may improve early identification and management of atopic children. The aim of this study was to perform a schoolchildren screening program for identification of children with allergic diseases.

METHODS

All parents of children attending to 13 primary schools in the city of Rome were requested to fill in a demographic data form and the ChAt questionnaire. Allergological evaluation was performed in the children with suspect of allergy (ChAt score > 2). Ocular examination was performed to identify signs of allergic conjunctivitis. The presence of allergic symptoms was related to demographic and environmental variables.

RESULTS

A total of 2667 children (mean age: 7.1 ± 1 years) were included, and 2489 (93.3%) parents completed the ChAt questionnaire. Results of ChAt questionnaire showed a previous diagnosis of allergic disease in 637 (25.6%) children and the potential presence of an allergic disease (ChAt score > 2) in 35.1%. Multivariate analysis showed that older age, male gender, and having less than two siblings were associated with higher risk of allergic disease. Visual screening showed the presence of clinical signs of allergic conjunctivitis in 2% of children. Allergologic evaluation in 334 children confirmed the diagnosis of allergic disease in 324 (97%) cases. Among them, 97 (29.9%) did not refer to a previous formal diagnosis of allergic condition.

CONCLUSIONS

This study confirmed that schoolchildren screening using ChAt questionnaire could represent a useful tool for early identification of yet undiagnosed atopic children.

Emerging role for Ureaplasma parvum serovar 3: Active infection in women with silent high-risk human papillomavirus and in women with idiopathic infertility

Recently, there are controversial opinions on the presence of Mycoplasmas/Ureaplasmas as colonizers or pathogens, and on the use of a targeted therapy. This study aimed to characterize Mycoplasmas/Ureaplasmas infections in reproductive age women, including the acquisition of sexually transmitted (ST) pathogens and poor birth outcomes. A total of 646 healthy Italian women fulfilled the inclusion criteria including 521 infertile women, 65 pregnant women, and 60 fertile women with identified risk factors and symptomatic for vaginitis/cervicitis. Multiplex and quantitative molecular techniques and direct automatic DNA sequencing were performed to assess the genome structure of Mycoplasma/Ureaplasma species and ST infected pathogens. Ureaplasma parvum serovar 3 represented the predominant colonizer of the urogenital tract of this series and the unique species significantly associated with ST pathogens coinfection (p < 0.01). U. parvum load >10⁴ bacteria/ml, suggestive of active infection, has been measured only in asymptomatic high-risk human papillomavirus infected women (24.3%) and in 40% of women with idiopathic infertility. To note, 16% of the follicular fluid from these idiopathic women resulted infected with U. parvum. In conclusion, the present study focused the attention on U. parvum serovar 3 as emerging microorganism in sexually active women that may have the benefit of targeted therapy.

[Regional HIV Surveillance in Italy: a starting point for the future national system]

BACKGROUND

the Italian National HIV Surveillance, instituted by the Ministerial Decree of March 31st, 2008, is based on 21 regional surveillance systems and adopts an essential data collection form with a definite data flow. The unification of HIV and AIDS surveillance systems and the implementation of an identical data collection form are priorities of the Italian National HIV/AIDS Action Plan 2017 (PNAIDS).

OBJECTIVES

to describe the 21 regional HIV surveillance systems and to verify the feasibility of their unification.

METHODS

in March 2017, a questionnaire containing 13 questions was sent to all the regional representatives of the 21 surveillance systems. The main questions were about timeliness, data flow, and quality of the system. The quality was measured through a subjective evaluation expressed by the regional referent through scores from 1 (minimum) to 10 (maximum) regarding four indicators (regional coverage, timeliness, correctness, and completeness of the data).

RESULTS

more than half of the regional systems use a computerized data collection method. Some of these regions have not completely adapted to the data collection form contained in the Decree and other regions declare a undernotification of the system. The majority of the regions record a slight notification delay by the reporting centres. Some regions report gaps in the completeness of the data received by the reporting centres.

CONCLUSIONS

the main strengths of the HIV surveillance system are computerization of the systems and slightly reporting delay. Regarding the quality of the regional systems and its data, the study reports a good self-evaluation. This study also showed useful indications to improve the national HIV surveillance system, such as the unification of HIV surveillance with the AIDS surveillance and the implementation of a unique national system, as suggested by guidelines of the PNAIDS 2017.

