[Trends in HIV prevalence and associated risk behaviors in female sex workers in Catalonia (Spain)]

Sexually transmitted infections among at-risk women in Ecuador: implications for global prevalence and testing practices for STIs detected only at the anorectum in female sex workers

OBJECTIVES

Anorectal sexually transmitted infections (STIs) such as Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG), present treatment challenges, potentially increase antibiotic resistance selection and if undetected may facilitate onward transmission. However, there are limited global prevalence data for anorectal STIs. We conducted a cross-sectional study to assess the prevalence and risk factors of non-viral genital and extragenital STIs in female sex workers (FSW) and female non-sex workers (NSW) in Ecuador.

METHODS

250 adult street and brothel FSWs and 250 NSWs, recruited from settlements in north-west Ecuador provided oropharyngeal and vulvo-vaginal swabs (VVS) as well as socio-demographic data. FSWs also provided anorectal swabs. PCR was used to detect CT, NG, Mycoplasma genitalium (MG) from all swabs and additionally Trichomonas vaginalis (TV) from VVS. Risk factors were analysed using logistic regression.

RESULTS

Prevalence of FSW vaginal, anorectal and oropharyngeal infection was 32.0% (95% CI 26.5% to 38.0%), 19.7% (95% CI 15.1% to 25.2%) and 3.2% (95% CI 1.6% to 6.2%), respectively, with most vaginal infections being TV (23.4%; 95% CI 18.5% to 29.2%). Overall FSW STI prevalence, at any anatomical site was 39.7% (95% CI 33.8% to 46.1%), with 12.1% (95% CI 8.5% to 16.9%) of infections detected only at the anorectum. Of all the CT and/or NG infections, 64.4% (95% CI 50.4% to 78.4%) were detected only at the anorectum. STI prevalence in NSWs in the vagina and oropharynx were 5.6% (95% CI 3.4% to 9.2%) and 0.8% (95% CI 0.2% to 2.9%), respectively, with most vaginal infections being MG (3.2%; 95% CI 1.6% to 6.2%). In multivariable analysis, risk factors among brothel-based FSWs for having an anorectal STI were vaginal CT, NG or MG (p<0.001), vaginal TV (p=0.029) and being 'in a relationship' (p=0.038).

CONCLUSIONS

High prevalence of CT and NG detected only at the anorectum in these FSWs indicate the possibility of missing significant infections if providing only genital testing and calls for greater research into the potential impact on global STI estimates if extragenital infections among at-risk women are not identified.

Características clínicas-serológicas de los pacientes adultos con VIH-SIDA atendidos ambulatoriamente

La infección por el virus de Inmunodeficiencia Humana (VIH) es un problema de salud pública mundial. El objetivo del estudio fue determinar las características clínicas-serológicas de los pacientes adultos con VIH-SIDA, atendidos ambulatoriamente en el Hospital Homero Castanier Crespo. Se realizó un estudio retrospectivo, transversal, analítico, observacional, cuantitativo. Se incluyeron en el estudio todos los pacientes con infección por VIH atendidos por la consulta externa. El total de pacientes en seguimiento fue de 54, predominando el sexo masculino (72,2%), heterosexuales (75,9%), y mayor frecuencia de casos en el rango de edades de 18 a 35 años. Ocupacionalmente el grupo estudiado era diversoG. En pacientes del sexo femenino (N: 15) predominaron las amas de casas (10/15) (66,6%). La mayoría habían sido diagnosticados en los últimos 5 años. Con relación a la carga viral de control al año de tratamiento, presentaban carga viral indetectable (menor a 40 copias/mL) el 48,1%, carga viral entre 40 a 10.000 copias/mL el 16,7%, mayor a 10.000 copias/mL el 7,4% y el 27,8% se encontraba en tratamiento menor a 1 año. Alrededor del 50% tenían un recuento de linfocitos T CD4 mayor a 200 mm3. La combinación antirretroviral en la mayoría de los pacientes (77,8%) era tenofovir/emtricitabina/efavirenz

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

Background

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

Methods

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

Results

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

Discussion

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

HIV, Chlamydia and gonorrhoea vulnerability depending to sex work site

INTRODUCTION

Women sex workers (WSW) are one of key population on the HIV and other sexually transmitted infections (STIs) monitoring and evaluation. Socioeconomic, structural factors and other factors associated with the workplace influence exposure to these infections. The objectives of this study were to describe and compare the social characteristics, risk behaviours and HIV, chlamydia and gonorrhoeae prevalence according to sex work site (street or highway, clubs and flats).

