Coverage rate of opportunistic and organised breast cancer screening in France: Department-level estimation

OBJECTIVE

In France, the national breast cancer screening programme (NBCSP), targeting women aged 50-74 years was rolled out nationwide in 2004. It aims at reducing breast cancer mortality. In addition to the NBCSP, the use of opportunistic screening is permitted in France. The objective of this study is to estimate both opportunistic use and overall coverage rates of breast cancer screening, among women 40-84 years of age, in France.

METHODS

The French medico-administrative health data system (SNDS) was used to identify women performing an opportunistic or organised mammography screening in France in 2016-2017.

RESULTS

The two-yearly opportunistic mammography screening is 18 % among women aged 40-84; it is 11 % among women aged 50-74, i.e., the target age range for organised screening, 36 % among women aged 40-49 and 13 % among women aged 75-84. The overall two-yearly screening coverage is 48 % for all women aged 40-84; it is 60 % among women aged 50-74, 36 % among women 40-49 and 16 % for those aged 75-84. Geographical variations in screening are lessened when the two screening strategies are considered, as they balance each other.

CONCLUSION

Although coverage in the NBCSP is around 50 % in France, more than one third of the women make use of opportunistic screening within and outside the target age range. Organized screening appears to improve equity of access to mammography screening service. The lack of data on opportunistic screening practices hinders the evaluation of French screening practices as a whole.

Breast cancer screening programme participation and socioeconomic deprivation in France

The objective was to quantify the relationship between deprivation and national breast cancer screening programme (NBCSP) participation at an ecological level in mainland France. Data from 4,805,390 women-living in 36,209 municipalities within 95 departments-participating in the 2013-2014 NBCSP were analysed using the French Deprivation Index (FDep). FDep population quintiles by municipality were computed to describe NBCSP participation according to deprivation. To better examine the relationship between continuous value of deprivation index and participation rates at the municipality level, we built a generalized linear mixed model. Geographical variations in participation rates were marked. The national standardized participation rate was higher in the intermediate quintiles (55%), 45% for the least deprived one and 52% for the most deprived one. Using our model, we also obtained an inverted U-curve for the relationship between NBCSP participation and municipality deprivation: participation was lower for both the least and most deprived municipalities. This relationship was also observed for each of the two subpopulations-urban municipalities and rural ones-considered separately. Introducing the FDep in the model reduced slightly the unexplained variations in participation rates between departments and between municipalities (with a proportional change in variance of 14% and 12% respectively). We highlight major disparities in departmental participation rates and FDep/participation profiles. However, deprivation appears to have only little influence on geographical variation in participation rates. There is a need to further understand the factors affecting geographical variation in participation rates, in particular the use of opportunistic screening.

Health-state utility estimates for health technology assessment: a review of the manufacturers' submissions to the French National Authority for Health

BACKGROUND

Our aim was to review the selection and methods used for deriving health state utility (HSU) estimates included in the cost-utility analyses (CUA) submitted by manufacturers to the National Authority for Health (HAS) during the first 2 years after the introduction of the economic evaluation for price setting in France.

METHODS

We reviewed all manufacturers' submissions that included a CUA and were assessed by HAS by the end of October 2015 (N = 34). We reviewed the identification, selection, and methods used to estimate HSU and compared them with those recommended by HAS.

RESULTS

A literature review to identify HSU was reported in only 13 (38%) submissions. The instruments for describing HSU were a preference-based generic instrument in 20 (59%) submissions; vignettes in five (15%); a condition-specific instrument in three (9%); and a combination of instruments in six (18%). The valuation perspective was the general population in 26 (76%) submissions; in only nine (26%) submissions, the valuation set was derived from the French general population.

CONCLUSIONS

We identified numerous concerns in the selection, valuation and use of HSU, as well as a frequent lack of clarity in the methods used. Most submissions (79%) included HSU that did not meet HAS recommendations.

Exploring Uncertainty in Economic Evaluations of Drugs and Medical Devices: Lessons from the First Review of Manufacturers' Submissions to the French National Authority for Health

OBJECTIVES

The objective of this paper was to evaluate how uncertainty has been accounted for in the cost-effectiveness analyses (CEAs) submitted by manufacturers to the French National Authority for Health (HAS) and to identify recurring concerns in these submissions.

METHODS

We used a cross-sectional design to evaluate manufacturers' submissions from the beginning of the evaluation process in October 2013 to the end of May 2015 (n = 28). The sources of uncertainty attached to these CEAs were categorized and assessed. Relevant data were extracted independently by two assessors.

RESULTS

Adherence to the HAS reference case was generally considered to be acceptable. Methodological uncertainty and parameter uncertainty were the sources of uncertainty that were most frequently explored by manufacturers. The quality of reporting of deterministic sensitivity analysis and probabilistic sensitivity analysis varied substantially across submissions, with a frequent lack of justification of the plausible range of parameter point estimates in 12 submissions (43 %). Structural uncertainty was explored much less frequently. Concerns related to omission of either important clinical events or relevant health states or extrapolation of the effects of the technology beyond the time horizon of the clinical trials were identified in 16 submissions (57 %).

CONCLUSIONS

This study presented a characterization of the treatment of uncertainty for the first 28 manufacturers' submissions to the HAS. This work identified important concerns regarding the exploration of sources of uncertainty. The findings may help manufacturers to improve the quality of their submissions and may provide useful insights for extending guidelines on uncertainty analysis in CEAs submitted to the HAS.

Cost-effectiveness analysis of universal newborn screening for medium chain acyl-CoA dehydrogenase deficiency in France

BACKGROUND

Five diseases are currently screened on dried blood spots in France through the national newborn screening programme. Tandem mass spectrometry (MS/MS) is a technology that is increasingly used to screen newborns for an increasing number of hereditary metabolic diseases. Medium chain acyl-CoA dehydrogenase deficiency (MCADD) is among these diseases. We sought to evaluate the cost-effectiveness of introducing MCADD screening in France.