Excess mortality related to circulatory system diseases and diabetes mellitus among Italian AIDS patients vs. non-AIDS population: a population-based cohort study using the multiple causes-of-death approach

Background

Chronic diseases, chiefly cancers and circulatory system diseases (CSDs), have become the leading non-AIDS-related causes of death among HIV-infected people, as in the general population. After our previous report of an excess mortality for several non-AIDS-defining cancers, we now aim to assess whether people with AIDS (PWA) experience also an increased mortality for CSDs and diabetes mellitus (DM), as compared to the non-AIDS general population (non-PWA).

Methods

A nationwide, population-based, retrospective cohort study was conducted including 5285 Italians, aged 15−74 years, who were diagnosed with AIDS between 2006 and 2011. Multiple cause-of-death (MCoD) data, i.e. all conditions reported in death certificates, were retrieved through record-linkage with the National Register of Causes of Death up to 2011. Using MCoD data, sex- and age-standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated by dividing the observed number of PWA reporting a specific disease among MCoD to the expected number, estimated on the basis of mortality rates (based on MCoD) of non-PWA.

Results

Among 1229 deceased PWA, CSDs were mentioned in 201 (16.4%) certificates and DM in 46 (3.7%) certificates among the various causes of death. These values corresponded to a 13-fold higher mortality related to CSDs (95% CI 10.8–14.4) and DM (95% CI: 9.5–17.4) as compared to 952,019 deceased non-PWA. Among CSDs, statistically significant excess mortality emerged for hypertension (23 deaths, SMR = 6.3, 95% CI: 4.0–9.4), ischemic heart diseases (39 deaths, SMR = 6.1, 95% CI: 4.4–8.4), other forms of heart diseases (88 deaths, SMR = 13.4, 95% CI: 10.8–16.5), and cerebrovascular diseases (42 deaths, SMR = 13.4, 95% CI: 9.7–18.2). The SMRs were particularly elevated among PWA aged < 50 years and those infected through drug injection.

Conclusions

The use of MCoD data disclosed the fairly high mortality excess related to several CSDs and DM among Italian PWA as compared to non-PWA. Study findings also indicate to start preventive strategies for such diseases at a younger age among AIDS patients than in the general population and with focus on drug users.

HIV avidity index performance using a modified fourth-generation immunoassay to detect recent HIV infections

BACKGROUND

Detecting recent HIV infections is important to evaluate incidence and monitor epidemic trends. We aimed to evaluate the diagnostic performance and accuracy of the avidity index (AI) for discriminating for recent HIV infections.

METHODS

We collected serum samples from HIV-1 positive individuals: A) with known date of infection (midpoint in time between last HIV-negative and first HIV-positive test); B) infected for >1 year. Samples were divided into two aliquots: one diluted with phosphate buffered saline (PBS) and the other with 1 M guanidine. Both aliquots were assayed by the Architect HIV Ag/Ab Combo 4th generation assay (Abbott). We compared AI found in recent (RI=<6 months from seroconversion) and established (EI) infections. The diagnostic accuracy was evaluated by receiver operating characteristic (ROC) curve analysis. The proportion of samples misclassified as recent (FRR) was calculated.

RESULTS

In total, 647 samples were collected: 455 in group A (51.6% RI and 48.4% EI) and 192 in group B. Among these, sixteen samples were from elite controllers, 294 from treated patients, 328 from patients infected with non-B subtypes. Samples before antiretroviral initiation showed a mean AI significantly lower among RI compared to EI (0.66+0.28 vs. 1.00±0.12; p<0.000). The FRR was 0% using a cut-off of ≤0.70. An extremely low FRR was observed among elite controllers, samples with low VL or CD4. HIV subtype had no impact on AI misclassifications. All individuals in group A reached the AI threshold of 0.80 within 24 months after seroconversion.

CONCLUSIONS

The AI is an accurate serological marker for discriminating recent from established HIV infections and meets WHO requirements for HIV incidence assays.