METHODS

Cross-sectional study on 400 WSW in Catalonia. Socio-demographic, sex work and behavioral characteristics were collected through personal interview. Oral fluid and urine samples were collected to determine STI prevalence.

RESULTS

WSW that exercised in the street or highway presented more precarious conditions and a greater vulnerability related to socioeconomic factors: older population, with a lower education level and with less economic remuneration for their service. Other factors associated with lifestyle or behaviour was also observed: greater injecting drug use, longer sex work or vulnerabilities associated with structural or social determinants: less access to health services, higher proportion of forced relations and stay in prison. The overall HIV, chlamydia and gonorrhoeae prevalence was 3.0%, 1.8% and 0.5%, respectively and higher in women who exercised on the street or highway, 5.6%, 1.9% and 1.2%, respectively.

CONCLUSION

The information generated in this study will be useful for the design specific preventive interventions aimed at this group.

HIV seroprevalence in five key populations in Europe: a systematic literature review, 2009 to 2019

Background

In Europe, HIV disproportionately affects men who have sex with men (MSM), people who inject drugs (PWID), prisoners, sex workers, and transgender people. Epidemiological data are primarily available from national HIV case surveillance systems that rarely capture information on sex work, gender identity or imprisonment. Surveillance of HIV prevalence in key populations often occurs as independent studies with no established mechanism for collating such information at the European level.

Aim

We assessed HIV prevalence in MSM, PWID, prisoners, sex workers, and transgender people in the 30 European Union/European Economic Area countries and the United Kingdom.

Methods

We conducted a systematic literature review of peer-reviewed studies published during 2009–19, by searching PubMed, Embase and the Cochrane Library. Data are presented in forest plots by country, as simple prevalence or pooled across multiple studies.

Results

Eighty-seven country- and population-specific studies were identified from 23 countries. The highest number of studies, and the largest variation in HIV prevalence, were identified for MSM, ranging from 2.4–29.0% (19 countries) and PWID, from 0.0–59.5% (13 countries). Prevalence ranged from 0.0–15.6% in prisoners (nine countries), 1.1–8.5% in sex workers (five countries) and was 10.9% in transgender people (one country). Individuals belonging to several key population groups had higher prevalence.

Conclusion

This review demonstrates that HIV prevalence is highly diverse across population groups and countries. People belonging to multiple key population groups are particularly vulnerable; however, more studies are needed, particularly for sex workers, transgender people and people with multiple risks.

Sexually transmitted infections and factors associated with risky sexual practices among female sex workers: A cross sectional study in a large Andean city

BACKGROUND

There are limited published data on factors related to risky sexual practices (RSP) affecting sexually transmitted infections (STIs) among female sex workers (FSWs) in Ecuador.

METHODS

Cross-sectional study of FSWs presenting for a consultation in a primary health care centre during 2017. A questionnaire was administered to collect information on RSP and potential risk factors including age, membership of an FSW association, self-report of previous STI diagnosis, previous treatment for suspected STI and temporary migration for sex work. Associations between RSP and potential risk factors were estimated by logistic regression. The proportion of STI was estimated from vaginal swabs by real-time PCR for four sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, and Mycoplasma genitalium).

RESULTS

Of 249 FSWs recruited, 22.5% had reported RSPs at least once during sex work. Among FSWs reporting unprotected vaginal sex in the previous three months, 25.5% had at least one other RSP type. 17.6% (95%CI 13.3-22.8) had at least one active STI. Prevalence of co-infections was 2.4% (95%CI 1.1-5.2). In multivariable analysis, RSP was associated with age (adjusted OR 1.06; 95%CI 1.02-1.10), membership of an FSWs association (aOR 3.51; 95%CI 1.60-7.72) and self-reported previous STI (aOR 3.43; 95%CI 1.28-9.17).

CONCLUSIONS

Among a population of female sex workers with high proportion of STIs, increasing age and belonging to an FSWs association was associated with a higher likelihood of engaging in RSP with clients. Engaging with FSWs organisations may reduce the burden of STI among sex workers.