METHODS

We developed a decision model to evaluate, from a societal perspective and a lifetime horizon, the cost-effectiveness of expanding the French newborn screening programme to include MCADD. Published and, where available, routine data sources were used. Both costs and health consequences were discounted at an annual rate of 4%. The model was applied to a French birth cohort. One-way sensitivity analyses and worst-case scenario simulation were performed.

RESULTS

We estimate that MCADD newborn screening in France would prevent each year five deaths and the occurrence of neurological sequelae in two children under 5 years, resulting in a gain of 128 life years or 138 quality-adjusted life years (QALY). The incremental cost per year is estimated at €2.5 million, down to €1 million if this expansion is combined with a replacement of the technology currently used for phenylketonuria screening by MS/MS. The resulting incremental cost-effectiveness ratio (ICER) is estimated at €7 580/QALY. Sensitivity analyses indicate that while the results are robust to variations in the parameters, the model is most sensitive to the cost of neurological sequelae, MCADD prevalence, screening effectiveness and screening test cost. The worst-case scenario suggests an ICER of €72 000/QALY gained.

CONCLUSIONS

Although France has not defined any threshold for judging whether the implementation of a health intervention is an efficient allocation of public resources, we conclude that the expansion of the French newborn screening programme to MCADD would appear to be cost-effective. The results of this analysis have been used to produce recommendations for the introduction of universal newborn screening for MCADD in France.

HIV testing in Europe: mapping policies

OBJECTIVES

In the absence of treatment and in the context of discrimination, HIV testing was embedded within exceptional procedures. With increasing treatment effectiveness, early HIV diagnosis became important, calling for the normalization of testing. National HIV testing policies were mapped to explore the characteristics and variations across European countries.

METHODS

Key informants within the health authorities of all EU/EEA countries were questioned on HIV testing policies, which were assessed within a conceptual framework and the level of exceptionalism and normalization was scored based on defined attributes.

RESULTS

Twenty-four out of 31 countries participated in the survey. Policies tended to support confidential voluntary testing, informed consent, and counselling. In the majority of countries, specific groups were targeted for provider-initiated testing. Taking together all attributes of HIV testing, 14 countries obtained a high score for exceptionalism, while only 3 achieved a high score on normalization. Italy, Lithuania and Romania had primarily exceptional procedures; Norway leant more towards normalization; Netherlands, the United Kingdom, and Denmark scored high in both.

CONCLUSIONS

In most EU/EEA countries, policies are integrating HIV testing in health care settings, through voluntary and targeted testing strategies. Current HIV testing policies exhibited a high level of exceptionalism with varying degrees of normalization. Further research should compare HIV testing policies with practices.

Chlamydia control activities in Europe: cross-sectional survey

BACKGROUND

Chlamydia is the most commonly reported bacterial sexually transmitted infection in Europe. The objective of the Screening for Chlamydia in Europe (SCREen) project was to describe current and planned chlamydia control activities in Europe.

METHODS

The authors sent a questionnaire asking about different aspects of chlamydia epidemiology and control to public health and clinical experts in each country in 2007. The principles of sexually transmitted infection control were used to develop a typology comprising five categories of chlamydia control activities. Each country was assigned to a category, based on responses to the questionnaire.

RESULTS

Experts in 29 of 33 (88%) invited countries responded. Thirteen of 29 countries (45%) had no current chlamydia control activities. Six countries in this group stated that there were plans to introduce chlamydia screening programmes. There were five countries (17%) with case management guidelines only. Three countries (10%) also recommended case finding amongst partners of diagnosed chlamydia cases or people with another sexually transmitted infection. Six countries (21%) further specified groups of asymptomatic people eligible for opportunistic chlamydia testing. Two countries (7%) reported a chlamydia screening programme. There was no consistent association between the per capita gross domestic product of a country and the intensity of chlamydia control activities (P = 0.816).

CONCLUSION

A newly developed classification system allowed the breadth of ongoing national chlamydia control activities to be described and categorized. Chlamydia control strategies should ensure that clinical guidelines to optimize chlamydia diagnosis and case management have been implemented before considering the appropriateness of screening programmes.

The epidemiology of HIV and AIDS reports in migrants in the 27 European Union countries, Norway and Iceland: 1999-2006

BACKGROUND

To describe the epidemiology of HIV and AIDS by geographical origin in the EU, 1999-2006.

METHODS

AIDS and HIV cases from the EU 27, Norway and Iceland reported to European Centre for Epidemiological Monitoring of AIDS were analysed.

RESULTS

Of 75,021 AIDS reports over 1999-2006, 35% were migrants. Of 2988 heterosexual AIDS reports in 2006, 50% were migrants, largely from Sub-Saharan Africa (SSA), 20% of 1404 AIDS cases in men who have sex with men (MSM) were migrants from Latin-America and Western Europe. Of 57 mother-to-child transmission (MTCT) AIDS cases, 23% were from SSA. AIDS cases decreased from 1999 to 2006 in natives (42%), Western Europeans (40%) and North Africa and Middle East (34%), but increased in people from SSA (by 89%), Eastern Europe (by 200%) and Latin-America (50%). Of 17,646 HIV infections in men and 9066 in females in 2006, 49 and 76% were migrants, largely from SSA. Of 169 MTCT infections, 41% were from SSA.

CONCLUSION

Migrants, largely from SSA, represent a considerable proportion of AIDS and HIV reports in EU, especially among heterosexual and MTCT infections. Their contribution is higher among female reports. A substantial percentage of diagnoses in MSM are migrants, largely from Western Europe and Latin-America.

