[Epidemiology of HIV infection in immigrants in Spain: information sources, characteristics, magnitude and tendencies]

Survey of diagnostic resources for STI in Spain

BACKGROUND

Scarce information is available on the resources to deal with the Sexually Transmitted Infections (STIs), both in the clinic and in the laboratory. The objective is to describe and know the reality of the clinics and laboratories that treat these infections in Spain.

METHODS

Cross-sectional observational study with data collection through a survey aimed at the members of the GEITS Group.

RESULTS

Responses were obtained from 24 centers (response rate 38.1%) belonging to 10 Autonomous Communities. Regarding STI consultations, 38% require that the patient present a health card to provide assistance, and 31.8% only provide it by referral from another doctor. The 52.4% perform diagnostic methods in the care center. Regarding laboratories, 18.2% do not offer immediate response diagnostic tests, although 100% have PCR against Neisseria gonorrhoeae and Chlamydia trachomatis, 47.8% against Mycoplasma genitalium and 65% detect lymphogranuloma venereum genotypes. All laboratories continue to perform culture and gonococcal sensitivity techniques, and 20% perform molecular methods for detection of MG antimicrobial resistance.

CONCLUSION

There is great variability in the provision of human and material resources both in the clinics and in the laboratories that attend STIs. In a significant number of centers there are limitations for patient access. Although laboratories have molecular biology technologies, not all of them offer immediate response tests. All laboratories detect N. gonorrhoeae infection by PCR and also by culture, which allows sensitivity testing in all centers.

Survey of diagnostic resources for STI in Spain

BACKGROUND

Scarce information is available on the resources to deal with the Sexually Transmitted Infections (STIs), both in the clinic and in the laboratory. The objective is to describe and know the reality of the clinics and laboratories that treat these infections in Spain.

METHODS

Cross-sectional observational study with data collection through a survey aimed at the members of the GEITS Group.

RESULTS

Responses were obtained from 24 centers (response rate 38.1%) belonging to 10Autonomous Communities. Regarding STI consultations, 38% require that the patient present a health card to provide assistance, and 31.8% only provide it by referral from another doctor. The 52.4% perform diagnostic methods in the care center. Regarding laboratories, 18.2% do not offer immediate response diagnostic tests, although 100% have PCR against Neisseria gonorrhoeae and Chlamydia trachomatis, 47.8% against Mycoplasma genitalium and 65% detect lymphogranuloma venereum genotypes. All laboratories continue to perform culture and gonococcal sensitivity techniques, and 20% perform molecular methods for detection of MG antimicrobial resistance.

CONCLUSION

There is great variability in the provision of human and material resources both in the clinics and in the laboratories that attend STIs. In a significant number of centers there are limitations for patient access. Although laboratories have molecular biology technologies, not all of them offer immediate response tests. All laboratories detect N.gonorrhoeae infection by PCR and also by culture, which allows sensitivity testing in all centers.

Economic Crisis and Sexually Transmitted Infections: A Comparison Between Native and Immigrant Populations in a Specialised Centre in Granada, Spain

This study aimed to analyse the influence of the economic crisis on the prevalence of sexually transmitted infections (STIs) in the immigrant population compared to the native population. A cross-sectional study was conducted by reviewing 441 clinical records (329 Spanish nationals and 112 non-Spanish nationals) of individuals who, between 2000 and 2014, visited an STI clinic in Granada and tested positive for an infection. Descriptive statistical analyses were performed, and infection rates, odds ratios, and 95% confidence intervals (CIs) were calculated. The mean age was 28.06 years (SD = 8.30; range = 16–70). During the period 2000–2014, the risk of being diagnosed with an STI was higher among non-Spanish nationals than among Spanish nationals (odds ratio (OR) = 5.33; 95% CI = 4.78–6.60). Differences between both populations were less marked during the crisis period (2008–2014: OR = 2.73; 95% CI = 2.32–3.73) than during the non-crisis period (2000–2007: OR = 12.02; 95% CI = 10.33–16.17). This may be due to underreporting of diagnoses in the immigrant population. Immigrants visiting the STI clinic in Granada are especially vulnerable to positive STI diagnoses compared to the native population.