HIV, Chlamydia and gonorrhoea vulnerability depending to sex work site

INTRODUCTION

Women sex workers (WSW) are one of key population on the HIV and other sexually transmitted infections (STIs) monitoring and evaluation. Socioeconomic, structural factors and other factors associated with the workplace influence exposure to these infections. The objectives of this study were to describe and compare the social characteristics, risk behaviours and HIV, Chlamydia and gonorrhoeae prevalence according to sex work site (street or highway, clubs and flats).

METHODS

Cross-sectional study on 400WSW in Catalonia. Socio-demographic, sex work and behavioral characteristics were collected through personal interview. Oral fluid and urine samples were collected to determine STI prevalence.

RESULTS

WSW that exercised in the street or highway presented more precarious conditions and a greater vulnerability related to socioeconomic factors: older population, with a lower education level and with less economic remuneration for their service. Other factors associated with lifestyle or behaviour was also observed: greater injecting drug use, longer sex work or vulnerabilities associated with structural or social determinants: less access to health services, higher proportion of forced relations and stay in prison. The overall HIV, Chlamydia and gonorrhoeae prevalence was 3.0%, 1.8% and 0.5%, respectively, and higher in women who exercised on the street or highway: 5.6%, 1.9% and 1.2%, respectively.

CONCLUSION

The information generated in this study will be useful for the design specific preventive interventions aimed at this group.

Sexually Transmitted Infections and Associated Factors in Southeast Spain: A Retrospective Study from 2000 to 2014

The World Health Organization estimates that more than one million people acquire a Sexually Transmitted Infection (STI) every day, compromising quality of life, sexual and reproductive health, and the health of newborns and children. It is an objective of this study to identify the factors related to a Sexually Transmitted Infection diagnosis in the province of Granada (Spain), as well as those better predicting the risk of acquiring such infections. In this study, 678 cases were analyzed on a retrospective basis, which were treated at the Centre for Sexually Transmitted Diseases and Sexual Orientation in Granada, between 2000–2014. Descriptive statistics were applied, and by means of binary logistic regression, employing the forward stepwise-likelihood ratio, a predictive model was estimated for the risk of acquiring an STI. Sex, age, occupation, economic crisis period, drug use, number of days in which no condoms were used, number of sexual partners in the last month and in the last year, and number of subsequent visits and new subsequent episodes were associated with an STI diagnosis (p < 0.05). The risk of being diagnosed with an STI increased during the economic crisis period (OR: 1.88; 95%-CI: 1.28–2.76); during the economic crisis and if they were women (OR:2.35, 95%- CI: 1.24–4.44); and if they were women and immigrants (OR: 2.09; 95%- CI:1.22–3.57), while it decreased with age (OR: 0.97, 95%-CI: 0.95–0.98). Identification of the group comprised of immigrant women as an especially vulnerable group regarding the acquisition of an STI in our province reflects the need to incorporate the gender perspective into preventive strategies and STI primary health care.

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.

Burden of HIV infection, vulnerable populations and access barriers to healthcare

In Spain, HIV incidence has remained stable and higher than the European average since 2000 due to insuf-ficient prevention measures. An estimated 130,000-160,000 people are believed to be living with HIV in Spain, including 18% who do not know they are infected, and half are late diagnoses, with a poorer clinical course, lower quality of life and life expectancy, as well as higher costs. Late diagnosis is more common in heterosexuals, intravenous drug users, people over 50 years of age and immigrants, whereas men who have sex with men are the only group where the rate of new diagnoses is increasing. An estimated 34% of people with HIV have a detectable viral load, mainly due to barriers that hinder diagnosis such as insufficient testing availability and the low risk perception of undiagnosed individuals and healthcare professionals.

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.

[Survey adaptation for bio-behavioural surveillance of HIV in Chilean female sex workers]

OBJECTIVE

To adapt a behavioural questionnaire for second-generation HIV/AIDS surveillance in female sex workers (FSWs) in the Metropolitan Region, Chile.

METHODS

Qualitative study of instruments validation. A Spanish instrument adapted in Catalonia was validated through a translation and back-translation of the original version. The content validity was determined through a modified Delphi method, via FSW and HIV experts representing community, political and institutional levels. Applicability aspects were determined by the application of the questionnaire to FSW in the Metropolitan Region.