Barriers to HIV testing in Europe: a systematic review

BACKGROUND

In the European Union (EU) and neighbouring countries, HIV/AIDS, of all infectious diseases, has one of the highest morbidity and mortality rates. An estimated 30% of people living with HIV are unaware of their infection, and may therefore not benefit from timely treatment or may transmit HIV to others, unknowingly. Evidence shows that opportunities are being missed to diagnose HIV infections in EU Member States, particularly in regular health care settings. There is a need to better understand the barriers to HIV testing and counselling with the aim to contribute to the decrease of the number of undiagnosed people.

METHODS

A systematic review of literature on HIV testing barriers in Europe was conducted, applying a free text strategy with a set of search terms.

RESULTS

A total of 24 studies published in international peer-reviewed journals and meeting the review's eligibility criteria were identified. Fourteen studies report on barriers at the level of the patient; six on barriers at health care provider level and seven on institutional barriers referring to the policy level. The barriers described are centralized around low-risk perception; fear and worries; accessibility of health services, reluctance to address HIV and to offer the test; and scarcity of financial and well trained human resources.

CONCLUSIONS

Some barriers to HIV testing and counselling have been illustrated in the literature. Nevertheless, there is lack of structured information on barriers considering (i) legal, administrative and financial factors, (ii) attitudes and practices of health care providers and (iii) perception of patients. Such data is critical to improve effectiveness of HIV testing and counselling.

Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) case reporting in the World Health Organization European Region in 2006

This article presents information on HIV and AIDS case reporting systems as part of a survey on HIV/AIDS surveillance practices in the World Health Organization (WHO) European Region. A standardised questionnaire was sent to the 53 national correspondents of the European Centre for the Epidemiological Monitoring of AIDS(EuroHIV). The HIV and AIDS case reporting section of the questionnaire comprised four parts: data collection system, HIV/AIDS case definition for surveillance, variables collected, and evaluation of surveillance systems). Individual-based data collection systems for HIV case reports have been implemented in 43 of 44 countries in the WHO European Region and for AIDS case reports in all the countries. For HIV case reports, a coded identifier is used in 28 countries, and full names are used in 11 countries. The European AIDS case definition has been adopted in 35 countries(80%). Information on molecular epidemiology is available in 30 countries, and HIV drug resistance is monitored in 11 countries.HIV/AIDS case reporting systems have been evaluated for underreporting in 17 countries and for completeness in 11 countries.This article outlines the future needs for HIV/AIDS surveillance and presents recommendations on how to improve data comparability across European countries in the WHO region.

Male circumcision in Slovenia: results from a national probability sample survey

OBJECTIVES

To estimate the prevalence of male circumcision and to explore its association with demographic characteristics and self-reported sexually transmitted infection (STI) diagnosis in Slovenia.

METHODS

Data were collected over 1999-2001 from a national probability sample of the general population aged 18-49 years at respondents' homes by a combination of face-to-face interviews and anonymous self-administration of questionnaires. Statistical methods for complex survey data were used to account for stratification, clustered sampling and weighting.

RESULTS

Overall, 4.5% (95% CI 3.2 to 6.5) of Slovenian male citizens reported being circumcised. Major variations in the prevalence of circumcision were observed across religious groups, with 92.4% (95% CI 59.8 to 99.0) of Muslims being circumcised, 1.7% (95% CI 0.9 to 3.1) of Roman Catholics, 0% of other religious affiliations (Evangelic, Serbian Orthodox, other), and 7.1% (95% CI 4.4 to 11.2) of those with no religious affiliation (p<0.001). The prevalence of circumcision did not vary across age groups. There were no significant differences in the proportion of circumcised and uncircumcised Slovenian men reporting ever being diagnosed with bacterial STI or viral STI.

CONCLUSIONS

The prevalence of circumcision among Slovenian men is low. No evidence was found for an association between STI diagnosis and circumcision status, which may be due to the low prevalence of both STI and circumcision in this population as well as a small sample size. In Slovenia, where HIV prevalence is <1/1000 citizens and HIV infection is concentrated in men who have sex with men, promoting male circumcision in the general population may not be effective for HIV prevention purposes.

Trends in HIV prevalence in blood donations in Europe, 1990-2004

INTRODUCTION

The comparison of HIV prevalence among blood donations in European countries provides an indication of the relative safety of the blood supply in different countries and over time.

METHODS

Data between 1990 and 2004 on annual numbers of blood donations and HIV prevalence in blood donations were collected from national correspondents in the 52 countries of the World Health Organization European Region. Data are presented for three geographic areas: West, Centre and East.

RESULTS

Since 1990, the number of blood donations has declined by 43% in the East and by 26% in the Centre, while remaining relatively stable in the West. In 2004, the number of blood donations was more than twice as high in the West in comparison with the East and the Centre. Over the same period, HIV prevalence among blood donations increased dramatically in the East, remained stable in the Centre and declined in the West. Since 2001, HIV prevalence levels of more than 10 per 100 000 donations were reported from six countries in the East (with a high of 128/100 000 in Ukraine), whereas in the rest of Europe the reported national HIV prevalence levels were lower than 10/100 000 donations. The prevalence of HIV was much lower among donations from repeat donors than from first-time donors.

CONCLUSION

In some eastern European countries public health interventions, such as deferring individuals at risk of HIV infection from donating blood and constituting a pool of regular donors, are urgently needed to assure the safety of the blood supply.

HIV/AIDS in Europe: trends and EU-wide priorities

There are an estimated 740 000 people living with HIV or AIDS in western and central Europe today, and 1.7 million in the neighbouring countries of eastern Europe and Central Asia

Cost-effectiveness of HIV post-exposure prophylaxis in France

OBJECTIVE

To assess the cost-effectiveness of HIV post-exposure prophylaxis (PEP) in France.