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

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

Pregnancy as an opportunity to diagnose human-immunodeficiency virus immigrant women in Catalonia

INTRODUCTION

Mother-to-child transmission (MTCT) is relevant in the global epidemiology of human-immunodeficiency virus (HIV), as it represents the main route of infection in children. The study objectives were to determine the rate of HIV-MTCT and its epidemiological trend between the Spanish-born and immigrant population in Catalonia in the period 2000-2014.

METHODS

A prospective observational study of mother-child pairs exposed to HIV, treated in 12 hospitals in Catalonia in the period 2000-2014. HIV-MTCT rate was estimated using a Bayesian logistic regression model. R and WinBUGS statistical software were used.

RESULTS

The analysis included 909 pregnant women, 1,009 pregnancies, and 1,032 children. Data on maternal origin was obtained in 79.4% of women, of whom 32.7% were immigrants, with 53.0% of these from sub-Saharan Africa. The overall HIV-MTCT rate was 1.4% (14/1,023; 95% CI; 0.8-2.3). The risk of MTCT-HIV was 10-fold lower in women with good virological control (P=.01), which was achieved by two-thirds of them. The proportion of immigrants was significantly higher in the period 2008-2014 (P<.0001), for the HIV-diagnosis (P<.0001), and antiretroviral administration (P=.02) during pregnancy, and for undetectable viral load next to delivery (P<.001). There were no differences in the rate of MTCT-HIV among Spanish-born and immigrant women (P=.6).

CONCLUSIONS

There is a gradual increase in HIV pregnant immigrants in Catalonia. Although most immigrant women were diagnosed during pregnancy, the rate of MTCT-HIV was no different from the Spanish-born women.

[HIV infection and immigration]

Migrants represent around one third of patients newly diagnosed with HIV in Spain and they constitute a population with higher vulnerability to its negative consequences due to the socio-cultural, economical, working, administrative and legal contexts. Migrants are diagnosed later, which worsens their individual prognosis and facilitates the maintenance of the HIV epidemic. In spite of the different barriers they experience to access healthcare in general, and HIV-related services in particular, access to antiretroviral treatment has been similar to that of the autochthonous population. However, benefits of treatment have been not, with women in general and men from Sub-Saharan Africa exhibiting the worse response to treatment. We need to proactively promote earlier diagnosis of HIV infection, the adoption of preventive measures to avoid new infections, and to deliver accessible, adapted and high-quality health-care.

Mortality in migrants living with HIV in western Europe (1997-2013): a collaborative cohort study

BACKGROUND

Many migrants face adverse socioeconomic conditions and barriers to health services that can impair timely HIV diagnosis and access to life-saving treatments. We aimed to assess the differences in overall mortality by geographical origin in HIV-positive men and women using data from COHERE, a large European collaboration of HIV cohorts from 1997 to 2013.

METHODS

In this observational cohort study, we included HIV-positive, antiretroviral-naive people accessing care in western Europe from COHERE. Individuals were eligible if enrolled in a cohort that collected information on geographical origin or ethnic origin from Jan 1, 1997, to March 19, 2013, aged 18-75 years, they had available information about sex, they were not infected perinatally or after the receipt of clotting factor concentrates, and were naive to combination antiretroviral therapy at cohort entry. Migrants' origins were grouped into seven regions: western Europe and similar countries (Australia, Canada, New Zealand, and the USA); eastern Europe; North Africa and the Middle East; sub-Saharan Africa; Latin America; the Caribbean; and Asia and the rest of Oceania (excluding Australia and New Zealand). Crude and adjusted mortality rate ratios were calculated by use of Poisson regression stratified by sex, comparing each group with the native population. Multiple imputation with chained equations was used to account for missing values.