RESULTS

The questionnaire, drafted in Spain, was successfully adapted to Chilean Spanish. The content validity process enabled sections to be created that address HIV in FSWs. The adapted questionnaire takes less than 15minutes to complete, which makes it usable in fieldwork. The 61 women surveyed came from different countries (all were Latin Americans) and had different educational levels; all this enabled potential applicability problems to be detected.

DISCUSSION

The adapted questionnaire for Chile contains all the UNAIDS indicators for FSWs, as well as the recommended indicators of Family Health International for bio-behavioural surveillance. Said questionnaire serves as a tool for second-generation HIV/other STD surveillance and further contributes to preventive policies in Chilean FSWs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors of the HIV Transmission in Men Who Have Sex with Men in Suizhou City from 2009 to 2013

Introduction

The primary transmission of human immunodeficiency virus (HIV) has been recently changing worldwide. In China, HIV transmission through heterosexual contact remains the predominant mode, but the prevalence of men who have sex with men (MSM) has been increasing.

Aim

This article investigated the overall epidemic trend and associated high-risk behavior among MSM in Suizhou City and explored the government's responses to the epidemic.

Methods

We conducted yearly cross-sectional behavioral surveillance surveys among MSM in Suizhou City from 2009 to 2013. Participation was anonymous and self-completed. Recruitment methods were consistently applied in each survey.

Main Outcome Measures

Semi-structured questionnaire surveys and yearly work summaries were conducted.

Results

Most of the MSM groups in Suizhou City were young adults (P < 0.05), well educated (P < 0.05), and married (P < 0.05). Two years after our interventions, we found an increasing trend of condom use during anal sex (P < 0.05), as well as commercial sex trade (P < 0.05).

Conclusions

HIV continues to spread rapidly among MSM in Suizhou City. The high-risk behavior among MSM remains a hindrance to HIV prevention. Innovative intervention approaches are essential for HIV surveillance and prevention among MSM in Suizhou City. Yang F, Shi X, He W, Wu S, Wang J, Zhao K, Yuan H, Martin K, and Zhang H. Factors of the HIV transmission in men who have sex with men in Suizhou City from 2009 to 2013. Sex Med 2015;3:24–31.

Condom use among female sex workers in Catalonia: why do they use a condom, why don't they use it?

The present study, based on social representation theory (Moscovici, 1961), aimed to identify the social representation of condom use (CU) in a collective of female sex workers (FSW) in Catalonia, considering both their work and private life. It involved 124 FSW and combined both qualitative and quantitative methodologies. Results suggest that both CU and non-CU represent strategies that FSW use mainly when confronted by threats to things they consider important. In work life, where CU is widespread, the most important thing is health protection, and the threat is represented by sexually transmitted infections. In private life, where non-CU is widespread, the most important thing is that their relationships adhere to an idealized relationship model, based on love, trust, and sexual gratification; this model lies in contrast to the status of the women as FSW. The threats are represented by both partner infidelity and their FSW status (symbolic threats).

Can we rely on the antiretroviral treatment as the only means for human immunodeficiency virusprevention? A Public Health perspective

The evidence that supports the preventive effect of combination antiretroviral treatment (cART) in HIV sexual transmission suggested the so-called 'treatment as prevention' (TAP) strategy as a promising tool for slowing down HIV transmission. As the messages and attitudes towards condom use in the context of TAP appear to be somehow confusing, the aim here is to assess whether relying on cART alone to prevent HIV transmission can currently be recommended from the Public Health perspective. A review is made of the literature on the effects of TAP strategy on HIV transmission and the epidemiology of other sexual transmitted infections (STIs) in the cART era, and recommendations from Public Health institutions on the TAP as of February 2014. The evolution of HIV and other STIs in Barcelona from 2007 to 2012 has also been analysed. Given that the widespread use of cART has coincided with an increasing incidence of HIV and other STIs, mainly amongst men who have sex with men, a combination and diversified prevention methods should always be considered and recommended in counselling. An informed decision on whether to stop using condoms should only be made by partners within stable couples, and after receiving all the up-to-date information regarding TAP. From the public health perspective, primary prevention should be a priority; therefore relying on cART alone is not a sufficient strategy to prevent new HIV and other STIs.