METHODS

We used a decision tree to evaluate, from a society's perspective, the cost of PEP per quality-adjusted life-year (QALY) saved. We used 1999-2003 PEP surveillance data and literature-derived data on per event transmission probabilities, PEP efficacy and quality of life with HIV. HIV prevalence and lifetime cost of HIV/AIDS management in the HAART era were derived from French studies. We assumed that mean life expectancy in full health was 65 years among uninfected individuals and that the mean survival time after HIV infection was 22.5 years. The costs of PEP drugs and follow-up were derived from the French public sector. A 3% annual rate was used to discount future costs and effects.

RESULTS

During 1999-2003, PEP was prescribed to 8958 individuals (heterosexual sex: 47.6%; homosexual sex: 28.4%; occupational exposure: 23.4%; drug injection: 0.6%); of those, 2143 were exposed to a known HIV-infected source. PEP was estimated to prevent 7.7 infections and saved 64.5 QALY at a net cost of euro 5.7 million, resulting in an overall cost-effectiveness ratio of euro 88,692 per QALY saved. PEP was cost saving for 4.4% of cases and cost effective (< euro 50,000 per QALY) in a further 11.3% of cases. In contrast, 72 and 52% of prescriptions had a cost-effectiveness ratio exceeding euro 200,000 and euro 2 millions, respectively, per QALY saved.

CONCLUSION

Overall, the French PEP programme is only moderately cost effective. PEP guidelines should be revised to target high-risk exposures better.

The changing face of the HIV epidemic in western Europe: what are the implications for public health policies?

In this review, we describe changes in dynamics of HIV transmission and shifts in affected populations in western Europe using HIV/AIDS surveillance data and published and unpublished reports. Despite substantial reductions in HIV-related morbidity and mortality since the introduction of highly active antiretroviral treatment, HIV continues to pose a major public health problem in western Europe. More than half a million people are living with an infection that remains incurable and requires costly lifelong treatment; many people remain unaware of their infection, and thousands of new infections continue to occur every year. Migrants from countries with a high prevalence of HIV/AIDS, notably sub-Saharan Africa, bear a disproportionate and increasing share of HIV throughout western Europe and, in most countries, account for the majority of heterosexually acquired HIV infections diagnosed in recent years. Prevention, treatment, and care must be adapted to reach migrant populations. Following a resurgence of risky sexual behaviour, HIV transmission may now be increasing among homosexual and bisexual men, and renewed safer sex campaigns are urgently needed.

HIV in central and eastern Europe

We describe recent trends in the HIV epidemic and the differences between eastern and central Europe, using surveillance data, and published and unpublished reports. During the past 5 years, most countries of the former Soviet Union have been severely affected by HIV epidemics that continue to spread as a result of injecting drug use. With an estimated 1 million individuals already infected--mostly injecting drug users--and high rates of syphilis, the region may soon also face a large-scale epidemic of sexually-transmitted HIV infection. Indeed, data indicate that an HIV epidemic, fuelled by heterosexual transmission, is emerging; its expansion will depend on the size of so-called bridge populations that link high-risk groups with the general population. The lack of evidence to indicate increased rates of HIV as a result of homosexual transmission could indicate the social vulnerability of homosexual and bisexual men in the region rather than the true epidemiological picture. In view of the current levels of HIV prevalence, eastern Europe will soon be confronted with a major AIDS epidemic. By contrast, rates of HIV in central Europe remain low at present, but behaviours that promote HIV transmission are present in all countries. Improved measures to prevent further HIV spread are urgently needed.

The HIV infection in Europe: large East-West disparity

In 2001, western Europe faces an endemic situation for AIDS (22.8 cases per million population) and for HIV infection (54.9 cases per million), the most affected groups remaining injecting drug users and the homo/bisexual men. However, numbers of new HIV diagnoses are increasing among persons infected through heterosexual contact. Central Europe have been relatively spared, with AIDS incidence under 6 cases per million per year, and new HIV diagnoses between 7 and 10 cases per million. On the other hand, eastern Europe shows an epidemic increase in the number of newly diagnosed HIV infections (233 cases in 1994, around 100,000 reported cases in 2001, ie 349 cases per million population) affecting all countries.

Current situation and regional perspective on HIV/AIDS surveillance in europe

AIDS reporting has been the principal means of monitoring the HIV/AIDS situation in Europe since 1984 [corrected]. HIV reporting was set up at the European level in 1999, although it has existed in most European countries since the 1980s. Anonymous individual data on AIDS and, if available, new HIV diagnoses, and data on HIV prevalence in various populations are reported from the 51 countries of the WHO European Region to EuroHIV, and aggregate data on HIV prevalence in various populations [corrected]. Data are presented after grouping the 51 countries into three geographic areas: the West, Center, and East. At end of 2000, in the West, AIDS incidence continued to decline except among those infected heterosexually; numbers of newly diagnosed HIV infections are relatively stable, but rising among heterosexually infected persons, many of whom originate from countries with generalized HIV epidemics. In the East, numbers of newly diagnosed HIV cases (mostly injection drug users) continue to rise steeply, particularly in the Russian Federation, Latvia, and Estonia. In the Center, levels of HIV and AIDS remain low. HIV reporting is becoming a central element of HIV/AIDS surveillance in Europe. Heterogeneity between countries in health care systems, HIV testing patterns and surveillance systems remain challenging for data standardization at the European level. Efforts should be made to use surveillance data for evaluating the effectiveness of HIV/AIDS prevention interventions.

Surveillance of HIV/AIDS in Europe: update at end 2000

In the Western area of Europe, AIDS incidence decreased by 12% in 2000 compared to 1999 (22 cases per million population). In the Eastern area, the incidence of notified cases remained low, but newly diagnosed cases are still rising. In the Centre, the rates of AIDS cases and HIV infections remain low. EuroHIV (European Centre for the Epidemiological of AIDS) coordinates the surveillance of AIDS in the WHO European Region since 1984 and of newly diagnosed HIV infection since 1999. The main findings of the latest update at end 2000 are presented here. To take into account the diversity of the epidemiological situation in the region, countries have been grouped into three geographic areas: the West (the 15 countries of the European Union plus Norway, Switzerland, Iceland, Israel, Malta) the East (the 15 Newly Independent States of the former Soviet Union) and the Centre (the remaining countries of the region).