FINDINGS

Between Oct 25, 1979, and March 19, 2013, we recruited 279 659 individuals to the COHERE collaboration in EuroCoord. Of these 123 344 men and 45 877 women met the inclusion criteria. Our data suggested effect modification by transmission route (pinteraction=0·12 for men; pinteraction=0·002 for women). No significant difference in mortality was identified by geographical origin in men who have sex with men. In heterosexual populations, most migrant men had mortality lower than or equal to that of native men, whereas no group of migrant women had mortality lower than that in native women. High mortality was identified in heterosexual men from Latin America (rate ratio [RR] 1·46, 95% CI 1·00-2·12, p=0·049) and heterosexual women from the Caribbean (1·48, 1·29-1·70, p<0·0001). Compared with that in the native population, mortality in injecting drug users was similar or low for all migrant groups.

INTERPRETATION

Characteristics of and risks faced by migrant populations with HIV differ for men and women and for populations infected heterosexually, by sex between men, or by injecting drug use. Further research is needed to understand how inequalities are generated and maintained for the groups with higher mortality identified in this study.

FUNDING

EuroCoord.

Clinical, epidemiological and treatment failure data among HIV-1 non-B-infected patients in the Spanish AIDS Research Network Cohort

INTRODUCTION

The prevalence of HIV-1 non-B variants is increasing in Spain, showing a higher number of transmitted drug resistance mutations (TDR) since 2002. This study presents the features of non-B-infected patients enrolled in the cohort of antiretroviral treatment (ART) naïve HIV-infected patients included in the Research Network on HIV/AIDS (CoRIS).

METHODS

The study includes a selected group of HIV-1 non-B-infected subjects from 670 subjects with pol sequences collected from 2004 to 2008 in the CoRIS cohort. Epidemiological-clinical-virological data were analyzed since cohort entry until October 2011, considering the presence or absence of treatment failure (TF).

RESULTS

Eighty two non-B infected subjects with known HIV-1 variants were selected from 2004 to 2008 in the CoRIS cohort, being mainly female, immigrants, infected by recombinant viruses, and by heterosexual route. They had an intermediate TDR rate (9.4%), a high rate of TF (25.6%), of losses to follow-up (35%), of coinfections (32.9%), and baseline CD4+ counts ≥350cells/mm(3) (61.8%). Non-B subjects with TF showed higher rates of heterosexual infection (85.7% vs. 69.5%, p<0.05), tuberculosis (30.8% vs. 9.1%, p=0.10) and hepatitis C (23.8% vs. 13.9%, p=0.34) coinfections and lower rates of syphilis (0% vs. 21.9%, p<0.05), and had more frequently received first-line ART including protease inhibitors (PIs) than patients without TF (70% vs. 30%, p<0.05). Interestingly, infection with non-B variants reduced the risk of TDR to nucleoside reverse transcriptase inhibitors and increased the risk to PIs.

CONCLUSION

HIV-1 non-B-infected patients in Spain had a particular epidemiological and clinical profile that should be considered during their clinical management.

Social factors associated with the knowledge about HIV of the immigrants from China, Latin America, the Maghreb and Senegal in the Basque Country (Spain)

The objective of this study was to identify the social factors that explain the differences in knowledge with regards to HIV/AIDS among immigrants in the Basque Country (Spain). We conducted a cross-sectional study based on information obtained in the Basque Health Survey for 754 immigrants from: 86 China, 368 Latin America, 237 the Maghreb and 74 Senegal. Odds ratios (95% CI) were calculated from logistic regression models to measure the degree of association between inadequate knowledge regarding transmission, prevention and places where HIV testing is offered, and the independent variables. We found that this inadequate knowledge is associated with place of birth, sex, a lower level of education, immigration status, difficulties in understanding Spanish, and not receiving advice about AIDS in primary care. These findings indicate that initiatives must be developed to promote equity in the provision of healthcare through clinical guidelines, including details of the specific needs of different groups of immigrants and considering gender issues.

Never tested for HIV in Latin-American migrants and Spaniards: prevalence and perceived barriers

Introduction

Increasing the uptake of HIV testing and decreasing the number of undiagnosed people is a priority for HIV prevention. Understanding the barriers that hinder people from testing is vital, particularly when working with especially vulnerable populations like migrants. Most data available on migrants are based on African migrants in the UK, while barriers to HIV testing in Latin-American migrants living in Europe remain unexplored. Still, they account for a quarter of new diagnosis in Spain and suffer higher rates of delayed diagnosis.

