The Experience of Implementing Urban HEART Barcelona: a Tool for Action.

Urban Health Equity Assessment and Response Tool (HEART) is a tool developed by the World Health Organization whose objective is to provide evidence on urban health inequalities so as to help to decide the best interventions aimed to promote urban health equity. The aim of this paper is to describe the experience of implementing Urban HEART in Barcelona city, both the adaptation of Urban HEART to the city of Barcelona, its use as a means of identifying and monitoring health inequalities among city neighbourhoods, and the difficulties and barriers encountered throughout the process. Although ASPB public health technicians participated in the Urban HEART Advisory Group, had large experience in health inequalities analysis and research and showed interest in implementing the tool, it was not until 2015, when the city council was governed by a new left-wing party for which reducing health inequalities was a priority that Urban HEART could be used. A provisional matrix was developed, including both health and health determinant indicators, which allowed to show how some neighbourhoods in the city systematically fare worse for most of the indicators while others systematically fare better. It also allowed to identify 18 neighbourhoods-those which fared worse in most indicators-which were considered a priority for intervention, which entered the Health in the Barcelona Neighbourhoods programme and the Neighbourhoods Plan. This provisional version was reviewed and improved by the Urban HEART Barcelona Working Group. Technicians with experience in public health and/or in indicator and database management were asked to indicate suitability and relevance from a list of potential indicators. The definitive Urban HEART Barcelona version included 15 indicators from the five Urban HEART domains and improved the previous version in several requirements. Several barriers were encountered, such as having to estimate indicators in scarcely populated areas or finding adequate indicators for the physical context domain. In conclusion, the Urban HEART tool allowed to identify urban inequalities in the city of Barcelona and to include health inequalities in the public debate. It also allowed to reinforce the community health programme Health in the Barcelona Neighbourhoods as well as other city programmes aimed at reducing health inequalities. A strong political will is essential to place health inequalities in the political agenda and implement policies to tackle them.

Hepatitis A among men who have sex with men in Barcelona, 1989-2010: insufficient control and need for new approaches.

BACKGROUND: Men who have sex with men (MSM) are a known group at risk for hepatitis A and outbreaks among this group are frequent. In Barcelona, vaccination for MSM has been recommended since 1994. In 1998 a vaccination campaign among preadolescents was implemented and an immunization program in gay bathhouses began in 2004. OBJECTIVE: to asses the incidence of hepatitis A in adults in Barcelona from 1989 to 2010 and to evaluate the outbreaks among MSM including all genotypes involved. METHODS: All cases of acute hepatitis A among young adults notified to the Public Health Agency of Barcelona from 1989 to 2010 were included for analyses. We calculated the annual incidence rate and the incidence ratio male-to-female (M:F) as a marker for MSM. Spearman's coefficient was used to evaluate trends. We also evaluated the outbreaks among MSM and compared their characteristics using Chi-squared and ANOVA test. Fragment amplification of the VP1/P2A region was used for genetic analysis. RESULTS: The median annual incidence for the period of study was 4.7/100000 among females and 11.7/100000 among males. The rate of hepatitis A for adult woman decreased over time (Spearman' coefficient = -0.63, p = 0.002), whereas there was no decrease for adult men (Spearman' coefficient = 0.097, p = 0.67). During the study period the M:F ratio increased (Spearman' coefficient = 0.73, p < 0.001).Three large outbreaks among MSM were detected. When comparing outbreaks, there was a decrease in the percentage of bathhouse users (from 47% to 19%, p = 0.0001) and sex workers (from 6.5% to 0%) while the percentage of HIV infected individuals did not change significantly (range: 21%-28%, p = 0.36). The isolated strains were closely related to those circulating in Europe. CONCLUSIONS: Annual incidences remain high among MSM without tendency to decrease. More strategies which effectively reach the whole MSM community are needed.

HIV infection late detection in AIDS patients of an European city with increased immigration since mid 1990s.

The study goal is to identify predictors of HIV infection late detection in an European city with increased immigration, and determine the effects of HAART era in HIV infection detection. We used Barcelona city AIDS registry (1987-2006). Late testers were those diagnosed of AIDS defining illness within less than 3 months from time of testing positive for HIV infection. Independent variables were: date of birth, sex, country of origin, HIV transmission category, prison history, city district of residence, AIDS diagnostic disease and HAART era when diagnosed. The statistical methods were based on logistic regression (Odds Ratio, OR and 95% confidence interval, CI). Among the 6186 AIDS patients, 43.9% (n=2741) were late testers. Being a male (OR: 1.57, 95% CI: 1.35-1.83), either < 30 years (OR: 1.21, 95% CI: 1.06-1.38) or > 40 years (OR: 1.20, 95% CI: 1.03-1.40), with heterosexual (OR: 3.07, 95% CI: 2.59-3.63) routes of transmission or men who have sex with men (OR: 2.20, 95% CI: 1.89-2.57) and with Pneumocystis jiroveci pneumoniae (OR: 1.71, 95% CI: 1.47-2.00) or tuberculosis (OR: 1.57, 95% CI: 1.36-1.82) were all independent risk factors for being a late tester. Conversely, injecting drug use (IDU) was associated with early detection (OR: 0.36, 95% CI: 0.33-0.40). Being migrant was associated with late testing only in the univariate analysis. Individuals with the detected factors (male, having any sexual risk behaviour and being > 50 years) should be in the main focus for HIV testing to further ensure continuous decrease in the slope of late detected HIV infections overall.

Increase in the non-HIV-related deaths among AIDS cases in the HAART era.

OBJECTIVE: To analyze the factors associated with survival and to describe the specific causes of death in a large cohort of individuals with Acquired Immune Deficiency Syndrome (AIDS) in the Highly Active Antiretroviral Therapy (HAART) era. METHODS: Subjects over 13 years old recorded in the AIDS registry of Barcelona and diagnosed between 1997-2005 were included. Survival analysis was performed. Causes of death were classified as being HIV-related or non-HIV-related. RESULTS: A total of 1,759 cases were analyzed, 640 (36.3%) of them died during the follow-up. The cumulative probability of survival at five years was of 64% (95% C.I. 62%-67%). The cause of death was non-HIV-related in 28.9% of the cases, among which the most frequent were cancers (20.8%) and liver diseases (18.8%). CONCLUSION: An increase in the proportion of non-HIV-related deaths has been observed compared to that in the pre-HAART era. The case management of HIV-infected people must be re-directed to influence the risk factors associated with these increasing causes of death.