Europe-wide surveillance for sexually transmitted infections: a timely and appropriate intervention

Sexually transmitted infections (STIs), including HIV, pose a significant threat to the health and wellbeing of Europeans and require concerted and sustained intervention. Over the past decade, the number of reported cases of STIs, including antimicrobial resistant Neisseria gonorrhoeae, has increased appreciably, and outbreaks of syphilis have recently been reported in many Member states of the European Union (EU). Young people, homosexual men, and those with poor access to health care (including preventive and educational services) seem to be particularly affected, with increased travel and migration, high risk sexual behaviours, and a deterioration of public health responses to STI control (for example, partner notification) being key driving factors. Many of these demographic and behavioural trends are similar across EU states, as is the desire to develop and implement effective STI prevention and control programmes.

Back-calculation by birth cohort, incorporating age- specific disease progression, pre-AIDS mortality and change in European AIDS case definition. European Union Concerted Action on Multinational AIDS Scenarios

OBJECTIVES

To adapt and improve methodology for back-calculation of AIDS in Europe and to examine the feasibility of estimating past HIV incidence by birth cohort.

METHODS

Empirical Bayesian back-calculation (EBBC) used Markov disease progression models, modified to allow for three diseases added to the AIDS case definition in 1993 and for pre-AIDS mortality, and estimation by penalized maximum likelihood with a neighbour prior. EBBC by 5-year birth cohort assumed a minimum age at infection and age-dependent progression rates; three versions, with varying age effects, were investigated using AIDS cases diagnosed prior to the introduction of highly active antiretroviral therapies (HAART).

RESULTS

Compared with the no age-effect version, EBBC by birth cohort tended to produce flattened HIV incidence curves in country-exposure groups with < 1000 AIDS cases, reflecting effects of the neighbour prior when data become sparse. Otherwise, birth cohort analysis, with moderate effects of age on progression, gave initially increasing incidence curves and consistent patterns across countries, with the 1960-1964 cohort most affected. In the European Union, incidence is estimated to have peaked in 1983 among homosexual men and in 1988 among injecting drug users; 460000 persons were estimated to be living with HIV/AIDS at the end of 1995.

CONCLUSIONS

Our improved methodology deals effectively with the change in AIDS case definition and has allowed quantitative assessments of the HIV epidemic by birth cohort using all AIDS cases diagnosed before 1996, thus providing a sound basis for public health policy at a time when estimation of more recent prevalence is compromised by the effects of HAART.

Cervical squamous intraepithelial lesions in HIV-infected women: prevalence, incidence and regression. European Study Group on Natural History of HIV Infection in Women

OBJECTIVES

To assess the impact of HIV-related immunodeficiency and antiretroviral treatment on the occurrence and evolution of abnormal Papanicolaou tests.

STUDY DESIGN

Cohort of 485 HIV-infected women with a known date of infection, enrolled during May 1993-April 1998 in 23 centres (gynaecology, infectious disease or STD clinics, or drug treatment centres) in 12 European countries; in 21 centres, follow-up was performed every 6 months (median follow-up: 2 years).

METHODS

Human papillomavirus (HPV) was detected at inclusion by Southern blot and PCR. The prevalence of squamous intraepithelial lesions (SIL), the incidence of SIL and regression from low-grade SIL were studied according to CD4 count after controlling for HPV detection results.

RESULTS

Compared with women with CD4 cell counts > 500 x 10(6)/l, women with CD4 cell counts < 200 x 10(6)/l had a twofold increase in both prevalence and incidence of SIL and in non-regression from untreated low-grade SIL; in addition, these women had a lower response rate to treatment of high-grade cervical intraepithelial neoplasia. The increase in SIL incidence associated with a low CD4 cell count was significant in women not receiving antiretroviral treatment (relative risk, CD4 cell count 200-499 x 10(6)/l, 1.9; CD4 cell count < 200 x 10(6)/l, 2.9; CD4 cell count > 500 x 10(6)/l, reference), whereas it was less marked and not statistically significant in treated women.

CONCLUSIONS

Severe HIV-related immunodeficiency strongly increases the risk of occurrence of SIL; antiretroviral treatment may reduce this risk, probably by restoring or at least preserving immune function.

HIV infection in Ukraine (1987-96)

In Ukraine, the number of reported HIV infections increased extremely rapidly during the second half of the 1990s, from less than 50 per year until 1994 to more than 12,000 in 1996. The increase was initially observed and was particularly striking in the regions along the Black Sea. The majority of reported HIV infections were diagnosed in injecting drug users. The extend of HIV spread through sexual transmission is more difficult to assess because of the strong social stigma attached to homosexuality and the lack of information on sexual behaviour in general. The reported number of syphilis cases have also dramatically increased, from 3,000 cases in 1990 to nearly 80,000 cases in 1996. In this paper, we describe the surveillance systems for, and epidemiologic data on HIV infections, AIDS, and other STD in Ukraine from 1987 to 1996. We review the contributions of different vulnerable groups and we also discuss the factors influencing the past spread and the potential for future spread of HIV infection and make recommendations for surveillance, research and prevention.

HIV reporting in western Europe : national systems and first European data

AIDS case reporting has been an essential tool for monitoring HIV infection in western Europe. Recent trends in AIDS have been affected by improved antiretroviral treatments that delay HIV disease progression, however, and no longer serve as indicators of

An age-period-cohort analysis of 50,875 AIDS cases among injecting drug users in Europe

BACKGROUND

The long average incubation time from HIV infection to AIDS makes it difficult to estimate recent HIV transmission from AIDS incidence data. Age-period-cohort (APC) analysis can separate out the effects of age, calendar time and birth cohort to provide a clearer picture of transmission trends.