Methods

Between May 2008 and March 2011, a mobile unit offered free rapid HIV tests in different Spanish cities. We compared the prevalence of no previous testing, adjusting for potential confounders by two multivariate logistic models, and described differences in perceived barriers to testing in Latin-American migrants living in Spain versus Spaniards. Participants included men who have sex with men (MSM), men who have sex exclusively with women (MSW), and women.

Results

Of the 5920 individuals who got tested and answered a self-administered questionnaire, 36.5% were MSM (20.4% previously untested), 28.9% were MSW (49% previously untested) and 34.6% were women (53% previously untested). Almost one quarter were Latin-American, of whom 30% had never been tested versus 45% of untested Spaniards. After adjusting for potential confounders, Spaniards were more likely to report no previous testing than Latin-Americans among women and MSW all together (Odds Ratio (OR)=2.0; 95% Confidence Interval (CI): 1.7–2.4) and among MSM (OR=1.6; 95% CI: 1.2–2.0). Among the 2455 who had never undergone an HIV test before, main barriers to testing were low perceived risk (54% Spaniards vs. 47% Latin-American) and concerns arising from the loss of anonymity (19.5% vs. 16.9%). Fear of rejection or discrimination and fear of legal problems were a barrier for <2%.

Conclusions

Latin-American migrants living in Spain were more likely to get tested than Spaniards. Regardless of nationality, low perceived risk was the main barrier to testing whereas fear of stigma or discrimination and fear of legal problems were merely incidental. However, new Spanish austerity policies regarding healthcare for migrants in response to the economic crisis may reverse this situation.

[Characteristics of a cohort of pregnant women with human immunodeficiency virus infection]

BACKGROUND

Mother-to-child transmission (MTCT) during pregnancy, delivery or breastfeeding, is the main route of HIV infection in children. Strategies aimed at promoting the health of HIV infected pregnant women and MTCT prevention have reduced transmission to below 2%. This paper presents the clinical and epidemiological features of a cohort from Madrid and compares foreign-born with Spanish-born women.

METHOD

Retrospective, observational and descriptive study on HIV infected pregnant women from South Madrid (n=70) and their offspring (n=78) who were born during the study period from August 1992 to January 2010.

RESULTS

Most pregnant women were infected by heterosexual transmission (51%). Most Spanish-born women (66%) were diagnosed before pregnancy (81%), while foreign-born women (34%) were diagnosed during pregnancy (70%). Foreign-born women had less obstetric check-ups (67%) than Spanish-born women (97%). The MTCT rate was 1.3% during the last ten years.

CONCLUSIONS

Heterosexual transmission is the primary mode of acquisition of HIV infection both for Spanish-born and foreign-born pregnant women. However, the HIV infection was diagnosed earlier in Spanish-born women. There were no differences in the effectiveness of antiretroviral therapy as a preventive measure against MTCT when it is started at an early stage.

[Assessment of the impact of the new health legislation on illegal immigrants in Spain: the case of human immunodeficiency virus infection]

The immigrant population in Spain, whether legal or not, has been entitled to healthcare under the same conditions as the Spanish population since the year 2000. The entry into vigour of the Royal Decree-Law 12/2012 of 20 April has significantly restricted this right, so that unauthorized or non-resident foreigners may now only receive emergency care, if they are under 18 or pregnant women. Out of an estimated 459,909 illegal immigrants in our country, 2,700 to 4,600 are probably infected with HIV; 1,800 to 3,220 know that they are infected, and 80% of the latter could receive antiretroviral treatment. The Royal Decree-Law is likely to cause many undesirable consequences in this population infected with HIV: increasing mortality, promoting the emergence of opportunistic diseases, increasing hospital admissions, increasing infections in the population (by HIV and other pathogens), or contributing to mother to child transmission of HIV. The expected increase in morbidity and mortality will be a greater cost in patient care, a cost which will be significantly higher in the more immunosuppressed patients. Therefore, the enforcement of the Royal Decree-Law will be much less cost-effective in the short term than was expected, and will negatively affect our country's public health, especially for those patients infected with HIV who will not be covered, thus increasing healthcare medium to long term costs, and moving away from the international health goals that were established.