METHODS

AIDS incidence data from 1981 to 1994 among intravenous drug users (IDU) for 12 Western European countries were used. Yearly incidences per 100,000 population or 100,000 person-years were calculated by age at diagnosis and 5-year birth cohort (1950-1954, 1955-1959, 1960-1964, 1965-1969 and 1970-1974), and corrected for reporting delay. Incidence patterns were compared between birth cohorts and countries.

RESULTS

For most countries the impact was greatest on the cohort born 1960-1964. Comparing incidence patterns in the 1965-1969 to 1960-1964 cohorts suggest the epidemic has plateaued at low to intermediate levels in Austria, Greece and the North-Western European countries, and at high levels in France, Italy and Switzerland. For most countries transmission amongst the 1970-1974 as compared to the 1965-1969 cohorts could not be assessed due to small numbers and short follow-up time. In Spain the epidemic was uncontrolled with a high incidence among recent birth cohorts. In Portugal the epidemic was still at an early and expanding phase.

CONCLUSIONS

The APC analysis revealed large country differences in the dynamics of the HIV/AIDS epidemic among IDU. Full interpretation of these differences is dependent on information from other sources about the local public health response and trends in drug injecting behaviours. Earlier introduction of the virus and higher prevalence of injecting drug use may explain some of the generally higher incidence in Southern European countries, but the larger part of it is most likely explained by local characteristics of drug users, such as younger age and more frequent sharing of needles and syringes, and a less effective public health response.

The HIV/AIDS epidemic in eastern Europe: recent patterns and trends and their implications for policy-making

OBJECTIVE

To describe recent patterns and trends in the HIV epidemic in eastern Europe.

METHODS

AIDS programme managers and epidemiologists of 23 countries were contacted and requested to provide national HIV surveillance data. Joint United Nations Programme on HIV/AIDS/World Health Organisation country fact sheets were reviewed and analysed, and this information was supplemented with published HIV prevalence and sexually transmitted disease case reporting information, unpublished travel reports and expert evaluations.

RESULTS

The cumulative number of HIV cases reported in the region increased more than fivefold between 1995 and 1997, from 9111 to 46573; Ukraine, Russia and Belarus accounted for about 90% of all new cases. Dramatic increases in the number of HIV-infected injecting drug users (IDU) were reported from these countries, and a similar pattern was emerging in Moldova, the Baltic States, the Caucasus and Kazakstan. In central Europe, the increase in the number of cases was much lower, and (with the exception of Poland) homosexual transmission was most common, whereas in the Balkan countries, cases due to heterosexual transmission were reported relatively more frequently. At the end of 1997, more than 50% of all cases region-wide had been reported from IDU. HIV prevalence data were inconclusive. The number of reported syphilis cases had risen significantly in the countries of the former Soviet Union.

CONCLUSION

Our data confirm that HIV must have been rapidly spreading among IDU in several countries of the former Soviet Union, whereas central and southeast Europe have so far escaped a more extensive spread of HIV. Factors that might have fuelled a massive spread among IDU include changes in drug demand and supply, migration and specific local drug production and consumption patterns. High rates of syphilis reported in the countries of the former Soviet Union highlight that subregion's increased vulnerability with regards to a further spread of the epidemic, via heterosexual intercourse, into the general population.

[European surveillance of infectious diseases: the case of AIDS and tuberculosis]

In 1992, the Maastricht treaty gave specific responsibilities to the European Community in the field of research, information and health education. Several European surveillance systems for infectious diseases have been organised. The surveillance of AIDS was set up in 1984 after the emergence of this new disease. Seven western European countries participated initially. The system currently covers 48 of the 51 countries of the WHO European region. Based on a common case definition, it enables analysis of trends and comparisons which considerably facilitate the understanding of the epidemic and its determinants, and the evaluation of preventive actions. European countries have now decided to set up a reporting system for HIV infection. The surveillance of tuberculosis started in 1996 in response to the reversal of trends in reported cases observed in western Europe and to the threat of multi-drug resistant tuberculosis epidemics. Common recommendations on definitions and data collection procedures facilitated its establishment. Most countries of the WHO European region participated in the first year, revealing a very heterogeneous epidemiological situation. The next objective is to set up a surveillance system for antituberculosis drug resistance. The European surveillance of AIDS and tuberculosis are examples of systems adapted to the specific characteristics of Europe: similarities in diagnostic procedures, similarities in access to treatments, and common requirements regarding both the exchange of information and the coordinated response to public health threats. They are not simply looking for a common denominator. They are creating a real momentum among participating countries towards a better quality and a higher level of pertinence of the information.

HIV prevalence in pregnant women in Europe: differences in assessment methods and prevalence levels across countries

OBJECTIVE

To describe methods used to assess HIV prevalence and to assess prevalence levels and time trends among pregnant women in various European countries.

METHODS

We used the European HIV Prevalence Database to examine annual HIV prevalence data in pregnant women for the years 1990 to 1996 (20 countries).

RESULTS

In Western Europe, prevalences were generally obtained through unlinked anonymous surveys, whereas in most Central, and Eastern European countries, they were based on testing programs (voluntary or mandatory). Prevalences (per 10,000) were highest (i.e., 10-30/10,000) in large western urban areas including Amsterdam, Barcelona, London, Milan, Paris, and Rome; between 1 and 2 in Scandinavian countries; and down to 0.5/10,000 in Central and Eastern European countries (except Ukraine, 1996: 5/10,000). Prevalences decreased in Rome, whereas they increased in London, the Czech Republic, and since 1995 in Russia and Ukraine; elsewhere, no time trends were detected.

CONCLUSIONS

Methodologic differences and potential biases should be considered when comparing these data. HIV prevalence in pregnant women is useful for monitoring the AIDS epidemic and for assessing and improving prevention. Efforts should be made to offer voluntary counseling and testing to women at risk for HIV and provide treatment to those who are infected.

Recommendations for HIV surveillance in Europe

The HIV/AIDS epidemic in Europe is now at an important turning point. In western Europe, AIDS incidence has been declining since 1996, partly as a result of new, more effective treatment of HIV infections. As these treatments delay the progression of HIV

Living with HIV. Experiences and perspectives of HIV-infected sexually transmitted disease clinic patients after posttest counseling

OBJECTIVES

To determine whether human immunodeficiency virus (HIV)-infected STD clinic patients receive needed services and to determine the social consequences of testing HIV-positive.

STUDY DESIGN

Sexually transmitted disease clinic patients in Baltimore, Miami, and Newark who had first been told about a positive HIV test 6 to 24 months previously were recontacted and interviewed.

RESULTS

Out of 416 persons we attempted to contact, we interviewed 142 who had first learned that they were HIV-infected 6 to 24 months previously. Most interviewees were male (57%), black (82%), and heterosexual and had a low socioeconomic status. Twenty-five percent said they had never received medical care for their HIV infection. Most of those not in care said they were never referred, were "in denial," or did not want medical care. Interviewees had disclosed their status selectively; but "because of HIV," 4% had lost a job, 1% had been asked to move by a landlord, and 1% had been assaulted. Seventy-six percent would recommend that others take an HIV test; 11% would not recommend it.

CONCLUSIONS

Most patients interviewed were getting medical care and, despite some negative consequences, most would recommend HIV testing to others. To identify and address local barriers to needed services, we suggest that clinic staff routinely recontact consenting HIV-infected patients after posttest counseling.

A birth cohort analysis of AIDS in Europe: high incidence among young persons at risk

OBJECTIVES

To study trends in AIDS incidence in Europe by age and year of birth.

DESIGN

Age-period-cohort analyses were adopted to distinguish the different time factors of calendar year, age and year of birth.

METHODS

Non-aggregate AIDS incidence data from 12 European countries (1978-1994) were adjusted for reporting delay and expressed per unit of population (per 100000 persons or 100000 person-years). Age-specific incidence patterns (absolute level and rate of increase) were compared between 5-year birth cohorts for homo-/bisexual men, injecting drug users (IDU) and heterosexual contact cases.

RESULTS

Mean age at diagnosis increased strongly amongst IDU, but less so among homo-/bisexual men and heterosexual contact cases. Of a total 110646 reported cases (116311 after adjustment for reporting delay), 87167 (78.8%) were among people born in 1950-1974 [91951 (79.1%) after adjustment for reporting delay]. The relative impact on specific birth cohorts differed strongly by exposure group. Incidences at age ranges of 20-24 and 25-29 years among cohorts born in 1965 and after were about the same level (homo-/bisexual men, IDU) or higher (heterosexual contact cases) than older birth cohorts when these were in the same age range; rates of increase were less among homo-/bisexual men and IDU, but higher among heterosexuals. There were large differences between counties.

CONCLUSIONS

Overall, AIDS incidence among cohorts born in 1965 and after is about the same level (homo-/bisexual men, IDU) or higher (heterosexual contact cases) than older cohorts when these were in the same age range. Rates of increase of AIDS incidence curves suggest reduced HIV transmission amongst the most recent cohorts of homo-/bisexual men and IDU, but among young heterosexuals the epidemic is still expanding.

Geography of AIDS-associated Kaposi's sarcoma in Europe

BACKGROUND

Classical Kaposi's sarcoma (KS) is about four times more common in southern Europeans than in northern Europeans.

OBJECTIVE

To describe the epidemiology of AIDS-associated KS (AIDS-KS) in Europe and to determine whether it occurs with increased frequency in southern Europe.

METHODS

Analysis of the 'European non-aggregate AIDS data set', as of September 1995. Countries with a cumulative total of > or = 50 KS cases as the presenting manifestation of AIDS were included. Homosexual men were excluded from south versus non-south comparisons because of possible confounding effects due to their route of HIV transmission.

RESULTS

KS was the presenting manifestation of AIDS for 13.3% (16,367 out of 122,679) of men and 2% (491 out of 24,826) of women. In all countries, the risk for KS was higher in individuals who acquired HIV infection via sexual rather than parenteral transmission. Among AIDS patients, there is little difference by sex in the risk of KS in injecting drug users (IDU) or transfusion recipients. The percentage with KS increased with age among homosexual and bisexual men, from 10% in the age group 15-19 years to 23% in the age group 30-39 years. In all countries, the percentage with KS declined over time. The risk of KS was not significantly higher in southern Europe. The percentage with KS in southern Europe was slightly lower than in northern Europe (P > 0.1) in male IDU (1.8% versus 2.1%), and only slightly higher (P > 0.1) in female IDU (1.5% versus 1.1%), in male transfusion recipients (3.5% versus 3.0%), in female transfusion recipients (2.4% versus 2.3%), and in both heterosexual men (7.5% versus 6.2%) and women (2.0% versus 1.6%) excluding those originating from countries where heterosexual HIV transmission is frequent.

CONCLUSIONS

The strong geographic predilection described for classical KS in southern Europe was not seen for AIDS-KS. If KS is caused by a viral infection in an immunodeficient host, our findings suggest the geographical variations in classical KS are not due to variation in prevalence of the causative virus but may be due to geographical variations in the prevalence of a form of mild immunodeficiency.

The HIV epidemic associated with injecting drug use in Europe: geographic and time trends

OBJECTIVES

To evaluate the magnitude and trends of the HIV epidemic associated with injecting drug use in Europe.

METHODS

AIDS cases associated with injecting drug users (IDU) diagnosed through 1995 were analysed, including IDU, homo-/bisexual IDU, heterosexual partners of IDU and children whose mothers were IDU. HIV seroprevalence studies among IDU were reviewed.

RESULTS

Of the 171,932 cumulative AIDS cases, 73,119 (43%) were IDU-associated (IDU, 89.0%; homo-/bisexual IDU, 3.5%: heterosexual partners of IDU, 6.2%; children with IDU mothers, 1.4%). Over 90% of IDU-associated cases were concentrated in south-western European countries with considerably higher rates in Spain (124 cases per million in 1995) than elsewhere (Italy, 68 per million; Portugal, 42 per million; France, 38 per million). During 1990-1995, incidence increased at an average annual rate of 11% overall and > 23% in central and eastern Europe; overall, incidence increased in older persons (12%) while decreasing in those aged 13-24 years (by 6%). HIV prevalence in IDU showed considerable geographic variation across and within countries. In several countries of western Europe, prevalence decreased. In the former Soviet Union, large HIV outbreaks have recently been detected among IDU through systematic HIV testing (e.g., in Ukraine, 6750 HIV infections were diagnosed in IDU tested during 1995-1996).

CONCLUSIONS

IDU have played a major role in the spread of HIV in Europe. In several western European countries, the incidence of HIV acquired through drug use has declined following high rates in mid-1980s. Studies to assess current transmission are needed and prevention efforts must be maintained. In eastern Europe, emerging epidemics reinforce the urgency for prevention.

AIDS trends in Europe: decrease in the west, increase in the east

In 1996, 24 920 AIDS cases were reported in the WHO European Region, bringing the cumulative total to 185 808 cases including 6969 (4%) paediatric cases (<13 years). For the first time since the start of the epidemic, the annual number of cases reported d

Reconstruction and prediction of the HIV/AIDS epidemic among adults in the European Union and in the low prevalence countries of central and eastern Europe

OBJECTIVES

To reconstruct the HIV epidemic and to provide forecasts of AIDS incidence among adults in the European Union (EU) and in a group of low prevalence (LP) countries of central and eastern Europe (including the Asian republics of the former Soviet Union).

METHODS

An empirical Bayesian back-calculation method was applied to AIDS incidence data reported by 31 March 1994. The HIV-infection curve was modelled as a yearly step function and a seven-stage Markov model of disease progression, incorporating effects of pre-AIDS treatment, was used. Estimation was by penalized maximum likelihood with empirical Bayesian smoothing. Data were analysed by transmission group and, within the EU, by country. Predictions of AIDS cases to 1998 were made assuming constant annual HIV incidence from 1993 onwards.

RESULTS

Estimated HIV prevalences per 100,000 population aged 15-59 years were, at 31 December 1993, 198 (n = 447,800) in the EU and 2.7 (n = 6840) in the 22 LP countries, with increases of 41% (EU) and 71% (LP) between 1989 and 1993. Among homo/bisexual men in the EU, prevalence appears to have stabilized since 1989 and AIDS incidence appears to be reaching a peak. Among all prevalent HIV infections in the EU, 42% were estimated to be among injecting drug users, 25% among homo-/bisexual men and 18% among persons infected heterosexually, compared with 29%, 35% and 19%, respectively, in the LP countries. Without allowing for the 1993 revision of the case definition, annual AIDS incidence is predicted to increase, between 1994 and 1998, by 24% in the EU and by 48% in the LP countries, with the largest percentage increases among heterosexually-infected persons.

CONCLUSION

The overall HIV prevalence rate is estimated to have been about 70-fold lower in the LP countries than in the EU in the early 1990s, but to be increasing much more rapidly in the former. Moreover, recent reports of rapidly increasing HIV infection rates suggest that back-calculation may seriously underestimate the size of the epidemic in the LP countries. Implementation of effective preventive measures is urgent if large-scale epidemics are to be avoided in the presently LP countries of the European region.

Communication of HIV serostatus between potential sex partners in personal ads

We studied reference to HIV in personal ads from 1986 to 1993 to assess knowledge of HIV serostatus as a criterion for selecting sex partners. Personals increased exponentially during 1986 to 1993. Men seeking men (MSM) were more likely (8%) to mention HIV than persons seeking other situations (0% to 1.6%). The proportion of personals mentioning HIV increased from 0.5% to 2.9% globally and from 1.9% to 12.2% for MSM (chi-square tests for trend; p < .001). Younger MSM mentioned HIV less often than MSM older than 35 years (odds ratio = .46; 95% confidence interval: 31 to .70). The increasing proportion of personals mentioning HIV suggests that serostatus is increasingly used as a criterion for partner selection, although most (84%) such ads concerned MSM. We discussed the implications of these findings for preventing sexual transmission of HIV.

Prevalence of HIV-2 infection in Europe

The HIV/AIDS pandemic is primarily caused by HIV-1. Another type of virus, HIV-2, is found mainly in certain West African countries In Europe, most of the cases of HIV-2 infection described have been in people from Africa. The objective of this study was

Syphilis and gonorrhea in Miami: similar clustering, different trends

During the second half of the 1980s, Miami had a syphilis epidemic while gonorrhea rates decreased. To determine whether the direction of these trends truly differed within all population subgroups or whether they resulted from aggregating groups within which trends were similar, records from four sexually transmitted disease clinics from 1986 to 1990 and census data from 1990 were used to compare race-, sex-, age-, and zip code-specific groups. Syphilis and gonorrhea clustering was similar; 50% of cases occurred in the same zip codes, representing 10% of the population. In all groups, gonorrhea decreased (aggregate 48%) while syphilis first increased (aggregate 47%) and then decreased. Determining reasons for these different trends may facilitate controlling these diseases.